DISORDER OF PIGMENTATION DERMATOLOGY

Hypopigmentation o Poorly response to treatment

o Lighter than normal skin Why? Due to depletion of melanocyte, so melanin is sequestered on
Hyperpigmentation remaining melanocyte on the hair follicle, that is where they stimulate
o Darker than normal skin melanin formation.
-so palms and the soles are non hairy areas, no melanin can be
VITILIGO stimulated
o It is difficult to treat
- Repigmentation of skin *in general, vitiligo is very sensitive to light. Those affecting the periorbital
o An acquired pigmentary anomaly of the skin manifestated by areas especially the children, it can affect the retina. Refer them to
depigmentation white patches surrounded by a normal or ophthalmologist to check the retina and the iris. It is also associated with
hyperpigmented or rarely an erythematous border diabetes, anemia, thyroiditis, Graves disease and Addisons disease and
o In vitiligo, there is totally whitein color unlike in hypopigmented lesion like alopecia areata. It can be inherited.
tinea versicolor, there is just lightening color in the surrounding skin *In children, most common is focal, segmental type. It is also associated with
o Hairs become white within the lesion premature graying of the hair. You can apply topical repigmenting agent.
o Lesions appear as areas of trauma Sometimes it will take two years for complete repigmentation
o Koebner response appear at the site of
o trauma like: Halo Phenomenon
o Elbow o Local loss of pigment around nevi and melanoma
o Knee o Fried egg appearance of the lesion
o Suggest metastasis in those with melanoma
o Indicated an autoimmune response against melanocytes so patients who
develop it have a better prognosis than patients without leukoderma
o Lesions are hypersensitive to UV and burn readily due to (-) melanin need
sun protection
o Ocular abnormalities are increases in patients with vitiligo, including iritis
and retinal pigmentary abnormalities
o Most frequently associated with other autoimmune disease such as IDDM,
pernicious anemia, Hashomito’s thyroiditis, Grave’s disease, Addison’s
disease and alopecia areata
o Not an autosomal dominant or recessive trait but has a multifactorial
genetic basis (30% hereditary)

Vitiligo in childhood
o Increase in segmental presentation
“Trichrome Vitiligo” – intermediate tan zones between o Autoimmune or endocrine anomalies frequently present
normal skin color and depigmentation o High incidence of premature graying in families
-sometimes within the white patch you can see that there is brown tan o Poor response to PUVA
macule— this brown spots is a sign of repigmentation, it means a good sign
-early in the onset, sometimes it is not yet white Occupational Vitiligo (chemical leukoderma)
o Chemicals such as thiols, phenolic compounds, catechol, derivatives of
4 Types of Vitiligo catechol, mercaptoamines and several quinines produce depigmentation
1. Localized or focal (segmental included) → accumulation of these within the melanocyte may damage or kill the
2. Generalized- most common cell
o Superficial o Usually the hands –if this is affected ask for history of contact chemical
o Symmetrical o Sometimes this is irreversible
3. Universal o The clinical pattern may be very similar to idiopathic vitiligo because
o Can affect the whole body lesions tend to be concentrated in areas of contact with the substance
4. Acrofacial

1. Focal Vitiligo Pathogenesis

o May affect one nondermatomal site (glans penis) or 3 possible mechanisms: (not yet proven)
o asymmetrically affect a single dermatome or non dermatomal area l 1. Autoimmunity – destroy of melanocytes
o Treatment resistant, earlier onset, auto immune 2. Neurohumoral factors
o 5% of adult and 20% of childhood vitiligo 3. Autocytotoxicity\
o Trigeminal area commonly affected- in the face
o Most common type in children Melanocytes- can be seen in basal layer
o Unilateral
o Less associated with autoimmune diseases Histopathology:
o Complete absence of melanocytes
2. Generalized Vitiligo o Every 10 keratinocytes, there is 1 melanocyte
o Most common
o Symmetrical, bilateral Differential Diagnosis:
o Sites: face, upper chest, dorsum of hands, axilla, and groin, skin around o Morphea
orifices like the eyes, nose, mouth, ears, nipples, umbilicus, penis, vulva o Lichen sclerosis
and anus o Pityriasis alba
o Tinea Vesicolor- there is still melanocytes but there is decreased number of
3. Universal Vitiligo melanosomes which is responsible in stimulating melanocytes
o Entire body surface is depigmented - Normal melanocytes but there’s decrease in melanin

