Analysis of symmetricity in the three different (sagittal, transverse and frontal) planes in generalized nonsegmental vitiligo.

BACKGROUND: Nonsegmental vitiligo is defined as being "often symmetrical", however, no work has tackled the point as to how valid it is to depend upon the concept of symmetricity in generalized nonsegmental vitiligo. AIMS: To investigate vitiligo symmetry, taking into account sites of predilection, the clinical characteristics of patients were studied. METHODS: This multicentric study included 712 nonsegmental vitiligo patients with 2876 examined lesions. Three models were drawn for each patient. Sagittal, transverse and frontal planes were drawn to divide the body into right/left, upper/lower and anterior/posterior halves respectively. Patients were examined by Wood's light and analyzed for symmetry. RESULTS: Bilateral involvement was present in 78% (P < 0.001). Studying the similarity of clinical involvement in the upper and lower body parts revealed that such similarity was present in 38%, with a significant positive association in some areas. Studying clinical similarity in the anteroposterior distribution pattern revealed a significant positive association in 11%. LIMITATIONS: Relatively low number of patients. CONCLUSIONS: We found significant bilateral symmetry in the lesions of 78% of vitiligo patients. Our work could aid in drawing the anticipated vitiligo map in patients with active disease, helping in increasing our understanding of the clinical behaviour of this disease.

Nonsegmental vitiligo follows Blaschko's lines and embryonic pigmentary segments.

BACKGROUND: Pathogenic mechanism that determines the localization of vitiligo patches and thus a patterned distribution in patients with nonsegmental vitiligo has remained poorly elucidated. A distributional similarity of the vitiligo patches with Blaschko's lines has been documented in patients with segmental vitiligo, both isolated segmental vitiligo and mixed vitiligo but never in cases of nonsegmental vitiligo. METHODS: Distribution of nonsegmental vitiligo patches on face and neck regions was assessed and compared with Blaschko's lines and also with embryonic pigmentary segments on the face. RESULTS: This study has documented distributional similarity of the nonsegmental vitiligo patches on face and neck with Blaschko's lines and the "embryonic pigmentary segments" among 154 (58.6%) cases. Patches around the palpebral and other fissures like periorbital, perinasal, perioral, and periaural were more common. In addition to the vitiligo patches, the spared areas were also found to respect the embryonic segmental outlines and follow the Blaschko's lines. CONCLUSION: Distributional pattern of the individual nonsegmental vitiligo patches along the Blaschko's lines and embryonic pigmentary segments suggests that mosaicism might control the susceptibility to the disease process in a patterned manner. LIMITATION: No genetic testing could be performed to confirm the hypothesis. Evaluation of nonsegmental vitiligo was done only on the face and neck areas.

A cross-sectional study of spontaneous repigmentation in vitiligo.

BACKGROUND: Spontaneous regression is well documented in several chronic skin diseases such as psoriasis, alopecia areata, and atopic dermatitis. However, information on vitiligo is scarce. AIMS: We studied the frequency, extent, and factors affecting spontaneous repigmentation in vitiligo. METHODS: A cross-sectional descriptive study was undertaken in 167 patients with vitiligo with an emphasis on history of spontaneous repigmentation. Where available, photographs documenting spontaneous repigmentation were also obtained. Repigmentation was defined as spontaneous if it occurred when the patient was off treatment for at least 3 consecutive months. RESULTS: Spontaneous repigmentation occurred in 36 (21.5%) patients with complete repigmentation in 6 (3.6%) patients. The extent varied from 0.5% to 100% (mean, 35.4 ± 37.9%) of vitiliginous skin. It occurred after 3 months to 47 years (mean, 8.7 ± 9.5 years) of onset of vitiligo and persisted for 2 months to 27 years (mean, 4.4 ± 6.2 years). Diffuse repigmentation was the most common pattern observed in 20 (55.6%) patients and there was a good color match in 26 (72.2%) patients. Likelihood of spontaneous repigmentation was 3.5 times greater in patients with more than 3 years of stable disease (P = 0.001). LIMITATIONS: The chief limitation was the dependence on patient recall for the data, except when documented by images. CONCLUSION: Spontaneous repigmentation occurs in one-fifth of patients with vitiligo. In some patients, the repigmentation is clinically significant and long-lasting. Considering its frequency and extent, spontaneous repigmentation should be taken into account both when evaluating novel interventions and counselling patients about the course of the disease.

Vitiligo on black skin: epidemiological and clinical aspects in dermatology, Cotonou (Benin).

