Guideline for the Diagnosis and Management of Vitiligo

D.J. Gawkrodger; A.D. Ormerod; L. Shaw; I. Mauri-Sole; M.E. Whitton; M.J. Watts; A.V. Anstey; J. Ingham; K. Young

Disclosures

The British Journal of Dermatology. 2008;159(5):1051-1076. 

In This Article

What Symptoms and Signs are Suggestive of Vitiligo?

Introduction

Vitiligo vulgaris/nonsegmental vitiligo is an acquired chronic depigmentation disorder characterized by white patches. These are often symmetrical and usually increase in size with time. This corresponds with a substantial loss of functioning epidermal and, sometimes, hair follicle melanocytes. Segmental vitiligo is a variant of vitiligo confined to one unilateral segment. One unique segment is involved in most patients but two or more segments on the same or opposite sides may be involved or depigmentation may follow a dermatome distribution or Blaschko's lines. Depigmenting or hypopigmenting skin diseases that are considered in the differential diagnosis of vitiligo are listed in Table 3 .

In symmetrical vitiligo, the commonest sites to be affected are the fingers and wrists, the axillae and groins and the body orifices such as the mouth, eyes and genitalia. As the pigment cells are destroyed, sometimes a 'trichrome' appearance of a white centre with an intermediate, pale area around it is found. In vitiligo skin there is no surface change and usually no redness. Very occasionally, inflammation is seen at the advancing edge of a vitiligo macule. Vitiligo can affect melanocytes in the hair roots, resulting in white eyelashes and white hair within the pale skin patches. Depigmentation can affect mucosal areas such as in the mouth. This can be prominent in darkly pigmented people.

The three main diseases that can be mistaken for vitiligo are tinea (pityriasis) versicolor, piebaldism and guttate hypomelanosis. Tinea versicolor is a superficial yeast infection that can cause loss of pigment in darker skinned individuals. It presents as pale macules typically on the upper trunk and chest, with a fine dry surface scale. Piebaldism is an autosomal dominant disease in which there is absence of melanocytes from the affected areas of the skin. It usually presents at birth with depigmented areas that are usually near the mid-line on the front, including a forelock of white hair. In idiopathic guttate hypomelanosis, multiple small, white macules are noted, mostly on the trunk or on sun-exposed parts of the limbs. When vitiligo affects only the genital areas, it can be difficult to exclude lichen sclerosus, which sometimes can coexist with vitiligo.

Patients with vitiligo often develop autoimmune thyroid disease or other autoimmune diseases and a history of autoimmune disease in a family member is obtained in 32% of patients.[3] In one series of 41 adults, a history of autoimmune thyroid disease was found in 14 (34%), suggesting that screening for abnormal thyroid function or the presence of autoantibodies to thyroid antigens may be helpful in the management of adults with vitiligo.[3]

As part of the initial assessment, the patient's skin type should be noted. The definitions are shown in Table 4 .

Methods

Evidence for this question came from consensus within the GDG.

Evidence Statements

General evidence on the diagnosis of vitiligo was considered and a consensus view was made by the group. This specific question has been addressed recently by Taieb and Picardo,[5] who undertook an assessment and evaluation of vitiligo, including a definition of the disease, in a consensus group (level of evidence 4).

Evidence to Recommendations

The group found that, in many cases, the diagnosis of vitiligo is straightforward but some cases present a difficult diagnostic challenge.

Recommendations

  1. Where vitiligo is classical, as in the symmetrical types, the diagnosis is straightforward and can be made with confidence in primary care

    Grade of recommendation D
    Level of evidence 4

     

  2. In patients with an atypical presentation, diagnosis is more difficult and referral for expert assessment by a dermatologist is recommended.

    Grade of recommendation D
    Level of evidence 4

     

  3. In adults with vitiligo, a blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid disease in patients with vitiligo.

    Grade of recommendation D
    Level of evidence 3

     

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