Vitiligo (Acquired Depigmenting Disorder) 

Vitiligo is a chronic, acquired disorder caused by the autoimmune destruction and loss of melanocytes, resulting in characteristic milky-white patches. The disorder is much more visibly obvious and distressing in skin of colour due to the stark contrast.

• Onset & Course

Most often starts in childhood/teen years or early adulthood. Course is unpredictable (periods of spread and stability).

• Symptoms

Usually asymptomatic (no pain/itch). Main complaint is the change in appearance and psychosocial impact.

• Distribution

Common initial sites: Face (perioral, periocular), Hands/feet (acral areas), elbows/knees, and around body orifices/genitals.

• Patterns

Generalized (Non-segmental): Bilateral, symmetrical patches (most common). 

Segmental: Unilateral, often dermatomal (tends to stabilize earlier).

• Associated Factors

Koebner phenomenon: Lesions appearing at sites of repeated trauma, pressure, or friction.

• Autoimmune Links

Strong personal or family history of Thyroid disease (Hashimoto's/Graves'), Type 1 Diabetes, Pernicious Anaemia, and Alopecia Areata.

• Psychosocial History (Crucial in SOC):

The stigma is severe due to the marked contrast of bright white against dark skin, leading to high rates of anxiety, depression, and social withdrawal.

• Primary Lesions: Well-demarcated, depigmented macules/patches that are milky- or chalk-white (leukoderma). The skin texture is normal (not scaly or atrophic).

• Distribution Check: Systematically check the face (especially around orifices), hands, feet, elbows, knees (bony prominences), axillae, groin, and hair-bearing areas.

• Leukotrichia (Poliosis): Presence of white hair on the scalp, eyebrows, or body hair within the patch, which indicates deep follicular melanocyte loss and may predict poorer repigmentation.

• Special Signs in SOC: Depigmented areas may be surrounded by hyperpigmented rims, making the contrast even more obvious.

• Bedside Tool: Wood’s lamp is invaluable; vitiligo lesions show brilliant, bright white fluorescence, making it essential for mapping the true extent, especially in light skin or subtle lesions in SOC.

The goals are to stop progression, induce repigmentation, protect depigmented skin, and support psychological well-being.

1. General & Supportive Measures

• Sun Protection (CRITICAL): Depigmented skin burns easily and cannot tan. Advise Broad-spectrum SPF 30–50+ daily to all exposed areas. In SOC, this also reduces the contrast between the white patches and the surrounding tanned normal skin.

• Cosmetic Camouflage: Skin-matching make-up, self-tanning products, or micropigmentation (medical tattooing) for stable areas are extremely valuable for managing stigma in darker skin.

• Psychological Support: Screen for and address anxiety/depression; offer counselling or support groups.

2. Medical Therapies

• Topical Corticosteroids:

  • Medium–high potency for limited periods; lower potency for face/flexures.

  • Caution in SOC: Risk of atrophy, telangiectasia, and striae is very visible; limit duration and monitor closely.

• Topical Calcineurin Inhibitors:

  • (Tacrolimus/Pimecrolimus) Preferred for face, neck, eyelids, and intertriginous areas to avoid steroid atrophy.

  • Excellent safety profile for face/flexures; often combined with phototherapy.

• Topical Ruxolitinib (1.5% cream):

  • JAK inhibitor cream; established option for limited non-segmental vitiligo.

  • Good data for facial vitiligo; a newer, targeted treatment.

• Narrowband UVB (NB-UVB):

  • First-line for more extensive disease. Given 2–3 times per week. Immunomodulates and stimulates melanocytes.

  • Very effective on face and trunk; requires careful dosing in SOC to avoid burns and post-inflammatory hyperpigmentation of normal skin.

• Systemic Steroids:

  • Short-course/mini-pulse oral steroids (e.g., weekend regimens) used by specialists to stabilise rapidly progressive vitiligo..

  • Used only for acute, active spread.

3. Surgical Options

Used for stable vitiligo (no new spread for ge 6–12 months) that has failed medical therapy.

• Procedures: Suction blister grafts, Punch grafting, Non-cultured melanocyte suspensions.

• Target: Localized patches, segmental vitiligo, and areas that rarely repigment medically (e.g., acral areas).

• SOC Note: Surgical results can be excellent but carry a risk of colour mismatch and koebnerisation (new vitiligo at the surgical site).

4. Depigmentation Therapy

Topical Monobenzyl Ether of Hydroquinone (Monobenzone) is reserved for very extensive vitiligo in darker skin where only small islands of pigment remain. This permanently removes the remaining pigment to create a uniform white appearance.

Skinsight – Vitiligo: https://skinsight.com/skin-conditions/vitiligo/

NCBI Bookshelf – Vitiligo (Jan & Masood, 2023): https://www.ncbi.nlm.nih.gov/books/NBK559149/

DermNet NZ – Vitiligo: https://dermnetnz.org/topics/vitiligo