Vitiligo 1 PDF

C I hted Ma .
VITILIGO
Problems and Solutions
edited by
Torello Lotti
University of Florence
Florence, Italy
Jana Hercogova
Motol University Hospital, Charles University
Prague, Czech Republic
n
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Series Introduction
Over the past decade, there has been a vast explosion in new information relating
to the art and science of dermatology as well as fundamental cutaneous biology.
Furthermore, this information is no longer of interest only to the small but
growing specialty of dermatology. Scientists from a wide variety of disciplines
have come to recognize both the importance of skin in fundamental biological
processes and the broad implications of understanding the pathogenesis of skin
disease. As a result, there is now a multidisciplinary and worldwide interest in
the progress of dermatology.
With these factors in mind, we have undertaken to develop this series of
books specifically oriented to dermatology. The scope of the series is purposely
broad, with books ranging from pure basic science to practical, applied clinical
dermatology. Thus, while there is something for everyone, all volumes in the
series will ultimately prove to be valuable additions to the dermatologist's
library.
The latest addition to the series, edited by Drs. Lotti and Hercogova, is both
timely and pertinent. The authors are well known authorities in the field of
vitiligo and hypmelanotic syndromes. We trust that this volume will be of broad
interest to scientists and clinicians alike.
Alan R. Shalita
SUNY Health Science Center
Brooklyn, New York
Copyrighted Material iii

Preface
Very few things can be more outrageously and incredibly discriminated against
than the color of the skin. When the authors asked themselves what was the
inspiration to begin their interest in vitiligo, they had to agree that, at the most
irrational level, their scientific interest in vitiligo is probably related to their hate
for discrimination. Still now what is probably more challenging in vitiligo is not
the chronicity of this progressive depigmenting disorder, but the irrational
feeling that these "white spots" may symbolize a punishment sent by God, i.e., a
sign of sin. The word "vitiligo" itself could come from the latin word "vitium", a
blemish or fault. Irrationally this feeling is apparently affecting the patients'
community, the general population, and, at some level even our scientific
community. How many physicians will irrationally tell their patients that there is
no treatment for vitiligo?
The flist part of this book provides a relevant source of updated
information from basic science and clinically oriented to eclectically help the
practicing dermatologist to make an appropriate therapeutic choice or, if needed,
selected multiple therapeutic approaches. On some controversial issues, we
provide at least two points of view from different experts in the field always
looking for expert guidance for the selection, initiation and follow-up of the
different treatments. A special emphasis is given to the self-esteem, body image
and self-perception of the vitiligo subjects and to the essential elements for
successful counseling. The last chapter in the section is devoted to the most
interesting Internet sources, to give the readers a continuously up-to-date source
for additional information.
The second part of the book is devoted to the other clinically relevant
hypomelanotic disorders-sometimes misdiagnosed as vitiligo-and to their
possible treatments. Thanks to the efforts of the distinguished international
authorship in this book, we tried to clearly identify the different problems facing
Copyrighted Material v
vi Preface
the researchers and patients dealing with vitiligo and to discuss the many
solutions currently available.
We hope that all the readers will agree with us that in the end it is not true
that there is nothing to do for vitiligo. In fact, just the opposite is true.
Torello Lotti, MD
Jana Hercogowi, MD
Contents
Series Inlroduction iii

Preface v
Contributors xi
1. Vitiligo: Disease or Symptom? From the Confusion

of the Past to Current Doubts
Torello Lotti, Giuseppe Hautmann, and lana HercogoviJ
2. Historical and Psycho-Anthropological Aspects
of Vitiligo 15
AIda Morrone
3. Vitiligo: Epidemiology 27
Luigi Naleli
4, Biology of Hypopigmentation 33
Giovanni Menchini. Torello Lalli, El'ridiki
Tsoureli-Nikita, lana Hercogova, and lean Paul Ortonne
5. Disorders in Healthy Relatives of Vitiligo Patients 51
Abelel Monem EI Mofty, Medhat A, EI Mofty,
and Samia M. Esmat
6. Basic Research: An Update 65
Karin U. Schallreuter
7. Vitiligo: The Autoimmune Hypothesis 79
lean-Claude Bystryn
8. Vitiligo: A Disorder of the Microvessels? 93
Elena Del Bianco, Giuseppe Muscarella, and Torello Lotti
Copyrighted Material vii
viii Contents
9. Pathogenesis of Vitiligo: Evidence for a Possible

Ongoing Disorder of the Cutaneous Microenvironment 99
Giuseppe Halltmann, Silvia Moretti, Torello Lotti,
and Jana HercogovQ
10. Free Radical Damage in the Pathogenesis of Vitiligo 123

JvJauro Picardo and Maria Lucia Dell'Anna
II. Possible Role of Nitric Oxide in the Pathogenesis of Vitiligo 137

Mario Vaccaro and Fabri::io Guarneri
12. Histopathological and Ultrastructural Features of Vitiligo 145

Daniela Massi
13. Clinical Variants of Vitiligo 159
Seung-Kyung Hann and Sungbin [/11
14. Vitiligo in Children 173

Flora B. de Waard-van der Spek and Arnold P. Oranje
15. Vitiligo: Focusing on Clinical Associations with

Endocrine, Hematological, Neurological,
and Infectious Diseases 179
Alex Llambrich and Jose MO Mascaro
16. Clinical Associations: Focusing on Autoimmune

and Rare Associations 189
G. Primavera and E. Berardesca
17. Ocular and Audiological Disorders in Vitiligo 201

Antonella Tosti, Bianca Maria Piraccini,
Mati/de [orizzo, and Giovanni Tosti
18. Differential Diagnosis for Vitiligo 207

Wennie Liao and James 1. Nord/und
19. Vitiligo: Emotional Aspects and Personality 225

Giuseppe Hautmann. Torello Lotti, and Jana HercogovQ
20. Therapeutic Guidelines for Vitiligo 235

M. D. Njoo and W. Westerhof
21. Efficacy and Adverse Effects of Psora len

Photochemotherapy in Vitiligo 253
Ljubomir Novakovic and John Hawk
Contents ix
22. Treatment of Vitiligo with UV and

Photosensitizing Substances 261
M.L. Flori, M. Pellegrino, A. Molinu, E. Stanghellini,
and L. Andreassi
23. Corticosteroids in Vitiligo 271
Alexander 1. Siratigos and Andreas D. Katsambas
24. Vitamins and Vitiligo 281
Evridiki Tsoureli-Nikita, Claudio Comacchi,
Giovanni Menchini, and Torello LOlli
25. Alternative Treatments for Vitiligo 285
l/aria Ghersetich, Benedetta Brazzini,
Torello Lotti, and Giovanni Menchini
26. Vitiligo: Problems and Surgical Solutions 293

Rafael Falabella
27. Tissue-Engineered Skin in the Treatment
of Vitiligo Lesions 313
Andrea Andreassi, Elisa Pianigiani,
Paolo Taddeucci, and Michele Fimiani
28. UV-B Narrowband Microphototherapy: A New
Treatment for Vitiligo 323
Giovanni Menchini, Torello LOlli,
Evridiki Tsoureli-Nikita, and lana Hercogovit
29. Vitiligo: Problems and Nonsurgical Solutions 335
Giovanni Menchini, Torello Lotti,
Evridiki Tsoureli-Nikita, and lana Hercogovit
30. Use of UVB in Vitiligo 341

Mario Lecha
31. Cover-Ups: The View of the Cosmetologist 347
Alida DePase
32. Cover-Ups: The View of the Dermatologist 351
Rossana Capezzera, Cristina Zane,
and Piergiacomo Calzavara-Pinton
33. Depigmentation and Vitiligo 359

Christina Antoniou and Electra Nicolaidou
x Contents
34. Vitiligo and the Internet 365

Giovanni Menchini, Torello Lotti,
Evridiki Tsoureli-Nikita, and lana Hercogow]
35. Halo Nevus 369
DemelJ'is loannides
36. Alezzandrini's Syndrome 377
Fabrizio Guarneri and Mario Vaccaro
37. Acquired HypomeJanoses 381
R. Konkolova
38. Idiopathic Guttate Hypomelanosis 389
Michelangelo La Placa and Sabina Vaccari
39. Leukonychia 393
Aurora Tedeschi, Maria Rita Nasca, and Giuseppe Micah
40. Vogt-Koyanagi-Harada Syndrome 403
Fabrizio Guarneri, Pasquale Aragona,
and Mario Vaccaro
41. Nevus Depigmentosus 413
Beatrice Bianchi, Torello Lotti, and lana Hercogow]
42. Hypomelanosis and Tuberous Sclerosis Complex 419
A. Patrizi and 1. Neri
43. Inherited Hypomelanotic Disorders 433
Nicoletra Cassano and Gino A. Vena
44. Piebaldism 449
Giovanni Maria Palleschi
45. Albinism 461
Evridiki Tsoureli-Nikita, Giovanni Menchini,
Torello Lotti, and H. Grossman
46. Chediak-Higashi Syndrome 473
Benedetta Bra;:~ini and l/aria Ghersel ich
47. Melanoma and Vitiligo 479
Dan Forsea
48. Vaccines and Vitiligo 485
Silvia Morelli and Paolo Fabbri
Contributors
Andrea Andreassi Arezzo's Hospital and University of Siena, Siena, Italy

L. Andreassi University of Siena, Siena, Italy
Christina Antoniou University of Athens School of Medicine, "A. Sygros"
Hospital, Athens, Greece
Pasquale Aragona University of Messina, Messina, Italy
E. Berardesca San Gallicano Dermatological Institute, Rome, Italy
Beatrice Bianchi University of Florence, Florence, Italy
Benedetta Brazzini University of Florence, Florence, Italy
Piergiacomo Calzavara-Pinton Spedali Civili, Brescia, Italy
Rossana Capezzera Spedali Civili, Brescia, Italy
Nicoletta Cassano Istituto Dermopatico dell'Immacolata, Rome, Italy
Jean-Claude Bystryn New York University School of Medicine, New York,
New York, U.S.A.
Claudio Comacchi University of Siena, Siena, Italy
Flora B. de Waard-van der Spek Erasmus Me, Rotterdam, The Netherlands
Elena Del Bianco University of Florence, Florence, Italy
Copyrighted Material xi
xii Contributors
Maria Lucia Dell'Anna San Gallicano Dermatological Institute, Rome,

Italy
Alida DePase Bergamo, Italy
Abdel Monem El Mofty Cairo University, Cairo, Egypt
Medhat A. El Mofty Cairo University, Cairo, Egypt
Samia M. Esmat Cairo University, Cairo, Egypt
Paolo Fabbri University of Florence, Florence, Italy
Rafael Falabella Universidad del Valle, Cali, Colombia
Michele Fimiani Arezzo's Hospital and University of Siena, Siena, Italy
M.l. Flori University of Siena, Siena, Italy
Dan Forsea University of Bucharest, Bucharest, Romania
Haria Ghersetich University of Florence, Florence, Italy
H. Grossman Regional Dermatology Training Center, Moshi, Tanzania
Fabrizio Guarneri University of Messina, Messina, Italy
Seung-Kyung Hann Korea Institute of Vitiligo Research, Seoul, Korea
Giuseppe Hautmann University of Florence, Florence, Italy
John Hawk St. John's Institute of Dermatology, London, England
Jana Hercogova Charles University, University Hospital Motol, Prague,
Czech Republic
Sungbin 1m Korea Institute of Vitiligo Research, Seoul, Korea
Demetris loannides Aristotle University Medical School, Thessaloniki,
Greece
Matilde lorizzo University of Bologna, Bologna, Italy
Andreas D. Katsambas University of Athens Medical School, Andreas
Sygros Hospital for Skin and Venereal Diseases, Athens, Greece
R. Konkolova Charles University, University Hospital Motol, Prague,
Czech Republic
Michelangelo La Placa University of Bologna, Bologna, Italy
Mario Lecha University of Barcelona, Barcelona, Spain
Alex Llambrich Hospital Clinic, Barcelona, Spain
Contributors xiii
Wennie Liao University of Cincinnati, Cincinnati, Ohio, U.S.A.

Torello Lotti University of Florence, Florence, Italy
Jose M a Mascaro Hospital Clinic, Barcelona, Spain
Daniela Massi University of Florence, Florence, Italy

Giovanni Menchini University of Florence, Florence, Italy
Giuseppe Micali CJinica Delmatologica, Universita di Catania, Catania, Italy
A. MoLinu University of Siena, Siena, Italy
Silvia Moretti University of Florence, Florence, Italy
Aldo Morrone Istituto Dermosifilopatico San Gallicano, Rome, Italy
Giuseppe Muscarella, University of Florence, Florence, Italy
Luigi Naldi U.O. Dermatologia, Ospedali Riuniti di Bergamo, Bergamo,
Italy
Maria Rita Nasca Clinica Dermatologica, Universita di Catania, Catania,
Italy
1. Neri University of Bologna, Bologna, Italy
Electra Nicolaidou University of Athens School of Medicine, "A. Sygros"
Hospital, Athens, Greece
M. D. Njoo Academic Medical Centre, University of Amsterdam, Amster-
dam, The Netherlands
James J. Nordlund University of Cincinnati, Cincinnati, Ohio, U.S.A.
Ljubomir Novakovic St. John's Institute of Dermatology, London, England
Arnold P. Oranje Erasmus MC, Rotterdam, The Netherlands
Jean Paul Ortonne Hopital L'Archet 2, Nice, France
Giovanni Maria Palleschi University of Florence, Florence, Italy
A. Patrizi University of Bologna, Bologna, Italy
M. Pellegrino University of Siena, Siena, Italy
Elisa Pianigiani Arezzo's Hospital and University of Siena, Siena, Italy
Mauro Picardo San Gallicano Dermatological Institute, Rome, Italy
Bianca Maria Piraccini University of Bologna, Bologna, Italy
xiv Contributors
G. Primavera San Gallicano Dermatological Institute, Rome, Italy

Karin U. Schallreuter University of Bradford, Bradford, United Kingdom
and Institute for Pigmentary Disorders e. V. in Association with the Ernst-
Moritz-Arndt University Greifswald Biotechnikum, Greifswald, Germany
E. Stanghellini University of Siena, Siena, Italy
Alexander J. Stratigos University of Athens Medical School, Andreas
Sygros Hospital for Skin and Venereal Diseases, Athens, Greece
Paolo Taddeucci Arezzo's Hospital and University of Siena, Siena, Italy
Aurora Tedeschi Clinica Dermatologica, Universita di Catania, Catania,
Italy
Antonella Tosti University of Bologna, Bologna, Italy
Giovanni Tosti S. Luca Hospital, Trecenta, Italy
Evridiki Tsoureli-Nikita University of Siena, Siena, Italy
Sabina Vaccari University of Bologna, Bologna, Italy
Mario Vaccaro University of Messina, Messina, Italy
Gino A. Vena University of Bari, Rome, Italy
W. Westerhof Academic Medical Centre, University of Amsterdam, and
Netherlands Institute for Pigment Disorders, Amsterdam, The Netherlands
Cristina Zane Spedali Civili, Brescia, Italy
1
Vitiligo: Disease or Symptom? From the
Confusion of the Past to Current Doubts
Torello Lotti and Giuseppe Hautmann

University of Florence, Florence, Italy
Jana Hercogova
Charles University, Prague, Czech Republic
THE ANCIENT CONFUSION

The word "vitiligo" itselfis said to have been first used by Celsus in the Latin
medical classic De re medicina in the first century A.D. With regard to the roots
of the term, there seems to be some difference of opinion between lexicogra-
phers and dermatologists. Some state that its appearance resembling the white
glistening of the flesh of calves (vituli) may have given rise to the generic term
vitiligo. Others suggest that it may be derived from vitelius, the Latin word for
"calf," because of the white patches in a calf's fur. Some believe that the name
represents a blemishing fault that in Latin is called vitium. The origin of the "I"
in the word vitiligo is uncertain. It may simply have been introduced for
reasons of euphony (1-3). Finally, the Lexicon of the Latin Language
published in 1841 in Boston by Facciolati and Forcellini is unable to clarify
the terminology. Instead of settling the confusion it even adds to it: "Vitiligo
(vitium) a kind of leprosy or cutaneous eruption consisting of spots, some-
times black (?), sometimes white, called morphea, alphus, mel as, leuce; also in
general a cutaneous eruption according to Celsus and Pliny (second century
A.D.)" (2,4). Thus, it is probable that in ancient times the references to white
spots on the skin represented not only vitiligo vulgaris but also other
disorders, such as leprosy, that leave white spots on the skin (5). Only in the
2 Lotti et al.
last century has the term" vitiligo vulgaris" been used specifically to refer to
the acquired, progressive disorder characterized by destruction of melano-
cytes in the skin and other organs.
It seems likely that vitiligo was recognized several millennia before
Christian times. Some of the earliest references date from 1500 B.C. (I).
Vitiligo has long been confused with leprosy, which may account for the so-
cial stigma attached to white spots on the skin (6). The Egyptian Ebers
Papyrus (ca. 1500 B.C.) notes several types of leukoderma, one associated with
swelling of the skin, the other macular. The first type might be a description of
leprosy, the second a description of vitiligo vulgaris. In the early Vedic
scripture Alharvaveda (ca. 1500 B.C.) from India, a Kilar or white disease
that might represent vitiligo is described. Around 800 B.C., sVitra, meaning
"whiteness," is mentioned in the Charaka samhita, a medical treatise. In the
ancient Japanese book Amarakosa (1200 B.C.), a collection of Shinto prayers,
a disorder called Shira-bilo, meaning "white man," is described. Whether this
reference is to albinism, vitiligo, or both is not known. Hippocrates described
white spots on the skin but did not seem to distinguish vitiligo and leprosy or
other disorders of depigmentation (7). He described many features of vitiligo
that have been emphasized in recent years. He noted that the disorder was
more easily treated when first diagnosed rather than many years after its
onset. In the Bible a variety of disorders characterized by hypo- or depig-
mentation is described. The Talmud records the association of sudden onset
of white hair with vitiligo vulgaris (7). Mercurialis attempted to explain the
pathogenesis of the depigmentation in his book, De morbus cUlaneis, suggest-
ing that if phlegm or "mucous blood" rather than blood nourished the skin,
the skin turned white. He distinguished the disease from morphea, which he
thought was hyperpigmentation. He distinguished several different forms of
depigmentation and suggested some therapeutic approaches (8).
Near the end of the nineteenth century, when skin diseases were still
presented in alphabetical order in many textbooks of dermatology, vitiligo
was defined as a pigmentary dystrophy. Gottheil in the late nineteenth century
called vitiligo vulgaris a form of atrophy of the pigment cells (9).
Louis Brocq termed the lack of pigmentation (achromy) in vitiligous
lesions combined with increases in pigmentation (hyperchromy) in the
lesions's peripheries "dyschromy" (10). Kaposi was one of the first to describe
the histopathological features of vitiligo. He stated that the only anatomical
change in vitiligous skin is the lack of pigment granUles in deep rete cells. An
increase in pigmentation can be found in the surrounding lesions. Sparsely
pigment-laden cells in the corium are unable to add much to the clinical aspect
of the skin's pigmentation (II). Obscure etiological mechanisms such as
emotional stressors other than traumatic factors triggering the eruption of
vitiligo have been extensively discussed by dermatologists. For them, a con-
nection with the nervous system seemed to be evident (10). At the turn of the
Vitiligo: Disease or Symptom? 3
twentieth century, different approaches were developed to the treatment of

vitiligo. Systemic application of bromides or iodides (or also valerianates) of
mercury, antimony, and arsenic did not show much effect. Besnier recom-
mended subcutaneous injection of pilocarpine and saline or bromoiodic
baths. Different mixtures containing croton oil, iodine, sublimate, and naph-
thol ha ve been used topically without convincing therapeutic results (10,12).
PRESENT (PARTIAL) KNOWLEDGE: THE DARK SIDES

OF THE ACHROMIC DISORDER
Nowadays, vitiligo may be considered and defined as the prototype of the
hypomelanotic disorders (3). As is well known, it occurs idiopathically and is
acquired in most cases. Clinically, it presents with circumscribed leukoderma
that may arise at any age, but it usually appears before the age of 30 years.
Approximately 1--4% of the world population is believed to be afflicted. Vari-
able penetrant autosomal dominant inheritance has been suggested, because
familial incidence is common. Few or many white macules appear on the
exposed areas, such as the dorsal aspects of the hands and the face and neck.
Facial lesions are commonly located around the eyes and mouth. Body folds
(axilla and groin) may also be initial sites.
There are two major commonly recognized forms of vitiligo: generalized
and segmental. The generalized form is characterized by depigmented mac-
ules involving both sides of the body in a remarkably symmetrical pattern; for
each spot on one side of the body, a spot similar in size and location is found
on the other side. This type of vitiligo might better be labeled bilateral,
symmetrical vitiligo. Segmental vitiligo is characterized by unilateral, sym-
metrical depigmentation. It could be termed unilateral, asymmetrical vitiligo.
This sharply demarcated distinction may raise the question whether sym-
metrical and asymmetrical vitiligo present the same etiopathological factors
or if they represent two different and distinct nosological entities with similar
clinical pictures. Confusion may result from the symmetrical segmental forms.
One question that must be addressed concerns halo nevi. Halo nevi have
been associated with vitiligo and said to represent the same abnormality in a
limited form (13,14). Moreover, it has been observed that halo nevi can be
observed in almost a third of young patients (7). The question is: Are halo nevi
a form of vitiligo? The answer is as yet unknown.
VITILIGO BEYOND THE SKIN

Pigmentation of the ears and eyes may also show degenerative changes in
some patients with vitiligo. The eyes have two embryologically distinct layers
of pigment cells: Immediately behind the neuroretina is the retinal pigment
epithelium, which is heavilCBfj}mfjhWRt iYl:lfeYif1?nd layer is the uveal tract,
4 Lotti et al.
consisting of the choroid, the ciliary body, and the iris. Most patients with
vitiligo have few symptoms related to the eyes; they might note a slight
decrease in night vision or mild photophobia or slight headaches. Discrete
areas of depigmentation, with associated pigment hyperplasia involving the
choroid and retinal pigment epithelium as well as active uveitis, have been
observed in as many as 40% of patients with vitiligo according to Hann and
Nordlund (14). Moreover, vitiligo patients exhibit some audiological abnor-
malities, such as sensorineural hypoacusis, which may be related to involve-
ment of the inner ear melanocytes (14).
A few patients have very severe inflammatory eye problems associated
with vitiligo. This has been called the Vogt-Koyanagi-Harada or the uveo-
meningo-encephalic syndrome. This syndrome is characterized by the asso-
ciation of vitiligo, an inflammatory uveitis, and, in some patients, meningeal
inflammation and dysacusis. Eye involvement has been described both with
bilateral, symmetrical vitiligo and with unilateral, asymmetrical vitiligo
(Alezzandrini syndrome). The Vogt-Koyanagi-Harada syndrome has as
one manifestation dysacusis; this association suggests that melanocytotoxic
processes causing vitiligo can be active in the pigment cells of the stria
vascularis of the inner ear. These pigment cells have been demonstrated to
be essential for the normal function of the cochlea and provide a pathophys-
iological basis for loss of hearing in their absence (7). Thus, another very
important question is whether vitiligo represents only a cutaneous pigmentary
disorder or a systemic disorder of the pigmentary system. Because several
patients with vitiligo who have audiological and ophthalmological changes
generally do not present symptoms or have vague complaints, involvement of
melanocytes in the extracutaneous parts of the body is often overlooked.
Thus, the Vogt-Koyanagi-Harada and Alezzandrini syndromes might be con-
sidered the most severe manifestations of vitiligo of the skin and the pig-
mentation of the eyes. Many researchers tend to consider the Vogt-Koyanagi-
Harada and Alezzandrini syndromes to be different diseases from vitiligo,
according to Hann and Nordlund (14).
THE SPECIAL DEPIGMENTATION PATTERN OF VITILIGO

Microscopically, vitiligo features the nearly total absence ofmelanocytes and
melanin within the epidermis and an increased cellularity in dermal layers
(Figs. I and 2). Characteristic histochemical and ultrastructural changes can
be observed. The physical disfigurement caused by vitiligous lesions often
leads to social embarrassment (6), and it is a major sociopsychological prob-
lem in areas where dark skin predominates.
The causes of vitiligo are still unknown. Similarly, the precipitating
factors are not well delineated. Some factors, such as melanocytotoxic
FIGURE 1 Histological picture of vitiligo: a mild diffuse and follicular hyperkera-

tosis. The papillary dermis shows a minimal fibrotic change. In the basal layer of
the epidermis absence of melanocytes is suggested by a lack of cells with peri-
nuclear halo (E-E, x100).
FIGURE 2 Immunohistochemical staining of 8-100 reactivity in vitiligo: presence

of dendritic cells in superficial layers of the epidermis (Langerhans cells) and ab-
sence of reactivity in the basal layer of epidermis (melanocytes) (x 10).
6 Lotti et al.
chemicals and the Koebner phenomenon (also termed the isomorphic re-
sponse), are wel1-documented precipitating factors, but their mechanism of
action is not completely understood.
Depigmentation can be induced by the exposure of some individuals to
chemicals that typical1y are derivatives of hydroquinone. It seems that not al1
individuals are equal1y susceptible to the depigmenting effects of wel1-known
melanocytotoxic chemicals. Whether this manifestation is vitiligo or depig-
mentation caused by mechanisms different from those responsible for vitiligo
vulgaris is not known.
The first chemical to be identified as a melanocytotoxin was monoben-
zone (15). When workers wore gloves containing this chemical, it destroyed
the melanocytes in the skin, leaving the hands of the workers depigmented.
This agent has been used for the treatment of individuals with. vitiligo too
extensive to repigment (16). There are many other reports of workers in in-
dustrial settings exposed to chemicals with structures similar to monobenzone
who have developed depigmentation (17-19).
There are other reports of individuals developing depigmentation
following exposure to commonly encountered items. These include cosmetics
(20), possibly paraphenylenediamine hair dyes (21), monobenzone in bleach-
ing creams (22), cinnamic aldehyde in toothpaste (23), and derivatives of
hydroquinone in germicides (24). The question is whether such chemical or
occupational depigmentation is in fact vitiligo with a known precipitating
cause or some other depigmenting disorder. In our opinion, they are different
and separate disorders because chemical and occupational depigmentation
tend to be limited to the sites of exposure to the melanocytotoxic agent. In
addition, the clinical course of depigmentation differs: Vitiligo general1y tends
to be progressive throughout the life of affected subjects, whereas chemical
depigmentation generally stops spreading after the offending agent is
removed. Thus, until there are definitive data to show that the two disorders
have a common pathogenetic pathway, we prefer to separate vitiligo from
chemical and occupational leukoderma.
It is well known that even minor injuries to the skin of patients with
vitiligo can leave depigmented areas when healed. This is called the isomor-
phic response. Small cat scratches, abrasions from fal1ing, surgical wounds,
and similar injuries have all been observed to cause depigmentation. Many
individuals who develop a sunburn following excessive sun exposure attri-
bute the depigmentation to the burn. These individuals invariably have very
fair skin. It is possible that the isomorphic phenomenon activated by the
sunburn is responsible for the depigmentation in susceptible individuals.
Another explanation is that the individual burned because the skin was
depigmented already and did not have the benefit of the protective effects
of the pigment system. Gauthier has stressed the importance of the isomor-
phic response, suggesting that this phenomenon might explain the onset and
distribution of vitiligo (25). Repeated mild trauma associated with rubbing,
wearing of clothes, and gentle pressure on the skin was thought to ind uce the
depigmentation observed in vitiligo. Nevertheless, this hypothesis must be
substantiated.
Another question may be represented by gray or white hair: Do they
represent a form of vitiligo? Gray hair can be considered the aging of mela-
nocytes of hair follicles, a process associated with interruption of melano-
genesis (14). In contrast, white hair usually suggests the complete absence of
melanocytes from the papilla of the hair follicle. White hair can be classified
into two major types: the first type has a genetic or familial etiology and
represents a rather common ca use of partial loss of pigment of the scalp hair
in younger adults in the third and fourth decades of life. This type of white
hair seems to be different from vitiligo. The second type of complete white
hair is uncommon but may be associated with vitiligo. White hair is usually
accompanied by interfollicular depigmentation, particularly when it is asso-
ciated with vitiligo (14). It seems likely that loss ofmelanocytes in the follicles
of those wi th vi tiligo represen ts the same destructive process active wi thin the
hair bulb follicle.
PATHOGENESIS OF VITILIGO: DISEASE OR SPECTRUM?

The pathogenesis of vitiligo vulgaris is not known, but there are many
hypotheses extant, each supported by intriguing data that are outlined in
other chapters of this volume. We present them briefly here.
Autoimmune Hypothesis
Supporting this hypothesis are the clinical associations of vitiligo with
polyglandular failure. This might be the strongest clinical indication avail-
able.
Patients with lymphoma may develop vitiligo. Most such patients have
immune deficiencies that are the cause of freq uent infections that could cause
vitiligo (3,7). The same problem is encountered in acquired immunodeficiency
syndrome (AIDS) patients who develop vitiligo. It has been hypothesized that
such patients might be affected by vitiligo because their immune systems,
either humoral or cytotoxic, are impaired (7).
The antibodies to melanocytes have been implicated. Nevertheless, al-
though autoantibodies are commonly found in high titers in patients with
vitiligo, they are not melanocyte specific. Only about 60% of patients with
vitiligo have such antibodies; this might be explained by the presence of low
titers to the enzyme. Would such low titers be capable of killing melanocytes?
8 Lotti et al.
It has been suggested that subjects without antibodies might have inactive
disease. Thus, to make any conclusions about the presence of antibodies and
disease activity, careful clinical studies are needed.
Such antibodies could be the markers of the disease rather than the
cause of it. This consideration might explain why melanomas from humans
but also many animals share the same antigenic determinants identified by
these antibodies (some of which are cytoplasmic and not membrane mole-
cules) (7,26,27).
Tyrosinase is usually identified by antibodies. Tyrosinase is thought to
be expressed exclusively within the cytoplasm of the melanocyte and not on
the cell surface; therefore, the contents of the pigment cells are released into
the circulation, where they initiate an immune response. Whether the antigen
is an intracellular antigen also requires further investigation. It is still
unknown whether the response initiates, accelerates, or merely marks the
disease. Thus, these data need confirmation.
Antibodies can kill melanocytes in vitro. This suggests that the immune
system might be involved in some way in killing melanocytes, at least in some
patients with vitiligo.
Individuals with endocrine disorders but without vitiligo also had such
antibodies; this raises the obvious question of the roie of these antibodies in
killing melanocytes.
Antibodies can kill melanocytes in vitro and in nude mice bearing
human xenografts; this observation has been cited as definitive, but, unfortu-
nately, that is not a valid conclusion. The cytotoxic effects of the antibodies in
vitro are complex. The concentration of the antibodies and the antigens
involved all remain to be elucidated. Common antigens, such as class I MHC
complex, might be involved and make the effect nonspecific. These problems
are apparently resolved using nude mice, as the loss ofmelanocytes detectable
by DOPA oxidase might represent loss of the enzyme only and not destruc-
tion of the melanocytic cell (7).
Thus, the role of the antibodies remains to be determined. The plethora
of data relating to an autoimmune mechanism for some individuals with
vitiligo is very supportive of this hypothesis, but cannot be considered proof
of this concept.
Genetic/Intrinsic Hypothesis
Vitiligo clusters in families (28,29). This could be the result of environmental
melanocytotoxins that affect certain families because of where they live. More-
over, this theory could easily be subsumed in other theories, such as the auto-
cytotoxic or autoimmune theories.
The cells have some inherent defect (30,31). This seems inescapable. It is
not clear the nature of the insult that makes the melanocyte susceptible to
injury. It is possible that phenols are one environmentally responsible agent.

It is also possible that one of the numerous cytokines or chemical mediators of
inflammation stimulates the cell and in some way become responsible for
cellular death (32).
The genetic/intrinsic theory seems to be a vague one that can incorpo-
rate almost any abnormalities discovered.
Autocytotoxic Hypothesis
Vitiligo seems to affect hyperpigmented skin more often than normal-colored
skin (33). This observation does not seem verifiable.
The skin around body orifices such as the eyes, mouth, nose, and
genitalia is considered hyperpigmented and thus susceptible to vitiligo (33).
The skin around orifices like the eyes and mouth is darker in some individuals,
but that may be related to vascular abnormalities and not melanin concentra-
tions, especially around the eyes. The genitalia are darker, but vitiligo seems
to affect these tissues late in many patients. Thus, these clinical observations
appear very tenuous (7).
Chemicals with structures similar to melanin intermediates have been
added to cultures of melanocytes or melanoma cells, and the cells underwent
cytolysis (34,35). That melanin precursors have the potential to be cytotoxic
seems real. Compounds such as phenols and quinones in fact are highly
reactive. It seems that some of these compounds have a cytotoxicity specific
for melanocytes. These in vitro data are intriguing but remain to be confirmed.
It is now known that melanin formation begins in the transport vesicles.
These observations call for further understanding of how melanin
formation occurs, the opportunities for leakage into vital areas of the cell,
and the effects of stimulating melanogenesis on such leakage.
Neural Hypothesis
The melanocyte and the nervous system are both derived from the neural
crest. Both cell types use the amino acid tyrosine for their major end products
(melanin and catechols, respectively). Catechols are very similar in structure
to some of the intermediates of the melanin pathway. The mostly embyo-
logical data seem too weak to draw conclusions.
It also has been observed that patients that have sympathectomy can
develop a hypopigmented iris, an observation suggesting that the melanocyte
is innervated (34). This might be explained as due not to a cytotoxic reaction
but rather to a loss of stimulation of uveal melanocytes.
Ultrastructural studies demonstrate frequent direct contact between cu-
taneous nerve endings and melanocytes in vitiligous skin or structural alter-
ations (swelling ofaxons, duplication of the basement membrane, etc.)
(37,38); the significance of t~p.fPRJffi~81~t¥jm~h1M1dingsis still unknown.
10 Lotti et al.
Aberrations in f?,-endorphins and met-enkephalin secretion have been

reported in vitiligo patients (39). Plasma met-en kephalin levels are generally
higher in vitiligo patients (especially in ones with active vitiligo) than in
controls. Because it is known that the release of met-en kephalin is affected in
humans during stress, it has been suggested that this abnormality may be
correlated with the emotional stress suggested to precipitate vitiligo in some
patients. Moreover, immunohistochemical observations suggest an increased
immunoreactivity to neuropeptide Y and vasoactive intestinal peptide (VIP)
at the marginal areas or within vitiligo macules (40). These results are very
difficult to interpret, and very little is known about the effects of neuro-
pep tides on human melanocytes.
The depigmented skin exhibits abnormalities of the autonomic nervous
system (i.e., increased adrenergic tone and decreased parasympathetic tone)
(41). This should not be surprising as one of three major epidermal cells is
absent, at least functionally.
Segmental vitiligo has been one of the strongest clinical manifestations
suggesting a neural origin. It also has been suggested that segmental vitiligo
responds to therapy with agents that alter neural function (36). The distribu-
tion of segmental vitiligo is often said to be dermatomal. In actuality, it is not
dermatomal (7) (i.e., it does not follow a specific pattern of cutaneous sensory
nerves). It has been stated that without implicating the nervous system it is
difficult to explain segmental vitiligo. That might be true, but it is not sufficient
for generating an hypothesis.
The role of the nervous system in the pathogenesis of vitiligo, if any, is
still undefined. Furthermore, no functional association has yet been made
between melanocytes and neural cells.
Other Hypotheses
It has been suggested that melanin synthesis stimulated and altered by mela-
tonin generates radical oxygens, causing melanocyte death (42). The role of
melatonin in melanocyte physiology is completely unknown at this time. It
has an important role in some animals, including other mammals. It seems to
have less effect directly on melanocytes than on the production of melanocyte-
stimulating hormone, at least in other animals. It has not been shown to stim-
ulate free radical formation.
It has been suggested that a previously unrecognized biochemical path-
way for the production ofthioredoxin is involved in the death ofmelanocytes
(43,44). The synthesis of tyrosine in the epidermis and the production of
tetrahydrobiopterin have also been implicated (45,46). The latter pathway is
interconnected with the thioredoxin pathway. It has been suggested that the
depigmentation is a result of a blockade of tyrosine synthesis within keratin-
ocytes related to an excess accumulation of7-tetrahydrobiopterin within the

epidermis and catechols in the serum and tissues (45,46). The accumulation of
tetrahydrobiopterin is due to a deficiency in the activity of the enzyme 40'-
hydroxytetrahydrobiopterin dehydratase that normally recycles the biopter-
ins. The accumulation of 7-tetrahydrobiopterin blocks the production of
tyrosine from phenylalanine. It is concluded that the melanocytes are de-
prived of the essential substrate for synthesis of melanin and that, because of
this, the skin turns white. This pathway is intriguing, but the thioredoxin
reductase pathway is present in most tissues, and its existence in the skin or
melanocytes is still debated. Thus, its role in vitiligo is unknown but would be
a good candidate mechanism to support a genetic hypothesis. The role of
tetrahydrobiopterin remains to be determined. That melanocytes are present
in depigmented skin but incapable of synthesizing melanin due to lack of
tyrosine does not correlate well with other data. The histology of the depig-
men ted skin suggests an absence of melanocytes. Moreover, this hypothesis
does not explain the clinical problem of treating non-hair-bearing skin with
PUVA. Such skin usually does not respond well for lack of a reservoir. This
hypothesis suggests instead that all skin should respond to therapy in a similar
fashion (7).
Finally, a variety of animals developing vitiligo manifested progressive
depigmentation with loss of active melanocytes such as observed in chickens,
mice, cats, dogs, pigs, and horses. Nevertheless, because vitiligo is probably a
complex syndrome with multiple etiologies, each animal model may only
represent a facet of this complex condition. In fact, each of the several animal
models proposed (the Sinclair pig, C57 BL 76 mivi'mivit mouse, Smyth
chicken, etc.) helps in the study of different facets of melanocyte destruction;
however, until a specific marker of vitiligo is demonstrated, none of them can
be considered a specific model for this complex condition
CONCLUSIONS: IS VITILIGO A DISEASE OR A SYNDROMIC

SPECTRUM?
As stated above, the etiology and pathogenesis of vitiligo are not yet known.
There are many hypotheses extant, each supported by intriguing data that are
currently insufficient to prove the accuracy of the theory. It seems likely that
vitiligo vulgaris represents at least one, but more likely several processes that
cause melanocyte destruction and inactivation. That this is true is suggested
by the various clinical presentations. Besides the typical vitiligo vulgaris, there
is segmental vitiligo. It seems unlikely that the same mechanism is responsible
for both disorders.
Patients with associated polyglandular failure might represent another
mechanism. Individual patients present with atypical features. Occasionally a
12 Lotti et al.
patient might have many features of vitiligo vulgaris, such as depigmented

patches on the extremities, face, and trunk, but the classic distribution on the
fingers, feet, and face is not present. Some individuals show marked loss of
pigment from the hair; others show none. These differences might have no
importance or significance, or they might be hints that different mechanisms
are involved.
The various theories outlined above are intended to summarize current
popular hypotheses. These theories are not all-inclusive and also are not
mutually exclusive (7). It is possible that several mechanisms are operative to
produce melanocyte destruction in a given individual, as happens in the Smyth
chicken.
Thus, we believe that although the clinical picture is quite similar, the
etiology and pathogenetic mechanisms vary individual by individual; thus, we
propose considering vitiligo as a type of leukoderma involving progressive,
acquired depigmentation with unpredictable course. It usually involves integ-
ument and probably affects the pigmentary system of other organs. There are
other forms of leukoderma, but in our opinion these should be considered
distinct entities until more information is available about their pathogenetic
mechanisms, and these disorders should be classified as specific forms of de-
pigmentation, such as chemical, occupational depigmentation, or depigmen-
tation associated with melanoma. Finally, we agree with those authors who,
on the basis of recent investigation, support the hypothesis that melanocytes
are never completely absent in the depigmented epidermis and thus capable of
recovering their functionality.
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15. Oliver EA, Schwartz L, Warren LH. Occupational leukoderma. Arch Dermatol
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16. Mosher DB, Parrish JA, Fitzpatrick TB. Monobenzyl ether of hydroguinone: a
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Occupational vitiligo due to unsuspected presence of phenolic antioxidant by
products in commercial bulk rubber. J Occcup Med 1988; 30:512-516.
19. Tosti A, Gaddoni G, Piraccinl BM, De Maria P. Occupational leukoderma due to
phenolic compounds in the ceramic industry? Contact Dermatitis 1991; 25:67-68.
20. Catona A, Lanzer D. Monobenzone, superfade, vitiligo and confetti-like depig-
mentation. Med J Aust 1987: 146:320-321.
21. Taylor JS, Maibach HI, Fisher AA, Bergfeld WF. Contact leukoderma asso-
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22. Dogliotti M, Caro 1, Hartdegan RG, Whiting DA. Leucomelanoderma in blacks.
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24. Bentley-Phillips R. Occupationalleukodemla following misuse of a disinfectant.
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2
Historical and Psycho-Anthropological
Aspects of Vitiligo
Aida Morrone
Istituto Dermosifilopatico San Gallicano, Rome, Italy
INTRODUCTION
It is extremely difficult to investigate the historical origins of vitiligo due to the
fragmentary nature of the available data, the lack of conclusive historical
information, and the many philological interpretations of terminology that
for centuries contributed to making acceptable historical research difficult.
Dealing with the psycho-anthropological aspects is even more difficult, and
these are even now the subject of discussion and debate. Several authors have
described interesting historical aspects (1~6), but their statements are ques-
tionable due to difficulties and errors in interpretation. Research on the his-
torical aspects and definitions of vitiligo remind us that the earliest reports on
patchy skin disease appeared circa 1500 B.C. Vitiligo has long been confused
with leprosy, which is an important explanation for the social and psycho-
anthropological stigma attached to white spots on the skin.
ANCIENT REFERENCES
The earliest mention of patchy skin disease that can be interpreted as vitiligo
dates back to approximately 1500 B.C. The Ebers Papyrus, dealing with med-
icine in the age of the Pharoahs, describes two types of skin disease involving
changes in the color of the skin. One type, involving tumors and mutations, is
likely leprosy, since it is affirmed that "thou shalt not do anything to it" (I).
Copyrighted Material 15
16 Morrone
The other seems to simply involve a lack of pigmentation; it is likely to be

vitiligo, because "only a change in color is found." It is said that in this case a
cured was effected (2).
References from the same era are found in the ancient sacred books of
India, the Alharva Veda from 1400 B.C. (3), in which a disease called Shwela-
kustha is mentioned, which may be vitiligo. [Shwetakustha is derived from
shvet (white) and kushtha (skin disease in general) and according to the
Sanskrit dictionary means "making the body repugnant or deteriorating the
blood."] Village dwellers used the term charak, meaning something that is
hidden or which is spread, both indicating a negative social condition (4,5)
In the Alharva Veda, particular reference is made to a disease called
kilas. The term "kilas" comes from the Sanskrit word kil, which means
"white," in the sense of "casting away." In a 1905 translation of the Alharva
Veda, kilas was identified as vitiligo. In the same books, a plant with black
seeds is mentioned as being used by [ndians in an attempt to restore normal
color to discolored skin: "0 plant, thou produced even color! Render this
(spot) its uniform color." Ancient Indian medical literature indicates that the
plant generally used was the Bavachee, or Psoralea corylifolia (6). Later it was
discovered to contain psoralene, a photodynamically active furocoumarin.
In the sacred Buddhist book Vina)' Pitah (624-544 B.C.), the word "kilas" is
mentioned in reference to those affected by leukoderma.
A collection of Shinto prayers from the Far East, Makatominoharai
(1200 B.C.), mentions shira bitu, meaning "white man," which in some cases
could be interpretated as vitiligo. Another Indian medical compilation, the
Charak Samhita (800 B.C.), mentions a disease called sJlilra, a Sanskrit term
meaning "spreading whiteness." L 'Ashwngahida)'a (600 H.C.) attempts to
explain the prognostic factors involved in these eruptions (2).
In the Greek literature there is great emphasis on "white spots"; for
example, the historian Herodotus (484-425 B.C.) reported that foreigners
affected by these lesions have probably "sinned against the sun" and should
leave the country immediately (7). He wrote in 449 B.C.:
If a Persian has leprosy or white sickness he is not allowed to enter
into a city or to have dealings with other Persians, he must, they say,
have sinned against the sun. Foreigners attacked by this disorder are
forced to leave the country, even white pigeons are often driven away
as guilty of the same offense.
Even Aristotle dealt with whiteness of the skin, which at that time was a
disturbing sign, particularly among dark-skinned people (7):
Why do boys and women suffer less from white leprosy than men, and
old women more than young ones? [s it because leprosy is an escape of
Historical and Psycho-Anthropological Aspects of Vitiligo 17
breath, and bodies of boys are not well ventilated but are thick and
those of women are less well ventilated than those of men? For the
breath is absorbed in the menses; the smoothness shows the thickness
of the flesh. But the flesh of older men and of old women is well aired;
for they alone like old buildings have gaps in the construction of their
parts.
Aristotle also observed that gray hair was a feature of leprosy and reasoned
that those who do not get gray hair cannot have leprosy.
Although skin disorders with anesthesia and paresthesia were described
in seventh-century China, as were various skin disorders in India as far back
as 7000 years, and alopecia with sensory changes and skin disturbances in
the Berlin Papyrus and the Ebers Papyrus, no evidence of leprosy has been
found among ancient Egyptian mummies or in the pre-Columbian Amer-
icas (although ceramics of pre-Columbian Middle Andean civilizations dis-
play evidence of many other diseases). Leprosy must not have been partic-
ularly common, and many leukodermas must have been something other than
leprosy.
Beyond ancient descriptio!ls, the first clear account of leprosy, accord-
ing to Kaposi (8), was given by Danielssen and Boeck (9) in 1842. Since it is
not possible to find definite evidence for leprosy in texts until the nineteenth
century, much historical "leprosy" may, in fact, be vitiligo.
The Indian Manu Smirti (200 B.C.) describes sweta kushtha, meaning
"white disease"-skin lesions that probably indicated vitiligo (3). It also
reports on the lack of respect given people affected by svilra, the loss of skin
color. People who had stolen clothing in an earlier life would be reincarnated
as people affected by svilra.
It appears that skin disorders were reported much earlier in Chinese lit-
erature, but descriptions remain rather vague until 600 A.D., when Dohi wrote
about Pin-yiial1-hon-lul1, probably today's leprosy (7). In the book Al11arkosha
(600 A.D.) the term svitra was used as a synonym for padasphola (flowers on
the legs), tlllakpuspi (flowers on the skin), and sidhl71ali (spreading whiteness).
In ancient Arabic texts, white skin was expressed using the term baras
and others like bahak or bohak (3). The word baras is mentioned in the Koran
regarding Jesus (Chap.3, vA8 and Chap.S, v.1 09). The Koran states that' In
accord with the will of God, Jesus was able to cure those affected by 'baras'"
(10). Patchy skin lesions, likely of leprous nature, were the most important
skin diseases mentioned in texts from the early European medical schools up
to the end of the fifteenth century. At that time a new important differential
diagnosis arose in leukoderma syphiliticum, because the number of lepers
decreased and the "new" lues venera, later known as syphilis, began to spread
over Europe.
18 Morrone
BIBLICAL REFERENCES
The Bible refers to many different skin conditions using the Hebrew word
Zara' at. Some of these were interpreted as signifying sin, representing a
punishment sent by God. The biblical term indicates "white spots," but does
not necessarily denote vitiligo (7). The roots of the controversy over various
interpretations of Zara' at can be found around 25GB.C., when Ptolomy II
ordered the translation of the Bible into Greek in order to make it accessible to
a grea ter number of people. Referring to persons declared unclean by reason
of Zara' at, the scholars of the Septuagint used the term "leprosy," which
does not correspond to modern dermatological terminology. At the time,
theologians also proposed the term "psoriasis" as a synonym for conditions
involving whitening of the skin. The term seems useful as an alternative to the
biblical concept of leprosy, as it does not imply the idea of a moral sin and
indicates simply any "skin condition." For many years researchers have been
interested in the true nature of the biblical "white spots," and many have
established that not all references are to leprosy. Rather, they represent a
variety of skin conditions and sometimes also mean vitiligo (7).
"MODERN" DEFINITIONS
The term vitiligo was used for the first time by A. Cornelius Celsus in his
classic text De medicina, which today, after careful examination of its contents
and biographical notes, is thought to date from around 25 B.C. (11). Regard-
ing the roots of the term, there seems to be some difference of opinion among
experts (12-14).
ANCIENT TREATMENTS
In Egypt the use of Ammi majus Linn. for the treatment of vitiligo dates back
to the time of Ibn El Bitar in the thirteenth century (15). This plant was
mentioned in his book Mofradat Al Adwiya under the name of aatrillal, a
Berberian word meaning bird foot. In Egypt it is known as Regl El Ghorab,
Gazar El Shy tan, and El Khella El Shytani. It was called Al11mi by Gallen, and
in the time of Charles the Great it became Ameum (16). Ibn El Bitar stated that
the plant resembled apium, but its flowers were white rather than yellow; its
fruit resembled those of celery and khellah (Al11ni visnaga Linn.) but are
longer, narrower, and have a pungent and slightly bitter flavor. Ibn El Bitar
mentioned that the fruit of this plant was used in the treatment of baras
(vitiligo or leukoderma). He also mentioned that the first people to recognize
the usefulness of the drug were a Berber tribe in northwest Africa called the
Ben Shoeib. This tribe sold the drug to vitiligo sufferers but kept its nature
secret. El Sherif, quoted by Abou Shady (16), maintained that the drug, mixed
with dried "snake skin" and Ruta leaves, powdered and administered in doses
of 5 derhum for 5 successive days, would cure bohak, especially if the patient
remains in the sun until he sweats.
Aatril/a/, a yellowish-brown powder, was sold by a few native Egyptian
herbalists as a remedy for vitiligo. It was given in daily doses of 4-12 g,
followed by exposure of the affected patches to the sun until blisters formed.
Microscopic examination of the commercial powder Aatril/al revealed
that it is identical to the powdered seeds of Ammi majus Linn. Fahmy and
Abou Shady in 1947 isolated three crystalline compounds from the powder,
which were named Al11moidina (8-metoxipsoralene), Aml11idina (8-isoamili-
noxipsoralene), and Maiudina or Bergapten (5-metoxipsoralene) (17).
VITILIGO IN THE NINETEENTH CENTURY

Toward the end of the nineteenth century, when skin diseases were still
presented in alphabetical order in many dermatology textbooks, vitiligo was
defined as a pigmentary dystrophy. Louis Brocq (1856-1928) called the lack
of pigmentation (achromy) in vitiliginous lesions combined with an increase
in pigmentation (hyperchromy) at the periphery of the lesions "dyschromy"
( 18).
Moritz Kaposi (1837-1902) was among the first to describe the histo-
pathological features of vitiligo. He stated that the only anatomical change in
vitiliginous skin is the lack of pigment granules in deep rete cells. An increase
in pigmentation may be found in the surrounding lesions (19).
Obscure etiological mechanisms, such as emotional stress or other
traumatic factors, may trigger the eruption of vitiligo, and a connection with
the nervous system seemed obvious (18,20). At the end of the nineteenth
century various approaches were developed in the treatment of vitiligo.
Systematic application of bromides or iodides (also valerianates) of mercury,
antimony, and arsenic showed no evidence of effectiveness. Ernest Besnier
(1831-1909) recommended subcutaneous injections of pilocarpine and saline
or bromoiodic baths. Various topical mixtures of croton oil, iodine, sub-
limate, and naphthol have been used without useful therapeutic results
(18,20).
Casual use of the terms vitiligo and leukoderma introduced confusion
into the scientific literature of the last century and is still felt to this day. Beigel
in his 1864 memoir reserved the term vitiligo for those cases in which al-
teration of the structure and loss of skin pigmentation are observed (21). This
obviously is not the way vitiligo is diagnosed today. Pearson et aI., at the be-
ginning of the twentieth century, used the term leukoderma to designate a
disease that seemed to be vitiligo (22).
20 Morrone
VITILIGO AND SELF-IMAGE

Vitiligo today often causes social embarrassment (more serious in countries
where dark skin is predominant), and the peeled physical appearance of the
hypopigmented lesions is often an element in serious psychological distur-
bances, even among light-skinned people (Fig. 1). Although vitiligo is not a
serious illness on a biological level, it becomes one at the psychosomatic level:
The anthropological and cultural difficulties implied are such that they create
inevitable psychological and sometime psychiatric repercussions (Fig. 2).
The skin and the central nervous system, as we know, have a common
origin at the ectodermic level, and this common origin justifies the interest in
the skin of psychologists, psychiatrists, and neurologists. Even anthropolo-
FIGURE 1 Vitiligo major in an Eritrean patient. MUltiple depigmented macules

confluent in large achromic lesions spread to cover almost the entire body.
FIGURE 2 Vitiligo major in an Ethiopian child. Such depigmentation in dark-skinned

individuals can lead to serious identity and cultural problems and to difficulties in
their social inclusion.
gists have shown great interest when faced with some skin conditions where
cultural and environmental aspects present a peculiar role.
The connection between the skin and self-image begins very early in our
ontogenesis. In fact, as Anna Freud tells us, at the beginning of life, being
hugged, caressed, and blandished make the various parts of the child's body
sensitive. It helps the child construct a healthy body image and makes his or
her narcissistic libido grow, and it simultaneously promotes the love object by
consolidating the bond between mother and child (23). The skin is important
in relation to the development of the body-self and the mental-self because of
its fundamental tactile function. Among its many other functions, there is a
so-called "dermo-optical" function, defined by the psychoanalyst Didier
22 Morrone
Anzieu (24). This function presumes that the skin has some visual function
other than being visible. It is to this, the visibility of the skin, that cosmetology
is related. Another function of the skin is thought to be that it inscribes "sen-
sorial traces," a sort of pictogram (25). Dermato-cosmetologists are familiar
with the painting of faces and bodies in various anthropological-cultural
settings, from prehistoric times to now, as if the skin were a mirror that reflects
reality (26).
The skin constitutes an interface between us and the exterior world and
can be considered a sort of envelope that limits and contains our body and
conditions our exchanges between interior and exterior. Furthermore, if rep-
resents the visible self and the esthetic self. Due to its visibility, the skin may be
the site where conflicts regarding exhibitionism are expressed.
PSYCHO-ANTHROPOLOGICAL IMPLICATIONS OF VITILIGO

The importance of psychic factors in the etiopathogenesis of vitiligo is by now
largely recognized, and the dermatologist, as Panconesi states, should always
use a psychosomatic method that takes into account important relations
between acute and chronic emotional situations and the appearance or
worsening of the skin lesions of vitiligo (27).
The skin, because of its bio-physiological complexity, is analogous on
an organic level to the structural complexity of the "r" on the psychic plane.
Furthermore, it is the multiplicity of its functions that aJ]ows it to express itself
as the element of separation and delineation of the "1" and communicate with
the exterior world (28). The skin represents at the same time, as the organ that
contains the body, an element of separation from and means of communica-
tion with the outside world (29).
The consequences of vitiligo in the social and working life of the patient
are grave, especially in people working in professional fields in which the
hands and face represent a tool for interaction with the public. The disease
may also lead to manifestations of depression and anxiety that cause diffi-
culties in interpersonal relations (30).
Although vitiligo occurs everywhere and can affect all populations, it
represents a particularly serious problem for those people whose skin is nat-
urally dark (skin phototypes V and VI) due to the contrast produced by the
white patches. Even for patients with lighter skin who tan easily (phototype
IV), the disease may be perceived as disfiguring and constitute a true medical
tragedy and a simple esthetic problem. For thi reason, although vitiligo is
pain-free and not associated with kin flaking, as is psoriasis, it can be a dev-
astating pathology. The contrast between the normal skin color and the
white patches can intrude into daily life, marriage, family, friendships, and
even the workplace, and the fact that these patients suffer from inferiority
complexes, become aggressive, feel shame, and sometimes become isolated

and resentful is not surprising (3]).
The presence of hypopigmented lesions, particularly in dark-skinned
people, may produce psychic tensions and existential difficulties because of
the possibility of being mistaken for a person with leprosy. It is interesting to
read the personal correspondence of Dr. Marian Levai, an American physi-
cian who works in India, reported by Mosher et al. (32):
In South India where the old Dravidian language of Tamil is spo-
ken, the condition is known as ven kushtam, "white leprosy." It is
often confused with leprosy, which is very prevalent in this area. In
brown skin, leprosy starts as hypopigmented mactlles that may, in
later stages, become thickened, insensitive to touch and eventually
depigmented. Vitiligo, of course, shows only depigmentation but
one individual may show both hypopigmented and depigmented
macules in different parts of his body at the same time. The con-
fusion of vitiligo with leprosy in the public mind means that it is
difficult for young men or women to obtain jobs, especially when
involvement of the face or other exposed areas makes the disease so
conspicuous.... In India, women can easily retreat into the seclu-
sion of the home; one of my patients did not even want to be seen in
the hospital and requested treatment at home. Men, however, are
expected to maintain contact with a hostile and suspicious society.
In my experience, psychologic tension, nervousness and depression
because of vitiligo seem to be more apparent in the educated city
dweller.
The fact that vitiligo is a long-lasting disease increases the risk of it
becoming a major fact in the daily life of patients and families. Lesions on the
genitals cause great anguish to those afflicted. In fact, many young patients
with vitiligo on the genitals think they must be repugnant to their partners.
The involvement of the hair bulbs (hair is chalk white) also carries a heavy
weight of embarrassment and preoccupation (31).
CONCLUSION
Ginsburg highlights the fact that, when considerating the psychological
impact of a skin disease such as vitiligo, is is necessary to remember that
the patient's life situation, including the social support network, consisting of
family, friends coworkers, and neighbors (but also people known through
their professional capacity, such as physicians or teachers) provides emo-
tional warmth and support, as well as practical help, as with child care or
financial assistance (33,34). If the patient has a devoted family and friends, he
24 Morrone
or she will probably be able to weather the storm of emotions and practical
problems generated by this chronic skin condition much better than if this
network is weak or nonexistent. The attitude of intimates, the people closest
to the patient, is among the most important factors that determine the impact
of any skin disease, including vitiligo (31).
REFERENCES
1. Ebbell B. The Ebers Papyrus. Copenhagen: Levin and Munksgaard, 1937
2. Nair BKH. Vitiligo-a retrospect. Int J Dermatol 1978; 17:755-757.
3. Koranne RV, Sachdeva KG. Vitiligo. Int J DermatoI 1966; 93:744-753.
4. Whitney WD. Atharva-Veda Samhita (Translation and Notes). Harvard Ori-
ental Series 1905. Vol. 7. Cambridge, MA: Lanman, Harvard University Press,
1905.
5. Singh G, et al. Vitiligo in ancient Indian medicine. Arch Dermatol 1974; 109:913.
6. Fitzpatrick TB, Pathak MA. Historical aspects of methoxsalen and other
furocoumarins. J. Invest. Dermatol. 1959; 32:229.
7. Goldman L, Moraites RS, Kitzmiller KW. White spots in biblical times. Arch
Dermatol 1966; 93:744-753.
8. Kaposi M. On albinismus and leucoderma. In: Hebra F, Kaposi M, eds. On
Diseases of the Skin. Vol. III. London: New Sydenham Society, 1874: 170-177.
9. Goldman, et al. White spots in biblical times. Arch Dermatol 1966; 93:744-753.
10. EI Mofty AM. Vitiligo and Psoralens. New York: Pergamon, 1968.
11. Fitzpatrick TB. Hypomelanosis. South Med J 1964; 57:995-1005.
12. Ortonne JP, Mosher DB, Fitzpatrick DB, eds. Vitiligo and other hypomelanoses
of hair and skin. New York: Plenum, 1983:129-310.
13. Nordlund JJ. Vitiligon. In: Thiel'S BH, Dobson RL, eds. Pathogenesis of Skin
Disease. New York: Churchill Livingstone, 1986:99.
14. Sutton RL. On definition of vitiligo (lett). Arch Dermatol 1965; 91:288.
15. Ibn El-Bitar. Mofradat Al Adwiya. I. Egyptian Government Press, 1877:4. (In
Arabic.)
16. Abou Shady HAA. Ammi majus Linn Thesis for Master of Pharmacy. Fac Med
Cairo University, 1948.
17. Fahmy IR. AboLi Shady HAA. Pharmacognostical study and isolation of
crystalline constituent, ammoidin. J Pharm Pharmac 1948; 20:281.
18. Brocq L, ed. Traitement des maladies de la peau. Paris: Doin, 1892:853-855.
19. Kaposi M, ed. Pathologie und Therapie del' Hautkrankheiten. 5th ed. Berlin:
Urban Lind Schwarzenberg, 1899:624,703-707.
20. Neumann I, ed. Lehrbuch del' Hautkrankheiten. Vienna: Braumi.iller, 1880:438.
21. Beigel H. Beitrag zur Geschichte Lind Pathologie des Albinismus partialis und del'
Vitiligo. Nova Acta Akad, K K Leopold Karolin, 1864.
22. Pearson K, et al. A Monograph on Albinism in Man: Drapers' Company Re-
search Memoirs. London: DLilau, 1911.
23. Panconesi E, Cossidente, Giorgini S, et al. A psychosomatic approch to der-

matologic cosmetology. lnt J Dermatol 1983; 22:449-454.
24. Anzieu D. Le Moi-Peau. Paris: Borda, 1985:1-180.
25. Castoriadis-Aulaguier P. La violence de I'interpretation. Paris: P.U.F., 1975:1-
157.
26. Ovidio.l cosmetici delle donne. A cura di Rosati G. Venice: Marsilio, 1985: 1-78.
27. Panconesi E. Stress and skin diseases: psychosomatic dermatology. Clin Der-
mato11984; 2:1-272.
28. Obermayer ME. Psychocutaneous Medicine. Springfield, IL: Charles C Thomas,
1955
29. Pancheri P. Trattato di Medicina Psicosomatica. Vol. I. Firenze: USES Edizioni
Scientifiche, 1984:151-179.
30. LePooIIC, Das PK, Van Den Wijngaard R, Bos JD, WesterhofW. Review of the
etiopathomechanisll1 of vitiligo: a convergence theory. Exp Dermatol 1993;
2(4)145-153.
31. Hautmann G, Panconesi E. Vitiligo: a psychologically influenced and Influenc-
ing Disease. Clin Dermatol 1997; 15:879-890
32. Mosher D, Fitzpatrick T, Ortonne J, Hori Y. Hypomelanoses and hypermel-
anoses. In: Freedberg I, et aI., eds. Fitzpatrick's Dermatology in General Med-
icine. New York: McGraw-Hill, 1999:949.
33. Ginsburg TH. The psychological impact of skin disease: an overview. Dermatol
C1in 1966; 14:473-484.
34. Greenblatt M, Becerna RM, Sorafetinides EA. Social networks and mental
health: an overview. Am J Psychiatry 1982; 139:977-983.
3
Vitiligo: Epidemiology
Luigi Naldi
U.O. Dermatologia, Ospedali Riuniti di Bergamo, Bergamo, Italy
The main objective of epidemiology is to find a means to prevent disease onset

(primary prevention) and to restore health once a disease has developed (sec-
ondary prevention). Others are to evaluate and optimize health care. There
are limited data on vitiligo to help address these objectives.
DESCRIPTIVE EPIDEMIOLOGY
The usual measures used to describe the distribution of a disease in a given
population are incidence and prevalence. Incidence refers to those cases newly
developed in a population over a given time period. Prevalence refers to those
cases that are present in a given population, irrespective of their onset, at a
point in time (point prevalence) or over a longer period of time (period
prevalence). Prevalence depends on incidence and on the average duration of
the disease in the population. If a disease persists without a cure for a long
time, it may give rise to significant prevalence rates even if its incidence rates
are remarkably low. It should be noted that incidence estimates require an
onset for the disease to be precisely defined. For many chronic disorders
characterized by subtle prodromal signs and symptoms like vitiligo, such an
onset may be difficult to establish.
Data on the prevalence of vitiligo in the general population are limited.
Point prevalence estimates have been obtained by the First Health and
Nutrition Examination Survey (HANES I study) organized by the National
Institutes of Health during the period 1971-1974 in the United States and
28 Naldi
recruiting a representative sample of7514 people aged 1-74 years (1). Vitiligo
prevalence was estimated at 4.9 cases per 1000 people (3.8 cases per 1000
males, 6.2 cases per 1000 females). In the study, the prevalence of vitiligo
increased from 0.6 case per 1000 at age 1-5 years to 13.6 cases per 1000 after
age 65. A point prevalence estimate of 3.8 cases per 1000 was obtained in a
study conducted on the Bornholm Island in Denmark (2). These estimates are
lower than the I % commonly reported.
To the best of this author's knowledge, no estimates of incidence rates
are available. Based on the prevalence rates mentioned above and considering
that the disease tends to persist over time, it seems reasonable to foresee
incidence rates in the order of a few new cases per 100,000 people per year. The
median age at onset as estimated in a sample of patient members of the U.K.
Vitiligo Society, was about 13 years (3). In a study of 160 families with at least
one member suffering from vitiligo, the mean age at onset was estimated at
about 19 years among males and 24 years among females (4). Vitiligo is an
important cause of disability, especially in young people. In spite of not being
one of the ten most frequently reported skin disorders in the HANES I study,
vitiligo ranked fifth in the study among the diseases that were more frequently
reported as a reason for concern in the age group 25-34 years.
ANALYTICAL EPIDEMIOLOGY
The main purpose of analytical studies, including case-control and cohort
studies, is to identify factors that may influence the onset of a disease. Their
results are expressed in terms of relative risks or odds ratios. The relative risk
is the ratio of disease incidence among those exposed to a purported causal
factor (risk factor) to the incidence among the unexposed. When derived from
case-control studies, odds ratios provide an estimate of the relative risk.
Causation of vitiligo is a complex phenomenon, involving both genetic
and environmental factors. There are largely divergent estimates of the pro-
portion of individuals with vitiligo reporting a family history of the disease.
Reasons for such variations may include heterogeneous criteria to define cases
and different modalities to collect a family history of the disease. It should be
noted, for example, that it is quite plausible that a history of vitiligo in one
family member may influence the request of consultation for another family
member (ascertainment bias). Unfortunately, there are no data concerning
vitiligo patients sampled from the general population. In most studies, about
20% of people with vitiligo report a first-degree relative as suffering from
vitiligo. In a family study, children of the proband had a 1.7-fold increased
risk of developing vitiligo as compared with other family members (4). In the
same study, the risk of vitiligo as compared with the general population was,
respectively, 7-fold higher among the parents of the proband, 12-fold higher
Epidemiology 29
among brothers and sisters, and 36-fold higher among the proband's children.
The family aggregation of vitiligo does not indicate simple mendel ian trans-
mission. It has been proposed that several recessive alleles at different auto-
somal loci should interact in an epistatic way to develop vitiligo. A number of
studies on the association of vitiligo with major histocompatibility antigens
(HLA) have been conducted, but they are inconclusive, suggesting, at most,
the existence of heterogeneous associations in different ethnic groups: a pos-
itive association with HLA-DR4 and a negative one with DR3 in blacks, a
positive association with BW-35 among Yemenite Jews, a positive association
with DR6 in the Dutch population, and a positive association with the rare
DRW 12 antigen in the German population.
We are not aware of any formal analytical study assessing the potential
role of environmental factors in the development of vitiligo. Interestingly,
vitiligo has been associated with a number of pathological conditions which,
in many instances, are immune-related diseases (Table I). It should be noted
that, even if no confirmatory epidemiological data are available, the disease
onset is frequently associated with stressful life events. Finally, it is common
clinical experience to observe the development of new vitiligo lesions in the
skin site of a physical trauma (Koebner phenomenon).
CLINICAL EPIDEMIOLOGY: NATURAL HISTORY

