Vitiligo Clinical Presentation

Updated: Jul 25, 2017
  • Author: Krista Roncone; Chief Editor: Dirk M Elston, MD  more...
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Physical Examination

Vitiligo is almost always diagnosed clinically upon physical examination. Vitiligo manifests as acquired depigmented macules or patches surrounded by normal skin. The macules are chalk or milk-white in color and are well demarcated. Lesions can be round, oval, or linear in shape. The borders may be convex. [1] Lesions enlarge centrifugally over time at an unpredictable rate. Lesions range from millimeters to centimeters in size. A Wood lamp may be necessary to see lesions on patients with lighter skin.

The most common sites of vitiligo involvement are the face, neck, forearms, feet, dorsal hand, fingers, and scalp. When found on the face, lesions may favor a periocular or perioral distribution. In the setting of widespread or generalized vitiligo, lesions may also occur around the genital region, areola, and nipple. Additionally, lesions may occur in regions frequently subjected to trauma, such as bony prominences, elbows, and knees. Koebner phenomenon is defined as the development of vitiligo in sites of trauma, such as a cut, burn, or abrasion. Koebnerization may occur in as many as 20-60% of vitiligo patients. [18]

Body hair in vitiliginous macules may be depigmented. This is known as leukotrichia, and it may indicate a poor prognosis with regard repigmentation therapy. [19] Spontaneous repigmentation of depigmented hair is unlikely to occur.

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Clinical Variants

Trichrome vitiligo is a clinical variant characterized by an intermediate zone of hypopigmentation located between the depigmented center and the peripheral unaffected skin. The natural evolution of the hypopigmented areas is progression to full depigmentation. This results in three shades of color in the same patient, as in the image below. The presentation and shades of trichrome vitiligo varies depending on the natural skin color of the patient.

Trichrome vitiligo. Trichrome vitiligo.

Marginal inflammatory vitiligo is a very rare variant in which a red, raised border is present at onset or may appear several months or years after initial onset. Mild pruritus may be present. See image below.

Marginal inflammatory vitiligo. Marginal inflammatory vitiligo.

Quadrichrome vitiligo is another variant of vitiligo, which reflects the presence of a fourth color (dark brown) at sites of perifollicular repigmentation. 

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Clinical Classifications of Vitiligo

Vitiligo may be divided into two groups: segmental and nonsegmental. It is important to note that other classification systems exist that choose to break down types of vitiligo based on having a localized or generalized distribution, with localized implying the lesion is restricted to a specific area and generalized implying more than one area is involved. However, the distinction between segmental and nonsegmental may be the most useful to the clinician, as it has an impact on progression, prognosis, and treatment.

Segmental vitiligo

This type manifests as one or more macules that may follow the lines of Blaschko. It is unilateral and does not cross the midline. Segmental vitiligo usually has an early onset and rapidly spreads in the affected area. The course of segmental vitiligo can arrest, and depigmented patches can persist unchanged for the life of the patient. This type of vitiligo is not associated with thyroid or other autoimmune disorders. See the image below.

Segmental vitiligo. Segmental vitiligo.

Nonsegmental vitiligo

Nonsegmental vitiligo has served as an umbrella term to include all types of vitiligo that cannot be classified as segmental vitiligo. [20] Of note, nonsegmental vitiligo is more strongly linked than segmental vitiligo to markers of autoimmunity or inflammation such as halo nevi and thyroid antibodies. [21]

Examples of nonsegmental vitiligo include the following (see the image below):

  • Focal vitiligo: This is characterized by one or more macules in a limited area that do not follow a segmental distribution.
  • Generalized vitiligo: This follows a nonsegmental distribution and is more widespread than localized or focal vitiligo.

Subtypes of generalized vitiligo include the following:

  • Acrofacial vitiligo: Depigmentation occurs on the distal fingers and periorificial areas.
  • Vulgaris vitiligo: This is characterized by scattered patches that are widely distributed.
  • Universal vitiligo: Complete or nearly complete depigmentation of the body occurs.
Nonsegmental vitiligo. Nonsegmental vitiligo.
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Causes

The exact cause of vitiligo is unknown; however, current theories focus on the destruction of melanocytes by autoimmune mechanisms, neural mechanisms, oxidant-antioxidant mechanisms, or intrinsic defects of melanocytes. See Pathophysiology for more detail.

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