BACKGROUND: Vitiligo is unsightly on darkly pigmented skin and leads important stigmatization because of the mix-up with leprosy. PATIENTS AND METHODS: We analyzed retrospectively the epidemiological and clinical patterns of vitiligo on darkly pigmented skin between 1988 and 2008 in the Department of Dermatology in Cotonou (Benin). The diagnosis was made based on the clinical characteristics of vitiligo. RESULTS: Two hundred and forty-six patients were seen, representing 0.9% of new consultations. The gender ratio was 1 : 1, and the mean age of patients was 25.9 years. The mean duration of the lesions was 30.9 months. Among the 246 patients, an associated pathology was found in 26% of cases. These included atopy (23.2%), diabetes (1.6%), thyroid disease (0.8%), and alopecia (0.4%). A family history of vitiligo was present in 1.2% of cases. The sites of the lesions were in descending order of frequency: head (60.6%), lower limbs (40.2%), upper limbs (33.3%), trunk (22.4%), genitals (13.0%), and neck (8.9%). On the head, the most common sites affected were the lips (65.1%), cheek (20.8%), and ears (16.8%). According to the different clinical forms, vitiligo was achromic (76%), speckled (12.6%), and trichromic (11.4%). Vitiligo vulgaris was the commonest form of the disease (52.4%), followed by localized vitiligo (36.2%), segmental vitiligo (9.8%), and vitiligo universalis (1.6%). Triggering factors were identified in 4.5% of patients. CONCLUSION: Our survey shows that the patterns of vitiligo are similar to that reported from other African countries with a few distinguishing particularities.

The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo.

BACKGROUND: Early lesions of vitiligo can be confused with various other causes of hypopigmentation and depigmentation. Few workers have utilized dermoscopy for the diagnosis of evolving lesions of vitiligo. AIM: To analyze the dermoscopic findings of evolving lesions in diagnosed cases of vitiligo and to correlate them histopathologically. METHODS: Dermoscopy of evolving lesions in 30 diagnosed cases of vitiligo was performed using both polarized light and ultraviolet light. RESULT: On polarized light examination, the pigmentary network was found to be reduced in 12 (40%) of 30 patients, absent in 9 (30%), and reversed in 6 (20%) patients; 2 patients (6.7%) showed perifollicular hyperpigmentation and 1 (3.3%) had perilesional hyperpigmentation. A diffuse white glow was demonstrable in 27 (90%) of 30 patients on ultraviolet light examination. Melanocytes were either reduced in number or absent in 12 (40%) of 30 patients on histopathology. CONCLUSION: Pigmentary network changes, and perifollicular and perilesional hyperpigmentation on polarized light examination, and a diffuse white glow on ultraviolet light examination were noted in evolving vitiligo lesions. Histopathological examination was comparatively less reliable. Dermoscopy appears to be better than routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy.

Tumor of follicular infundibulum: an unsuspected cause of macular hypopigmentation.

We present three cases of a rare eruptive variant of tumor of follicular infundibulum. Two patients presented with hypopigmented macules. The clinical differential diagnoses considered in these two cases were vitiligo, lichen sclerosus et atrophicus, and idiopathic guttate hypomelanosis. In the third case, the lesions were hypopigmented flat topped maculo-papules diagnosed clinically as verruca plana. In all three cases, the histopathological features of plate like growth of pale keratinocytes connected to the epidermis and peritumoral condensation of elastic fibers were diagnostic. Although no satisfactory treatment is available, the exclusion of other clinical differential diagnosis particularly vitiligo with its psychosocial implications underscores the importance of skin biopsy.

Randomized controlled study to evaluate the effectiveness of dexamethasone oral minipulse therapy versus oral minocycline in patients with active vitiligo vulgaris.

BACKGROUND: Oral minocycline has been recently shown to halt disease progression in active vitiligo. AIMS: The present study was planned to compare the efficacy and tolerability of oral minocycline with oral mini pulse (OMP) corticosteroids in active vitiligo. METHODS: A total of 50 patients with actively spreading vitiligo were randomized to receive either minocycline 100 mg/day (Group I-25 patients) or OMP 2.5 mg dexamethasone on 2 consecutive days in a week (Group II-25 patients) for 6 months. These were followed-up at every 2 weeks interval. Mean vitiligo disease activity score (VIDA) and mean Vitiligo Area Scoring Index (VASI) were assessed in all patients in addition to the photographic comparison before and after treatment. RESULTS: Both groups showed a significant decrease in VIDA from 4.0 to 1.64±0.86 (P<0.001) in Group I and from 4.0 to 1.68±0.69 (P<0.001) in Group II. However, the difference between the mean VIDA scores in the two groups was not statistically significant (P=0.60) at the end of treatment period. The mean VASI declined from 1.71±1.45 to 1.52±1.43 Group I (P=0.06) and from 1.39±1.31 to 1.17±1.34 in Group II (P=0.05). The difference between VASI in Group I and II was not significant at the end of 24 weeks of treatment (P=0.11). CONCLUSION: Both dexamethasone OMP and oral minocycline are effective drugs for managing the arrest of disease activity in vitiligo.