AND PROGNOSIS
There are limited data concerning the natural history and prognosis of
vitiligo. A prognostic study should be based on a representative sample of
affected individuals followed for a sufficiently long period of time, loss to
follow-up should be reduced to a minimum, outcome measures should be
clearly defined at the beginning of the study, and adequate analytical methods
should employed (survival analysis, Cox models).
TABLE 1 Pathological Conditions Associated with Vitiligo
Alopecia areata
Pernicious anemia
IgA selective defect
Thyroid diseases (frequently associated with autoantibodies)
Addison's disease
Congenital melanocytic nevi
MELAS syndrome (mitochondrial encephalomyopathy,
lactic acidosis, and stroke episodes syndrome)
30 Naldi
Segmental vitiligo, which in many series accounts for 10-20% of the

affected individuals, have an earlier onset and a more rapid evolution as
compared with generalized vitiligo (5). Moreover, segmental vitiligo is rarely
associated with immune-related disorders, the Koebner phenomenon, or
stressful life events. Once it appears, vitiligo follows a chronic course. In
segmental vitiligo, disease activity seems usually to cease with the extension of
the disease to the involved dermatome within one year, while new lesions can
appear lifelong in generalized vitiligo. In a cohort study involving 61 patients,
the Koebner phenomenon, experimentally induced, had a prognostic value
correlated with disease activity (6).
According to a survey conducted on a large sample of patients mem-
bers of the U.K. Vitiligo Society, only about 14% of patients experienced a
spontaneous improvement of their disease at some point during their life.
Patients with a more limited extension of the disease more frequently re-
ported spontaneous improvement compared to patients with more extensive
disease (3).
Vitiligo has a remarkable impact on the patient's quality of life, well-
being, and social life (7). It has been documented that an intervention pro-
viding psychological support according to a cognitive-behavioral paradigm
may have an impact on the disease burden and severity (8). Few data are
available concerning factors that may influence therapeutic choices and pref-
erences of patients and physicians. In the already mentioned survey involving
members of the U.K. Vitiligo Society, about 40% of male patients and 70% of
females reported a regular use of camouflage, while only about 20% of all
patients had undertaken a medical or surgical procedures at the same stage of
their disease. A survey of 332 Dutch dermatologists documented that only
16% of all dermatologists regularly offered their vitiligo patients an active
treatment (9). There was no consensus on the active treatment of choice. Such
a situation may be common to other countries. In Holland it has been docu-
mented that the development and dissemination of clinical guidelines based
on the results of three systematic reviews resulted in better agreement between
dermatologists on treatment strategies. These systematic reviews indicated
that topical high-potency steroids and narrow-band ultraviolet B light ir-
radiation were the treatment modalities supported by the best available evi-
dence for, respectively, localized vitiligo and generalized vitiligo (10).
SUMMARY
Vitiligo is a relatively common skin disease affecting 3-5 individuals per 1000
people. The causative model probably involves genetic-environmental inter-
action, but the environmental factors are largely unknown. Epidemiological
research may contribute to a better understanding of the etiological and
Epidemiology 31
prognostic factors and aid in the evaluation of the long-term outcome of the
disease, improving its management.
REFERENCES
I. Johnson M-LT, Roberts J. Skin conditions and related need for medical care
among person 1-74 years. U.S. Department of Health, Education and Welfare
Publication No. (PHS) 79-1660, Hyattsville, MD, 1978.
2. Howitz J, Brodthagen H, Schwartz M, et al. Prevalence of vitiligo. Arch Der-
matol 1977; 113:47-52.
3. Agarwal G. Vitiligo: an under-estimated problem. Fam Pract 1998; 15:S19-
S23
4. Majumder PP, Nordlund JJ, Nath SK. Pattern of familial aggregation of viti-
ligo. Arch Dermatol 1993; 129:994-998.
5. Koga M, Tango T. Clinical features and course of type A and type B vitiligo. Br
J Dermatol 1988; 118:223-228.
6. Njoo MD, Das PK, Bos JD, Westerhof W. Association of the Koebner phe-
nomenon with disease activity and therapeutic responsiveness in vitiligo vul-
garis. Arch Dermatol 1999; 135:407-413.
7. Kent G, Al'Abadie M. Psychologic effects of vitiligo: a critical incident analysis.
J Am Acad Dermatol 1996; 35:895-898.
8. Papadopoulos L, Bor R, Legg C. Coping with disfiguring effects of vitiligo: a
preliminary investigation into the effects of cognitive-behavioural therapy. Br J
Med Psychol 1999; 72:383-896.
9. Njoo MD, Bossuyt PM, Westerhof W. Management of vitiligo. Results of a
questionnaire among dermatologists in the Netherlands. lnt J Dermatol 1999;
38:866-872
10. Njoo MD, Westerhof W, Bos JD, Bossuyt PM. The development of guidelines
for the treatment of vitiligo. Arch Dermatol 1999; 135:1514-1521.
4
Biology of Hypopigmentation
Giovanni Menchini and Torello Lotti

Evridiki Tsoureli-Nikita
University of Siena, Siena, Italy
Jana Hercogova
Jean Paul Ortonne
Hopital L'Archet 2, Nice, France
The substance responsible for skin color is melanin, a pigment produced by

melanocytes and transferred to surrounding keratinocytes. Absence or loss of
pigmentation of the skin is due to three main etiological factors: an absence/
loss of melanocytes, a deficit of melanin formation, or no melanocytic
etiology (Table I). The most frequent diseases characterized by white patches
are shown in Table 2, along with the related etio-pathogenesis of hypopig-
mentation.
CONGENITAL ALTERATION OF PIGMENTATION

The diseases characterized by congenital alteration of pigmentation are
normally due to a genetic defect that alters the melanin synthesis/distribution
or that regulates the multistep process of commitment of neural crest cells to a
differentiated cell type (primarily the melanocyte) or melanosome biology
(transport, transfer, biogenesis, melanization) (Tables 3-6) (44). Of the con-
genital alterations in pigmentation, only nevus anemicus is not characterized
Co)
.l:-
TABLE 1 Etiological Factors of Hypopigmentary Disorders
Melanocytopenic Melanopenic
Etiological (melanocytes decreased (melanin decreased Nonmelanocytic
factors or absent) or absent) (no melanin defect)
() Chemical Catechols Arsenicals

0 Monobenzylether of hydroquinone Chloroquin
<::l
~ Para-substituted phenols Glucocorticoids
'§: Sulfhydryls Hydroxychloroquino
CD Hydroquinone
0.. Mercaptoethylamines
s:
Q) Retinoids
CD Endocrine Addison's disease
~ Hypopituitarism
Hypothyroidism
Genetic Ataxia telangiectasia Albinism (Types I-III Nevus anemicus
Piebaldism oculocutaneous albinism)
Vitiligo
(Alezzandrini's syndrome, idiopathic,
Vogt-Koyanagi-Harada syndrome)
Waardenburg's syndrome s:
(1)
Woolf's syndrome ::J
(')
Xeroderma pigmentosum :T
::J
Ziprkowski-Margolis syndrome
Inflammatory Actinic reticuloid
Mycosis fungoides
Leprosy
Pityriasis alba
Woronoff's ring
-
(1)
~
CJ
Onchocerciasis Postinflammatory (OLE, o'
Pityriasis lichenoides chronica eczema, psoriasis) o
(Q
Pinta Post-Kala-Azar '<
Yaws Sarcoidosis
Syphilis -
o
::r
'<
Tinea versicolor "0
o
Metabolic Alpert's syndrome "0
cO'
Chromosomal 5p defect 3(1)
-o-'
Osteopathic striae :;,
Prolidase deficiency I II
Para-neoplastic Leukoderma acquisitum Melanoma (Halo)
() :;,
centrifugum
.g Nutritional Vitamin B 12 deficiency Chronic protein loss
~
Kwashiorkor
'§: Malabsorption
CD
0.. Nephrosis
~ Physical Burns (ionizing, thermal, UV) Trauma
Ulcerative colitis
Postdermabrasion
CD
~ Miscellaneous Alopecia areata
Postlaser
Canities Anemia
Scleroderma Horner's syndrome Edema
Idiopathic guttate
Hypomelanosis
Vagabond's leukoderma
Co)
U1
36 Menchini et al.
TABLE 2 Dermatological Diseases Characterized by White Patches
Disease Etio-pathogenesis
Congenital
Tuberous sclerosis The inheritance is autosomal dominant;
the hypopigmented ash-leaf macule
shows normal melanocyte numbers
with decreased pigmentation. Electron
microscopy shows smaller melanosomes
with defective melanization.
Oculocutaneous albinism } Mutations in genes that regulate the
types 1, 2, and 3 multistep process of melanin synthesis
Ocular albinism and distribution by the melanocyte are
Chediak-Higashi syndrome the basis for these diseases.
Hermansky-Pudlak syndrome
Waardenburg's syndromes Failure of melanocytes in the skin, eyes,
types 1,2 & 3 and/or ears to become completely or
Apert syndrome partially established in their target sites
Pfeiffer syndrome during embryogenesis.
Jackson-Weiss syndrome
Crouzon syndrome
Hirschsprung syndrome
Piebaldism
Hypomelanosis of Ito Genetic unidentified mosaicism;
the number of melanocytes is decreased,
and the amount of melanin in
hypopigmented areas is decreased.
Nevus-anemicus Results from a congenital anomaly in
which vascular hypersensitivity is localized
to catecholamines. The melanocytes are
preserved and regularly distributed.
Non-congenital
Tinea versicolor Skin lesions are either hypopigmented
or hyperpigmented. In patients with
hypopigmentation, tyrosinase inhibitors
competitively inhibit an enzyme necessary
for melanocyte pigment formation. In
hyperpigmented macules, there is
enlargement of melanosomes made by
melanocytes in the basal layer of
the epidermis.
Idiopathic guttate The exact cause is not agreed upon;
hypomelanosis however, it is hypothesized that ultraviolet
light plays an important role. Significantly
less dopa oxidase-positive, KIT +, and
melanocytes are seen in the lesions
. ht <;QiTlPtared,to normal skin.
C opyng ea lVIalena
Biology of Hypopigmentation 37
TABLE 2 Continued
Disease Etio-pathogenesis
Pityriasis alba The cause is unknown. On electron

microscopy, reduced numbers of
active melanocytes and a decrease
in number and size of melanosomes
are seen in affected skin.
Vitiligo Unknown. Autoimmune processes and/or
hydrogen peroxide accumulation are the
most probable causes.
by a genetic defect related to melanocyte. The congenital hypopigmentary

diseases that result in one or more defects in the production of melanin due
to dysfunction of melanocytes in the skin, eyes, and/or ears are the follow-
ing: oculocutaneous albinism (OCA) types 1,2, and 3; ocular albinism (OA)
(I); Chediak-Higashi syndrome (CHS); and Hermansky-Pudlak syndrome
(HPS).
These diseases all present with a generalized complete or partial loss of
pigmentation of the skin and hair (Fig. lc). Mutations in genes that regulate
the multistep process of melanin synthesis and distribution by the melanocyte
are the basis for these diseases:
OCA type I results from mutations in the tyrosinase gene, which maps
to human chromosome Ilq 14-2 and is inherited as an autosomal
recessive trait.
OCA type 2 (2) results from mutation in the P gene, which maps to
human chromosome 15qll-13 and is inherited as an autosomal re-
cessive trait. The function of the P protein in melanin synthesis has yet
to be determined, but it is probably related to the altered melanosome
biology.
TABLE 3 Disorders of Melanosome Transport and Transfer
Human disease Mouse model Gene mutated Protein function
Griscelli syndrome
GS1 Rab27A Movement of
melanosomes
CTL granule secretion
Myosin Va Movement of
GS2
melanosomes
38 Menchini et al.
TABLE 4 Disorders of Melanosome Biogenesis
Human disease Mouse model Gene mutated Protein function
Hermansky-Pudlak
syndrome (HPS)
HPS1 Pale ear Human type 1: Trafficking of
HPS1 melanocyte-specific
proteins
HPS2 Pearl AP3B1 Lysosomes trafficking
of membrane
proteins
HPS3 Cocoa Human type 3: ?
HPS3
HPS4 Light ear Human type 4: Similarity with HPS1
HPS4
Chediak-Higashi Beige CHS1 Membrane protein
syndrome
OCA type 3 results from mutation in the tyrosinase-related protein-l

(TRP-I) gene, which maps to human chromosome 9p23 and is inher-
ited as an autosomal recessive trait. These mutations provoke both
alterations in melanosome maturations and reduction in melanocyte
proliferation.
OA, CHS, and HPS genes are known (Xp22.3-22.2, Iq42-43, and
1Oq23.l-23.3, respectively) but although they encode proteins of still
unknown functions, they seem to be related to melanosome and Golgi
melanocyte functions.
Waardenburg's syndromes 1-3 and the Apert, Pfeiffer, Jackson-Weiss,
and Crouzon syndromes (A, P, J-W, and C), Hirschsprung syndrome, and
piebaldism (Fig. Id) are all characterized by the complete or partial absence of
melanocytes in the skin and hair. Mutations in genes that regulate the
multistep process of commitment of neural crest cells to a differentiated cell
type (primarily the melanocyte) are the basis for these diseases. These
mutations result in a failure of melanocytes to reach their normal destination
in developing skin, hair, eyes, and ears during embryogenesis (3-7).
Hypomelanosis ofHo (HI) is a syndrome with hypopigmented whorls of
skin along the Blaschko lines described for the first time by Ito in 1952. HI
appears to be the negative image of incontinentia pigmenti (IP). Chromo-
somal mosaicism and sporadic mutations are considered to be the causes, but
the identification of a specific altered gene has not yet been confirmed. How-
CD
0'
0'
(Q
TABLE 5 Disorders of Melanosome Melanization

-
'<
o
:I:
'<
"t:I
o
"t:I
\0'
Mouse gene 3
Human pigmentation
disorder
Oculocutaneous
locus and
mutant name
Tyr (albino)
Human gene
product
Tyrosine (11 pi)

Proposed functions
Limiting enzyme
General structure
Type 1 transmembrane
--
CD
;:,
III
o;:,'
()
0 albinism type 1 in melanin biosythesis protein
~ (OCA1)
~,
::':3" Oculocutaneous P (pind-eyed dilute) P (15q11.2-12) Melanosome Protein containing 12
CD albinism type 2 acidification transmembrane
0.. receptor
(OCA2)
s::
OJ Oculocutaneous Tyrp (brown) TRP1fTyrp1 Melanin Type 1 transmembrane
CD albinism type 3 (9p23) biosynthesis/tyrosinase protein
~ (OCA3) stabilization
Oculocutaneous Uw (underwhite) MATP (15p) Membrane-associated Sucrose transporter
albinism type 4 transporter protein
(OCM)
w
CD
~
o
TABLE 6 Disorders of Melanocyte Development
Human disease Mouse model Gene mutated Protein Function
Piebaldism Dominant spotting C-kit (4q11-12) Kit tyrosine kinase Melanocyte

()
o migration/development
~ Waardenburg's syndrome
~. WS1 Sploch PAX3 (2q35) Pax3 transcription Transcription
~
0..
factor factor/melanocyte
survival
~ WS2 Microphthalmia MITF (3p12-14) MITF transcription
factor
Transcription
factor/melanocyte
CD
~ Sploch PAX3 (3p12-14) Pax3 transcription
survival
factor
WS3 Dominant megacolon SOX10 (22q13) SRY-box containing Transcription
gene 10 factor/melanocyte
development
WS4 Lethal spotting EDN3 (20q13.2-13.9) Endothelin-3 Melanocyte development
Piebald spotting EDNRB (13q22) Endothelin receptor B Melanocyte development 15:
(1)
j
(")
::T
j
~
~
I a) Normal
I b) Vitiliqo
I c) Albinism I
I d) Piebaldism I
xX
)) X ii \""'\,
} 1 ()
vvvvvv \J \....v vvVJ '~ U
.
"'\1 J
~ .....
LEGEND
r ( Melanocyte
Melanin
o0 ~Pidermal keratinocytes
Lamellae of stratum corneum

1 Piamented -I
I Not oiamented =1
FIGURE 1 (a) In normochromic healthy skin, some melanocytes synthesize and

transfer melanin to keratinocytes, giving the normal color to the skin. (b) During
vitiligo, loss of melanocytes results in areas of hypopigmented skin. (c) Albinism is
characterized by a genetic defect that causes a partial or total deficit of melanin
synthesis, while melanocytes are normally represented. (d) Piebaldism is charac-
terized by a genetically produced amelanosis due to failure of melanocyte migra-
tion to the skin during embryogenesis.
42 Menchini et al.
ever, some authors believe that IP and HI are distinct diseases with separate
gene loci: Xp28 for IP and 9q33-ter, 15qll, Xpll, and Xp21.2 for HI (8).
Nevus anemicus, described first by Vomer in 1906, is a congenital lo-
calized vascular anomaly that presents clinically as a hypopigmented macule
or patch. This disorder is believed to be related to a localized hypersensitivity
to catecholamines. Nevus anemicus is best termed as a "pharmacological ne-
vus" resulting from increased vascular sensitivity to catecholamines (9).
NONCONGENITAL ALTERATION OF PIGMENTATION

Tinea versicolor is a chronic superficial cutaneous fungal infection caused by
M alassezia fUijur. Azelaic acid produced by the fungi through oxidation of
unsaturated fatty acids of skin surface lipids competitively inhibits tyrosinase
and, consequently, melanocyte.pigment formation (10).
Idiopathic guttate hypomelanosis (IOH) is an acquired, benign leuko-
derma of unknown etiology. It is most commonly a complaint of middle-aged,
light-skinned women, but is increasingly seen in both sexes and older dark-
skinned people with a history of chronic sun exposure. The exact cause is not
agreed upon. It has been hypothesized that ultraviolet light plays an impor-
tant role in the development of leukoderma (II).
Pityriasis alba is a common hypopigmented dermatitis that occurs
primarily in school-aged children. There can be numerous (up to 20 or more)
hypopigmented macules, which are well defined and range in size from 1 to 4
cm. A minority of patients have erythema and pruritus that may occur prior
to the appearance of the lesions. A subgroup of patients has associated atopy.
In these subjects stigmata of that disorder may be found.
Histological findings are nonspecific; however, findings may include a
basal layer with irregular pigmentation, follicular plugging, edema between
epithelial cells (i.e., spongiosis), or atrophy of the sebaceous glands. On
electron microscopy, reduced numbers of active melanocytes and a decrease
in the number and size of melanosomes are seen in affected skin (12).
VITILIGO
Depigmentation resulting from vitiligo is due to loss of melanocytes (or
melanosomes) for unknown reasons because of scarce and controversial
findings in microscopic specimens (Fig. 1b). On the basis of serological,
genetic, immunohistochemical, and metabolic findings, several pathogenetic
mechanisms have been proposed (Table 7). In particular, two main areas of
research are presently very promising and not reciprocally exclusive: the first
examines melanocyte metabolic processes in tetrahydrobiopterin (BH 4 )-
impaired homeostasis to explain the presence of abnormal levels of 6-bio-
TABLE 7 Vitiligo: Hypothesized

Pathogenetic Mechanisms
Pathogenetic hypothesis
Autoimmune
Hydrogen peroxide accumulation
Viral
Stress
Infections
Melatonin receptor dysfunction
Impaired melanocyte proliferation
Impaired melanocyte migration
Neurological factors
pterin (via H 2 0 2 oxidation of BH 4 ), which is cytotoxic for melanocytes, and

the second analyzes the autoimmune response promoted by cytotoxic
CD8 + T lymphocytes versus melanocytes.
METABOLIC PATHOGENESIS OF VITILIGO

During the last decade several metabolic abnormalities were demonstrated in
the epidermis of subjects affected by vitiligo (14-17) (Table 8). On these
findings are based the most important theories of nonimmune pathogenesis of
vi tiligo. In particular, some authors have stressed the importance of increased
sensitivity of melanocytes to peroxidative agents as a pathogenetic factor in
TABLE 8 Epidermal Metabolic Abnormalities in Vitiligo
Epidermal metabolic abnormalities Levels Ref.
6BH 4 levels T 15
7BH 4 levels T 21
PAH activity 1 16
DH dehydratase activity 1 15
H20 2 levels T 15
Catalase levels T 16
Phenylethanolamine-N-methyltransferase activity 1 22
R>2-Adrenoceptors i 17
c-kit receptor 1 18
Calcium uptake 1 25
Norepinephrine levels T 29
44 Menchini et al.
vitiligo (13). Although the causes of weakness in scavenging free radicals

produced during melanin biosynthesis are still not clear, two theories are most
convincing: epidermal accumulation of H 20 2 and abnormal expression of
tyrosinase related protein-l (TRP-I).
H2 0 2 Accumulation
To evaluate this interesting hypothesis recently stressed by Schallreuter et al.
(14-17), it is necessary to focus on some peculiar aspects of melanogenesis and
on the synthesis/recycling of 6(R)-L-erythro-S,6, 7,8-tetrahydrobiopterin
(6BH 4 ).
Both keratinocytes and melanocytes are capable of de novo synthesis,
regulation, and recycling of 6BH 4 . During melanin synthesis, 6BH 4 is the
cofactor for the hydroxylation of L-phenylalanine into L-tyrosine by phenyl-
alanine hydroxylase (PAH). In this reaction 6BH 4 is reduced into 4a-OH-BH 4
(DH). The newly formed DH is dehydrated in to quinonoid dihydrobiopterin
(q-BH2) by DH dehydratase. The 6BH 4 recycling is completed with the fol-
lowing NADH-dependent reduction. The rate-limiting step in the synthesis of
6BH 4 is represented by the levels of guanosine triphospate cyclohydrolase I
(GTP-CHI) which uses GTP as a starting substrate.
In vitiligo patches there is increased de novo synthesis and recycling of
6BH 4 with low DH dehydratase activities. The 6BH 4 accumulation with a low
DH dehydratase activity causes abiogenic formation of 7-isomer (7BH 4),
which severely inhibits the activity of both PAH and tyrosinase-fundamen-
tal enzymes that playa pivotal role in melanin biosynthesis (Fig. 2). The
barely detectable activity of PAH is not sufficient to transform enough L-
phenylalanine, which increases in vitiligo patches (20-22). Melanocyte accu-
mulation of L-phenylalanine and 7BH 4 causes, thanks to decreased DH and
PAH activities, the production of H 2 0 2 during a short circuit in the 6BH 4
recycling process.
The high H 2 0 2 levels accumulated (IS) are cytotoxic, especially for
melanocytes, because they can: (a) deactivate catalase (16), a catalyst for the
conversion of hydrogen peroxide into water and oxygen (it has one of the
highest turnover numbers for all known enzymes-40,000,000 molecules/s);
(b) oxidize 6BH 4 and 7BH 4 into 6-biopterin, which is cytotoxic for melano-
cytes and induces activation of dendritic cells followed by selective T-cell
proliferation (24).
Nowadays, the first step, which leads to the impairment of DH activity
or the accumulation of H 2 0 2 still remains obscure. Another important
enzyme involved in the pathogenesis of vitiligo is thioredoxin (TR), which
is an electron acceptor in 6BH 4 recycling and a reducing agent for hydrogen
peroxide, superoxide anion, nitric oxide, and glutathione at pH 7.0 (26,27).
First pathogenetic stressor

(metabolic, immune, viral ?)
IL-2, IL-8. IL-6, TNF, IFN-y
FIGURE 2 Possible abnormal cellular and humoral immune mechanisms of viti-

ligo. Antigens produced by melanocytes (MC) can be recognized by antigen-spe-
cific immune effector cells including cytotoxic T cells, T helper cells, and B cells.
After processing of antigens by antigen-presenting cells (APC), antigenic peptides
are presented to the T-cell receptors of cytotoxic T lymphocytes in the context of
major histocompatibility complex (MHC) class I molecules. Cognate help (via cyto-
kine production) by antigen-specific T helper cells, in the context of antigenic pep-
tides presented on MHC class II molecules, is required for a long-lasting cytotoxic
T-cell response against melanocytes that can lead to their destruction. In humoral
immunity, antigens are captured by the antigen-specific membrane immunoglob-
ulins of B cells (LyB) . The production and secretion of antigen-specific antibodies
by B cells are also dependent on cognate help (via cytokine production) by antigen-
specific T helper cells (CD4+). Anti-melanocyte antibodies can destroy pigment
cells by either antibody-dependent complement-mediated damage or antibody-
dependent cell-mediated cytotoxicity.
46 Menchini et a!.
The thioredoxin production in both keratinocyte and melanocytes is induced

by UV-B irradiation.
Even if this theory is proved by adequate laboratory tests and the H 2 0 2
removal is accompanied by some vitiligo patch repigmentation (25), several
vitiligo clinical characteristics do not find any adequate explanation fitting
within this theory.
Abnormal Expression of TRP-1

The normal synthesis and distribution of melanin is a highly regulated process
restricted to melanocytes and retinal pigment epithelium. A variety of pig-
ment regulatory genes have been identified in the melanin biosynthesis
pathway or localized to the melanosome. The rate-limiting enzyme in mela-
nogenesis is tyrosinase, and the deposition of melanin in the melanosomal
matrix may require TRP-l, TRP-2, and Pmel 17. These proteins and other
melanocytic proteins are presently being used as targets for the immunother-
apy of melanoma. In the setting of this immunotherapy of melanoma, vitiligo
is a well-known and not unusual side effect.
Mutation in the TRP-l protein is associated with oculocutaneous
albinism type 3 in humans (26) and with brown pelage in the mouse (27).
These mutations both provoke alterations in melanosome maturation and
reduction in melanocyte proliferation, opening a new field of research in
vitiligo pathogenesis.
AUTOIMMUNE PATHOGENESIS
An autoimmune pathomechanism in vitiligo is supported by certain evidence:
(a) vitiligo is associated with several autoimmune diseases (thyroiditis,
diabetes, atrophic gastritis, etc.); (b) effective therapies in inducing repigmen-
tation also have immunosuppressive effects (i.e., corticosteroids, ultraviolet
radiation, cytotoxic drugs); (c) immunotherapies for melanoma often cause
vitiligo patches; and (d) many vitiligo patients have abnormal serum levels of
autoantibodies and autoreactive T cells against melanocyte antigens. Certain
major histocompatibility complex (MHC) antigens, polymorphisms of the
cytotoxic T lymphocyte antigen 4 (CTLA-4) gene, and mutations in the
autoimmune regulator (AIRE) gene have all been associated with the devel-
opment of autoimmune disorders like vitiligo (Table 9) (18,19,41). A recent
study shows that on chromosome I there is a locus associated with suscep-
tibility to autoimmunity and particularly to vitiligo (41). This hypothesis
supposes that, in presumably genetically predisposed subjects, autoimmunity
arises as a secondary phenomenon following melanocyte destruction resulting
from other factors. Aberrant T-cell reactivity (genetically predisposed/
TABLE 9 Immunological Abnormalities in Vitiligo Subjects
Immune system Vitiligo abnormalities
MHC Class III C2 deficiency (28), C4 increased

frequency of heterozygous (29)
Peripheral T cells Circulating T cytotoxic lymphocytes
specific for MelanA and tyrosinase (31,32)
T-cells in vitiligo patches T cytotoxic lymphocytes specific for
MeianA/MART1 (32)
Cytokines Granulocyte-macrophage colony-stimulating
factor (GM-CSF), growth factor for
melanocytes (21), is reduced in patients with
active vitiligo (33,42)
Macrophages Increased numbers in perilesional skin (40)
induced) most likely arises and causes vitiligo after being stimulated by
antigens from the released melanocytes due to their destruction by non-
immunological mechanisms (viral/bacterial infections melanocyte metabolic
stress, physical/chemical skin injury, etc.) (Fig. 2). One of the most important
antigens implicated in this function is MelanA, as recently stressed by Lang
et al. (27).
Both cellular and humoral immunity are probably involved in the
pathogenesis of vitiligo, even if the former is considered the most important
and the first chronological aberration by the majority of experts in the world.
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40. Van del' Wjngaard R. Local immune response in skin of generalized vitiligo
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50 Menchini et al.
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5
Disorders in Healthy Relatives of Vitiligo
Patients
Abdel Monem EI Motty, Medhat A. EI Motty,

and Samia M. Esmat
Cairo University, Cairo, Egypt
FAMILY HISTORY OF VITILIGO

A family history has been reported in 6.25-38% of vitiligo cases in different
studies (I-II). About 20% of vitiligo patients have at least one first-degree
relative with vitiligo (12). Children are at greatest risk, followed by sisters and
brothers (siblings), parents and grandparents (I). A positive family history of
vitiligo was reported in about II % in India (13) and Korea (14) compared to
around 34% in the French West Indies (6) and Omani patients (15). No
significant difference could be detected in the positivity of family history of
vitiligo between children and adult cases (14,16).
ASSOCIATION OF VITILIGO WITH OTHER DISORDERS

The first report of vitiligo in association with other disorders was that
of Thomas Addison, who reported in 1855 the association of vitiligo with
adrenal insufficiency (17). In his report of 13 cases of adrenal insufficiency, one
case had vitiligo and another had halo nevus. This was followed by many
studies that revealed the common association of vitiligo with Addison's
disease (18). Vitiligo is now believed to be one of the most frequent auto-
immune abnormalities accompanying Addison's disease (19), but it is a very
rare sign of secondary adrenal insufficiency (20). Other autoimmune endo-
52 EI Matty et al.
crine diseases showed increased incidence with vitiligo. The increased inci-
dence of adult-onset diabetes mellitus has been reported in vitiligo patients. In
a study of 512 patients with this type of diabetes, 25 cases (4.9%) had vitiligo
(21). A clinical association of vitiligo with juvenile diabetes could not be
proven (22). However, reported cases of juvenile diabetes mellitus associated
with vitiligo were suggested to have a genetic predisposition (23). Vitiligo is
one of the important associations reported with pernicious anemia (24).
Pernicious anemia had an incidence of 3.7% in vitiligo patients, which is 30
times higher than in the general population (25). An increased association of
vitiligo with polyglandular dysfunction has been reported (26), where vitiligo
might precede the glandular disorder by many years (27). Association with
myasthenia gravis was also reported (28). Vitiligo is one of the common
dermopathies associated with autoimmune thyroid disease (29-31). Among
other organ-specific autoimmune diseases, a statistically significant associa-
tion was observed by Schallreuter et a!. in thyroid disorders, while no others
could be confirmed (32).
The prevalence of malignant melanoma was found to be seven times
more common in vitiligo patients than in the normal population (33).
Many other associated autoimmune cutaneous disorders have been re-
ported. These include alopecia areata (13,34), psoriasis (35), atopic dermatitis
(13), dermatitis herpetiformis (DH) (36), and collagen diseases such as rheu-
matoid arthritis (37), lupus erythematosus (LE) (38,39), and scleroderma (40).
Reports are also present on associations with other diseases involving the
immune system, such as lymphomas (42), Sezary syndrome (43), and acquired
immunodeficiency syndrome (AIDS) (44). A high prevalence of vitiligo in
patients with lepromatous leprosy was also reported (44).
Premature graying of hair is a common finding in vitiligo patients, while
halo nevus occurs in 50% of cases (45). In a recent study on 1,436 patients, 2%
had associated halo nevi, 1.4% had atopic dermatitis, 0.7% had bronchial
asthma, 0.6% had diabetes, 0.5% had thyroid diseases, and 0.4% had alo-
pecia areata (13).
In a survey of two large patient groups by the Vitiligo Society in the
United Kingdom and the National Vitiligo Foundation in the United States,
which included 2,040 vitiligo patients, results revealed that the prevalence of
nonvitiligo autoimmune disorders was greater among the U.S. group (43%)
versus the U.K. group (21 %). Thyroid diseases comprised half of these as-
sociations. No correlation could be detected between the incidence of these
disorders and the family history of vitiligo (46). It was found that autoimmune
disorders occurred more frequently in patients with nonsegmental vitiligo
than in those with segmental vitiligo (10,47), but Hann and Lee maintained
that this does not prove that autoimmunity does not playa role in segmental
vitiligo (48).
Disorders in Healthy Relatives of Vitiligo Patients 53
Associated disorders were found to be less common in children with

vitiligo compared to adults (14). This might reflect the normal increase of
autoimmune disease that occurs with aging (7).
Association of ocular, auditory, and meningeal involvement with
vitiligo has been studied, as leptomeninges, inner ear, uveal tract, and retinal
pigment all contain melanocytes (4). Asymptomatic iritis and uveitis were
detected in 7% of cases, while discrete areas of pigment loss on fundus
examination were detected in 30-40% of cases (49). An association of deaf-
ness with vitiligo has also been reported, although auditory abnormalities are
not common characteristics of vitiligo (50).
GENETIC SUSCEPTIBILITY TO AUTOIMMUNE DISORDERS

The association of HLA antigens with vitiligo is a controversial issue.
Significant differences in HLA typing were obtained between segmental and
nonsegmental vitiligo (51) and between familial and nonfamilial cases (52).
The significance of HLA phenotype in the pathogenesis of vitiligo remains to
be elucidated. The apparent difference in HLA phenotype suggests a different
genetic background for familial and nonfamilial vitiligo.
Studies on the major histocompatibility antigens revealed that HLA
DR4 and HLA DQW3 have been implicated in susceptibility to a variety of
autoimmune disease (53). HLA DR4 was found to influence the susceptibility
for vitiligo, especially in cases with family history of vitiligo, in black (54) and
Caucasian Americans (55). In a Dutch population, DRB4*0101/0101 and
DQB I *0303/0303 alleles were found to predispose individuals to vitiligo, with
a significant family-based association with DQBI0303 (56). In 50 Omani
patients, HLA DR7 was significantly increased in those patients with
acrofacial compared to focal disease (57).
Recently, genes other than MHC antigens were found to be likely in-
volved in susceptibility to autoimmunity based on experimental and func-
tional data. The gene encoding toxic T lymphocyte-associated antigen 4
(CTLA 4) has been suggested as a candidate gene for conferring susceptibility
to autoimmunity in vitiligo as well as other autoimmune diseases (58). The
autoimmune susceptibility locus (1 PAIS I) is associated with vitiligo, while a
chromosome 6 locus (AITD I) is associated with susceptibility to auto-
immune thyroid diseases. It was found that the AITD I locus might mediate
the incidence of Hashimoto thyroiditis in AIS I-susceptible family members of
vitiligo patients (59). Another genetic linkage was detected between vitiligo
and systemic lupus erythematosus (SLE). Families of SLE patients with
members affected by vitiligo were found to share a significant linkage at a
susceptibility gene locus SLEV 1 at 17p 13, thus having an important genetic
54 EI Matty et aJ.
effect. This might explain the incidence of either disorder in the family
members of the other (60).
These findings suggest that vitiligo patients and their family members
inherit a predisposition to alteration in immunoregulation that may lead to
the occurrence of vitiligo as well as other associated autoimmune disorders.
The frequent association of vitiligo and other autoimmune diseases in the
same family members could be attributable to unstable mutations in a set of
genes that control endocrine and gastric epithelium in autoimmune endocrine
disorders as well as melanocytes in vitiligo, leading to organ-specific auto-
immunity (61), or due to genetic linkage with other autoimmune diseases (60).
The genetic predisposition to vitiligo apparently allows for a diversity of
anatomical patterns, and it was suggested that a similar mechanism is respon-
sible for the occurrence of different organ-specific autoimmune disorders
in members of the same family (62). This might provide clues to the higher
prevalence of autoimmune diseases in healthy relatives of vitiligo patients.
FAMILY HISTORY OF OTHER DISORDERS IN

HEALTHY RELATIVES
The association of autoimmune disorders is not limited to vitiligo patients but
affects their relatives as well (63). The incidence of such conditions in relatives
was found to be higher than their incidence in vitiligo patients themselves (7).
A family history of autoimmune endocrine disorders in childhood vitiligo was
found to be more common than in adult vitiligo patients (16).
While the incidence of a family history of autoimmune disorders was as
high as 75% in some studies (7), it was not significantly higher than the normal
population in others (64). Multiple studies were done with variable results
(Table I). While the incidence of diabetes mellitus in the general population
was about 2-4% (65), it ranged up to 22% among relatives of vitiligo patients
(7) Thyroid disorders occurred in 20% in vitiligo relatives (7) compared to a
range of 5-19% among the normal population (66).
Among the first- and second-degree relatives of 62 vitiligo patients, 15
had a family history of diabetes mellitus, 9 had pernicious anemia, and 5 had
thyroid disorders (67). In another study at least one first-degree relative was
affected by hypothyroidism in 26.1 % of cases and alopecia areata in 4.4% of
cases (I). Patients with vitiligo and polyglandular insufficiency syndromes
also had a positive family history of similar conditions or endocrinal disorder
without vitiligo. In seven cases of vitiligo associated with two or more glan-
dular insufficiencies, a family history of diabetes mellitus was found in one
hypothyroidism in one, and pernicious anemia in two (68). Among 92 of
European American pedigrees of SLE, 16 had one or more family members
affected by vitiligo (61).
TABLE 1 Incidence of Various Disorders in Healthy Relatives of Vitiligo Patients
Comparison
Degree of Incidence with general
Disorder relation N(%) population Ref.
Autoimmune and endocrine disorders:

20 patients 1st&2nd 15/20 (75%) Significant 7
70 black patients 1st & 2nd 25/70 (36) Insignificant 64
271 adult patients *Immediate family 166/271 (62%) Not performed 16
**Extended family 105/271 (38%)
82 child patients *Immediate family 23/82 (28%) Significant 16
**Extended family 57/82 (70%) Significant
Diabetes mellitus:
20 patients 1st & 2nd 22% Significant 8
62 patients 1st & 2nd 15/62 (25.1 %) Not compared 67
Thyroid disorders:
20 patients 1st&2nd 20% Significant 8
62 patients 1st&2nd 5/62 (8.3%) Not compared 67
160 white patients 1st 6/23 (26.1%) Not compared 1
Pernicious anemia:
62 patients 1st & 2nd 9/62 (2.6%) Not compared 67
Others:
Early graying of hair
271 adult patients *Immediate family 39/271 (14.4%) Significant 16
**Extended family 47/271 (17.3%) Significant
82 child patients *Immediate family 18/82 (21.9%) Not compared 16
**Extended family 35/82 (42.7%)
Alopecia areata 1/23 (4.4%) Not compared
160 white
patients 1st
Early hearing 1/23 (4.4%) Not compared
loss 1st
**Extended family 1/14 (7.1%)
Ocular problems 1st 2/23 (8.8%) Not compared
**Extended family 1/14(7.1%)
Autoantibodies
Antithyroglobulin 1st & 2nd 9/40 (22.5%) Significant 8
1st & 2nd 13/40 (32.5%) Significant 8
Antimicrosomal
antibodies
* Parents and siblings.

** Other blood related family members.
56 EI Matty et al.
The incidence of premature graying of hair is a common finding in

healthy relatives of vitiligo patients. White streaking starts in the early
twenties in vitiligo patients and other members of their families, compared
to the thirties in the general population (46). In a study of 82 patients who
were children no associated autoimmune disorders were found apart from 2
cases that had alopecia areata.
On the other hand, the incidence of autoimmune endocrine disorders
and premature graying of hair in immediate and extended families was
significantly higher than in controls. When compared to families of adult
pa tients, a significant increase in the incidence of autoimmune disorders was
observed in extended families of childhood cases, while no significant differ-
ence was obtained in the incidence of premature graying of hair in extended or
immediate families (16).
In an ongoing study of 274 Egyptian vitiligo patients (69), we found a
positive family history of vitiligo in 48 (17.5%) cases. The incidence of other
autoimmune disorders in healthy relatives was positive in 77 (28.1 %) cases.
The incidence of diabetes mellitus and thyroid disorders was higher than the
available records in the general population, but the statistical significance was
not estimated (Table 2).
Vitiligo has been observed among patients with melanoma (32). The
presence of vitiligo is thought to be a manifestation of host suppression of
malignant melanocytes (70). Lerner et al. (71) were the first to highlight the
TABLE 2 Prevalence of Autoimmune Endocrine Disorders and Other

Associations in Healthy Relatives of 274 Egyptian Vitiligo Patients
Disorder Degree of relation Incidence, N (%)

Diabetes mellitus 1st 23 (8%)
2nd 18 (6.56%)
Thyroid disorders 1st 7 (2.55%)
2nd 4 (1.5%)
Early graying of hair 1st 5 (1.8%)
2nd 6 (2.2%)
Systemic lupus 1st 1 (0.35%)
erythematosus 2nd 2 (0.7%)
Psoriasis 1st 2 (0.7%)
Alopecia areata 1st 2(0.7%)
2nd 7 (2.55%)
Ocular problems 1st 7 (2.55%)
2nd 5 (1.8%)
increased incidence of vitiligo, halo nevi, early graying of hair, or halo pri-
mary melanoma in families of melanoma patients. They reported 12 families
of melanoma patients who had close family members with these sedimentary
disorders. They suggested that the instability of the abnormal pigment cells in
both melanoma and vitiligo might be related. Such instability might lead to
loss, leading to depigmentation, or transformation leading to melanoma.
Patients who develop vitiligo first may have a lower incidence of melanoma
than the general population due to the suppressive effect on melanocytes. In
their kinships the frequency of transformation may be low, but it is probably
higher than the normal population. Therefore, melanocytes of those with a
genetic background of vitiligo might be predisposed to malignant transfor-
mation (7 I).
LABORATORY FINDINGS
In addition to the increased frequency of history of autoimmune disorders,
the apparently healthy relatives of vitiligo patients also showed significant
altered laboratory findings.
Antimelanocyte antibodies were detected in 82% of vitiligo patients (72)
and correlated with the extent of depigmentation (73); however, whether their
role is primary or secondary is not clear (72). The antibody response to
melanocytes was found to be heterogeneous, and this was confirmed by the
presence of antibodies to at least three distinct antigens in one third of vitiligo
patients but in none of the normal individuals. Antibodies to these antigens
were present in 46, 25, and 31 % of vitiligo patients, but in only 19,0, and 0%,
respectively of the normal individuals. There was no difference in antibody
response between patients with generalized and segmental vitiligo, suggesting
a similar pathogenesis (74). Studies are now directed toward determining the
melanocyte specific antigens toward which the autoantibodies are directed
(75). Melanin concentrating hormone receptor 1 (MCHR1) is a novel auto-
antigen in which highly specific immune reactivity against this antigen could
be observed in vitiligo patients (76). Vitiligo patients were also found to have
increased levels of organ-specific autoantibodies compared to the normal
population (77). A significant increase in antithyroid globulin was obtained in
white (78,79) as well as in black (64) vitiligo patients. Increased incidence of
anti-smooth muscle antibodies was also reported (80). The presence of organ-
specific autoantibodies did not correlate with the clinical features of vitiligo
(64), but correlated positively with the incidence of autoimmune disorders in
families of patients (64,78), but this relation was not obtained in all studies (7).
When the first-degree relatives of 20 vitiligo patients were tested for the
presence of organ-specific autoantibodies, there was a significant increase in
the frequency of antithyroid globulin and antimicrosomal antibodies in first-
58 EI Matty et al.
degree relatives compared to normal controls (7). There was no significant

increase in antiparietal or antiadrenal autoantibodies. The incidence of
antimelanocyte antibodies in relatives has not been tested.
When subsets ofT-cell populations were studied in vitiligo patients and
their first-degree, apparently healthy relatives, high levels of CD4 + lympho-
cytes and high CD4jCD8 ratio were obtained compared to normal controls.
This immunological abnormality, together with the presence of autoanti-
bodies in the patients and their healthy relatives, seems to be an important
finding in vitiligo (81). Whether the presence of these immunological abnor-
malities in relatives of vitiligo patients indicates an increased risk for devel-
oping vitiligo or other autoimmune diseases is not known. However,
apparently healthy persons with antithyroid antibodies were found to have
a hidden subclinical defect which was identified as exaggerated thyrotropin-
releasing hormone response (82). Two apparently healthy relatives with T-cell
subset abnormality developed vitiligo 2 years later (81). This could suggest
that such abnormalities in humoral (7) or cell-mediated immunity (81) in
those relatives indicate latent or subclinical disease that may manifest later on
follow-up examination.
Healthy relatives of vitiligo patients seem to have a higher risk of de-
veloping other autoimmune disorders. This is probably related to genetic
factors common to vitiligo and other autoimmune diseases. However, most
stuclies done so far have depended mainly on family history, and more so-
phisticated epidemiological studies are needed to quatitate these risks and
compare them to the general population in different parts of the world. Ge-
netic studies are being conducted to identify the susceptibility genes respon-
sible for the association of vitiligo and other autoimmune disorders in vitiligo
patients as well as their relatives.
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59. Alkhateeb A, Old StetlerW, Talbert J, Uhlhorn C, Taylor M, Fox A, Miller C,
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60. Nath SK, Kelly JA, Namjou B, Lam T, Bruner GR, Scofield RH, Aston CE,
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61. Ferguson-Smith MA. Unstable mutations in vitiligo and multiple endocrine
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63. ortel B, Alge C, Pandy A. Phototherapeutic options for vitiligo. In: Krutmann J,
62 EI Matty et al.
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6
Basic Research: An Update
Karin U. Schallreuter
University of Bradford, Bradford, United Kingdom and
Institute for Pigmentary Disorders e. V. in Association with
the Ernst-Moritz-Arndt University Greifswald Biotechnikum,
Greifswald, Germany
INTRODUCTION
The incidence of vitiligo worldwide has not been accurately determined, but
studie in Europe indicate that 0.5% of the population may be affected. while
in India reports of 4% have been suggested (I). Even if the lower value is
correct, vitiligo must be regarded as one skin disease confronting physicians
worldwide (I). This disabling depigmentation disorder was recognized thou-
sands of years ago, but despite many scientific investigation and numerous
clinical reports, the etiology of vitiligo is still unsolved. Several hypotheses
have been proposed for the depigmentation process, but none of them can
explain the plethora of clinical and basic scientific data (1,2). The clinical
signature of the disease is the loss of constitutive pigment from the skin, and
most publications account for this by either showing a decreased number of
functioning melanocytes or the complete absence of these cells in the
depigmented epidermis (1-4). However, a recent study by Tobin et al. clearly
proved that melanocytes are still present, even in longstanding vitiligo (4).
There has been much debate over how melanocytes lose their functionality
and viability in vitiligo, and certainly the most popular hypothesis is selective
autoimmunity to melanocytes. Nowadays there is clear evidence that vitiligo
is a disease affecting the entire epidermis, although most of the studies have
concentrated on the melanocyte (5,6). In addition to the loss of functioning
66 Schallreuter
melanocytes, the keratinocytes and Langerhans cells are disturbed in this

disease (4,7). This chapter is an attempt to highlight some results from basic
research and to try to connect these data to the clinical picture of vitiligo.
IN VITRO AND IN VIVO EVIDENCE FOR EPIDERMAL H2 0 2

ACCUMULATION IN VITILIGO
Over the past two decades it has been demonstrated by several investiga-
tors that the entire epidermis of patients with vitiligo shows signs of oxida-
tive stress yielding various degrees of vacuolation in all cellular components
(4-10). Only recently has the proof of oxidative stress in vitiligo been ac-
complished in vivo by measuring hydrogen peroxide (H 2 0 2) directly in the
depigmented epidermis by noninvasive Fourier transform (FT)-Raman spec-
troscopy, where H 2 0 2 yields a distinctive peak due to the 0-0 stretch at
875 cm- I (5,6). This oxidative stress can continue even in melanocytes and
keratinocytes cultured under in vitro conditions unless these cultures are pro-
tected by anti-oxidant enzymes such as catalase (5, II). This epidermal H 2 0 2
can be removed by a topical cream application containing a catalyst that
oxidizes H 2 0 2 to O 2 and H 2 0, thus mimicking the reaction of the antioxidant
enzyme catalase. The active catalyst is a narrow band DYB-activated bis
MnlJ[ (EDTAh (HC0 3-)2 complex and has been named pseudocatalase (12).
Pseudocatalase can successfully remove H 2 0 2 as demonstrated by in vivo FT-
Raman spectroscopy.
The removal of epidermal H 2 0 2 yields cessation of the disease in 90% of
all patients and initiates repigmentation in approximately 60% of the patients
treated (5,6). These results highlight the importance of oxidative stress in the
pathomechanism of vitiligo.
CONSEQUENCES OF H2 0 2 ACCUMULATION IN VITILIGO

Low Epidermal Catalase and Glutathione Peroxidase Foster
H2 0 2 in the Millimolar Range
The biochemical basis for the accumulation of H 2 0 2 in patients with vitiligo
has been the target of much research. Initially it was shown that patients with
vitiligo have low levels of catalase in their entire epidermis (13). However,
although catalase levels are decreased, the expression of catalase mRNA re-
mains unaltered in these patients (5). These early data were recently con-
firmed, showing that melanocytes established from the nonlesional skin of
vitiligo patients contained lower than normal catalase activities (14). These in
vitro results are in agreement with increased levels of H 2 0 2 in vivo in the
epidermis of this patient group, because this reactive oxygen species can
Basic Research: An Update 67
inactivate catalase by degradation of the porphyrin active site of this enzyme

after concentrations exceed Vl1lax levels (15). Recent studies have shown that
peripheral blood lymphocytes from vitiligo patients also have low catalase
levels and that these cells are susceptible to H 2 0 2 stress. (16). Under normal
conditions with low catalase levels, the antioxidant enzyme glutathione
peroxidase functions as a backup enzyme for the efficient removal of H 2 0 2 .
In this context, it has been shown that these enzyme activities are also com-
promised following an age-dependent profile (17).
Two of the key enzymes for the removal ofH 2 0 2 are impaired in vitiligo.
Melanocytes are in particular sensitive to H 2 0 2 stress because even cells under
normal physiological conditions have lower catalase and glutathione perox-
idase activities than keratinocytes (18). Earlier studies showed that thiore-
doxin reductase is also decreased in vitiligo (for review, see Ref. 19). This
enzyme contains a selenocysteine active site and directly reduces H 2 0 2 to H 2 0
with a Km of2.5 x I 0-3M. Moreover, biochemical studies have recognized six
possible sources of H 2 0 2 in active progressive vitiligo (Table I).
Pterins and H2 0 2 in Vitiligo

Vitiligo can be diagnosed by demonstrating a distinct fluorescence in the
depigmented epidermis when it is exposed to Wood's light (UVA 351 nm),
whereas leukodermas of other origin do not fluoresce (20). A comparison of
vitiligo and one example of a laser-induced leukoderma is shown in Figure 1.
In 1994 it was discovered that the fluorescent compounds in vitiliginous epi-
dermis were oxidized pterins (20,21). The accumulation of oxidized pterins
arose from the recognition that patients with vitiligo have a defective de novo
synthesis/recycling/regulation of the essential cofactor (6R)-L-erythro-5,6,
7,8-tetrahydrobiopterin (6BH 4 ). The decreased/absent recycling of 6BH 4
causes the production of its abiogenic isomer 7BH 4 , and micromolar con-
TABLE 1 Sources of Epidermal H2 0 2 Accumulation in Vitiligo

1. Defective de novo synthesis/recycling and regulation of the essential cofactor
(6R)-L-erythro-5,6,7,8-tetrahydrobiopterin (20,21)
2. Increased epidermal monoamine oxidase A activities (22)
3. Increased NADPH-oxidase activities from the activation of neutrophils and
macrophages that can sometimes be observed in the perilesional infiltrate in
vitiligo (1,23)
4. Photo-oxidation of epidermal 6-biopterin and sepiapterin (24)
5. Increased inducible nitric oxide synthase (19)
6. Decreased thioredoxin reductase expression and activity (19)
68 Schallreuter
FIGURE 1 A comparison of vitiligo (A) and a laser-induced leukoderma (B) upon

Woods light examination. The clinical picture presents leukoderma. Upon Woods
light examination there is no fluorescence in laser-induced depigmentation. Mean-
while, vitiligo presents the characteristic fluorescence of oxidized pterins (20,21).
centrations of7BH 4 inhibi t phenylalanine hydroxylase (PAH), preventing the

turnover of L-phenylalanine to L-tyrosine, consequently causing a buildup of
L-phenylalanine in the epidermis (25,26). This buildup has indeed been
demonstrated in vivo using FT-Raman spectroscopy (26). The disrupted
recycling of 6BH 4 leads to the synthesis of H 20 2 by PAH as the cofactor is
rapidly converted to quinonoid dihydropterin (qBH 2 ) by a short circuit
(Table 1). A detailed overview of our understanding of the defective pterin
metabolism in vitiligo is presented in Figure 2. Only recently has it been
discovered that H 2 0 2 deactivates the rate-limiting recycling enzyme 4a-
carbinolamine dehydratase (DH) because H 2 0 2 alters directly the structure
of this enzyme (27). Consequently, the buildup ofH 2 0 2 is autocatalytic. It was
demonstrated that H 2 0 2 rapidly oxidizes 6BH 4 to 6-biopterin and this
L-Phenylalanine
R
e
g
/I
!G G
GFRP . - . .
a I
n
.
Sepiapterio Reductase
6-Pyruvoyl-PH.-Synthase
g
... ,.
GTP-Cyclohydrolase I GTP
• Synonyms: Plcrin-4a-carbinolamine dehydratase (PCD) and
Dimerisation Cofactor of Hepatocyte Nuclear Factor 1 (DeoH)
FIGURE 2 Defective 6BH 4 synthesis leading to 7BH 4 and H2 0 2 production in vitiligo.

Both epidermal melanocytes and keratinocytes have the full capacity for de novo
synthesis/recycling and regulation of 6BH 4 (20,21). The rate-limiting step for the de
novo synthesis of 6BH 4 is GTP-cyclohydrolase I (GTP-CH-I). This enzyme is
controlled by L-phenylalanine (positive feedback) via the GTP-CH-I feedback
regulatory protein (GFRP), as well as several cytokines [tumor necrosis factor-a,
mast cell growth factor (MGF), interleukin-2, and )I-interferon]. 6BH 4 downregulates
GTP-CH-I via GFRP. Furthermore, 6BH 4 is the essential cofactor (a) for phenyl-
alanine hydroxylase to metabolize L-phenylalanine to L-tyrosine in melanocytes and
keratinocytes and (b) for tyrosine hydroxylase to convert L-tyrosine to L-dopa in
catecholamine biosynthesis in keratinocytes. 6BH 4 is also a regulator of tyrosinase
activity in melanocytes, inhibiting the enzyme by an allosteric mechanism. The
recycling of 6BH 4 is catalyzed by the rate-limiting 4a-hydroxy-BH 4 dehydratase (DH)
via quinonoid dihydropterin (qBH 2 )· In vitiligo, 6BH 4 is overproduced, and DH
activities are decreased or absent due to deactivation by H2 0 2 , consequently 4a-
hydroxy-BH 4 is nonenzymatically converted to 7BH 4 , which in turn inhibits phe-
nylalanine hydroxylase, resulting in accumulation of H2 0 2 and compromised L-
tyrosine supply.
oxidation product is cytotoxic to melanocytes under in vitro conditions with

an Le so == 10- 7 M (28). Only recently was the presence of epidermal pterin 6-
carboxylic acid as the final photo-oxidation product of 6-biopterin and other
pterins demonstrated, and this photo-oxidation coincides with the generation
of H 2 0 2 (24). The results suggested that defective pterin synthesis coupled to
oxidative stress can directly influence the melanocyte population and integrity
70 Schallreuter
in vitiligo primarily due to the cytotoxicity of 6-biopterin and other oxidized

pterins.
Catecholamine Metabolism in Vitiligo

The presence of increased levels of 6BH 4 and low levels of L-tyrosine in vitiligo
provides ideal conditions for increased activity of the 6BH 4 tyrosine hydrox-
ylase (TH), the key enzyme for catecholamine biosynthesis (29). Both
keratinocytes and melanocytes express TH isoform I, the most active of the
four different isoforms of this enzyme (29,30). In this context it has been
reported that patients with active vitiligo have elevated levels of noradrenaline
in their skin and plasma, as well as high levels of catecholamine metabolites in
their urine (21,31). Increased noradrenaline synthesis in the epidermis of these
patients causes the induction of the catecholamine-degrading enzymes mono-
amine oxidase A (MAO-A) and catecholamine-O-methyl-transferase
(COMT) (32,33). MAO-A produces H 2 0 2 as a reaction product from the
oxidation of noradrenaline, and therefore the increased expression of epi-
dermal MAO-A contributes significantly to the severe H 2 0 2 stress in vitiligo.
NADPH Oxidase and the "Oxygen Burst"

Several investigators have reported the presence of a cellular infiltrate in the
perilesional skin of patients with vitiligo (I). This infiltrate produces an
"oxygen burst" leading to the generation of superoxide anion radical (02")
from O 2 via NADPH-oxidase (23,34,35). In a normal inflammatory reaction,
02" concentrations increase up to 20-fold. After disproportionation this
concentration would produce a IO-fold increase in H 2 0 2 (23). The perilesional
border in vitiligo presents in some cases a cellular infiltrate. However, the
numbers of infiltrating neutrophils and macrophages are usually very low or
even absent in long-lasting disease. Therefore, it is very difficult to assess the
true H 2 0 2 contribution deriving from this perilesional infiltrate. Cells in the
perilesional epidermis in vitiligo show no difference in vacuolation (i.e., lipid
peroxidation) compared to cells in both lesional and nonlesional skin (4-6).
However, recently it has been shown that H 2 0 2 can activate peripheral blood
dendritic cells by upregulating surface markers involved in T-cell interactions
(36). This H 2 0 r driven process promotes interaction with MHC class II
molecules (DQ and DR) as well as costimulatory molecules CD 40 and CD 86
(36). After exposing dendritic cells in culture to H 2 0 2 , these cells promote T-
cell proliferation compared to untreated controls lacking H 2 0 2 exposure (36).
The effect of H 2 0 2 can be blocked in vitro upon the addition of the anti-
oxidant N-acetylcysteine (36). In the same context, it has been shown that
simulated solar irradiation upregulates B7.1 and B7.2 costimulatory mole-
cules in epidermal Langerhans cell (37) In vivo H 20 2 generation by UVB (311
nm) and by solar exposure at the Dead Sea has been shown using FT-Raman
spectroscopy (38). Based on these data it is tempting to conclude that H 20 2
could modulate the response of epidermal Langerhans cells in vitiligo (4,5,36).
Hence these data could directly link H 20 2 stress to cell damage and the onset
of an adaptive cellular immune response (36).
A Possible Role for Tyrosinase-Related Protein-1 in Vitiligo

TRP-l is a melanosomal membrane-associated protein which has 43% se-
quence homology to tyrosinase, and it controls both the activity and stability
of this key enzyme in melanogenesis (39,40). Halaban and Moellmann
demonstrated catalase/peroxidase activities ofTRP-l, and these authors sug-
gested that this protein protects tyrosinase from oxidative degradation (39).
In this context, it has been established that H 2 0 2 is a potent competitive
inhibitor of human tyrosinase and that superoxide anion radical (0 2) is a
preferred substrate for this enzyme compared to molecular oxygen (41). Thus,
melanogenesis could primarily be considered as an antioxidant defense
mechanism protecting the melanocyte against oxidative stress (42). Further-
more, it was suggested that TRP-l protects both tyrosinase and melanosomal
integrity. Jimbow et al. reported that melanocytes established from the peri-
lesional skin of patients with vitiligo expressed a TRP-I containing II addi-
tional amino acids at the C-terminaJ end of its sequence (43). This sequence
was identical to murine TRP-l (43). The initial transcript for human and
murine TRP-I shows 93% sequence homology (44). Therefore, posttransla-
tional processing via an unidentified protease occurs in the human system,
producing a protein lacking II residues from the C-terminal. These authors
speculated that this protease appears to be either lost, inhibited, or inacti-
vated in vitiligo (43). In vitiliginous melanocytes, the murine form ofTRP-1
is expressed, and this protein loses its function for protecting melanosome
integrity due to defective interactions with both tyrosinase as well as the
melanosome chaperone calnexin (43,45). In this context, it is interesting to
note that animal models lacking active TRP-I develop an adaptive auto-
immune response to melanocytes, providing another example of a potential
role for H 2 0 2 in fostering a cellular immune response (36,46).
Epidermal Calcium Homeostasis and Oxidative Stress

in Vitiligo
The influence of oxidative stress on calcium uptake/efflux has been established
for a long time (34). Earlier studies on the transport of isotopically labeled
45 ca lcium with keratinocytes and melanocytes established from the depig-
men ted epidermis of pa tients wi th vi tiligo revealed a significan t decrease in the
rates for calcium uptake in these cells (47,48). Several investigators have
72 Schallreuter
shown that the extracellular concentration of calcium, which controls the

kinetics for its uptake and efflux, strongly influences melanogenesis in mela-
nosomes (49). Recently it has been confirmed that L-phenylalanine transport
and its intracellular turnover to L-tyrosine is a calcium-dependent process in
normal human melanocytes under in vitro conditions (50). L-phenylalanine is
actively transported in these cells via the well-established L-phenylalanine/
sodium/calcium ATPase antiporter mechanism (50). Because the majority of
eumelanin is synthesized in melanocytes from the autocrine conversion of L-
phenylalanine to L-tyrosine via PAH, then the perturbation of calcium
homeostasis in these cells from patients with vitiligo very likely plays a crucial
role in the loss of pigment in vitiliginous melanocytes (48,50).
COMPROMISED L-PHENYLALANINE TURNOVER

IN VITILIGO
Previously it was recognized that epidermal cell extracts from patients with
vitiligo have low phenylalanine hydroxylase activities (20). The application of
in vivo FT-Raman spectroscopy allowed the determination of phenylalanine
by following the peak at 1004 cm'), and the results indeed confirmed an
accumulation of epidermal phenylalanine in this patient group (26). Utilizing
a kinetic analysis of the individual systemic phenylalanine turnover after oral
loading with phenylalanine, it was demonstrated that 40% of all patients
tested (n > 800) have a significantly slower phenylalanine metabolism com-
pared to healthy controls. However, 60% of the patients have no problems
producing L-tyrosine from L-phenylalanine via phenylalanine hydroxylase
(26). As described earlier, L-phenylalanine is actively transported into the cell
by a calcium-dependent ATPase antiporter mechanism (50). The question
arises whether a perturbed calcium homeostasis in vitiliginous cells explains
this phenomenon.
VIRAL INFECTIONS IN VITILIGO

Over recent years Grimes et al. have proposed a viral etiology for vitiligo
(51,52). Using Polymerase chain reaction (PCR) techn.iq ues, cytomegalovirus
(CMV) and Epstein-Barr virus (EBV) have been detected in the epidermis of
patients with this disorder in California (51,52). Based on these findings, the
authors suggested a viral induced pathomechanism. However, the direct asso-
ciation of CMV with vitiligo in California is difficult to assess, since 85% of
the population are positive for CMV, whereas the incidence of vitiligo is only
approximately 0.5-1 %. Recent studies from our own group re-evaluated this
possibility of viral-induced disease on 72 patients with vitiligo compared to
healthy controls (n = 70). There was no direct evidence for CMV, herpesvirus
IIIL or varicella virus using peR techniques in skin biopsies or in the serum
from these patients (53). However, even these findings cannot exclude a viral
involved "hit-and-run" mechanism, despite a lack of direct evidence for virus
detection in loco or in serum. In fact, it has been shown in animal models that
virus infection can trigger an autoimmune response due to molecular mimicry
of viral peptide sequences activating subsets ofT cells. This hypothesis could
support viral-induced T cells as a target against melanocytes. In these models
the virus causing autoimm uni ty escapes detection after the onset of the disease
(54,55). In this context, it is noteworthy that viruses can attract an infiltrate of
leukocytes and macrophages leading to the oxygen burst concomitant with
the production of reactive oxygen species (ROS), such as superoxide anion
radical (0 2) and H 2 0 2 , as discussed earlier in this chapter.
VITILIGO AND SKIN CANCER

