Vitiligo

Vitiligo

Vitiligo is an acquired pigmentary disorder characterized by well circumscribed depigmented macules and patches that are typically asymptomatic but cosmetically distressing. The underlying mechanism involves melanocyte destruction leading to absence of functional melanocytes, most likely mediated by autoimmune processes with CD8 T cell cytotoxicity playing a central role. Clinically, vitiligo can be precipitated by trauma through the Koebner phenomenon, and a more progressive course is suggested when associated with systemic features. The disease has distinct clinical classifications. Acrofacial vitiligo affects the face and distal extremities, while segmental vitiligo presents unilaterally and stops at the midline, frequently in children, often with leukotrichia. Generalized or vulgaris vitiligo is the most common form, accounting for the majority of cases. Associations are clinically important, with thyroid dysfunction being the most common, and other autoimmune associations include alopecia areata, halo nevi, Vogt-Koyanagi-Harada syndrome, granulomatous uveitis, aseptic meningitis, and deafness. Alezzandrini syndrome presents with unilateral facial depigmentation and poliosis accompanied by ipsilateral ocular and auditory deficits. Treatment options include potent topical corticosteroids and narrowband UVB or excimer laser for repigmentation, cellular grafts such as melanocyte keratinocyte transplant for segmental disease, and depigmentation therapy with monobenzyl ether of hydroquinone in widespread severe cases. Recently, JAK inhibitors like ruxolitinib have gained FDA approval. Prognosis is variable, with poor outcomes linked to mucosal involvement, leukotrichia, Koebnerization, trichrome and confetti-like lesions, and early childhood onset. Favorable prognostic indicators include recent onset, younger age, and localization to face, neck, or trunk. Repigmentation typically begins in a perifollicular pattern, highlighting the importance of melanocyte reservoirs in hair follicles.

Pathophysiology

• Brown camouflage outfits = Vitiligo
• Camouflage = Well circumscribed depigmented asymptomatic macules and patches
• Shooting melons = Melanocyte destruction → absence of functional melanocytes
• CD8 knight stabbing melon = Autoimmune theory suggests alterations in cellular/humoral immunity → melanocyte destruction
• Kid falling and hurting himself = Koebner phenomenon (vitiligo secondary to trauma)
• Crying = More progressive course

Classifications

• Camouflage mask, gloves and shoes = Acrofacial vitiligo affects face + distal extremities
• Half the body covered in camouflage = Segmental vitiligo stops at the midline
• Child = Occurs primarily in children
• White hair = Frequently occurs with leukotrichia
• Full camouflage = Generalized/vulgaris
• #1 finger = Most common type

Associations

• Bowtie = Thyroid dysfunction is the most common association
• Halo = Halo nevi
• Barber cutting hair = Alopecia areata
• Voyager kayak = Vogt Koyanagi Harada syndrome
• Grandma wearing glasses that are on fire = Bilateral granulomatous uveitis
• Neck brace = Aseptic meningitis
• Headphones = Deafness
• Bald = Alopecia
• White stripe on scalp = Poliosis
• Camouflage outfit = Vitiligo
• Lizard dreaming = Alezzandrini syndrome
• Half the face with a camouflage mask = Unilateral facial vitiligo/poliosis
• Eyepatch and headphone on same side = Visual/hearing impairment on same side

Treatment

• Cooler = Potent topical steroids
• Shining a narrow flashlight = NB UVB phototherapy/excimer laser
• Uprooted watermelon and carrots = Cellular grafts – melanocyte keratinocytic transplant procedure for segmental vitiligo
• Next to kid with half camouflage outfit = For segmental vitiligo
• Pale white queen covered in water = Depigmentation with monobenzyl ether of hydroquinone
• Smooth complexion = Depigments skin to create even pigmentation in severe cases
• On a beanstalk with Rolex watch = Oral JAK inhibitors like topical ruxolitinib is FDA approved

Prognosis/clinical course

• Crying kid falling in river = Bad prognostic indicators
• Sticking tongue out = Mucosal involvement
• White hair = Leukotrichia
• Brown, black, white comb = Trichrome lesions
• Injured = Koebnerization
• Shot by confetti gun = Confetti like depigmentation
• Smiling kid = Good prognostic indicators
• Wearing a watch = Recent onset
• Young child = Younger patient
• Wearing a facemask and chest plate = Lesions of the face/neck/trunk
• Brown plant in a pot = Follicular repigmentation is typical (migration of melanocytes from hair follicles)