CASE REPORT: VITILIGO IN A -28 YEAR OLD WOMAN

Sujala Manakandan
Department of Dermato-Venereology, Medical School, Udayana University/ Indera Hospital,
Denpasar

ABSTRACT
Vitiligo is a depigmented skin disorder that affects the skin and/or mucous membranes often
noticed by skin discoloration with an unknown etiology. They tend to appear at an early onset
of age and prevalent in both genders. Phototherapy is the first line treatment of choice. We
presented a 28 year old woman with skin discoloration on her fingers and toes. The general
examination was within normal limits with optimal vital measures. On dermatological
examination, found depigmented macules, with a well demarcated border, geographic
presentation and distributed bilaterally. In microscopic studies, no short hyphae with cluster
of spores were found. The patient was treated with phototherapy PUVB three times a week
on the affected area. For non-phamarmacological treatment, patient was advised to wear
suitable clothes that protect the nonphotoprotected skin from sunburn. The therapy response
and prognosis was good.
Keywords: Vitiligo, depigmented, phototherapy

INTRODUCTION

the face and the extremities known as the

Vitiligo is a depigmenting disorder

acrofacial pattern or unilateral following

that varies in shapes and sizes and affects

the dermatomal distribution known as the

the skin and/or mucous membranes.1,3,4,6

segmental vitiligo pattern.1,6

The cause of vitiligo is still unknown. 1,6

However, varies multifactorial factors that
have been found to play a complex role in
the development of the disease such as
genetics, autoimmune, oxidative stress,
cytotoxic and others that aid in the
destruction

of

melanocyctes.1,3,4,5,6

In

addition, vitiligo also can be triggered by

other external factors such as sunburn,
trauma and stress.1 Vitiligo tends to appear
in the early onset of childhood usually
before 20 years of age and there are no
apparent differences in the distribution of
incidents in either gender, ethnic or social
backgrounds.1,4,5,6

Most patients often suffer low self

esteem and experience an emotional
burden due to the discolouration patches
that gives a poor body image. Besides,
most patients do not understand that this
condition needs proper treatment and may
require some time for the recovery of the
patches to the original skin colour.
Besides, most physicians often overlooked
this skin disease to be caused by a fungal
infection such as tinea vesicolor or
pityriasis alba. Therefore, a proper history
taking

and

examination
diagnose

an

effective

should
this

be

clinical

assessed

clinical

to

condition

The most common clinical finding

comprehensively to ensure patients do not

of this disorder is depigmented macules

self medicate themselves that could lead to

lesions that have well demarcated borders

other serious medical complications in

appearing in either chalky or milky white

unattended or chronic use.1,5,6

colour.1,6 Generalized vitiligo is the most

common pattern that is symmetrically
distributed throughout the body.1,6 This
pattern also called as nonsegmental vitiligo
frequently involves body parts around the
orifices (eyes, nose, mouth), extensor
surfaces (elbows, knees, digits) and flexor
surfaces (axillae, groins and genitals). 1,5,6
However, vitiligo also covers areas such as

Moreover,

patients

should

be

emphasized that even with the right and

proper

treatment,

vitiligo

is

an

unpredictable chronic skin discolouration

that has a relapsing disorder and needs a
longer time in the repigmentation of the
skin. In conclusion, patient should be
educated

comprehensively

about

the

disease

itself,

plan

of

therapy

and

prognosis for a better outcome.1,6

has a hard time coping in her working

place with her colleagues due to the
perception of it being infectious.

THE CASE
A woman aged 28 years old from
Mengwi with registration number 1302574
came by herself to Indera Hospital with a
chief complaint of discolouration of white
patches on her fingers and toes of both
extremities since 2005. According to the
women, the discolorations started on her
fingers first which widespread in more
numbers and different sizes to her both
hands. After one year, it appeared on the

On

physical

examination

the

women appeared to be compos mentis with

Glasglow Coma Scale of E4V5M6. Her
vital signs appeared to be normal with
blood pressure 120/80mm Hg, pulse rate
of 90 times per minute, respiratory rate of
22

times

per

minute

and

axillary

temperature of 37.1 degree Celcius. The

women appeared well nourished with a
body mass index of 22.3.

toes of her both legs. The women

In further general examination, the

experienced such for the first time and had

women appeared normocephaly with no

never consulted to a doctor before

anemia or icterus sign of the eyes. Ear,

assuming it was pigmentation and would

nose and throat examinations were within

disappear by itself.

normal

She denied any itchiness and any

sense of pain in the involved area. The
women also had no history of sharing
personal items such as towel or cloth with
her family members or the usage of
cosmetic products. Besides, she has a good
hygiene habit by changing her clothes or
showering

frequently

when

sweating.

