Vitiligo is a common acquired skin condition in which epidermal melanocytes are lost,
leading to complete loss of pigment, i.e. depigmentation, rather than hypopigmentation
(partial pigment loss). Average age of onset is 20 years, but vitiligo may commence in
childhood. Up to a third report a family history of vitiligo. Psychological impact may be
profound, particularly in individuals with darkly pigmented skin. Vitiligo is associated
with various autoimmune diseases, including thyroid disease.
What should I look for?
• Smooth (no scale) white (depigmented) macules and/or patches.
• Are you sure that the pale skin is abnormal? Might it be possible that the rest of the skin
is hyperpigmented? For example, melasma may be confused with facial vitiligo, when
hyperpigmented facial lesions surround normal, but pale-looking, skin.
• Pigment loss may be non-segmental (localized, generalized, or acrofacial) or segmental
(unilateral following a dermatomal distribution; one or more segments may be affected).
• Non-segmental: common on fingers, wrists, axillae, groins, perioral and periorbital skin,
and genitalia. Check sites sensitive to pressure, friction, or trauma (Koebner
phenomenon), e.g. belt-line, beneath the watch strap.
• Rims of depigmented skin around melanocytic naevi—halo naevi— are ten times
commoner in vitiligo. The melanocytic naevi regress, leaving depigmented macules.
• Genital vitiligo—the patient may be too embarrassed to report the vitiligo. Lichen
sclerosus may coexist with genital vitiligo.
• White hairs on eyelashes and scalp, as well as white body hair within areas of vitiligo
(leukotrichia).
• A ‘trichrome’ appearance with a white depigmented centre, a surrounding light brown
zone of varying width, and dark brown normal skin. Seen rarely in developing patches in
dark skin.
• Inflammation at the advancing edge of a macule—uncommon.
• Mucosae may be affected in patients with dark skin.
What should I do?
• Exclude other causes of pigment loss.
• Assess the psychological impact of vitiligo using DLQI.
• Check thyroid function (high prevalence of thyroid antibodies).
• Examine the skin under Wood light to confirm diagnosis (the depigmented skin appears
bright white), and determine the extent of disease, particularly in pale skin.
• Record the extent of vitiligo with photographs.
• Management is challenging—sun protection is essential.