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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 1  |  Issue : 1  |  Page : 28-30

Novel dermoscopic findings of perifollicular depigmentation and evolving leukotrichia in areas of clinically unaltered pigmentation: An early predictive sign of impending vitiligo!


1 The Skin Clinic and Research Centre, Gurgaon, Haryana, India
2 Departments of Dermatology and STD,Maulana Azad Medical College and LN Hospital, New Delhi, India
3 Departments of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, New Delhi, India

Date of Web Publication26-Jun-2014

Correspondence Address:
Sidharth Sonthalia
The Skin Clinic and Research Centre, C 2246 (Ground Floor), 'Suhridaya,' Sushant Lok 1, Block C, Gurgaon 122 009, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5847.135438

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  Abstract 

Dermoscopy is a simple noninvasive technique that aids in the diagnosis of disorders of hyperpigmentation. However, its role in diagnosis of vitiligo is relatively infantile with only few published reports. We report the case of a young man who sought consultation for diffuse facial hyperpigmentation suggestive of photomelanosis. Dermoscopy from a pigmented forehead lesion revealed perifollicular depigmentation (PFD) without leukotrichia, in a background of reticular hyperpigmentation. There was no clinical evidence or past history of vitiligo. Family history of early-onset recalcitrant vitiligo was positive in mother. The patient developed rapidly progressive vitiligo with leukotrichia within the next 4 weeks. Dermoscopic re-evaluation from the same region revealed a reduction in hyperpigmentation, widening of PFD, leukotrichia of few hairs and rarefaction and pigment reduction of other hair shafts suggestive of impending leukotrichia. He developed the treatment-refractory disease over the next 6-8 months. Therefore, though perifollicular pigmentation is preserved in the lesional skin in most cases of vitiligo, PFD seen on dermoscopy may paradoxically indicate impending vitiligo especially in a high-risk case e.g. positive family history. This case has been documented to highlight the role of dermoscopy and the sign of PFD in early detection of vitiligo.

Keywords: Depigmentation, dermoscopy, leukotrichia, perifollicular, vitiligo


How to cite this article:
Sonthalia S, Sarkar R, Arora R. Novel dermoscopic findings of perifollicular depigmentation and evolving leukotrichia in areas of clinically unaltered pigmentation: An early predictive sign of impending vitiligo!. Pigment Int 2014;1:28-30

How to cite this URL:
Sonthalia S, Sarkar R, Arora R. Novel dermoscopic findings of perifollicular depigmentation and evolving leukotrichia in areas of clinically unaltered pigmentation: An early predictive sign of impending vitiligo!. Pigment Int [serial online] 2014 [cited 2019 Oct 15];1:28-30. Available from: http://www.pigmentinternational.com/text.asp?2014/1/1/28/135438


  Introduction Top


Vitiligo is one of the most common disorders of hypopigmentation with both genetic and environmental factors contributing to its incompletely understood etiopathogenesis. Diagnosis is primarily clinical, seldom requiring any investigative techniques. Dermoscopy is usually employed to examine melanomas and other pigmented lesions. However, it has recently been used in the early diagnosis of localized vitiligo. A pattern of depigmentation with residual reservoirs of perifollicular pigment is considered characteristic signifying focally active or repigmenting vitiligo. [1] Dermoscopy has also been used for evaluation of treatment response of vitiligo, especially in segmental variety. [2] We report the case of a young man who presented with facial hyperpigmentation, but incidental dermoscopic finding of perifollicular depigmentation (PFD) translated into an early indicator of impending vitiligo, confirmed on the occurrence of progressive vitiligo within the next 4 weeks.