4. Acrofacial Vitiligo *you have to differentiate other hypopigmented lesions from depigmented
o Affects the distal fingers and facial orifices – perioribital area and ones—do BIOPSY
perioral area

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 DISORDER OF PIGMENTATION DERMATOLOGY
Treatment
Aim of treatment
o (+) small brown spots in follicle
o Treatment is responsive
o 15%-20% with spontaneous repigmentation
o Sun protection
o Topical steroids-face; medium to high, 1st line especially in children,
moderately potent
o You will see brown spots in the hair follicle-good sign!
o If no reponse for after two months, you change in to another treatment
modality: apply repigmenting agent, dilatation
o After applying the repigmenting agent, you have to advice the patient to
expose the himself to expose in the sun for 5-15 minutes to stimulate
3. Multiple Lentigenes Syndrome
melanin pigment, maximum of 30 minutes
o Autosomal dominant
o Psoralen then PUVA- generalizd vitiligo
o Dark brown macules 1-5 mm in diameter
-you can exposed the patient in the sun
o Sites: trunk, palms and soles, buccal mucosa, genitalia and scalp
-gradual exposure to UV light
o Epidermal grafting, autologous minigrafts
Leopard Syndrome
-prior to this, do BIOPSY
o Total depigmentation – if >50% of BSA
→ Speckled appearance of skin shortly after birth
*in universal type, only a small portion of normal skin is left, make it even: you
L Lentigenes
can depigment the normal skin para puti na sya lahat 
E ECG abnormalities
O Ocular hypertelorism
→ Application of monobenzone (monobenzyl ether
P Pulmonic stenosis
of hydroquinone) BID for 3-6 months on pigmented
A Abnormalities of Genitalia
areas; permanent
R Retardation of Growth
D Deafness
*in generalized type, in large part of the body—they can do Q switched Laser
for cosmetic purposes
Treatment:
o Liquid nitrogen
LENTIGO
o For rough and elevated lesions
→ is a hyperpigmented lesion
o Laser – IPL (intense pulse light)
o Sunscreen
1. Lentigo Simplex
o To avoid new appearance of lesions
o Sharply defined, rounded, brown or black macules
o Bleaching creams
o appear anywhere on the body or mucosa
o Avoid Sun exposure
o Arise in childhood but may appear at any age
o No predilectation for areas of sun exposure
Melasma
o No therapy needed
o Also known as “pekas” in Tagalog
o Common in brown skinned individuals (Asians,
o Indians)
o Brown patches on the malar area and forehead
o Occurs frequently during pregnancy or menopause
o May be seen in ovarian disorder and birth control pill and dilantin use

Whitening agents can be applied

2. Solar Lentigenes (Liver Spots)

o Persistent, benign, discrete, hyperpigmented
o macules of irregular shape, occurring of sun exposed
o skin
Melasma of pregnancy usually regress for 1 year
o Sites: back of hand, forehand, face
o Commonly affected: golfers, farmers
*Melasma arise from inflammatory hyperpigmentation after applying maxi-
o Prone to those who have: blue eyes, blond hair, fair skin
peels, our skin is very thin—will cause burn- namumula sa una then
mangigngitim

3 Clinical Patterns:
1. Centrofacial – T zone of the face
2. Malar - cheeks
3. Mandibular - jaw
o Not common because it is not directly exposed to the sun

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 DISORDER OF PIGMENTATION DERMATOLOGY
Treatment:
o Topical bleaching agents- this will just lighten the melanocyte, only remove
the epidermal melanin. As soon as the patient will have exposure to the
sun-babalik ulit, iitim pa din
o Most effective is still hydroquinone or laser
o Sun avoidance
o Sun protection is best
o If ever you’re going to use sunblock, every hour because it can be washed
out when you perspire

Idiopathic Guttate Hypomelanosis

o Small macules (less than 10 mm)

o Usually multiple, a dozen or two in one area
o shaply defined
o hypo/depigmented macules on the shins, neck and forearms
o Very common acquired disorder that affects women more than men
usually occurring after 40 years old (middle aged women)
o Has multiple white spots
o Minor cosmetic significance

Treatment
o Just observe because it sometimes disappear
o spontaneously
o But you can apply lotions or emollients for dry skin and then the lesion will
repigment

…be blessed to be a blessing… 

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