It is generally accepted that the cutaneous pigment protects against the
development of skin cancers. The sun protection factor (SPF) for melanin
ranges between 2 and 5 (56). Since patients with vitiligo lack this protective
mechanism, it would be anticipated that affected individuals would run a
higher risk for developing skin cancers. Surprisingly, patients even with
longstanding vitiligo of >25 years duration have no evidence for increased
photodamage such as actinic keratosis and solar elastosis as well as increased
numbers of basal cell and squamous cell carcinoma (57-59).
The reason for this puzzling lack of increased skin cancers in vitiligo is
still unknown. Recently, an increased epidermal functioning p53 has been
detected (59). Surprisingly, this increased p53 is not associated with increased
apoptosis in these patients (4,60). Earlier it was recognized that thioredoxin
reductase activities and protein levels are decreased in vitiligo (19): This
decreased enzyme expression could well be caused by the increased wild-type
p53 levels in this disease considering that thioredoxin reductase is an
established transcriptional target for p53 (61). In this context it should be
noted that p53 can be induced by flM levels of hydrogen peroxide (62). In
vitiligo this scenario could be certainly valid. The question remains whether
p53 is induced as a protective mechanism in prevention of skin cancer in
vitiligo. This could be an interesting new concept to explain the observed
paucity of solar-induced damage and skin cancer overall. Further work is
necessary to gain more insight into these interesting observations
THE HUNT FOR THE VITILIGO GENE

Since more than 40% of patients with vitiligo have more than one affected
family member with this d6"8~~dhtetf~teH~?isposition is strongly sug-
74 Schallreuter
gested. Only recently have major attempts been made to find the "vitiligo
gene." There is no evidence as yet for any mutation on the PAH gene in
vitiligo (KUS, unpublished results). The defective recycling of 6BH 4 via DH
suggested the possibility of a polymorphism in the DH gene (20,21). However,
recent studies have shown that DH is directly deactivated by HzO z (27).
Examination of the sequence of the DH gene in 10 patients with vitiligo
revealed only wild-type DH (27). It still remains to be established whether
polymorphisms occur on the pathway for de novo synthesis and regulation of
6BH 4 synthesis. Another report suggested that this disease is caused by a
mutation in GTP-cyclohydrolase I, the rate-limiting enzyme for 6BH 4 syn-
thesis (63). This result could not be substantiated, as none of the GTP-
cyclohydrolase I mutations in patients from the world data bank expressed
vitiligo (64,65). An attempt to investigate a possible mutation in the regu-
latory protein GFRP has revealed only a wild-type sequence for the 6BH 4 -
binding domain (KUS, unpublished results). Only very recently has a genetic
association of the catalase gene with susceptibility to vitiligo been reported
(66). In this study, a TIC single nucleotide polymorphism (Asp 389) on exon 9
of catalase was discovered. The restriction in the nuclease Bst Nl was used to
cleave the T allele and show that this polymorphism is statistically significant
in vitiligo. It is proposed that this polymorphism interferes with catalase
tetrameric subunit assembly, thus making catalase more succeptible to HzO z
stress with a concomitant decreased activity (66). This discovery would
certainly be in agreement with all biochemical in vitro and in vivo evidence
for H~02 accumulation in vitiligo.
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29. Schallreuter KU, Lemke KR, Pittelkow MR, Wood JM, Korner C, Malik R.
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953-957.
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33 LePoole C, Wijngaard Van den, Smit NPM, Oosting J, Westerhof W, Pavel S.
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.Copyrighted Material
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7
Vitiligo: The Autoimmune Hypothesis
Jean-Claude Bystryn
New York University School of Medicine, New York, New York, U.S.A.
POSSIBLE CAUSES OF VITILIGO

The immediate cause of vitiligo is the selective destruction of melanocytes.
These are absent in established lesions of vitiligo and damaged at the mar-
gin of active lesions (1). The cause of the disease is not known. There are
three major hypotheses: (a) self-destruction of melanocytes by toxic prod ucts
they produce; (b) neutral dysfunction, as vitiligo can be segmental, can stop
abruptly at the midline, and may spare denervated areas; (c) autoimmunity
against melanocytes-currently the most popular hypothesis.
This review summarizes the evidence supporting the autoimmune
hypothesis. It falls into two categories: (a) indirect evidence-immune
abnormalities which by themselves cannot explain the selective destruction
of melanocytes; (b) direct evi.dence-immune abnormalities associated with
vitiligo that can selectively destroy these cells. The a utoimmune hypothesis
was first suggested by indirect evidence, i.e., the association of vitiligo with
a variety of autoimmune diseases and/or autoantibodies. It was greatly
strengthened by subsequent direct evidence that vitiligo is associated with
abnormal antibodies against melanocytes and that these can cause depig-
mentation when given to animals.
80 Bystryn
VITILIGO IS DEPIGMENTED, BUT NOT ALL

DEPIGMENTATION IS VITILIGO
In evaluating the causes of vitiligo, it is critical to be aware that melanocytes
can be destroyed in depigmentary diseases other than vitiligo and by different
immune mechanisms, and that different mechanisms may be involved in
causing depigmentation in different conditions or experiments. To relate an
immune abnormality to the pathogenesis of vitiligo, it is necessary to dem-
onstrate not only that the abnormality is present but that it is responsible for
the particular type of depigmentation that occurs in vitiligo. This becomes
particularly important when relating immune abnormalities in melanoma or
in animals with pigment loss to the pathogenesis of human vitiligo.
INDIRECT EVIDENCE THAT VITILIGO IS AN AUTOIMMUNE

DISEASE
Vitiligo is usually (2,3), but not invariably (4), associated with a 2- to la-fold
increase in autoantibodies against numerous organs, particularly the thy-
roid, adrenals, and gastric parietal glands. Patients with vitiligo are also
more likely to have autoimmune diseases such as Hashimoto's thyroiditis,
Addison's disease, alopecia areata, pernicious anemia, chronic mucocutane-
ous candidiasis, and diabetes mellitus (1,5). Conversely, vitiligo is 10-15 times
more common in patients suffering from certain autoimmune diseases.
Other abnormalities in nonspecific parameters of humoral or cellular
immunity have also been reported, but none has been consistent (6). Circu-
lating T cells are variously reported as low (7) or normal (8) in number, and
helper T cells and the helper/suppressor T-cell ratio as elevated (9) or de-
creased (8), and Langerhas cells in depigmented skin as increased, decreased,
and normal.
Other indirect observations that suggest that vitiligo could be an auto-
immune disease include:
1. Vitiligo is a systemic disease. One quarter of patients with vitiligo
have destruction of pigment cells in the eye (10), and choroidal
depigmentation associated with panuveitis is common in Sinclair
swines (II) and Smyth chickens (12), which develop vitiligo. Thus,
vitiligo is a systemic process that can affect pigment cells in all parts
of the body.
2. Most effective treatments that induce repigmentation such as PU-
VA, topical steroids, and topical cytotoxic drugs are immunosup-
pressive, suggesting that their benefit results from suppression of
local immune reactions damaging melanocytes.
Vitiligo: The Autoimmune Hypothesis 81
3. The improved clinical outcome of patients with melanoma and

vitiligo suggest that immune reactions targeting malignant mela-
nocytes can also destroy normal melanocytes.
4. Bursectomy, which impairs antibody responses, and cyclosporin A,
which inhibits T-cell-mediated immune responses, both delay the
appearance and reduce the severity of vitiligo in Smyth chickens,
suggesting that both humoral and cellular immue reponses may be
involved in the pathogenesis.
Taken together, these observations indicate that the immune system is
involved in vitiligo, but they cannot explain the selective damage to melano-
cytes that occurs in the disease.
DIRECT EVIDENCE THAT VITILIGO IS AN AUTOIMMUNE

DISEASE
Association of Vitiligo with Melanocyte Antibodies
The most convincing evidence that vitiligo is an autoimmune disease is that
specific antibodies to melanocyte cell-surface antigens are present in most
patients with vitiligo and that these antibodies can cause the disease when
passively transferred into animals. These antibodies are referred to as vitiligo
(VIT) antibodies.
VIT antibodies were initially demonstrated by immunoprecipitation of
melanocyte-surface antigens and by indirect immunofluorescence (13,14).
Their presence has since been confirmed by multiple other procedures,
including complement-dependent cytotoxicity (15), antibody-dependent cel-
lular cytotoxicity (16), immunoblotting, live-cell and conventional ELISA
(17,18), and passive transfer experiments (19).
VIT antibodies are found in most patients with vitiligo, particularly in
those with active disease (14), but are unusual in persons with nonpigmentary
skin diseases. The antibodies target cell-swface antigens because: (a) the
antigens can be radioiodinated by the lactoperoxidase technique, a procedure
that labels only molecules exposed on the external surface of cells; (b) the
antibodies give typical granular patterns of surface staining on viable
melanocytes by indirect immunofluorescence; and (c) the antibodies can kill
melanocytes in cytolytic assays.
VIT Antibodies in Animals with Vitiligo

Antibodies to melanocytes also occur in a variety of animals that develop
vitiligo, including Tervuren dogs, Siamese cats, Arabian horses, and Sinclair
82 Bystryn
miniswines (20,21). They are present in 95% of Smyth chickens with vitiligo-
like depigmentation, but not in normally pigmented birds (22). The antigens
targeted in these animals are similar to those defined by VIT antibodies in
humans. Thus, humans and animals with vitiligo have similar immunological
abnormalities.
Relation of VIT Antibodies to Vitiligo Activity

The incidence and level of VIT antibodies correlates to the extent of depig-
mentation and to the activity of the disease. They have been reported in 50%
of persons with minimal vitiligo and in 93% of those with more extensive
disease (23). VIT antibodies have been reported in 80% of patients with active
vitiligo but in none with inactive disease using a live cell ELISA assay (17) and
in 85% of patients with active disease compared to 44% of those with inactive
disease by complement-dependent cytolysis (15). The titer of VIT antibodies
decreases in patients who respond to PUVA therapy (24), indicating that titer
is related to disease activity.
VIT Antibodies Can Kill Melanocytes

VIT antibodies can kill melanocytes in vitro by two different mechanisms:
complement-dependent cytotolysis and an tibody-dependent cellular cytolysis
(16). In a large study, Cui et al. found complement-dependent cytolytic
melanocyte antibodies in 32% of 56 vitiligo patients but in only 6% of 47
control individuals (15). The antibodies reacted selectively to melanocytes,
and their level was related to disease activity.
Melanocytes are unusually susceptible to immune damage in compar-
ison to other epidermal cells (16). The LD so of melanocytes to peroxide-
mediated injury (a major effector mechanism of injury mediated by immune
cells) is 10 times greater than that ofkeratinocytes and 100 times greater than
that of fibroblasts. Thus, even weak immune responses against melano-
cytes may injure these cells in vivo and may injure them without harming
other cells that express the same antigens, resulting in selective destruction of
melanocytes.
Induction of Vitiligo by VIT Antibodies

The strongest direct evidence that vitiligo is an autoimmune disease is that the
disease can be caused in animals by passive transfer of VIT antibodies.
Purified IgG of vitiligo patients kills melanocytes in normal human skin in
vivo when passively administered to nude mice grafted with human skin (19).
IS CELLULAR IMMUNITY INVOLVED IN THE PATHOGENESIS

OF VITILIGO?
Until recently, cellular immunity was not believed to be involved in vitiligo as
inflammatory cells are sparse in vitiligo lesions, although not completely ab-
sent (25-27). When present, the infiltrate is more prominent at the periphery
of active lesions (26,28). The infiltrate consists predominantly of CD8 + T
cells, but also contains CD3 +, CD4 +, T cells, and macrophages (28). The T
cells express the skin homing receptor, cutaneous lymphocyte-associated
antigen (CLA), and are activated as evidenced by increased expression of
class II MHC (29), perforin, and granzyme-B (26,30). The infiltrating T cells
are mainly clustered in the vicinity of disappearing melanocytes (30). Perile-
sionalmelanocytes express increased amounts of class II MHC and reAM-I,
rendering them more susceptible to attack by T cells (31).
These observations have been interpreted to mean that cellular immu-
nity is not involved in vitiligo (because the infiltrate is sparse) or is involved
(because the infiltrate is more prominent where' the lesions are most active). It
has not been determined whether these abnormalities precede and hence are a
possible cause of the disease or are a result of it.
With the advent of very sensitive assays for antigen-specific T cells, it
became possible to look for T cells reactive against melanocyte antigens in
patients with vitiligo. Because these assays are new, only limited information
is available. Ogg et al. reported that cytotoxic T lymphocytes (CTL) directed
against the pigment cell-associated antigen Melan A/MART-I were present
in 7 of9 HLA A*02-positive patients with vitiligo compared to I of 6 normal
patients (32). The majority of the positve cells expressed the skin homing
receptor CLA. As described below, T cells specifically targeting several
pigment cell-associated antigens are present in animals with experimentally
induced depigmentation of hair follicles, but the relation of this type of pig-
ment loss to vitiligo is not clear.
Overall, these observations suggest that cellular mechanisms may playa
role in vitiligo, but the evidence is less direct and weaker than that for anti-
body responses.
WHICH ANTIGENS ARE TARGETED BY AUTOIMMUNE

REACTIONS IN VITILIGO?
The antigens targeted by anti-pigment cell immune responses in vitiligo are
critical in the pathogenesis of the disease, as these antigens may be both the
cause and/or the target of the process that kills melanocytes. The identifica-
tion of these antigen(s) has been complicated by several erroneous assump-
tions: that any antigen targeted by antibodies or T cells in vitiligo is a cause of
84 Bystryn
the disease even when the responses may be present in only a minority of
patients, that the immune abnormalities present in melanoma are involved in
vitiligo, and that any pigment cell antigen that is immunogenic in humans is
involved in vitiligo.
Whatever the antigens are, they must be expressed on the surface of
melanocytes to account for their ability to kill these cells by complement- or
antibody-dependent cellular cytotoxicity. Another clue to their nature is the
reciprocal relationship between epidermal and hair follicle melanocytes. The
first type of melanocytes is attacked in vitiligo, while the second is spared (hair
follicles are the source of melanocytes in vitiligo lesions that repigment) (33),
whereas the reverse occurs in alopecia areata, where pigmented hair follicles
are preferentially attacked (34). This indicates that the antigenic properties of
epidermal and hair follicle melanocytes differ, as confirmed experimentally
(34), and that epidermal melanocytes express more of the antigen(s) recog-
nized by vitiligo sera. Thus, at least some vitiligo antigens appear to be
differentiation antigens expressed by only epidermal melanocytes.
Multiple melanocyte antigens appear to be involved in vitiligo. VIT
antibodies react to melanocyte antigens of 40-45, 75, and 90 kDa, denomi-
nated VIT40, VIT75, and VIT90. Antibodies to VIT90 are present in 35-45%
of patients with vitiligo, but in only < 4% of individuals with unrelated skin
diseases (35,36). Antibodies to VIT40 and to VIT75 are present in 74-76%
and 57~72%, respectively, of vitiligo patients compared to in 4-14% and 4-
8% of control individuals (35,36). All three antigens are cell-surface antigens
as they are labeled by the lactoperoxisase technique, which preferentially
labels surface proteins, and are poorly labeled by 3sS-methionine, which labels
predominantly internal proteins (37). VIT90 is a pigment cell-associated
antigen expressed most strongly by melanocytes and to a lesser extent by
melanoma cells, and is undetectable on control cells. VIT40 and VIT75 are
common tissue antigens expressed by most pigment and control cells, but they
are expressed more strongly on melanoma than on melanocytes. VIT40 is
either complexed, or shares an antigenic epitope, with class I HLA. VIT75 and
VIT90 differ from most currently known pigment cell antigens as they do not
co-migrate and/or are not immunoprecipitated by monoclonal antibodies to
these antigens (37). In particular, VIT75 is unrelated to tyrosinase and to
TRP-I, even though it is of similar size, because it does not react with mono-
clonal antibodies TA99 and TMH-L VIT90 is unrelated to gpl00, p97, or
S100 as it does not react with monoclonal antibodies to these molecules (37).
The fact that some vitiligo antigens may be normal tissue antigens also
expressed by non-pigmented cells does not exclude their playing a role in
the pathogenesis of vitiligo because melanocytes are unusually susceptible to
damage by immune mechanisms (16). Thus, weak immune reactions to these
antigens could damage melanocytes while sparing more resistant unrelated
cells that express the same antigens.
Another melanocyte surface antigen associated with vitiligo is the

melanin-concentrating hormone receptor 1, antibodies to which have been
reported in 16% of 55 patients with vitiligo but in none of 74 control in-
dividuals (38). Other antigens that have been associated with vitiligo include
tyrosinase, gp75jTRP-l, TRP-2, gplOOjPmel17, and Melan-AjMART-1.
However, the data indicative of their involvement in human vitiligo is weaker.
Tyrosinase has been described as a vitiligo antigen because antibodies to
it were initially described in a majority of vitiligo patients (39), CD8 + T cells
against this antigen may present in patients with vitiligo (57), and because
passive transfer of cytotoxic lymphocytes targeting a tyrosinase peptide can
depigment hair follicles in mice (40). However, the association of tyrosinase
antibodies with vitiligo has not been confirmed in more recent and larger
studies (41,42). The relationship of depigmentation of hair follicles in mice to
human vitiligo is unclear, as hair follicle melanocytes are normally spared in
vitiligo, the association of vitiligo with T cells to tyrosinase has not been
confirmed in other studies (48,49), and immunization to vaccines containing
tyrosinase peptides rarely causes depigmentation even though it can induce
T-cell responses against this antigen (55,56).
Gp75, also known as tyrosinase-related protein-1 (TRP-I), has been
described as a vitiligo antigen because antibodies to it were reported in one
study (43), active (44) or passive (46) immunization to TRP-I depigments hair
follicles in mice, and gp75 is similar in size and tissue distribution to VIT75
(45). However, the association of anti-TRP-I with vitiligo was not confirmed
in subsequent studies (38), the loss of pigment in mice is restricted to re-
growing hair follicles (46), which is not the melanocyte population targeted in
vitiligo, and VIT75 and gp75 are immunologically distinct in immunodeple-
tion experiments (35,36). Furthermore, gp75 is a cytoplasmic antigen, where-
as VIT75 is on the cell-surface. Thus, while immune attack against gp75 can
cause pigment loss, it is unlikely to be an antigen involved in the pathogenesis
of vitiligo.
Other antigens described as targets of immune responses in vitiligo
include Melan-AjMART-l, TRP-2, andjor gp 100jpme1l7. The most consist-
ent association has been with melan-AjMART-I, with T-cell responses
against this antigen being reported in three studies (48,57,49), but the studies
were small. A report that immunization to MART-l causes vitiligo is based
on a single patient (50), and the pigment loss occurred only at sites of in-
flammation and blister formation, suggesting that it resulted from post-
inflammatory depigmentation rather than vitiligo. Reports that antibodies
to TRP-2 (54,58) and gp100jpme1l7 (47) are often associated with vitiligo
were not confirmed in a subsequent study (38), and T-cell responses to gp 100
are rare in patients with vitiligo (48,49,57). Lastly, immunization to these
antigens does not cause pigment loss in mice (44) or humans (55 56), even
though it can stimulate im~ftgfifRRfWtaterial
86 Bystryn
A clue to the relative importance of the different VIT antibodies in the

pathogenesis of the disease comes from the observation that while vitiligo is
common in patients with VIT40, VIT75, and VIT 90 antibodies, it is relatively
uncommon in patients with melanoma who have the same antibodies. This
could be explained by VIT90 playing the predominant role in pathogenesis as
this antigen is expressed more strongly on melanocytes than on melanoma
cells.
ROLE OF IMMUNE MECHANISMS IN THE PATHOGENESIS

OF VITILIGO
The presence of antibodies to melanocytes in patients with vitiligo, their
absence in persons without this disease, and the selective expression of vitiligo
antigens on melanocytes provide the essential framework required for vitiligo
to be an autoimmune disease. This immune abnormality appears to actually
mediate the disease because it appears before rather than after the onset of
depigmentation, there are relations between the presence and level of anti-
pigment cell immune responses and the extent and activity of the vitiligo, and
because the disease can be passively transferred with antibodies.
Key issues in terms of the pathogenic role of the irrul1une abnormalities
associated with vitiligo include:
I. Can anti-pigment cell immune responses actually injure melano-
cytes in vivo or are they simply interesting epiphenomena?
2. Are these immune abnormalities a cause or an effect of the disease?
3. Ifimmune mechanisms do cause pigment cell destruction in vitiligo,
how do they do so?
Anti-Pigment Cell Immune Responses Can Injure

Melanacytes In Vivo
Passive and active immunization studies in mice indicate that antibodies or
T cells directed against pigment cell antigens can each individually cause
depigmentation. Depigmentation can be caused by purified IgG antibodies or
by T cells alone (51). Passive administration of human VIT antibodies to nude
mice grafted with normal human skin causes loss of pigmentation in the skin
(19). Depigmentation has been induced in mice by immune responses directed
to any of several different antigens, including tyrosinase (52), TRP-l (44,53),
and TRP-2 (54), and in humans by immune cells targeted against MART-l
(SO).
While it is unclear whether depigmentation in mice is vitiligo because
the melanocytes that are damaged reside in hair follicles rather than in the
epidermis, these experiments clearly demonstrate that melanocytes can be
destroyed in vivo by either antibody or T cells alone and that the damage can
be caused by immune responses directed against anyone of several different
pigment cell-associated antigens. Which particular immune mechanism and
antigen(s) cause vitiligo remains uncertain. As described below, the strongest
evidence indicates that vitiligo is the result of an antibody response directed
against several different melanocyte antigens.
Immune Abnormalities Associated with Vitiligo: Cause

or Result?
The strongest evidence that the immune abnormalities are a cause rather than
a result of pigment loss comes from studies in Sinclair swine and Smyth
chickens with spontaneous depigmentation, where circulating pigment cell
antibodies usually appear before the onset of pigment loss (21,22). That,
together with the fact that neonatal bursectomy in chickens minimizes
depigmentation, suggests that VIT antibodies are not a result of pigment cell
destruction.
If autoimmune responses against melanocytes are the cause of vitiligo,
the stimulus for their appearance remains unknown. One intriguing possi-
bility is tha t it results from exposure to cross-reacting antigens expressed by
microorganisms. This is suggested by the high incidence of anti-pigment cell
antibodies in patients with chronic mucocutaneous candidiasis (13,14).
Mechanisms of Immune Damage to Melanocytes in Vitiligo

Because depigmentation can be caused in vivo by either humoral or cellular
immune mechanisms alone, vitiligo could result from either or both of these
mechanisms. The available evidence is stronger for antibody responses being
the primary mechanism for the following reasons:
I. Multiple large studies confirm the association of vitiligo with anti-
pigment cell antibodies.
2. These antibodies are also present in animals with vitiligo.
3. There is an association between the presence and level of VIT anti-
bodies and the extent and activity of vitiligo.
4. VIT antibodies precede, rather than follow, the appearance of viti-
ligo in animals.
5. VIT antibodies can kill human melanocytes in vitro and in vivo.
6. Passive transfer of VIT antibodies induces the disease in animals.
In contrast, the evidence supporting a role for cellular mechanisms
consists of: (a) the presence of a sparse cellular infiltrate most pronounced
at the border of active lesions; (b) the ability of T cells targeted against
88 Bystryn
melanocyte antigens to cause depigmentation in vivo; and (c) one small study
demonstrating an association between anti-pigment cell T cells and vitiligo.
The actual mechanism(s) by which VIT antibodies kill melanocytes are prob-
ably multiple, and include both complement-dependent cytotoxicity and anti-
body-dependent cellular cytotoxicity, as pigment cells can be killed in vitro
and in vivo by both mechanisms.
Immune responses against any of a number of pigment cell antigens can
result in the killing ofmelanocytes in vivo. The specific antigen(s) targeted by
the autoimmune responses in vitiligo are probably multiple and remain to be
fully defined. They include cell-surface antigens of 40, 75, and 90 kDa. As
some of these antigens are preferentially expressed by pigment cells, whereas
others are common tissue antigens, two distinct mechanisms may mediate the
selective destruction of melanocytes in vitiligo. One is an immune response
directed to antigens preferentially expressed by melanocytes, such as the
90kDa antigen. The other is immune responses against common tissue anti-
gens that are also expressed by cells other than melanocytes (such as the 40
and 75 kDa antigens). These could nonetheless damage melanocytes selec-
tively, as these cells are much more sensitive to immune injury than unrelated
cells expressing the same antigens.
SUMMARY
There is considerable evidence that vitiligo is an autoimmune disease medi-
ated by immune reactions directed against melanocytes. The particular im-
mune mechanism(s) involved in the disease remains to be fully defined, but the
current evidence p-oints to humoral (VIT antibodies) responses playing the
predominant role.
ACKNOWLEDGMENTS
Supported in part by USPHS Research Grants NIH Grant 5 ROI CA89270-
02 and by grants from the Rose M. Badgeley Residuary Trust.
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8
Vitiligo: A Disorder of the Microvessels?
Elena Del Bianco, Giuseppe Muscarella,

and Torello Lotti
Pathogenetic hypotheses of vitiligo include a synergistic one, which indicates

that several simultaneous processes (autoimmune, neurobiological, oxida-
tive, infective) could induce, in genetically predisposed subjects, the disap-
pearance of melanocytes at the cutaneous level. The complex of these events
eventually produces the appearance of cutaneous nonpigmented patches.
IMMUNONEUROENDOCRINE SYSTEM INVOLVEMENT

IN VITILIGO
Immunoneuroendocrine system involvement in this pattern of events is
suggested by clinical, ultrastructural, and biochemical data. Clinically a
segmental distribution of depigmented areas is described in some patients in
which vitiligo involves different derma tomes. Occasionally vitiligo has been
described as truly dermatomal, e.g., limited to the distribution of trigeminal
nerve (I). Moreover, neuronal involvement is supported by other clinical
observations: Vitiligo developed in the area supplied by nerves damaged in a
brachial plexus injury (2), and it was described in association with viral
encephalitis (3) and with Horner's syndrome due to multiple sclerosis (4). In
animals it was demonstrated that denervation alters skin pigmentation (5) and
that nerve stimulation lightens pigmentation by aggregating melanosomes (6).
At the microscopic level studies have shown the presence of nerve fibers
in contact with melanocytes, degenerative and regenerative processes in
94 Del Bianco et al.
terminal cutaneous nerve fibers, and altered immunoreactivity for neuro-

peptides and general neuronal markers in the skin of vitiligo patients (7,8).
These neuronal alterations suggest involvement of the autonomic nervous
system in events leading to the destruction of melanocytes. AI'Abadie et al. (9)
proposed that neuropeptides released in vitiligo patients by endogenous
(stress) or exogenous stimuli (traumatic events as in Koebner phenomenon)
may initiate a cascade of reactions, involving both the immune system and the
vascular system, resulting the destruction of melanocytes. Interestingly,
Mozzanica et al. (10) showed an increase in ~-endorphin and met-enkephalin
in the plasma of vitiligo patients. Moreover, it is known that neuropeptides
can have a stimulatory or inibitory effect on immune cells and are potent
vasoactive agents, so that they could be the mediators of the sweating
alteration reported in vitiliginous skin (11).
Cutaneous microcirculation could represent an important "bridge"
between nervous system and melanocytes, which are often a target of neuro-
transmitters released by cholinergic endings. The sympathetic nervous system
has a profound effect on the blood flow through the skin (12), mostly affecting
the arterioles and arteriovenous anastomoses, i.e., thermoregulatory vessels.
Therefore, one could hypothesize that assessment of cutaneous blood flow
can be used as a parameter to reflect the sympathetic nerve function of a
certain skin area and that analysis of microcirculation in vitiligo patients
could help clarify the pathogenetic mechanism of depigmentation.
LASER-DOPPLER FLOWMETRY
Laser-Doppler flowmetry (LDF), like other methods for the analysis of
microcirculation, can represent a useful tool in vitiligo research. This non-
invasive technique provides a semiquantitative assessment of microvascular
blood perfusion. LDF measurements from the skin reflect blood flow in
capillaries, arterioles, and venules, including in the upper papillary plexus.
Detection is not influenced by blood flow to underlying skeletal muscle.
Traditional laser-Doppler f10wmeters consist of a helium-neon laser of
wavelength 632.8 nm that, via an optical fiber applied on the skin, is assumed
to penetrate 1-2 mm below the skin surface. This wavelength corresponds to
an optical window in the skin spectrum, which means that at this wavelength
the skin is completely translucent. In the tissue a part of the incident light is
backscattered with the same wavelength by anatomical static structures and
another part is backscattered with a shift in wavelength by moving red blood
cells. Only the second part is collected and assessed; the mean spectrum of
shifted wavelengths is computed. The blood flow is determined by the product
of the number of red blood cells moving in the measured volume (within the
surface capillaries of the skin) and the mean velocity of these blood cells. The
Vitiligo: A Disorder of the Microvessels? 95
result is a signal with the dimension of a flux (a moving volume) but given in
arbitrary units (volts). The curve shows cardiac pulsations on which are
superimposed lower frequency vasomotion waves. A software program is
available to fully analyze the signal: select the frequency of rhythmical vari-
ations, measure the slope of a change, maximum, minimum, and medium
values between two points, and make almost any measurements (13).
LDF IN VITILIGO
At the cutaneous level is present a complex microcirculatory network that is
different in different body regions and that is regulated by numerous physical,
chemical, and biological factors. Therefore, before testing by LDF, the
patient should rest lying down on a bed for 15 minutes in a room where the
temperature is kept at between 22 and 23°C. Moreover, in vitiligo analyses by
LDF, several authors reported that it had been necessary to examine both
depigmented patches and healthy surrounding areas in order to compare the
microcirculatory blood flow (14).
Recently, a marked increase in cutaneous blood flow was demonstrated
by LDF in segmental-type vitiligo as compared to contralateral normal skin,
while a weak difference was found among nonsegmental-type vitiligo, lesion
side clinically normal skin, and contralateral normal skin (14). These data
correia te with those obtained in our previous study involving vitiligo patients,
without differentiating among the two types of vitiligo (segmental and non-
segmental). In fact, our results show blood flow weakly increased in vitiligo
patches in comparison with surrounding clinically normal skin (Fig. 1).
However using LDF we found in all patients examined an interesting increase
in blood flow in repigmenting lesions that resulted in almost two times greater
blood flow measured in normal skin at least 2 cm away from the lesions (Fig. 2)
(15).
It is possible that a regulation of cutaneous vessels, probably through
sympathetic nerve fibers, represents an important step in the recovery of
depigmented areas; on the other hand, it could be a concurrent phenomenon
not yet described. The existence of a correlation between melanogenesis,
pigmentation, and functional changes in cutaneous microcirculation is sug-
gested by studies that show an abnormal local pigmentation after venous
stasis or after therapeutic venous sclerosis (16). Wu and co-workers showed a
disturbance of sympathetic nerve functions in the vitiliginous skin and that
this dysfunction plays a role in the pathogenesis of segmental-type vitiligo
(14).
Based on these preliminary observations, LDF and other methods for
analysis of cutaneous microcirculation could be used to study microvascular
alteration in vitiligo. Submitting vitiligo patients to periodic LDF analysis
I:rl <0
m
8!
(/'J
~
~
Z
::::J
()
0 Z
~:;:j. 0
...-I
tg.
<b
0..
~
~ '.;
en
~
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~
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o
o
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FIGURE 1 Cutaneous blood flow, assessed by laser-doppler flowmetry, of a patient affected by vitiligo. The lower panel III
shows the blood flow of a vitiligous area in stationary phase; the upper panel shows the blood flow of a healthy area 2 cm -
from the vitiligous one.
<
a:
to'
!=!
:t>
c
(ii'
E.I :1 ...Co
0
...
(I)
;:J --
0
;r
(I)
()
0 z s::
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~ 0 ...... --- ... _- _.
~, ~ <
(I)
:::l" rJJ III
III
<b
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~ •.,J
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-
ai' ~
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FIGURE 2 Cutaneous blood flow, assessed by laser-doppler flowmetry, of a patient affected by vitiligo. The lower panel (0
.....
shows the blood flow of a healthy area at 2 cm from the vitiligous one; the upper panel shows the blood flow of a
repigmenting vitiligous area.
98 Del Bianco et al.
could be useful to assess the evolution of the pathology after therapeutic

treatments in order to evaluate efficacy.
Further research in this field could document the mechanism by which
microcirculation plays a role in the pathogenesis of vitiligo.
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response increase in segmental-type vitiligo lesions. J Dennatol Sci 2000; 23:53-
62.
15. Del Bianco E, Muscarella G, Lotti T. La vitligine: un disturbo microcitcolatorio?
Lotti Ted. UTET. Milano: La vitiligine. Nuovi concetti e nuove terapie, 2000:
31-33 Milan.
16. Merlen JF, Coget J, Sarteel AM. Pigmentation in venous stasis. Phlebologie
1983; 36304-314
9
Pathogenesis of Vitiligo: Evidence for
a Possible Ongoing Disorder of the
Cutaneous Microenvironment
Giuseppe Hautmann, Silvia Moretti, and Torello Lotti

Jana Hercogova
INTRODUCTION
The characteristic histological picture of vitiligo is the total absence of
melanin and melanin-forming cell, or melanocytes, with an otherwise normal
dermis and epidermis (1--4). The etiology of this event is unknown, and several
hypotheses have been proposed to explain the loss of melanocytes. Thus, the
pathogenesis of vitiligo is still not known. There are many hypotheses extant,
each supported by intriguing data that currently are insufficient to prove the
accuracy of the theories. Among the hypotheses so far suggested, the most
important seem to be (a) the autoimmune theory, (b) the intrinsic/genetic
theory, (c) the autocytotoxic theory, and (d) the neural theory. An eclectic
theory has also been suggested.
AUTOIMMUNE THEORY
Clinical and experimental data seem to demonstrate the role of an auto-
immune reaction in the pathogenesis of vitiligo. In particular, recent data
100 Hautmann et al.
underline the relevant role of autoantibodies and of autoreactive T lympho-

cytes against melanocyte-derived antigens. Briefly, the clinical and epidemiol-
ogical findings that support this hypothesis are as follows (Table I):
I. There are many reports of vitiligo in association with organ-specific
autoimmune diseases, such as Hashimoto's thyroiditis, hyperthy-
roidism, Addison's disease, pernicious anemia, juvenile diabetes
mellitus, and alopecia areata. In particular, vitiligo represents a
common clinical feature (10-15% of the cases) of the so-called
autoimmune polyglandular syndromes, which consist of the asso-
ciation of several autoimmunological disorders of thyroid, adrenal
glands, blood (pernicious anemia), pancreas (insulin-dependent dia-
betes mellitus), and chronic mucocutaneous candidiasis (5).
2. Vitiligo often represents a clinical mark of autoimmune diseases
that are clinically or subclinically evident (6,7).
3. In a follow-up study lasting 10 years, it has been shown that among
the clinically healthy relatives of subjects with vitiligo, disease onset
occured in 11.3% of the relatives with antithyroid and/or gastric
mucosae autoantibodies and in 0.9 of the relatives without these
autoantibodies (6,7);
4. Topical application or systemic administration of corticosteroids
can stop disease progression and induce cutaneous repigmentation
(8,9).
The experimental findings supporting the autoimmune hypotheses are as
follows.
Vitiligo patients very often (20-30%) present with organ-specific auto-
antibodies (mainly directed to thyroid or gastric autoantigens). Similar ab-
normalities are found in first-degree normal relatives (10-12).
Eighty percent of vitiligo patients present with autoantibodies to mela-
nocytic antigens; in normal control subjects these antibodies are present in
TABLE 1 Factors Supporting the Autoimmune Hypothesis
Association with organ specific autoimmune disease

Clinical mark of autoimmune diseases clinically or subclinically evident
Onset in 11.3% of clinically healthy relatives with antithyroid and/or gastric
mucosae autoantibodies
Improvement with topical application or systemic administration of steroids
Organ-specific circulating autoantibodies in 20-30% of cases
Autoantibodies to melanocytic antigens in 80% of cases
Role of autoreactive T lymphocytes
Pathogenesis of Vitiligo 101
10% of cases. These autoantibodies are usually immunoglobulins of the G

class (lgGl, 2, 3) and rarely are IgA. Several laboratory techniques are able
to detect them; the incidence and level of antibodies correlates with the extent
of depigmentation and the activity of the disease. Vitiligo antibodies have the
functional capacity to kill pigment cells by two different mechanisms: com-
plement-dependent cytotoxicity and antibody-dependent cellular cytotoxic-
ity. The principal target of antimelanocyte antibodies in vitiligo seems to be
reprensented by tyrosinase, the key enzyme of melanogenesis. The molecular
weight of tyrosinase is 69-75 kDa. Serum antibodies against tyrosinase, a 69-
75 kDa protein, were detected in 77% of vitiligo patients, 12% of patients
with autoimmune endocrine disease without vitiligo or a history of vitiligo,
and 0% of normal controls. Antibodies to tyrosinase are prevalently detected
during the phases of activity of the disease and in subjects with a great extent
of depigmentation. In the serum of vitiligo patients there are other antibodies
directed most commonly to the 40-45, 75, and 90 kDa antigens, designated
Vit45, VIT75, and VIT90, respectively; these antigens are preferentially
(VIT90) expressed on the melanocyte surface. Antibodies to VIT45 and to
VIT75 are present in 74-76% and in 57-72% of vitiligo patients, respectively,
compared to in 4-14% and in 4-8% of control individuals. Research on
transplantation of human lesional skin on athymic mice has clarified the
possible pathogenetic role of these autoantibodies. In this experimental
setting, the lesional skin repigments, whereas in normal human transplanted
skin there is a massive loss of melanocytes after infusion of IgG of vitiligo
patients (10-26).
Beyond the possible pathogenetic role of these specific autoantibodies,
some researchers underline the relevant role of autoreactive T lymphocytes;
microscopic analysis shows these cells strictly apposed to aberrant melano-
cytes and vacuolized keratinocytes, at the lesional border of the active mac-
ules; the cellular infiltrate is located mainly under the dermoepidermal
junction and is poorly represented at the lesional border of active vitiligo
vulgaris, whereas it is abundant in inflammatory vitiligo. Immunohistochem-
ical investigation demonstrated that the cellular infiltrate consists mostly of
CD8+ T cells and CD36+ macrophages.The T lymphocytes are CD25+ and
DR+ (presenting the signs of activated cells) and are near to basal kerat-
inocytes and melanocytes that express on their surface high levels ofICA M-I
and HLA-II molecules. The amount of cell infiltrate in the inflammatory
vitiligo correlates with the progressive degeneration and subsequent loss of
melanocytes. The characterization of the autoantigens recognized by the T
lymphocytes has to be exactly defined, although some data seem to suggest
that these are melanocytic differentiation antigens (MDA), such as tyrosinase
and Melan-A/MART-I. In fact, if precursors of autoreactive tyrosinase-
specific circulating T cells of normal subjects are activated in vitro by a
102 Hautmann et al.
synthetic tyrosinase-analogue nona peptide, these cells are cytolytic for target
cells expressing the antigen on their surface (both constitutively and by pas-
sive adhesion). Moreover, in vitiligo subjects there have been demonstrated
circulating lymphocytes expressing on their surface a specific hormone recep-
tor able to recognize and lyse HLA-A201 + Melan-A/MART-I + melano-
cytes (27-34).
Finally, experimental studies by Boissy utilizing animal models able to
develop vitiligo-like lesions confirm the pathogenetic role of autoreactive T
lymphocytes in vitiligo. Thus, it seems demonstrated that the cellular infiltrate
is subsequent to the presence of aberrant melanocytes, and that there is not
the total loss of melanocytes if neonatal bursectomy, that blocks the onset of
the inflammatory infiltrate, is done. These experimental data seem to suggest
that the T cell-mediated citotoxicity do not happen in the early phases of the
melanocytic damage but is very relevant in the subsequent phases, with the
complete depletion of residual melanocytes (33,34).
INTRINSIC/GENETIC HYPOTHESIS
This hypothesis emphasizes the central role of a genetically determined sus-
ceptibility of melanocytes to environmental factors. At the basis of this hy-
pothesis are several genetic studies demonstrating a genetic predisposition
to the phenotypic expression of the disease. In particular, Nath and co-
workers and Ramaiah and co-workers (35,36), observing the highest inci-
dence of vitiligo (90.38%) among the Soma Vanishan people in Bangalore,
indicated that at least three diallelic unlinked genes are involved in the
expression of the disease, so that vitiligo could be considered a polygenic
disorder (37).
The genetic factors would be able to determine the expression of the
disease because they can provoke an increased susceptibility of the melano-
cyte to several environmental stimuli. This susceptibility has been demon-
strated on the basis of both in vitro studies on cultured melanocytes of vitiligo
subjects and studies on animal models (38-41). In brief, the research data
show that the cultured melanocytes of vitiligo patients present a decreased
capacity of growth and proliferation; moreover, they present a decreased and/
or aberrant expression of specific proteins, such as the receptor for SCF (c-
Kit) or the tyrosinase-related protein (TRP-I). Research on animal models
confirmed these results and demonstrated the particular sensibility of mel-
anocytes to cell vitality conditioning factors (apoptotic factors) secreted by
follicular keratinocytes (42). Moreover, studies on professional vitiligo (viti-
ligo induced by contact with phenol deriva tives, idroquinone, or catechols)
seem to confirm that many depigmentating agents are able to explain their
activity not aspecifically but as specific cytotoxic agents to genetically sus-

ceptible melanocytes (43,44).
AUTOCYTOTOXIC HYPOTHESIS
This hypothesis was introd uced by Lerner in 1971 and suggests tbat there is a
self-destruction of melanocytes by toxic prod ucts made by tbese cells because
of a defect of the natural protective mechanisms that take away the toxic
precursors of melanin (45) (Table 2). Experimental evidence supporting this
interpretation is as follows:
I. Electron microscopic studies have demonstrated tbat in tbe achro-

mic lesional skin of rapid expanding vitiligo, there is an extracellular
storage of granular material in the epidermis. Melanocytes and ke-
ratinocytes present vacuolization that is a morpbological expression
of early cellular oxidative damage (46).
2. It bas been shown that several depigmentating agents (hidroqui-
none, catechol, etc.) may bave selective cytotoxic effects on mel-
anocytes; tbe ultrastructural features of this damage overlap the
bistological picture of vitiligo (47,48).
3. In vitro and in vivo experimental studies have demonstrated an in-
creased susceptibility of melanocytes to substances produced during
melanin synthesis, such as tyrosine-like molecules, melanin precur-
sors, or intermediate metabolites (in particular, phenolic derivatives
and dopa-chinones) (49).
Recently, biochemical studies have documentated that tbe intracellular
storage of reactive oxygen intermediates (superoxide anion radical, hydrogen
peroxide, bydroxyl radicals) could provoke the autocytotoxicity of the
melanocyte, whereas the intermediate products of tbe melanin synthesis
are not implicated. This occurs because of multiple defects of the activity
of several enzymes, such as catalase, thioredoxin-reductase, and tetrahydro-
biopterin (50-53). Low catalase levels (catalase is able to transform super-
TABLE 2 Factors Supporting the Autocytotoxic Hypothesis

Electron microscopy: epidermal storage of granular material; vacuolization
of melanocytes and keratinocytes
Hydroquinone-induced depigmentation is ultrastructurally overlapping to vitiligo
Increased suceptibility of melanocytes to substances produced during
melanogenesis
104 Hautmann et al.
oxide anion radicals in water) have been demonstrated in lesional and

perilesional skin (50,51,54), suggesting the hypothesis of toxic damage by
hydroxyl radicals to the melanocytic surface (51 ,54). Recently it has been also
demonstrated that there is a remarkable increase in the amount ofH 2 0 2 in the
lesional skin of vitiligo subjects, and this oxygen intermediate can be removed
by UVB-activated pseudocatalase (55).
Thioredoxin-reductase is a potent scavenger of free radicals and is pres-
ent on the melanocytic surface. Keratinocytes of the lesional skin of vitiligous
subjects present an increased concentration of Ca 2+ ions in comparison to
keratinocytes of both healthy normal control and normal skin of vitiligous
patients (52). This increased extracellular concentration of Ca 2+ ions is
mediated by the inhibition of the thioredoxin-reductase and induces increased
storage of superoxide anions in melanocytes and subsequent cellular death
(52,56). On the contrary, each factor that induces an increase in intra-
melanocyte calcium levels able to increase the thioredoxin-reductase activity
with subsequent reduction of superoxide anions. It has been suggested that
the beneficial therapeutic effects of UVA treatment are linked to the above-
mentioned mechanism (57-59).
Finally, Schallreuter et al. have suggested that the depigmentation in
vitiligo is a result of a blockade of tyrosine synthesis within keratinocytes re-
lated to an excess accumulation of7-tetrahydrobiopterin within the epidermis
and catechols in serum and tissues (60,61). The accumulation of 7-tetrahy-
drobiopterin is due to a deficiency of the activity of the enzyme 4a-hydroxy-
tetrahydrobiopterin dehydratase which normally recycles the biopterins.
Thus, there is an increased accumulation of 7-tetrahydrobiopterin in the
melanocytes and increased synthesis of catecholamines in the keratinocytes,
with increased levels in serum and urine (62,63). 7-Tetrahydrobiopterin, act-
ing selectively on the phenylalanine hydroxylase, blocks the synthesis of tyro-
sine and subsequent reduction of the functional activity of the melanocyte
(64). The reduced functional activity of 4a-hydroxytetrahydrobiopterin dehy-
dratase would provoke an increased production of H 2 0 2 that is cytotoxic to
the melanocyte (61,62).
Strictly related to these data, Maresca's recent research shows that in
melanocytes of vitiligous patients there is an imbalance between substances
that control oxidative stress (54): in fact, there are increased vitamin E and
superoxide dismutase levels and reduced catalase and ubiquinone activities.
This imbalance might be the reason for the increased susceptibility ofmelano-
cytes of vitiligous patients to peroxidant agents and physical and chemical
stressors.
Recent experimental data demonstrate the very early activation of the
melatonin receptor with subsequent intracellular storage of intermediate
toxic products of melanogenesis and of reactive oxygen intermediates; these
results seem to confirm the autocytotoxic theory and supply a further link
between the above-examined hypotheses (65,66).
NEURAL HYPOTHESIS
This hypothesis (Table 3) is supported by clinical, histological, ultrastruc-

tural, and biochemical evidence. This theory emphasizes the possible role of
the cutaneous nerve endings and the released neuromediators on the func-
tional activity and vitality of melanocytes.
The most important clinical evidences that support this hypothesis are:
1. Diseases of central nervous system such as neurofibromatosis or
sclerosis tuberosa present cutaneous features that may include
hypopigmented or hyperpigmented lesions (67,68).
2. Infectious diseases involving the skin and the nervous system
(syphilis, leprosy, pinta) present cutaneous lesions that consist of
hypopigmentation; in particular, in tuberculoid leprosy, hypopig-
mentation and anesthesia coexist in the cutaneous areas innervated
by the peripheral nerves involved in the disease (69).
3. Vitiligo may occur in the cutaneous areas innervated by a trauma-
tized peripheral nerve or following transverse myelitis. In this last
condition, vitiligo begins in the upper part of the body, whereas in
the skin areas underlying the spinal damage, the skin was normally
pigmented (70,71).
In generalized vitiligo, there have been reported increases in body temper-
ature, bleeding, and sweating (72). In segmental vitiligo, lesional skin presents
with increased bleeding and an aberrant response to intradermal injection of
epinephrine and to the sweat-inducing factors (73-75).
Microscopic and ultrastructural evidence consist of the demonstration
of the coexistence of degenerative and regenerative alterations of the sensitive
TABLE 3 Factors Supporting the Neural Hypothesis
Diseases of the central nervous system present cutaneous features including

depigmentation
Infectious diseases involving the skin and the central nervous system present
cutaneous lesions consisting of hypopigmentation
Onset of vitiligo in cutaneous areas innervated by a traumatized peripheral nerve
Increase of body temperature, bleeding time, and sweating in vitiligo patches
Immunoistochemical demonstration of abnormalities of neuropeptidergic
innervation in vitiligo patches
106 Hautmann et al.
nerve endings in the lesional skin and at the border of the lesion and the
demonstration of the presence of a rearrangement and an ultrastructural re-
organization of Schwann cells (76).
Immunohistochemical studies have shown the role played by neuropep-
tides, such as neuropeptide Y (NPY), that is particularly expressed perivas-
cularly in the papillary dermis at the peripheral sites of the lesion. Nerve
growth factor and calcitonin gene-related peptide receptors (NGFr-IR and
CGRPr-IR) have been demonstrated to be overexpressed in the epidermis and
papillary dermis at the margin of the lesion (76,77). These neuropeptides can
modulate dendricity, adherence, motility of melanocytes, and melanin syn-
thesis and melanosome transfer. Moreover, neuropeptides can play an immu-
nomodulant role and be a potential link with the autoimmune alterations of
vitiligo (78,79) High blood and urinary levels of some neurotransmitters
(catecholamines, dopamine, norepinephrine, epinephrine) have been shown
in patients with vitiligo. These neurotransmitters are cytotoxic both directly
by inhibition of enzymatic activities or reactive oxygen intermediate produc-
tion and indirectly by activation of the a-adrenergic receptors of cutaneous
arterioles with subsequent vasoconstriction and hypoxia that supports the
reactive oxygen intermediate production.
Adrenergic neurotransmitter catabolism is generally due to two en-
zymes, catechoJ-O-methyltransferase (COMT) and monoamine oxidase
(MAO); their expression is usually aberrant in vitiligo. There is increased
activity ofCOMT: thus, it follows that ortho-quinone production is increased
with cytotoxic activities during melanin synthesis. The increased activity of
MAO is linked to the increased production of H 2 0 2 , which is cytotxic to the
melanocyte (80).
ECLECTIC HYPOTHESIS
The above-mentioned hypothesized pathogenetic mechanisms consider viti-
ligo as a pathological event that affects, primarily or secondarily, only the
melanocyte, without considering the interactions that modulate the relation-
ships among melanocytes and the other epidermal and dermal cells, which are
able to influence both the functional activity and the survival of melanocytes.
Melanocytes are neural ectoderm-derived cells that migrate during embryonic
development to the epidermis, where they are attached to the basement mem-
brane and to surrounding keratinocytes by various types of paired adhesion
molecules. There are no melanocyte-keratinocyte adhesion structures that
can be detected by electron microscopy, and it is assumed that keratinocytes
and melanocytes interact through adhesion pairs that are much Jess organized
than those that hold epidermal keratinocytes in place. It is a sum~d that
meJanocytes and keratinocytes interact through the homophilic adhesion
molecule E-cadherin (81), which is expressed on melanocytes and keratino-

cytes (81,82). Melanocytes probably also interact with keratinocytes through
a2()I and a3()1 integrins, possibly binding to laminin Y (LmY) (83). Mela-
nocytes also are stabilized in the basement membrane zone by the a2()1 and
a3()J integrins, binding to Iaminins and collagen and to fibronectin through
the av()I integrin. The precise nature of these melanocyte-keratinocyte in-
teractions in vivo is unknown.
The major biological function of melanocytes is the synthesis of mel-
anin, which is packaged in melanosomes, and the transfer of these organelles
TABLE 4 Factors That Modulate Melanocyte Growth and/or Morphology

in Culture
Factor Main activity
Growth factors, cytokines

BFGF Growth stimulation
MGF/SCF Growth stimulation
MGF/SF Growth and motility stimulation
Insulin/IGF-1 Growth stimulation
EGF Growth and motility stimulation
NGF Growth stimulation
GH Growth stimulation
TGF-a Growth and motility stimulation
TGF-f.'> Growth inhibition
LTC 4 Growth and motility stimulation, differentiation
inhibition
ET-1 Growth, motility, melanogenesis stimulation
IL-1 Growth, melanogenesis inhibition; pigmentation
IL-6 Growth, melanogenesis inhibition; pigmentation
TNF-a Growth, melanogenesis stimulation
PGE 2 , PGD 2 Melanogenesis stimulation; dendricity
CA2+ - and Cation-binding proteins
Ca 2 + Growth stimulation
Ceruloplasmin Growth stimulation
Transferrin Growth stimulation
CAMP-Increasing substances
a-MSH Growth, motility stimulation; pigmentation
Protein-kinase C activators
TPA Growth stimulation
Physical agents
Ultraviolet rays Growth promotion; melanogenesis stimulation;
morphological alterations
Source: Modified from Ref. 118.

108 Hautmann et al.
TABLE 5 Semiquantitative Expression of Epidermal Cytokines in

Achromic Lesional Skin
Cytokine % of stained c cells Positivity location

a Basal/suprabasal
GM-CSF 11-30
SCF 11-30 Basal/suprabasal
bFGF 11-30 Basal/suprabasal
IL-6 31-50 Basal/suprabasal
TGF-13 <10 Basal/suprabasal
TNF-a 31-50 Basal/suprabasal
a Percentage of stained keratinocytes compared to the entire population of

epidermal keratinocytes.
to keratinocytes. Within keratinocytes, melanosomes localize over the

nucleus and protect the epidermis from the damaging effects of ultraviolet
radiation. This function depends on the intimate interaction of melanocytes
and keratinocytes. Thus, a number of studies have led to the delineation of
several groups of chemically defined mitogens: we summarize the factors that
modulate the growth of melanocyte in culture in Table 4.
Recent experimental data underline the intricate interactions that exist
between melanocytes and cells present in the skin, such as keratinocytes,
Langerhans cells, endothelial cells, fibroblasts, and mast cells. Moreover, lym-
phocytes and macrophages infiltrating the skin in vitiligo are able to influence
melanocytic activity as well as the pituitary hormone ex-melanocyte stimulat-
ing hormone (ex-MSH) and the neuropeptides released by sensory nerve end-
ings of the skin. Each of the above-mentioned cells can influence melanocyte
activity and survival, both positively and negatively, by soluble mediator
production. In particular, keratinocytes, spontaneously or by UV-induced
TABLE 6 Semiquantitative Expression of Epidermal Cytokines in Perilesional

Skin
Cytokine % of stained c cells Positivity location
GM-CSF 51-100a Basal/suprabasal, continuous disposition

SCF 31-50 Basal/suprabasal, zonal disposition
bFGF 31-50 Basal/suprabasal zonal/continuous disposition
IL-6 11-30 Basal/suprabasal, zonal/continuous disposition
TGF-13 <10 Basal/suprabasal
TNF-a 11-30 Basal/suprabasal, zonal/continuous disposition
aPercentage of stained keratinocytes compared to the entire population of epidermal

keratinocytes.
TABLE 7 Expression of Epidermal Receptors
Cytokine Perilesional skin Lesional skin
GM-CSF R Rare Rare

suprabasal dendrytic suprabasal dendrytic
cells «10%8) cells «10%)
IL-6 R Rare Rare
suprabasal dendrytic suprabasal dendrytic
cells «10%) cells «10%)
C-KIT+ Several basal dendrytic cells + 1 case with some basal,
(mean value of cells with dendrytic cells +
dendrytic morphology over 200 (mean value of cells with
basal keratinocytes = 22.5) dendrytic morphology over
200 basal keratinocytes = 0.5)
aPercentage of stained keratinocytes compared to the entire population of epidermal

keratinocytes.
(a)
(b)
FIGURE 1 Immunohistochemical staining of IL-6 reactivity in lesional (a) and pe-

rilesional (b) skin (x10): intense presence of IL-6 in the basal and suprabasal
layers of the epidermis of lesional skin.
110 Hautmann et al.
activation, can synthesize and secrete several cytokines that have both a
stimulatory effect (NGF, ILGF, GR, EGF, TGF-a) and an inhibitory action
(TGF -[3, II-I, IL-6, IFN-a) on melanocyte activities. Endothelial cells (by
production of endothelins) and fibroblasts (by bFGF, FGF-6, SCF, RGF
secretion) have a stimulatory effect on the melanocyte. Mast cells are able to
produce several inflammatory mediators such as histamine leukotrienes, and
prostaglandines that stimulate the melanocyte; moreover, mast cells secrete a
growth factor, stem cell factor (SCF), that interacts with melanocytes by the
specific receptor c/Kit (84-115).
As said above, experimental evidence supports the relevant role that
keratinocytes, mast cells, and fibloblasts play in the modulation of growth
and/or differentiation of melanocytes. Keratinocytes produce growth factors
and cytokines with stimulating (TGF-a, bFGF, NGF) and inhibitory (IL-I,
IL-6, TNF-a) effects on melanocytic activity. Fibroblasts produce insulin-like
growth factor (IGF-l), which stimulates melanocytes (95,96), whereas mast
cells secrete SCF (also known as mast cell growth factor or steel factor), which
(a)
(b)
FIGURE 2 Immunohistochemical staining of GM-CSF reactivity in lesional (a) and

perilesional (b) skin (x 10): the expression of this cytokine is reduced in lesional
skin, whereas it is highly expressed in perilesional skin.
is able to stimulate melanocyte proliferation. Thus, in healthy skin there is a

molecular microenvironment that favors the survival of the melanocyte. The
creation of this favorable microenvironment could regulate the possible "co-
operative relationship" between these cells-melanocyte, keratinocyte, mast
cell, fibroblast.
These data enhance and complete the concept of the epidermal melanic
unit of Masson and Fitzpatrick (116), as it puts the melanocyte in the center
of a series of stimulating and/or inhibitory stimuli produced by keratinocytes,
mast cells, fibroblasts, lymphocytes, macrophages or nerve endings. Thus, an
alteration of this microenvironment constituted by cytokines and growth
factor can explain the disappearance of the melanocyte as a result of its early
apoptotic death. Therefore, the achromic lesion of vitiligo may be the result of
an alteration in stimulant/inhibing effect signaling (represented by growth
factors and cytokines) with a subsequent excess of inhibition. According to
this eclectic hypothesis, vitiligo is the expression of a change in the normal
(a)
(b)
FIGURE 3 Immunohistochemical staining of bFGF reactivity in lesional (a) and
perilesional (b) skin (X10): in lesional skin the expression of this. growth factor is
reduced, while it is normally expressed In penleslonal skin, with a continuous
disposition in the basal and suprabasal layers of epidermis.
112 Hautmann et al.
cellular communications among melanocytes, keratinocytes, mast cells, and

fibroblasts with a biochemical imbalance (related to growth factors, cyto-
kines, inflammatory mediators, adhesion molecules) that does not permit
melanocytic survival in the epidermal environment. The creation of an
adverse microenvironment for the melanocyte should induce the early death
of this cell by apoptosis and the formation of achromic lesions that become
definitive because near melanocytes and reservoir cells are unable to colonize
these areas.
Recently researchers have investigated the hypothesis that the expres-
sion of epidermal, keratinocyte-derived cytokines may be modified in vitiligo
(117). Results show the following:
I. In perilesional skin the number of epidermal melanocytes stained
for NKI-beteb ranged from 15 to 32 (per 200 basal cells) and in
nonlesional skin from 17 to 33. The Dum bel' of melanocytes stained
for HMB45 ranged from 7 to 24 (per 200 basal cells) in perilesional
(a)
(b)
FIGURE 4 Immunohistochemical staining of SCF reactivity in lesional (a) and pe-

rilesional (b) skin (x 10): in lesional skin the expression of this growth factor is
reduced, while it is normally expressed in perilesional skin, with a zonal disposition
in the basal and suprabasal layers of epidermis.
skin, whereas in nonlesional skin it varied from 10 to 28. No signifi-

cant difference in melanocyte number was found between perile-
sional and nonlesional skin. No melanocytes were found in vitiligo
lesional skin.
2. Mast cells have been studied by the identification of tryptase
activity. Tryptase-positive cells were localized in the perivascular
and periadnexial dermis, with a percentage of 15-20% of the dermal
cell population. There was no difference between lesional, perile-
sional, and nonlesional skin
3. As reported in Tables (5-7), all samples showed some staining for
the tested cytokines but because the results in specimens tested for
TGF-r?> reactivity always fell below 10% of the epidermis, they were
classified as nonreactive. The lesional skin reactivity for GM-CSF,
SCF, and bFGF fell into the 11-30% category, and the reaction for
IL-6 and TNF-O' into the 31-50% category. On the contrary, in
(a)
(b)
FIGURE 5 Immunohistochemical staining of C-Kit reactivity in lesional (a) and pe-
rilesional (b) skin (x 10): absence of c-Kit expression in lesional skin and presence
of this receptor in perilesional skin on several basal dendritic cells.
114 Hautmann et al.
perilesional skin and nonlesional skin, the percentages of stained

epidermis for GM-CSF and bFGF were higher (51~100% and 31-
50%, respectively) and for IL-6 and TNF-Cl' lower (11-30% for
both) (117). The findings for SCF were the same for perilesional
and nonlesional skin (3l~50%). The expression of the epidermal
receptors indicated no significant difference in GM-CSF and IL-6
receptors in lesional and perilesional skin, whereas the expression
of c-KIT was significantly higher in perilesional skin than in le-
sional one. Figures 1-5 show the immunohistochemical reactivity
of IL-6, GM-CSF, bFGF, SCF, and c-Kit in lesional and perile-
sional skin.
CONCLUSIONS
The etiology and pathogenesis of vitiligo are not clearly understood. Various
causative factors have been implicated in the depigmentation processes of
vitiligo, including cytological, environmental, immunological, and neuro-
logical destruction of melanocytes. Many pathogenetic hypotheses, each
supported by intriguing data, have been proposed. The various theories
outlined above are intended to summarize current popular hypotheses. These
theories are not all-inclusive, and they are not mutually exclusive. It is possible
that several mechanisms are operative in producing melanocyte destruction in
a given individual. The recent data here discussed (117) seem to provide
evidence of an important change in the expression of epidermal cytokines in
vitiligous skin. This modifica tion, which supports the eclectic theory, does not
seem to contradict the other hypotheses.
REFERENCES
I. Ortonne JP, Bose SK. Vitiligo: where do we stand? Pigment Cell Res 1993;
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10
Free Radical Damage in the
Pathogenesis of Vitiligo
Mauro Picardo and Maria Lucia Dell' Anna

San Gallicano Dermatological Institute, Rome, Italy
INTRODUCTION
Several different hypotheses have been proposed to explain the mechanism
underlying melanocyte impairment in vitiligo (1-4). Among these, some
groups have suggested free radical-mediated damage (5-10). In vitro, ex
vivo, and in vivo data have been presented for a shift in the antioxidant/pro-
oxidant ratio responsible for oxidative stress. However, at this time the mech-
anism of melanocyte disappearance is not fully defined: the possible apoptotic
pathway has not been completely demonstrated, and a normal pattern of Bcl-
2, Bax, p2 I, and p53 expression by melanocytes, even after ultraviolet (UV)-B
treatment, has been reported (11).
The skin appears to be the target of oxidative stress for two reasons: (a)
the location between the external environment and the body makes it an easy
target for chemical and physical pro-oxidants and (b) some specific types of
cutaneous metabolism generate free radicals (Table I). However, skin is rich
in natural defenses against oxidative stress, including small radical trapping,
as in the case of vitamins and glutathione (GSH), and enzymes such as super-
oxide dismutase (SOD), catalase (Cat), glutathione peroxidase (GPx), thio-
redoxin/thioredoxin reductase, and thioredoxin peroxidase (12,13) (Table 2).
124 Picardo and Dell'Anna
TABLE 1 ROS Produced During Cellular Activity

Species Sources
O2 NADH deydrogenase
Ubiquinone cyt c intersection
Xanthine oxidase
Aldheyde oxidase
NADPH oxidase
H2 0 2 SOD
Nitric oxide synthase
Xanthine oxidase
6BH 4 recycling
NADPH oxidase
Pteridines oxidation
MAO-A
CoO oxidation
TNF-a signal
EXPERIMENTAL EVIDENCE OF CUTANEOUS OXIDATIVE

STRESS IN VITILIGO
Vitiligo Melanocytes in Culture

In vitro melanocytes from perilesional and uninvolved areas of the vitiligo
epidermis show a delay in growth, a failure to restart after trypsinization, and
may require catalase (14,15). In the long term, culture morphological modi-
fications, such as dilatation of rough endoplasmic reticulum, circular RER
profiles, and membrane-bound compartmentalized melanosomes, have been
described. These characteristics do not depend on the phase of the disease or
passage number and are not necessarily all present at the same time. These
aberrations can then alter the interaction with other epidermal ceJls even in
normal areas, and in mouse models the dilated RER is associated with an
impairment of protein trafficking, including tyrosinase and RER storage
(16). However, in reconstructed epidermis, possibly due to the short term of
the culture, morphological or functional alterations in melanocytes or kerat-
inocytes were not found (17).
Besides the morphological features, a functional impairment has been
reported in vitiligo melanocytes. We found an alteration in the antioxidant
pattern with increased SOD and lowered Cat activities, associated with an
augmented susceptibility to pro-oxidant agents (7). A localized burst of hy-
drogen peroxide might affect the heme active site of the enzyme, lowering its
activity (18), but it is also possible that as a consequence of the low catalase
TABLE 2 Antioxidant System Components
..."T1
(1)
Antioxidant Property Activity Location (1)
:0
III
SOD MnSOD, tetrameric 80 kDa 8
2H+ + 20 2'- -> H20 2 + O 2 Mitochondria Co
(i'
CuZnSOD, dimeric 32 kDa; Cytosol ~
constitutive 0
Cat Heme group containing; 2H 20 2 -> 2H 20 + O 2 * Peroxisomes III
3
constitutive III
to
(1)
Lipoic acid system Lipoic acid + lipoamide GSH, Vitamin E, ascorbate Membrane
dehydrogenase and CoO regeneration Mitochondria :5
-y-L-glutamyl-L-cysteinyl-glycine; Free radicals direct scavenger; Mitochondria <
()
o
GSH a:
constitutive substrate for GPx. and cytosol to
~~
Vitamin E Lipid-soluble; lowered by UV; Lipoperoxides reduction Membrane 0
(0'
::':3" inducible
CD GPx Se-dependent; GPx1 to GPx4 b 2H 20 2 ~ 2H 20 + 02 c ; Mitochondria
0.. and cytosol
lipoperoxide reduction
~ GSH reductase GSH regeneration Mitochondria
CD and cytosol
~
~ GSH-S-transferase Lipoperoxides and pyrimidine Mitochondria
dimer reduction and cytosol
TrxR NADPH-dependent homodimer 2H+ + 20 2'- -> H20 2+0 2 Mitochondria
with Sec in C-terminus motif ascorbate reduction and cytosol
Gly-Cys-Sec-Gly-COOH
Ascorbate Water soluble; inducible Vitamin E reduction Cytosol
CoO Involved in electron flow; Lipoperoxide reduction and Inner mitochondrial
lowered by UV before vitamin E regeneration membrane
vitamin E; constitutive
a MnSOD can be induced by oxidative stress or thioredoxin. ....