  Case Report Top


A 21-year-old male patient presented with diffuse hyperpigmentation over the forehead, cheeks and neck of 3 months duration. He had a history of chronic unimpeded occupational sun-exposure. There was no itch or redness. He had no preceding history of any oral, topical medication or any history of topical plants and ayurvedic preparations application. On examination, irregular patchy hyperpigmentation with indistinct margins involving the forehead and malar region was visible. The clinical appearance did not suggest melasma, or any other distinctive facial hyperpigmentary condition. Scalp examination revealed mild seborrhea. A clinical diagnosis of photomelanosis with seborrhea was made. Examination was followed-up with hand-held dermoscopy (EScope; Nakoda Marketing, Mumbai, Maharashtra, India) of a pigmented spot over the right side of the forehead. To our surprise, the dermoscopic images not only revealed reticular hyperpigmentation, but also conspicuous PFD without leukotrichia [Figure 1]a]. However, there was no clinical evidence of any hypo- or de-pigmented macules anywhere over the face, lips or elsewhere suggestive of vitiligo. On taking further history, the patient denied any past history of vitiligo or any other hypopigmentary condition. Interestingly, family history of early-onset persistent vitiligo refractory to multiple treatments was positive in his mother. His mother was not available for evaluation being an outstation resident. The patient was started on sunscreens, ciclopirox (1%) anti-dandruff shampoo and oral-antioxidant capsules. A depigmenting cream was avoided at that point of time. On review after 4 weeks, he had developed multiple normoesthetic nonitchy and nonscaly hypo- and de-pigmented macules (with trichrome pattern and leukotrichia at places) over the face, neck, upper chest, and back, characteristic of vitiligo [Figure 2]a and b]. Lips and other mucosae were spared. There was no seborrhea and 10% KOH smear from the lesions was negative for fungal elements. The lesions had developed and spread within a week. Repeat dermoscopic evaluation from the same forehead spot revealed a reduction in hyperpigmentation along with more conspicuous and widened areas of PFD. While vellus hairs revealed obvious leukotrichia, terminal hair shafts displayed prominent rarefaction and pigment reduction, suggestive of impending leukotrichia [Figure 1]b]. Dermoscopy from established vitiligo lesions revealed pronounced depigmentation and leukotrichia. The patient was suggested laboratory evaluation including complete blood count, thyroid function tests, plasma glucose levels, anti-thyroid peroxidase antibodies, serum vitamin B 12 levels, and anti-parietal cell antibodies to rule out other auto-immune conditions. He was started on topical tacrolimus (0.1%) ointment twice a day, continued on oral anti-oxidants and called for review in 2 weeks or earlier if lesions increased in number. Unfortunately, he was lost to clinical follow-up, but telephonically informed us after 8 months about further worsening of his disease and lack of response to at least 6 months of oral steroids and topical PUVASOL, prescribed by another dermatologist.
Figure 1: (a) Dermoscopy from forehead area with photomelanosis showing reticular hyperpigmentation in the interfollicular regions (white arrow) and perifollicular depigmentation (black arrows) (original magnification, ×250), (b) Repeat dermoscopy from the same area showing reduction in hyperpigmentation in the interfollicular regions (solid white arrow), leukotrichia (solid black arrow) and rarefaction and pigment reduction in other hair shafts (solid white arrow with black outline). Perifollicular depigmentation has widened (original magnification, ×250)

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Figure 2: (a) Forehead lesions revealing patchy tanned areas of photomelanosis (white arrow) (from where dermoscopy was done on both occasions), and established depigmented macules of vitiligo, (b) Multiple depigmented lesions of vitiligo over the back, forming trichrome pattern at places (black arrow)

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  Discussion Top


The diagnosis of vitiligo is primarily clinical without the need of any diagnostic tools. Presence of clinically evident leukotrichia further enhances diagnostic accuracy and also signifies poorer prognosis especially in segmental vitiligo. [2],[3] However, noninvasive tests are helpful: (1) When diagnosis is in doubt e.g. in evolving disease, and (2) for objective evaluation of treatment response. Three techniques are helpful for this purpose - digital photography with computerized image analysis, dermoscopy, and reflectance confocal microscopy. [1],[2],[3],[4],[5]

Dermoscopy (digital epiluminescence microscopy or "dermatoscopy") magnifies the clinical image manifold and allows appreciation of subtle features invisible to the naked eye. This noninvasive and easy-to-use technique may be performed with a hand-held instrument or by video dermoscopy. While video dermoscopy permits high-resolution viewing at higher magnifications, the hand-held dermoscope is more convenient for quick office evaluation. Dermoscopy is most commonly used for the examination of melanomas, pigmented lesions, and hair-loss. It use in diagnosis and differentiation of hypopigmented lesions is relatively novel. In vitiligo, it has been used in the detection of clinically inapparent leukotrichia, especially in the segmental variant. [2],[3] It has also been used to assess treatment response, and to aid in diagnosis of blue vitiligo and nail trichrome vitiligo. [3],[6],[7]

