IS IT VITILIGO? KEY INSIGHTS FOR DIFFERENTIAL DIAGNOSIS

Vitiligo is a relatively common acquired disorder of pigmentation characterized by the development of well-defined, depigmented macules on the skin. Biopsies of lesional skin revealed loss of epidermal melanocytes. Lesions may occur in a localized or generalized distribution and may coalesce into large, depigmented areas. Given the contrast between the white areas and normal skin, the disease is most disfiguring in individuals with darkly pigmented skin. It has a profound impact on the quality of life of both children and adults. Patients with vitiligo often experience stigmatization, social isolation, and low self-esteem. Vitiligo typically presents with asymptomatic depigmented macules and patches, milk or chalk white, that lack clinical signs of inflammation (Figure 1).¹

DIFFERENTIAL DIAGNOSIS OF VITILIGO

Many common and uncommon disorders are characterized by areas of depigmentation that may mimic vitiligo. ¹

Nevus depigmentosus

TNevus depigmentosus presents as a hypopigmented, quasi-dermatomal lesion of
the left forehead¹

Distinguishing characteristics: Circumscribed, segmental area of depigmentation or hypopigmentation; a form of cutaneous mosaicism, caused by an altered clone of melanocytes with a decreased ability to produce melanin, abnormal melanosomes, and inability to transfer pigment to keratinocytes¹

Pityriasis alba

Hypopigmented macules are present on the face of this young patient with
pityriasis alba¹

Distinguishing characteristics: Characterized by hypopigmented, mildly scaling
patches common on sun-exposed areas.¹

Idiopathic guttate hypomelanosis

Multiple small, hypopigmented macules on a background of sun-induced skin
damage are present on the arm¹

Distinguishing characteristics: Characterized by multiple small, asymptomatic,
porcelain-white macules primarily on the sun-exposed areas of the limbs.¹

Tinea (pityriasis) versicolor

Multiple hypopigmented macules on the neck, shoulder, and chest¹

Distinguishing characteristics: Presents as pale macules typically located on the
upper trunk and chest, with a ne, dry surface scale. Involved areas often fluoresce a
golden yellow when examined under a Wood’s lamp.¹

Vitiligo can present with diverse clinical manifestations. While generalized vitiligo is relatively easy to diagnose, identifying early-stage disease can be challenging, as it may resemble other forms of hypopigmentation and depigmentation. A thorough understanding of vitiligo’s various presentations is essential for accurate diagnosis and treatment. Early-stage vitiligo can
resemble other hypopigmented or depigmented skin disorders, making differentiation crucial. Recognizing signs of disease activity helps optimize treatment selection and predict prognosis.²

References:

1. Grimes PE, Tsao H, Alexis AF, et al. Vitiligo: Pathogenesis, clinical features and diagnosis. Available at
  https://pearlgrimesmd.com/wp-content/uploads/2023/09/Vitiligo_-Pathogenesis-clinical-features-and-diagnosis-UpToDate.pdf. Accessed on 17 December 2024.
2. Goh BK, Pandya AG. Presentations, signs of activity, and differential diagnosis of vitiligo. Dermatol Clin. 2017;35(2):135–144.

Expert opinion – Dr Manjunath JV

This article focuses on the differential diagnosis of vitiligo, a common pigmentary disorder. It provides guidance on distinguishing vitiligo from other causes of white patches, which is essential for determining appropriate treatment. A Wood’s lamp examination is a simple yet effective tool for identifying vitiligo lesions. In uncertain cases, a skin biopsy may be performed, as discussed in the article. Accurate diagnosis not only guides therapy but also plays a key role in alleviating the anxiety and social stigma often associated with the condition.