b GPx isoforms have different locations but all use GSH as substrate. I\)
c.n
C Reduction of hydrogen peroxide to water lowers the hydroxyl radical formation via Fenton reaction.
126 Picardo and Dell' Anna
activity, following oxidative stress, the cell reaches a toxic level of H 2 0 2 and
other peroxides (7). Moreover, both tyrosinase and TRP 1, crucial enzymes of
the melanogenetic pathway, which can upregulate the expression of LAMP-I ,
a scavenger of the toxic intermediates of the melanin pigment, have been
shown to be compromised in vitiligo melanocytes; in particular, a marked
decrease of TRP-l expression, probably due to posttrascriptional and post-
translational alterations, with a change of its interaction with calnexin, has
been described (8)
H2 0 2 in Epidermis
Even if the exact order in which antioxidant alteration and peroxidative
damage, reported to occur in vitiligo, takes place has not been completely
clarified, the generation of reactive oxygen species (ROS) appears to be the
cause of a decreased level of antioxidants in the skin. An increased epidermal
H 2 0 2 level has been described both in vivo and ex vivo in the active phase of
vitiligo. It is associated with reduced catalase and glutathione peroxidase
activities. Moreover, histological evidence of oxidative stress-mediated dam-
age with vacuolar degeneration, indicative of lipid peroxidation, and granular
deposits in keratinocytes and melanocytes have been reported even in normal-
appearing skin (6,19). The absence of apoptosis has been linked to the ability
of pS3, switched on by H 2 0 2 , to overcome the deleterious effect of hydrogen
peroxide itself (18).
Vitiligo and Thioredoxin Reductase

In vitiligo, a low level of cutaneous thioredoxin reductase (TrxR) activity was
found (18). This enzyme is crucial in the elimination of superoxide anion, is
involved in the oxidation/reduction of the (6R)-I-erythro-S,6,7 ,8-tetrahydro-
biopterin (6BH 4 ) cofactor, and is the only reductase able to reduce 6-biopterin
to quinonoid dihydropterin (qBH 2). After the TrxR inhibition, and in
association with oxidative stress, GSSG formation and glutathionylation of
protein thiols take place (12,13) (Fig. 1).
Biopterin Metabolism
Defective recycling of tetrahydrobiopterin in the phenylalanine hydroxylase
(PAH) reaction could participate in intracellular H 20 2 generation (20).
In active vitiligo, increased synthesis of 6BH 4 , an essential cofactor for
tyrosine hydroxylase (TH) activity, has been reported as probably being due
to an alteration of 4a-hydroxy-6BH 4 dehydratase (DH) (21). In the epidermis,
both melanocytes and keratinocytes can de novo synthesize and recycle 6BH 4 ,
Free Radical Damage in Vitiligo 127
meblin
synthesis
TROll;; TRl"ed
NADPH
'-'
t
_ NADf.
CaldiUm
FIGURE 1 A possible link between melanocyte metabolism and redox status

alteration, as proposed by Schalireuter et al. (18).
which, at a high concentration, can be toxic for the melanocytes. Moreover,

hydrogen peroxide, as well as UVB, oxidizes 6BH 4 to 6-biopterin, which in
vitro is toxic for melanocytes (22,23). Thus, melanocyte degeneration may be
the consequence of the 6BH 4 action since the H 2 0 2 removal by addition of
catalase restores melanocyte pigmentation (24). The rate-limiting enzyme for
the de novo synthesis of 6BH 4 , GTP-cyclohydrolase I (GTP-CH I), is
controlled by IFN-)', IL-2, and TNF-ex (5,25), and therefore a higher
production of these cytokines by different mechanisms may playa part in
the cellular damage. The low DH activity is probably due to a deactivation
and not to a gene mutation, as the normal level can be restored after H 2 0 2
removal, and because the H 2 0 2 can induce an oxidation of Cys 81 and Trp 65
near the catalytic site with a consequent alteration of the activity. During
6BH 4 recycling, the isomer 7BH 4 is non-enzymatically produced and is able to
inhibit 4a-carbinolamine dehydratase activity leading to a H 2 0 2 accumula-
tion. The 7BH 4 -dependent PAH inhibition causes the release ofH 2 0 2 , which
is able in turn to degrade the tetrahydropyrrole ring of catalase even in non-
lesional areas (5,25). In addition, a mutation in GTP-CH I has been reported
in syndromic vitiligo (vitiligo associated with dopa-responsive dystonia)
'where the GTP-CH I activity in PBMNC is less than 20% with respect to
the normal value (5,26,27).
128 Picardo and Dell' Anna
Calcium and the Adrenergic System

Ten years ago, Schallreuter et al. suggested an involvement of keratinocytes in
the pathophysiology of vitiligo, describing a defective calcium transport that
can cause an increased level of O 2_. An alteration in calcium metabolism has
been reported in vitiligo keratinocytes and melanocytes. Calcium is able to
inhibit thioredoxin reductase. A rise of intracellular calcium causes a major
shift in cellular redox status due to the production of oxidized thioredoxin.
Moreover, calcium release turns on NADPH oxidase, thus promoting the
oxygen burst by the cellular infiltrate in perilesional areas (18,28,29). The
altered intracellular level of calcium is associated with an increased expression
of [3radrenoceptors (28). However, there are conflicting reports about
adrenoceptor involvement in vitiligo. An increase in cutaneous (X- and
[3-adrenoceptor function in segmental vitiligo, with or without a change in
plasma catecholamine (probably depending on the phase of the disease), has
been described. In any case, local or systemic noradrenergic metabolism
dysfunction can be involved in melanocyte death due to a direct cytotoxic
effect or the induction of an oxidative stress (30,31).
Catecholamine Synthesis in Vitiligo

In vitiligo there is defective catecholamine biosynthesis (5) with an over-
production of norepinephrine associated with increased catecholamine-O-
methyl transferase (COMT) activity and COMT metabolite level. The
induction of MAO-A is a consequence of the high norepinephrine level.
MAO-A is able to oxidize both norepinephrine and epinephrine, yielding
ammonia, 3,4-dihydroximandelic aldehyde, and hydrogen peroxide (21).
These data are in agreement with previous reports indicating an altered
catecholamine synthesis and high plasma and urinary levels of catecholamine
metabolites, such as homo vanillic acid (HVA) and vanillylmandelic acid
(VMA) in patients with active vitiligo (30). Other authors have further es-
tablished this in the initial phase of the disease (32), suggesting that the hy-
peractivity of the monoaminergic system might be involved in the early phase
and not in the progression of the disease. Stress-dependent catecholamine
discharge may be associated with an epidermal and dermal ischemia-hypoxia,
leading to an overproduction of toxic radicals (quinones, semi-quinone radi-
cals, oxyradicals) with a conseq uent epidermal oxidative stress.
a-MSH
A great deal of evidence has been accumulated about (X-MSH function in
the pigmentation process. (X-MSH controls the level of tyrosinase activity
through a receptor-independent pathway beyond a receptor-dependent
mechanism (33). a-MSH-induced tyrosinase activation could protect mela-

nocytes from the damaging effect of the superoxide anion as it is used by the
enzyme. The antioxidant activity of a-MSH is also carried out through its
ability to complex 6BH 4 . Moreover, it is able to antagonize the action of pro-
inflammatory cytokines, protecting melanocytes by cell-mediated cytotox-
icity. In vitiligo the low epidermal level is possibly due to a reduced ability of
the vitiligo melanocytes to cleave proopiomelanocortin to a-MSH (34,35).
The effect of a-MSH is counteracted by MCH (melanin-concentrating
hormone), which reduces the rise in cAMP and melanogenesis via the specific
receptor MCHRI. Interestingly, in vitiligo, autoantibodies against MCHRI
have been reported, although the exact clinic relevance has not yet been
clarified (36)
Modification of Epidermal Behavior

In the lesional area of vitiligo us skin, the growth factors released by kerat-
inocytes (GM-CSF, bFGF, SCF), appear to be reduced, whereas the level
of cytokines (JL-Ia, lL-6, TNF-a, TGF-(?» that inhibit melanogenesis is
increased. Keratinocytes producing TNF-a induce ICAM-I expression on
melanocytes, facilitating the lymphocytic oxygen burst. Superoxide anion
can destroy the tetrapyrrole ring of Cat, inhibit tyrosinase, and, once con-
verted in OH', bleach melanin (19).ln addition, TNF-a might inhibit melano-
cyte function through tyrosinase and TRP-l impairment (37,38).
EXPERIMENTAL EVIDENCE OF SYSTEMIC OXIDATIVE

STRESS IN VITILIGO
Recently, a systemic alteration of the antioxidant pattern similar to that de-
scribed in melanocytes (7) has been reported during the active phase of viti-
ligo. Moreover, increased ROS generation (Fig. 2) and a higher percentage
of apoptosis were found in peripheral blood mononuclear cell (PBMNC)
from active vitiligo patients with respect to stable patients or normal subjects,
inhibited by cyclosporin A, a drug acting on the mitochondrial permeability
transition pores (39). These results suggested the hypothesis that an impair-
ment of the mitochondrial electron transport chain (ETC), a source of both
ATP and ROS, plays a central role in the destruction of melanocytes during
vitiligo. The threshold of sensitivity of the ETC to peroxidative damage is
dependent on cell type and intracellular content of the antioxidant, which
could explain the specific melanocyte degeneration (40). Moreover, the ETC
is susceptible to several exogenous and endogeneous factors, such as calcium,
TNF-a, ROS, and catecolamines, all reported to be altered during the active
phase of vitiligo (Fig. 3).
*p<f).(lOOl
180 ··~.OS
" 170
E 160 ft.
~ 1~
~ 140
a:~ 130
is 12.0
~~ 110
100 +-~L-_-'--r---L _ _L - - - - r - - L . . _ - - L - - - r - . . . L - _ - ' - - . ,

oonlrol dable mc:tJv~CaA
FIGURE 2 In PBMC from active vitiligo patients, an increased intracellular ROS

generation was found with respect to those from stable patients or normal
subjects, Pretreatment with CsA significantly reduces the intracellular ROS level.
FIGURE 3 Mitochondria appear to originate from both ATP and ROS, The in-
creased susceptibility of melanocytes to pro-oxidant stimuli could be dependent on
an intrinsic mitochondrial defect.
GENETIC DATA
Recent genetic studies have shown a possible basis for the reduced Cat activity
in vitiligo epidermis. A catalase gene polymorphism (TIC heterozygosis),
leading to an alteration of the correct assembly of the subunits, was reported
(41 ).
In contrast to the results of the Schallreuter group, a lower COMT
activity in acrofacial vitiligo was found, possibly due to allelic polymorphism.
In the COMT-LL genotype the G-A substitution leads to lower enzymatic
activity and higher a-quinone levels with respect to COMT-HL and COMT-
HH genotype (42).
ANIMAL MODELS
The avian model of vitiligo is found in Barred Rock Plymouth (BPR) and
White Leghorn (WL) chickens. The low level of GSH and SOD (50-60%) in
feather melanocytes from BPR and WL with respect to wild-type jungle fowl
(IF) leads to their premature death. The possibility of mimicking the WL
phenotype by treating the JF melanocytes with buthionine sulfoxime (BSO)
indicates GSH involvement (2,9,43).
THERAPEUTIC ASPECTS
Some treatment approaches for vitiligo further support the free radical
theory.
The topical application of pseudocatalase, a low molecular weight
inorganic compound with catalase activity, plus calcium chloride and UVB
phototherapy has been reported as stimulating repigmentation in most
patients treated (44-46), even if the preliminary results have not been con-
firmed by other groups. Administration of an antioxidant cocktail containing
vitamin E acetate, selenium methionine, f?>-carotene, and ubiquinone is
frequently associated with UBV narrow band phototherapy and seems to
increase the positive results with respect to UYB alone and reduce the UYB
doses (47,48). The association of oral supplementation with vitamin E and
PUYA (psoralen plus UV-A) phototherapy was found to reduce the lipo-
peroxidative process induce by UYA without affecting the clinical improve-
ment of the vitiligo lesions (49).
Finally, considering the potential dangerous effects of sun exposure in
connection with cutaneous oxidative stress, lifestyle modifications could pre-
vent disease reactivation. In particular, the use of a broad spectrum sunscreen
(SPF 15 or greater) should be suggested with the aim to decrease the short-
and long-term side effects of UV and contrast between the normally pig-
men ted skin and the lighter areas. On the other hand, local application of a
cream containing low molecular weight antioxidant molecules, including
tocopherol, ascorbic acid derivatives, carnosine, etc., could reduce the side
effects of UV exposure without inhibiting the possible repigmentation
induced by the natural sun irradiation.
CONCLUDING REMARKS
The pathogenetic mechanisms underlying vitiligo have yet to be completely
understood, and different hypotheses, probably not mutually exclusive, have
been advanced (3,4). However, several metabolic impairments and an
increased release of pro-inflammatory cytokines, which can lead to pro-
oxidant effects, have been reported in vitiligo. The increased susceptibility
of melanocyte, could be dependent on an intrinsic defect such as the impair-
ment of mitochondrial function. The persistent alteration of the pro-oxidant/
antioxidant ratio could be the first pathogenetic event in melanocyte degen-
eration, occurring even after external stimuli. The subsequent release of
melanocyte antigens could lead to an autoimmune response, which can
maintain and propagate the disease (Fig. 4)
/.:::~
( :eJatonin
{ receptor I;eactivity
\ toxic intermediates
'\ catecholamins
"'" discharge
",
~oclies
FIGURE 4 A revised convergence theory including mitochondrial impairment.

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11
Possible Role of Nitric Oxide in the
Pathogenesis of Vitiligo
Mario Vaccaro and Fabrizio Guarneri

University of Messina, Messina, Italy
Vitiligo is a common progressive depigmentation of the skin, due to destruc-

tion of melanocytes. Although its cause is still to be exactly defined, the
hypothesis of an autoimmune etiology of vitiligo is supported by increasing
evidence (I) (Table 1).
Recent studies have suggested that vitiligo could be the result of pro-
grammed melanocyte death or destruction due either to increased sensitivity
to oxidative stress, coming from toxic intermediates of melanin (a melano-
cyte-specific protein) or from other sources (melanocytes of patients suffering
from vitiligo are highly sensitive to oxidative stress, UVB exposure in com-
parison with normal melanocytes) (2), or to an ongoing local immune re-
sponse, likely mediated by skin-homing T cells (T cells were frequently found
in apposition to activated melanocytes) (3).
Increasing evidence suggested the greater complexity of the scenario:
several cells are involved (antigen-presenting cells, lymphocytes, keratino-
cytes, endothelial cells), communicating through a network of many different
mediators that affect melanocyte migration, proliferation, and differentia-
tion. In fact, the epidermal microenvironment can be considered a crucial
milieu for the normal life and function of melanocytes (4-6).
The immunological network, and all of its circuits, seems to be also
modulated by neuropeptides released by sensitive nerves (7,8) in response to
several factors of various nature. Neuropeptides can, in fact, influence the
138 Vaccaro and Guarneri
TABLE 1 Defining Criteria for an Autoimmune Pathogenesis in Vitiligo
Criterion Comment
Autoantibody transfer of disease IgG from vitiligo patients elicits

melanocyte destruction when
injected into nude mice grafted
with human skin
Reproduction of disease in IgG from vitiligo patients induces
experimental animal models depigmentation when injected into
nude mice grafted with human skin
Genetically determined animal Well studied Smyth line chickens
models
Identification within lesion Autoreactive, melanocyte-specific
autoantibody or autoreactive T cells and autoantibodies were found
T cell in blood of vitiligo patients, but still not
demonstrated in skin lesions
Statistical association with Significant association of HLA-DR4
particular MHC haplotype in several populations
Lymphocyte infiltrate in target Observation of activated T lymphocytes
organ at the periphery of lesions
Association with other autoimmune Frequent association of vitiligo and
diseases in the same individual autoimmune thyroiditis or Addison's
or family disease
Favorable response to Good response to topical steroids,
immunosuppression topical cytotoxic drugs, and PUVA
Source: Ref. 1.
reactions of cutaneous blood vessels and the activity of immune cells, kerat-
inocytes, and melanocytes.
Summarizing three hypotheses are currently proposed to explain mel-
anocyte death/dysfunction in vitiligo: autoimmune, autocytotoxic, and neu-
ral. They are not mutually exclusive, and the real pathogenic mechanism
probably resul ts from their concurrence (I).
Mutual interaction between melanocytes, keratinocytes, lymphocytes,
Langerhans cells, and innervation, mediated by inflammatory mediators,
cytokines, and nitric oxide, could have a central role in the regulation of main
cell functions, as well as in melanocyte dysfunction and/or destruction
observed in vitiligo (Fig. I).
Nitric oxide, a highly reactive free radical with a short half-life, is in-
volved in several biological processes like vascular homeostasis, neurotrans-
mission, immunomodulation, and inflammation (9,10). Nitric oxide, in fact,
plays an important role in inflammatory processes: it is a powerful vaso-
dilatatory agent, increases vascular permeability and cytokine production,
NO in Vitiligo 139
FIGURE 1 Possible role of nitric oxide in the pathogenesis of vitiligo.
increases cell production of hydrogen peroxide, and can interact with super-
oxide anion to produce peroxynitrite, an important mediator of free radical-
induced cell damage.
The idea of a vital principle in a gaseous state, suggested by Galeno in
De usu partiwn corporis, has been considered only in the last 10 years, with a
remarkable impact on clinical and basic research: the role of nitric oxide in
many biological systems is well known and widely documented, but the com-
prehension of the fine regulatory mechanisms of cell growth and death,
inflammation, and immune response is a recent and still not complete acqui-
sition. Nitric oxide has several roles in skin physiology (important endogen
regulator of microcirculation, melanogenesis, keratinocyte response to UV
radiation, cell growth and differentiation), and increasing evidence has been
found for its critical role in many inflammatory, hyperproliferative, and auto-
immune diseases, other than in carcinogenesis and in tumor diffusion (11-15).
The exact knowledge and the characterization of the role of this mediator in
cutaneous diseases will not only provide another contribution to the com-
prehension of skin biology, but also will create the basis for the development
of new therapeutic approaches able to modify, stop, or retard the course of
several pathologies.
Nitric oxide, a highly reactive messenger (it has no electric charge and
can then pass through membranes; it also has an unpaired electron and can
thus bind oxygen free rad\9t>\eyfJ§n~mli_fMfn), is produced during the
conversion of L-arginine into L-citrulline (a NADPH-dependent reaction),

catalyzed by enzymes belonging to the family of nitric oxide synthase (NOS).
Two major isoforms of NOS are known: "constitutive" (c-NOS), further
divided into neuronal (n-NOS) and endothelial (e-NOS) types, and "induc-
ible" (i-NOS), involved in the regulation of cell homeostasis and in the
modulation of immune and cytotoxic response, respectively (9,10,16).
Nitric oxide has important functions, both regulatory and cytotoxic: the
former are realized through modifications of transcription factors, cell mo-
tility, mitochondrial functions, and apoptosis, while the latter are realized
through energetic damage, glycolysis block, destruction of the Krebs cycle
and oxidative phosphorylation, inhibition of ATP production and DNA syn-
thesis, and DNA deamination (16). In cutaneous physiopathology the pre-
valence of its cytotoxic activity over the regulatory one is due, probably, to
the concentration of nitric oxide produced, the cell types involved, the stage of
the disease, and many other factors. Low levels of nitric oxide generated by
c-NOS are thought to be important in signal transduction mechanisms, while
high levels produced by i-NOS could play an important role in cytostasis and
cytotoxicity and hence in the limitation of Thl-induced tissue damage that
occurs in various inflammatory conditions (16,17).
Despite the well-known importance of nitric oxide in several physio-
logical and pathophysiological conditions, its role in human melanogenesis is
still under investigation. It has been found that in normal skin UVA and UVB
induce production of nitric oxide, particularly by keratinocytes and melano-
cytes, through the activation of c-NOS, leading to an increase in tyrosinase
activity and melanin synthesis (paracrine and autocrine mediation of UV-
induced melanogenesis) (18). Many inflammatory mediators and cytokines
have been demonstrated able to directly affect melanogenesis (4-6), but their
site of action and their possible effects on pigment production are not
perfectly known. The induction of i-NOS also requires multiple cytokines
and endotoxins, including TNFa, IFN)', IL-I, IL-2, IL-6, IL-8, GM-CSF,
and LPS (16).
Recent studies have demonstrated that normal human melanocytes in
culture can express i-NOS when stimulated by LPS/cytokines, suggesting a
possible participation of i-NOS in hypopigmentary disorders (19). Cytokines
can also induce overproduction of tetrahydrobiopterin, a potent inhibitor
of melanin biosynthesis (20) and essential cofactor in enzymatic activity of
i-NOS (21,22). Large amounts of nitric oxide could lead to self-destruction of
melanocytes (11) and reduce de novo attachment ofmelanocytes to the extra-
cellular matrix (23), causing skin depigmentation (19). This mechanism could
be important in vitiligo, where an initial imbalance of epidermal cytokines at
sites of lesions could cause tetrahydrobiopterin overexpression and i-NOS
activation, with consequent nitric oxide overproduction leading to loss and
self-destruction of melanocytes (Fig. 2).
NO in Vitiligo 141
FIGURE 2 Confocal image obtained in "depth coding mode" (Iesional skin). Over-
expression of i-NOS in basal and suprabasal layers.
However. it is still to be verified whether this complex scenario is due to

an immune disturbance, an intrinsic susceptibility of melanocytes, an altered
regulatory epidermal milieu. or all these factors. In any case, in vitiligo the
inadequate response to nitric oxide represents an event sufficient to induce
depigmentation.
If vitiligo is really a nitric oxide-mediated disease, the use of NOS
inhibitors (24), nitric oxide scavengers (25), or tetrahydrobiopterin inhibitors
(22) should be considered in its treatment. However, because of nitric oxide's
involvement in many different physiological functions, secondary effects of
this approach should be carefully evaluated, especially with regard to its pos-
sible toxicity. Further studies are then needed to develop more selective in-
hibitors in order to achieve better efficacy and fewer collateral effects of this
potential treatment. Copyrighted Material
REFERENCES
I. Kemp EH, Waterman EA, Weetman AP. Autoimmune aspects of vitiligo.
Autoimmunity 2001; 34:65~77.
2. limbow K, Chen H, Park JS, Thomas PD. Increased sensitivity of melanocytes
to oxidative stress and abnormal expression of tyrosinase-related protein in
vitiligo. Br 1 Dermatol 2001; 144:55-65
3. van den Wijngaard R, Wankowicz-Kalinska A, Le Poole C, Tigges B, Westerhof
W, Das P. Local immune response in skin of generalized vitiligo patients. De-
struction of melanocytes is associated with the prominent presence of CLA + T
cells at the perilesional site. Lab Invest 2000; 80: 1299-1309.
4. Gordon PR, Mansur CP, Gilchrest BA. Regulation of human melanocyte
growth, dendricity, and melanization by keratinocyte derived factors. 1 Invest
Dermatol 1989; 92:565-572
5. Morelli lG, Norris DA. Influence of inflammatory mediators and cytokines on
human melanocyte function. J Invest Dermatol 1993; 100:19IS-195S.
6. Moretti S, Spallanzani A, Amato L, Hautmann G, Gallerani I, Fabiani M,
cytokines at sites of lesions. Pigment Cell Res 2002; I 5:87~92.
7. AI'Abadie MS, Senior HJ, Bleehen SS, Gawkrodger Dl. Neuropeptide and
neuronal marker studies in vitiligo. Br J Dermatol 1994; 131:160--165.
8. AI' Abadie MS, Warren MA, Bleehen SS, Gawkrodger Dl. Morphologic obser-
vations on the dermal nerves in vitiligo: an ultrastructural study. Int 1 Dermatol
1995; 34:837-840
9. Knowles RG, Moncada S. Nitric oxide synthase in mammals. Biochem 1 1994;
298:249-258.
10. Lowenstein Cl, Dinerman lL, Snyder SH. Nitric oxide: a physiologic mes-
senger. Ann Intern Med 1994; 120:227-237.
II. Qureshi AA, Lerner LH, Lerner EA. From bedside to the bench and back.
Nitric oxide and cutis. Arch Dermatol 1996; 132:889-893.
12. Weller R. Nitric oxide~a newly discovered chemical transmitter in human
skin. Br 1 Dermatol 1997; 137:665-672.
13. Bruch-Gerharz D, Ruzicka T, Kolb-Bachofen V. Nitric oxide in human
skin: current status and future prospects. 1 Invest Dermatol 1998; 110:1-7.
14. Weller R. Nitric oxide, skin growth and differentiation: more questions than
answers? Clin Exp Dermatol 1999; 24:388-391.
15. Ormerod AD, Copeland P, Hay I, et al. The inflammatory and cytotoxic ef-
fects of a nitric oxide releasing cream on normal skin. J Invest Dermatol 1999;
113:392-397.
16. Kolb H, Kolb-Bachofen V. Nitric oxide in autoimmune disease: cytotoxic or
regulatory mediator? Immunol Today 1998; 19:556-561.
17. Ahmed B, Van Den Oord JJ. Expression of the inducible isoform of nitric oxide
synthase in pigment cell lesions of the skin. Br J Dermatol 2000; 142:432-440.
18. Romero-Graillet C, Aberdam E, Clement M, Ortonne JP, Ballotti R. Nitric ox-
ide produced by ultraviolet-irradiated keratinocytes stimulates melanogenesis.
1 Clin Invest 1997; 99:635-642.
NO in Vitiligo 143
19. Rocha 1M, Guillo LA. Lipopolysaccharide and cytokines induce nitric oxide
synthase and produce nitric oxide in cultured normal human melanocytes. Arch
Dermatol Res 2001; 293:245-248.
20. Schallreuter KU, Wood JM, Ziegler I, Lemke KR, Pittelkow MR, Lindsey NJ,
Gutlich M. Defective tetrahydrobiopterin and catecholamine biosynthesis in
the depigmentation disorder vitiligo. Biochem Biophys Acta 1994: 1226:181-
192.
21. Sakai N, Kaufman S, Milstein S. Tetrahydrobiopterin is required for cytokine-
induced nitric oxide production in a murine macrophage cell line (RAW 264).
Mol Pharmacol 1993; 43:6-10.
22. Bune AJ, Brand MP, Heales SJ, Shergill JK, Cammack R, Cook HT. Inhibition
of tetrahydrobiopterin synthesis reduces in vivo nitric oxide production in ex-
perimental endotoxic shock. Biochem Biophys Res Commun 1996; nO(l): 13-
19.
23. Ivanova K, Le Poole IC, Gerzer R, WesterhofW, Das PK. Effect of nitric oxide
on the adhesion of human melanocytes to extracelluar matrix components. J
Pathol 1997; 183:469-476
24. Hobbs AJ, Higgs A, Moncada S. Inhibition of nitric oxide synthase as a po-
tential therapeutic target. Annu Rev Pharmacol Toxicol 1999; 39:191-220.
25. Fricker SP, Slade E, Powell NA, Vaughan OJ, Henderson GR, Murrer BA,
Megson IL, Bisland SK, Flitney FW. Ruthenium complexes as nitric oxide scav-
engers: a potential therapeutic approach to nitric oxide-mediated diseases. Br J
Pharmacol 1997; 122:1441-1449.
12
Histopathological and Ultrastructural
Features of Vitiligo
Daniela Massi
INTRODUCTION
Vitiligo is an acquired, idiopathic, and, in the majority of cases, progressive
disorder of the skin characterized by depigmented patches of variable size,
which enlarge and coalesce to form extensive areas of leukoderma (1-3). On
clinical examination, stable patches of vitiligo appear as completely depig-
men ted areas sharply demarcated from the surrounding skin. In expanding
lesions, there may occasionally be a rim of erythema at the border and a thin
zone of transitory partial depigmentation. Repigmentation may lead to sev-
eral shades of color within a particular lesion. In the pathogenesis of vitiligo,
biochemical (4), neurological (5), and immunological (6) factors appear to be
involved to a varying extent according to the clinical subset of the disease.
Recently, a "convergence theory" combining all pathogenetic hypotheses, has
been suggested.
Patients with vitiligo note the loss of color from their skin when the
disorder first begins or spreads. There are basically two mechanisms by which
the melanin might disappear from the skin and the skin turn white: (1)
melanocytes may be absent from depigmented areas, or (2) melanogenesis
may have been silenced in melanocytes still present within the lesion. In this
regard, there is a long-standing controversy over whether melanocytes in
vitiligo lesions are actually lost or are still present but functionally dormant or
inactivated. Needless to say, both pathogenesis and response to treatment are
146 Massi
dependent on this crucial issue. In this view, the histopathological and

ultrastructural investigations undertaken to demonstrate the morphological
changes in the skin in patients affected by vitiligo are of outmost importance
in order to gain insights into the pathophysiology of the disease.
LESIONAL SKIN
The clinical presentation of the disease may be quite variable and complex.
Likewise, under the microscope, the histopathological features observed in
skin specimens taken from affected patients are not uniform, depending on
the site (lesional vs. perilesional vs. normally pigmented, nonlesional skin),
type, and duration oflesion under examination. However, most of the earlier
studies almost unanimously concluded that long-standing depigmented
patches show a complete loss of melanin and absence of melanocytes from
the epidermis (Figs. 1-5). To enhance the visualization of melanin synthesis
and deposition in the epidermis, the Masson-Fontana silver reduction stain-
ing technique (7) was perfomed on split skin obtained from depigmented
patches (8) demonstrating the absence of melanin. In addition, histochemical
procedures specific for the identification ofmelanocytes have been developed
to detect quiescient or inactive melanocytes in tissues. For these histochemical
procedures, tissues or cells were fixed or incubated in a buffer solution con-
taining either tyrosine or I-dihydroxyphenylalanine (DOPA), the substrates
for melanin reaction products at sites where functional tyrosinase exists, i.e.,
within the melanosomes located in the cytoplasm of melanocytes. Hu et aI.,
performing DOPA histochemistry, demonstrated that most vitiligo lesions
were DOPA-negative (8). Occasionally, islands of DOPA-positive cells were
observed in the vitiliginous skin. These DOPA-positive cells were smaller and
less dendritic than normal melanocytes. The authors suggested that these
cells likely represented inactive melanocytes. Subsequent studies employing
DOPA histochemistry on split vitiligo skin also demonstrated the loss or pres-
ence of a few abnormal melanocytes in depigmented areas (9).
. In line with these observations, Le Poole et a1. in 1993 published a
comprehensive immunohistochemical study using a panel of I polyclonal
and 17 monoclonal antibodies directed against melanocytes and concluded
that melanocytes are indeed absent within vitiliginous lesions, although in
epidermal split-skin preparations residual staining attributed to degenerated
melanocytes was occasionally observed (10). In addition, Dippel et a1. dem-
onstrated that the c-kit receptor, a molecule expressed early in melanocyte
differentiation, was undetectable in vitiligo skin (II). This finding is consistent
with the hypothesis that nonfunctional melanocytes are absent from vitiligo
lesions.
However, there are some sporadic reports indicating that vitiligo lesions
are not fully devoid of melanocytes (12, I3). Also in our experience melano-
Histopathological and Ultrastructural Features of Vitiligo 147
FIGURE 1 Normal skin (hematoxylin and eosin). Epidermal melanocytes appear

as clear cells in and immediately beneath the basal cell layer. Nuclei of
melanocytes are smaller and more deeply basophilic than those of contiguous
keratinocytes. Melanin is present at all levels of the epidermis, but the basal cell
layer is the most heavily pigmented.
FIGURE 2 Perilesional skin (Giemsa). Melanocytes are absent from the basal cell
layer while melanin is still p~~dtM~J<eratinocytes.
148 Massi
FIGURE 3 Perilesional skin (S-100). S-100 immunohistochemical expression

shows absence of melanocytes, whereas suprabasal Langerhans cells are evident.
FIGURE 4 Normal skin (semi-thin section, toluidine blue). Scattered vacuolated

melanocytes are present within the epidermis. The clear space is an artifact of
fixation.
FIGURE 5 Lesional skin (semi-thin section, toluidine blue). Melanocytes are ab-
sent from the basal cell layer.
cytes may be detected at ultrastructural level and are indeed present in lesional
skin from vitiligo patients (unpublished observations) (Figs. 6-8). In partic-
ular, Husain et al. showed that enzymatic hydroxylation of tyrosine to DOPA
in epidermal homogenates of vitiligo was due to the presence of tyrosinase
(12). Such residual amounts of the melanocyte-specific enzyme tyrosinase
detected in lesional vitiligo provided evidence for the presence ofmelanocytes
within lesional skin. A more recent study reported that although in 1- to 3-
year-old vitiligo lesions neither active or inactive melanocytes are found,
nonnegligible amounts of melanin were detected in a few keratinocytes in the
basal epidermal layer (14). In particular, late-stage maturation (III/IV)
melanosomes were detected and clumped as melanin granules within basal
keratinocytes (14). The authors concluded that melanosomes can persist in
keratinocytes for some time after the onset of vitiligo (14). In agreement with
these observations, Tobin et al. showed that melanocytes could be isolated
and established in vitro from all samples of lesional and normal skin,
independent of disease duration and independently from treatment (13). In
addition, small amounts of mature melanin granules were observed in the
amelanotic skin of vitiligo patients, suggesting that some partially functioning
melanocytes must be retained in this disorder. The retention of rare intact
melanocytes in lesional skin of vitiligo was therefore taken to support the view
that a subpopulation of "resistant" epidermal melanocytes could be present.
150 Massi
FIGURE 6 Normal skin (electron micrograph). Uptake of numerous compound

melanosomes released from melanocytes into adjacent keratinocytes.
While these rare melanocytes were usually amelanotic, some contained poorly
melanized granules. Interestingly, the authors also found extracellular mel-
anin granules lying free in the interstitial space within both amelanotic and
normal epidermis. Since these granules were not always associated with
melanocyte cytoplasm or melanocyte dendrites, they could possibly be
released by degenerative or partially functioning melanocytes. A premature
delivery of pre-melanosomes from melanocytes to keratinocytes or ingestion
FIGURE 7 Perilesional skin (electron micrograph). Although reduced in number,

scattered melanosomes are still observed within rare melanocytes.
of immature melanosomes by keratinocytes after fragmentation/degenera-

tion of melanocytes was postulated (13).
It is commonly thought that repigmentation is associated with repopu-
lation of amelanotic areas by the melanocytic reservoir of the hair follicles
(15,16). In particular, a combination of hair follicle split-DOPA stains and
hair follicle split-scanning electron microscopy demonstrated inactive,
DOPA-negative melanocytes in the outer root sheaths of normal hair follicles.
These inactive melanocytes are also seen in the outer root sheaths of hair
152 Massi
FIGURE 8 Lesional skin (elecron micrograph). Rare melanocytes are still present,
although no melanosomes are seen. Keratinocytes contain numerous bundles of
tonofilaments.
follicle from vitiliginous patches. Treatment of vitiligo stimulates these

inactive melanocytes in the middle and lower parts of the outer root sheaths
to divide, proliferate, and migrate upward to the dermal-epidermal junction
of overlying skin. Melanocytes then spread to form the pigmented islands
clinically visible in repigmented lesions (15,16). However, if rare melanocytes
are indeed present also in lesional skin, as recent studies have suggested, it is
likely that this is not the only mechanism by which repigmentation occurs.
In one study, Merkel cells were reported to be absent from stable

Jesional skin, supporting a neural involvement in vitiligo (17). Conversely,
in long-standing patches of vitiligo, Langerhans cells were reported to be
normal in number although distributed more basally than usual (18). How-
ever, a recent study evaluating Langerhans cell distribution in vitiliginous
epidermis by immunohistochemistry demonstrated that there were no topo-
graphical differences in the presence of Langerhans cells in lesions, at the
border, or in pigmented skin of patients with inflammatory vitiligo (19).
Degenerative changes affecting nerves have also been reported. In
particular, numerous nerve endings were seen in close contact with the basal
lamina (20). On ultrastructural examination, approximately three quarters of
all dermal nerves in vitiligo biopsies show an increased thickness of the basal
membrane of Schwann cells (21). Furthermore, about half of the abnormal
dermal nerves in vitiligo skin showed minor axonal degeneration and nerve
regeneration, the latter possibly being a reactive change to earlier axonal
damage (21). Overall, these observations suggest that neural factors may play
a role in the pathogenesis of the disease.
PERILESIONAL SKIN
Data from the literature suggest that the peripheral area of expanding lesions
that are clinically hypopigmented rather than fully depigmented usually
shows a few melanocytes and some melanin granules within the basal layer
of the epidermis, although reduced in number as compared with normal skin
(22). At the advancing border of vitiligo patches, melanocytes are often prom-
inent, increased in size, and show long dendritic processes containing melanin
granules. In contrast, some reports have described the melanocytes at the
border to be histopathologically (9) and ultrastructurally (23) normal. Still to
be determined is whether different melanocytes' conditions at the border of
the vitiligo patches correlate to the state of the lesions (progressing vs. dor-
mant disease).
Boissy and Nordlund have occasionally noticed that melanocytes in the
perilesional normally pigmented skin immediately nearby an amelanotic
vitiligo lesion exhibit cellular shrinkage and increased nuclear heterochro-
matin, indicating that these cells might be in the initial stages of apoptosis
(24). The authors suggested that, theoretically, keratinocytes could effectively
phagocytize fragmented apoptotic melanocytes and carry the debris with
them as they migrate up the stratum corneum where they desquamate off the
epidermis. Removal of melanocytes undergoing apoptosis by the keratinocyte
would be consistent with the lack of prominent inflammation and immune
response at the lesional borders of most patients with vitiligo.
Keratinocyte damage has also been demonstrated at the edge of the
vitiligo lesions. Indeed, f~y1lightfM~Mfltion of the basal cell layer
154 Massi
associated with a mild lymphohistiocytic infiltrate has been described

(23,25,26). Ultra-thin sections have better shown vacuolated keratinocytes
and extracellular granul~r material between the melanocytes and the keratin-
ocytes, as well as between keratinocytes themselves, suggesting that the ke-
ratinocyte is also affected by the pathological process causing vitiligo (23,27).
Fibrillar masses similar to colloid bodies may also be present in the upper
dermis and in the basal lamina (20).
The border of depigmented areas often shows a scant perivascular
lymphohistiocytic infiltrate within the superficial dermis as well as superficial
edema. Inflammatory cells are invariably present if there is an inflammatory
border on clinical examination. If serial sections are examined, a lymphocyte
will be sometimes found in close apposition to a melanocyte at the advancing
edge. Erythematous borders are also usually associated with variable tele-
angectasies. A heavy Iymphohistiocytic infiltrate in the upper dermis is more
rarely observed (27).
Immunohistochemical studies confirmed a highly significant increase in
the number of lymphocytes in epidermis and superficial dermis around the
margin of the zone of melanocyte depletion in lesions of vitiligo and have
shown that the infiltrate is almost entirely composed ofT cells, many of which
are activated (MHC class II + , IFN 'Y + ) (28). In particular, the most intense
epidermal T-cell infiltration was detected within 0.6 mm of the edge of the
lesion. These observations are consistent with the hypothesis that lesional T
cells-rather than circulating antimelanocytic antibody-may be responsible
for the supposedly autoimmune, but characteristically patchy destruction of
melanocytes in vitiligo. Nevertheless, many of the infiltrating T cells are
probably innocent bystanders, recruited from the circulation by upregulated
cell-adhesion molecules near sites of melanocytic damage. In three cases
of inflammatory vitiligo patients, an immunohistochemical investigation
demonstrated that in perilesional dermis CD68 + macro phages are more
numerous than in lesional and nonlesional skin (19). CD3 + T cells were sig-
nificantly increased in perilesional as compared with nonlesional or lesional
skin. More importantly, within the epidermal compartment, T cells were
substantially more numerous in perilesional skin than in control skin. Such T
cells were mainly concentrated where the melanocyte destruction takes place,
within the basal layer of the epidermis (19).
NORMALLY PIGMENTED NONLESIONAL SKIN

The pigmented skin at di tant sites from depigmented patches has been
considered histologically unremarkable, with melanocytes being normal in
number and morphology. However, electron microscopic studies have shown
that these areas may show signs of melanocytic degeneration in the form of
intracellular edema and vacuolar formation (23). In addition, it has also been
demonstrated that melanocytes in the pigmented skin ofpatients with vitiligo
may exhibit ultrastructural abnormalities including dilation of rough endo-
plasmic reticulum, circular RER profiles, and/or membrane-bound compart-
ments ofmelanosomes (29). However, these abnormal structures in cultured
melanocytes were not always concomitantly expressed and could not be
associated with any specific clinical feature of vitiligo (29).
CONCLUSIONS
The pathogenetic mechanisms by which the melanocytes are lost in vitiligo
patients have not been yet unequivocally identified. Likewise, at present some
controversies exist concerning the histopathological and ultrastructural
features in skin specimens from affected patients. Although earlier studies
repeatedly indicated that lesional skin shows an absence of melanin and
melanocytes, along with degenerative changes affecting both melanocytes and
basal/supra basal keratinocytes, more recent investigations demonstrated that
melanocytes are never completely absent in the depigmented epidermis and
that these melanocytes maintain the capability of recovering their function-
ality. Further studies are therefore needed to clarify this highly debated issue
that has obvious therapeutic implications.
REFERENCES
1. Koranne RV, Sachdeva KG. Vitiligo Int J Dermatol 1988; 27:676-681.
2. Nordlund JJ, Lerner AB. Vitiligo. It is important. Arch Dennatol 1982;
118:5-8.
3. Sharquie KE. Vitiligo. Clin Exp DermatoJ 1984; 9:117-126.
4. Lerner A. On the etiology of vitiligo and gray hair. Am J Med 1971; 51:141-
147.
5. Ortonne JP, Mosher DB, Fitzpatrick TB. Vitiligo and other hypomelanosis of
hair and skin. New York: Plenum Medical Book Co., 1983:1-55.
6. Harning R, Cui J, Bystryn Je. Relation between the incidence and level of
971078-1080.
7. Masson P. Pigment cells in man. NY Acad Sci Special Publication 1948; 4: 15-
51.
8. Hu F, Fosnaugh RP, Lesney PF. In vitro studies on vitiligo. J Invest Dermatol
1959; 33:267-280.
9. Bleehen SS. Histology of vitiligo. In: Klaus N, ed. Pigment Cell 5: Part II of
Preceedings of the X International Pigment Cell Conference Cambridge, MA.
Basel: S. Karger, 1979:54-61.
]0. Le Poole IC, van den Wijngaard RM, Westerhof W, Dutrieux RP, Das PK.
156 Massi

investigation. J Invest Dermatol 1993; 100:816-822.
II. Dippel E, Haas N, Grabbe J, Schadendorf D, Hamann K, Czarnetzki BM.
Expression of the c-kit receptor in hypomelanosis: a comparative study be-
tween piebaldism, naevus pigmentosus and vitiligo. Br J Dermatol 1995;
132182-189.
12. Husain I, Vijayan E, Ramaiah A, Pasricha JS, Madan NC. Demonstration of
tyrosinase in the vitiligo skin of human beings by a sensitive f1uorimetric method
as well as by '4C(U)-L-tyrosine incorporation into melanin. J Invest Dermatol
1982; 78243-252.
13. Tobin DJ, Swanson NN, Pittelkow MR, Peters EM, Schallreuter KU. Melano-
cytes are not absent in lesional skin of long duration vitiligo. J Pathol 2000;
191:407-416.
14. Bartosik J, Wulf HC, Kobayasi T. Melanin and melanosome complexes in long
standing stable vitiligo-an ultrastructural study. Eur J Dermatol 1998; 8:95-97.
15. Cui J, Shen LY, Wang Gc. Role of hair follicle in the repigmentation of vitiligo.
J Invest Dermatol 1991; 97:410-416
16. Arrunategui A, Arroyo C, Garcia L, et al. Melanocyte reservoir in vitiligo. Int J
Dermatol 1994; 33:484-487.
17 Bose SK. Probable mechanism of loss of Merkel cells in completely depigmented
skin of stable vitiligo. J Dermatol 1994; 21:725-728.
]8. Birbeck MS, Breathnach AS, Everall JD. An electron microscope study of basal
melanocytes and high-level clear cells (Langerhans cells) in vitiligo. J Invest
Dermatol 1961; 3751.
19. Ie Poole IC, van den Wijngaard RMJGJ, WesterhofW, Das PK. Presence ofT
cells and macrophages in inflammatory vitiligo skin parallels melanocyte disap-
pearance. Am J Pathol 1996; 148:1219-1228.
20. Morohashi M, Hashimoto K, Good TF, Newton DE, Rist T. Ultrastructural
studies of vitiligo, Vogt-Koyanagi pigmenti achromians. Arch Dermatol 1977;
113:755-766.
21. AI'Abadie MS, Warren MA, Bleehen SS. Morphologic observations in the der-
mal nerves in vitiligo: an ultrastructural study. Int J Dermatol 1995; 34:837-840.
22. Brown J, Winkelmann RK. Langerhans cell in vitiligo: a qualitative study. J
23. Moellmann G, Klein-Angerer S, Scollay DA, Nordlund JJ, Lerner AB. Extra-
cellular granular material in the normally pigmented epidermis of patients with
vitiligo. J Invest Dermatol 1982; 79:321-330.
24. Boissy RE. Histology of vitiliginous skin. Tn: Hann SK, Nordlund JJ, eds.
Vitiligo. Oxford: Blackwell Science Ltd., 2000:23-34.
25. Hann SK, Park YK, Lee KG, Choi EH, 1m S. Epidermal changes in active
vitiligo. J Dermatol 1992; 19:217-222.
26. Galadari E, Mebregan AH, Hashimoto K. Ultrastructural study of vitiligo. Int J
Dermatol 1993; 32:269-271.
27. Bhawan J, Bhutani LK. Keratinocyte damage in vitiligo. J Cutan Pathol 1983;
10:207-212
28. al Badri AMT, Todd PM, Garioch 11, Gudgeon J E, Stewart DG, Goudie RB. An
immunohistological study of cutaneous lymphocytes in vitiligo. J Pathol 1993;
170:149-155.
29. Boissy R, Liu YY, Medrano EE, Nordlund JJ. Structural aberration of the
rough endoplasmic reticulum and melanosome compartmentalisation in long
term cultures of melanocytes from vitiligo patients. J Invest Dermatol 1991;
97:395-404
13
Clinical Variants of Vitiligo
Seung-Kyung Hann and Sungbin 1m

Korea Institute of Vitiligo Research, Seoul, Korea
CLINICAL VARIANTS OF VITILIGO

Vitiligo may occur on any part of the integument, but the face, dorsum of the
hands, axillae, umbilicus, nipples, sacrum, and inguinal regions are the most
frequently involved sites, exhibiting two general patterns: unilateral or bilat-
eral. In the previous chapters the most common forms of vitiligo have been
described. These include:
I. Localized forms:
a. Focal: one or more macules localized in one area not showing
zosteriform or segmental pattern
b. Segmental form: involving a unilateral segment of the body
and stopping abruptly at the midline of the affected segment
c. Mucosal form: limited to mucous membranes
2. Generalized forms:
a. Universalis: with complete or nearly complete depigmenta-
tion
b. Vulgaris: with scattered macules
c. Acrofacial: involving the distal part of the extremities and the
face
d. Mixed
160 Hann and 1m
In this chapter we will describe the most interesting clinical variants of the
disease: the segmental, bilateral segmental, and trichrome forms, vitiligo with
raised borders, and blue vitiligo.
SEGMENTAL VITILIGO
In 1977, an investigator divided vitiligo into segmental and nonsegmental
types. He described segmental vitiligo as depigmented patches confined to a
definite dermatome, akin to herpes zoster (I). He proposed that the patho-
genesis and clinical manifestation of the two types were different from each
other, based on his experiment in which sweat secretion was stimulated by
local injection of physisotigmine. The segmental type results from dysfunc-
tion of the sympathetic nervous system in the affected skin area, while the
nonsegmental type results from an immunological mechanism.
The clinical features of vitiligo have been reported by many investiga-
tors. However, the study of segmental vitiligo has rarely been reported, and
the numbers of patients studied limited. The incidence of segmental type is
variable; one group of investigators reported 5% (2), another group reported
27.9% (3), and previous Korean studies showed a range between 5.5 and
161 % (4,5).
Vitiligo develops at all ages, but it usually occurs in young people
between the ages of 10 and 40. However, according to an epidemiological
study reported in 1977 (6), abollt half of the patients developed vitiligo after
40 years of age, which was very different from other clinic-based studies. On
the other hand, one group reported that onset of nonsegmental vitiligo could
occur at any age, whereas segmental vitiligo generally affected the young. In
our report (7), segmental vitiligo developed before 30 years of age in 87.0% of
TABLE 1 Site of Segmental Vitiligo
Site Men (%) Women (%) Total (%)
Head and neck 57(62.6) 87(65.9) 144(64.6)

Face 49(53.8) 65(49.2) 114(51.1)
Neck 7(7.7) 20(15.2) 27(12.1)
Scalp 1(1 .1) 2(1.5) 3(1.4)
Trunk 21(23.1) 34(25.8) 55(24.7)
Chest and abdomen 17(18.7) 31 (23.5) 48(21.5)
Back 4(4.4) 3(2.3) 7(3.1)
Extremities 13(14.3) 11 (8.3) 24(10.8)
Upper extremities 7(7.7) 7(5.3) 14(6.3)
Lower extremities 6(6.6) 4(3.0) 10(4.5)6
Total 91 132 223
Clinical Variants of Vitiligo 161
the patients, and 41.3% were younger than 10 years. This is in accord with the
report that segmental vitilligo occurs in young people before age 30 (3).
The commonly involved sites of vitiligo are exposed areas, such as
the face and dorsum of the hand. In our study of segmental vitiligo, the in-
volved sites were the face, trunk, neck, extremities, and scalp, in descending
order (Table I). An older study reported that vitiligo occurs as single lesions
in 75% of cases (8), which was the situation with 87% of the patients in
our study.
Dermatomal distribution revealed that the trigeminal nerve (Fig. I) was
most frequently involved, followed by the thoracic (Fig. 2), cervical, lumbar,
and sacral nerves (Table 2).
FIGURE 1 Segmental vitiligo distributed in ophthalmic and maxillary branches of

trigeminal dermatome. Copyrighted Material
162 Hann and 1m
FIGURE 2 Segmental vitiligo distributed along thoracic dermatome.
We appraised whether hand dominancy has any relation with vitiligo

involving the right or left side of the body, but there was no significant
relationship between these two factors. The left side was slightly more
involved, regardless of the dominant hand. Poliosis, known to be associated
with vitiligo in 8.9-45% of cases, occurred in 48.6% in our study. The
eyebrows and scalp hair were mostly involved (46.7%); this is because when
vitiligo involves the face, neck, and scalp, poliosis of the eyebrows and scalp
hair is commonly present (67.4%). Physical trauma, sunburn, psychological
TABLE 2 Dermatomal Distribution of Segmental Vitiligo
Dermatome Men (%) Women (%) Total (%)
Trigeminal 49(53.9) 65(50.8) 114(52.1)

Cervical 12(13.2) 26(20.3) 38(174)
Thoracic 19(20.9) 31 (24.2) 50(22.8)
Lumbar 10(11.0) 4(3.1) 14(64)
Sacral 1(1.1) 2(1.6) 3(14)
Total 91 128 219
stress, inflammation, pregnancy, contraceptives, etc. are known to be the

precipitating factors of vitiligo. But unlike other reports, there was nothing
particularly worth mentioning except for sunburn, trauma, and pregnancy.
Family history was present in 11.5%, compared to the 7.4% reported by one
group (5) and 12% by another (9).
A pair of investigators claimed that segmental vitiligo is not associated
with other autoimmune diseases (2), but another group found that they were
associated in about 9.5% of cases (5). One group of investigators asserted that
an autoimmune disease occurred more significantly in nonsegmental vitiligo
than in segmental vitiligo and that this difference was due to different
pathogenetic mechanisms (3). In our report, association with thyroid diseases,
diabetes mellitus, pernicious anemia, and halo nevus, which frequently
accompany vitiligo, was seen in 3.4% (7), and this was lower than in the
other report (10); however, that could not justify the conclusion that auto-
immune mechanisms are restricted to nonsegmental vitiligo, because systemic
and topical steroid treatment and psoralen and ultraviolet A (PUVA) therapy
can inhibit spreading and induce repigmentation of new lesions of segmental
vitiligo, especially on the face (11).
BILATERAL SEGMENTAL VITILIGO

The depigmented lesions of segmental vitiligo do not always assume a true
dermatomal pattern according to the peripheral nervous system. Not all the
patterns of segmental vitiligo follow dermatomal distribution, unlike herpes
zoster. Blaschko's lines or acupuncture lines can be applied to the pattern of
segmental vitiligo. In our recent study (12), 5 cases of bilateral segmental
vitiligo were found among 240 cases of segmental vitiligo, in which the vitiligo
lesions appeared on the same or different derma tomes on both sides of the
body (Fig. 3). The clinical characteristics of bilateral segmental vitiligo are
shown in Table 3. PUVA therapy and steroid treatment could induce repig-
mentation or stop progression of vitiliginous lesions in bilateral segmental
vitiligo.
164 Hann and 1m
FIGURE 3 Bilateral segmental vitiligo distributed in linear pattern on both right and
left thoracic dermatome. The right side lesions are located at the shoulder and
arm; the left side lesions are located at the lower chest and upper abdomen, which
do not cross the midline.
Because segmental vitiligo has clinical features that differ from non-
segmental vitiligo, it is quite important to classify the type of vitiligo. The
depigmented patches of segmental vitiligo usually remain unchanged for the
rest of the patient's life. Therefore, stable segmental vitiligo is a good can-
didate for epidermal grafting and can be cured almost completely without
recurrence.
TABLE 3 Clinical Characteristics of Bilateral Segmental Vitiligo
Distribution
Patient Response
sex/age Duration Left Right Treatment to treatment
F/4 2 months Chest, back, arm Chest, arm Systemic steroid No progression
F/6 4 yr Chest, back, arm Buttock, thigh Topical steroid No change
F/8 2 yr Chest, back, arm Chest, back, arm Topical steroid Repigmentation
F/27 3 yr Chest, back, arm Chest, back, arm Systemic PUVA Repigmentation
F/12 2 yr Chest, arm Chest, back, arm Systemic PUVA Repigmentation
On the other hand, if segmental vitiligo occurs bilaterally, following the

same or different dermatomes, it may cause confusion in defining the type of
vitiligo. As segmental vitiligo can rarely appear bilaterally following derma-
tomal distribution, such as in herpes zoster, it may mimic some other type of
nonsegmental vitiligo. The clinical course of bilateral segmental vitiligo seems
to be the same as unilateral segmental vitiligo.
TRICHROME VITILIGO
The term trichrome vitiligo was first suggested in 1964 by Fitzpatrick (13).
The lesions have an intermediate zone of hypochromia located between the
achromic center and the peripheral unaffected skin. This results in three
shades of color-brown, tan, and white-in the same patient (14) (Fig. 4).
The trichrome lesion naturally evolves to a typical vitiligo macule. The sig-
nificance of trichrome is unknown, but it is clearly a metastable or transi-
tional pigmentary state, though it may persist for months to years with little
change. Fitzpatrick (13) and Pincus (15) interpreted trichrome as suggestive
of a gradual centrifugal spread of hypomelanosis or a stepwise depigmen-
tation. However, other reports pointed out that the sharp demarcation be-
tween the three areas in their cases, as well as the lack of gradual changes
of color and the stability of the lesion, is inconsistent with the interpretation
of trichrome vitiligo as an active centrifugal spreading lesion. Therefore,
whether trichrome vitiligo is a temporary phenomenon of active spreading
vitiligo or a hypomelanosis showing an unusual progression pattern remained
to be defined. However, our recent study (16) showed that trichrome vitiligo is
an active, centrifugally spreading lesion through clinico-histopathological
studies.
The study showed that among the 21 vitiligo patients showing trichrome
lesions, 95.2% were classified as having vitiligo vulgaris and 85.7% had
spreading lesions clinically. Histopathological findings also showed the char-
acteristics of active spreading vitiligo. Therefore, trichrome vitiligo was re-
garded as a phenomenon ~pyHl1J:lmMYfe;OO-areas of active vitiligo.
166 Hann and 1m
FIGURE 4 Trichrome vitiligo showing light brown band between vitiliginous and
dark brown perilesional skin.
Of the trichrome lesions, 85.5% were localized to the trunk region,

including the abdomen, back, and buttock, leading to the assumption that
trichrome vitiligo predominates in unexposed skin (Table 4).
According to previous reports, sun-exposed areas are the predilection
sites of vitiligo and lesions in these areas commonly show rapid progression.
In contrast, the fact that trichrome vitiligo lesions predominated in unexposed
skin could be one of the reasons the characteristic trichrome features
appeared, possibly because of slow progression of the disease. Melanocyte
density and skin thickness could also be factors contributing to the develop-
ment of trichrome features. Blacks have a relatively higher frequency of
trichrome vitiligo compared with whites and similarly most of the patients in
TABLE 4 Location of Trichrome Vitiligo
Location No. of patients (%)
Back 12(57)
Abdomen 4(19)
Buttock 2(9.5)
Chest 1(4.8)
Arm 1(4.8)
Leg 1(4.8)
Total 21(100)
our study had skin type IV or darker. Therefore dark skin also seems to be a
contributing factor to the pathogenesis of trichrome vitiligo.
The histological findings of trichrome vitiligo showed the most dense
distribution of melanin granules in the perilesional normal skin, followed by
normal skin, light brown skin, and vitiliginous skin, in descending order. As
such, the characteristic trichrome color may be an expression of changes in
melanin granules rather than melanocyte numbers.
Hyperpigmentation seen around the periphery of white patches is typi-
cally found in vitiligo. This was also observed in the trichrome lesions in which
perilesional normal skin showed a slightly darker color compared with
normal skin and histologically a higher density of melanin granules. Other
histological findings such as vacuolar degeneration of the basal cell layer,
monon uc1ear cell infiltration of the epidermis and dermis, and melanophage
deposition in the dermis were more prominent in light brown skin and
perilesional normal skin than in vitiliginous and normal skin. Among these
changes, vacuolar degeneration of the basal cell layer and inflammatory cell
infiltration were especially accen tuated around the melanocytes in the basal
cell layer (Table 5; Fig. 5). However, overall destruction of keratinocytes
TABLE 5 Histological Findings of Trichrome Vitiligo
Inflammatory cell
infiltration
Vacuolar degeneration
Epidermis Dermis of basal cells
Vitiliginous skin 1 (4.8)a 6(28.6) 5(23.8)

Light brown skin 13(61.9) 12(57.1 ) 13(61.9)
Perilesional normal skin 16(762) 16(76.2) 19(90.5)
Normal skin 2(9.5) 3(14.3) 7(33.3)
a Number (percentage in parent~f/f»figp,~eifffflfcJ&r7al

168 Hann and 1m
FIGURE 5 Hematoxylin-eosin staining of trichrome vitiligo. Vacuolar degeneration

of the basal cell layer and mild inflammatory cell infiltration in epidermis and dermis
are more prominent in light brown skin (LBS) and perilesional normal skin (PLNS)
than vitiliginous skin (VS) and normal skin (NS) of trichrome vitiligo. (Original mag-
nification x 200.)
coexisted, and we presume that the target of destruction is not limited to

melanocytes but also involves keratinocytes as well.
Perilesional normal skin shows more severe vacuolar change of the
basal layer and inflammatory cell infiltration than light brown skin and his-
tologically is already in the process of vitiligo evolution, despite its normal-
looking appearance. Therefore, without appropriate treatment, a change
clinically into light brown skin can be predicted. Light brown skin clinically
and histologically shows features of active vitiligo, although the degree of
histological change is subtle compared with perilesional normal skin. The
histological features of light brown skin and perilesional normal skin are
congruent with findings of active vitiligo lesions of more than 1 year's dura-
tion showing vacuolar degeneration of basal cell layer, mononuclear cell in-
filtration of the epidermis and dermis, and melanophage deposition (17,18).
In view of such similarities, trichrome vitiligo could be a variant form of active
vitiligo.
The number of melanocytes in trichrome vitiligo was greatest in perile-
sional normal skin followed by light brown skin and vitiliginous skin, with
vitiliginous skin showing at least a few melanocytes, albeit less than that of
normal skin (Table 6). These results are contradictory with other studies of
vitiligo (17,19,20), which report absence of melanocytes in the depigmented
patches confirmed by immunohistochemical staining or electron microscopy.
The clinical and histological findings of trichrome vitiligo suggest a slower
progression of lesions than typical vitiligo, and this could be why melanocytes
remain in the white patches.
Langerhans cells may playa major immunological role in vitiligo.
Interaction between keratinocytes, melanocytes, and Langerhans cells is
thought to initiate depigmentation, but the exact mechanism is unknown.
In patients with nonsegmental-type vitiligo, a marked depletion of Langer-
hans cells was noted in active lesions and a repopulation of Langerhans cells
was noted in stable lesions (21). In inflammatory vitiligo, an increase in
Langerhans cells was observed in adjacent normal skin compared with
vitilignous skin and normal skin (22). Our study showed that light brown
skin and perilesional normal skin exhibit an increase in Langerhans cell
number compared with vitiliginous skin and normal skin (Table 7). From our
findings, an increased number of Langerhans cells may be involved in actively
spreading vitiligo.
Vitiligo lesions of the trunk are known to respond favorably to systemic
PUV A therapy in comparison to systemic steroid therapy, and the existence
of inactive melanocytes in the epidermis or follicles is a decisive factor
influencing treatment results (23,24).
TABLE 6 Numbers of S-100+ Melanocytes in Patients with Trichrome Vitiligo
Patient no. VS LBS PLNS NS
1 23 a 23
2 5 14 19
3 5 15 18 20
4 2 14 13 15
5 4 8 14 16
6 5 15 16 17
7 8 13 15 16
8 8 8 17 12
9 4 13 16 16
10 2 7 11 14
Mean ± SOb 4.8 ± 2.2 11.9 ± 3.3 16.8 ± 3.0 16.3 ± 3.5
LBS, light brown skin; NS, normal skin; PLNS, perilesional normal skin; VS, vitiliginous skin.
a Number of melanocytes per 6 high-power fields (x400).
b PLNS and LBS: p < 0.05; LBS and VS: p < 0.05
170 Hann and 1m
TABLE 7 Number of CD1a+ Langerhans Cells in Patients with Trichrome

Vitiligo
Patient no. VS LBS PLNS NS
1 62 a 73 36
2 52 58 47
3 39 67 54 37
4 36 28 44
5 21 50 50 45
6 33 65 47 24
7 34 60 31
8 52 44 33
9 14 34 36 28
Mean ± SDb 295 ± 9.8 55.7 ± 11.1 54.3 ± 10.4 36.7 ± 8.6
LBS, light brown skin; NS, normal skin; PLNS, perilesional normal skin; VS, vitiliginous skin.
a Number of Langerhans cells per 6 high-power fields (x400).
b LBS and PLNS compared with VS and NS: p < 0.05.
Trichrome vitiligo responded especially well to systemic PUVA treat-

ment. This is because a few melanocytes were still remaining in the white
lesions, thereby contributing to the repigmentation process. Therefore, early
systemic PUVA therapy should be considered in patients with trichrome
features to shorten treatment duration and achieve satisfactory end results.
VITILIGO WITH RAISED BORDERS

