A 27-Year-Old Woman With White Spots on Her Face

Miriam Kinai, MB ChB

Disclosures

September 14, 2018

Vitiligo can be classified as localized, generalized, or universal. Patients with localized vitiligo have unilateral segmental areas of depigmentation limited to one part of the body (such as one side of the face or one limb). These lesions may have a dermatome-like distribution and, although vitiligo is usually chronic and progressive, in some patients with segmental vitiligo the depigmented macules and patches remain localized and do not spread. Patients with generalized vitiligo have widely distributed depigmented macules and patches, usually on both sides of the body. This is the most common pattern and the lesions are usually symmetrical but may be asymmetrical. Patients with universal vitiligo have total or near-total depigmentation of their skin.

Morphologic variations of vitiligo include the following:

  • Trichrome vitiligo, in which patients have 3 zones of different colors; these range from the central achromic zone, to its surrounding hypochromic zone, to the outermost peripheral normal colored skin zone

  • Quadrichrome vitiligo, in which a fourth dark color is present in areas undergoing perifollicular hyperpigmentation

  • Pentachrome vitiligo, with 5 zones of different colors

  • Inflammatory vitiligo, in which an erythematous border surrounds the vitiliginous area

In addition to the dermatologic effects, vitiligo tends to have an emotional and psychological impact. Patients with vitiligo, particularly adolescents who have dark skin types, can experience emotional stress, develop low self-esteem, stigmatization, social anxiety, and even depression. This is especially true if the depigmented patches are on the genitals or on highly visible areas, such as the face and hands.

The diagnosis of vitiligo is generally made clinically based on the history and physical examination. A Wood's lamp examination accentuates the ivory or chalk-white colored vitiliginous depigmented macules and patches, thereby helping to differentiate them from hypopigmented lesions. A Wood’s lamp is also useful in revealing the extent of vitiligo in patients with type I and II skin types.[4] A skin biopsy can help differentiate vitiligo from hypopigmented lesions because it demonstrates a complete absence of melanocytes in the affected skin.

Patients with vitiligo have an increased incidence of Graves disease, Hashimoto thyroiditis, Addison disease, alopecia areata, diabetes mellitus, pernicious anemia, and other autoimmune diseases. Therefore, laboratory tests in vitiligo should be determined by associated signs or symptoms suggesting other autoimmune disease; these tests may include the following: complete blood count (CBC), vitamin B-12 levels and antiparietal cell antibodies tests for associated pernicious anemia, thyroid function tests, antithyroglobulin tests, fasting blood glucose tests for associated diabetes mellitus in patients with polydipsia or polyuria, and antinuclear antibody tests.

The differential diagnosis of vitiligo includes idiopathic guttate hypomelanosis, tinea versicolor, halo nevus, leprosy, postinflammatory hypopigmentation, pityriasis alba, ash leaf macules of tuberous sclerosis, nevus depigmentosus, chemical leukoderma, and piebaldism.

Although spontaneous repigmentation does occur in a few cases, the treatment of vitiligo is challenging because no single treatment results in the repigmentation of all patients. This fact should be communicated to patients, especially those with vitiligo in areas known to be resistant to treatment (such as the hands and feet). The patient’s response to treatment should be monitored with serial clinical photography. The choice of therapy depends on the size, number, and location of the hypopigmented patches and can be classified as medical, surgical, or adjunctive.

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