Today's Symptom: progressive depigmentation

NEWS/ QUIZ

2 MIN QUIZ

Progressive depigmentation

A 23-year-old woman with Fitzpatrick Skin Type 3 presents with patches of depigmentation around her hairline, left and right temples, and lips. The patient first noticed small, depigmented spots forming on her hands, elbows, knees, feet, and shins around 12 months ago, but the spots became noticeably worse after a recent vacation at the beach. After extensive sun exposure, larger patches of pigment loss with dark edges formed in visible areas. The patient doesn’t often use sunscreen and says she didn’t think she needed to with her darker skin tone.

The patient is generally in good health. Her mother has rheumatoid arthritis (RA), and RA runs in the family, but the patient has never been diagnosed with RA. The patient reports being psychologically impacted by the loss of pigmentation. She is often self-conscious or embarrassed when in public and says the condition significantly disrupts her daily life.

What is the diagnosis?

Select the correct answer

A) Melasma

B) Postinflammatory hypopigmentation

C) Vitiligo

D) Tinea versicolor

E) Chemical Leukoderma

CORRECT

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INCORRECT

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Answer is: C

Vitiligo is the most common depigmentation disorder in the world.¹ It has an estimated prevalence as high as 2.3% of the total population and with varying prevalence in the US between 0.05% to 1.55%.² A recent large population-based study of 40,888 adults suggested that undiagnosed vitiligo may account for more than 40% of all vitiligo cases.² The disease is characterized by a loss of melanocytes in the epidermis which causes complete depigmentation in areas on the skin and results in “chalk-white” macules with distinct boundaries.^{1 3} Nonsegmental, generalized vitiligo is one of the most common types.⁴ It typically starts in smaller areas and manifests in depigmented patches of skin that occur bilaterally, often in a symmetrical fashion, and are distributed randomly over the entire body.⁴ Acrofacial vitiligo, another common subtype, typically forms first on the distal extremities, face, and lips before progressing to other areas of the body.⁴ All types of nonsegmental vitiligo can begin in childhood and adulthood.¹ These conditions often start in highly sensitive areas of the body that experience friction and pressure, or that are prone to trauma before becoming a progressive condition with occasional flareups that also affect surface areas of the skin.¹

The pathogenesis of nonsegmental vitiligo and its various subtypes is not fully elucidated; however, the medical consensus is that the mechanisms of progressive-type vitiligo are driven by autoimmune disorders with a host of multifactorial components, including genetics, autoimmune responses, oxidative stress, inflammatory responses, and biochemical defects, that result in the loss of functional melanocytes.^4,5 Other disorders that can cause pigmentation loss need to be ruled out first, but this patient’s family history of autoimmune disease, combined with the patient’s reported medical history and the rapid acceleration of the depigmented areas, indicates this patient may have a progressive form nonsegmental vitiligo.^1,4Oxidative stress, caused by increased sun exposure, may have contributed to the sudden progression of the disease. These areas are more pronounced in people with darker skin types, which can cause hyperpigmentation in some cases.^1,4 Nonsegmental vitiligo that spreads rapidly often requires urgent intervention to assess potential aggravating factors of the disease.^_1,4 Due to the increased psychosocial impacts and stigma associated with the disease, clinicians should consider offering additional psychological support to patients during evaluation.^1,4

References:

1. Taïeb A, Picardo M. Vitiligo. N Engl J Med. 2009;360(2):160-169. doi:10.1056/NEJMcp0804388

2. Gandhi K, Ezzedine K, Anastassopoulos KP, et al. Prevalence of vitiligo among adults in the United States. JAMA Dermatol. 2022;158(1):43-50. doi:10.1001/jamadermatol.2021.4724

3. Yaghoobi R, Omidian M, Bagherani N. Vitiligo: a review of the published work. J Dermatol. 2011;38(5):419-431. doi:10.1111/j.1346-8138.2010.01139.x

4. Bergqvist C, Ezzedine K. Vitiligo: A Review. Dermatology. 2020;236(6):571-592. doi:10.1159/000506103

5. Dell’Anna ML, Picardo M. A review and a new hypothesis for non-immunological pathogenetic mechanisms in vitiligo. Pigment Cell Res. 2006;19(5):406-411. doi:10.1111/j.1600-0749.2006.00333.x

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