Generally, vitiligo macules have distinct margins. However, raised borders
have, on a few occasions, been observed at the margins of the depigmented
borders. This is a rare macroscopic presentation of vitiligo, and only few cases
have been reported (25,26). Vitiligo with raised borders has been reported in
males and females at any age.
The red, raised borders may be present from the onset of vitiligo or may
appear several months or years later. A mild pruritus may be present.
Histological features of the raised borders show eczematous changes in the
epidermis with absence or decrease of melanin pigmentation and fairly dense
lymphocytic and histocytic infiltrate in the upper dermis. Complete regression
of the red, raised borders has been reported in several patients either
spontaneously or after topical steroid therapy.
The significance of this localized inflammatory reaction is unknown.
According to several histological studies, the presence of a mild lymphocytic
infiltrate at the border of active vitiligo may be observed even in the absence
of clinical inflammation. Thus, the occurrence of red, raised borders could
represent simply an amplification of the usual inflammatory process occur-
ring in vitiligo (26).
Inflammatory vitiligo macules with an edematous border and slight
scali ness are very unusual. As the inflammatory component disappears, the
skin becomes depigmented. It has been suggested that this inflammatory
pattern occurs in atopics (27).
BLUE VITILIGO
The blue coloration of vitiligo macules has been observed in a patient already
affected by postinftammatory hyperpigmentation in whom vitiligo developed.
Histological examination of the blue vitiligo lesions showed an absence of
epidermal melanocytes and numerous melanophages in the dermis. The blue
coloration subsequently disappeared with follicular repigmentation typical of
resolving vitiligo (28).
REFERENCES
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261.
2. EI Mofty AM, EI Mofty M. Vitiligo: a symptom complex. Int J Dermatol 1980;
19:238-247.
3. Koga M, Tango T. Clinical features and course of type A and type B vitiligo. Sr J
Dermatol 1988; 118:223-228.
4. Song MS, Hann SK, Ahn PS, Ims, Park YK. Clinical study of vitiligo: com-
parative study of type A and type B vitiligo. Ann Dermatol 1994; 6:22-30.
5. Park KC, Youn JI, Lee YS. Clinical study of 326 cases of vitiligo. Korean J
Dermatol 1988; 26:200-205.
6. Howitz J, Brodthagen H, Schwartz M. Prevalence of vitiligo: epidemiologic
survey on the Isle of Borholm, Denmark. Arch Dermatol 1977; 113:47-52.
7. Hann SK, Lee HJ. Segmental vitiligo: clinical findings in 208 patients. J Am Acad
Dermatol 1996; 35:671-674.
8. Lerner AB. On the etiology of vitiligo and gray hair. Am J Med 1971; 51: 147-156.
9. Hann SK, Park YK, Whang KC, Kim HJ Clinical study of 174 patients with
generalized vitiligo. Korean J Dermatol 1986; 24:798-805.
10 Park SY, Youn JI, Lim SD. A clinical study of217 cases ofvitiljgo. Korean J
Dermato] 1981; 19:145-152.
II. Kim SN, Lee HS, Hann SK. The efficacy of low dose of oral corticosteroids in
vitiligo patients. Int J Dermatol 1999; 38:546-550.
12. Lee HS, Hann SK. Bilateral segmental vitiligo. Ann Dermatol1998; 10:129-131.
13. Fitzpatrick TB. Hypomelanosis. South Med J 1964; 57:995-1005.
172 Hann and 1m
14. Fargnoli MC, Bolognia JL. Pentachrome vitiligo. J Am Acad Dermatol 1995;
33853-856.
15. Pincus H. Vitiligo: what is it? J Invest Dermatol 1959; 32:281-284.
16. Hann SK, Kim YS, Yoo JH, Chun YS. Clinical and histopathologic character-
istics of trichrome vitiligo. ] Am Acad Dermat01 2000; 42:589-596.
17. Hann SK, Park YK, Lee KG, Choi EH, 1m S. Epidermal changes in active
vitiligo. ] Dermatol 1992; 9:217-222.
18. Gokhale BB, Mehta LN. Histopathology of vitiliginous skin. Int J Dermatol
1983; 22:477-480.
19. Le Poole IC, Das PK, van den Wijngaard RM]G], Bose JD, Westerhof W.
Review of the etiopathomechanism of vitiligo: a convergence theory. Exp Der-
mato11993; 2:145-153.
20 Le Poole Ie. van den Wijngaard RMJGF, WesterhofW, Dutrieux RP, Das PK.
investigation. ] Invest Dermatol 1993; 100:816-822.
21. Kao CH, Y u HS. Depletion and repopulation of Langerhans cells in non-
segmental type vitiligo. J Dermatol 1990; 17:280-296.
22. Le Poole IC, van den Wijngaard RM]G], WesterhofW, Das PK. Presence ofT
cells and macrophages in inflammatory vitiligo skin parallels melanocyte dis-
appearance. Am ] Pa thol 1996; 148: 1219-1228.
23. Ortonne JP, Schmitt D, Thivolet]. PUVA-induced repigmentation of vitiligo:
scanning electron microscopy of hair follicles. J Invest Dermatol 1980; 74:40-42.
24. Cui 1, Shen L, Wang G. Role of hair follicles in the repigmentation of vitiligo. 1
25. Michaelsson G. Vitiligo with raised borders. Report of two cases. Acta Dermatol
Venereol (Stockh) 1968; 48:158-161.
_6. Eng AM. Marginal inflammatory vitiligo. Cutis 1970; 6:1005-1008.
27. Ortonne ]P. Special features of vitiligo. In: Hann SK, Nordlund ]1, eds. Vitiligo.
Blackwell Science Ltd., 2000:70-75.
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30829-831.
14
Vitiligo In Children
Flora B. de Waard-van der Spek

and Arnold P. Oranje
Erasmus Me, Rotterdam, The Netherlands
Vitiligo is an acquired idiopathic hypomelanotic disorder characterized by

circumscribed depigmented macules resulting from the loss of cutaneous
melanocytes. Cutaneous depigmentation is most obvious. However, mucous
membranes and eyes may also reveal loss of pigmentation in vitiligo. The
general prevalence of vitiligo throughout the world is about I per 200 indi-
viduals, and both sexes are affected equally. However, there are locations in
the world, such as isolated villages in India, where the prevalence is much
higher, as high as 8% (I).
There are numerous hypotheses about the etiology of vitiligo, but no
data to definitely prove one theory above the other. There are numerous
causes for the loss of melanocytes. An autoimmune etiology has been sug-
gested (2). Several observers noted that a number of their patients with vitiligo
had other disorders considered to be of autoimmune origin. Such disorders
included thyroid and adrenal disease, alopecia areata, and insulin-depen-
dent diabetes mellitus. Furthermore, circulating antibodies an T lymphocytes
which react against melanocyte an tigens are present in the sera of a significant
proportion of vitiligo patient compared with healthy individuals (2). Re-
cently the melanin-concentrating hormone receptor I (MCHRI) was identi-
fied as a novel autoantigen related to vitiligo (3).
Vitiligo seems to have a predilection for sibs, although its transmission
does not follow Mendelian genetics (l). Other pathogenetic factors mentioned
174 de Waard-van der Spek and Oranje
are neurological factors, toxic metabolites, and lack of melanocyte growth

factor (4).
Two known mechanisms for the destruction of cells are necrosis and
apoptosis. Recently apoptosis, rather than necrosis, has been hypothesized as
the mechanism for removal of melanocytes in vitiligo (5). Apoptosis can be
induced by a variety of factors, including immune cytokines, some environ-
mental chemicals, or other molecular mechanisms.
CLINICAL FEATURES OF VITILIGO IN CHILDREN

Vitiligo typically begins during childhood or adolescence. Approximately 25%
of individuals develop the first signs of cutaneous depigmentation before 10
years of age and 50% before 23 years. Less than 10% of those afflicted develop
vitiligo after the age of 42 years (6). Depigmented patches can occur anywhere
on the body. Vitiligo is often first noticed as pale maCltles on sun-exposed sites
of the face or the dorsal aspects of the hands. The distribution is usually
symmetrical and may show a periorificial pattern. Another pattern is unilat-
eral or segmental vitiligo, sometimes in a dermatomal distribution (7). Early
or advancing lesions may be partially depigmented and have a freckled ap-
pearance or multishaded hue. This is called trichrome vitiligo. As the disease
progresses most lesions become completely devoid of pigment. Although
vitiligo causes destruction of interfollicular melanocytes, it often spares the
follicular pigmented cells. Hairs within patches of vitiligo often remain pig-
mented, but in older lesions the hairs also become amelanotic. Some patients
with vitiligo also have halo nevi. Trauma to the skin can also result in further
depigmentation (Koebner phenomenon) (8).
DIFFERENTIAL DIAGNOSIS
The diagnosis of vitiligo is made clinically based on the symmetrical distri-
bution of depigmentation developing in most cases in the first two decades of
life. The diagnosis can be difficult in the early course. In the differential di-
agnosis skin diseases like pityriasis alba, pityriasis versicolor, hypopigmented
macules like ash leaf spots, albinism, piebaldism, postinflammatory hypo-
pigmentation, leukcoderma, or leprosy in patients immigrating from an en-
demic area must be kept in mind.
TREATMENT
Treatment ofvitiJigo in children requires an approach that manages not only
pathophysiological aspects of the disease, but also the psychological and so-
cial implications of having a visible skin disorder as vitiligo. Psychological
Vitiligo in Children 175
support is often necessary as the condition can have a profound effect on the
self-image of the affected individual (9).
A causative treatment is not yet available for vitiligo. Current modal-
ities are directed to stop progression and to achieve repigmentation in order to
repair the morphology and functional deficiencies of the depigmented skin
areas. Treatment of vitiligo can be divided into nonsurgical repigmentation
therapies, autologous transplantation methods, and depigmentation thera-
pies (10).
Different sources of ultraviolet (UY) light can be used to stimulate re-
pigmentation either alone ("unsensitized" phototherapy) or in combination
with chemicals which are activated by light, as with photochemotherapy. As
"unsensitized" phototherapy, broad-band UYB seems only to be moderately
effective in treating vitiligo. It is being replaced by narrow-band UYB: the
more erythemogenic wavelengths are removed, and wavelengths between
305 and 311 nm are used. This therapy has certain advantages over PUVA
(psoralen + UYA) in that no pills are required for treatment and the effects
on photocarcinogenesis and photoaging could possibly be reduced (II). A
study on the effect of narrow-band UVB therapy in seven patients with vitiligo
showed rapid repigmentation in many of them, including those with skin
photo types IV and V. This study extended previous observations that narrow-
band UYB is a useful and well-tolerated treatment option for patients with
vitiligo (12).
With PUVA therapy, oral or topical, results vary and complete repig-
mentation is achieved only in a few patients, while cosmetically acceptable
improvement is achieved in a majority of the patients. The total number of
treatments required is between 50 and 300. PUVA has not been approved for
children (11).
Phenylalanine is not phototoxic, but the combination of UV light and
phenylalanine seems to result in some pigmentation. Reported success rates
vary from 14 to 83%.
Topical calcipotriol may enhance the effect ofPUVA in the treatment of
vitiligo (13,14). Melanocytes are known to express 1,25-dihydroxyvitamin D 3
receptors, and, although their exact role in melanogenesis is not clear, some
investigators have suggested that 1,25-dihydroxyvitamin D 3 is involved in the
regulation of melanin synthesis (14). Vitamin D 3 is also known to have im-
munomodulatory effects, which may be an important mechanism of action if
vitiligo is considered to be an autoimmune T-cell~mediated disease. Very
recently, promising casuistic results have been obtained with application of
Taurotimus ointment.
The idea of stopping the process causing destruction of melanocytes via
the immune hypothesis seems to be very attractive. Growth factors and leu-
kotriens have found to be important in melanocyte proliferation and mi-
gration. A possible potential practical use of any of these polypeptides and

proteins remains to be determined. Some immunomodulating agents have
been successfully used in vitiligo. Topical corticosteroids can be useful for
small localized lesions. In an open retrospective assessment comparing the
results of treatment of vitiligo with topical steroids in adults and children,
using moderately potent to very potent steroids, children appeared to have a
better outcome than adults. Younger or darker skinned patients and those
with vitiligo affecting the head and neck had better results with topical steroid
use than older or paler skinned patients and those with vitiligo affecting other
parts of the body (15).
Systemic corticosteroids can be very helpful in arresting rapidly spreading
disease and can induce repigmentation, but their role in the treatment of vitiligo
remains controversial because of the potential for serious side effects (II).
Surgical methods intended to repigment leukoderma are a therapeutic
option if patients have stable disease. Two types of surgical techniques are
available: tissue grafts and cellular grafts, with in-between autologous
cultured epithelial grafts. Tissue grafts are full-thickness punch grafts, split-
thickness grafts, and suction blister grafts (16). In cellular grafts noncultured
keratinocytes and melanocytes or cultured melanocytes can be used. The
method with cultured melanocytes is time consuming and requires special
laboratory equipment. The first commercially available product in this new
field for the treatment of vitiligo is MelanoSeed (Bio Tissue Technologies AG,
Freiburg, Germany). This consists of autologous melanocytes, which are cul-
tured in Good Manufacturing Practice (GMP) laboratories certified accord-
ing EU guidelines. A skin biopsy of healthy well-pigmented skin is taken (full
thickness skin). Within 28 days the cell quantity necessary for the trans-
plantation is cultured. The transplantation area is prepared in an optimal way
by means of a dennabrasion. After healing the treated vitiligo area can be given
narrow-band UVB phototherapy to ensure optimal repigmentation (17).
Micropigmentation is another name for tattooing and may be helpful
for very stable recalcitrant small lesions. The color often does not match per-
fectly with the normal skin.
In widespread disease with only a few areas of normal pigmented skin,
treating the normal skin with depigmentating agents is an option. This is a
permanent irreversible process, which can be performed with a depigmenta-
tion cream or treatment with the Q-switched ruby laser (II).
In a meta-analysis and review of available literature on the nonsurgical
repigmentation therapies, class 3 corticosteroids and UV-B were the most
effective and safe therapies for localized and for generalized vitiligo, re-
spectively. Considering autologous transplantation methods, no compara-
tive controlled trials were included, so the treatment recommendations for
transplantation should be viewed with caution. Split-thickness skin or epi-
Vitiligo in Children 177
dermal blistering grafting can be recommended as the most effective and

safest techniques. Only a small number of patients treated with culturing
techniques has been studied. Limited data on depigmentation therapies
are available: using a depigmentation cream (monobenzone) or using a laser
(Q-switched ruby laser). Bleaching with cream take months or years to re-
sult in evident signs of depigmentation; laser therapy could give faster results
(10).
Most of the above-mentioned therapies require many months. There is
always the option of using camouflaging cosmetics. The use of sunscreens is
also recommended. Sunburn reactions of the depigmented skin will be pre-
vented, and the tanning response of normally pigmented skin will be limited.
PROGNOSIS
Depigmented patches remain for life. Partial repigmentation is common in
isolated spots of individuals of all ages who have had the disease for variable
periods of time. The amount of spontaneous repigmentation is rarely cosmeti-
cally sufficient (6).
CONCLUSIONS
Vitiligo is an acquired idiopathic hypomelanotic disorder. There are numer-
ous hypotheses about the etiology of vitiligo, but no data to definitely prove
one theory above the other. There is no standard treatment. Treatment of
vitiligo can be divided into nonsurgical repigmentation therapies, autologous
transplantation methods, and depigmentation therapies. Future studies of
treatment should also focus on the permanency of the induced repigmenta-
tions and the long-term risk-benefit ratios of the modalities.
REFERENCES
l. Nordlund 11. The epidemiology and genetics of vitiligo. Clin Dermatol 1997;
15:875-878.
2. Kemp EH, Waterman EA, Weetman AP. Autoimmune aspects of vitiligo.
Autoimmunity 2001; 43(1):65-77.
3. Kemp EH, Waterman EA, Hawes BE, et a!. The melanin-concentrating hor-
mone receptor 1, a novel target of autoantibody responses in vitiligo. 1 Clin
Invest 2002; 109(7):923-930.
4. Njoo MD, Westerhof W. Vitiligo. Pathogenesis and treatment. Am 1 Clin Der-
matol 2001; 2(3):167-181
5. Huang CL, Nordlund 11, Boissy R. Vitiligo: a manifestation of apoptosis? Am
1 Clin Dermatol 2002; 3(5):301-308
6. Lamerson C, Nordlund 11. Vitiligo. In: Harper JI, Oranje AP, Prose NS, eds.
Textbook of Pediatric Dermatology. London: Blackwell Science, 2000:880-891.
7. Shaffrali FCG, Gawkrodger DJ. Management of vitiligo. Clin Exp Dermatol
2000; 25:575-579
8. Handa S, Kaur 1. Vitiligo: clinical findings in 1436 patients. J Dermatol 1999;
26(10):653-657.
9. Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of vitiligo:
a preliminary investigation into the effects of cognitive-behavioural therapy. Br
J Med Psychol 1999; 72385-396.
10. Njoo MD, Westerhof W, Bos JD, et al. The development of guidelines for the
treatment of vitiligo. Arch Dermatol1999; 135:1514-1521.
II. Taneja A. Treatment of vitiligo. J Dermatol Treatm 2002; 13: 19-25.
12. Scherschun L, Kim 11, Lim HW. Narrow-band ultraviolet B is a useful and
well-tolerated treatment for vitiligo. J Am Acad Dermatol 2001; 44(6):999-
1003.
13. Ermis 0, Alpsoy E, Cetin L, et at Is the efficacy of psora len plus ultraviolet A
therapy for vitiligo enhanced by concurrent topical calcipotriol? A placebo-
controlled double-blind study. Br J Dermatol 2001; 145:472-475.
14. Ameen M, Exarchou Y, Chu AC. Topical calcipotriol as mono therapy and in
combination with psoralen plus ultraviolet A in the treatment of vitiligo. Br J
Dermatol 200 I; 145:476-479.
15. Cockayne S, Messenger AG, Gawkrodger DJ, et at Vitiligo treated with topical
steroids: children with head and neck involvement respond well. J Am Acad
Dermatol 2002; 46(6):964-965.
16. Geel N van, Ongenae K, Naeyaert J-M. Surgical techniques for vitiligo: a re-
view. Dermatology 200 I; 202: 162-166.
17. Westerhof W, Lantz W, Yanscheidt W, et at Vitiligo: news in surgical treat-
ment. JEADY 2001; 15:510-511.
15
Vitiligo: Focusing on Clinical Associations
with Endocrine, Hematological,
Neurological, and Infectious Diseases
Alex L1ambrich and Jose Ma Mascaro

Hospital Clinic, Barcelona, Spain
INTRODUCTION
Vitiligo is a common, acquired, depigmentary disorder of the skin that affects
1-2% of the general population, without racial, sex, or regional differences
(1-3). The majority of vitiligo patients are healthy and have no associated
pathology, but it is well known that vitiligo occurs in relation to other dis-
eases, mainly linked with the immune system. Since the I960s, numerous
reports have tried to prove the association between vitiligo and autoimmune
disorders. The clinical observation that 10-15% of patients with autoimmune
diseases develop vitiligo in comparison with 1-2 % of the general population
(4) and the high prevalence of autoantibodies to melanocytes in the serum of
patients with vitiligo (5,6) support the autoimmune hypothesis.
Segmental vitiligo, characterized by localized lesions in a dermatomal
distribution, seems to be linked less frequently to autoimmune disorders than
nonsegmental vitiligo (7,8). A pathogenic mechanism involving a dysfunction
of sympathetic nerves in the affected area in segmental type may be the cause
for these differences (Fig. 1).
180 L1ambrich and Mascaro
~ I VlTILIGO 1----.
~--------, ~--------,
Check: associated clinical Check: routine blood
manifestations analyses
.-----..------~,---,
---I
Glycemia
TSH, T4
Antithyroidal Hemogram I
antibodies
........
Hyperglycemia
I Anemia
Suspect':
RheullIlltold arthritis
Lupus erytlienilttosus
Seronegallve
~pondYloarthritis
j tlYf>'l'Ibyroldlsm:
Qravcs(Uase<:km:::'ls disease
~--~
I /--"-~OI~~iS
[fl
, Macrocytosis I
Bi.GOT.LOH
Suspect:
I 1
'l:J\yroto'l1oosi., .
1 Myas:tb~Dia
graViS
Toxicgoitet:
Antinuclear antibodies
Rheumaroidal metor
HLA-B27
1
Antiacetylcholine
,S~pect:
Pemkioas
aa~mia
Suspect;
llemCllytlc anemia
autOimmu.ut-
receptor antibody
Edrophonium test
Electromyogram
I Coombs' lest
FIGURE 1 Guidelines for diagnosis. Bi: bilirubin; GOT: glutamic oxoaloacetic trans-
aminase; LDH: lactic dehydrogenase. (*) HCV screening based on Yamamoto's
study (62).
VITILIGO AND ENDOCRINE DISORDERS

Thyroid Disease
Thyroid dysfunction is the endocrine disease most frequently associated with
vitiligo. In 1929,25 patients with vitiligo and Grave's disease were reported by
Parhon and Derevici (9). Since then, some authors have thought that patients
with vitiligo have a propensity to develop thyroid dysfunction, and several
reports of thyroid disease, including hyperthyroidism (Graves' disease,
thyrotoxicosis, toxic goiter) (l0-15) and hypothyroidism (Hashimoto's thy-
roiditis) (16,17) in association with vitiligo have been published. Depending
on the series, the prevalence of thyroid dysfunction in vitiligo patients is quite
variable, ranging from 30% (18) to 0.5 % (19). This difference makes it diffi-
cult to come to any definite conclusion about this association. These studies
show that the prevalence of thyroid dysfunction is higher in females than in
males, especially from the fifth decade. Routine screening for thyroid disease
Clinical Associations 181
(T3, T4, and TSH tests) in vitiligo patients may be useful (18,20), although
some authors suggest that screening tests are only justifiable when a vitiligo
patient shows suspected clinical manifestations of thyroid disease (21). Auto-
antibodies to thyroid gland (anti thyroglobulin and anti microsomal anti-
bodies) are found more commonly in the serum of vitiligo patients than in
the general population (5,18). These can be found on average in 10-17% of
patients with vitiligo (6). Some patients with vitiligo may exhibit autoanti-
bodies to thyroid gland in the serum but no dysfunction (5,20,22). On the
other hand, it has been estimated that 0.62% (23) to 12.5% (24) of patients
with thyroid disease can develop vitiligo.
One should bear in mind that vitiligo and associated thyroid dysfunc-
tion do not follow any exact chronology, i.e., vitiligo can occur before, during,
or after the onset of thyroid disease. Also, the clinical courses of both
disorders are independent, and the treatment of either does not affect the
other's evolution (25).
Polyglandular Syndrome
Polyglandular syndrome is a multiendocrine dysfunction associated with
organ-specific autoantibodies. At present two forms of this disease are con-
sidered: type I (Addison's disease and hypoparathyroidism) and type II (dia-
betes mellitus type I, Addison's disease, and autoimmune thyroid disease).
Organ-specific autoantibodies to glandular tissue and activation of lympho-
cytes T are the main causes of destruction of the endocrine system. This syn-
drome is commonly linked with other nonendocrine autoimmune diseases,
such as vitiligo, alopecia areata, pernicious anemia, and mucocutaneous can-
didiasis. An association between polyglandular syndrome and vitiligo, mainly
the generalized type, has been posited (26-29), and in several cases autoanti-
bodies to melanocytes have been detected in the serum of these patients (26).
This association supports the hypothesis that vitiligo, at least in these pa-
tients, is an autoimmune disorder (30).
Others
In 1855 Addison described 13 patients with adrenal insufficiency caused by
tuberculosis, two of whom also had vitiligo (31). Numerous cases of vitiligo
associated with autoimmune adrenal insufficiency have since been reported,
although less frequently than thyroid dysfunction (32,33).
Diabetes mellitus, a disease caused by the destruction of Langerhans
islets of the pancreas mediated sometimes by autoantibodies, may also be
associated with vitiligo (34-37). Dawber (34,35) found that vitiligo was pres-
ent in 4.8% of diabetic patients and moreover observed that 1-7% of vitiligo
patients were also diabetic€o~gf.7~§i~m#inlyappears in cases of late-
onset vitiligo (34). At present it is not possible to confirm if an authentic as-

sociation between both diseases exists or if this association is casual.
There are some reports of gonadal atresia associated with vitiligo in the
context of autoimmunity (38,39).
VITILIGO AND HEMATOLOGICAL DISEASES

Pernicious and hemolytic anemia, two types of autoimmune anemia, may
occur associated with vitiligo.
Pernicious anemia is a disease resulting from the destruction of parietal
gastric celJs mediated by autoantibodies that cause defective synthesis of in-
trinsic factor and, therefore, a defective absorption of vitamin B 12. Of patients
with pernicious anemia, 1.6~1 0.6% exhibit vitiligo (23,40). Bleifeld found
defective vitamin B 12 absorption (Schilling test) in one-third of patients with
vitiligo (41). It is estimated that 13% of patients with vitiligo have antiparietal
cell antibodies in their serum (6).
An association between vitiligo and autoimmune hemolytic anemia is
less common (42,43).
Other hematological diseases, such as lymphoma (44) and leukemia
(45), have been occasionally associated with vitiligo.
VITILIGO AND NEUROLOGICAL DISEASES

Yogt-Koyanagi-Harada syndrome (YKHS) (46-48) is a uncommon disease,
probably autoimmune, which causes multiple manifestations including cuta-
neous (vitiligo, poliosis, alopecia areata), ocular (uveitis, optic neuritis) audi-
tory (labyrinthitis), and neurological (meningoencephalitis) alterations. Some
authors suggest that VKHS is a systemic disease with a wide clinical spectrum.
Vitiligo with asymptomatic ocular affectation would constitute one of the
extremes of these spectrum; we found a complete presentation of VKHS (20).
Myasthenia gravis is an autoimmune neurological disease that has been
associated with vitiligo in a few cases. Kubota et al. studied the frequency of
vitiligo among 202 patients with myasthenia gravis (49). Only one of their
patients (0.5%) showed vitiligo.
VITILIGO AND CUTANEOUS DISEASES

One of the diseases most frequently linked to vitiligo is alopecia areata. In
1968 Cunliffe et al. found that 16% of patients with vitiligo had patches of
alopecia areata (18). This average is quite variable depending on the study. In
a recent study that analysed 1436 Indian patients with vitiligo, only 0.4%
exhibited alopecia areata (19).
A B
FIGURE 2 Onset of vitiligo in a patient diagnosed with melanoma.
Halo nevus has been commonly described in patients with vitiligo (25).
These cases have been explained by the activation of lymphocytes that destroy
melanocytes of the normal skin and melanocytes of the nevus.
Association between malignant melanoma and vitiligo is rare, but very
interesting (Fig. 2). Onset of vitiligo in patients affected with malignant mela-
noma has been widely discussed (50-54). Some authors have suggested that
the response of the immune system to malignant melanocytes may also de-
stroy some normal meJanocytes of the skin (6). This hypothesis is supported
by studies that have proved the presence of antibodies to melanocytes in the
serum of patients with melanoma similar to antibodies of vitiligo patients
(55)
Some dermatoses commonly present in patients with vitiligo, such as
atopic dermatitis (19), psoriasis (56,57), and lichen planus, are considered
casual associations. Other dermatoses rarely associated with vitiligo, such as
dermatitis herpetiformis (58), morphea (59), and 20-nail dystrophy (60),
could be linked with a common pathogenic mechanism.
VITILIGO AND INFECTIOUS DISEASES

Hepatitis C virus (HCY) has been associated with many cutaneous disorders
(61). Frequently in these skin alterations immunological mechanisms are
involved, suggesting that HCY is involved in immunological abnormalities.
Recently, Yamamoto reported five patients with vitiligo who were infected by
HCV; he recommended HCV serological screening in patients with vitiligo
(62).
Vitiligo has also been associated with human immunodeficiency virus
(HIV) infection. Partial repigmentation of vitiligo lesions after administration
of antiretroviral treatment suggests that HIV may also have a role as a pre-
cipitating factor in vitiligo (63).
OTHER DISEASES
Padula et al. in 2001 studied 234 patients with seronegative spondyloarthritis
(SpA). This study showed that 3.4% of patients with SpA also presented
vitiligo lesions, whereas only 1.06% of control patients exhibited vitiligo le-
sions. The difference between the two groups was statistically significant (p <
0.005). These results suggest that vitiligo and SpA do not coexist by chance,
but that vitiligo should be included in the list of diseases associated with SpA
(64).
Sporadic cases of vitiligo have been published associated with other
internal diseases such as sarcoidosis (65,66), systemic lupus erythematosus
(67), discoid lupus erythematosus, and rheumatoid arthritis (68-70).
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13. Ramanathan M, Abidin MN, Muthukumarappan M. The prevalence of skin
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14. Mullin GE, Eastern JS. Cutaneous signs of thyroid disease. Am Fam Phys
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16. Shong YK, Kim JA. Vitiligo in autoimmune thyroid disease. Thyroidology
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18. Cunliffe WJ, Hall R, Newell D1, Stevenson CJ. Vitiligo, thyroid disease and
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20. Barnes L. Vitiligo and the Vogt-Koyanagi-Harada syndrome. DermatoJ Clin
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24. Miklaszewska M, Zukowski W, Dankiewicz J, Nowak A. Clinical and immu-
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16
Clinical Associations: Focusing on
Autoimmune and Rare Associations
G. Primavera and E. Berardesca

San Gallicano Dermatological Institute, Rome, Italy
Large population surveys have shown a prevalence of vitiligo ranging from

0.5 to 2% (1,3,4). Vitiligo is usually considered a cosmetic problem not in-
fluencing the general health conditions of the patients (1-4). Nevertheless, it is
sometimes associated with other disorders: cutaneous (common or unusual)
abnormalities (Table I), ocular and otic abnormalities, and some auto-
immune diseases (Tables 2, 3).
CUTANEOUS ABNORMALITIES
Halo nevi (Sutton's nevi) have been reported in 1-20.6% of vitiligo patients
(5-10). These nevi may be multiple or solitary, and vary greatly in number and
size (7). Barona et aL found that halo nevi could be considered as a risk factor
for the development of vitiligo (5).
Leukotrichia in vitiligo occurs commonly, with a prevalence of 9-42%
(6,10-13). Depigmented hairs occur with or without an underlying vitiligo
macule. Dutta et aL consider poliosis a marker for poor prognosis in re-
pigmentation (II), but this observation has not been confirmed.
The prevalence of canities (premature graying of hair) in vitiligo
patients is said to be 1.5-21.4% (6,7,14). Halder et aL (14) found that
premature graying hair occurs more frequently in adults with vitiligo com-
pared to children with vitiligo (21.4% vs. 3.8%), and this would be expected
because graying normally occurs as one gets older. However, they also found
190 Primavera and Berardesca
TABLE 1 Prevalence of Cutaneous Abnormalities in Vitiligo Patients
% Prevalence
Cutaneous abnormalities No. of studies Min. Max.
Leukotrichia 6 9.00 45.00

Canities 3 1.50 21.40
Halo nevi 6 1.00 20.60
a statistically significant increase in prevalence of canities in the family of

vitiligo children, so it is probable that the premature graying in these children
with vitiligo was related to the increased incidence of early graying in their
immediate families (14).
ORGAN DISORDERS
Human melanocytes, whose embryonic origin is from the neural crest, are
located in the skin, hair follicles, mucous membranes, leptomeninges, uveal
tract, and retinal pigment epithelium (RPE) of the eye and the inner ear (in the
cochlea, wall of the modiolus, spiral lamina, Reissner's membrane, stria
vascularis in the vestibular system, saccule, utricle, ampullae). Thus, pigmen-
tary disorders of the skin may be associated with similar pigmentary
abnormalities in the eye and in the ear. The pathogenesis of these associated
defects, which could indicate that vitiligo is a systemic disease of melanocytes,
is unknown. Patients with vitiligo who demonstrate audiological and oph-
TABLE 2 Prevalence of Vitiligo in Autoimmune Disorders
% Prevalence
Autoimmune disorders No. of studies Min. Max.
Thyroid 1 6.83
Diabetes 3 2.70 10.00
IDDN 3 1.7 9.6
NIDDN 2 0.4 3.3
Anemia perniciosa 2 9 10.6
Addison 1 9.6
PGA type 1 2 8 13
PGA type 2 4 4.5 30
Alopecia areata 1 3.5
Autoimmune and Rare Associations 191
TABLE 3 Prevalence of Autoimmune Disorders in Vitiligo
% Prevalence
Autoimmune disorders No. of studies Min. Max.
Thyroid 12 0.50 43.00

Diabetes 7 0.60 7.10
Anemia perniciosa 5 0.4 30
Addison 2 0.4 2.1
Autoimmune gastritis 2 9.6 15
Alopecia areata 6 0.4 16
thalmological changes are usually free of symptoms, and these changes may
be more interesting to the biologist than to the clinician.
The association of vitiligo with inflammation of the uveal tract and
hypopigmentation and/or degeneration of the retinal pigment epithelium not
secondary to ocular inflammation is well established. In 1979 Albert et al.
described 44 (36.6%) patients with RPE depigmentation and 9 (7.5%) with
uveitis in 120 patients with vitiligo (15). In 1983 Wagoner et al. found 60
(27%) of 223 patients with vitiligo to have some evidence of RPE hypopig-
mentation or atrophy, or both; II (4.8%) of these 223 patients also had uveitis
(16).
Direct evidence of significant melanocyte alterations of the inner ear in
vitiligo patients has not been reported. If melanocytes of the inner ear do in
fact prevent hearing loss, their possible involvement in vitiligo may be evi-
denced by audiometric analysis. The results of three studies indicate that
patients with vitiligo had a significant prevalence of auditory abnormalities
in comparison with healthy subjects, even though none of the hypoacusis
patients were deaf and the auditory changes detected were all of minimal
disturbance to the patients (17-19). In particular, Tosti et al. found 8 patients
(16%) with neurosensorial hypoacusis in 50 patients affected by vitiligo (17).
On the contrary, both Orecchia et al. (20) and Ozuer et al. (21), in contrast
with previous reports, suggest that there is no proof of involvement of ear
melanocytes in vitiligo. Auditory investigations may provide more accurate
knowledge in vitiligo patients.
AUTOIMMUNE DISEASE
Vitiligo is frequently associated with other autoimmune disorders such as
autoimmune thyroid disease, diabetes mellitus, alopecia areata, pernicioLls
anemia, Addison's disease, autoimmune gastritis, and autoimmune polyen-
docrine syndromes. Examples are shown in Tables 2 and 3. This frequent

association supports the hypothesis that an autoimmune response is involved
in the pathogenesis of vitiligo. Patients with generalized vitiligo seem to have
more frequent association with autoimmune disease than do patients with
segmental vitiligo (5).
Thyroid diseases, particularly hyperthyroidism, hypothyroidism,
Graves' disease, and Hashimoto's disease, but not thyroid carcinoma [only 3
cases reported in which vitiligo was associated to carcinoma of the thyroid
(22)], have a prevalence of 0.5-43% in vitiligo patients, a figure that is
significantly higher than the I % reported for autoimmune thyroid disease in
the general population (6,7,9,10,22-28) (Table 3). In the same way, the
prevalence of vitiligo in the general population is 0.5-2% (1,3,4), whereas in
subjects with autoimmune thyroid disease it rises to 6.8% (29). Indeed, Shong
and Kim found vitiligo in 20 out of 293 patients with autoinunune thyroid
disease (6.83%) and in only 2 of 227 patients with nonautoimmune thyroid
disease (0.88 %) (29). There was no significant difference in frequency of vitiligo
between nonautoimmune thyroid disease patients and the general population.
These findings are consistent with the possibility that vitiligo is very closely
associated with autoimmune thyroid disease but not with nonautoimmune
thyroid disease. In addition, circulating thyroid autoantibodies (Ab anti-thy-
roid microsomes, Ab anti-thyroid cytoplasm, Ab anti-thyroglobulin), along
with other organ-specific antibodies (such as gastric parietal cell antibodies),
are commonly detected in the sera of vitiligo patients (9,30,31) (Table 4).
Vitiligo may begin before, at the same time, or after thyroid disease
(29,32). The course of thyroid disease and vitiligo do not have any predictable
relationship; treatment of the thyroid disease has no bearing on the vitiligo
and vice versa.
Both insulin-dependent diabetes mellitus (IDD) and non-insulin-
dependent diabetes mellitus (NIDD) occur in 0.6-7.1 % of vitiligo patients
(6,7,9,10,24-26), which corresponds with the frequency in the normal pop-
ulation. Conversely, vitiligo occurs in 2.7-10% of diabetic patients (33-35)
compared to 0.5-2% reported in the general population. Few studies confirm
the association between insulin-dependent diabetes and vitiligo (33,36,37)
(prevalence, 1.7-9.6%), while the prevalence of vitiligo in NIDD (0.4---3.3%)
was no higher than that reported in the nondiabetic population (33,38).
Dawber describes the majority ofvitiliginoLls diabetics to be "maturity onset"
(39), but this apparent relationship with age of onset of vitiligo appears to be
artifactual, with vitiliginoLls diabetics being older at onset simply because they
had time to develop both diseases.
The prevalence of pernicious anemia in vitiligo patients is 0.4-30%
compared with 0.13% of the normal population (40-42). Among those with
pernicious anemia, vitiligo has been documented in 1.6-10.6% (40,41,43).
TABLE 4 Prevalence of Organ-Specific Autoantibodies in Vitiligo Patients
Autoantibody No. of patients % with Ab Ref.
Thyroglobulin TgHA 20 40 31
Thyroglobulin TgHA 321 6,9 6
Microsomal TMA 373 18,5 24
Microsomal TMA 20 50 31
Gastric parietal cell GPCA 20 30 31
Gastric parietal cell GPCA 321 5,6 6
Gastric parietal cell GPCA 373 9,6 24
Adrenal gland 321 0,9 6
Adrenal gland 20 0,5 31
Adrenal gland 80 4 45
Grunnet et al. (40) observed these patients to have the most widespread viti-
ligo, and Dawber (41) found that pernicious anemia is more common among
those with late-onset vitiligo, but neither of these observations has oeen
confirmed.
Addison's disease is normally associated with a peculiar generalized
melanosis, but Thomas Addison described two patients affected also by viti-
ligo. The prevalence of Addison's disease in vitiligo patients is reported to be
0.6-2% (6,24), while in subjects with Addison's disease the prevalence of
vitiligo seems to be higher than that reported for the general population (44).
In a study of91 Addison patients, 9 were found to have vitiligo (9.8%) (44).
The adrenal gland antibodies are not commonly detected in the sera of vitiligo
patients (31,45) (Table 4).
Two studies suggest an association between vitiligo and autoimmune
atrophic gastritis. Zauli et al. performed in 65 patients with vitiligo gastric
biopsies and titers of antihuman parietal cell antibodies (GPCA). Histological
evidence of autoimmune atrophic gastritis was obtained in 10 cases (15%), all
of whom were positive for the antibodies (46). Betterle et al. also found in 373
vitiligo patients 36 cases positive for GPCA, and in 34 (94%) of these cases a
gastric biopsy revealed signs of atrophic gastritis (24). Many other studies
confirm the higher incidence of GPCA in the sera of vitiligo patients (6,31,45)
(Table 4)
Human vitiligo patients are known to have greater chance of having

alopecia areata than people without vitiligo, although the prevalence is still
disputed. There is great variability; in fact alopecia areata has been reported in
04-16% of vitiligo patients (6,7,10,24-26). Conversely vitiligo occurs in 1.8%
of adult and 3.5% of children patients with alopecia areata (47,48).
Vitiligo is always present in multiple endocrinopathy syndromes, in
particular in the autoimmune polyglandular syndrome (PGA) type I and type
II. PGA is characterized by the coexistence of several autoimmune diseases,
affecting predominantly the endocrine glands. PGA type I is variably asso-
ciated with mucocutaneous candidiasis, autoimmune tissue destruction, and
ectodermal dystrophy. Vitiligo occurs in 8-13% of cases (49,50). PGA type II
is a disorder of the thyroid, adrenal, and pancreas (IDDM). Vitiligo is present
in 4.5-30% of patients affected by this syndrome (50-52).
Although the association of myasthenia gravis (MG) and vitiligo has
been well described in the literature (53), only 5 case reports have been pub-
lished (54-58). In all these, the authors suggest a possible underlying auto-
immune basis for both diseases. However, because vitiligo is a common skin
disorder, the question of whether simultaneous vitiligo and MG represent a
coexistence or true association has yet to be answered. Kubota et al. (54).
revealed a rather low frequency (0.5%) of vitiligo in 202 patients with MG,
suggesting that the association between MG and vitiligo may be infrequent.
Cruz et al. (55) reported that only 1 of over 60 MG patients « 1.7%) who also
had thyroiditis developed vitiligo. Because both MG and vitiligo are fre-
quently associated with thyroid disease, a possible genetic factor closely
linked with thyroid disease may explain the coexistence of the two disorders.
Hyperpigmentation and depigmentation in morphea or scleroderma
have been mentioned in the medical literature since 1898 (59), but an
association with vitiligo has been reported infrequently. Only 14 case reports
have been published (5,60). Lerner and Sansung (61) reported that 6 of 191
patients with scleroderma or morphea had vitiligo as well. Two retrospective
studies (5,62) confirm the low prevalence of morphea and scleroderma in
vitiligo patients (0.2-0.9%).
RARE ASSOCIATIONS
Few cases in the literature describe the association between vitiligo and 20-
nail dystrophy (63-65), dermatitis herpetiformis (66,67), and spondyloarthri-
tis (68) (Table 5). Vitiligo has also been observed in Vogt-Koyanagi-Harada
syndrome, and recently in human immunodeficiency virus (HIV)~ and
acquired immunodeficiency syndrome (AIDS)~infected patients.
Vitiligo is present in about 10-20% of patients affect by Vogt-Koya-
nagi-Harada syndrome (69,70). This disease is an autoimmune systemic dis-
TABLE 5 Vitiligo and Rare Associations
No. of patients
Disease described in literature Ref.
Dermatitis herpetiform is 12 66, 67

Nail dystrophy 11 63-65
Morphea/scleroderma 14 5, 60
Spondyloarthritis 8 68
Myasthenia gravis 5 54-58
order where an autoimmune mechanism, influenced by genetic factors,

appears to be directed against melanocytes. In this syndrome inflammatory
disorders occur in multiple organs containing melanocytes, including uvea
(resulting in acute bilateral pan uveitis), skin (resulting in vitiligo and alopecia
areata), central nervous system (resulting in meningitis), and inner ear
(resulting in hearing loss and tinnitus). It is postulated that the Vogt-
Koyanagi-Harada syndrome may be part of the systemic disease vitiligo (71).
In 1987 Duvic et al. reported the development of vitiligo in 4 patients
with HIV-related conditions and in I patient with hepatitis who later
developed AIDS (72). Two other reports demonstrated the onset of vitiligo
in patients with HIV infection (73,74). Although few vitiligo cases among
several hundred HIV -positive persons is not higher than expected, these
reports suggest that vitiligo may be an example of an autoimmune disease
triggered by viral infection in a genetically predisposed host.
In 2002 Yamauchi et al. (75) described the first patient with vitiligo
who fulfilled the criteria for idiopatic CD4 + T lymphocytopenia (ICTL).
Although the exact origin of ICTL is still unclear, the concurrence of both
rTCL and vitiligo in this patient does not preclude the possibility of an
underlying occult viral infection, which may trigger the decrease in CD4 + T
cells, thus eliciting an autoimmune reaction towards melanocytes that results
in their depletion.
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17
Ocular and Audiological Disorders
in Vitiligo
Antonella Tosti, Bianca Maria Piraccini,

and Matilde lorizzo
University of Bologna, Bologna, Italy
Giovanni Tosti
S. Luca Hospital, Trecenta, Italy
OCULAR MELANOCYTES
The melanocytes of the eye consists of: (a) uveal, iris stroma, and conjunctival
melanocytes; and (b) specialized pigment cells of the retinal and ciliary body
pigment epithelia. The embryonic origins of ocular tissues take place from
neural ectoderm (optic cup), neural crest (connective tissue), surface ectoderm
(epithelium), and mesoderm (muscle and vascular endothelium). Ocular
melanocytes derive from the optic cup neural ectoderm, except for uveal
and iris stroma melanocytes that, like skin and hair melanocytes, originate
from the neural crest. Whereas skin and hair melanocytes produce melanized
melanosomes for exportation to the adjacent cells, uveal melanocytes and
pigment epithelia are continent and do not release their melanosomes. Mela-
nogenesis is only a transient activity of ocular pigment cells.
Pigment cells play multiple roles in the eye. They create the black room
environment necessary for the visual function, adsorbing diffracted light
energy and preventing image degradation by light scattering and reflection
within the eye, contributing to the achievement of clear retinal images, free of
glares and halos. Moreover, ocular melanocytes probably contribute to the
201
202 Tosti et at.
degradation of toxic derivates from photochemical reactions that take place

continuously in the eye.
Retinal pigment epithelium (RPE) cells have multiple specialized func-
tions, including:
I. Preservation of photoreceptor integrity
2. Phagocytosis of rod and cone outer segments
3. Heterophagy of waste molecules from photoreceptor outer seg-
men ts
4. Vitamin A esterification, isomerization, storage, and transport
5. Metabolite transport to and from outer retina and choroidal cir-
culation
The ciliary body pigment epithelium produces the aqueous humor.
Uveal and iris stroma melanocytes appear during the 20th gestational week
and continue their melanogenesis for several years after birth, explaining the
changes in the iris color from light blue to dark and the darkening of the iris
stroma and choroid during childhood (I). Melanogenesis in the RPE starts at
the 4th week of gestation and is completely stopped shortly after birth. Ret-
inal pigment epithelial cells are reactive to many stimuli, but do not seem to be
able to resume melanogenesis. Acquired changes in fundus pigmentation are
caused by clearing or migration of RPE cells or by the accumulation of
pigment into macrophagic cells following focal destruction of RPE.
VITILIGO AND THE EYE

Ocular abnormalities observed in vitiligo rarely have a clinical impact or
cause visual disturbances. On the other hand, they have high theoretic and
pathogenetic interest. Vitiligo patients may present various pigment changes
in the fundus, in particular atrophic spots in the RPE or cborioretinal scars,
probably related to previous inflammatory events (2).
Uveitis occurs more frequently in vitiligo patients compared with the
general population (3). Moreover, RPE function may be impaired in vitiligo,
in fact the electro-oculographic Arden index, which represents an overall
evaluation of the standing electrical potential of the photoreceptor-RPE
complex, is significantly depressed in vitiligo patients (4). These findings sug-
gest a more widespread involvement of RPE cells in vitiligo (5). The evidence
of a significant link between fundus abnormalities and vitiligo is currently
under discussion (6).
On the other hand, there is a spectrum of well-known ocular diseases
that presents with associated depigmented skin patches and systemic symp-
toms with leptomeningeal or inner ear pigment cell involvement (Table I). All
of these diseases present a common condition of a probable autoimmune
0
0
TABLE 1 Hypounpigmented Alterations Associated with Ocular Diseases c:
Qj"
Syndrome
...
Ocular involvement Cutaneous involvement Systemic manifestations III
::J
Q.
Vogt-Koyanagi-Harada Bilateral iridocyclitis, Vitiligo, alopecia, CSF pleocytosis; meningismus l:>
posterior uveitis, poliosis with headache; tinnitus, hearing c:
Q.
serous retinal detachment, loss and vertigo; cranial nerve o'
optic disk swelling, involvement 0
lC
atrophic RPE patches o'
~
Sympathetic ophthalmia Bilateral granulomatous Vitiligo, alopecia, Meningismus, tinnitus, hearing 0
() pan uveitis after poliosis (rare) loss and vertigo (rare) (ii'
0
'b penetrating injury of the ...
0
Q.
~ eyeball due to either ...CD
~ accidental trauma or surgery
CIl
<D Birdshot retinopathy Bilateral multiple depigmented Audiological anomalies

::J
0.. <
s: or cream-colored lesions a:
Q) at the level of the RPE to'
<D Melanoma-associated Bilateral iridocyclitis, Vitiligo CSF pleocytosis; meningismus with 0
~ vitiligo and retinopathy posterior uveitis, headache; tinnitus, hearing loss

serous retinal detachment, and vertigo; cranial nerve
optic disk swelling, involvement
atrophic RPE patches
Vogt-Koyanagi-Harada Bilateral iridocyclitis, posterior Vitiligo, alopecia, CSF pleocytosis; meningismus with
syndrome after uveitis, serous retinal poliosis headache; tinnrtus, heaMng loss
cutaneous injury detachment, optic disk and vertigo; cranial nerve
swelling, atrophic involvement
RPE patches
I\J
0
W
204 Tosti et al.
reaction against melanocytes. This fact may explain the widespread involve-
ment of pigment cells in these diseases. A similar diffuse movement of the
melanocytic population may be posited in vitiligo (7).
EAR MELANOCYTES
The inner ear epithelium contains many melanocytes, particularly in the
vascular streak of the cochlea. The embryonic source of ear melanocytes is not
yet well established; studies on mice mutant for different alleles oflocus W, the
regulator of development and migration of melanocytes deriving from neural
crest, reported that melanocytes migrate toward the inner ear during growth
and do not originate from the epithelium, in contrast with melanocytes of
retinal pigmented epithelium. It is probable that ear melanocytes, such as
cutaneous and uveal melanocytes, derive from neural crest.
Ear melanocytes produce melanin, and studies on animals suggest that
the number of melanosomes can be higher after an acoustic trauma (8).
Although the role of ear melanocytes is still unknown, data on both animals
and humans are suggestive of the importance of pigmented melanocytes for
the development and preservation of uditive function. Hypoacusis is, for
example, typical of Waardenburg's syndrome and piebaldism, where the
development of melanocytes is altered.
Cochlear melanocytes also seem to be important for the transmission
of electrical impulses at the audiological receptor level, as has been demon-
strated in studies that have identified an altered inner cochlear potential in
albino mice (9). Some authors think that melanin has a protective role against
audiological traumas due to toxins or noise. The loss of hearing associated
with aging could be related to a reduction of pigmentation of the inner ear
( 10).
THE EAR AND VITILIGO

Most patients with vitiligo do not have audiological diseases, and from a
practical point of view audiological examination is not necessary.
In the literature there are two reported families with both vitiligo and
neurosensorial deafness probably transmitted as an autosomal recessive
defect, and some cases, at times familial, of vitiligo associated with neuro-
sensorial deafness and pigmentary retinopathy (I I).
Audiological studies on patients with vitiligo give contrasting results:
our experience, like that of Ardic et al., indicates that patients with vitiligo,
above all males, suffer from light neurosensorial hypoacusis more often than
controls (12,13). Other authors, however, did not confirm these data (14,15).
Ocular and AUdiological Disorders in Vitiligo 205
11 is important to point out that studies carried out so far have not
evaluated whether vitiligo represents a risk factor for the development of
hypoacusis from toxins or noise. These studies have, in fact, excluded from the
beginning patients exposed to well-known causes of hypacusia. In the future it
would be important to evaluate if patients with vitiligo exposed to noise or
taking ototoxic drugs have an higher incidence of hypoacusis or a more
serious form ofhypoaclisis than subjects without vitiligo exposed to the same
injuries. If melanin is protective only against traumas from other causes, these
are the patients who should be studied.
REFERENCES
J. Wolff E. Anatomy of the Eye and Orbit. 7th ed. Philadelphia: WB Saunders,
1976:434.
2. Barnes L. Vitiligo and the Vogt-Koyanagi-Harada syndrome. Dermatol Clin
1988; 6:229-239.
3. Albert DM, Nordlund JJ, Lerner AB. Ocular abnormalities occurring with
vitiligo. Opthalmology 1979; 86: J 145-1160.
4. Tosti A, Maccolini E, De Pad ova MP, et al. Anomalie funzionali dell'epitelio
pigmentato retinico nella vitiligine. Cron Dermatol 1987; 3:375-378.
5. Colombati S, Tosti G, Zotti CA, et al. The retinal pigment epithelium in vitiligo.
Retinal Pigment Epithelium, Proceedings. Amsterdam: Kugler and Ghedini,
1989:303-305.
6. Cowan CL, Hadler RM, Grimes PE, et al. Ocular disturbances in vitiligo. J Am
Acad Dermatol 1986; 15: 17-24.
7. Rathinam SR, Namperumalsamy P, Nozik RA, et al. Vogt-Koyanagi-Harada
syndrome after cutaneous injury. Opthalmology 1999; 106:635-638.
8. Gratton MA, Wright CG. lperpigmentation of chinchilla stria vascularis
following acoustic trauma. Pigment Cell Res 1992; 5:30-37.
9. Conlee JW, Bennert MI. Turn-specific differences in the endocochlear potential
between albino and pigmented guinea pigs. Hear Res 1993; 65:141-150.
10. Boissy RE. Extracutaneous melanocytes. In: Nordlund JJ, Boissy RE, Hearing
VJ, et al. eds. The Pigmentary System. Physiology and Pathopysiology. New
York: Oxford University Press, 1998:59-73.
II. Tosti A, Bardazzi F, De Padova MP, et al. Deafness and vitiligo in an Italian
family. Dermatologica 1986; 172: 178- J79.
12. Tosti A, Bardazzi F, Tosti G, et al. Audiologic abnormalities in cases of vitiligo.
JAm Acad Dermatol 1987; 7:230-233.
13. Ardic FN, Aktan S, Kara CO, et al. High-frequency hearing and reflex latency in
patients with pigment disorders. Am J Otolaryngol 1998; 19:365-369.
J4. Orecchia G, MareHi MA, Fresa D, et al. Audiologicdisturbances in vitiligo. JAm
Acad Dermatol1989; 21:1317-1318.
15. Escalante-Ugalde C, Publano A, Montes de Oca E, et al. No evidence of hearing
loss in patients with vitiligo. Arch Dermatol 1991: 127:1240.
18
Differential Diagnosis for Vitiligo
Wennie Liao and James J. Nordlund

University of Cincinnati, Cincinnati, Ohio, U.S.A.
Vitiligo is one of many disorders that can present as leukoderma or cutaneous

hypopigmentation (1-6). It is characterized by asymptomatic, well-demar-
cated, smooth, chalk-white macules (5-7). The epidermis is normal except for
rare cases of inflammatory vitiligo (8,9). The depigmented lesions are
accentuated under Wood's lamp examination, even in individuals with very
light, type I skin color. The Wood's lamp emits a blue light, which illuminates
only the epidermis, in contrast to white light, which illuminates both the
epidermis and the dermis. Under blue illumination, epidermis with small
amounts of melanin appears dark, and that without melanin appears white. It
should be noted that the accentuation of depigmentation is not unique to
vitiligo but is observed in any disorder in which there are alterations in the
quantity of epidermal melanin. The absence of melanin in vitiligo is due to an
absence of melanocytes (lO). Histological studies confirm an absence of
melanocytes (II).
Vitiligo may be classified as either segmental, localized, or generalized.
In the segmental form, depigmentation is limited to one area of the skin-
often one side of the face or unilaterally on an extremity. Although the areas
of depigmentation are patterned, they do not seem to conform to dermatomes
or to Blaschko's lines. Localized vitiligo is characterized by a few small-to-
larger patches of depigmentation with no identifiable preceding rash or cause.
The areas tend to be stable for many years. In the generalized form, de-
pigmentation typically is symmetrical and involves the dorsa of the hands,
208 Liao and Nordlund
face, wrists, elbows, knees, and periorificial areas (around the eyes, nostrils,
mouth, umbilicus, and genitalia). It is almost always progressive.
The differential diagnosis for vitiligo is extensive (12) given the wide
range of disorders that can present with leukoderma (Table l). However, a
thorough history and a careful examination of the morphology and distri-
bution of hypopigmented lesions often enable one to easily differentiate
TABLE 1 Differential Diagnosis of Vitiligo
Genetic
Chediak-Higashi syndrome
Hypomelanosis of Ito
Oculocutaneous albinism
Piebaldism
Tuberous sclerosis
Vogt-Koyanagi-Harada syndrome
Waardenburg's syndrome
Infectious
Leishmaniasis (post kala-azar)
Leprosy
Onchocerciasis
Pinta
Secondary syphilis
Tinea versicolor
Yaws
Neoplastic
Melanoma with associated depigmentation
Mycosis fungoides
Iatrogenic
Arsenic
Azelaic acid
Dermabrasion
Monobenzyl ether of hydroquinone
Liquid nitrogen
Tretinoin
Topical/intralesional corticosteroids
Nutritional
Kwashiorkor
Selenium deficiency
Physical/Chemical
Burn
Irradiation
Phenols/catechols
Differential Diagnosis for Vitiligo 209
Inflammatory
Atopic dermatitis
Discoid lupus erythematosus
Pityriasis lichenoides chronica
Psoriasis
Miscellaneous
Halo nevus
Idiopathic guttate hypomelanosis
Lichen sclerosus et atrophicus
Morphea
Nevus anemicus
Nevus depigmentosus
Pityriasis alba
Sarcoidosis
vitiligo from other disorders. Some of the more common disorders mimicking
vitiligo and their distinguishing features will be discussed in this chapter.
These disorders include tinea versicolor, postinflammatory hypopigmenta-
tion, pityriasis alba, chemical leukoderma, idiopathic guttate hypomelanosis,
halo nevus, nevus depigmentosus, nevus anemicus, cutaneous scleroderma,
mycosis fungoides, lichen sclerosus et atrophicus, sarcoidosis, leprosy, pinta,
and piebaldism.
TINEA VERSICOLOR
Tinea versicolor is a common superficial infection caused by the yeast
Malessezia furfilr. Often involving the upper trunk (Fig. 1), as well as the
neck and upper arms, this disorder presents with multiple, scaling, annular,
hypopigmented macules. The spots in a few individuals are moderately pru-
ritic but more often they are asymptomatic and unsightly. The macules may
also be brown or pink, hence the name "versicolor." Scrapings of the powdery
scale from these lesions after the addition of potassium hydroxide reveal
numerous hyphae and spores ("spaghetti and meatballs") under the micro-
scope. Wood's lamp examination reveals a golden fluorescence of the lesions.
The presence of scale, the typical distribution on the upper trunk, and the
findings on microscopy should distinguish this yeast infection easily from
vitiligo.
POSTINFLAMMATORY HYPOPIGMENTATION
Postinflammatory hypopigmentation and depigmentation occur most often
with the various forms of dermatitis, with psoriasis, or with discoid or sub-
FIGURE 1 Extensive tinea versicolor on the back of a young man. There are large
confluent patches of hypopigmented skin. The small, annular lesions at the
periphery of the patches are suggestive of tinea versicolor. A KOH confirms the
diagnosis.
acute cutaneous lupus erythematosus. But any inflammatory disorder has the
potential to produce hypo- or depigmentation. Lesions usually are ill-defined,
off-white irregular macules or patches located at the sites of previous
inflammatory lesions. A history of ill-defined pruritic patches and of an
atopic diathesis would suggest atopic dermatitis as an etiology. Well-defined,
erythematous, scaly plaques, especially on the elbows or knees, would suggest
psoriasis. Lesions of discoid lupus, typically located on the ears, scalp, and
sun-exposed areas, often are well demarcated and have accompanying
features such as epidermal atrophy and scale to distinguish them from the
smooth lesions of vitiligo. In all cases of postinflammatory hypopigmenta-
tion, a history or the presence of inflammatory lesions would differentiate this
form of leukoderma from vitiligo. In addition, the epidermis in most forms of
postinflammatory hypo- or depigmentation is atrophic, scaly, or altered in
some way. Vitiligo by definition has a normal epidermis except for the absent
melanin. Were there any doubt clinically about the nature of the lesion, a
biopsy would definitively distinguish vitiligo from postinflammatory pigment
changes.
FIGURE 2 Pityriasis alba in one of twin boys. The face is hypopigmented.
PITYRIASIS ALBA
Pityriasis alba is an asymptomatic disorder affecting mostly children (Fig. 2)
and young adults with atopic diatheses. The ill-defined, hypopigmented,
finely scaling patches of this disorder are lIsually located on the lateral aspects
of the cheeks and upper arms and on the thighs. The ill-defined borders of the
lesions, their scaliness, and their typical distribution contrast with the well-
demarcated, smooth maCltles and patches of vitiligo, which are lIsually
located around the eyes and mouth on the face and on the distal parts of
the hands and feet.
CHEMICAL LEUKODERMA
Chemical leukoderma is an entity that closely mimics vitiligo morphologically
and histologically. Chemical leukoderma is caused by exposure to a variety of
chemicals, mostly derivatives of phenols and catechols such as monobenzone,
para-tert-butyl phenol, or catechol or similar aliphatic and aromatic com-
pounds (13-29). Exposure usually occurs in the workplace such as hospitals,
factories, or chemical industries and results in well-demarcated, depigmented
macules (Fig. 3), usually isolated on the hands and forearms, where exposure
is most common. Occasionally, inflammation or allergic contact dermatitis of
the affected skin may precede the development of chemical leukoderma.

Histologically, the lesions cannot be distinguished from those of vitiligo.
Idiopathic vitiligo and chemical leukoderma both show reduced numbers of
melanocytes. A thorough occupational/exposure history and a high index of
suspicion for chemical leukoderma (especially in patien ts who work in
industrial settings), in addition to patch testing, would help to establish this
diagnosis and distinguish it from vitiligo. For some individuals, idiopathic
vitiligo may truly be due to chemical leukoderma secondary to an unidentified
contactant such as foods, some of which are known to contain phenolic
derivatives.
IDIOPATHIC GUTTATE HYPOMELANOSIS

Idiopathic guttate hypomelanosis (IGH) is a very common, asymptomatic
disorder affecting the sun-exposed areas of the arms and legs of middle-aged
and older people. Characterized by multiple, well-demarcated, small (usually
2-5 mm) white macules, this disorder may progress with an increasing number
of lesions. Despite their numbers, their size typically remains small,S mm,
although some as large as 2 cm have been observed. The epidermis has an
atrophic and shiny surface. This alteration in the surface makes distinction of
vitiligo from IGH easy. In addition, the distribution and typically larger size
oflesions in vitiligo differentiate vitiligo from IGH.1f necessary, histology can
distinguish between the two disorders. Lesions of IGH usually reveal epi-
dermal atrophy and a patchy decrease of melanin/melanocytes.
HALO NEVI
A halo nevus, also known as Sutton's nevus, is a melanocytic nevus sur-
rounded by a well-demarcated, depigmented ovoid halo of otherwise normal
skin (Fig. 4). With time, the central melanocytic nevus disappears and a well-
demarcated, white, smooth macule or patch remains. Almost always the
depigmented macule itself disappears with time. Most common in children
and adolescents, a halo nevus usually occurs on the trunk and extremities.
Often patients have more than one, and some individuals may have over 50.
The histology of a halo nevus is dependent on the stage of its evolution.
Characteristic findings include nevus cells admixed with a dense lymphocytic
FIGURE 3 (A) Chemical leukoderma on the right hand of a woman working with
phenolic germicides. Only the hand had depigmentation, most prominent between
the fingers where the chemical is occluded. (B) A depigmented spot on the forehead
of an Indian woman who wore a bindi that contained monobenzone in the glue.
FIGURE 4 Multiple halo nevi with depigmentation surrounding nevi.
infiltrate at the dermal-epidermal junction and in the dermis and a loss of

melanocytes within the halo. A history of a melanocytic nevus within a
depigmented macule is usually sufficient to distinguish a halo nevus from a
lesion of vitiligo. If this history is uncertain, the presence of other halo nevi (in
earlier stages with a central nevus) and/or a biopsy will differentiate between
the two entities. Some observers suggest that halo nevi are localized versions
of vitiligo (30-36). Vitiligo may occur more frequently in patients with halo
nevi compared to the general population (33). On the other hand, halo nevi
are common in young people, as is vitiligo.
NEVUS DEPIGMENTOSUS
Nevus depigmentosus is a peculiar disorder that is usually a congenital lesion
characterized by a stable, well-demarcated, hypopigmented macule or patch
FIGURE 5 A nevus depigmentosus in a dermatomal distribution around T10. The

patch was hypopigmented and appeared in adult life.
with an irregular border (37-39). Occasionally it may be depigmented, as may

the hairs within such a lesion. It may mimic the distribution of segmental
vitiligo or may occasionally be distributed along Blaschko's lines or even over
a dermatome (Fig. 5). Thus, the lesion may be ovoid or rectangular but may
also be linear or whorled. Most often found on the trunk or neck, this lesion
grows only as the patient grows and usually is solitary. Because it is congenital,
stable, and usually solitary, nevus depigmentosus is easily distinguished from
vitiligo. Nevus depigmentosus can also be acquired, often around the time of
puberty. When acquired, it is hypopigmented and patterned such that it
usually does not resemble either segmental vitiligo or localized vitiligo. How-
ever, a localized nevus depigmentosus that is depigmented might be difficult to
distinguish from segmental vitiligo.
NEVUS ANEMICUS
Nevus anemicus is a congenital or acquired lesion most often found on the
chest or back of female patients (40-44). The lesion is often a well-defined,
hypopigmented irregular macule surrounded by similar, adjacent smaller
mantles. This lesion does not enhance with Wood's lamp examination as it is
due to an abnormality of the dermal blood vessels rather than of epidermal
melanocytes or melanin. In addition, with pressure applied by a glass slide

(diascopy), the border of the lesion becomes obscured. This diascopic finding
and the Wood's lamp examination differentiate nevus anemicus from vitiligo.
CUTANEOUS SCLERODERMA
Scleroderma is an acquired disorder that begins with tightening of the skin of
the face and fingers. Follicular depigmentation and repigmentation give the
skin a "salt-and-pepper" appearance. On palpation, the skin is firm and
"bound down" because of decreased skin elasticity. Histology reveals an
increased amount of compacted collagen with thickening of the dermis. The
FIGURE 6 A man with widespread mycosis fungoides, a lymphoma of the skin.

