Vitiligo

History Taking

Chief Complaint:

• Patches of skin losing their pigment

• Depigmentation of the skin that is progressive

History of Presenting Complaint:

• Initial appearance of small, white patches on the skin, often symmetric and localized

• Progression of the condition, with patches growing larger or increasing in number over time

• Areas of skin most affected could include hands, face, lips, and around body openings

• Hair within affected areas may also become white

• Depigmented patches of skin may be sensitive to sunburn

• Symptoms may have caused distress or concern due to their cosmetic appearance

System Review:

• No associated pain, itching, or irritation of the skin unless there's associated dermatitis

• No systemic symptoms like fever, weight loss, fatigue

Past Medical History:

• History of autoimmune diseases such as thyroid disease, pernicious anemia, or type 1 diabetes

• History of other skin conditions such as psoriasis, eczema

• Any other systemic illnesses

Drug History:

• Recent use of new medications that might have triggered an autoimmune response

• Use of immunosuppressive drugs

Family History:

• History of vitiligo or other autoimmune diseases in the family

Personal History:

• Stressful events or physical trauma preceding the onset of symptoms

• Personal habits that could affect the skin (e.g. excessive exposure to sunlight or chemicals)

Social History:

• Impact on social life due to cosmetic appearance of the condition

• Employment or hobbies involving exposure to industrial chemicals or sunlight

Physical Examination

General Examination:

• Assessment of patient's general wellbeing

• Visible skin changes and their impact on patient's demeanor

• Inspection of the overall distribution of skin lesions

Hands and Arms Examination:

• Depigmented patches on the skin of hands and arms

• White hair within the depigmented areas if present in hair-bearing regions

Face Examination:

• Depigmented patches on facial skin, lips, around eyes or nose

• Inside the mouth, white patches may be present

• Involvement of eyelashes and eyebrows with loss of pigment

• Check for signs of autoimmune conditions, such as uveitis or iritis, that can sometimes coexist with vitiligo.

Neck Examination:

• Presence of depigmented patches on the front or back of the neck

Cardiac, Respiratory, Abdomen, Neurological Examination:

• Generally, these systems are not involved in vitiligo and would likely yield negative findings unless the patient has an unrelated concurrent condition.

Additional Examination (if required):

• Thyroid examination: Examine for any evidence of thyroid disease, as it can be associated with vitiligo in the context of an autoimmune syndrome.

Investigations

Laboratory Tests:

• Full Blood Count: To rule out anemia that may be associated with autoimmune diseases

• Thyroid function tests: To identify possible coexisting autoimmune thyroid disease

• Vitamin B12 and folate levels: To identify possible coexisting pernicious anemia

• Autoantibody screen: Antinuclear antibody (ANA), anti-thyroid peroxidase (TPO) antibodies, anti-gastric parietal cell antibody to detect autoimmune diseases that can be associated with vitiligo

Imaging:

• No specific imaging tests are typically necessary for the diagnosis or management of vitiligo.

Invasive Tests:

• Skin biopsy: This can be helpful in doubtful cases to confirm the diagnosis of vitiligo. It shows a complete absence of melanocytes.

Other Tests:

• Wood's lamp examination: Under this UV light, depigmented skin in vitiligo will appear bright blue-white, helping to confirm the diagnosis and assess the extent of the disease.

• Audiometry: In case of associated autoimmune inner ear disease, not typically required for vitiligo, but may be considered if patient reports hearing loss.

Management

General Management:

• Patient education: Explaining the nature of the disease, its chronic course, and unpredictability of the treatment outcome

• Sun protection: Advising on the use of sunscreens, protective clothing and avoiding peak sun exposure times to prevent sunburn

Medical Management:

• Topical corticosteroids: First-line treatment for localized vitiligo

• Calcineurin inhibitors: Topical tacrolimus or pimecrolimus can be used, particularly on the face and neck

• Psoralen plus ultraviolet A (PUVA) therapy: Considered in widespread vitiligo or when topical treatments are ineffective

• Narrow-band ultraviolet B (NB-UVB) light therapy: Another option for widespread vitiligo

• Oral corticosteroids: May be used short-term for rapidly progressive disease

Surgical Management:

• Skin grafting: May be considered in patients with stable disease who have not responded to medical treatments

• Melanocyte transplantation: Considered in select cases

Other:

• Cosmetic camouflage: Makeup or dyes to mask the depigmented areas

• Psychological support: Given the significant psychosocial impact of the disease, referral to a psychologist or support group may be beneficial

• Regular follow-up: To assess treatment response and manage any side effects of therapy