Conference Coverage

Visual examinations yield signs to guide vitiligo treatment


 

EXPERT ANALYSIS FROM WCD2019

– Subtle signs beyond depigmentation alone can guide management of vitiligo, Michelle Rodrigues, MBBS, said at the World Congress of Dermatology.

Dr. Michelle Rodrigues, a dermatologist in private practice in Melbourne Kari Oakes/MDedge News

Dr. Michelle Rodrigues

Signs of high disease activity can be visually observed and, when found, can compel urgent treatment, Dr. Rodrigues said. “If we identify and understand these [signs, they] can change our management plan, and the patient’s outcomes ... picking these up quickly, getting the best response you can, can help our patients tremendously.”

To assess clinical signs of severity in vitiligo, “use the tools that you have in your practice – your dermatoscope, your Wood’s lamp.”

Showing an image of the leg of a patient with vitiligo, Dr. Rodrigues said, “I know this patient’s vitiligo is very, very active. Why?” Clues come when there are areas of hypopigmentation at the rim of lesions, with depigmentation at the center. The presence of pigmentation, hypopigmentation, and depigmentation within the same lesion indicates high disease activity. This finding is the trichrome sign, also called the “blurry borders” sign in some regions, said Dr. Rodrigues, a dermatologist in Melbourne and the founder of Chroma Dermatology, which specializes in treating pigment problems and diagnosing and managing skin conditions in patients with skin of color.

Next, Dr. Rodrigues said, look at hair growth within the vitiliginous area. “If you’re unable to see that clinically, it’s really important to get that dermatoscope onto the patient, and look within a patch, to see whether or not you can actually see white hairs or normal colored hairs,” she said. This finding will help to determine both treatment plan and prognosis, since leukotrichia is a marker of disease severity in vitiligo.

Be alert to Koebnerization, said Dr. Rodrigues; the presentation may be subtle. As an example, she shared an image of a patient with depigmented patches on the dorsum of each foot. It wasn’t until the patient removed her foot gear – rubber slide-type sandals with a single broad strap over the dorsum – that Dr. Rodrigues recognized that “there was clear Koebnerization from the constant friction as a result of the wearing of the shoes.

“This can also be seen when patients scratch themselves, as can be seen with the itch that vitiligo can sometimes cause,” she said.

She noted that about 10% of patients with vitiligo have pruritus as a prominent symptom. Here, she said, is where a Wood’s lamp can be helpful as well. “Sometimes we can’t appreciate the very, very subtle Koebnerization, especially in patients with lighter skin. Getting out that Wood’s lamp and looking at other areas of involvement is really important,” she said. Areas of high disease activity and signs of progression that might otherwise be missed will be more obvious under the ultraviolet light.

It’s important to look beyond the obvious patches of vitiligo to examine the surrounding skin. Searching for “confetti depigmentation” – tiny white dots of depigmentation scattered over the otherwise normally pigmented skin – also marks high disease activity. An area with these dots – each often only a few millimeters in diameter – is likely destined for rapid depigmentation unless aggressive treatment is started. “We know that without treating these areas there will be very, very rapid and aggressive depigmentation. And remember that in areas that have a paucity of hair follicles, it might be irreversible ... so recognizing these signs is absolutely critical.”

The final clue to highly active disease that’s likely to move quickly without intervention can be found at the border of a vitiligo lesion. Look for a fine rim of erythema and some scale, Dr. Rodrigues said. This sign is common, and often seen early in the disease course. When this erythematous region is biopsied, ”You’ll see an intense inflammatory response, with an interface dermatitis. Again, this tells us that the patient may have a poorer prognosis if we don’t commence treatment early on.”

As a final clinical tip, Dr. Rodrigues reminded attendees that when one sign of disease activity is seen, others are often present. A thorough clinical examination is needed to document aggressive disease. “Please make sure that if you find one, you’re looking for other signs of disease severity as well.”

Dr. Rodrigues reported that she had no disclosures relevant to her presentation.

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