Note the numerous depigmented patches of skin. At times, mycosis fungoides can
present as hypopigmented macules on the skin.
texture of the lesion often is enough to distinguish scleroderma and its

localized forms from vitiligo.
MYCOSIS FUNGOIDES
Mycosis fungoides, a type of cutaneous T-cell lymphoma, can present as well-
demarcated, hypopigmented macules (Fig. 6), more often in patients with
darker skin. While these macules may exhibit some erythema, epidermal
atrophy, and/or fine scale, many times these lesions may be clinically
indistinguishable from those of developing vitiligo. A biopsy is usually
required to distinguish the two disorders. The histology of hypopigmented
mycosis fungoides is diagnostic and typically shows atypical lymphocytes and
epidermotropism. Both of these features are absent in vitiligo.
LICHEN SCLEROSUS ET ATROPHICUS (LS&A)

LS&A is a disorder affecting females predominantly. Most often involving the
genitalia (Fig. 7), lesions consist of ill-defined, white, atrophic, smooth
patches. On extragenital sites, the lesions may begin as well-demarcated
papules with follicular plugging, which coalesce into plaques that eventually
become atrophic with a shiny surface and white color. Genital lesions are
often symptomatic. Pruritus and dysesthesia are the most common com-
plaints. Vitiligo may share a similar distribution as LS&A but the shiny
surface and other changes and symptoms of the latter help distinguish it from
the former. At times, a biopsy is necessary to distinguish LS&A from vitiligo,
especially when the lesions are situated on the genital areas of young girls.
SARCOIDOSIS
Sarcoidosis is a multisystem disorder characterized by non-caseating gran-
ulomata in internal organs as well as in the skin. While skin lesions classically
present as red-brown firm papules and plaques, ill-defined, hypopigmented
macules (Fig. 8) and plaques have been described in patients with this
disorder. The ill-defined borders of lesions, histology, and inyolvement of
other organs all distinguish sarcoidosis from vitiligo.
LEPROSY (HANSEN'S DISEASE)

Leprosy is a chronic infection with a predilection for the skin and nerves
caused by Mycobacterium leprae, an acid-fast bacillus endemic in Asia,
Africa, and Latin America. Cutaneous manifestations of leprosy are varied,
depending on the type ofleprosy. Well-defined, hypopigmented macules and
A
FIGURE 7 (A) Lichen sclerosus et atrophicus of the vulva. This disorder often is
very pruritic. However, it may not be possible to distinguish this disorder from
vitiligo by clinical observation alone and a biopsy might be necessary. (8) Lichen
sclerosus et atrophicus on the penis, also labeled balanitis xerotica obliterans. The
skin is atrophic. A biopsy is diagnostic.
FIGURE 8 Sarcoidosis presenting as numerous hypopigmented macules on the

trunk.
patches which are anesthetic are most often found in tuberculoid and border-
line leprosy. The lesions are few in number, usually randomly scattered and
hypopigmented. The loss of color is never complete in lesions of leprosy. Pal-
pable or enlarged nerves sometimes may be detected near these lesions. The
hypopigmentation, the anesthetic nature and spotty distribution of the
lesions, the palpable nerves, and a geographical history distinguish leprosy
from vitiligo.
PINTA
Pinta is an infection endemic to rural Central and South America caused by
the spirochete Treponema cm-aleuIn. The infection causes the serological test
for syphilis to be reactive. The tertiary or late stage of pinta is characterized by
symmetrical, hypo- or depigmented patches typically over bony prominences
(elbows, knuckles, wrists, knees, and ankles). Histologically, the epidermis of
these lesions often shows marked atrophy and loss of hair follicles. These
lesions may be admixed with brown or slate-gray patches. Tertiary pinta
usually occurs months to years after the scaly papules and plaques of
secondary pinta (termed pintides)_ An antecedent eruption of these papules
and plaques and a geographical history, in addition to positive treponemal
tests, differentiate pinta from vitiligo.
A
B
FIGURE 9 (A) Piebaldism manifested as depigmented patches on the neck
extending to the chest. The child was born with these depigmented patches and a
white forelock. Note the dark macules within the white area. (B) Piebald skin on the
knees. Note the pigmented macules within the white patch. The depigmentation
was present at birth.
PIEBALDISM
Piebaldism is a type of localized depigmentation. It is first manifested at birth
in most individuals as a white forelock on the scalp and as areas of depig-
mentation on the ventral surface (Fig. 9A) of the trunk and at times on the
arms or legs (Fig. 9B). If a child is very fair in color at birth, the depigmenta-
tion might not be noted until the child is older, around 4-6 months of age.
Usually there is a strong family history of similar lesions, since the disorder is
tran mitted as an autosomal dominant trait. The lesions are clinically and
histologically identical to those of vitiligo. However, there are no definitive
cases of vitiligo present at birth. The earliest documented cases of vitiligo ha ve
been observed at around 6 months of age. The white forelock, the pattern of
depigmentation on the ventral surface, and the family history make the
distinction between vitiligo and piebaldism easy.
OTHER DISORDERS
Many other disorders are associated with or characterized by localized,
partial, or generalized loss of pigmentation such as albinism. These usually
are not difficult to distinguish from vitiligo because many are congenital,
genetic, or have associated findings. Details about other disorders listed in
Table 1 can be found in textbooks of dermatology or in Nordlund et al.'s
comprehensive review of pigmentation and its disorders (45).
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2000:7-12.
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15. Gellin GA, Maibach HI, Misiaszek MH, Ring M. Detection of environmental
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20. Le Poole IC, Yang F, Brown TL, Cornelius J, Babcock GF, Das PK, et al.
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University Press, 1998.
19
Vitiligo: Emotional Aspects
and Personality
Giuseppe Hautmann and Torello Lotti

Jana Hercogova
Vitiligo is often considered as emotionally triggered. Sometimes there are

associated eye abnormalities, autoantibodies, and a high incidence of asso-
ciated disorders, such as Hashimoto's thyroiditis, diabetes mellitus, perni-
cious anemia, Addison's disease, myasthenia gravis, lupus erythematosus,
Crohn's disease, scleroderma, alopecia areata, atopic dermatitis, and biliary
cirrhosis. Many of these disorders have been reported to be associated with
psychological problems (1,2).
There are observations supporting an autosomal incomplete inheri-
tance with variable expression and incomplete penetrance (I). To date, the
etiology and the pathogenesis of vitiligo are still unknown, although there
have been reports of several precipitating factors, such as severe sunburn,
repeated trauma, and emotional stress (vitiligo has been reported to be more
frequent during wars, after bombing attacks) (1-4).
Obermayer (5), one of the first to investigate psychosomatic dermatol-
ogy (he used the improper but apt term "psychocutaneous"), in fact classified
vitiligo among the dermatoses "sometimes influenced by emotional factors,"
while Whitlock (6) thought it generally unwise to base one's opinion "on
patient' reports of alleged emotional causes" when concluding a psycho-
genesis of vitiligo. Griesemer and Nadelson (7) calculated that 33% of their
226 Hautmann et al.
cases of vitiligo could be considered emotionally triggered, with a biological

incubation period of 2-3 weeks between the stress event and the clinical
manifestation of the vitiligo patches.
Lerner (8) reported the statistical data obtained from 200 subjects with
vitiligo by a questionnaire. When asked the question: "Do you think your
vitiligo is associated with (or caused by) any particular event such as emo-
tional upset, accident, sunburn, etc.?," 70% of patients answered that several
events (e.g., relevant emotions, nervousness, internal diseases, accidents,
surgery, pregnancy, or birth) aggravated or provoked vitiligo; 35% of this
70% was attributed to emotions, traumatic events, and nervousness. More-
over, to the question: "What factors make your vitiligo spread?," 15% of
patients responded: nervousness. Finally, when asked the question: "What
illnesses besides vitiligo do you have at the present time?," 35% of the
interviewed patients associated vitiligo with nervousness and to psychoso-
matic diseases (8). Ortonne et al. (9) obtained overlapping results; in 46 of 100
patients it was possible to delineate a possible factor that had provoked the
disease. In 24 cases it was due to psychological distress, such as familial,
scholastic, affective troubles, emigrations, or the birth of a sibling, whereas in
22 cases it was due to physical traumas, such as accidents, surgery, illnesses,
pregnancies, sunburns, etc. (9). Nevertheless, although several cases have
been reported of the onset of vitiligo after emotional stress, there are few
psychodynamically oriented studies detailing the premorbid personality traits
that might account for the disease.
Corraze and Dupre (10), examining 16 subjects (10 men and 6 females)
with vitiligo, reported that the reaction to this disease consists ofa distressing
and tormented affect that has long-ranging repercussions. In these cases it was
possible to analyze the early periods of the infancy of the patients, finding that
these subjects presented marked traits of neuroticism, consisting of psycho-
motor agitation, pavor nocturnus, and enuresis. A common trait of these
subjects was the affective immaturity, with a real infantilism. There were
behaviors that suggested a regression to the oral phase, such as bulimia ner-
vosa, tabagism, and alcoholism. Their sleep was often interrupted by anxiety
and nightmares. There were often panic attacks. Men suffering from vitiligo
presen ted significant trai ts of avoidan t and dependent personali ty; moreover,
they idealized their mothers as strong, dictatorial figures and tried to redis-
cover this figure in their wives. Men often presented marital conflicts and
many were divorced or separated; some had sexual dysfunctions. Women pre-
sented psychomotor agitation, sexual dysfunction, somatizations, and anger
and aggressivity toward the male sex. In several cases the relationship between
the onset of the skin disease and life stress events was well established:
frequently there was the loss of a loved object (anxious separation from the
family, marital separation, death of one parent, etc.). In two cases the vitiligo
Vitiligo: Emotional Aspects and Personality 227
onset was related to the notice of conjugal betrayal. In three women, vitiligo
was related to undesired pregnancies. Even the localization of the dermatosis
has been reported as related to these evident affective relationships (that may
re-actualize unconscious conflicts): two men who had been betrayed devel-
oped vitiligo on the genital areas; two women who did not accept their preg-
nancy developed vitiligo on their abdomens; and a woman who cleaned the
sheets where her son's girlfriend had aborted developed disease on the hands
in a few hours (10).
As is well known, vitiligo can occur at any age, but it appears pre-
ferentially in younger adult females. Its peak incidence is between 10 and
30 years of age: the patient notes the appearance of one or more sharply
circumscribed white spots (especially noticeable when the skin is tanned),
often with clearly hyperpigmented margins. Thus, because of the contrast, the
lesions are particularly evident and the subject is disturbed by the unaesthetic
effect (especially in the case of young women). At onset, the lesions are only a
few small, well-circumscribed foci, but they may increase in number and
become confluent or take on bizarre shapes, the diffusion and course of these
patches being capricious, irregular, and unpredictable with generally little
possibility for spontaneous or therapeutic repigmentation. It progresses
primarily without other symptoms; in fact, only rarely is there itching, which
may be very intense when the partially unprotected patient exposes himself to
the sun. Vitiligo is usually classified on the basis of its extension: there are
localized types (focal and segmental), generalized types (acrofacial and
vulgaris), and a universal type.
The treatment of vitiligo is still not satisfactory; there are several ap-
proaches (systemic with PUVA, l3-caroteneor topical with sunscreens, cortico-
steroids, camouflage), with variable results. Thus, this skin disease creates
important aesthetic problems, sometimes with noteworthy somatopsychic
repercussions, in particular when the white macules are diffuse or located on
normally exposed skin areas (hands and face), especially in young women.
The low rate of therapeutic success, even with relatively recent methods
(PUVA, Kellin, and UVA treatment), and the necessity to touch up or hide
the unpleasant white spots aggravate the state of "psychic suffering." Only
the microphototherapy Bioskin ®, a new therapeutic regimen using puntiform
irradiation with a light with peak at 311 nm, which permits repigmentation
without concomitant increased darkening of the apparently normal skin,
seems to reduce "psychic suffering" in a group of subjects.
We cite here a case reported by Bassi of a pretty 22-year-old young
woman, married with a child, who was admitted to the hospital because she
was afraid that her skin lesions would enlarge. She presented vitiligo localized
on her right hand and three little spots on her breast and abdomen. A
psychologically oriented interview revealed (she had not noted before) that
228 Hautmann et al.
her lesions were locaJized in the same areas where her father presented war
wounds, making evident a process of identification (1 J).
WhiJe vitiligo occurs worldwide and affects all races, it is particularly a
problem in persons whose normal skin color is brown or black (skin photo-
types V and VI) because of the strong contrast of brown and black skin with
the chalk-white color of the vitiligo macules. White persons who can acquire a
deep tan (skin phototype IV) also have a more serious problem of disfigure-
ment. For these people, vitiligo can be a major medical tragedy and not simply
a cosmetic disorder. Therefore, although vitiligo is painless and not associated
with shedding scales of skin as in psoriasis, it can be a devastating malady. The
contrast between the normally colored skin and the white spots gives these
affected people a harlequin or leopard-like appearance that can limit their
potential for leading normal lives in terms of marriage, famiJy, friendship, and
even work. It is no wonder that patients with vitiligo have been found to suffer
from feelings of inferiority, to become aggressive, to feel a sense of shame, and
sometimes to become secluded and resentful (I). In the study by Porter et al.
(12) conducted on III subjects with vitiligo, vitiligo-induced anxiety and psy-
chological distress is intensely represented; about two thirds of the inter-
viewed patients admitted to being very embarrassed due to the skin disease,
and many of them attempted to hide the spots. Many of these patients em-
ployed cosmetics, clothes, gJoves, and socks in the summer to hide the lesions.
In this study, patients indicated that family members did not give enough
support (12).
According to Porter et al. (12), patients adopt three different behaviors
to cope with vitiligo: (a) some adopt so-called "mastery active" psychological
mechanims: they read and study about the skin disease, and in this way they
learn to accept it with minor embarrassment; (b) the "acceptors," about 40%
of all the patients, show good self-esteem and do not seem to be embarrassed
or try to hide the skin lesions; (c) the third group is aJmost always depressed
due to the vitiligo: they do not accept it and are usually embarrassed, making
"heroic" attempts to hide the white spots. They have very few social contacts
and often Jose their jobs. This usually happens in young people, especially
males who are not willing to use cosmetics to camouflage the achromic skin.
Morever, this group feels less desirable sexually.
An example of this reaction is the following letter from one patient with
vitiligo, as reported by Fitzpatrick (13). These words show how the subject's
adult life was dominated by the scourge of vitiligo and how this seriously
restricted her activities, especially in the summer:
Many people seem to believe that it shouldn't bother me because it
isn't painful. Sure it isn't painful, but it certainJy is doing a job on
me mentally. Well, I have had vitiligo almost half my life and to be
honest I feel as though life stopped somewhere around age 23 or so

for me. This is when it started getting bad. Since then I have been in
a sort of limbo waiting for a cure to take place. I am not enjoying
life the way it was meant to be. I am simply existing, waiting for my
cure so I can catch up with and join the rest of the beautiful people.
I may sound bitter about this and maybe I am. I don't recall doing
anything bad enough to deserve this, and why has it been decided
for me to have instead of you anyway? Why did I get it now instead
of when I got real old and wouldn't care? People just expect me to
accept it and continue on. I get these disgusted looks, as if "Here
she comes, the walking talking horror show." I feel I should join the
circus as one of their freak acts. They have the snake man, an albino
lady, a fat lady, now what they need is the bleach lady. I feel like
"Casper the friendly ghost." All I want is to be friends, but the sight
of me makes people feel ill at ease, very uncomfortable with me.
When the doctor asked me what vitiligo means to me, my first
answer was that I feel like a mistake. If it isn't a mistake then all you
one-colored persons are the mistake. I don't see all you one-colored
persons trying to get bleached out till you're two colors. So this
shows that it is just that: I am a mistake! I believe if there were no
hope for me I would crack up, but if I were lucky I would end it all
first. They say where there is life there is hope. The doctors say they
will treat me only as long as I am repigmenting. At least fully
dressed, with long pants and long-sleeved shirts, I look almost like
one of you humans. To be rid of vitiligo would be like being reborn
for me, to be normal and happy.
In examining what the patient brings to the equation, it is clear that age
and sex are likely to be important factors influencing the impact of this
aesthetically disabling skin disease. In fact, a cutaneous disorder like vitiligo
that usually starts during adolescence or early adulthood, when people
typically consolidate their sense of self and sexual identity, may have a
profound impact on self-image, self-esteem, and interpersonal relationship.
Furthermore, the status of patients' self-esteem and body image as they were
before this disfiguring dermatological illness can be seen clinically as an
important determinant of how they are likely to cope with the skin disease.
Basically, an individual's self-image relates to early developmental experi-
ences, to how the young child was perceived, accepted, and taken care of
within the family. A person who, as result of "good enough" parenting,
believes that he or she is a good person who is competent, cared for by other
people, in reasonable control of his or her life, has a healthy self-love,
approves of his of her own values, and looks reasonably attractive would be
230 Hautmann et al.
expected to cope with a skin disease better than a person who saw himself or
herself as worthless, ugly, and rejected before its onset (1,14).
The fact that vitiligo is a chronic disease increases the risk that it will
become a major fact in the daily lives of patients and their families. Skin
lesions on the face and hands (very frequent in vitiligo) can be seen by any
casual observer and may make it impossible for the patient to work, especially
if the occupation requires direct interaction with the public (e.g., salesperson
or child care worker). Lesions on the genitals are fraught with meaning and
anguish for those afflicted. In fact, many yOllng patients with vitiligo localized
on the genitals (or with particularly evident genital lesions) think they will be
repugnant to a sexual partner and consider themselves obliged to make love
only in the dark. The involvement of the hair bulbs (the hair is chalk white)
also carries a heavy weight of embarrassment and concern.
Another aspect of vitiligo that may have psychological repercussions is
the treatment: PUVA treament is at present one of the most effective
therapies; however, three to four treatments per week for many months are
required before repigmentation from perifollicular openings is achieved.
Thus, the duration of this treatment may induce the patient to embark on a
"career of patienthood," connoting once more the intrusion of the disease
into many aspects of daily life (15).
According to Ginsburg (14) one must take into account the patient's life
situation, including the social support network, attitudes of intimates, work
situation, and the actual experiences of rejection. The social support network
(16), consisting of family, friends, co-workers, and neighbors (but also
physicians, teachers), provides emotional warmth and support as well as
practical help, such as with child care or financial assistance. If a vitiligo
patient has devoted friends and family, he/she probably will weather the
storm of emotions and practical problems generated by this chronic skin
affection much better than if this network is weak or nonexistent. The
attitudes of intimates, the people closest to the patient, are among the most
important determinants of the impact of skin disease, including vitiligo.
Children with vitiligo (17) will deal with the disease well or be devastated
by it depending on the attitude of their parents and siblings, other relatives,
friends, teachers, babysitters, and so on. When parents' unconscious resent-
ment of the demands of such children was gradually acknowledged through
counseling (18), they were able to reverse the dysfunctional parent-child
relationship. If parents are direct, affectionate, and understanding, without
allowing themselves to be manipulated, and if they are not secretive or
ashamed, the child has a good chance of growing up relatively unscathed
psychologically. If the patient can work productively and experience positive
relationships with co-workers and supervisors, self-esteem will be enhanced
and the impact of the disease mitigated.
People with visible disfiguring skin disease, which vitiligo can be, are
extremely sensitive to the way others perceive them and often will withdraw
because they anticipate being rejected. Indeed, strangers and even intimate
friends can make extremely hurtful and humiliating comments. When this
does happen the impact is profound: patients can experience subjective
emotional distress; some seek professional help and experience interference
with various aspects of employment; others use tension-lessening, oblivion-
producing substances such as alcohol (1,14).
The concept of disability as a result of skin disease leads to a heightened
appreciation of the intrusiveness of these diseases into daily life, affecting
occupational and recreational activities as well as the emotional concomi-
tants. Ryan (19.20) proposed the concept of organ failure with regard to skin,
parallel to heart failure, kidney failure, and respiratory failure. Along with
protection against environmental injury, thermoregulation, and sensory
perception, display is an essential function of the skin. Failure of display
may result in reduced social and sexual communication and, often, social
rejection, isolation, and severe disability in the afflicted person's life. In certain
cultures vitiligo is a major social problem. The ex-Prime Minister of India,
Nehru, ranked vitiligo as one of his country's three major medical problems,
alongside malaria and leprosy. In India, a woman may have many problems
and experience great difficulties in getting married if she has vitiligo, and if a
woman develops vitiligo after marriage it is grounds for divorce by the
husband. In India vitiligo (or leukoderma) is regarded as "white leprosy" (13).
Moreover, if people do not know what macules are, fantasies about the
cause and contagion may be a problem. In fact, cultural attitudes are crucial
for the repertoire of feelings, thoughts, and responses that define health and
disease as experienced by the person with a skin disease, as well as by the
onlooker who does not have a skin disorder. Although patients may project
their own self-disgust onto others, many people avoid the afflicted person or
intrude with questions and unsolicited advice, sometimes making cruel and
tactless comments. Such is the complexity of the psychology that patients say
that if they did not have skin disease, they too would avoid people who do.
The unconscious assumptions and fantasies underlying these behaviors
probably relate to anxiety about maintaining control of one's psychological
and physical borders, to narcissistic longings for perfection, and to guilt. In
fact, when a person develops any severe or chronic ailment, they often ask:
Why me? Such a thought seems to imply that the disease is experienced as a
punishment, presumably caused by unconscious feelings of guilt. And it is
surprising how people (our patients included) attribute skin lesions to sexual
causation and contagion. The spot, the "dirty" macule that erupts onto the
skin, is linked symbolically to "dirty" thoughts and wishes (generally related
to sexual activities), with the skin lesions implying impurity and danger.
232 Hautmann et al.
The white patch of vitiligo, made even whiter by the hyperchromic

border, is seen and experienced by some patients as a "strange, brilliant,
reflecting white." According to one of our patients, it appears to be like an
object of "extraterrestrial" origin, confirming the sensation of that certain
subjects experience when they first note that "negative-like" mark on the skin,
a sensation that is repeated each time the mark is seen. The threat ofa possible
diffusion/extension that some subjects foresee as fatal (despite our reassur-
ance and that of their relatives) is heightened because it is in complete
opposition with the current diffuse idea that "tanned is beautiful" (for men
and women) and/or the ideology predominant in mass media, art, and
romantic cinema that, especially for females, seduction and attraction are
favored (for these patients, these factors are conditioned sine qua non) by skin
without blemishes (with all the psychological meanings implicit in a spot or
blemish, even when it is white, expressing absence and negativity, but also
guilt, sin or defect, lack, and, above all, diversity).
The anthopologist Douglas (21), studying a New Guinea tribe, says:
"Reaction to dirt is continuous with other reactions to ambiguity and
anomaly which lead to anxiety and from there to suppression and avoidance.
. . . A polluting man is always in the wrong. He has developed some wrong
condition or simply crossed some line which should not have been crossed,
and this displacement unleashes danger for someone." This concept refers
back to the assumption by many onlookers that a skin disease is inherently
contagious and probably of sexual origin. As Susan Sontag wrote (22):
"nothing is more punitive than to give a disease a meaning-that meaning
being invariably a moralistic one." This kind of thought may represent an
insult to a patient's narcissism and self-integrity; thus, it is possible that shame
ensues. Sometimes, deep-seated feelings of defectiveness can be intensified.
Feelings about the skin lesions may be displaced onto the self as a whole, as
though patients formulate the syllogism: skin lesions are ugly, and I have skin
lesions; therefore I am ugly. Skin disease, even when visible only to the
patients themselves (e.g., vitiligo on the genitals), implies imperfection. If a
person is without blemish, whether the blemish is physical, moral, or
psychological, he or she is safe from shame and humiliation.
A 23-year-old female university student declared that she would never
"force" her boyfriend whom she loved (he was in love with her, open, and
intelligent) to bear the sight of her as she was and thus to diminish (she was
sure) his amorous capacities out of disgust provoked by her "leprosy-like"
skin. Above all, she added, even if the young man's sexual prowess held up
and he was psychologically able to bear and overcome the situation for now,
with time and the "inevitable" lessening of passion the problem would
reemerge in full drama. Long-term treatment, first in consultation with
us-dermatologists and psychiatrists-and then strict psychotherapy,
together with the affectionate and comprehensive behavior of the boyfriend

and, finally, the fortunate arrest of the extension of the patches with no new
lesions in a year, permitted, in this very difficult case, slow acceptance by the
patient of her condition and a stable couple relationship (I).
In fact, the aim ofliaison consultation is close collaboration between the
non psychiatric medical staff and the psychia trist. The purpose is to teach the
non psychiatric physician to include psychosocial variables in patient care
programs and enable him/her to deal with patients in making an integrative
diagnosis. Thus, liaison psychiatric consultation with psychiatrists and/or
psychologists is to be distinguished from psychiatric consultation, tout court,
which the patient often does not want, indeed fears, and which could be
dangerous if forced (immediate insensitive referral to a psychiatrist can even
lead to suicide in especially delicate subjects). The patient has chosen the
dermatologist for assistance, superficial and deep, regarding his or her surface
and depths, and the dermatologist must give care using any and all treatments
possible, supplying counseling, sometimes in collaboration (but in direct
contact: two to one) with a psychologist or psychiatrist, even in the case of
patients with vitiligo.
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21. Douglas M. Purity and Danger, an Analysis of the Concept of Pollution and
Taboo. London, AK, 1984.
22. Sontag S. Illness as Metaphor. New York: Vintage Books, 1978:3.
20
Therapeutic Guidelines for Vitiligo
M. D. Njoo
Academic Medical Centre, University of Amsterdam,
Amsterdam, The Netherlands
W. Westerhof
Academic Medical Centre, University of Amsterdam,
and Netherlands Institute for Pigment Disorders,
Amsterdam, The Netherlands
It is regrettable that many physicians consider vitiligo a trivial cosmetic skin

disorder and tell the patients they should just live with their pigmentary
disorder and that any treatment for it is a waste of time and effort. Due to this
fatalistic attitude the patients are discouraged from seeking therapy. There-
fore a positive approach to the patient by explaining to them the nature of
the disease process, the likely prognosis, and the treatment options with
expected results is recommended. Although there is still no therapeutic pan-
acea for vitiligo, many options may lead to satisfactory results in most pa-
tients. A review of the literature is presented to discuss the efficacy and safety
of some classical and some interesting new therapies. Finally, evidence-based
guidelines for the treatment of vitiligo are presented.
NONSURGICAL REPIGMENTATION THERAPIES

Narrowband UV-B
Narrowband fluorescent tubes (Philips TL-O I/ I 00 W) with an emission spec-
trum of 310-315 run and a maximum wa velength of 311 nm are used for this
235
236 Njoo and Westerhof
therapy (1-3). The starting dose is 250 mJjcm 2 (for all skin types), which is
increased 10-20% until minimal erythema occurs in the depigmented areas.
Because some parts of the body (sllch as the face) may reach minimal
erythema faster than others, different dosimetry per body region may be
needed. Treatment frequency is twice weekly and never on two consecutive
days. The advantages of narrowband UV-B over oral psoralen plus UV-A
(PUVA) therapy include shorter treatment times, no oral drugs required (no
systemic effects), no drug costs, fewer burning incidents, no hyperkeratosis
seen after long-term irradiation, less contrast formation between depig-
men ted and normal pigmented skin, no need for posttreatment eye photo-
protection, and safe use in children and pregnant and lactating women (4).
Short-term side effects of narrowband UV -8 may include pruritus and
xerosis cutis (1,2). This can be treated with emollients. Long-term side effects
of narrowband UV-B are unknown. The mechanisms of UV-B-induced
repigmentation in vitiligo are still being investigated. Narrowband UV-B is
becoming more popular than oral PUVA because of the frequently observed
short- and long-term side effects of oral PUVA. Narrowband UV-B is
considered the first-line therapy for adults and children (>6 years old) with
generalized vitiligo.
Psoralen Plus UV-A

Psoralen photochemotherapy consists of the combined use of the photo-
sensitizing chemical compound psora len and UV radiation to induce a
beneficial effect not produced by either alone. Psoralens can be applied either
topically or orally, followed by exposure to either artificial UV or natural UV
(PUVASOL) (5). Most often used in modern vitiligo treatment are methox-
salen or 8-methoxypsoralen, bergapten or 5-methoxypsoralen, trioxsalen or
4,5',8-trimethylpsoralen, and unsubstituted psoralen (PS) (Fig. 1). The UV
dose is gradually increased until minimal asymptomatic erythema of the
depigmented skin occurs. Treatments are given twice weekly. UV-blocking
sunglasses should be worn for 8 hours after the psoralen is taken orally and
during the next day when exposed to natural sunlight.
Absolute contraindications for PUVA therapy include skin type I, skin
malignancies, and pregnant or lactating females (for oral PUVA). Relative
contraindications are patients younger than 12 years (for oral PUVA) (6,7).
Short-term cutaneous side effects of PUV A therapy are increased con-
trast formation between normal pigmented skin and lesional skin, photo toxic
reactions (from erythema to blisters and burns), pruritus, xerosis cutis, and
Koebner phenomenon (7). Short-term systemic side effects are only observed
with oral PUV A and may include nausea, vomiting, mild epigastric discom-
fort, headaches, dizziness, (transient) elevation of liver function tests, insom-
Therapeutic Guidelines for Vitiligo 237
(a) (b)
FIGURE 1 Results of one-year narrowband UV-B therapy in a child with gen-

eralized vitiligo.
nia, nervousness, fatigue, and drowsiness (7). Long-term effects of PUVA

therapy have also been described (7). Most commonly reported are lichen-
ification, desquamation, telangiectasia, lentigines or freckles, leukoderma
punctata, aging, wrinkling, and skin malignancies. Cataract is related only to
the use of oral PUVA. The major advantages of topical PUVA over oral
PUVA therefore include lower required UV -A doses and lack of systemic and
ocular toxicity (5). Because of the possible side effects, pretreatment diag-
nostic tests such as liver and renal function tests and ophthalmological
examination should be repeated annually (5).
Several studies ha ve indicated that PUVA therapy is probably beneficial
via a variety of complex mechanisms. Light microscopic and ultrastructural
studies have shown that PUVA stimulates hypertrophy (increase in size),
proliferation, and enzymatic activity of the melanocytes residing in the outer
root sheath of hair follicles as well as melanocytes located at the margins of
vitiliginous lesions (8-11). Repigmentation is therefore regarded as the result
of the migration of these stimulated melanocytes into the depigmented skin
areas (12). Another study suggested that PUVA therapy may elicit the release
of a certain melanocyte-stimulating growth factor that is capable of stimulat-
ing melanocyte proliferation in vitiligo (13). It is also suggested that PUVA-
induced repigmentations are at least in part immunologically mediated.
Investigators found that the so-called vitiligo-associated melanocyte antigens
(14) and antimelanocyte antibodies (15) were decreased after a course of

PUVA therapy.
Broadband UV-B
The results of this phototherapeutic modality in the treatment of vitiligo were
first reported in 1990 by Koster and Wiskemann (16). Surprisingly, no
phototoxic reactions were observed. However, caution is needed during the
UV-B dose increments because it is known that shorter wavelengths are
responsible for erythema formation in the skin. According to the German
study, broadband fluorescent tubes (Philips TL- 12, Westinghouse FS, Wald-
mann UV-6 or UV-21) with an emission spectrum of290-320 nm can be used.
Thestart dose is 20 mJ/cm 2 (for all skin types), which should be increased by
20% until lesional minimal erythema occurs. Patients are treated twice to
thrice weekly.
Short-term side effects may include erythema, pruritus, and xerosis
cutis. The shorter wavelengths of broadband UV-B may more rapidly and
frequently lead to erythema reactions when compared to narrowband UV-B.
Long-term side effects of broadband UV-B are unknown. The mechanisms of
action of broadband UV-B in vitiligo are unknown.
Long-Term Cancer Risk of Photo(chemo)therapy in Vitiligo

There is a reluctance among dermatologists to prescribe prolonged photo-
(chemo)therapy as it may increase the risk for carcinogenesis in the long term,
as observed in patients with psoriasis (17). In patients with psoriasis, long-
term PUVA therapy was found to be associated with an increased risk for skin
cancer, especially squamous cell carcinoma (SeC) (18). Based on epidemio-
logical data, a statistically increased incidence of nonmelanoma skin cancer
has been observed in patients who had received a cumulative UV-A dose
exceeding 1000 J/cm 2 More recently, Stern et al. also found the risk of
melanoma to be increased among those receiving at least 250 PUVA treat-
ments (19). These findings cause concern, but remarka bly, a similar increased
risk for these skin cancers has not been documented among patients with
vitiligo (20,21).
Patients with vitiligo receiving photo(chemo)therapy do not have a
higher risk of developing skin cancer than do patients with psoriasis-the risk
may even be lower. Unlike patients with psoriasis, those with vitiligo do not
expose themselves to extra sun rays (most patients use sun-protective agents),
do not use tar preparations, cytostatic drugs (methotrexate), or immunosup-
pressive drugs (cyclosporine), and receive lower cumulative PUVA or UV-B
doses. To date, only two vitiligo patients have been described with squamous
cell carcinoma after oral PUV A therapy (22,23). A striking aspect of these
cases was that the time between the start of oral PUVA therapy and the
development of the skin cancer was only 3 years, which is a relatively short
time for tumor induction in general. This suggests that these two cases may
have suffered from a defective DNA repair mechanism and/or an abnormal
immune surveillance.
In daily clinical practice, some precautions can be undertaken to min-
imize the risk of cancer in duction by photo(chemo) therapy. First, the "skin-
saving principle" can be applied: parts of the body where no lesions are
present (especially the face) should be shielded during treatments. Also, parts
that have repigmented satisfactorily should, if possible, be shielded during
subsequent treatments (for example, by wearing trousers). Genitals should
also be shielded, because genital tumors have also been observed after PUVA
therapy (18) and beca use these areas, as a rule, do not respond to photo-
(chemo)therapy (20). Other safety measures include the prevention of un-
necessary exposure to natural sunlight on both treatment and non treatment
days and the use of UV-blocking agents on sun-exposed areas. Until more
epidemiological data become available, we suggest that recommendations for
vitiligo patients regarding safe maximum cumulative PUVA doses and safe
maximum number of UV-B treatments follow those advised for psoriasis
patients: 1000 J/cm '(2,24) and 300 treatments (25), respectively.
Other Forms of Photo(chemo)therapy

According to the results of our meta-analysis, other forms of photochemo-
therapy, such as khellin plus UV-A or phenylalanine plus UV-A, are not
effective and/or are associated with side effects. These modalities are not
recommended for vitiligo and are therefore not mentioned in this review.
Corticosteroids
Corticosteroids can be administered in different ways: topically (26-28), in-
tralesionally (29), and orally (30-34). Low-, mid-, and high-potency prepa-
rations have been used. The mechanism of action of corticosteroids in vitiligo
is unclear. It is often assumed that corticosteroids suppress inflammatory
processes that are frequently observed in active progressing lesions (35). The
use of oral corticosteroids was associated with decreased serum levels of anti-
melanocyte antibodies among patients with active vitiligo (36,37). It is not
known whether the corticosteroids used in the clinical studies in vitiligo have a
direct stimulating effect on melanocyte division and migration. Furthermore,
it is striking that the best results are achieved on sun-exposed areas (such as
face and neck). Both perifollicular as well as perimarginal repigmentation

patterns can be seen with corticosteroids. Because most studies were not
controlled, (unintentional) UV exposure may also have contributed to the
repigmentations associated with the use of these corticosteroids. Regular fol-
lOw-up visits are needed to monitor the well-known corticosteroid-induced
local and systemic side effects.
AUTOLOGOUS TRANSPLANTATION METHODS

In general, autologous transplantation methods are only indicated after
medical treatment has failed. These methods can be used in combination
with medical and/or irradiation therapies. Transplantation may also be con-
sidered as a first option to treat patients with stable and/or focal (segmental)
vitiligo. Autologous transplantation of melanocytes should not be regarded
as a causal therapy. Even after a successful grafting, depigmentation of the
grafts may still occur when reactivation of the disease takes place. All pro-
cedures can be performed under local anesthesia.
The general selection criteria for autologous transplantation methods
are (38,39):
1. Resistance to medical therapy
2. Stable vitiligo
3. Absence of the Koebner phenomenon
4. Positive minigrafting test
5. No tendency for scar or keloid formation
6. Patient older than 12 years
Minigrafting (Fig. 2)
Two mm full thickness punch grafts are harvested [rom normally pigmented
donor sites (such as the hip, buttocks, and outer thigh) and are subsequently
transplanted to depigmented acceptor sites in which similar punched-out skin
had been removed. The grafts are placed 5-8 mm apart and are covered with a
transparent adhesive tape. Subsequently, grafted areas are irradiated with
UV -A (10 J/cm 2) twice a week to promote the outgrowth o[ pigment cells
from the minigrafts. A [acial tanner or a sunbed can be used as the UV-A light
source that can be performed at home. Pigment can be observed concentri-
cally migrating, within a maximum diameter 0[8 mm, [rom the grafts into the
depigmented skin within 8 weeks following transplantation (40).
Complications at the donor site may include light scarring, postinflani-
matory hyper- or hypopigmentation, and infection. At the recipient site, cob-
(a) (b)
FIGURE 2 The minigrafting technique to repigment localized and stable vitiligo

patches, (a) before and (b) after the treatment.
blestone-effect or variegated appearance of the grafts, sinking pits, and

infection have been observed as adverse effects (40).
Thin Split-Thickness Skin Grafting

The recipient area is dermabraded with a diamond burr until uniform pin-
point capillary bleeding occurs. A very thin split-thickness epidermal graft
(0.1-0.15 mm thick) is then removed from a normally pigmented donor area
(usually the hips or buttocks) with an electrically driven dermatome. As an
alternative, the same dermatome can also be used to remove the lesional
recipient skin instead of dermabrasion. The maximum size of the grafts is
about 150 cm 2 The graft is gently placed onto the dermabraded achromic
areas. Donor areas are covered with dry sterile gauzes and an adhesive foil.
Wound dressings of the recipient area consist of sterile suture strips, sterile
gauze impregnated with an antibiotic, dry sterile gauze, and adhesive band-
age. After removal of the wound dressings after 2 weeks, the grafted area and
the donor site can be irradiated with UV-A twice weekly to promote
repigrnentation (41).
At the donor site, light scarring, postinflammatory hyper- or hypopig-
mentation, and infection may occur as adverse effects. Milia, hematoma,
thick graft margins, wrinkles in graft, and infection are possible complications
at the recipient site (41).
Grafting of Epidermal Blisters

For this method, a suction blister apparatus that is capable of exerting 200
mmHg negative pressure to separate the epidermis from the dermis at the
normally pigmented donor skin is essential (42). Two days before trans-
plantation, blistering of the depigmented lesion is induced using liquid nit-
rogen or topical psoralens plus UV-A therapy. After blister formation, the
depigmented epithelium is removed and the roofs of the pigmented donor
blister are grafted to the denuded lesional areas. Scarring does not occur at the
donor site. Infection is sometimes seen at the recipient site.
Grafting of Cultured Autologous Melanocytes

During this procedure, autologous melanocytes are expanded by in vitro
culturing techniques and transplanted into a previously denuded achromic
skin area. This is an expensive technique that requires special laboratory
expertise. However, it may represent an adequate method to repigment larger
vitiliginous skin areas in the future. There are several methods to obtain cul-
tured autologous melanocytes.
Grafting of Pure Melanocytes. Autologous melanocytes are grown for a

period of 4 weeks in a special medium containing 12-0-tetradecanoyl-phorbol
13-acetate (TPA), cholera toxin (CT), and isobutylmethylxanthine (IBMX).
Then suction blistering is performed in the recipient achromic sites. The
cultured melanocytes are then injected into the blister cavities. Using this
method, Lerner et a1. in 1987 observed a satisfying degree of repigmenta tion
in two patients with piebaldism (43). Because TPA is a potent tumor pro-
moter, the safety of this medium remains questionable. Therefore, culturing
of melanocytes in physiological reagents is highly recommended (43,44), but
this is very expensive.
Grafting of M elanocvtes Mixed with Keratinocytes (45-48). Autologous

melanocytes and keratinocytes are mixed cultured on a collagen-coated
membrane for 2 weeks. The membrane is then transplanted into dermabraded
or liquid nitrogen denuded Vitiliginous skin. After 1-2 weeks the collagen
membrane detaches from the graft spontaneously. Repigmentation in the
graft gradually occurs 2-6 months after the day of transplantation. A major
advantage is that TPA or cholera toxin is not required. In mixed cultures, the
essential melanocyte growth factors are provided by the keratinocytes. In
some cases the treated skin area appears lighter than the normal pigmentation
because the number of the grafted melanocytes is too low. The recipient area
may also show light hypertrophic scarring or atrophy. At the donor si te, slight
scarring, postinflammatory hyper- or hypopigmentation, and infection are
possible adverse effects. The recipient site is sometimes complicated by
improper color matching and infection.
Grafting of Noncultured Melanocyte Suspension

More simplified methods of grafting of fresh epidermal cell suspensions
bearing melanocytes have also been successfully used to repigment vitiligo
maCltles. After trypsinization ofa shave biopsy taken from the occipital area,
Gauthier and Surleve-Bazeille injected a suspension containing keratinocytes
and melanocytes into liquid nitrogen blisters induced within the vitiligo
macules (49). Olsson and Juhlin modified the technique in 1998 (50). They
took a shave biopsy from the buttocks, separated the cells, and concentrated
the melanocytes in vitro. The final suspension, containing the basal layer
and about half of the stratum spinosum, was subsequently applied to der-
mabraded vitiliginous areas with a size 8-10 times larger than the donor area.
Slight scarring, postinflammatory hyper- or hypopigmentation, and in-
fection may complicate the donor site. Improper color matching and infection
can sometimes be seen at the recipient site.
DEPIGMENTATION THERAPY
For patients with extensive areas of depigmentation (>80%) and/or disfigur-
ing lesions on the face who do not respond to repigmentation therapies,
depigmentation of the residual melanin should be considered. These patients
should be informed that bleaching or removal of the remaining pigmentation
is a permanent and irreversible process. During and upon completion of the
therapy, patients are permanently at risk for acquiring sunburn from acute
solar irradiation. Patients must therefore be advised to minimize sun exposure
and to apply broad-spectrum sunscreens.
Bleaching Agents
Monobenzylether of hydroquinone (MBEH) is nowadays mostly applied to
remove residual melanin in patients with vitiligo universalis. MBEH is a
potent melanocytotoxic agent. The modes of actions are diverse and are well
summarized elsewhere (51). Loss of pigment can also occur at distant sites of
application. The mechanism behind this phenomenon is unclear (52).
The treatment should start with a single daily application to a test spot.
Ifno adverse reactions occur, greater skin areas can be gradually treated with
a frequency of once to twice daily. It normally requires 1-3 months to initiate
response (52). Depending on the percentage of the residual pigmentation, 6
months to 2 years may be required to complete the therapy. Patients must
avoid direct contact of the treated area with untreated skin or with normal
pigmented skin of other individuals (partners) for at least 2~3 hours after
application of the cream. In the Netherlands, 4-methoxyphenol (monomethyl
ether of hydroquinone or 4-hydroxyanisole) in a 20% cream can be used as an
alternative to MBEH (53). Short-term side effects are (contact) dermatitis,
pruritus (54), and corneal and conjunctival melanosis (55). Long term, leu-
komelanoderma en confetti and exogenous ochronosis may occur as adverse
effects (56). These long-term effects have not yet been reported in patients with
vitiligo universalis.
Laser Therapy
Another form of depigmentation therapy for vitiligo has also been developed,
making use of a Q-switched ruby (QSR) laser apparatus. The QSR laser beam
with a wavelength of 694 nm is capable to selectively destroy melanin and
melanin-containing structures in the skin. As a result, the risk for scar for-
mation is minimal (57). Depigmentation by laser therapy is reported to
achieve faster depigmentation, compared with depigmentation using a
bleaching agent (53,57). On the other hand, some health insurance companies
do not reimburse the treatment costs, so that some patients cannot afford this
therapy. Since laser treatment is thought to cause depigmentation by koebne-
rization, patients with a negative Koebner phenomenon will not respond to
this therapy.
NOVEL THERAPEUTIC APPROACHES

Fluticasone Propionate plus UV-A Therapy
A recent study showed that combination therapy using a potent cortico-
steroid (ftuticasone propionate) applied once daily and UV-A irradiation (10
2
J/cm ) performed twice weekly is an effective and safe method to repigment
localized vitiligo lesions (58). The combination therapy led to a higher per-
centage of repigmentation than either ftuticasone propionate or UV-A alone.
Perifollicular and marginal repigmentation could be observed as soon as 6
weeks after the start of therapy in both adult and pediatric patients. After 9
months of therapy, clinical and histological examinations revealed no signs of
atrophy or telangiectasia in the treated skin. A major benefit of this modality

is that it can be performed easily at home using UV-A tanning equipment
(e.g., a facial tanner) as the light source.
Focused Microphototherapy
The clinical effects of focused microphototherapy have been studied since
1990 by a group of investigators in Milan, Italy (59). For this form of photo-
therapy, UV-B light with a spectrum of280-315 n111 is used. The skin is pre-
pared by application of water and glycerin to facilitate the penetration of the
UV-B rays in the skin. Subsequently, a dark pad with 2 111m holes is applied to
the skin. The light is shined through the holes and causes a mild to moderate
burn on the skin. Treatments are given daily for a week and thereafter several
times weekly or twice a month. In addition, the therapy requires a highly
advanced computer program and a videocamera to control and to monitor
the UV-B-delivering equipment. The results of the study showed that the
more frequent the treatments, the more rapid the pigment returns. About 25%
of the patients experience excellent results, having most oftheir pigment back,
whereas 50% have only moderate repigmentation. As with other forms of
photo(chemo)therapy, acral sites of the body reveal a poor response.
It is regarded as a major advantage that, by using the focused micro-
phototherapy, only depigmented skin can be treated so that unaffected skin
areas are not unnecessarily exposed to UV-B irradiation. In this manner,
contrast formation between the depigmented and the normal pigmented skin
can be avoided. However, this therapy requires expensive equipment and
trained personnel and will therefore not be available for many patients
around the world.
Pseudocatalase plus UV-B Therapy

Based on the results of oxidative stress and calcium dysregulation in vitiligo, a
substitute for depleted catalase together with calcium, a new topical treatment
modality has been developed. A low molecular weight manganese complex
(MW 328) has been synthesized that functions effectively to remove hydrogen
peroxide from patients. Intracellular matrix concentrations of calcium are
adjusted with 10- 2 M calcium chloride. Therapy involves a twice-daily
application of pseudocatalase cream and a suberythemal dose of UV-B light
twice a week. The treatment yielded more than 90% repigmentation of hands
and faces in a pilot study with 33 patients (60). However, this study was
uncontrolled, and it is unknown whether the observed repigmentation should
be attributed to pseudocatalase alone, to the combination of the substance
with UV-B therapy, or to UV-B therapy alone.
Systemic Antioxidant Therapy

Based on the antioxidant theory, a clinical trial is being performed in Italy
using the oral administration of compounds such as ubiquinone, vitamin E,
selenium, and methionine (61). It is unknown whether this trial has included a
placebo group. The rationale to use these substances for vitiligo is contro-
versial; antioxidants are also used as alternative forms of therapy for a variety
of disorders, although their mechanism of action is unknown and probably
nonspecific.
Melagenine and Infrared and/or UV Radiation

Melagenine is a hydroalcoholic extract of the human placenta that is
synthesized in Cuba (62). Topical melagenine in combination with infrared
radiation or exposure to natural sunlight have been reported to be effective for
the treatment of vitiligo. However, this could not be confirmed by other in-
vestigators (63). Not much is known about the biochemistry, biological
activity, or pharmacology of this drug. Melagenine may contain a lipoprotein
that stimulates melanogenesis and melanocyte proliferation. To date there
seems to be poor quality control in the production of this drug (64).
Grafting of Follicular Melanocytes

Repigmentation of leukotrichia in vitiligo has been achieved using epidermal
blister grafting in combination with oral PUVA by Halm et al. (65) and using
a single hair grafting technique by Na et al. (66). These observations suggest
that epidermal melanocytes could migrate or transfer to the hair follicle.
Direct evidence for such a mechanism has not yet been provided. Because
outer root sheath (ORS) melanocytes constitute a natural reservoir for the
repigmentation process in vitiligo, they may be useful for grafting purposes.
Further studies are needed to investigate the therapeutic possiblities of such
techniques in vitiligo.
EVIDENCE-BASED GUIDELINES FOR THE TREATMENT

OF VITILIGO
We have performed a meta-analysis of the literature in order to position, in
relation to each other, currently available forms of nonsurgical and surgical
repigmentation therapies and depigmentation therapies in terms of their
effectiveness and safety profiles (67,68). A treatment was regarded as being
successful when more than 75% repigmentation was observed. Based on the
results of these studies, treatment with a potent local corticosteroid is ad-

vised for patients with localized vitiligo [mean success rate, 56% and 95%,
respectively; confidence interval (CI), 50-62%]. When patients exhibit gen-
eralized vitiligo, UV-B therapy is recommended (mean success rates, 63%
and 95%, respectively; CI, 50-76%). However, there were no statistical dif-
ferences in the success rates of oral PUVA, narrowband UV-B, and broad-
band UV-B. With regard to autologous transplantation methods, split-
thickness skin grafting and epidermal blister grafting can be recommended
as the most effective and safest techniques (mean success rates, 87%, 95%;
CI, 82-91 %; and mean success rates, 87%, 95%; CI, 83-90%, respectively).
Minigrafting had the highest rates of adverse effects, but was shown to be
the easiest, fastest, and least expensive method. No definite conclusions can
be drawn with regard to the effectiveness of culturing techniques, because
only a small number of patients have been studied. The choice of method also
depends on certain disease characteristics and the availability of specialized
personnel and equipment.
During formal consensus meetings, the results of these studies were
discussed, and evidence-based guidelines for the treatment for vitiligo have
been developed. The guidelines consist of a treatment scheme. Recommen-
dations regarding first and alternative choices are given according to the age
of the patient, clinical type, severity of disease, and disease activity. In all
cases, advice regarding the use of camouflage and sunblocking agents should
always be given. If necessary, psychological counseling may be recommended.
These guidelines were disseminated and implemented at the Netherlands
Institute for Pigment Disorders and the Department of Dermatology of the
Academic Medical Center in Amsterdam, the Netherlands (69).
The literature studies have also identified some shortcomings in current
vitiligo research. So far, only a few randomized controlled trials (RCTs) have
been performed for patients with localized as well as generalized forms of
vitiligo. Some recommendations in our guidelines are based on data from
noncontrolled studies. RCTs are regarded as the "best available scientific
evidence." The inclusion of the results of such trials into practice guidelines
can increase the strength and validity of treatment recommendations. Physi-
cians would also feel more confident with guidelines that contain the best
available evidence. More RCTs should therefore be performed in future.
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18. Stern RS. Lange R, Members of the photochemotherapy follow-up study. Non-
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after first treatment. J Invest Derma tol 1988; 91: 120-124.
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21. Lindelof B, Hedblad MA, Sigurgeirsson B. On the association between vitiligo
and malignant melanoma. Acta Derm Venereol (Stockh) 1998; 78:483-484.
22. Buckley DA, Rogers S. Multiple keratoses and squamous carcinoma after PUVA
treatment of vitiligo. Clin Exp Dermatol 1996; 21:43-45.
23. Takeda H, Mitsuhashi Y, Kondo S. Multiple squamous cell carcinomas in situ in
vitiligo after long-term PUVA therapy. J Am Acad Dermatol 1998; 38:268-270.
24. British Photodermatology Group. British Photodermatology Group guidelines
for PUVA. Br J Dermatol 1994; 130:246-255.
25. Studniberg HM, Weller P. PUVA, UV-B, psoriasis and nonmelanoma skin
cancers. J Am Acad Dermatol1993; 29:1013-1022.
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27. Bleehen SS. The treatment of vitiligo with topical corticosteroids. Light and
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28. Kumari J. Vitiligo treated with topical c1obetasol propionate. Arch Dermatol
1984; 120:631-635.
29. Kandil E. Treatment of localized vitiligo with intradermal injections of
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30. Moon TK, 1m SB, Hann SK, Cho SH, Park YK. The effect of small doses of oral
cortico steroids in vitiligo patients. Korean J Dermatol 1995; 33:880-885.
31. Kim SM, Lee HS, Hann SK. The efficacy of low-dose corticosteroids in the
treatment of vitiligo. Int J Dermatol 1999; 38:546-550.
32. Pasricha JS, Khaitan BK. Oral mini-pulse therapy with betamethasone in vitiligo
patients having extensive or fast-spreading disease. Int J Dennatol 1993; 32:753-
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33. Kanwar AJ, Dhar S, Dawn G. Oral minipulse therapy in vitiligo. Dennatologica
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Treatment of localized vitiligo with Ulobetasol cream. Int J Dermatol 1990;
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cytotoxicity after systemic steroid treatment in vitiligo patients. J Dermatol Sci
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37. Hann SK, Chen D, Bystryn Jc. Systemic steroids suppress antimelanocyte
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38. Falabella R, Arrunategui A, Barona MI, Alzate A. The minigrafting test for
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39. WesterhofW, Boersma B. The minigrafting test for vitiligo: detection of stable le-
sions for melanocyte transplantation. JAm Acad Dermatol 1995; 33: 1061-1062.
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33:990-995.
4 I. Njoo MD, Nieuweboer-Krobotova L, Westerhof W. Repigmentation of
leukodermic defects in piebaldism by dermabrasion and thin split-thickness skin
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44. Olsson MJ, Juhlin L. Transplantation of melanocytes in vitiligo. Br J Dermatol
1995; 132:587-591.
45. Falabella R, Escobar C, Borrero I. Transplantation of in vitro cultured epidermis
bearing melanocytes for repigmenting vitiligo. J Am Acad Dermatol 1989; 21:
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ment for vitiligo: autologous cultured-epithelial grafts. J Dermatol Surg Oncol
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of epidermal culture for the surgical treatment of vitiligo. Int J Dermatol 1998;
37:595-598
48. Guerra L, Capurro S, Melchi F, Primavera G, Bondanza S, Cancedda R, Luci A,
de Luca M, Pellegrini G. Treatment of stable vitiligo by timedsurgery and
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58. Westerhof W, Nieuweboer-Krobotova L, Mulder PGH, Glazenburg EJ Left-
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21
Efficacy and Adverse Effects of Psoralen
Photochemotherapy in Vitiligo
Ljubomir Novakovic and John Hawk

St. John's Institute of Dermatology, London, England
INTRODUCTION
Psoralen photochemotherapy with a combination of the furocoumarin
psoralen (P), ingested or topically applied, and cutaneous ultraviolet A
(UVA) irradiation, is often used and considered the most effective therapy
for vitiligo. Such treatment with natural sunlight and topical psoralens dates
back to ancient times, the Hindus in India having used the seeds of Psoralea
corylifolia Linnaeus and the Egyptians Ammi majus Linnaeus as sources for
the active chemical. EI Mofty was the first to perform careful clinical studies,
however, and reported the successful repigmentation of vitiligo with oral 8-
methoxypsoralen (8-MOP) and sunlight in 1948 (1). Such ingestion, rather
than the topical use of psoralens and subsequent exposure to sunlight,
appeared at that stage to be the most successful treatment of vitiligo yet
available. However, one disadvantage was long treatment times because of
inadequate intensities of UVA radiation sources. The development of a high-
intensity UVA lamp in 1974, therefore-initially used for the treatment of
psoriasis (2) and subsequently also vitiligo (3)-marked the beginning of
convenient therapy, while accurate UVA dosimetry, crucial for safe and
efficient PUVA therapy, was also introduced at that time.
This chapter will concentrate on key issues facing dermatologists in
phototherapy clinics, namely which vitiligo patients are likely to do well with
253
254 Novakovic and Hawk
PUVA, what adverse effects they may face, and what treatment schedule is
best.
PRETREATMENT ASSESSMENT AND CONSULTATION

All vitiligo patients should be assessed for their suitability for PUVA prior to
commencement of treatment. Contraindications are the same as for other
PUVA-responsive disorders (4), and although the suggested lower age limits
are only guidelines, topical PUVA should be considered first for children if at
all possible. A further important issue is the assessment of patient skin cancer
risk, which should include documentation of the patient's skin type and any
prior severe sunburning episodes as well as previous exposure to sunlight and
artificial ultraviolet radiation, including any past phototherapy. Any previous
history of photosensitivity should also be noted and evaluated as well as any
current potentially photosensitizing medication; usually the photosensitivity
from psoralen far outweighs any possible drug photosensitivity.
Before PUVA treatment is initiated, it is also extremely important to
give a detailed explanation of the potential treatment advantages and also
drawbacks to patients. They should thus understand that for both oral and
topical PUVA, up to 15-20 treatments are normally required for any visible
pigmentary response, and up to 100 or more for complete repigmentation, ifit
occurs, especially for widespread disease. Therefore, it is necessary that the
patients comply with their long-term treatment schedule carefully and under-
stand that many months are normally required to achieve a satisfactory result.
Patients should also be aware that the initial therapeutic response is usually in
the form of widespread perifollicular repigmentation and that the contrast
between normal and vitiligo skin will initially become more obvious as PUVA
stimulates the darkening of the unaffected skin. Once satisfactory repigmen-
tation has been achieved, however, maintenance PUVA should not be under-
taken.
Patients should also be provided where possible with a written infor-
mation leafiet on PUVA treatment containing a detailed explanation of the
possible acute and long-term side effects of treatment. In addition, an
explanation should be provided of the chances of repigmentation for the
patient in question. Finally, at the end of consultation, patients should sign a
consent form as a useful formal means of pointing out the PUVA risks.
TREATMENT PROTOCOLS
Patients with widespread vitiligo are best managed with oral PUVA therapy,
the psoralens of choice being 8-methoxypsoralen (8-MOP) and 5-methoxy-
psoralen (5-MOP). Trimethylpsoralen (TMP) is also available but much less
Psoralen Photochemotherapy in Vitiligo 255
phototoxic because of poor gastrointestinal absorption and is therefore less

frequently used. The ora] preparations are available in different formulations,
and this should be taken into consideration as the different forms may achieve
different peak blood levels. Thus, patients take 8-MOP in a dose of25 mg/m 2
body surface 2 hours prior to UVA exposure or 5-MOP in a dose of 50 mg/m 2
body surface 3 hours before; irradiations are given twice weekly, the initial
UVA dose for all skin types being 0.5 J/cm 2 The dose is then increased by 0.5
J/cm 2 at each visit with the aim of not inducing any erythema (or at the most,
barely perceptible erythema) of the vitiligo patches. The maximum single
exposure dose should not exceed 5 Jjcm 2 , but should be less if erythema shows
any sign of development.
Topical PUYA therapy may be considered for patients with limited
vitiligo, generally affecting less than 10% of skin surface. Topical PUVA
is also preferable to oral PUVA in children, in patients with significant hepatic
dysfunction or a tendency to gastrointestinal disturbance, in patients with
cataracts, and where compliance with the eye protection may be poor or pso-
ralen-drug interactions anticipated, for example, with warfarin (5). Although
topical PUVA is associated with an increased risk of a blistering phototoxic
reaction, its lack of systemic side effects makes it a very reasonable choice for
this selected group of patients.
For topical PUVA, 8-MOP is generally preferred to 5-MOP and TMP
as it is less phototoxic; the treatment is given twice weekly as for oral PUVA.
For whole body bath PUVA, 30 mL of 1.2% 8-MOP in an aqueous solution
are diluted in ]00 L water to a concentration of 3.6 mg/L. A IS-minute pso-
ralen bath is then followed by immediate exposure to UVA, an initial UVA
dose is 0.05 Jjcm 2 being increased by 0.05 J/cm 2 at each visit, adjusted if
necessary to diminish the chances of significant or even just perceptible ery-
thema of the vitiligo patches; the exposure dose should not exceed 0.6 J/cm 2 .
For paint PUYA, undiluted 0.15% 8-MOP may be used, the initial UVA dose
again being 0.05 J/cm 2 for the face but 0.1 J/cm 2 for the body, and is increased
by 0.05 J jcm 2 for the face and O. I J/cm 2 for the body at each visit, again so as
2
to avoid erythema of the patches and with a maximum dose of 0.6 Jjcm .
Progress is best monitored by clinical photographs at about 3- to 4-
month intervals in all patients on PUYA therapy to enable an easy assessment
of response. If definite, albeit often mild, repigmentation has not occurred
within the initial 3--4 months, PUYA is unlikely to be effective thereafter and
should be discontinued.
COMBINATION THERAPY
Combination therapy has been claimed to improve the results of PUYA
therapy alone, several studies having suggested that topical calcipotriol the
active metabolite of vitamin 0, in conjunction with PUVA may be more

effective than PUVA alone, the combination perhaps achieving earlier
repigmentation with a lower cumulative UV A dose (6-8). Topical cortico-
steroids, frequently used alone as the first-choice therapy for vitiligo, have
also been advocated for use in combination with PUV A, while epidermal
grafting has been claimed a very useful adjunct to PUVA therapy for areas
that do not respond to PUY A.
EFFICACY OF PUVA IN THE TREATMENT OF VITILIGO

The efficacy of PUYA in the treatment of vitiligo depends mostly on the
anatomical site affected by vitiligo and, to a lesser extent, the patient skin type
and the recency of onset of the disease.
Hair follicles in particular are a major reservoir of melanocytes, from
which they can migrate into the surrounding pale skin during repigmentation;
other mechanisms are migration from adjacent dark skin and reactivation of
still present melanocytes within any recently developed vitiliginous areas.
Therefore, large vitiligo patches not of recent onset affecting parts of the body
that lack hair follicles, such as acral sites, peri orificial areas of the face,
genitalia, nipples, and scars, usually respond minimally to PUVA. In con-
trast, patients with vitiligo of the face, trunk (Fig. I), arms, and legs (Fig. 2)
FIGURE 1 Virtually total repigmentation after many months of PUVA therapy;

however, the color of the repigmented areas is inappropriate.
Psora len Photochemotherapy in Vitiligo 257
FIGURE 2 Good but cosmetically still unsatisfactory repigmentation; very obvious

white areas persist, and the color of repigmented areas is again inappropriate.
frequently achieve good or complete repigmentation; however, leukotrichia

(the loss of hair color in any vitiligo patch), implying the loss of follicular
melanocytes as well, suggests a poor response. Segmental vitiligo also often
responds poorly to PUVA, being frequently associated with the loss of hair
pigmentation.
A recent 10-year retrospective study (9) has confirmed the results of
previous studies (10,11) that PUVA is at best moderately effective in wide-
spread vitiligo because of slow repigmentation over many months in wide-
spread longstanding disease, failure of acral sites to repigment, abnormal
repigmentation color, and high relapse rates, leading to poor cosmetic out-
comes. The only statistically significant prognostic indicator of relapse was
patient age at the start of treatment, with younger patients tending to retain
their pigmentation longer than older patients. Only about 10% of patients
repigmented fully, although 60% more had good but not full repigmentation;
however, about 50% began to relapse within 1-2 years of ceasing PUVA.
Vitiligo of recent onset, however, is probably more likely to respond to PUVA
than longstanding disease, although this appears not to be well documented.
Patients with darker skins are more likely to achieve successful repig-
mentation, although this may often be unsightly (Fig. 3). However, this does
appear to revert toward normal over many months in many patients.
FIGURE 3 Widespread repigmentation after many months of PUVA; once again

the outcome is cosmetically unsatisfactory, with white areas still persisting and
repigmentation of the wrong color.
PUVA SIDE EFFECTS

The acute side effects of PUVA are related to psoralen phototoxicity, the
clinical features being erythema, edema, vesiculation, and necrosis similar to
those seen in sunburn but with a more delayed time course, with peak at about
72-96 hours; this is more likely with topical PUVA. Oral PUVA with 8-MOP
is sometimes associated with nausea and vomiting and in such cases should be
replaced with 5-MOP, which is nearly free of such side effects as well as being
less phototoxic to the skin.
Following oral ingestion, 8-MOP can be detected in the ocular lens in
humans for at least 12 hours (12). Thus, although there is in fact no definite
evidence from PUVA follow-up studies of an increased incidence of cataracts,
UVA-protective glasses must be worn for at least 12 hours after psoralen
tablet ingestion to prevent theoretically possible long-term ocular damage by
patients on oral PUYA.
The long-term side effects of PUYA include premature photoaging of
the skin and an increased risk of the development of skin cancer. Thus, studies
have reported an increased number of actinic keratoses and squamous cell
carcinomas (SeC) in PUVA-treated vitiligo patients (13-15). This incidence
in PUV A-treated psoriasis correlates with cumulative UYA dose; because it is
Psoralen Photochemotherapy in Vitiligo 259
much lower in vitiligo patients, however, squamous cell carcinoma (SCC)

incidence also appears to be significantly less.
A recent long-term PUVA follow-up study of psoriasis patients has also
suggested a slightly increased risk of melanoma (16), with a greater risk in
patients exposed to high doses with increasing lengths of time since treatment
began. Thus, although similar studies have not yet been published for vitiligo
patients on long-term PUVA therapy, it is expected, as with SCC, that they
may be at a lower risk and virtually negligible risk for melanoma as they
receive much lower cumulative UVA dose than for psoriasis.
CONCLUSION
PUV A has become established in one form or another over thousands of
years as a moderately to occasionally very effective treatment for vitiligo,
usually with no major adverse effects in the short term. However, it is by no
means a cure. All suitable patients should be given a detailed explanation
beforehand of the proposed treatment schedule and the potential advantages
and drawbacks of the therapy. After many months of around twice-weekly
therapy, more or less satisfactory but usually not complete repigmentation,
not infrequently abnormally formed, is achieved in carefully selected patients.
However, increasing evidence for the comparable efficacy and probably
greater safety of narrowband UVB phototherapy in the treatment of vitiligo
suggests that the use of PUVA may steadily decrease over the coming years.
ACKNOWLEDGMENT
We thank Sister Trish Garibaldinos for her help with PUVA treatment
protocols.
REFERENCES
I. EI Morty AM. A preliminary clinical report on the treatment of leukoderma with
Ammi majus Linn. J Egypt Med Ass 1948; 31 :651-660.
2, Parrish JA, Fitzpatrick TB, Tanenbaum L, et al. Photochemotherapy of psoriasis
with oral methoxsalen and longwave ultraviolet light. N Engl J Med 1974; 291:
1207-1211.
3. Parrish lA, Fitzpatrick TB, Shea C, et al. Photochemotherapy of vitiligo. Arch
Dermatol1976; 112:1531-1534
4. British Photodermatology Group. British Photodermatology Group guidelines
for PUVA. Br J Dermatol 1994; 130:246-255.
5. Halpern SM, Anstey AV, Dawe RS, et al. Guidelines for topical PUVA: a report
of a workshop of the British Photodermatology Group. Br J Dermatol 2000;
142:22-31.
6. Ermis 0, Alpsoy E, Cetin L, et al. Is the efficacy of psoralen plus ultraviolet A

therapy for vitiligo enhanced by concurrent topical calcipotriol? A placebo-
controlled double-blind study. Br J Dermatol 145; 200 I :472~75.
7. Ameen M, Exarchou V, Chu AC. Topical calcipotriol as monotherapy and in
combination with psora len plus ultraviolet A in the treatment of vitiligo. Br J
Dermatol 2001; 145:476~79.
8. Al Rubaie S. An open randomised study of treatment of 39 patients of gener-
alised vitiligo with narrow-band UVB versus topical calcipotriol + PUVA ther-
apy for a maximum period of 12 months. Ann Dermatol Venereol 2002; 129:
IS107.
9. Kwok YKC, Anstey AV, Hawk JLM. Psora len photochemotherapy (PUVA) is
only moderately effective in widespread vitiligo: a 10-year retrospective study.
Clin Exp Dermatol2002; 27:104-110.
10. Elliott JA. Methoxsalen in the treatment of vitiligo: an appraisal of the perma-
nency of the repigmentation. Arch Dermatol 1959; 79:237-243.
Ii. Wildfang IL, Jacobsen FK, Thestrup-Pedersen K. PUVA treatment of vitiligo: a
retrospective study of 59 patients. Acta Derm Venereol (Stockh) 1992; 72:305-
306
12. Lerman S, Megaw J, Willis I. Potential ocular complications from PUVA
therapy and their prevention. J Invest Dermatol 1980; 74:197-199.
13. Halder R, Battle EF, Smith EM. Cutaneous malignancies in patients treated with
psoralen photochemotherapy (PUVA) for vitiligo. Arch Dermatol 1995; 131:
734-735.
i4. Buckley DA, Rogers S. Multiple keratoses and squamous carcinoma after
PUVA treatment of vitiligo. Clin Exp Dermatol 1996; 21 :43~5.
15. Takeda H, Mitsuhashi Y, Kondo S. Multiple squamous cell carcinomas in situ in
vitiligo lesions after long-term PUVA therapy. J Am Acad Dermatol 1998; 38:
268-270.
i6. Stern RS, the PUVA Follow-Up Study. The risk of melanoma in association with
long-term exposure to PUVA. J Am Acad Dermato12001; 44:755-761.
22
Treatment of Vitiligo with UV
and Photosensitizing Substances
M.L. Flori, M. Pellegrino, A. Molinu,