Clinicopathological correlation of acquired hypopigmentary disorders.

Acquired hypopigmentary disorders comprise a significant group of disorders that affect Indians and Asians. The pigment disturbance in darker skin individuals can be very distressing to the patient and the family. These disorders cover a wide array of pathologies including infections, autoimmune processes, lymphoproliferative disorders, and sclerosing diseases. Histological diagnosis is particularly important because treatments for these diseases are varied and specific. This review will focus on histopathological diagnosis based on clinicopathological correlation for commonly encountered disorders such as leprosy, vitiligo, lichen sclerosus, pityriasis alba (PA), and pityriasis versicolor (PV). Atypical or uncommon clinical presentation of classic diseases such as hypopigmented mycosis fungoides (HMF) and hypopigmented sarcoidosis are also included.

A descriptive study to characterize segmental vitiligo.

BACKGROUND: Segmental vitiligo is a small but unique subset of vitiligo requiring due importance due to its lack of response to medical treatment but excellent response to surgical treatment. Characterization of the pattern of segmental vitiligo will also help to understand the pathogenesis of the disease. AIM: To characterize clinically the features of segmental vitiligo, a cross-sectional clinical study at dermatology outpatient department at AIIMS was carried out. METHODS: Consecutive 188 patients were evaluated to characterize the clinical features of segmental vitiligo by detailed history, clinical examination, and photography. Frequency of each clinical feature was calculated. RESULTS: Certain features such as early onset, initial progression of disease followed by stability, blaschkoid pattern, irregular margins, leucotrichia within and beyond the vitiligo lesion, and islands of pigmented macules within the vitiligo lesion were found to be characteristic of the disease. CONCLUSIONS: A combination of various features such as early onset of disease, blaschkoid pattern, irregular margins, leucotrichia, and islands of pigmented macules within the vitiligo lesion are helpful in diagnosis of the disease.

Topical treatment in vitiligo and the potential uses of new drug delivery systems.

Vitiligo is a psychologically devastating condition. Topical therapy is employed as first-line treatment in localized vitiligo. Currently, several topical agents are available in many forms viz. methoxsalen (solution and cream), trioxsalen (solution), corticosteroids (gel, cream, ointment and solution) and calcineurin inhibitors (ointment and cream). Although topical therapy has an important position in vitiligo treatment, side-effects or poor efficacy affect their utility and patient compliance. Novel drug delivery strategies can play a pivotal role in improving the topical delivery of various drugs by enhancing their epidermal localization with a concomitant reduction in their side-effects and improving their effectiveness. The current review emphasizes the potential of various phospholipid based carriers viz. liposomes, transferosomes, ethosomes, lipid emulsions, solid lipid nanoparticles and organogels in optimizing and enhancing the topical delivery of anti-vitiligo agents, whilst reducing the side effects of drugs commonly used in its topical treatment.

Topical placental extract: does it increase the efficacy of narrowband UVB therapy in vitiligo?

BACKGROUND: Narrowband UVB therapy is presently one of the most effective therapies for generalized vitiligo. Many topical agents have been used in combination with narrowband UVB therapy to increase its efficacy in causing repigmentation in vitiligo. Placental extract is used topically usually in combination with sun exposure to cause repigmentation of vitiligo lesions. AIMS: The present study aims to study whether the efficacy of narrowband UVB therapy would be enhanced by addition of topical placental extract to the treatment regimen. METHODS: Ninety patients with vitiligo having more or less bilaterally symmetrical lesions on the face, trunk or limbs and receiving narrowband UVB therapy were enrolled for the study and instructed to apply topical placental extract (placentrex) lotion on their vitiligo lesions on the right side of the body. The other side of the body received narrowband UVB therapy alone and served as the control side. The extent of repigmentation achieved was assessed by VASI scoring and compared between the symmetrical lesions present on the two sides at monthly intervals and at the end of study period. RESULTS: Seventy-eight patients with 218 symmetrically distributed lesions, excluding those present on the hands or feet, were evaluated for study results at the end of treatment period. The time to onset of repigmentation as well as the mean NB-UVB dosage required was the same on the two sides. The mean repigmentation achieved was 63% (VASI score of 3.69) on the right (placental extract) sided lesions in comparison with 62% (VASI score of 3.60) on the left (control) sided lesions. Greater than 90% repigmentation was achieved in 70 symmetrical lesions in 24 patients. Of these 70 lesions, 39 were located on the right side of the body while 31 belonged to the left side of the body. CONCLUSIONS: Addition of the topical placental extract was seen to have a modest but a statistically insignificant effect on the efficacy of NB-UVB therapy in causing repigmentation in vitiligo.