Vitiligo Clinical Presentation

Updated: Jul 20, 2022
  • Author: Shekhar Neema, MD; Chief Editor: Dirk M Elston, MD  more...
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Presentation

History

Vitiligo presents as asymptomatic, milky white colored lesions. The lesions may be localized in focal or segmental vitiligo and generalized in non-segmental vitiligo. Universal vitiligo shows generalized depigmentation. Hairs in the affected region may be white, and this is known as leukotrichia. Patients with generalized vitiligo may present with sunburn due to inadvertent sun exposure or actinic keratosis in long-standing vitiligo. Lesions may appear at the site of trauma (koebnerization).

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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. Dermoscopy may also help in the diagnosis of vitiligo. It shows diffuse white glow in established lesion;  reverse pigmentary pattern in evolving vitiligo; micro-koebnerization, comet-tail like appearance in unstable vitiligo and reticular pigment network and peri-follicular pigment in stable and repigmenting vitiligo. [18]

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. [19]

Body hair in vitiliginous macules may be depigmented. This is known as leukotrichia, and it may indicate a poor prognosis with regard to repigmentation therapy. [20] 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 3 shades of color in the same patient, as in the image below. The presentation and shades of trichrome vitiligo vary 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. 

Blue vitiligo is a variant of vitiligo in which a bluish tinge is seen in the depigmented macule. This bluish hue is due to the presence of dermal melanophages.  [21]

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Clinical Classifications of Vitiligo

Vitiligo may be divided into 2 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 1 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. [22] Of note, nonsegmental vitiligo is more strongly linked than segmental vitiligo to markers of autoimmunity or inflammation such as halo nevi and thyroid antibodies. [23]

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.

  • Mucosal vitiligo

Nonsegmental vitiligo. Nonsegmental vitiligo.
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Complications

The visual nature of the disease results in severe psychosocial and psychological consequences, especially in individuals with darker skin. It can result in social stigma and depression. 

Inadvertent sun-exposure results in acute sunburn, and chronic sun damage can result in non-melanoma skin cancers 

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