E. Stanghellini, and L. Andreassi
INTRODUCTION
Vitiligo is difficult to treat. The objective of therapy is currently to stabilize the
disease and promote repigmentation of achromic areas so that skin color
becomes even. This objective can be achieved by various methods based on a
recent series of biological discoveries. Immunohistochemical methods and
electron microscopy have demonstrated that there is a reserve population of
amelanotic, functionally inactive DOPA-negative melanocytes, having ample
cytoplasm and condensed nuclear chromatin, in the peripheral part ofpiloseba-
ceous follicles. In vitiligo, these follicular melanocytes are the anatomical
substrate through which repigmentation may be obtained. Recent studies have
confirmed that in areas ofrepigmentation of vitiligo obtained by proliferation
of reserve melanocytes, these cells progressively migrate into the superficial
part of the infundibula and hence into the surrounding epidermis. As a result
of this process, the melanocytes become morphologically and functionally
mature. Their migration is promoted byexposure to ultraviolet (UV) radiation.
UV RADIATION
Ultraviolet radiation is nonionizing electromagnetic radiation in the 100--400
nm band, corresponding to photon energies of 3.1-12.4 eV. The Commission
262 Flori et al.
Internationale de I'Eclairage (CIE) has divided this spectral region into three
bands: UV-A (400-315 nm), UV-B (315-280 nm), and UV-C (280-100 nm).
In the medical literature, however, one frequently finds band limits different
from these. Indeed, the UV-B region is regarded as being from 280 to 320 nm
and the UV-A band is subdivided into UV-A2 (320-340 nm) and UV-Al
(340-400 nm).
The well-known benefits of sunlight for treating vitiligo and many other
skin diseases led to the development of increasingly sophisticated artificial
sources, which now rival or supersede results obtainable by heliotherapy. In
the early twentieth century, carbon arc lamps, introduced by Finsen in 1890,
were widely used. They were superseded by the more practical medium-
pressure mercury arc lamps, which emit more UV radiation, first used by
Andersen to treat psoriasis in 1923. For many years dermatologists endeav-
ored to use sources that reproduced sunlight artificially, such as arc and
xenon lamps. The introduction of mercury vapor lamps with the subsequent
addition of heavy metal halogens to make spectral emission more homoge-
neous was an enormous advance. The most modern and versatile sources are
currently low-pressure mercury vapor fluorescent lamps. The emission spec-
trum is continuous with variable percentages ofUV-A and UV-B and almost
no UV-c. By combining lamps in different ways and using filters to eliminate
UV-C and/or UV-B below 295 nm, instruments with improved clinical
versatility for various types of therapy have been developed.
These therapies range from selective phototherapy with UV-B and wide-
spectrum phototherapy with UV-AB, to UV-A phototherapy which mayor
may not be used in conjunction with photosensitizing agents. A further
therapeutic aid was recently obtained with a new fluorescent lamp (Philips
TL-Ol) emitting with high intensity in a very limited band (310-315 nm)
having a narrow principle emission band peaking at 311 ± 2 nm and two small
lines at 304 and 334 nm as well as modest emission in the visible band. This
new lamp has proved to have better activity than traditional UV-B sources,
and lower long-term cancer risk has been demonstrated in mice. Narrowband
UV-B phototherapy is more effective and less irritating than traditional
phototherapy.
NARROWBAND UV-B PHOTOTHERAPY

Although successful therapy of vitiligo with narrowband UV-B has been
reported, no standard protocol yet exists. Treatment variables (doses, usually
below the erythema threshold, total number of exposures, and any associated
topical or systemic treatments) are usually adapted on an individual basis,
including personal phototype. In our experience, narrowband UV-B exposure
can be given three times a week with doses increasing by 50 mJ/cm 2 per session
Treatment with Photosensitizing Agents 263
up to a maximum single do e of 1800-2000 mJ/cm 2 . In most cases, color

is restored after 50-100 sessions. Patients beginning therapy from the first
manifestations of vitiligo enjoy the best resul ts. The response is particularly
good in young subjects with lesions situated on the face and neck. Long-
standing. extensive, and acral forms of vitiligo respond less well or not at all.
Interestingly, most patients do not experience progression of lesions in the
course of therapy.
Recovery from vitiligo is an extremely gradual process, even with
narrowband UV-B therapy. Repigmentation usually takes place in three
phases: (a) a long latent phase with large variations from subject to subject; (b)
a rapid improvement phase, presumably associated with migration and mul-
tiplication of melanocytes causing a 30-50% reduction in patch area; (c) a
slower response phase or resistance (in older parts of patches where melano-
cytes have been absent for the longest and where conditions are presumably
less favorable for their colonization).
MICROPHOTOTHERAPY AND EXCIMER LASER

The idea of targeted microphototherapy was recently suggested. Narrowband
UV-B is used with a fiber optics system to direct radiation to specific areas of
skin. The instrument includes a computer for programming and controlling
intensity (0.02-0.2 JIcm 2 Is) and application time. One protocol consists of one
session per day for 5 consecutive days followed by a 'lO-day pause and then
one session per week for about 20 weeks. Treatment is usually well tolerated
and without side effects. Another recent innovation, still in the experimental
phase, is excimer laser therapy with monochromatic rays at 308 nm for
treating limited stable patches of vitiligo.
PHOTOCHEMOTHERAPY
Photochemotherapy consisting of UV phototherapy after topical or systemic
administration of photosensitizing substances is still one of the most effective
treatments of vitiligo. The best known is PUVA therapy in which psoralens
are the substance administered before exposure to UV-A radiation. Table 1
shows other photosensitizing agents used for this purpose.
Psoralens are tricyclic furocumarines of the furochrome family, wide-
spread in the plant kingdom and currently produced by chemical synthesis.
Their major feature is strong photosensitizing activity on various biological
substrates mediated by UV-A. This capacity to induce skin pigmentation
was used historically in popular medicine to heal white skin patches. A herba-
ceous leguminous plant, Psoralea corylifolia, containing psoralens was used in
India. In Egypt, an umbrellifera known as Ammi majus, which grows wild in
264 Flori et al.
TABLE 1 Agents Used in Photochemotherapy

TMP in tablets
8-MOP in gelatin capsules
5-MOP in tablets or capsules
Khellin in tablets
Phenylalanine in tablets
TMP in solution for local application
8-MOP in solution for local application
Khellin in solution for local application
Angelicine cream
Miscellaneous (L-dopa, tyrosine, melagenin, pseudocatalase,
extract of Polypodium leucotomus, etc. )
the Nile valley and contains 8-methoxypsoralen (8-MOP, xanthotoxin or

amoidine), was used. The plants are described as being reduced to a poultice
and applied to the achromic patches before exposure to sunlight. Modern use
of 8-MOP in the treatment of vitiligo is attributed to El Mofty, a doctor of
Egyptian origin. In 1948 he initially used extracts of the plant; later, when the
chemists Fahmy and Abu Sady isolated pure furocumarine, he used it orally
and topically to treat vitiligo. Widespread use of photochemotherapy began
in 1947 when Parrish et al. administered 8-MOP systemically and used
instruments providing high-emission UV-A.
In the absence of light, psoralens form complexes with DNA bases.
After absorption of UV-A rays, monofunctional 3,4- or 4',5' -cyclobutane
adducts form with pyrimidine bases ofONA. In the presence of psoralens that.
absorb a second photon, bifunctional adducts with double 5,6-pyrimidine
bonds form between opposite chains that prevent DNA synthesis and hence
cell division. This mechanism is the reason that PUVA therapy is effective in
diseases characterized by hyperproliferation of cells. It is not yet clear what
mechanism is responsible for stimulating melanocyte proliferation. Melano-
cyte growth factors have been reported in circulation after PUVA treatment.
PUVA therapy also has an immunosuppressive effect on T lymphocytes
and Langerhans cells and a selective toxic effect on mononuclear phagocytes
as well as inhibiting mast cell degranulation. Photochemotherapy with
psoralens has been found to release many cytokines, which means that it
affects the environment in which melanocytes and keratinocytes interact.
After irradiation with UV, keratinocytes produce a series of cytokines (SCF,
GM-CSF, b-FGF, TGF-O') that stimulate melanocytes and others (TGF-r\
IL-l, IL-6, IFN-O') that inhibit them. It seems likely that together, these effects
act synergically to promote conditions favorable for recolonization of
achromic areas by melanocytes.
The choice of the type of PUVA treatment, namely topical or oral

administration of psoralens, depends on factors such as age of patient (oral
administration is contraindicated in children under 12 years of age), extent of
lesions (topical application is advisable when less than 20% of the skin surface
is affected by vitiligo), and site of lesions (distal achromic areas and segmental
forms respond relatively poorly to topical treatment). Topical PUVA therapy
is indicated for patients suffering gastrointestinal side effects such as nausea
and vomiting after oral administration of photosensitizing substances, as well
as for patients with cataracts, retinopathy, liver and/or kidney disorders, and
cardiovascular disease.
Before systemic PUVA therapy, pa tients should be screened for contra-
indications, such as liver disorders, autoimmune diseases, and photoderma-
titis. Other contraindications are cancer, pregnancy, lactation, and phototype
I according to Fitzpatrick.
TMP
TMP is preferable to 8-MOP in terms of phototoxicity and is safer if sunlight
is used (chemoheliotherapy) and with UV-A sources. In TMP + UV-A
treatment with a high-intensity artificial source, TMP is given about an hour
before exposure at a dose in the range 0.6-0.9 mg/kg. The interval is necessary
so that maximum concentration of TMP can be reached in the skin, though
the pharmacokinetics of the drug show wide variations within and between
patients. The initial dose of UV-A given is the minimum photo toxic dose
(MPD) calculated by phototest. Before TMP is administered, increasing
doses of UV -A are directed to a target area of skin not normally exposed to
sunlight, for example, a buttock. Forty-eight hours later, the skin response is
recorded. The MPD is the minimum dose of UV-A that produces slight
pigmentation with clear borders.
Individual initial UV-A doses are 2 J/cm 2 in weekly sessions. The dose
is then increased by I J/cm 2 each week up to a single maximum dose of 12 J/
cm 2 Treatment with sessions every 2 or 3 weeks usually continues for at least
10-12 months. To be effective, the protocol must be observed rigorously with
regard to dose, frequency of sessions, and duration. Because photosensitiza-
tion persists after the session the patient must wear protective sunglasses for
the rest of the day and protect exposed areas of skin against sunlight by means
of sunscreen and clothing for at least 8 hours. In a recent retrospective study,
Kwok et al. (2) found that about 8% of patients treated achieved complete or
almost complete repigmentation, 60% of patients achieved 30-90% repig-
mentation, 30% achieved more than 30% repigmentation, and only 2%
continued to worsen despite treatment. The number of sessions necessary to
achieve these results ranged from 50 to 100.
266 Flori et a!.
In subjects unresponsive to PUVA therapy, efficacy can be potentiated

by combining treatments, for example, topical application of steroids or
calcipotriol.
TOPICAL AND SYSTEMIC 8-MOP AND 5-MOP

One of the most widely used sensitizers is 8-MOP administered at a dose of 0.6
mg/kg 2 hours before irradiation with UV-A. In order to avoid qualitative
and quantitative variations that could confound the results of treatment,
patients should be given the drug at the same time of day and after the same
quantity of food. After the phototherapy session, the patient should wear
protective sunglasses and cover achromic areas with clothing or sunscreen.
For patients developing strong photo toxic reactions or gastrointestinal
problems, 5-methoxypsoralen (5-MOP) at a dose of 1.2 mg/kg may be a valid
2
alternative. The dose ofUV-A is 1-2 J/cm 2 with increments of I J/cm every
two sessions until moderate erythema develops. Some authors maintain slight
erythema in the achromic patches during treatment. Two or three treatments
are given per week. It is generally advisable not to exceed a maximum single
dose of 12 J/cm 2
PUVA treatment can also be done with topical sensitization. A 0.01-
0.10% propylene glycol solution of 8-MOP is generally applied 30 minutes
before exposure of achromic areas to UV-A. The initial dose ofUV-A is 0.12-
0.25 J/cm 2 with two sessions per week and similar increments every week.
Once slight erythema is obtained, the dose is kept constant. After each session,
the treated areas are cleansed and protected with high SPF sunscreen. This
type of treatment avoids administration of systemic agents, which is impor-
tant for patients with liver disease and for children. However, the technique is
not easy to carry out, there being a high risk of hyperpigmentation at the
periphery of the treated area and a high incidence of severe photo toxic
reactions.
TOPICAL AND ORAL KHELLIN

Another possibility is to use khellin associated with UV-A (KUVA). Khellin
is a natural furochromone extracted from the plant Ammi visnaga, used in the
past at much higher doses as a coronary dilator in the therapy of angina
pectoris. Like psoralens, khellin reacts with DNA bases in the presence ofUV
rays, forming cross links between the two chains and preventing their
replication. Khellin is less mutagenic than psoralens in vitro and less photo-
toxic. This means that exposure to sunlight or UV sources can be longer
without the need for protection in the hours following treatment.
Therapy consists of an oral dose of 100 mg khellin 2.5 hours before irra-
diation with high-intensity UV-A lamps. The initial dose ofUY-A is 6-8 J/cm 2
twice a week with increments up to a maximum of 12 J/cm 2 Reported side
effects include gastrointestinal symptoms such as nausea, vomiting, lack of
appetite, and headache, and changes in liver function (increased -y-GT and
transaminase), which reverse 5-12 weeks after suspension of therapy. Patients
should therefore be screened for liver function before undergoing KUYA.
Khellin has also been used topically as a 3-5% cream or 2% lotion
(acetone and propylene glycol~based) and shows an evident pigmentation
capacity with exposure to UV-A. The topical approach is useful for localized
and small patches of vitiligo, especially in children. An advantage of topical
KUY A with respect to topical PUYA is that exposure time is not limited by
the possibility of phototoxic reaction.
ANGELICINE
Another approach became possible with the synthesis of so-called angelicines,
angular furocumarines extracted from certain umbrelliferae. The natural
extracts do not provoke erythema or pigmentation. Introduction of methyl
groups increases pigmentation capacity up to that of psoralens but without
any of their disadvantages. Angelicine rriethylated in position 6 (6-MA) has
low phototoxicity and is therefore suitable for local treatment of vitiligo by
virtue of their capacity to stimulated epidermal melanocytes to produce
melanin. Good results have also been obtained applying an ethanol glycol
solution of 6,4,4' -trimethylangelicine to vitiligo patches 30 minutes before
irradiation with UV-A. Three sessions are given per week with an initial dose
of 1 J/cm 2 and progressive increments of 0.5 J/cm 2 every three sessions for 3
months. Retrospective studies have shown slight side effects (slight itching
and erythema), and follow-up after 6 months confirmed stability of the results
obtained.
ORAL PHENYLALANINE
The amino acid phenylalanine has also been used to treat vitiligo. The
mechanism of action is unclear. It is postulated that phenylalanine modifies
surface markers of Langerhans cells, inhibiting synthesis of autoantibodies
usually present in increased numbers in vitiligo. The number of patients
treated has not yet been sufficiently large to evaluate the efficacy of this
therapy. Oral doses of 50 mg/kg have been given 30--45 minutes before
2
exposure to UY-A three times a week. An initial UY-A dose of I J/cm with
progressive increments of I J/cm 2 per session up to a maximum of9-12 J/cm 2
268 Flori et al.
have been used. Available data indicate mean treatments for 5-6 months
before pigmentation becomes evident.
MISCELLANEOUS
Various substances are reported in the international literature to be used
systemically and/or topically with natural or artificial irradiation in the
treatment of vitiligo. Most studies have been without controls and patient
numbers too few for statistical analysis of the results. It is therefore too early
to propose these agents for clinical use. For the sake of completeness, we
mention substances such as L-dopa, tyrosine, melangenin, pseudocatalase,
and Polypodium leucotol1luS extract.
Psoralens have also been used in conjunction with UV-B (290-320 nm).
On the hypothesis that psoralens are also activated by exposure to broadband
UV-B, a comparative study was done between PUVA and PUVB in the
treatment of vitiligo. The treatments were found to be equally effective, but
UV-B was associated with a higher risk of phototoxicity due to its greater
capacity to cause erythema.
CONCLUSIONS
The only photosensitizing agents currently registered for medical use in Italy
are 8-MOP and TMP, but it has recently been difficult to obtain them in tablet
form The problem of obtaining both new and registered agents has meant
that PUVA has been used much less, particularly since phototherapeutic
alternatives, such as narrowband UV-B became available. These alternatives
are as effecti ve as PUV A for treating vitiligo and other skin diseases, with the
advantages of lower risk of phototoxic reactions and the possibility of
dispensing with systemic administration of drugs and with sun protection
after irradiation. However, the two treatments are complementary rather
than really alternative
REFERENCES
I. Badawy Abdel-Naser M, Hann S-K, Bystryn J-c. Oral psora len with UV-A
therapy releases circulating growth factor(s) that stimulate cell proliferation. Arch
Dermatol 1997; 133:1530-1533.
2. Kwok YKc. Anstey AV, Hawk JLM. Psoralen photochemotherapy (PUVA) is
only moderately effective in widespread vitiligo: a 10-year retrospective study. Clin
Exp Dermatol2002; 27:104-110.
3. Yalc;in B, Sahin S, BLikLilmez G, et al. Experience with calcipotriol as adjunctive
treatment for vitiligo in patients who do nOl respond to PUVA alone: a pre-
liminary study. J Am Acad Dermatol2001; 44:634-637.
4. Ameen M, Exarchou V, Chu AC. Topical calcipotriol as monotherapy and in
combination with psora len plus ultraviolet A in the treatment of vitiligo. Br J
Dermatol 2001; 145:476-479.
5. Ennis 0, Alpsoy E, Cetin L, et al. Is the efficacy of psora len plus ultravjolet A
therapy for vitiligo enhanced by concurrent topical calcipotriol. A placebo-
controlled double-blind study. Br J Dermatol 2001; 145:472-475.
6. Westerhof W, Nicuwcboer-Krobotova L, Mulder PGH, et al. Left-right
comparison study of the combination of fluticasone propionate and UV-A vs
either fluticasone propionate or UV-A alone for the long-term treatment of
vitiligo. Arch Dermatol 1999; 135:1061-1066.
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equally effective. Photodermatol Photoimmunol Photomed 200 I; 17: 159-163.
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intramolecular enaminone reactions. Z Naturforsch 2002; 57b:557-562.
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10. Scherschum L, Kim JJ, Lim HW. Narrow-band ultraviolet B is a useful and well-
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23
Corticosteroids in Vitiligo
Alexander J. Stratigos
and Andreas D. Katsambas
University of Athens Medical School, Andreas Sygros Hospital for Skin
and Venereal Diseases, Athens, Greece
INTRODUCTION
Since there is no definite cure for vitiligo, current treatment modalities aim
to achieve repigmentation in the lesions and to stabilize the depigmentating
process. PUVA therapy, phototherapy (UYB or narrowband UVB), topical
and systemic corticosteroids, levamisole, melagenina, 5-fluorouracil, topical
pseudocatalase, and surgical techniques (autologous minigrafting, autolo-
gous epidermal grafting) have been used in vitiligo patients with variable
success (1-4). Even in the case of partial or complete response to any of these
treatments, the risk of disease relapse remains indefinitely. In this chapter we
review the role of corticosteroids in the treatment of vitiligo and discuss their
efficacy and safety profile in the management of this common condition.
TOPICAL CORTICOSTEROIDS
Topical steroid preparations are often the first line of treatment for vitiligo,
primarily due to the ease and convenience of their application on the affected
areas. They are particularly useful in pa tien ts wi th localized patches of vitiligo
and with vitiliginous lesions that have an inflammatory component. They are
also the preferred mode of treatment for vitiligo in children. In a question-
naire-based interview of physicians managing vitiligo patients in the Nether-
lands, topical corticosteroid therapy was chosen by 79% of the respondents
272 Stratigos and Katsambas
for localized and generalized vitiligo in children less than 12 years old. In
adults, topical steroid therapy was prescribed by 64 % and 71 % of the inter-
viewed physicians for localized and generalized vitiligo, respectively (5).
Several studies have reported the efficacy of topical steroids in re-
pigmenting vitiliginous skin, but only a few have addressed this issue in a
rigorous manner. The reported rates of repigmentation following topical
steroid therapy in localized vitiligo vary significantly among investigators,
and efforts to compare these results objectively are hampered by interstudy
differences with regard to the type, extent, and duration of vitiligo, the steroid
preparations used, the clinical end points, and the overall study design
(controlled versus noncontrolled). In general, good to excellent repigmenta-
tion has been reported to occur in 9-92% of patients after a treatment period
of2 to several months (6-9). In a meta-analysis of 10 randomized controlled
studies on nonsurgical repigmentation, therapies for localized vitiligo showed
that the pooled odds ratio for topical class III steroids versus placebo was
14.32 (95%; CI, 245-83.72), while in 29 patient series the success rate of
repigmentation for topical class 3 and 4 corticosteroids was 56% and 55%,
respectively (5). Atrophy was the most common adverse effect for local
corticosteroid therapy, occurring most commonly in patients receiving intra-
lesional steroids (33%), followed by patients treated with class 4 cortico-
steroids (14 %) and class 3 corticosteroids (2 %).
When considering the therapeutic effect of topical corticosteroids in
vitiligo, several parameters should be taken into account, e.g., the location of
vitiligo, the duration of the disease, the patient's skin type, and the type
of vitiligo. In a study by Kandil (6), facial lesions responded most favorably to
topical steroid treatment, showing a diffuse increase of pigmentation until
normal skin color was attained. Lesions on the trunk, neck, and extremities
also responded well to treatment, exhibiting a follicular pattern of repigmen-
tation. Acral sites, such as the distal parts of the fingers, showed the least
response to topical steroids, although the dorsal surface of the hands achieved
partial repigmentation. On the face, patches of vitiligo around the eyes and on
the eyelids repigmented satisfactorily, although caution should be exercised
when using topical steroids on the eyelid area due to the risk of increased
intraocular pressure and glaucoma. It is unclear why facial vitiligo repigments
more readily compared to other body sites, but the high permeability of facial
skin to topical steroids, the increased numbers of residual melanocytes in the
unaffected facial skin, and the apparent reversibility of melanocyte damage in
facial lesions have been proposed as potential explanations (10).
The type of vitiligo has been reported to influence the success rate of
topical steroids in vitiligo. In one study using 0.12% betamethasone-17-
valerate, 0.01 % fluocinolone acetonide, or 0.1 % triamcinolone acetonide in
patients with vitiligo, segmental vitiligo did not respond to treatment, in
Corticosteroids in Vitiligo 273
contrast to generalized or bilateral localized vitiligo, which showed a partial

or complete response in 82.5% of patients (7). Other studies, however, have
reported a better response of segmental vitiligo to steroid therapy if the
treatment is done at an early stage (ll). In a study by Geraldez and Gutierrez
(I 2),25 Filipino patients with vitiligo oflimited extent (less than 20% of body
surface involved) were treated intermittently with clobetasol propionate
cream, twice daily for 2 weeks and then once daily thereafter. Six months
after the completion of the therapeutic trial, 22 of the 25 patients experienced
at least 90% repigmentation, while two patients (8%) failed to show any
response. Younger lesions appeared to respond faster and better, suggesting
that the duration of the disease may playa role in the therapeutic response to
corticosteroids. In addition, the age of the patient, the anatomical site of
the lesions, and the presence or absence of achromotrichia appeared to be
significant prognostic factors of the response to treatment. A retrospective
comparative analysis of nonsurgical repigmenting modalities for vitiligo in
500 Indian patients showed that topical steroids (clobetasol propionate and
sun exposure) induced moderate to excellent repigmentation in 89% of
patients (207/232) with localized vitiligo (less than 10% involvement of total
body surface), compared to 93% of the psoralen plus sun exposure group (73
of 78 patients) and 79% in the topical psoralen plus UVA radiation group (15
of 19 patients) (13). Contrary to these findings, Goldstein et al. (9) reported a
low rate of repigmentation in vitiligo patients after a 3- to 4-month course of
topical steroid therapy. About 70% of patients failed to respond to treatment
with hydrocortisone I %, hydrocortisone butyrate 1%, desonide 0.05%, or
other low-potency steroids. The remaining 30% were treated with medium- to
high-potency fluorinated steroids without showing considerable response.
Skin type may also affect the rate of repigmentation in vitiligo. In a
comparative study by Kumari (8), facial lesions of vitiligo in dark-skinned
individuals (Asian or black) responded better to intermittent use of clobetasol
propionate compared to similarly treated lesions in light-skinned patients.
Repigmentation of 90-100% was achieved in more than 8 of patients with
facial vitiligo and more than 40% of patients with vitiligo on other parts of the
body. The higher response rate in dark-skinned people has been attributed to
a higher prevalence of reversible melanocyte damage in these patients.
In practical terms, the selection of the appropriate topical steroid de-
pends mainly on the site of application. In general, medium strength topical
steroids are preferentially used in children and on nonfacial and noninter-
triginous sites on a daily basis for several months, provided that the treated
sites are observed regularly for early signs of telangiectasia or atrophy. Super-
potent topical steroids can be applied in selected treatment areas (elbows,
knees, hands), but obviously the risk of cutaneous atrophy is higher with these
agents. Treatment with topical steroids should last for at least 3 months. If
repigmentation is observed during this period, then the treatment can be

continued for a total of 6-9 months, provided that the treatment sites are
closely supervised for potential adverse effects telangiectasia, atrophy. If
the treated area does not show any signs of repigmentation after 3 months
of topical steroid use, then the treatment should be discontinued. Caution
should be exercised in delicate areas of application, for example, the eyelids,
where the prolonged use of topical steroids may complicate developmental
glaucoma in children and aggravate adult glaucoma (14).
INTRALESIONAL STEROIDS
Intralesional steroids have been used in vitiligo in an effort to improve the
efficacy of steroid treatment and increase their delivery to deeper epidermal
and dermal structures. In an uncontrolled study, Knadil (IS) treated 26
patients with vitiligo by intralesional injections of triamcinolone acetonide
(10 mgjmL). He noted a "complete" or "almost complete cure" in 58% of
treated patches (30/52) and a "satisfactory hyperpigmentation" in 29% of
lesions (15/52). A low risk of adverse effects was observed with only 8%
of patches exhibiting atrophy 10 months after the last injection. In contrast to
these findings, Visistha and Singh (16) compared the efficacy of intralesional
steroids with water injections in vitiligo and did not observe any significant
difference in repigmentation between the two groups. In addition, they re-
ported a high incidence of various adverse effects in the steroid group, such as
atrophy, telangiectasia, and intradermal hemorrhage. Similar findings were
noted by Goldstein et al. (9), who concluded that intralesional triamcinolone
is ineffective for vitiligo and left slight dermal atrophy and telangiectasia.
Other adverse effects of intralesional therapy include the f0l111ation of striae
distensae, a decrease in the mobility of finger joints from atrophy of the skin
after steroid injections, and the severe pain associated with the injections in
certain anatomical areas (10). For these reasons, the use of this modality is
generally avoided in the treatment of vitiliginous skin, with the exception
perhaps of vitiligo-associated leukotrichia, where topical application of
steroids is quite cumbersome.
SYSTEMIC STEROIDS
Vitiligo is widely considered an autoimmune disorder leading to the destruc-
tion of melanocytes. It has been proposed that systemic corticosteroids may
arrest the progression of vitiligo through their immunosuppressive properties
and lead to repigmentation of the affected lesions. This hypothesis has been
supported by evidence of a decrease of complement-mediated cytotoxicity by
autoantibodies to melanocytes and reduced antibody titers to surface anti-
gens of melanocytes in the serum of vitiligo patients who received oral cor-
ticosteroid therapy with clinical improvement (17). Based on these data,
systemic corticosteroids have been used to treat extensive and actively
spreading vitiligo.
An initial approach involved the use of long-acting adrenocorticotropin
hormone (ACTH), which was thought to have a direct stimulatory effect on
epidermal melanocytes via the MSH receptors located on the surface of
melanocytes. One group of investigators administered 25-40 JU of ACTH
twice weekly for a period of 5-6 weeks in vitiligo patients who had previously
failed therapy with PUVA (18). Repeat treatments were given with 2- to 4-
week break intervals and to a maximum of four courses. After 6 months, 80%
repigmentation occurred in 16 (59%) of those treated, 50% repigmentation in
6 (22%), and ~20% repigmentation in 4 patients (15%). These findings were
contradicted by the study of Hermandez-Perez (19), who administered two 5-
week courses of 40 mg of ACTH gel in vitiligo patients and noted poor results
in 70% of patients (14/20) with less than 20% ofrepigmentation. Only 30% of
treated patients (6/20) exhibited more than 80% repigmentation but depig-
mentation occurred rapidly after discontinuation of therapy.
Imamura and Tagami (20) used a mixture of prednisolone, betameth-
asone, paramethasone acetate, and methylprednisolone in 22 patients with
generalized and localized vitiligo. They noted a satisfactory response in 35%
patients (6/22) with more than 75% repigmentation in at least one patch
within 6 months of therapy. They also noted that repigmentation became
evident after 4 weeks of treatment and that vitiligo patches on exposed areas
had a more marked response. In addition, patients with generalized lesions
responded better than those with localized vitiligo. Lesions of more than 10
years duration or those refractory to other treatments, e.g., PUVA therapy,
responded less well to oral steroids.
The use of systemic steroids has been associated with a long list of side
effects, including gastrointestinal distress, facial swelling, body weight in-
crease, striae distensae, acneiform eruptions, menstrual disturbances, osteo-
porosis, and avascular necrosis of bone. In order to minimize these potential
side effects, safer steroid regimens, such as low-dose oral steroids or oral
intermittent (pulse) therapy with betamethasone or dexamethasone, have
been used in patients with extensive or rapidly spreading vitiligo. Kim et al.
(21) used low-dose steroid therapy (0.3 mg prednizolone/kg) in actively
spreading vitiligo and noted an arrest of the progression of the disease in 71
of81 patients (87.7%) and some repigmentation in 57 of81 patients (70.4%)
after 4 months of tapered treatment. Interestingly, patients with <2 years dis-
ease duration had a better response, with repigmentation occurring in 38 of
49 patients (77.6%). In patients with vitiligo of >2 years duration, repig-
mentation was achieved in 20 of 32 patients (62.5%), while spreading oc-
curred in 9 of the treated patients (28.1 %). Differences in repigmentation rates

were also noted depending on the type of vitiligo, with lesions of segmental
vitiligo showing repigmentation in 76.7% of 30 patients, localized vitiligo in
87.5% of 8 patients, and generalized vitiligo in 62.8% of 43 patients. In
addition to these observations, the study confirmed once more the favorable
outcome of facial lesions to oral steroid therapy, with repigmentation oc-
curring in 69.8% of 63 patients. Of the 81 patients in the study, 35 did not
report any side effects, while 46 complained of one or more side effects, the
most common being facial edema (21 % of patients), weight gain (17.3 %), and
acneiform eruptions (9.9%). Other reported symptoms were gastrointestinal
distress, frequent urination, increased appetite, abdominal pain, hypertricho-
sis, menstrual irregularities, diarrhea, and striae distensae. The authors
concluded that low-dose oral corticosteroids were effective in preventing
the progression and inducing repigmentation of actively spreading vitiligo.
Pasricha and Khaitan (22) treated 40 Indian patients with extensive or
fast-spreading vitiligo with an oral minipulse therapy with betamethasone/
dexamethasone 5 mg given as a single oral dose after breakfast on 2 con-
secutive days every week. After 1-3 months of treatment, the vitiligo was
arrested in 32 of 36 patients (89%), while in 2 patients higher steroid doses of
7.5 mg/day were required to achieve complete arrest of their vitiligo. Within
2--4 months, 32 of the patients (80%) showed evidence of lesional repigmen-
tation, the extent of which differed from patient to patient and from lesion to
lesion in the same patient. Six patients (15%) showed 76-99% repigmenta-
tion, 3 patients (7.5%) had 51-75% repigmentation, and 21 patients (58.3%)
achieved < 25% of repigmentation. Weight gain (5-7 kg), bad taste, head-
ache, transitory general weakness, facial puffiness, and acne were the most
frequently experienced symptoms by these patients. Kanwar et al. (23) studied
a different oral minipulse therapy in patients with rapidly spreading vitiligo
(23). The regimen consisted of dexamethasone (5 mg for adults, 2.5 mg for
children) given on 2 consecutive days a week. A range of 5-25 doses was tried.
Only 14 of the 32 patients (43.8%) who completed the trial had a mild-to-
moderate repigmentation without appearance of new lesions. In 18 patients
(56.2%) no response was observed. In patients who repigmented, the response
occurred after the first 15 weeks of treatment. Of the 9 children that completed
the study, only 4 had mild-to-moderate repigmentation. No significant side
effects were reported by the treated patients.
Both of these studies on the role of pulse steroid therapy on vitiligo were
centered on Indian or Asian patients. Since ethnic background has been
suggested to playa role in the therapeutic response of vitiligo, a study by
Radakovic-Fijan et al. (24) explored the efficacy and safety of dexamethasone
pulsed therapy in 29 Austrian patients with progressive or stable disease. The
patients were given weekly pulses of to mg of dexamethasone each on
2 consecutive days followed by 5 days off treatment for a maximum of 24

weeks. Although the disease activity was arrested in 22 of 25 patients (88%)
with active vitiligo, only 2 patients (6.9%) showed more than 50% repigmen-
tation. No response was noted in 21 patients (72.4%). As in the study of
Pasricha and Khaitan (22), the probability of marked repigmentation was
found to correlate wi th increasing duration of the treatment. Side effects were
recorded in 20 patients (69%) and included weight gain, insomnia, acne,
agitation, menstrual disturbances, and hypertrichosis. The plasma levels of
cortisol and corticotropin were markedly decreased 24 hours after the second
dexamethasone dose, but returned to baseline during the off-treatment
periods. These findings suggested that oral dexamethasone pulse treatment
was effective in arresting progression of vitiligo but had a limited capacity to
induce cosmetically acceptable repigmentation when given as monotherapy in
this patient population. Finally, in a smaller European study of 14 patients
with generalized vitiligo, high-dose methylprednisolone pulse therapy (8 mg/
kg body weight) induced an arrest of the disease activity in 85% of the treated
patients (25). Repigmentation occurred in 71 % of patients with progressive
vitiligo but in none of the six patients with stable disease. With the exception
of one patient who developed intermittent arterial hypertension during
therapy, all other patients tolerated the treatment well.
COMBINATION THERAPIES
Topical steroids have been effectively combined with other modalities in the
treatment of vitiligo. Daily application of potent topical steroids has been
noted to substantially improve the results of PUVA therapy on recalcitrant
vitiligo lesions (26). In a recent left-right comparative study, it was shown that
the combined treatment with fluticasone and UV A radiation led to a higher
repigmentation response compared to treatment with either fluticasone or
UVA radiation alone (27).
CONCLUSIONS
The outcome of steroid treatment in patients with vitiligo appears to depend
on several factors, such as the type and extent of vitiligo, the location of the
lesions, and the duration of the disease. Topical steroids are considered the
first line of treatment for localized vitiligo in children and adults. As with
other treatment modalities in vitiligo, facial lesions show the most favorable
response to topical steroids, while acral lesions respond the least. The efficacy
of intralesional corticosteroids in vitiligo remains questionable and is gen-
erally associated with a high incidence of adverse effects such as cutaneous
atrophy and telangiectasia. Systemic steroids have been shown to arrest the
progression of vitiligo and induce repigmentation in the affected areas, but

their use requires careful patient screening and serial laboratory tests. Low-
dose systemic steroids or pulsed regimens with dexamethasone or betameth-
asone are currently preferred due to their lower risk of side effects.
REFERENCES
I. Antoniou Ch, Katsambas A. Guidelines for the treatment of vitiligo. Drugs 1992;
43(4):490--498.
2. Le Poole IC, van den Wijingaard RMJGJ, Westerhof W, et al. Presence or
absence ofmelanocytes in vitiligo lesions: an immunohistochemical evaluation. J
3. Shaffrali FCG, Gawkrodger DJ. Management of vitiligo. Clin Exp Dermatol
2000; 25:575-579
4. Antoniou Ch, Schulps H, Michas T, Katsambas A, Frajis N, Tsagaraki S,
Stratigos J, Vitiligo therapy with oral and topical phenylalanine with UVA
exposure. lnt J Dermatol 1989; 28(8):545-547.
5. Njoo MD, WesterhofW, Bos JD, Bossuyt PMM. The development of guidelines
for the treatment of vitiligo. Arch Dermatol1999; 135:1514-1521.
6 Kandil E, Vitiligo response to 0.2% betamethasone 17-valerate in flexible col-
loidum. Dermatologica 1970; 141:277-281.
7. Koga M, Vitiligo: a new classification and therapy. Br J Dermatol 1999; 97:255-
261.
8. Kumari J, Vitiligo treated with topical clobetasol propionate. Arch Dermatol
1984; 120631-635.
9. Goldstein E, Haberman HF, Menon lA, Pawlowski D. Non-psoralen treatment
of vitiligo. Part II. Less commonly used and experimental therapies. Int J
Dermatol1992; 3l:314-319,
10. Hann SK. Steroid treatment for vitiligo. In: Hann Seung-Kyung, James J
Nordlund, eds. Vitiligo. Oxford: Blackwell Science, 2000: 173-] 81.
J I. Moon TK, 1m S, Har1ll SK, Cho SH, Park YK. The effect of small doses of oral
corticosteroids in vitiligo patients. Korean J Dermatol 1995; 33:880-885.
12. Geraldez CB, Gutierrez GT A clinical trial of clobetasol propionate in Filipino
vitiligo patients. Clin Therap 1987; 9:474--482.
13. Handa S, Pandhi R, Kaur I. Vitiligo: a retrospective comparative analysis of
treatment modalities in 500 patients. J Dermatol 2001; 28:461--466,
14. Morgan MR. Possible side effects of topical steroids. Am Fam Phys 1981; 23:
171-174.
15. Knadil E. Treatment of localized vitiligo with intradermal injection of triam-
cinolone acetonide. Dermatologica 1970; 140: 195-206.
16. Visistha LK, Singh G. Vitiligo and intralesional steroids. Ind J Med Res 1979;
69:308-311.
17. Hann SK, Kim HI, 1m S, et al. The changes of melanocyte toxicity after systemic
steroid treatment in vitiligo patients. J Dermatol Sci 1997; 6:201-205.
J 8. Gokhale BB, Gokhale TB. Corticotropin and vitiligo (preliminary observations).

Br J Dermatol 1976; 95:329.
19. Hermandez-Perez E. Vitiligo treated with ACTH. lnt J Dermatol 1979; 18:587-
589.
20. Imamura S, Tagami H. Treatment of vitiligo with oral corticosteroids. Derma-
tologica 1976; 153:179-185.
21. Kim SM, Lee HS, Hann SK. The efficacy oLlow-dose oral corticosteroids in the
treatment of vitiligo patients. lnt J Derrnatol 1999; 38:546-550.
patients baving extensive or fast-spreading disease. lnt J Dermatol 1993; 32:753-
757
23. Kanwar AJ, Dhar S, Dawn G. Oral minipulse therapy in vitiligo. Dermatology
1995; 190:251-252.
24. Radakovic-Fijan S, Furnsinn-Friedl, Honigsmann H, Tanew A. Oral dexameth-
asone pulse treatment for vitiligo. JAm Acad Dermatol2001; 44:814-817.
25. Seiter S, Urugel S, Tilgen W, Reinhold U. Use ofbigh-dose methylprednisolone
pulse therapy in patients with progressive and stable vitiligo. lnt J Dermatol
2000; 39:624-627.
26. Honig B, Morison WL, Karp D. Photochemotherapy beyond psoriasis. J Am
Acad 1994; 31:775-790.
27. Westerhof W, Nieuweboer-Krobotova L, Mulder PG, Glazenburg EJ. Left-
right comparison study of the combination of f1uticasone propionate and UV-A
vs eitber f1uticasone propionate and UV-A alone for the long treatment of
vitiligo. Arch Dermatol2999; 135:1061-1066.
24
Vitamins and Vitiligo
Evridiki Tsoureli-Nikita, Claudio Comacchi,

Giovanni Menchini, and Torello Lotti
The hypothesis that a deficiency of certain nutritional elements contributes in

part to the pathogenesis of vitiligo has been proposed. Recent research has
sought to demonstrate that replacement therapy with deficient vitamins or
trace elements can lead to successful repigmentation (1).
Vitamins are organic substances necessary in small quantities for
cellular metabolism. These compounds need to be ingested because they
cannot be synthesized by the organism, yet playa crucial role in the
development and maintenance of vital functions. Vitamins can be classified
as water-soluble or lipid-soluble (Table I) (2).
Provitamins are the inactive precursors of vitamins that can be activated
to become vitamins through external factors [e.g., ultraviolet (UV) radiation]
or enzymatic action. Recently vitamins such as vitamin B 12 , folic acid, ascor-
bic acid, and vitamin D derivatives, alone or in association with photo-
therapy, have been introduced in the treatment of vitiligo (2--4).
In 1992 Montes et al. (3) found abnormally low levels of vitamin B I2 and
folic acid in 15 patients affected by vitiligo. For the next 3 years, certain
patients recovered oral supplementation of folic acid, vitamin C, and vitamin
B 12 . After only 3 weeks of treatment, vitiligo spread ceased, and at the end of
the second year, more than 80% of patients treated had experienced signifi-
cant repigmentation of vitiligo patches (3).
282 TSQureli-Nikita et a!.
TABLE 1 Hydrosoluble and Liposoluble Vitamins
Hydrosoluble vitamins Liposoluble vitamins
Thiamine (B 1 ) Retinol (A)

Riboflavin (B 2 )
Nicotinamide (PP) Vitamin 0
Pantothenic acid ex-Tocopherol (E)
Pyridoxine (B 6 ) Vitamin K
Biotin
Folic acid
Cobalamin (B 12 )
Ascorbic acid (C)
Juhlin et al. (4), based on the positive results described above, utilized an
association of oral folic acid and vitamin B I2 with eliotherapy (or UVB
exposure in winter) to treat patients affected by vitiligo. The results obtained
have been encouraging, far better than those obtained with phototherapy or
vitamins alone (4). A possible explanation for this therapeutic effect seems to
be associated with metabolism of pteridins contained in folic acid. Schall-
reuter et al. (5) have suggested that the pteridin part of folic acid could
interfere with the recycling of reduced pteridins found in vitiligo. Pteridins
deficiency could significantly decrease tyrosine concentration, leading to
inhibition of pigmentation.
It is known that N-N-methylene-tetrahydrofolate regulates plasma
levels of homocysteine, giving a methyl group to homocysteine in order to
produce methionine. This process is vitamin B l2 dependent; it seems that
vitamin B I2 downregulates the metabolism of homocysteine, partly respon-
sible for the depigmentation in vitiligo (I).
It has recently been hypothesized that the cofactor 5,6,7,8-tetrahydro-
biopterin (6BH 4 ) is involved in the pathogenesis of vitiligo. During vitiligo
there is increased de novo synthesis and recycling of 6BH.j with low DH
dehydratase activity. The 6BH 4 accumulation with low DH dehydratase ac-
tivity causes the formation of a 7-isomer (7BH 4 ), which inhibits phenylalanine
hydroxylase enzyme (PAH) and tyrosinase, an enzyme that plays a pivotal
role in melanin biosynthesis. The weak activity of PAH is not sufficient to
transform an adequate quantity ofL-phenylalanine, and the consequent mela-
nocyte accumulation of L-phenylalanine and 7BH 4 causes, thanks to the de-
creased DH and PAH activities, production of H 2 0 2 during a short circuit in
the 6BH 4 recycling process (6,7).
The high H 2 0 2 levels accumulated are cytotoxic to melanocytes in that
they: (a) deactivate catalase (a catalyst for the conversion of hydrogen per-
Vitamins and Vitiligo 283
oxide into water and oxygen, with one of the highest turnover rates for all
known enzymes-40,000,000 molecules/sec); (b) oxidize 6BH 4 and 7BH 4 into
6-biopterin, which is cytotoxic for melanocytes; and (c) induce activation of
dendritic cells followed by selective T-cell proliferation. The dietary intake of
a-tocopherol (vitamin E) and ascorbic acid (vitamin C) in patients with viti-
ligo reinforces the organism against oxidative stress and free radical forma-
tion due to the mechanism described above (8).
Because vitiliginous areas that respond best to phototherapy are those
containing black or brown hair (vs. white), the presence of melanocyte pre-
cursors (melanoblasts) in the hair bulbs has been proposed in the context of
the vitiligo patches. In fact, vitamin B J2 and folic acid would exert their bene-
ficial effects not only by correcting the BH4 excess, but also by stimulating
dermis and hair bulb melanoblasts (9,10). It has recently been demonstrated
that patients with vitiligo exhibit reduced levels of intracellular calcium in
both keratinocytes and melanocytes (II). The calcium decrease leads to high
thioredoxin levels, which could inhibit tyrosinase activity. For this reason it
has been hypothesized that synthetic derivatives of vitamin D act on melano-
cyte receptors for 1,25-dihydroxy vitamin D, modifying and equilibrating the
altered calcium homeostasis. In 1998 Parsad et al. demonstrated that the
combination of PUVA plus calcipotriol permitted a more rapid repigmen-
tation of vitiliginous patches compared to PUVA treatment alone (12).
The effective treatmen t of vitiligo requires prompt evaluation of the site
and extent of the lesions, as well as the degree of pigmentation of the sur-
rounding skin. Vitamin therapy has proven to be useful and leads to satis-
factory repigmentation when applied consistently and in appropriate dosages.
Nevertheless, the long time required for the treatment-months or even
years-before seeing results, indicates the need for further study of such sup-
plementation in order to better understand how and when to use vitamins for
vitiligo.
REFERENCES
I. Hann SK, Nordlund n, eds. Vitiligo. London: Blackwell Science, 2000:222-240
2. Lotti T, ed. La Vitiligine: Nuovi Concetti e Nuove Terapie. Milan: Utet, 2000:96-
140
3. Montes LF, Diaz ML, Lajous J, Garcia NJ. Folic acid and vitamin B12 in
vitiligo: a nutritional approach. Cutis 1992; 50:39-42.
4. Juhlin L, Olsson MJ. Improvement of vitiligo after oral treatment with vitamin
B12 and folic acid and the importance of sun exposure. Acta Derm Venereol
1997; 77:460-462
5. Schallreuter KU, Schulz-Douglas V, Bunz A, Beazley W, Korner C. Pteridines in
the control of pigmentation. J Invest Dermatol 1997; 109(1 ):31-35.
284 Tsoureli-Nikita et al.
6. Rokos H, Beazley WD, Schallreuter KU. Oxidative stress in vitiligo: photo-

oxidation of pterins produces H 2 0 2 and pterin-6-carboxylic acid. Biochem Bio-
phys Res Comm un 2002; 292(4):805-811.
7. Schallreuter KU, Moore 1, Wood 1M, Beazley WD, Peters EM, Maries LK,
Behrens-Williams SC, Dummer R, Blau N, Thony B. Epidermal H 2 0 2 accu-
mulation alters tetrahydrobiopterin (6BH4) recycling in vitiligo: identification of
a general mechanism in regulation of all 6BH4-dependent processes? 1 Invest
Dermatol 200 I; 116(1): 167-174.
8. Akyol M, Celik YK, Ozcelik S, Polat M, Marufihah M, AtaJay A. The effects of
vitamin E on the skin lipid peroxidation and the clinical improvement in vitiligo
patients treated with PUYA. Em 1 Dermatol 2002; 12(1):24-26.
9. Norris AL, Bailey A, Askham 1, Whitehouse A, Clissold PM, Markham AF,
Meredith DM. The expression of the c-kit receptor by epidermal melanocytes
may be reduced in vitiligo. Br 1 Dermatol 1996; 134(2):299-306.
10. Grichnik 1M, Ali WN, Burch lA, Byers JD, Garcia CA, Clark RE, Shea CR.
KIT expression reveals a population of precursor melanocytes in human skin. 1
Invest Dermatol 1996; 106(5):967-971.
J1. Schallreuter KU, Pittelkow MR, Swanson NN. Defective calcium transport in
vitiliginous melanocytes. Arch Dermatol Res 1996; 288: 11-13.
12. Ameen M, Exarchou Y, Chu AC. Topical calcipotriol as monotherapy and in
combination with psoralen plus ultraviolet A in the treatment of vitiligo. Br 1
Dermatol200J; 145(3):476.
25
Alternative Treatments for Vitiligo
lIaria Ghersetich, Benedetta Brazzini,

and Torello Lotti
Giovanni Menchini
Alternative and experimental treatment options have been added to the

armementarium of established treatments used for vitiligo including psoralen
photochemotherapy (PUYA), UYB phototherapy, corticosteroids, cosmetic
camouflage, depigmentation, permanent tattooing, and surgical treatments.
Considering these options, it is not always easy to determine the efficacy of
alternative treatment options for vitiligo, as nearly 10% of patients vitiligo
can undergo spontaneous repigmentation. In addition, the placebo effect of
any treatment must also be considered.
L-PHENYLALANINE
Several studies have demonstrated that treatment with oral and/or topical
L-phenylalanine and sunlight or UYA induces repigmentation of vitiligo
patches, especially if used in combination with other treatments. Phenylala-
nine is not photo toxic; it actually induces tolerance to sun exposure ofvitiligo
patches. Phenylalanine inhibits the activities of cytolytic antibodies, allows
sunlight to stimulate the migration of melanocytes from adjacent areas, and
encourages the production of melanin in the damaged melanocytes of the
follicular bulb (1-3).
286 Ghersetich et al.
Existing algorithms suggest that 50 mg/kg of L-phenylalanine be given

to patients 30 minutes to I hour before UVA therapy. The initial dosage of
1 J/cm 2 is increased I J/cm 2 every two treatments up to a maximum dose of
7-9 J/cm 2 for skin types I-III and 12-15 J/cm 2 for skin types IV-V. It is
recommended to treat patients twice weekly for 12-36 weeks (1). A second
method is to give patients 50 mg/kg of phenylalanine daily 45 minutes before
30 minutes of sun exposure and to have patients apply a 10% phenylalanine
gel 15 minutes after the oral dose (2).
L-Phenylalanine can also be used in combination with narrowband
UVB microphototherapy. Patients ingest 1500 mg ofL-phenylalanine 3 hours
before UVB exposure.
Follicular repigmentation of the hypopigmented macules usually occurs
after 3-6 months of therapy. Good repigmentation occured on the periorificial
areas, especially the face, but no satisfying results were seen on the trunk or distal
portions of the limbs (1-3). No serious side effects have been reported aside from
mild nausea. Contraindications include phenylketonuria, abnormal kidney
and liver function, malignant skin diseases, pregnancy breast-feeding, history
of arsenic exposure, prior radiotherapy (Fig. I) and autoimmune disorders.
KHELLIN AND UVA

Khellin is a furanochromone derivative isolated from seeds of the plant
(Ammi visnaga) found in eastern Mediterranean areas. Its chemical structure
is very similar to that of psora lens, and it exerts similar photobiological ther-
apeutic effects.
Khellin forms prevalently monofunctional photoadducts with cellular
DNA and is therefore less photo toxic, mutagenic, and carcinogenic than
psoralens, but it is apparently able to induce repigmentation similarly to pso-
ralens (4).
It has been reported that khellin is a useful alternative drug, when
combined with UVA (KUVA), for the treatment of patients with localized
(nonsegmental) or generalized vitiligo. Khellin can be administered either
systemically or topically and in combination with sunlight or UV A therapy
(5-7).
For topical treatment, a 2% solution of khellin in acetone 90% and
propylene glycol 10% must be applied to affected areas I hour before UV
exposure. When topical khellin is combined with sunlight exposure, the
patient is recommended to sunbathe initially for 10 minutes and increase
the exposure time 10 minutes each week up to a maximum of90 minutes. The
therapy is performed 3 days a week on alternate days for at least 4 months.
When UVA exposure is chosen, patients undergo a constant UVA dose that
Alternative Treatments for Vitiligo 287
FIGURE 1 Ammi visnaga.
varies, according to the skin phenotype, between 10 J/cm 2 for skin types I-III
and IS J/cm 2 for skin types IV-V.
For systemic therapy, patients are treated with an oral daily single
100 mg dose of khellin. On the day ofUV exposure 100 mg of khellin must be
administered 2.5 hours before irradiation. The UV therapy is the same as for
topical khellin.
Therapy is maintained as long as the repigmentation process continues
and should be stopped when repigmentation ceases. Short-term side effects
may occur with both topical and systemic administration of khellin, but long-
term side effects other than hyperpigmentation of healthy skin have not been
reported. The short-term side effects are mainly represented by mild nausea,
orthostatic problems, and elevation of liver transaminase (8). When liver
transaminase levels increase, khellin must be discontinued.
MELAGENINA I AND II
Melagenina 1 is a hydroalcoholic extract of the human placenta identified
in Cuba in 1976 (9). Melagenina I contains lipids, free fatty acids, amino
acids, phospholipids, and mineral salts (copper). The active ingredient is an
a-lipoprotein prepared by crushing the cotyledons of human (or other mam-
malian) placentas and extracting the low molecular weight lipoprotein with
95% ethanol (10, II). This purified active principle is called melagenina II.
The a-lipoprotein EP-50 added to dihydroxyphenylalanine (DOPA)
seems to accelerate the conversion of DOPA to melanin. However, this re-
action is dependent on the pH (alkaline pH) and the presence of mineral salts
(copper and other cations) in the solution.
Melagenina should be applied to all vitiliginous areas of the body three
times a day, usually at 8-hour intervals. The treated areas are exposed once a
day for 15 minutes to infrared light or sunlight. To date, no adverse local or
systemic effects have been reported. The results, in terms of repigmentation,
reported in the literature are very controversial (12,13), and the quality and
safety controls used are unclear. For example, it is not clearly specified
whether each placental sample is screened for the presence of infectious
agents (in particular AIDS and hepatitis viruses).
The use of mel agenina remains experimental until random double-blind
studies are performed for both efficacy and safety.
MINOXIDIL
Topical application of rninoxidil (14) in combination with PUVA seems to
accelerate repigmentation in vitiligo patients. The theory behind this therapy
was based on the fact that repigmentation in vitiligo patches occurs first in the
perifollicular areas and that minoxidil induces darkening of hair in addition to
regrowth. However, later experiences failed to demonstrate the effectiveness
of this therapy (15).
HOMEOPATHY
The disciplines of homeopathy and homeotossicology consider vitiligo not
as a cutaneous disease, but as an external reflection of an inner pigment dis-
order. Vitiligo is therefore considered a disorder of the entire human system
and not just of the skin. On these bases, homeopathic doctors strongly believe
in treating vitiligo exclusively with oral therapy.
In addition, each individual suffering from vitiligo (or any other disease)
is considered a unique case, and therefore homeopathy believes in treating the
patient and not the disease. This means that each patient is specifically treated
as a whole.
Homeopathy promotes a constitutional approach based on the analysis
and evaluation of various factors affecting the human constitution to deter-
mine the disease diagnosis and the exact treatment. Every case of vitiligo
requires evaluation of the patient's "constitution," which includes various
aspects of the physical features as well as an in-depth study of the emotional
sphere (emotions, psychosocial background, etc.). When the homeopathic
remedy selected is administered in the correct dose, it brings back harmony
at the constitutional level, stimulating normal pigmentation. Unfortunately,
double-blind studies are lacking.
AYURVEDIC MEDICINE
Ayurveda was originally a Hindu medical healing system which had its
beginning more than 2500 years ago in the sixth century R.C. (Fig. 2). It was
adapted by Buddhists and other religious groups and has recently undergone
a rebirth in India and throughout the western world, where it is considered a
viable alternative to allopathic Western medicine. Ayurveda is actually a
humoral medical model. The humors are defined as air, bile, phlegm, and
blood. Ayurveda postulates that most humans are born in humoral balance
but soon lose this balance due to unbalanced diet, unbalanced emotional
experiences, or traveling away from the physical location on the Earth which
is most in harmony with his or her constitution. The primary means of return-
ing to humoral balance is diet. While Ayurveda has general recommendations
for diet that anyone can follow for optimal health, more serious illnesses are
treated by a qualified Ayurvedic physician. For the treatment of vitiligo,
FIGURE 2 Symbol of ayurvedic medicine.
ayurvedic medicine usually uses vegetarian products made with leaves, fruits,
radishes, and barks of various plants administered orally. Accompanying
exposure to sunlight or UV radiation is not necessary. Usually 3-6 months of
therapy is needed. Double-blind studies are not available.
CLIMATOLOGICAL AND BALNEOLOGICAL THERAPIES

Vitiligo is a dermatological disease that can benefit from sun exposure and the
use of mineral spring waters and mud from the Dead Sea (16,17). The Dead
Sea is located at the lowest point on Earth-400 m below sea level-and it is
the saltiest lake, its salinity reaching 290 giL. The natural elements and min-
erals in the sea, in addition to the mud present on its shores, give the water
their curative powers. An other important factor in this cure is from the natu-
rally filtered ultraviolet radiation, which permits prolonged exposure to
sunlight with minimal phototoxicity. The therapeutic effects are in part due
to the thick atmospheric layer over the Dead Sea, with its vapor and haze, and
to the large amounts of ozone present. The climatic conditions may also have
a positive effect on the neuro-immuno-cutaneous-endocrine system, by in-
ducing the release of neuropeptides such as a-melanocyte-stimulating hor-
mone and proopiomelanocortin (POMe), the precursor of endorphins, that
seem to playa central role in OYB-induced cutaneous melanogenesis (18,19).
REFERENCES
1. Cormane RH, Siddiqui AH, WesterhofW, Schutgens RBH. Phenylalanine and
UV A light for the treatment of vitiligo. Arch Dermatol Res 1985; 277: I26-
130
2. Cormane RH, Siddiqui AH, WesterhofW, Schutgens RBH, Hu R, Mohan VI.
Treatment of vitiligo with L-phenylalanine and light. Sr J Dermatol 1986; 115:
587
3. Camacho F, Mazuecos J. Treatment of vitiligo with oral and topical phenyl-
alanine: 6 years of experience. Arch Dermatol 1999; 135:216-217.
4. Morliere P, Honigsmann H, Averbeck D, Dardalhon M, Huppe G, Ortel B,
Santus R, Dubertret L. Photo therapeutic, photobiologic and photosensitizing
properties of khellin. J Invest Dermatol 1988; 90:720-724.
5. Mandell AS, Haberman HF, Pawlowski D, Goldstein E. Non PUVA non-
surgical therapies for vitiligo. Clin Dermatol 1997; 15:907-9 I9.
6. Orecchia G, Perfetti L. Photochemotherapy with topical khellin and sunlight in
vitiligo. Dermatology 1992; 184(2):120-123.
7. Ortel B, Tanew A, Honigsmann H. Treatment of vitiligo with khellin and
ultraviolet A. JAm Acad Dermatol 1988; 18(4 pt 1):693-701.
8. Duschet P, Schwartz T, Pusch M, Gschnait F. Marked increase of liver trans-
aminase after khellin and UVA therapy. J Am Acad DermatoJ J989; 21:592-593.
9 Cao CM, Taboas M, Garcia J, Gonzalez E. Estudio experimental y c1inico del
efecto pigmentante epidermico del extracto placentario humano. In: Melagenina,
ed. Seleccion de Trabajos de Investigacion Publicados y Presentados en Eventos
Cientificos, 1976-1989. Havana, Cuba: Palacio de las Convenciones de Cuba,
1989:21-30.
10. Cao CM, Taboas M. Placental alfa-lipoprotein for stimulating the synthesis of
melanin. German Patent. 3229-738 (Ch-AG J-K-37-07) February 16, 1984.
II. Nordluna 11, Halder R. Melagenina: an analysis of published and other available
data. Dermatologica 1990; 181:1-4.
12. Cao Me. Melagenina: 16 anos de experiencia cubana en el tratamiento del
vitiligo. La Melagenina, Nuevo Medicamento Cubano para el Trattamento del
Vitiligo. Havana, Cuba: lmpreso, 1989:3-20.
13. Suite M. Quamina DBE: Treatment of vitiligo with topical melagenina-a
human placental extract. J Am Acad Dermatol 1991; 24: 1018-1019.
14. Oumeish OY. Climatotherapy at the Dead Sea in Jordan. Clin Dermatol 1996;
14:659-664.
15, Srinivas CR, Shenoi SD, Balachandran e. Acceleration of repigmentation in
vitiligo by topical minoxidil in patients on photochel11otherapy. Int J Dermatol

1990; 29(2): 154-155.
16. Orecchia G, malagoli PG, Santagostino L. Topical minoxidil does not potentiate
the effect of sunlight in vitiligo repigmentation. Ann Ital Dermatol Clin Sper
1994; 4881-83
17. Kushelevsky AP, Harari M, Kudish AI, Hristakieva E, Ingber A, Shani J.
Safety of solar phototherapy at the Dead sea. J Am Acad Derl11atol 1998; 38(3):
447-452.
18. Chakraborty A, Slol11insky A, Ermak G, Hwang J, Pawelek J. Ultraviolet B
and melanocyte stimulating hormone (MSH) stimulate mRNA production for
alpha MSH receptors and proopiomelanocortin-derived peptides in mouse mel-
anoma cells and transformed keratinocytes. J Invest Dermatol 1995; 105:655-
659.
19. Lotti T, Bianchi B, Brazzini B, Hercogova J, Ghersetich 1. Can the brain in-
hibit inflammation generated in the skin? The lesson of alpha-melanocyte-stim-
ulating hormone. lnt J Dermatol2002; 41(6):311-318.
26
Vitiligo: Problems and Surgical Solutions
Rafael Falabella
Universidad del Valle, Cali, Colombia
GENERAL CONSIDERATIONS
Most vitiligo patients become affected between 5 and 30 years of age, but a
good number of them develop this condition thereafter (1); sometimes the
disease appears after age 50, although it is infrequent after the seventh decade
of life. The condition does not produce a physical handicap, it is asympto-
matic, but may be psychologically devastating (2). The cause of vitiligo is not
completely known, but many factors contributing to depigmentation have
been documented. Although medical therapy has improved considerably in
recent years, at the present time complete repigmentation cannot always be
achieved, particularly in acral regions. Surgical therapy has provided addi-
tional success for refractory areas, offering higher repigmentation rates, but
proper selection of patients for such treatments is important to reach ade-
quate results.
Vitiligo is a condition with two main clinical forms of presentation:
unilateral vitiligo (segmental, asymmetrical) and bilateral vitiligo (nonseg-
mental, symmetrical) (3). Unilateral vitiligo affects young patients mainly
before the age of 20, most of them having a rapid course for a few months after
which stabilization occurs without further depigmentation. Involvement of
regional areas on one side of the cutaneous surface is usually observed, and
remarkably high rates of repigmentation with surgical techniques are fre-
quently achieved in this form of vitiligo (4,5). In contrast, bilateral vitiligo is a
slow-developing condition, sometimes rapid spread, with a tendency to
progress throughout the years, and with fewer possibilities of stabilization.
294 Falabella
In a small percentage of these individuals, arrest of the condition may occur,

but surgical repigmentation may only be obtained in less than 50% of the
treated patients (5,6).
This chapter will deal not only with the techniques, but also with the
problems associated with the mechanisms of repigmentation and specific
difficulties observed when surgery is performed.
PATHOGENESIS OF VITILIGO: CLUES FOR SURGICAL

SOLUTIONS
When surgical intervention is considered, general knowledge as to why
depigmentation occurs in vitiligo is important for understanding the possi-
bilities and limitations of such therapies. Intrinsic damage to melanocytes
leading to the intracellular accumulation of abnormal proteins (7), immune
alterations with humoral and cellular participation (8), autocytotoxic damage
to pigment cells because of the generation of catechols, phenols, and other
molecules during melanin synthesis (9), pathological changes of fine nerve
endings within the epidermis and upper dermis together with neuropeptide
disturbances (10), and biochemical altera tions of pteridines wi th subseq uent
increase of hydrogen peroxide and free radicals (II) have been implicated in
the pathogenesis of vitiligo as etiological theories, in which different molecules
may provoke toxic and/or inhibitory effects on pigment cells, but the real
cause and sequence of events leading to depigmentation are yet to be de-
termined. A convergence theory, suggesting that all factors described in these
theories may contribute to the pathogenesis of vitiligo, has also been proposed
(12). In other ailments associated with vitiligo, such as endocrine disorders,
which are the most frequently observed, organ-specific antibodies have also
been described. Among these alterations, thyroid disorders, diabetes, hypo-
parathyroidism, adrenal insufficiency, and hypogonadism, either alone or in
combination, as in the polyglandular endocrine syndromes types I and II, are
the endocrinopathies reported (13). In summary, although the ultimate cause
of vitiligo is not completely known, this condition reflects not a mere
pigmentation loss but the result of profound immunological alteration and
other molecular defects acting for variable periods of time that originate
melanocyte destruction; nevertheless, and regardless of the affected area,
melanocytes may be present in depigmented skin even after years of onset (14)
and may still respond to medical therapy under appropriate stimulation.
When the condition becomes stabilized and the acting depigmenting noxa
becomes in some way arrested, the possibilities for repigmentation are con-
siderably higher and surgical therapies may be successful.
Vitiligo: Problems and Surgical Solutions 295
THE REPIGMENTATION PROCESS