Chuh and Zawar described its use as an early diagnostic tool for localized vitiligo, in which they reported a pattern of depigmentation with residual reservoirs of perifollicular pigment being characteristic. [1] While in their report, clinical suspicion of vitiligo was confirmed on dermoscopic observation of depigmentation with preserved perifollicular pigment; in our case, PFD over a background of reticular hyperpigmentation from the hyperpigmented forehead spot was an incidental and unexpected finding. However, within 4 weeks multiple florid vitiligenous lesions with characteristic trichrome pattern and grossly visible leukotrichia surfaced. Further, dermoscopic re-evaluation from the same spot revealed more pronounced features that is, reduced hyperpigmentation, more conspicuous and widened areas of PFD, few white vellus hairs and rarefaction and pigment reduction of terminal hairs suggestive of impending leukotrichia. Thus, retrospectively, finding of such dermoscopic features in clinically nonvitiligenous-appearing skin should prompt the clinician to suspect impending or evolving vitiligo and keep the patient in follow-up.

Two conclusions need further discussion in this report. Firstly, apart from the classical finding described by Chuh and Zawar, the "reverse" dermoscopic pattern seen in the present case that is, PFD in a background of interfollicular reticular hyperpigmentation (due to photomelanosis) from a clinically unsuspecting and inapparent lesion should also be considered as a dermoscopic feature of impending and/or established vitiligo. Secondly, leukotrichia appeared in nonlesional skin on dermoscopy only when vitiligo became clinically obvious in other regions. Thus, PFD rather than leukotrichia may be considered as an earlier dermoscopic marker of impending disease. However, more reports detailing the dermoscopic features of early or impending vitiligo are warranted to confirm the specificity and applicability of our observation.

Though our patient could not be followed-up clinically, we were informed of the rapidly progressive and treatment-refractory nature of his vitiligo telephonically. In vitiligo, repigmentation depends on available melanocytes from three important sources: The hair follicle, the border of vitiligo lesions, and unaffected melanocytes within depigmented areas. [8] Among them, the main source is the hair follicle. In view of this, the presence of expanding PFD and evolving leukotrichia on dermoscopy of clinically normal areas and clinically apparent leukotrichia in vitiliginous lesions seems to be consistent with the lack of response to treatment in the present case. Logically extrapolating, these dermoscopic findings may indeed be suggestive of a grim prognosis.

 
  References Top

1.Chuh AA, Zawar V. Demonstration of residual perifollicular pigmentation in localized vitiligo - a reverse and novel application of digital epiluminescence dermoscopy. Comput Med Imaging Graph 2004;28:213-7.  Back to cited text no. 1
    
2.Lee DY, Park JH, Lee JH, Yang JM, Lee ES. Is segmental vitiligo always associated with leukotrichia? Examination with a digital portable microscope. Int J Dermatol 2009;48:1262.  Back to cited text no. 2
    
3.Lee DY, Kim CR, Park JH, Lee JH. The incidence of leukotrichia in segmental vitiligo: Implication of poor response to medical treatment. Int J Dermatol 2011;50:925-7.  Back to cited text no. 3
    
4.Nugroho H, Ahmad Fadzil MH, Shamsudin N, Hussein SH. Computerised image analysis of vitiligo lesion: Evaluation using manually defined lesion areas. Skin Res Technol 2013;19:e72-7.  Back to cited text no. 4
    
5.Kang HY, le Duff F, Passeron T, Lacour JP, Ortonne JP, Bahadoran P. A noninvasive technique, reflectance confocal microscopy, for the characterization of melanocyte loss in untreated and treated vitiligo lesions. J Am Acad Dermatol 2010;63:e97-100.  Back to cited text no. 5
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6.Di Chiacchio NG, Ferreira FR, de Alvarenga ML, Baran R. Nail trichrome vitiligo: Case report and literature review. Br J Dermatol 2013;168:668-9.  Back to cited text no. 6
[PUBMED]    
7.Chandrashekar L. Dermatoscopy of blue vitiligo. Clin Exp Dermatol 2009;34:e125-6.  Back to cited text no. 7
[PUBMED]    
8.Parsad D, Pandhi R, Dogra S, Kumar B. Clinical study of repigmentation patterns with different treatment modalities and their correlation with speed and stability of repigmentation in 352 vitiliginous patches. J Am Acad Dermatol 2004;50:63-7.  Back to cited text no. 8
    


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