Block 4.1 (Medicine)

by :Maryam AL-Qahtani

Objectives

Discussion the case: History taking Differential diagnosis Physical examination Final diagnosis: Definition Etiology & Pathogenesis Classification Tests Prognosis and Treatment

Introduction

23 years old male, graduated from commerce college was anxious and worried regarding the white patches that affected his fingers and elbows.

DD

Postinflammatory hypopigmentation

Chemically induced depigmentation

Pityriasis alba Idiopathic guttate hypomelanosis

Tinea versicolor

Vitiligo

Vitiligo: disorder in which white patches of skin appear on different parts of the body when the skin no longer forms melanin

Chemically induced depigmentation: Working with chemicals such as phenols may cause depigmentation

postinflammatory hypopigmentation : is a decrease in pigmentation rather than absence.is associated with a history of antecedent trauma or inflammation• Signs of inflammation

Pityriasis alba is a mild form of eczematous dermatitis that presents with hypopigmented macules and small patches on the face, and less frequently on the upper extremities. Fine scale may be visible. The disorder is most common in children with an atopic history.

Idiopathic guttate hypomelanosis :characterized by multiple, small (<6 mm), well-defined, depigmented macules; lesions are most frequently found on the forearms and anterior lower legs • Usually related to sun exposure and start in leg

Tinea versicolor :is a superficial fungal infection that can present as hypopigmented macules and patches with fine scale .The upper trunk and shoulders are most commonly involved, but other sites may be affected

History taking

Personal data:

Name Age Occupation Social status Education level. Main complaint

cont...History of skin lesions:

When? ( + sudden or gradual ) Where? ( + other sites + other lesions +

bilateral or unilateral ) associated symptoms : Is there Itching Redness (erythema) Pain What is the distribution of the lesion? How the lesion change ? (colour change ,

scale or bleeding ) Is there a correlation between the onset of

skin lesions and any particular event or exposure?

cont... Past medical history : Chronic disease ? Operation? Illnesses ( hospitalization)? Skin disease ? Autoimmune disorders? Trauma ? Sun or Chemical exposure ?

Family medical history of skin disease like vitiligo ……

History of medication : When ? Dose ? such as prescription, over-the-counter, or herbal? Is it affective ?

cont...

History of allergies

Social history

Sexual history

Travel history

Case

He had first seen a spot 2 years ago on elbows. It had gradually spread on both the fingers ,

knees, elbows, and thigh.No change in the lesion (no scale or bleeding )No associated symptoms.No history of chronic disease , trauma or

chemical exposure .Positive family history of vitiligo : grandfather.No history of medications.

DD

Postinflammatory hypopigmentation

Chemically induced depigmentation

Pityriasis alba Idiopathic guttate hypomelanosis

Tinea versicolor

Vitiligo

DD

Pityriasis alba Tinea versicolor

Vitiligo

PE Identification of primary

lesion (s) Site Size Shape Arrangement

Number Surface Borders/edges Distribution Colour

Vitiligo

Definition

Vitiligo is a condition of chronic skin disease in which a loss of cells that give color to the skin (melanocytes) results in smooth, white patches in the midst of normally pigmented skin.

Can also affect the mucous membranes, hair

and the eye.

Etiology & Pathogenesis

The cause of vitiligo is unknown

Genetic

Immune Trigger factor

Pathogenesis

Pathogenesis

Autoimmune theory

Neurogenic hypothesis

Self-destruct hypothesis

Classification

Segmental vitiligo (SV)Non-segmental vitiligo (NSV)

Non-segmental vitiligo (NSV): Mostly generalized over a large area of the skin

and bilateral .

Symmetry in the location of the patches of depigmentation.

New patches also appear over time and can be generalized over large portions of the body or localized to a particular area.

Can come about at any age.

Classes of non-segmental vitiligo:

Generalized Vitiligo

Universal Vitiligo

Focal Vitiligo

Acrofacial Vitiligo

Mucosal Vitiligo

Segmental vitiligo (SV) : less common usually develops in one unilateral

region has an earlier age of onset than

generalized vitiligo Mostly Focal with some macules. It spreads much more rapidly

than NSV. it is much more stable/static in

course its association with autoimmune

diseases appears to be weaker than that of generalized vitiligo.

Tests

Wood Lamp

Examination

Dermatopathology

(skin biopsy )

Electron

Microscopy

Laboratory Studie

s

Prognosis and Treatment

o Vitiligo is a chronic disease. The course is highly variable, but rapid onset followed by a period of stability or slow progression is most characteristic.

o There is no cure for vitiligo.

The aim of treatment:

is to reduce the contrast in color between affected and unaffected skin.

cont...The approaches to the management of vitiligoare as follows:

Sunscreens

Cosmetic Coverup

Repigmentation

Depigmentation

cont...Repigmentation

Localized Macules

•Topical glucocorticoids

•Topical calcineurin inhibitors: Tacrolimus and

pimecrolimus . •Topical photochemotherapy [topical 8-

methoxypsoralen (8-MOP) and UVA]

•Excimer laser (308 nm) Best results in the face.

Generalized Vitiligo

•Systemic photochemotherapy:

PUVA therapy(Psoralen+ UVA)

•Narrow-band UVB, 311 nm.

cont...Depigmentation

The objective of depigmentation is “one” skin color in patients with extensive vitiligo or in those who have failed or reject other treatments.

Treatments:• Bleaching of normally pigmented skin with monobenzylether of

hydroquinone 20% (MEH) cream is a permanent, irreversible process.

• The success rate is >90%.

Michael Jackson

Vitiligo is a disease in which the pigment cells of

the skin, melanocytes, are destroyed in certain

areas.

Vitiligo results in depigmented, or white,

patches of skin in any location on the body.

Vitiligo can be focal and localized to one area,

or it may affect several different areas on the

body.

Vitiligo tends to run in families.

References

Fitzpatricks Color Atlas and Synopsis of Clinical Dermatology , 7th Edition.

Vitiligo- UpToDate. The Merck Manual.

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