When melanocytes are stimulated during medical therapy, pigment cells
originate and proliferate from three different sources: (a) from the piloseba-
ceous unit, which provides the highest number of cells, migrating from the
external root sheath toward the epidermis (15); (b) from spared melanocytes
that were not affected during depigmentation, present in large numbers within
hypopigmented areas, and being less numerous in depigmented lesions (14);
and, finally, (c) from the border of lesions, migrating up to 3-4 mm from the
edge. Jn recent years a new population of immature melanocytes expressing the
C-kit protein (an important molecule implicated in melanocyte development
and migration during embryogenesis), located mostly around the follicular
ostium but less abundant in the rete pegs and eccrine sweat ducts, has been
described; these cells have been suggested as the true melanocyte reservoir
and would provide pigment cells for repigmentation of the new epidermis
regenerating after trauma or other types of skin injury or to replace melano-
cytes tha t disappear by destruction or apoptosis, as may happen in vitiligo (16).
VITILIGO: A "COSMETIC" VERSUS "SOCIAL" DISEASE

Vitiligo is a symptom-free disease and does not provoke the usual manifes-
tations of cutaneous illness, namely pruritus, pain, burning or stinging sen-
sations, paresthesia, and so on. However, patients are very concerned with
this ailment and feel that developing depigmentation will interfere with their
interacting with other individuals. Social rejection is not uncommon, and
employment opportunities are frequently limited by some sort of stigmatiza-
tion not observed in other common dermatoses (2,17). However, it is fre-
quently claimed by insurance companies and health programs that this is a
"cosmetic" disease, and coverage is denied as a general rule. Dermatologists
must be aware of this difficulty and should make every effort to prove, beyond
a doubt, that patients did not have the condition when they enrolled in their
insurance program and that the disease imposes limitations on many normal
life activities, as in other physical ailments, leading to important social im-
plications. For vitiligo surgery, but also for medical therapy, this is a very
important issue.
SELECTION OF CANDIDATES FOR SURGICAL

REPIGMENTATION
Repigmentation surgery is done with invasive methods, and for this reason,
since vitiligo may initially respond well to a number of medical therapies,
296 Falabella
these should be tried as a first-line therapeutic approach; therefore, although

much improvement may be achieved with surgical interventions, they are only
useful when lesions become refractory to medical treatments, in which case
melanocyte grafting and/or transplantation may offer additional benefit to
some selected patients.
Stable Disease
In spite of the difficulty in assessing the stability of vitiligo, the more accu-
rately this factor is determined, the higher the possibility of success. It has
been proven beyond a doubt that unilateral (segmental) vitiligo is the most
stable form of vitiligo and the one that responds best to surgical maneuvering,
with numerous publications supporting this fact (18). On the other hand,
when bilateral vitiligo exhibits stability, repigmentation may also be attained
with surgical therapy, but as a rule only half of these patients will improve (5).
The most important factors that help to establish stability are:
1. No progression of lesions or development of additional depigmen-
tation during at least 2 years: although some patients may become
stable before this time, a relatively recent and apparently nonpro-
gressive lesion may be active and unresponsive to surgical treat-
ment, or a slow progressing one may be difficult to evaluate.
2. Spontaneous repigmentation, which is a sign of vitiligo inactivity.
3. A positive minigrafting test showing repigmentation around 4~5
minigrafts of 1.0 or 1.2 mm, implanted 3--4 mm apart within an
achromic area to be repigmented, is a clear indication of future
recovery, if surgical methods are used, and may also disclose the
type of response; besides, it is the most accura te evidence of vitiligo
stability and, when the test is positive, it may predict a high rate of
success.
4. Absence of new koebnerization, including response at the donor
site after removing small punches for the minigrafting test.
5. Diagnosis of unilateral (segmental) vitiligo per se is almost a syno-
nym for stable disease with an excellent repigmentation response
when treated.
Methods and Size of Lesions

Depending on the size of the area to be treated, the method may vary and
becomes an important factor to be defined. Simple methods such as mini-
grafting and suction epidermal grafting are useful for small- or medium-sized
lesions; in contrast, the only methods that may be feasible for extensive de-
pigmented defects are those involving in vitro culture techniques (19).
Lesions on Exposed Areas

Most patients express a desire for treatment of at least those lesions on ex-
posed areas that are visible to other people. In addition, one of the most
important refractory anatomical regions, namely the dorsum of the hands,
can sometimes be successfully repigmen ted in patients with stable disease (20);
although the dorsum of the fingers does not usually respond to surgical
therapies, repigmentation can also be achieved in selected patients with
stabilized disease (18,21).
Age
Because of the invasive nature of surgical procedures, they are not recom-
mended in children; nevertheless, highly motivated preadolescents can be
treated if there is a high possibility ofrepigmentation, but sedation or general
anesthesia should be considered. It is not surprising to see patients beyond the
age of 50 who may be interested in surgical repigmentation.
Psychological Aspects
This is an important factor that needs to be evaluated. Some patients with
high emotional trauma because of depigmentation may seek advice about
invasive procedures. Surgical methods are not perfect and may result in minor
side effects that may not be accepted by these patients. A psychological eval-
uation may be needed to ascertain the real need for surgical treatment.
Photographic Records
Adequate photographic documentation of lesions before the procedure,
complemented by postsurgical illustrations, is recommended to help in
determining the percentage of improvement, quality of repigmentation, and
possible occurrence of side effects.
Patient's Expectations
Photographs of other patients may be of value in illustrating the expected
outcome. Repigmentation is not often comparable with normally pigmented
skin, and the final results vary considerably from patient to patient. However,
most individuals are pleased with the achieved results, if performed ade-
quately, and the minor imperfections are far less important than the notice-
able improvement of vitiliginous skin, mainly in patients with a dark
complexion (22); however, in some patients it is surprising to see that surgical
repigmentation may look even better than is observed in many patients after
medical therapy.
298 Falabella
Achromia Versus Hypopigmentation

The best lesions to treat are those corresponding to completely depigmented
lesions in patients with skin types III-VI. Hypopigmented lesions do not
repigment appropriately and sometimes may develop moderate hyperpig-
mentation. Once again, a mini grafting test may disclose this possible side
effect before it happens.
Method and Donor Site

Appropriate training with a specific method is an important prerequisite to
performing surgical therapy. The donor site should be as hidden as possible,
and the gluteal region may be a suitable donor area for this purpose in most
patients. These facts should be taken into consideration, as patients will not
be satisfied if significant side effects occur Donor sites should also be
appropriately handled to prevent additional damage to healthy and normally
pigmented donor skin during surgical procedures (23).
Serial Procedures
Most procedures require more than one intervention, especially in relatively
large lesions, and several stages may be needed to accomplish full recovery or
to treat minor depigmented defects not responding to previous interventions.
Combination methods may be of value to accomplish this goal.
Contraindications
A bleeding defect, if not corrected, is a contraindication for surgery. Patients
who developed hyperpigmentation in previous areas of trauma should be
carefully evaluated before making a decision on surgical therapy.
Cost and Insurance Reimbursement

Costs depend on the method used, and although culture techniques are the
most expensive, at present they are usually covered by research centers. When
performing minigrafting, thin dermo-epidermal graft or suction epidermal
graft costs can be estimated by comparing these procedures with other os-
metic methods; for example, the time involved in these techniques is helpful to
determine more accurately the possible procedure costs. Perhaps most
important is to provide all the necessary information to insurance companies,
to make clear that this is not merely a "cosmetic" repair, since the patient
did not have the achromic defect at birth or when enrolling in their insur-
ance coverage, and also because depigmented lesions frequently become a

handicap by decreasing job opportunities and social interaction.
SURGICAL COMBINATION THERAPY

The possibility of combination therapy should be kept in mind from the
beginning of surgical repigmentation, and this is an important concept that
should always be considered (24). It is not infrequent for small spots within a
repigmented area to remain depigmented in spite of an appropriate proce-
dure; if these areas are large enough, the intervention may be repeated to
overcome the repigmentation failure; if small, minigrafting is a very useful
method for residual depigmented areas. When repigmentation becomes
unsuccessful, another method could be tried, although chances of repigmen-
tation may be lower when previous failures occur. In addition, combining
surgical methods with PUVA therapy (25,26) may be very useful to obtain
deeper and faster repigmentation.
DIFFICULT-TO-TREAT AREAS
With surgical procedures, much improvement is achieved, particularly in
unilateral vitiligo; however, there are certain areas that are difficult to repig-
ment, such as joints, lips, eyelids, genitalia, cutaneous folds, dorsum of hands
and feet, and especially fingers and toes. In some of these anatomical sites,
postoperative movement of grafted zones prevents a good take, and in spite
of appropriate immobilization, repigmentation is difficult to achieve; some of
these areas may need regrafting, and recovery is possible in some patients.
Nevertheless, other factors not known at present may prevent a good
repigmentation response. Further research to render these areas more suscep-
tible to medical or surgical therapy, either alone or in combination, will be a
great contribution for treating acral vitiligo.
METHODS
Five basic methods have been described for repigmentation surgery, but sev-
eral modifications of such methods ha ve also been published. These methods
can be summarized as follows: (a) non cultured epidermal suspensions; (b)
thin dermo-epidermal grafts; (c) suction epidermal grafting; (d) punch mini-
grafting; and (e) cultured epidermis with melanocytes or cultured melanocyte
suspensions (23).
How to decide on a specific method is a matter of the surgeon's
preference and knowledge of a given technique. In general, all methods are
300 Falabella
useful for repigmentation, and the most important factor leading to accept-
able results is expertise when performing the technique. Also, the less inva-
sive the method and the less dermal manipulation is done, the fewer are the
possibilities of scarring. Graft size and thickness when manipulating the
dermis is critical in obtaining a smooth repigmented surface. These facts
should be discussed with the patient.
Noncultured Melanocyte Suspensions

This is a rather simple method by which repigmentation is achieved when
grafting a noncultured epidermal suspension bearing both keratinocytes and
melanocytes; after grafting, the depigmented defects recover within months
because of the pigment cells present in this cellular suspension.
Initially a thin shave from the donor site is harvested and immediately
digested with 0.25% trypsin for 2 hours at 3rc. Separation of the epidermis
from the dermis occurs, and with vigorous pipetting, epidermal cells, includ-
ing melanocytes, will separate and form a cell suspension. After washing the
cells with phosphate buffer saline and reconstituting the cell suspension, it is
injected into blisters raised by liquid nitrogen freezing or "seeded" on the
recipient site previously prepared by removing the depigmented epidermis
with superficial dermabrasion (27). The recipient site is covered for 5-7 days
with nonadherent or semi-permeable dressings. After complete healing,
repigmentation will begin and continue gradually during the following
months. A modification of this method, by adding a melanocyte culture
medium to prepare the epidermal suspension, has been described (28); with
this enriched cell suspension, it is possible to enhance the repigmentation yield
and cover larger depigmented defects (Fig. 1).
Thin Dermo-epidermal Grafts

The aim of thin dermo-epidermal grafts is to replace the achromic lesions of
vitiligo with very thin sheets of epidermis and dermis, harvested from the
donor site with a suitable dermatome at a depth of 0.1-0.3 mm, which is
critical to avoid the scarring that usually occurs when using thicker grafts. The
recipient site is prepared by removing the epidermis and papillary dermis with
superficial dermabrasion; once this is done, the thin dermo-epidermal sheets
are grafted directly on the already abraded area. Grafts are placed next to
each other, covered with petrolatum gauze, and secured with surgical wrap-
pings which are kept on for one week. Repigmentation is shortly achieved in
the following weeks, since me1anocytes are present within the thin grafts. The
method is very useful, although the yield is that of a l-to-l ratio. Difficult
~ ~:
~
b '
FIGURE 1 Noncultured melanocyte suspensions: (a) donor site: a thin dermo-

epidermal sample is harvested by shaving; (b) after digestion with 0.25% trypsin, a
melanocyte-keratinocyte suspension is obtained; (c) recipient site: the epidermal
suspension is spread onto a superficially dermabraded depigmented surface; (d)
repigmentation occurs by coalescence of neighboring treated spots until complete
recovery is achieved.
areas, such as the dorsum of hands and fingers, have been grafted with success
(29). However, good to excellent results depend on the thin nature of grafts
and appropriate immobilization (Fig. 2).
It is important to rule out a keloidal diathesis to avoid developing this
complication on both donor and recipient sites. Since the superficial dermis
is manipulated, the cosmetic result may disclose minor defects such as hyper-
or hypopigmentation, and in some patients slight scarring may occur. A
modification of this technique is the so-called flip-top graft, where small 3-
5 mm thinly shaved dermo-epidermal fragments are inserted under very thin
similar flaps raised on the recipient site (30); with this method, multiple grafts
separated a few mm from each other provide small pigmentary islands that
will coalesce by pigment spread within a few months after grafting.
Epidermal Grafting
Epidermal grafting has become very popular and yields excellent results;
many publications refer to the absence of secondary effects, particularly
302 Falabella
\-, IA v\. 'vlf\A.l

d
FIGURE 2 Thin dermo-epidermal grafts: (a) recipient site: the depigmented epi-
dermis is removed by very superficial dermabrasion; (b) donor site: a thin dermo-
epidermal graft is harvested with a suitable dermatome; (c) recipient site: the
thin graft is placed onto the dermabraded area; (d) recipient site: repigmentation
occurs shortly after healing and pigmentation also spreads between adjacent
grafts.
scarring, which allows reusing the donor site for treating additional areas. The
method is performed in two phases:
I. Donor site: the grafts are harvested with any of the diverse types of
custom-made suction devices so far reported (21,25,26,31); dif-
ferent types of syringes have been also used as suction devices with
success (32,33). The preferred suction diameter for individual blis-
ters should not be larger than I cm to avoid excessive bulging of the
skin within the suction device that may interfere with blistering.
Blisters develop in 3-4 hours, but ifheat is provided during suction,
epidermal grafts may be harvested in less than I hour (25,34).
2. Recipient site and grafting maneuvers: removal of the achromic
epidermis may be achieved in different ways; if liquid nitrogen is
used, the procedure is done b¥ freezing small 5-10 mm spots;
blistering occurs a few hours later, but grafting is performed 2
days later when the inflammatory changes originated by freezing

su bside; the blistered epidermis is only removed on the day of graft-
ing, just prior to implanting the epidermal sheets. An alternative
method is to remove the epidermis from the recipient site by
superficial dermabrasion or ultrapulse CO 2 laser (35,36). Immedi-
ately after the recipient site is properly denuded, the blister grafts
are then cut with iris scissors, transferred to a thin transparent
grafting spatula, and grafted onto the recipient site (37), a ma-
neuver that can also be performed with thin acetate films (38). When
the procedure is terminated, nonadherent dressings are placed on
the grafted surface and wrapped with elastic bandages for 5 days
(Fig. 3); after healing, sunlight exposure for 10-15 minutes daily is
recommended for stimulating neo-melanogenesis. Repigmentation
occurs gradually by melanocyte and pigment spread around the
I
0J
FIGURE 3 Suction epidermal grafting: (a) donor site: 1-3 hours after suction,
donor blistered epidermis is ready for grafting; (b) donor site: the blister graft is
released with iris scissors and harvested with a thin grafting spatula; (c) recipient
site: the graft is placed onto a depigmented area, previously blistered 2 days
before with liquid nitrogen freezing; (d) recipient site: repigmentation occurs by
melanocyte proliferation and pigment spread arising from the grafted spots.
304 Falabella
grafted epidermis until complete coalescence is achieved. PUVA

may enhance markedly the repigmentation process (25,26).
Minigrafting
Because of its simplicity minigrafting has become one of the most commonly
used method for vitiligo surgery. Two phases are necessary in this procedure:
I. Donor site: after local anesthesia, multiple perforations are made
with a small punch measuring 1.0-1.2 mm. Minigrafts are then
harvested with iris scissors and manipulated with a fine-tipped
forceps or hypodermic needles used as handling instruments, placed
on a nonadherent dressing moistened with normal saline solution
and kept under sterile conditions until transferred to the recipient
site. The gluteal region, near to the midline, is an excellent donor site
for most patients.
2. Recipient site and grafting maneuvers: the depigmented skin must
be prepared before harvesting the minigrafts by perforating the
recipient holes with a punch of a similar size, at a distance of 3--4
mm from each other. For facial lesions in young patients a 1.0 mm
punch is recommended, leading to good repigmentation and no
scarring at all; punches of a larger size may provoke unsightly scar-
ring provoking a "cobblestone" appearance (23). The harvested
minigrafts are transferred to the recipient site, and Monsel solution
is applied to the grafted surface to seal the periphery of minigrafts
and thus prevent postoperative transudation that may interfere
with a good take. The grafted surface is finally covered with Mic-
ropore tape directly on the minigrafts to assure adequate im-
mobilization without any other special dressing, which is removed 2
weeks later after adequate healing occurs. Other methods that can
be tried for covering the treated surface are transparent semi-per-
meable or nonadherent dressings, according to the surgeon's ex-
perience (Fig. 4). After an appropriate take, repigmentation occurs
gradually around each minigraft up to 2 mm from the edge and by
coalescence of the small pigmentary islands, but moderate daily
sunlight exposure is important after healing for several months to
stimulate melanogenesis (37,39) (Fig. 5).
Cultured Epidermis with Melanocytes and Melanocyte

Suspensions
With modern technology, cultured epidermis with melanocytes and pure
melanocyte suspensions have been successfully used to repigment vitiliGo.
Copyrighted Material b
FIGURE 4 Minigrafting: (a) donor site: minigrafts are harvested with a small 1.0 or
1.2 mm punch; (b) donor site: minigrafts are removed to be transferred to
nonadherent surgical dressing moistened with saline solution; (c) recipient site:
minigrafts are placed within perforations of similar size previously done at a dis-
tance of 3-5 mm apart from each other; (d) recipient site: repigmentation gradually
occurs by coalescence of melanocytes and pigment spread arising from adjoining
minigrafts.
Epidermal sheets may be obtained with a small donor skin sample, from
which an epidermal suspension is made by 0.25% trypsin digestion and
seeded in culture flasks with appropriate culture media to stimulate both
keratinocytes and melanocytes. A thin epidermal sheet is obtained after 3
weeks, which is removed from the culture vessel, placed onto a nonadherent
gauze, and finally transferred to the recipient site previously denuded with
liquid nitrogen freezing (40), superficial dermabrasion (35), CO 2 or pulsed
Erbium-Y AG lasers (36,41). Melanocyte suspensions may also be cultured in
a similar manner with very specific media but without epidermal cells, spread
onto the recipient surface, and covered for 5-7 days until a good cellular take
occurs (42,43). Repigmentation is attained in both cases during the following
weeks and months, but sunlight exposure or PUVA will enhance and facilitate
the recovery of the grafted lesions (Fig. 6). When using a hyaluronic artificial
matrix for growing keratinocytes and melanocytes (44) or transplantation of
epidermal sheets with melanocytes on achromic areas denuded with diather-
1110surgery (45), remarkabltc5pWR)Ht~tfIMmt#l~1s have also been reported.
306 Falabella
(a)
(b)
FIGURE 5 (a) Unilateral vitiligo on the side of the face in this 17-year-old boy
developed 10 years before and remained stable. A positive minigrafting test
(arrow) discloses the possibility of repigmentation by surgical methods. (b) One
and a half years later, after three minigrafting procedures, the lesion was
completely repigmented. (From Ref. 51.)
Melanocyte suspensions kept under freezing for several months and recul-
tured again after thawing have been transplanted onto achromic defects,
resulting in successful repigmentation, indicating an enormous potential for
future repigmentation technologies (46). One advantage of these methods is
that a large population of cells may be obtained from a small donor site, and
large areas can be treated in a single session.
ARTIFICIAL UV OR SUNLIGHT EXPOSURE FOLLOWING

TREATMENT
Neomelanogenesis begins shortly after melanocyte grafting or transplanta-
tion and continues for several months at a slow rate. However, faster and
FIGURE 6 Cultured epidermis with melanocytes and melanocyte suspensions: (a)

donor site: a small thin skin sample is harvested; (b) the skin is processed in the
laboratory through several stages to develop melanocyte suspensions or epi-
dermal sheets with melanocytes; (c) recipient site: the thin, in vitro cultured
epidermal sheet is placed on a depigmented defect previously prepared by super-
ficial dermabrasion, or the melanocyte suspension is spread onto a similar lesion;
(d) recipient site: repigmentation gradually develops within the following months by
coalescence of the epidermal grafts or by proliferation of melanocytes arising from
the grafted pigment cell suspension.
deeper repigmentation is observed when UV exposure, either with natural

sunlight or PUVA, is done. It is frequently observed that if no UV exposure is
additionally administered, repigmentation may be slow, incomplete, or may
even fail. UV exposure may be initiated after graft survival is demonstrated
and continued until full repigmentation is attained. Initially, grafts and the
repigmented surface frequently exhibit a hyperpigmented appearance, but in
time this effect will fade and gradually subside, matching the surrounding skin
appearance in most patients.
SIDE EFFECTS OF VITILIGO SURGERY

Surgical procedures are invasive methods in which manipulation of donor
and recipient sites is performed. Careful handling of both sites should be
properly done to avoid important side effects.
308 Falabella
Keloids
A keloidal diathesis should be ruled out, and patients bearing keloids should
not be treated. This complication can be easily prevented by observing the
patient's old scars. If doubts still persist, a small test area, such as the
minigrafting test, should be done before performing the definitive procedure.
Hyperpigmentation
A similar approach is recommended for patients with a tendency for post-
traumatic hyperpigmentation. In such cases, a hypopigmented lesion could be
converted into a markedly pigmented defect, which may look unsightly and
even worse than the initial depigmented lesion; this complication could be
more likely due to an enhanced pigmentation diathesis than a common side
effect of melanocyte grafting and UV light exposure. Old trauma to the skin
may disclose permanent areas with hyperpigmentation that may be inter-
preted as a warning against performing repigmentation surgery.
"Cobblestoning"
This effect occurs when performing grafting with large punches; punch grafts
of 3-4 mm are not recommended because of the poor cosmetic results (47).
The preferred sizes are 1.2 mm for trunk and extremities and 1.0 mm for fa-
cial areas, particularly in young patients (23).
Scarring
Hypertrophic scars, thick grafts, and grafted areas with uneven surfaces are
the most important side effects occurring when dealing with dermo-epidermal
grafts. Very thin sheets are necessary for obtaining good to excellent results.
For this purpose, a suitable dermatome with the ability to shave very thin
dermo-epidermal sheets is important; the thickness should be around 0.1-0.3
mm, and therefore a plain knife or surgical blade for surgical shaving does
not provide suitable graft thickness.
Infection
When procedures are carried out with adequate asepsia, this is an infrequent
complication.
CONCLUSIONS AND POSSIBLE SOLUTIONS

Surgical methods are important for treating stable and refractory vitiligo after
failure with medical therapies. High repigmentation rates are obtained with
all procedures so far described in most anatomical locations, but they are of
little success for acral areas. Unilateral vitiligo is the clinical form with the best
response to grafting and transplantation methods, although a good propor-
tion of patients with inactive bilateral disease also respond well. Nevertheless,
appropriate patient selection is important to achieve maximal results.
What can we expect from future therapy? The ideal situation would be
that melanocytes could migrate continuously under the influence of a specific
molecular signal, since they are only able to migrate a few mm, mostly from
the periphery of the hair follicle reservoir or from the edge of lesions, when
adequate therapy is administered. In recent years several molecules acting as
signals, such as leukotriene C4, transforming growth factor alpha (48), basic
fibroblast growth factor, stem cell factor, and endothelin-l (49), have been
shown to stimulate pigment cell migration in culture in a random, nonlinear
manner. If similar and more potent and/or specific molecules become
identified and available, it is conceivable that when applied to vitiliginous
skin, they could stimulate melanocyte migration, originating a continuous
movement of these cells from the edge of pigmented skin toward depigmented
skin that would be very useful for recovering extensive vitiligo areas.
Furthermore, if small grafts of normally pigmented skin are implanted within
large depigmented defects, even several cm apart from each other, theoret-
ically, melanocytes arising from these artificially created pigmentary reser-
voirs could be stimulated with such molecules and a faster and probably
complete repigmentation would be achieved. In addition, combination ther-
apy with PUVA, UVB, or lasers. together with these stimulatory molecules,
could also help to enhance repigmentation (50). Future research will provide
the answers, but perhaps, in this regard, the future is not too far away.
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2000: 129-136.
9. Hann SK, Chun WHo Autocytotoxic hypothesis for the destruction of mela-
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of pteridines in pigmentation. In: Hann SK, Nordlund JJ, eds. Vitiligo. Oxford:
Blackwell Science Ltd., 2000:151-159.
12. Njoo M D, WesterhoF W. Vitiligo. Pathogenesis and treatment. Am J Clin Der-
matol 2001; 2:167-181.
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Humbert P, Vidal E, Aumaitre O. Vitiligo in multiple autoimmune syndrome: a
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1998; 19:348-352.
14. Tobin DJ, Swanson NN, Pittelkow MR, Peters EM, Schallreuter KU. Melano-
cytes are not absent in lesional skin of long duration vitiligo. J Pathol 2000;
191407-416
15. Cui J, Shen LY, Wang Gc. Role of hair follicles in the repigmentation of
vitiligo. J Invest Dennatol 1991; 97410-416
16. Grichnik JM, Ali WN, Burch JA, Byers JD, Garcia CA, Clark RE, Shea CR.
KIT expression reveals a population of precursor melanocytes in human skin. J
Invest Dermatol 1996; 106:967.
17. Porter J, Beuf A, Lerner A, Nordlund JJ. Psychological reaction to chronic
skin disorders: a study of patients with vitiligo. Gen Hosp Psych 1979; 1:73-77.
18. Falabella R. Surgical therapies for vitiligo. In: Hann SK, Nordlund JJ, eds.
Vitiligo. Oxford: Blackwell Science Ltd., 2000 193-200.
19. Olsson MJ, Juhlin L. Transplantation ofmelanocytes in vitiligo. Br J Dermatol
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20. Falabella R, Escobar C, Borrero 1. Treatment of refractory and stable vitiligo
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21. Falabella R. Surgical techniques for repigmentation. In: Robinson SK, Arndt
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28. Olss n MJ, Juhlin L. Leucoderma treated by transplantation of a basal cell
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grafting. J Am Acad Dermatol 1995; 33:646-648.
30. McGovern TW, Bolognia J, Letfell DJ. Flip-top pigment transplantation: a
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31. Falabella R. Repigmentation of leukoderma by autologous epidermal grafting.
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32. Kim HU, Yun SK. Suction device for epidermal grafting in vitiligo: employing
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33. Gupta S, Shroff S, Gupta S. Modified technique of suction bli tering for epi-
dermal grafting in vitiligo. Int J Dermatol 1999; 38:306-309.
34. Peachey RD. Skin temperature and blood flow in relation to the speed of suc-
tion blister formation. Br J Dermatol 1971; 84:447-452.
35. van Geel N, Ongenae K. De Mil M, Naeyaert JM. Modified technique of auto-
logous noncultured epidermal cell transplantation for repigmenting vitiligo: a
pilot study. Dermatol Surg 2001; 27:873-876.
36. Oh CK, Cha JH, Lim JY, Jo JH. Kim SJ, Jang HS, Kwon KS. Treatment of
vitiligo with suction epidermal grafting by the use of an ultrapulse CO 2 laser
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37. Falabella R. Surgical therapies for vitiligo and other leukodermas, part I:
minigrafting and suction epidermal grafting. Dermatol Ther 200 I; 14:7-14.
38. Albert S, Shenoi SD. Acetate sheets in the transfer of epidermal grafts in
vitiligo. JAm Acad Dermatol 2001; 44:719-720.
39. Falabella R. Treatment of localized vitiligo by autologous minigrafting. Arch
Dermatol 1988; 124:1649-1655.
40. Falabella R, Escobar C, Borrero 1. Transplantation of in vitro cultured epi-
dermis bearing melanocytes for repigmenting vitiligo. J Am Acad Dem1atol
1989; 21 :257-264.
41. Kaufmann R, Greiner D, Kippenberger S, Bernd A. Grafting of in vitro cul-
tured melanocytes onto laser-ablated lesions in vitiligo. Acta Derm Venereol
1998; 78:136-138.
42. Lontz W, Olsson MJ, Moellmann G, Lerner AB. Pigment cell transplantation
for treatment of vitiligo: a progress report. J Am Acad Dermatol1994; 30:591-
597.
43. Olsson MJ, Juhlin L. Transplantation of melanocytes in vitiligo. Br J Dermatol
1995; 132:587-591.
44. Andreassi L. Pianigiani E, Andreassi A, Taddeucci P, Biagioli M. A new
model of epidermal culture for the surgical treatment of vitiligo. Int J Dermatol
1998; 37:595-598.
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cultured melanocytes after cryostorage. Acta Derm Venereol (Stockh) 1994;
74:226-228.
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miniature punch grafting: a prospective study of 1,000 patients. Dermatology
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lAm Acad Dermatol 1983; 9:514-521.
27
Tissue-Engineered Skin in the Treatment
of Vitiligo Lesions
Andrea Andreassi, Elisa Pianigiani,

Paolo Taddeucci, and Michele Fimiani
Arezzo's Hospital and University of Siena, Siena, Italy
INTRODUCTION
Vitiligo is a disfiguring disease that causes selective destruction of melano-
cytes and leads to the development of achromic lesions. Several surgical
techniques have been developed in order to achieve repigmentation of the
grafted achromatic areas in stable vitiligo, such as transplant of the tops of
suction blisters (1,2), minigrafts (3,4), thin grafts (5), and transplant of
suspensions of noncultured melanocytes and keratinocytes (6). Recently,
surgical and cultural methods have furthered the possibilities of treating stable
cases of vitiligo unresponsive to standard therapies. Membranes of autologous
epidermis containing melanocytes grown in vitro (7), or suspensions of
cultured melanocytes applied directly to abraded achromatic areas of the skin
(8), have been demonstrated to be effective in this field.
In 1991 we developed a new model of epidermal cultures consisting of
cells grown on a membrane of hyaluronic acid (HA) completely esterified with
benzyl alcohol (Laserskin). The membranes were perforated in order to allow
cell proliferation in the holes and early colonization of the wound bed. For
some time, we used HA composite cultures as grafts in burn patients with good
results in terms of reepithelization and functional recovery (9). We observed
that melanocytes also proliferated in these cultures and were detectable by
314 Andreassi et al.
DOPA reaction and S-100. This led us to graft this composite cultures in
patients suffering from vitiligo (10).
OUR EXPERIENCE
The study population consisted of 59 patients (36 women, 23 men) ranging in
age between 16 and 66 years (median: 33, 22), apparently free of systemic
disease. All had localized, focal, or segmental vitiligo, refractory for at least 6
months to conventional topical and systemic therapies. The history of vitiligo
ranged from 2 to 20 years and had been stable for at least 2 years. Results were
evaluated by image analysis after 3, 6, 12, and 18 months and expressed as
percent repigmentation.
Materials
The biomaterial used as a support for the cell culture was a semi-synthetic
biopolymer of hyaluronic acid, 100% esterified with benzyl alcohol, in the
form of a transparent, flexible, perforated membrane with orderly arrays of
laser drilled 40 [.lm micropores and larger 0.5 mm holes for fluid drainage
(Laserskin, Fidia Advanced Biopolymers, Abano Terme, Italy). The high
degree of esterification makes the membrane insoluble. The membrane was
sterilized by gamma radiation.
Cultures
Split thickness sheets of normally pigmented skin measuring 2 x 3 cm were
obtained from the buttock of each patient under local anesthesia by means of
an electric dermotome. Primary keratinocyte cultures were prepared by the
classic method of Rheinwald and Green (II). Briefly, the sample was washed
in phosphate-buffered saline (PBS) supplemented with antibiotics and cut
into strips. The strips were placed in Petri dishes containing 0.5 gjL trypsin
and 0.2 gjL ethylene-diaminotetra-acetic acid (EDTA) solution and incu-
bated for 20 minutes at 3rC. The epidermis was separated from the dermis
and scraped to obtain a cell suspension. Cells were washed in Dulbecco-mod-
ified Eagle's medium (D-MEM) supplemented with antibiotics, 10% fetal
calf serum (FCS), L-glutamine, and then resuspended in 15 mL culture
epithelial cell medium (CEC) consisting of D-MEMjHam's (3: I) with 10%
FCS, 0584 mgjmL L-glutamine, 100 UjmL penicillin, 100 mgjmL strepto-
mycin, 0.4 [.lgjmL hydrocortisone succinate, 5 [.lgjmL insulin, 5 [.lgjmL trans-
ferrin, 2 x 10- 9 M triiodothyronine and 10-9 cholera toxin without epidermal
growth factor (EGF). All materials were procured from Sigma unless other-
wise noticed.
Treatment with Tissue-Engineered Skin 315
The cell suspension was seeded at a density of30,000 cellsjcm 2 in 75 cm 2

flasks previously provided with 20,000 cellsjcm 2 of lethally irradiated 3T3
fibroblasts. Composite cultures on Laserskinmembranes were obtained from
primary semiconfluent cultures (Fig. I). HA membranes were cut into pieces
4-6 cm 2 in area and fixed to the bottom of 6 cm diameter Petri dishes by means
of white petrolatum. The cell suspension was plated at a density of 30,000-
50,000 cells cm2 on the membranes, prepared the previous day with a feeder
layer of lethally irradiated 3T3 fibroblasts. The medium was replaced com-
pletely every 2 days until confluence; 10-15 days after plating the membranes
were detached and grafted.
Grafting Procedure
All subjects were treated as outpatients. The day before the operation the
areas to be treated were chosen. Achromatic lesions to be treated, each 10-200
mm 2 in size, were deepithelized by laser ablation. The epithelium was removed
with pulsed Er:YAG laser (pulse energy: 5 Jjcm 2 ) using four pulse series. The
area was then covered with the keratinocyte sheets, held in place with oily
antiseptic gauze, which was changed every 5 days. The carrier was left in place
until it detached spontaneously (7-10 days).
The dressing was removed 5-7 days later and the area medicated with
normal saline solution. The buttock wound was medicated daily with silver
sulfodiazine cream until healed. The results were evaluated as an extent of
FIGURE 1 Composite cultures of Laserskin ™

TABLE 1 Results in Vitiligo Patients Grafted with Autologous Epidermis

on HA Biopolymer Support
Patients no., Duration of Size Repigmentation

age (yr), sex vitiligo (yr) Grafted area (cm 2 ) (%)
1.23, F 2 Face 10 100

2.27, M 4 Left hand 60 95
3.66, M 2 Right arm 80 96
4.47, M 4 Neck 60 100
5.32, M 10 Hands 80 0
6.37, M 8 Left hand 80 53
7.26, M 10 Left chest 200 90
8. 60, F 4 Left arm 40 40
9.21, F 2 Chest 20 91
10.39, F 10 Neck, forearms 80 49
11.31, M 9 Arms 100 71
12.34, M 7 Chest 100 60
13.38, F 5 Left forearm 100 42
14. 30, F 3 Right forearm 100 53
15.46, M 11 Left forearm 100 82
16.49, M 5 Right hand 50 72
17. 19, F 3 Left forearm 100 90
18.42, F 8 Forearms 100 82
19.28, F 4 Face 40 60
20.26, M 3 Forearms 100 72
21.41,M 4 Face, neck 50 65
22. 22, F 6 Back 100 85
23.16, F 3 Legs 100 85
24. 17, M 4 Hands 60 25
25.34, F 7 Forearms 100 70
26. 18, F 3 Hands 50 25
27. 19, F 6 Left forearm 100 62
28.36, M 4 Neck 80 90
29. 18, F 6 Left leg 100 100
30. 20, F 4 Face 50 32
31.31, F 5 Left forearm 100 65
32.40, F 8 Neck 100 75
33.27, M 4 Face 50 20
34.28, M 2 Thigs 100 85
35.21, F 5 Neck 80 65
36. 26, F 6 Forearms 100 85
37.42, M 7 Genitalia 20 0
38.52, M 20 Face, neck 80 35
39. 24, F 5 Hands 60 52
40. 44, F 12 Forearms 100 72
TABLE 1 Continued
Patients no., Duration of Size Repigmentation

age (yr), sex vitiligo (yr) Grafted area (cm 2 ) (%)
41.20, F 8 Face 40 25
42.61, M 15 Forearms 100 75
43. 34, F 6 Forearms 100 82
44.65, M 4 Face 80 90
45. 16, M 2 Hands 60 35
46. 17, M 4 Neck 80 55
47.28, M 8 Face, neck 80 75
48. 43, F 6 Hands 60 48
49. 35, F 4 Left forearm 80 100
50. 65, F 18 Forearms 100 60
51. 47, F 12 Left forearm 100 62
52. 34, F 8 Forearms 100 70
53. 23, F 3 Face 50 35
54. 43, F 11 Forearms 100 80
55. 23, F 5 Hands 60 65
56. 16, F 4 Left forearm 80 65
57. 17, F 3 Left leg 80 100
58. 39, F 5 Forearms 100 85
59. 37, F 6 Left forearm 100 90
repigmentation of the achromatic area. The surface of repigmentation was

calculated by image analysis using a special algorithm 3, 6, 12, and 18 months
after the operation and was expressed as a percent area of repigmentation.
The difference between the percent of repigmentation observed at each time
period was then evaluated using the Wilcoxon signed rank test.
Results
The clinical re ults obtained in our patients are summarized in Table I. No
relevant side effects were observed in our patients. Compliance was excellent
in alJ cases, since all cases were treated as outpatients. The first signs of
repigmentation were observed 1 month after grafting. InitialJy, islands of
pinkish pigmentation were observed. Later, these spread to form patches that
were sometimes hyperchromatic. In some cases, these patches finalJy fused
completely and became pigmented like the surrounding skin. In most cases,
repigmentation continued to increase for 3-6 months after grafing. The
Koebner effect was not observed at the site of the skin biopsy in any patient,
and there were no cases of relapse at follow-up after 18 months (Figs. 2, 3).
(A)
(8)
FIGURE 2 (A) Vitiligo on hands of 26-year-old man. (8) Twelve months after graft
of same patient.
DISCUSSION
Vitiligo may be treated in many ways (12,13). The planning of a successful
low-risk protocol requires the evaluation of many parameters, such as the site,
degree of involvement, phototype, psychological impact, compliance, and
type of treatment. Many authors have used different surgical techniques to
treat certain forms of vitiligo. These methods have achieved different degrees
(A)
(8)
FIGURE 3 (A) Vitiligo on thighs of 28-year-old man. (8) Twelve months after graft
of same patient.
of repigmentation and include transplantation of the tops of suction blisters

(1,2), minigrafts (3,4), thin grafts (5), and transplantation of suspensions of
noncultured melanocytes and keratinocytes (6). Some of these methods may
have side effects that compromise the outcome: pebbly pigmentation is
common with minigrafts, and graft retraction may occur with thin grafts.
More recently, epidermal cultures (7) or cultured autologous melanocytes (8)
320 Andreassi et at.
have been shown to improve the outcome of surgical treatment of vitiligo.

Interestingly, it is likely that transplantation is a sufficient stimulus for
inducing melanocytes to reenter the cell cycle, even when inactive (14). Since
vitiligo seems to be related to a dysfunctioning of the epidermal melanin unit
(15), autologous cultured epidermis may be an optimal therapeutic choice in
selected cases. Epidermal cultures obtained from normally pigmented sites
may, in fact, provide a source of healthy melanocytes and keratinocytes for
the repigmentation of achromatic patches (7,16). Moreover, in our opinion,
therapies combining surgery and cell culture have advantages over the direct
transplantation of epidermis, because only one biopsy is performed and the
culture cells can be stored frozen and used in subsequent grafts. Cultured
epidermis is difficult to handle, and manipulation affects cell vitality. The
present method has none of these disadvantages, being simple, easy to
perform, and using cultures that are vital when grafted. Also, this method,
using composite cultures of autologous keratinocytes and melanocytes grown
on membranes of HA polymer, is more effective than traditional cultured
epidermis without the biomaterial support. The cells are seeded on the
perforated membrane and grow actively in the holes, colonizing the wound
bed and enabling repigmentation and reepithelialization. The membrane is
easy to handle on the graft site and does not require any special medication.
The fact that melanocytes can be cultured together with keratinocytes makes
this technique useful in vitiligo patients refractory to all other known
therapies. It gives good results even for large areas of achromatic skin, which
can be grafted in stages with membranes stored in liquid nitrogen. Moreover,
it seems preferable to use this type of composite culture, rather than a
monoculture ofmelanocytes, because recent results suggest that the metabolic
alteration of the keratinocytes within the framework of the epidermo-melanin
unit plays a primary role in the pathogenesis of vitiligo (15). Our results show
that in compliant vitiligo patients in whom the disease has been stable at least
2 years, the present technique produces complete and lasting repigmentation
without side effects. This method is also successful for large areas of ach-
romatic skin, which can be grafted in stages.
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5. Kahn AM, Cohen MJ. Vitiligo: treatment by dermabrasion and epthelial sheet
grafting. J Am Acad Dermatol 1995; 33:646-648.
6, Gauthier Y, Surleve-Bazeille JE. Autologous grafting with non cultured mela-
nocytes: a simplified method for treatment of depigmented lesions, J Am Acad
Dermatol1992; 26:191-194.
7, Falabella R, Escobar C, Borrero I. Treatment of refractory and stable vitiligo of
in vitro cultured epidermal autografts bearing melanocytes, J Am Acad
Dermatol 1992; 26:230-236.
8, Olson MJ, Juhlin L. Transplantation of melanocytes in vitiligo. Br J Dermatol
1995; 132:587-591.
9. Andreassi L, Casini L, Trabucchi E, et al. Human keratinocytes cultured on
membranes composed of benzyl ester of hyaluronic acid suitable for grafting.
Wounds 1991; 3:116-126.
10. Andreassi L, Pianigiani E, Andreassi A, et al. A new model of epidermal culture
for the surgical treatment of vitiligo. Int J Dermatol 1998; 37:595-598.
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12. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for vitiligo. J Am
Acad Dermatol 1996; 35:620-626.
13. Antoniou C, Katsambas A. Guidelines for the treatment of vitiligo. Drugs 1992;
43:490-498.
14. Haddad MM, Xu W, Medrano EE. Aging in epidermal melanocytes: cell cycle
genes and melanins. J Invest Dermatol Symp Proc 1998; 3:36-40.
15. Schallreuter KU, Wood JM, Pittelkow MR, et al. Increased MAO-A activity in
the epidermis of patients with vitiligo. Arch Dermatol Res 1996; 288: 14-18.
16. Zachariae H, Zachariae C, Deleuran B, et al. Autotransplantation in vitiligo:
treatment with epidermal grafts and cultured melanocytes. Acta Dermato-
Venereol 1993; 73:46-48.
28
UV-B Narrowband Microphototherapy:
A New Treatment for Vitiligo

Jana Hercogova
INTRODUCTION
Although the precise biological mechanisms stimulated by ultraviolet (UY)
light have yet to be confirmed, the efficacy of UY-B in vitiligo therapy is
probably due to the high production of cis-urocanic acid, responsible for the
cutaneous immune suppression that includes morphological and functional
alterations of Langerhans cells (1-4). Data show that the mechanisms under-
lying UY-B-induced melanogenesis depend on a linear nitric oxide-GMPc
transduction pathway. In fact, nitric oxide and GMPc, through the activation
of protein kinase G, mediate the effects of UY-B radiation on melanocytes
(3,4). Other reports attribute the increased melanocyte proliferation and
melanogenesis to the activation of the cyclic-AMP pathway by a-melano-
tropin (5) or through melanocyte-stimulating hormone receptor-binding
activity and melanocortin receptor gene expression, which are enhanced by
UV-B irradiation (6).
Thanks to these achievements in the last 10 years, we have taken part in
a gradual transformation of the practice of phototherapy for vitiligo. The first
323
324 Menchini et al.
step was the modification of the wavelength used from ultraviolet A (UV-A)
to UV-B (7-10). Unfortunately, phototherapy with UV-B light was delayed
because of its hypothesized role in carcinogenesis. In fact, at equal doses UV-
B induces more DNA dimers than UV-A (5,6). Simultaneously, other studies
showed that the UV-B wavelength that is most effective in inducing repig-
mentation is the band at 311 nm (II). This evidence had critical importance in
the development of new UV-B bulbs providing less intensity and a more
restricted spectrum. The narrowband UV-B generator (Philips TL-OI)
produces a high percentage of UV-B close to the peak of 311 nm and allows
the dermatologist to use a lower intensity and cumulative dose, obtaining
optimal efficacy on vitiligo patches (12,13). Nevertheless, patients suffering
from vitiligo receive a high cumulative dose of radiation during their lives,
and this leads to other cutaneous disorders like excessive tanning, photo-
aging, telangiectasis, etc.
FIGURE 1 The Bioskin microphototherapy device.
UV-B Narrowband Microphototherapy 325
FIGURE 2 Simplified scheme of the Bioskin device: a potent xenon generator

(1) emits a beam of visible and UN irradiation (2), which is filtered by a particular
interference filter (4) to obtain UV-B narrowband only. The time of emission is
controlled by the operator, which acts on a time-controlled leaf shutter (3). The
operator can also modify the intensity of the UV-B beam thanks to an iris di-
aphragm (6). Finally, the UB-V narrowband beam passes through a specific optical
fiber (7) to reach the skin of the patient.
100
90
~
c: 80
.~ 70
f1I
'E 60
Gl
'0 50
C 40
..
-
Gl Of
/
~ 30
./ ... ~
Q. 20
~
10
o "
279281 283285 287 289 291 293 295 297 301 303305307309 311 313315317319321 323 325 327
Wave-length (nanometers)
FIGURE 3 Bioskin emission spectrum: the maximum peak is at 311 nm.

326 Menchini et al.
In order to avoid side effects, a new phototherapy device, Bioskin ®, has

been developed that allows selective narrowband UV-B (311 nm) treatment
limited to the white patches. This new device has been particularly efficient in
the treatment of limited affected areas of vitiligo vulgaris and segmental
vitiligo (14,15). This new technique has several advantages: it does not
increase the color contrast between normal pigmented and affected skin
the total irradiation dose is minimal and depends on the percentage of body
TABLE 1 Characteristics of Patients

Characteristic No. of subjects a
Age (y)
8-10 22
11-20 94
21-30 167
31-40 201
41-50 132
~51 118
Type of vitiligo
Segmental 68
Nonsegmental 666
Sex
Male 331
Female 403
Skin type
I 1
II 18
III 131
IV 557
V 25
VI 2
Disease duration (y)
<1 156
1-5 151
6-10 219
11-20 116
21-30 55
31-40 29
41-50 8
Course of disease
Stable 479
Unstable 255
aN = 748.
TABLE 2 Mean Irradiation Doses of

Various Areas During Each Session
Area Mean dose (mJ/cm 2 )
Eyebrows 70
Face 120
Chest 220
Arms 300
Legs 280
Hands 500
Feet 480
surface affected, and it is possible to irradiate different parts of the body (i.e.,
hands and feet) with a dose five or six times higher than the dose used for other
parts (i.e., eyelids).
BIOSKIN EQUIPMENT
Bioskin (Fig. I) is a phototherapy device consisting of a short arc generator
emitting a beam of visible and ultraviolet radiation, filtered by a particular
(b)
(a)
FIGURE 4 (a) This 68-year-old woman has suffered from vitiligo vulgaris for 30
years; (b) after 9 months of Bioskin treatment, more than 90% of the vitiliginous
areas were repigmented.
328 Menchini et al.
interference filter in order to obtain the UV-B narrowband (Fig. 2). The time
of emission is regulated by the operator, which acts on a time-controlled
2
shutter. Bioskin can provide a spectrum of intensity up to 400 mW/cm with
an emission spectrum ranging from 300 to 320 nm and a peak emission of 311
nm (Fig. 3). According to the extent of the vitiligo patches, different conical
hoods (1-5 cm diameter) can be applied at the end of the optical fiber to obtain
different light spot diameter (Fig. 3).
(b)
FIGURE 5 Complete repigmentation (a) before and (b) after therapy in a 57-year-
old woman with a neck-localized form of vitiligo.
BIOSKIN MICROPHOTOTHERAPY
In a recent study (16) (Table I) 734 patients were irradia ted once every 2 weeks
for 12 consecutive months. The UV-B narrowband irradiation was performed
by the Bioskin device. During each microphototherapy session, all vitiligo
patches were irradiated (excluding genital areas and mucous membrane).
Although Bioskin equipment can provide a large spectrum of intensity (0-400
2
mW/cm ), in this study an intensity of 50 mW/cm 2 was used for all patients
during all sessions.
The initial dose of irradiation was 20% less than the minimum erythema
dose (MED) evaluated on a vitiligous area at least 3 days before the beginning
of the treatment. During the following sessions the dose was increased by 20%
in every session until the development of erythema was noted. When erythema
developed, the dose of the next session was diminished by 20% only in the
erythematous area.
Approximately 94% of our patient population had skin types II or III.
The MED of Iesiona I skin in these patients was between 180 and 810 mJ/cm 2
evaluated with an intensity of irradiation of 50 mW/cm 2 Since the various
body areas of the same subject show different erythema levels, the irradiation
(a)
(b)
FIGURE 6 Complete repigmentation (a) before and (b) after of a man affected by
Vitiligo vulgaris after 4 months of Bioskin microphototherapy.
330 Menchini et al.
dose for certain areas (i.e., hands, feet) was considerably increased compared
to others (i.e., eyebrows, axillae). Table 2 shows the mean doses used during
each session on different body areas. The extent of depigmentation varied
from 3% to 38%.
THE EFFICACY OF BIOSKIN MICROPHOTOTHERAPY

The duration of the clinical study was 2 years and 8 months (February 1999
through October 2001); the number of the patients recruited was 734. A mean
of 40 treatment sessions were scheduled for each patient. After 6 months of
treatment, 108 patients discontinued Bioskin microphototherapy treatment
after reaching a level of cosmetically acceptable repigmentation, while 14
subjects dropped out for personal reasons. In the majority of the cases,
repigmentation started about 2 months after the beginning of the micro-
phototherapy. Usually the face showed faster and better repigmentation
(Figs. 4-7) than the distal areas (Fig. 8).
FIGURE 7 A young man affected by the vulgaris form of Vitiligo: (a,b) at the be-
ginning of Bioskin microphototherapy; (c,d) after 9 months of treatment, the re-
pigmentation rate is 92%.
FIGURE 8 Repigmentation results on the hand of a 65-year-old woman affected

by a acrofacial form of vitiligo. After 9 months of treatment the repigmentation
results were 85%.
At the end of the study period the results were as follows (Fig. 9): 510
subjects (69.8%) of the 734 had achieved normal pigmentation on more than
75% of the treated areas (112 of these were totally repigmented), 155
(21.12%) individuals achieved 50-75% pigmentation of the treated areas,
and only 69 (9,40%) showed less than 50% repigmentation (vitiligo was
aggravated in 5 of these subjects). The differences in the repigmentation of
segmental and nonsegmental vitiligo were not statistically significant.
The repigmentation rate obtained from this study is similar to those
reported in other international studies using total body irradiation with UV-B
normal band light sources and, overall, demonstrate the numerous advan-
332 Menchini et al.
RESULTS
70,0
.
II 60,0
c:
CII
I II
Q.
'0 40,0
CII
~ 30,0
'E
CII 20,0
~
~ 10,0
0,0
> 75% 50-75% <50%
Percentage of repigmentation
of the treated vitiligo patches
FIGURE 9 Results after 12 months of Bioskin microphototherapy in 734 subjects

affected by vitiligo.
tages of the microphototherapy. The subjects enrolled in this study, as well as

in other studies, presented a maximum skin involvement (vitiligous patches)
of30% with respect to the total body surface, which means that the other 70%
of the skin surface was not exposed at the UV-B radiation.
Since the possibility of developing skin tumors is directly proportional
to the cumulative irradiation dose and to the number of cells irradiated (in this
case the extension of the cutaneous surface treated), this new phototherapy
method has been suggested to reduce carcinogenic risk. This technique also
permits the treatment of children younger than 10 years having vitiligo
patches on less than 10% of the cutaneous skin surface, in light of the
extremely low UV-B cumulative dose applied. In addition, the absence of
hyperpigmentation of the perilesional (nonaffected) skin offers all patients the
chance to undergo phototherapy that, if ineffective, will not worsen the
dyschromic aspect, i.e., will not increase the darkness of the skin surrounding
the white patches. An interesting aspect of this new technique is the possibility
to vary the irradiation dose according to the specific anatomical location of
the areas to be treated and their different responsiveness. The irradiation dose
of each single area is, in our algorithm, 20% lower than the MED of that
particular area. In this way, the irradiation dose can be adjusted according to
the reaction of the irradiated areas. It is possible to increase the dose in less
responsive areas, using constant irradiation on the areas that respond. Some
areas are apparently more sensitive than others and tend to develop some
erythema even after low-dose irradiation (i.e., eyebrows, axilJae).
UV-B Bioskin microphototherapy, despite being a relatively expensive
and not yet well-established treatment for vitiligo, is in our experience an
efficacious, safe, and well-tolerated treatment for vitiligo when limited to less
than 30% of the body surface.
REFERENCES
I. Amerio P, Toto P, Feliciani C, Suzuki H, Shivji G, Wang B, Sauder DN. Re-
thinking the role of tumour necrosis factor-alpha in ultraviolet (UV) B-induced
immunosuppression: altered immune response in UV-irradiated TNFRI R2
gene-targeted mutant mice. Br J Dermatol2001; 144(5):952-957.
2. EI-Ghorr AA, Pierik F, Norval M. Comparative potency of different UV sources
in reducing the density and antigen-presenting capacity of Langerhans cells in
C3H mice. Photochem Photobiol 1994; 60(3):256-261.
3. Goettsch W, Garssen J, de Gruijl FR, van Loveren H. UV-B and the immune
system. A review with special emphasis on T cell-mediated immunity. Thymus
1993; 21 (2):93-1 14.
4. Moodycliffe AM, Kimber I, Norval M. The effect of ultraviolet B irradiation and
urocanic acid isomers on dendritic cell migration. Immunology 1992; 77(3):394-
399
5. Cooke MS, Mistry N, Ladapo A, Herbert KE, Lunec J. Immunochemical
quantitation of UV-induced oxidative and dimeric DNA damage to human
kera tinocytes. Free Radic Res 2000; 33(4):369-381.
6. de Gruijl FR. Photocarcinogenesis: UV A vs UYB. Methods Enzymol 2000;
319:359-366.
7. Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UY-B
radiation vs topical psora len plus UY-A. Arch Dermatol 1997; 113: 1525- J 528.
8. Scherschun L, Kim JJ, Lim HW. Narrow-band ultraviolet B is a useful and well-
tolerated treatment for vitiligo. JAm Acad Dermatol 2001; 44(6):999-1003.
9. Njoo MD, WesterhofW, Bos JD, Bossuyt PM. The development of guidelines
for the treatment of vitiligo. Clinical Epidemiology Unit of the Istituto Dermo-
patico dell'Immacolata-Istituto di Recovero e Cura a Carattere Scientifico (IDI-
IRCCS) and the Archives of DermatoJogy. Arch DermatoJ 1999; 135(12):1514-
1521.
10, Koster W, Wiskemann A. Phototherapy with UY-B in vitiligo. Z Hautkr 1990;
65( II) 1022-1024
II. EI-Ghorr AA, Norval M. The UY waveband dependencies in mice differ for the
suppression of contact hypersensitivity, delayed-type hypersensitivity and cis-
urocanic acid formation. J Invest Dermatol1999; 112(5):757-762.
12. Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo in children
with narrow-band (TL-O I) UYB radiation therapy. J Am Acad Dermatol 2000;
42(2 pt 1):245-253.
334 Menchini et al.
13. Njoo MD, Spuls PI, Bos JD, Westerhof W, Bossuyt BB. Nonsurgical repig-
mentation therapies in vitiligo. Arch Dermatol 1998; 134: 1532-1540.
113(2): 102-108.
15. Mechini G, Tsoureli-Nikita E, Hercogova J, Lotti T. UV-B Radiation micro-
phototherapy in vitiligo vulgaris: results after one year of treatment in 528
patients. Int J Immunopath Pharmacol 2002; 13(5):365-369.
16. Menchini G, Tsoureli-Nikita E, Hercogova J, Lotti T. Narrow-band UVB mi-
crophoto-therapy: a new treatment for vitiligo. J Eur Acad Dermatol Venereol.
In press.
29
Vitiligo: Problems and Nonsurgical
Solutions

Jana Hercogova
The treatment of vitiligo, a chronic and recalcitrant disease, is difficult, and

patients and dermatologists are often frustrated and discouraged by the
persistence and irregular remission and relapses of the psychologically influ-
enced and influencing disease. Nevertheless, a positive and emphatic approach
to the vitiligo patient is mandatory. In our experience, subjects present with
three major questions:
I. Can the progression of the disease be stopped?
2. Can hyperpigmentation of the nonaffected skin be avoided during
trea tment?
3. Is 100% repigmentation possible?
When asked these questions, our replies include the following nonsurgical
explanations and proposals.
336 Menchini et al.
CAN THE PROGRESSION OF THE DISEASE BE STOPPED?

Vitiligo is progressive in 73.6% of cases and regressive in 1.3 % (1). We usually
explain to our patients that progression (and prognosis) depends on the
modality of spreading: segmental or nonsegmental. In 89% of the cases of
segmental vitiligo, disease activi ty ceases after 11-25 months of rapid spread-
ing over the affected dermatome, while nonsegmental vitiligo shows less
progression only when it starts on the face (52.4% of cases). Furthermore,
Koebner phenomenon and mucosal involvement are signs of significant
progression (2). In 89% of cases we can arrest patch extension in nonseg-
mental vitiligo with oralminipulse corticosteroid therapy (5 mg betametha-
sone on 2 consecutive days per week) (3), and extension of segmental vitiligo
can be blocked with PUVA therapy. Nevertheless, we inform our patients that
treatment results are unpredictable and clinical trials are still ongoing.
CAN HYPERPIGMENTATION OF NONAFFECTED SKIN BE

AVOIDED DURING TREATMENT?
Avoiding hyperpigmentation of nonaffected skin is a primary request of
subjects who are concerned with the disfiguring effects of the disease and
various treatments. Thus, total body phototherapy and photochemotherapy
must be avoided in such cases. There are only two ways to avoid border hyper-
pigmentation during cure: application of topical corticosteroids or Bioskin ®
311-UV-B-focused microphototherapy.
Topical Corticosteroids
Low-, medium-, high-, and very high-potency topical corticosteroids (CCS)
can be used as first-line treatment for patients with vitiligo (5~7). The most
effective CCS seem to be class III and IV (betamethasone valerate 0.1-0.2%
and clobetasol propionate 0.05%) (8-10). However, when the face, eyelids, or
intertriginous areas need to be treated, class I and II steroids (hydrocortisone,
fluocinolone acetonide 0.0 I %, or triamcinolone acetonide 0.1 %) should be
used in order to decrease the risk of onset or worsening of glaucoma.
Topical CCS should be used in cases of localized vitiligo « 20% of the
skin surface involved), but not in segmental vitiligo. Good results have been
obtained in generalized vitiligo, but the possible side effects limit this as a first-
choice treatment.
Early lesions, especially these localized on the face and neck, respond
best and most quickly to topical steroids, and this treatment is most effective
Problems and Nonsurgical Solutions 337
on vitiligo patches of dark-skinned subjects (8,9). Corticosteroid cream

should be applied on depigmented skin I or 2 times a day for not more than
4 months (10-14). If there is no evidence ofrepigmentation after 3 months, the
treatment should be discontinued.
Caution must be exercised when using topical steroids. The possibility
of onset of side effects must be considered and therapy discontinued if nec-
essary. Continuous use of topical steroids frequently leads to steroid-induced
acne, epidermal atrophy, telangiectasia, local soreness, erythema, striae
distensae, ecchymosis, hypertrichosis, pruritus, rosacea, or red-face syndrome
(15). Vitiligo may affect children under 12 years of age (16), and physicians
must consider that children, especially infants, are at an increased risk for side
effects from topical steroid therapy. Thus, it is important not to use mid- or
high-potency steroids, but only low-potency corticosteroids such as hydro-
cortisone, dexamethasone, and flumethasone, in children. Recent studies rec-
ommend the use of class III topical CCS (fluticasone propionate and
betamethasone valerate) for children under 12 years of age (17).
Narrowband Focused Microphototherapy

It is possible to treat only the vitiligo patches, avoiding normal skin, especially
in subjects like children and if the surface affected does not exceed 20% of the
total body surface. This allows reducing total dosage without compromising
the results of the therapy (18).
In order to limit side effects, a new phototherapy device, Bioskin, has
been introduced that allows selective narrowband UV-B (311 nm) treatment
limited to the white patches. The predominant part of the Bioskin device is the
UV-B generator that generates a focused beam of UV-B light. This light is
transmitted on vitiligo skin by a special optical fiber. The main characteristics
of the Bioskin generator are that it produces UV -B rays, in a spectrum of300-
320 nm, with maximum emission at 311 nm; the energy displayed by the UV-B
generator is 0-400 mJ/cm 2 /s and the diameter of the light spot is of 1-5 cm.
This method has been particularly efficient in the treatment oflimited affected
areas and segmental vitiligo (23-25) and has several advantages; in particular,
it does not increase the color contrast between normal pigmented and affected
skin, and the total irradiation dose is minimal depending on the percentage of
body surface affected.
The method consists of weekly sessions of irradiation of all vitiligo
patches. The dose is 20% lower than the minimum erythema dose (MED),
which is measured before the beginning of the treatment. Since the treatment
permits differentiated irradiation, it is possible to irradiate hands and feet with
a dose five or six times higher than the dose used for eyelids.
338 Menchini et al.
IS 100% REPIGMENTATION POSSIBLE?

It is frustrating for us as dermatologists to inform our patients that presently
there is no sure treatment for vitiligo. Nevertheless, in our experience patients
respond well to a sympathetic approach, including information about the
social, cultural, and psychological aspects of the disease and even facts from
relevant studies in the literature. In particular, we emphasize three trends:
I. In 1978, an investigator reported a case of a 73-year-old man who
had a 20-year history of "piebaldism" on the face. After I year of
treatment with oral prednisone (15-30 mgjday) for polymyalgia
rheumatica, his face was completely repigmented (20).
2. Up to 100% repigmentation has been observed after 1-2 years of
continued treatment of oral folic acid and ascorbic acid plus paren-
tal treatment with vitamin B I2 (21).
3. Spontaneous regression of the disease is seen in 1.3% of cases
(2).
Finally, we inform patients that microphototherapy (23-25) and surgery (i.e.,
melanocyte grafting and transplantation or suction epidermal grafting) have
been reported to result in 100% repigmentation on limited and stable patches
of vitiligo (22). However, we also point out that:
I. It is not wise to administer 15-30 mgjdie per os prednisone for one
year in an attempt to obtain total repigmentation of the face, and
after stopping the treatment, vitiligo can re-present.
2. The results of Montes et al. (21) with vitamin B I2 require con-
firmation.
3. Spontaneous regression is not a common event in vitiligo.
4. Bioskin microphototherapy may be costly and time consuming,
5. In cases of vitiligo surgical treatments should can be used only for
small, stable lesions.
At the end of such a discussion, patients are usually much more relaxed, and
sometimes they even say "Actually, maybe for now there isn't anything to do
for my vi tiligo. "
CONCLUSIONS
Subjects with vitiligo present continually to us asking for a cure. In fact, most
of them know that there is no sure cure and that the outcome of possible
treatments is unpredictable. Nevertheless, in reply to their three main ques-
tion, today we can propose some interesting, highly effective treatment
strategies that are well tolerated and safe in the long term (22-25), including
Problems and Nonsurgical Solutions 339
local steroid treatment, Bioskin focused microphototherapy, and surgical

procedures plus a series of general treatments.
REFERENCES
l. Hann SK, Chun WH, Park YK. Clinical characteristics of progressive vitiligo.
Int J Dermatol 1997; 36(5):353-355.
2. Hann SK, Park YK, Chun WHo Clinical features of vitiligo. Clin Dermatol1997;
5(6):891-897.
patients having extensive or fast-spreading disease. Int J Dermatol 1993; 32(10):
753-757.
4. Korean J Dermatol 1995; 33:880.
5. Njoo MD, Bossuyt PMM, Westerhof W. Management of vitiligo. Results of a
questionaire among dermatologists in the Netherlands. Int J Derrnatol 1999; 38:
866-872.
6. Mandell AS, Haberman HF, Pawlowski D, Goldstein E. Non PUVA nonsur-
gical therapies for vitiligo. Clin Dermatol 1997; 15:907-919.
7. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for vitiligo.
American Academy of Dermatology. J Am Acad Dermatol 1996; 35:620-626.
8. Kumari J. Vitiligo treated with topical clobetasol propionate. Arch Dermatol
1984; 120:631-635.
9. Geraldez CB, Gutierrez GT. A clinical trial of clobetasol propionate in Filipino
patients. Clin Ther 1987; 9:474-482.
10. Kandil E. Vitiligo-response to 0._ 010 betamethasone 17-valerate in flexible
collodion. Dermatologica 1970; 141:277-28l.
II. Kandil E. Treatment of vitiligo with 0.1 % betamethasone 17-valerate in iso-
propyl alcohol-a double-blind trial. Br J Dermatol 1974; 91 :457-460.
12. Clayton R. A double blind trial of 0.05% clobetasol propionate in the treatment
of vitiligo. Br J DermatoI1977; 96:71-73.
13. Guozhu H, Changgeng S, Ganyun Y, et a!. The terapeutic effect of sicorten
oinJllent in patients with vitiligo. Br J Dermatol 1977; 97:255-26l.
14. