Simple cases
Case 43
42-year-old man with white spots on face and backs of hands
History
How long have you had these spots?
For a few years.
Vitiligo usually starts in children or young adults.
Do they itch?
No.
Other differential diagnostic considerations include tinea versicolor and tinea corporis.
Do they bother you?
Yes; I hate them.
Few diseases impact as much on quality of life as this one.
Does anyone else in the family have spots like this?
Not that I know of.
This disease runs in families, but the exact genetic pattern is unclear.
Are you otherwise healthy?
Yes, except that I have had diabetes mellitus since childhood.
This disease is associated with diabetes mellitus, autoimmune thyroid disease, pernicious anemia and other autoimmune disorders. It can also be triggered by emotional stress and severe sunburns.
Have the spots changed over time?
Yes, some go away, others get larger, and new ones come.
This is the typical story in this disorder. Other congenital hypopigmented patches are permanent.
Lesion
Choose the right efflorescences:
No scales are seen or felt.
This is the perfect macule; normal skin but white.
An erosion is superficial skin defect, not seen here.
Hives are transient swellings.
Diagnosis
Choose the right diagnosis:
False. A café-au-lait macule is a hyperpigmented macule. Sometimes patients with extensive vitiligo will only have a few patches of normal skin left in a white field; these can resemble café-au-lait macules.
Very good. This is classic vitiligo, involving the acral areas (face and hands). The waxing and waning of lesions, the total depigmentation (as melanocytes are lost) and the extreme impact on the patient are typical.
A lentigo simplex is a tiny dark macule.
No, but a good try. Tine versicolor can present with dark or light macules, but they are scaly and the KOH examination is strikingly positive. Almost always limited to chest and back.
Therapy
Choose the right therapy(ies):
Probably the best treatment for small lesions.
The risk/benefit ratio is not acceptable.
The treatment of choice for adults, but not everyone achieves long-lasting relief.
This promising therapy is only carried out in specialized centers and is very expensive.
Since no perfect treatment is available, sometimes camouflage make-up is the best answer. Few patients are willing to accept this advice.
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