According to the women, this was the first

time she had been experiencing it and

limits.

Abnormal

secretions,

growth or hiperemia were absent. There

were no palpable lymph nodes at the neck
region. Both the thoracic and abdominal
examinations were within normal limits.
There were no signs of deformities, edema
nor atrophy of the muscles of both upper
and lower extremities. The extremities
appear warm with normal limits of motor
and sensory function.
According to the dermatologically

neither of her family members had any

findings,

the

patches

history of such skin disorder. As a result,

bilaterally at the extremities of the fingers

she often felt embarrassed to wear shorts

and toes region. The efflorescense was

or sleeveless whenever she goes out and

multiple

hypopigmented

were

limited

macules

that

appear milky in colour, with a well

tests are however helpful such as thyroid

demarcated

geographic

hormone levels, antibody tests, complete

presentation, measuring from 0.1cm to

blood count and others are an indication in

8cm in diameter, bilaterally distributed

aiding to diagnose vitiligo since there is an

with no scales.

association between autoimmune diseases

border,

and vitiligo for example Graves disease,

pernicicious anemia, diabetes mellitus and
many more. However, there were no
indications of blood examinations for this
patient as this patient denies any other
complaints and she appears in a condition
of good health and nutrition.
Based on the anamnesis, clinical
examination and laboratory finding, we
assessed the patient with vitiligo. The
Figure 1. Picture shows the clinical
presentation of the skin lesions on the
patients fingers and hand.

management of the women was listed as

non-pharmacological and pharmacological
therapy. Firstly, the woman was advised to

From history taking and physical

wear long sleeves and pants which

findings three differential diagnosis were

included stockings to avoid the rays of

raised named vitiligo, tinea vesicolor and

sunlight that causes sunburn on the

pityriasis alba. The diagnosis of vitiligo is

nonphotoprotected skin. In addition, the

however based primarily on clinical

patient was educated by the dermatologist

examination.

physical

and given full information about the

examination, there were no fine scales or

patients disease and the mode of treatment

pruritus

lesions.

planned out. For the pharmacological

Microscopic examination was done for this

treatment, patient is given phototherapy

patient and hyphae with clustered spores

that

were absent from the findings.

radiation 3 times a week where for every

found

From
at

the
the

skin

In conclusion, tinea vesicolor and

pityriasis alba can be excluded from the
diagnosis. Several screening laboratory

uses

narrowband

ultraviolet

phototherapy visit, the duration of each

treatment is increased for an extra 10
minutes. The patients prognosis was
hoped to be excellent with a good patient

compliance by routinely following the

phototherapy

treatments

in

Indera

Hospital.

The

skin

discolorations

that

appeared without any pruritus or sense of

pain at the site of lesions often raised as a
chief complain in the clinical setting by

DISCUSSION

most patients because hypopigmentation or

Vitiligo is a type of depigmented

depigmentation

is

easily

noticed

on

skin disorder that frequently occurs at the

Easterner for their tanned skin. This often

early onset before 20 years of age and

causes cosmetic dissatisfaction among

often involves the torso also known as

patients that make them feels ashamed to

generalized

appear in the public and therefore seek

vitiligo.

