Thursday, 25 June 2015

Vitilligo

Vitiligo lesions are characterized as follows:
White or hypopigmented, well demarcated
(Round, oval, or linear in shape
Borders may be convex).
Centrifugal enlargement.
Initial lesions occur most frequently on the hands, forearms, feet, and face, favoring a perioral and periocular distribution.

Clinical classifications
Vitiligo can be classified as follows:
1.Localized
2.Generalized
3.Universal

Localized vitiligo can exist in the following forms:
A.Focal: Characterized by 1 or more macules in 1 area.
B.Segmental: Manifests as 1 or more macules in a dermatomal or quasidermatomal pattern; occurs most commonly in children; more than half the patients with segmental vitiligo have patches of white hair or poliosis.
C. Mucosal: Mucous membranes alone are affected.

Generalized vitiligo can manifest as the following:
A.Acrofacial: Depigmentation occurs on the distal fingers and periorificial areas.

B.Vulgaris: Characterized by scattered patches that are widely distributed.

C.Mixed: Acrofacial and vulgaris vitiligo occur in combination, or segmental and acrofacial vitiligo and/or vulgaris involvement are noted in combination.

Universal vitiligo results in complete or nearly complete depigmentation. It is often associated with multiple endocrinopathy syndrome.

Diagnosis
Although the diagnosis of vitiligo is made on the basis of clinical findings, biopsy is occasionally helpful for differentiating vitiligo from other hypopigmentary disorders.
Microscopic examination of involved skin shows a complete absence of melanocytes in association with a total loss of epidermal pigmentation. Superficial perivascular and perifollicular lymphocytic infiltrates may be observed at the margin of vitiliginous lesions, consistent with a cell-mediated process destroying melanocytes.

Other documented histologic findings include the following:
Degenerative changes in keratinocytes and melanocytes in the border lesions and adjacent skin.
Epidermal vacuolization.
Loss of pigment and melanocytes in the epidermis is highlighted by Fontana-Masson staining and immunohistochemistry testing.
Woods lamp examination can be done.

Management
A. Medical treatments-
Systemic phototherapy: Induces cosmetically satisfactory repigmentation in up to 70% of patients with early or localized disease.

Steroid therapy: Systemic steroids (prednisone) have been used, although prolonged use and their toxicity are undesirable.

Topical therapies includes steroids, tacrolimus, pimecrolimus, vitamin D analogs.

Depigmentation therapy: If vitiligo is widespread and attempts at repigmentation have not produced satisfactory results, depigmentation may be attempted in selected patients.

Another innovation is therapy with an excimer laser, which produces monochromatic rays at 308 nm to treat limited, stable patches of vitiligo.

Micropigmentation: can be used to repigment depigmented skin in dark-skinned individuals.

B. Surgery
Types of repigmentation surgery are as follow:
1. Noncultured epidermal melanocytic transfer.
2. Thin dermoepidermal grafts.
3. Suction epidermal grafting.
4.Punch minigrafting.
5.Cultured epidermis with melanocytes or cultured melanocyte transfer.

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