Vitiligo

24
Vitiligo is a common, acquired, idiopathic dis-
coloration of the skin characterized by well-
circumscribed, ivory/chalky white colored
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contrast to leukoderma where a cause of such a
change is known. The lesion may be surrounded
by a ring of tan or intermediate color around
which is the normal skin, the ‘trichrome’. The
hair over the patch may be either normal or
white (leukotrichia). Occasionally, vitiligo may
be associated with autoimmune disorders like
thyroid diseases, diabetes mellitus, pernicious
anemia. Figure 24.1: Vitiligo areata: Well-circumscribed ivory/
The extent of involvement is variable. There chalky white color macule(s) surrounded by ring of
tan or intermediate color, around which is the normal
may be one, two or a few macules or it may be (trichrome)
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the following:
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distributed along a dermatome or lines of
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be the only site involved or it may be a part
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7KHSUHFHGLQJFODVVLÀFDWLRQQRWRQO\KHOSVLQ Figure 24.2: Vitiligo zosteriform/segmental: Macules
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 108
Figure 24.3: 9LWLOLJRDFURIDFLDOLV(IIHFWLQJWKHIDFHMLSV
of the hands and feet
Figure 24.4: Vitiligo vulgaris: Generalized involving
extensive areas of the body
Textbook of Clinical Dermatology
Figure 24.5: Vitiligo mucosae: Exclusive mucous mem-
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Prognosis, therefore, may be judged by the
following:
Duration of the vitiligo: Shorter the duration,
better the prognosis.
Age of the patient: Younger the patient, better
the prognosis.
Leukotrichia: Its presence carries the poor
prognosis.
0DFXOHVRYHUWKHÀHVK\DUHDV They have better
chance for repigmentation in contrast to those
over the bony areas.
Vitiligo areata, and zosteriform vitiligo: These
respond favorably to treatment.
Dopa reaction: Positive dopa reaction in vitro
depicts good prognosis.
TREATMENT
Psoralens form the mainstay of treatment for
vitiligo. Three types of psoralens are in use:
a. Basic psoralen
 Vitiligo
b. 8-methoxypsoralen
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Treatment may be initiated with any one.
Sometimes a patient, refractory to one, may res-
pond to the other.
The precise mode of action of psoralens is
unknown. However, it is likely that following
absorption, psoralens concentrate in the cyto-
plasm of the melanocytes. On subsequent expo-
sure to sunlight (PUVASOL) or ultraviolet A
109
tolerance. Patients may be encouraged to take
longer exposure, provided they tolerate the
heat without developing any phototoxic and/
or actinic damage. Care should be taken to
protect the eyes with sunglasses and the normal
surrounding skin by application of para-amino-
benzoic acid (PABA) cream or lotion, a UVA
light sunscreen.
In favorable cases, persistant erythema, a
prelude to repigmentation is noticed usually
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tem in the melanocytes, the tyrosinase, concer-
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response following PUVASOL/PUVA may also
initiate repigmentation.
A dose of 0.6 mg/kg is adequate to produce
repigmentation. After oral administration,
maximum concentration of the photosensitizing
drug in the blood is achieved after two
hours. In tropical and subtropical countries,
maximum UVA radiation from sunlight is
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maximum photosensitization, it is advisable
to take psoralens in the recommended dose
after breakfast, followed by exposure of the
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time is gradually increased to a maximum of
after a month’s exposure. In case the erythema
does not appear during this period, the treatment
may be abandoned. Subsequent repigmentation
starts either from the margins of the macule
and/or the hair follicles. These small island
of pigmentation may gradually increase and
coalesce to form a uniform pigmented macule,
a cosmetically favorable outcome. Occasionally
depigmentation recurs after stoppage of the
treatment. In that event psoralen therapy should
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mg) of prednisolone or its equivalent. The latter
is more useful in case there is an underlying
autoimmune disorder.
Other Modalities of Treatment
Topical psoralens: It is applied early in the
morning over the vitiliginous macule, protect-
PLQXWHV7DEOH ing the surrounding area with PABA cream. The
Table 24.1: Duration of exposure in PUVA areas are immediately exposed to early sun for
Color of the skin DERXWPLQXWHVDQGWKLVLVJUDGXDOO\LQFUHDVHG
Steps of exposures Light Dark in subsequent weeks to a maximum of one hour.
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6HFRQGH[SRVXUH PLQ PLQ Topical Corticosteroids
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)RXUWKH[SRVXUH PLQ PLQ They are useful in cases of vitiligo areata.
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In an individual patient, the maximum SURSLRQDWH7HQRYDWH7RSLQDWHDUHXVHG
duration varies with the basic skin color and for topical application.
 110 Textbook of Clinical Dermatology
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It may be used to hide the patch if other modes
of therapy have failed.
Skin Grafting
This is done if there is a patch on an exposed
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it should be ensured that the disease has
stabilized and not progressing.
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In vitiligo vulgaris, where only a few islands of
pigmentation are left 20 percent monobenzyl
ether of hydroquinone should be administered
topically to these islands, to attain uniform
depigmentation.
RECOMMENDED READING
1. Sehgal VN. Letter: Trioxsalen therapy for vitiligo.
Arch Dermatol 
2. Sehgal VN. Effectiveness of oral trioxalen therapy
for vitiligo. Arch Dermatol
  6HKJDO 91 $ &RPSDUDWLYH FOLQLFDO HYDOXDWLRQ RI
trimethylpsoralen, psoralen and 8-methoxypso-
ralen in vitiligo. Int I Dermatol
pattern of vitiligo amongst India. J Dermatol (Japan)

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clinico-epidemiological features. Indian J Dermatol
Venereol Leprol5HYLHZ
  6HKJDO 91 6ULYDVWDYD * 9LWLOLJR WUHDWPHQW
options: An evolving scenario. J Dermatolog Treat

  6HKJDO 91 6ULYDVWDYD * 9LWLOLJR Auto-immu-
nity and immune responses. Int J Dermatol