However,

this

complication may also present and cover

medical

only

extremities

indicated that the discoloration is a

regions.

manifestation caused by destruction of

inflammation

melanocyctes induced by several factors

response, oxidative stress and others are

such as autoimmune antibodies, cytotoxic

often associated with vitiligo even though

T lymphocyctes, possible associated HLA

the definite cause of vitiligo is still

gene factor, free radicals and others.1-6

on

the

(acrofacial)
Genetics,

face

or

and

segmental

autoimmune,

unknown. Supporting to the above fact, in

our case was a woman aged 28 whom
experienced white like patches on her
fingers and toes symmetrically. This
argument is further
epidemiological

supported with the

evidenced

peak

incidents among those aged in the early 20

years of age whereby the skin lesions
started appearing in 2005 when the women
was aged 17 years old. However, the
causing mechanism still remains a mystery
due to another fact there were no presence
of family history of such skin disorder or
any specific autoimmune disease found in
this woman.1-6

help.

Pathological

studies

Hallmark in the skin disorders are

the

skin

lesions

also

known

as

efflorescence. However, there are some

skin diseases that may share some
common efflorescence, hence mimicking
each other giving a raise to various
differential

diagnosis.

Therefore,

comprehensive and systematic evaluation

is the golden rule in assessing a patient
right. Careful clinical evaluation is done
on the patient in ruling out the differential
diagnosis for clinical importance. For
instance, the depigmented macules on the
skin as in the case above suggested several
differential diagnosis such as vitiligo, tinea
vesicolor and pityriasis alba. Therefore, an

adequate

clinical

knowledge

and

woman in this case has never experienced

experience are essential in differentiating

such erythematous lesions as evident from

these skin diseases.1,5,6

the anamnesis. As in vitiligo, sunburn will

Even though present in both tinea

vesicolor and pityriasis alba, however
discolorations usually not accompanied by
scales and itching prior to sweating, in

also be an extensive complaint in those

with pytiriasis alba, in contrast with tinea
vesicolor

patients

whom

will

be

experiencing pruritus with sun exposure.9

contrast to vitiligo which is an acquired

Various techniques or methods

depigmented skin disorder that may vary

were used in ruling out the differential

from chalky or milky white that have well

diagnosis. A confirmatory run such as

demarcated macules. Sunburns are also

Woods lamp examination and KOH

often another complain by vitiligo patients

examination is done to confirm the clinical

that most patients are forced to wear

findings. The Woods lamp examination

clothes that cover their whole body. In

highly suggests tinea vesicolor if a

addition, Woods lamp examination in

yellowish to golden fluorescence was

vitiligo gives an attenuated morphology

found at the involved skin area.1,6 On the

unlike the yellow florescense in tinea

other

vesicolor. Adding on, to support the

mandatory in ruling out tinea vesicolor.

diagnosis,

an

Hence, in the subject above, by using a

association of familial history and the

cellophane tape to collect the cells of the

initial lesions often bloom with bilateral

skin from the lesion and the tape was then

distributions throughout the body.1,4,6,7

mounted on a glass slide with KOH parker

vitiligos

often

have

As for pytiriasis alba, it is a nonspecific dermatitis with an unidentified

etiology. Secondly, pytiriasis alba is often
associated with an atopic presentation and
has the appearance of red fine scaly
macules that often mimics tinea vesicolor.
Pytiriasis alba initially develops from a

hand,

KOH

examination

was

solution to selectively stain the sample.

The

microscopic

evaluation

showed

absences of short hyphae with clusters of

spores also knows as the Spaghettis and
meatballs

appearance

which

highly

supports it as a fungal infection, more

specifically named tinea vesicolor.11-12

small erythematous macule to a sclay

The first choice treatment for this

erythema which then slowly disappears

patient will be phototherapy using the

leaving behind a fine scaly hypopigmented

narrowband ultraviolet B radiation 3 times

area.8-10 In contrast to this theory, the

a week with a dosage of 50nm that gives a

better repigmentary effect and is currently

phototherapy using narrowband ultraviolet

a preferred treatment for its established

B radiation. In addition, the patient was

safety in children and also pregnant

also advised to wear suitable clothes that

women. In addition, there is no need for an

covered and protects the involved areas

eye protection or to time the exposure with

from sunburn. The prognosis of the patient

any drug intake. Adding on, the patient

is expected to be excellent with a good

was advised to wear clothes such as long

patient compliance.

sleeves, pants and stockings to cover the

involved areas from getting sunburn that
could

worsen

the

depigmented

skin

lesions.1,2,5,6

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