FFinalistSouthampton · 2027
Dermatology
AKT · Dermatology/Inflammatory & papulosquamous

Vitiligo

Autoimmune destruction of melanocytes

Overview

An acquired autoimmune disorder in which melanocytes are destroyed, producing well-demarcated patches of complete DEPIGMENTATION (stark white). Non-segmental (symmetrical, commonest, associated with other autoimmune disease) and segmental (unilateral, dermatomal, younger). The discriminator from pityriasis versicolor is the absence of scale and the total pigment loss.

Recognise

  • Well-demarcated, completely white (depigmented) macules/patches, often symmetrical (hands, perioral, periocular, genitalia)
  • Koebner phenomenon (depigmentation at sites of trauma); leukotrichia (white hairs within patches)
  • Associations: autoimmune thyroid disease, type 1 diabetes, pernicious anaemia, Addison disease, alopecia areata

Red flags

  • Major psychosocial impact (especially in skin of colour); depigmented skin burns easily (sun protection)

Differentials & how to tell them apart

Pityriasis versicolorHYPO-pigmented (not depigmented) with fine scale on the trunk, yeast — vitiligo is stark white with no scale
Pityriasis albaill-defined hypopigmented patches in atopic children, fine scale
Post-inflammatory hypopigmentationfollows a prior dermatosis, partial pigment loss
Tuberous sclerosis (ash-leaf macules)congenital hypopigmented macules + other features

Clinical image

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Vitiligo — clinical imagesDermNet

Investigations

Clinical; Wood lamp accentuates depigmentation (bright blue-white). Screen for associated autoimmune disease (especially thyroid function/antibodies).

Management

Sun protection + a topical corticosteroid or calcineurin inhibitor to attempt repigmentation

  1. 1Sun protection, cosmetic camouflage, and psychological support for all. Limited disease → a potent topical corticosteroid (trunk/limbs) or a topical calcineurin inhibitor (face/eyelids) to attempt repigmentation. Screen for associated autoimmune disease.Gate: Vitiligo is DEPIGMENTATION without scale — distinguish it from pityriasis versicolor (hypopigmented WITH fine scale, treated with an antifungal); the wrong label leads to the wrong treatment
  2. 2Extensive/unresponsive → narrowband UVB phototherapy; refractory → specialist options. Lifelong sun protection of depigmented skin.
Topical corticosteroid or calcineurin inhibitor — first-line to try to repigment limited disease (calcineurin inhibitor for face/eyelids)
Phototherapy (narrowband UVB) — extensive or unresponsive disease
Sun protection + camouflage — protect depigmented skin and address cosmesis

Key points

Stark-white + no scale + symmetrical = vitiligo; check the thyroid. The depigmented skin has no melanin protection, so it sunburns readily.

Monitor & prognosis

Repigmentation response; associated autoimmune screen.

Variable and unpredictable; repigmentation is slow and often incomplete.

Source: NICE CKS Vitiligo; BAD guideline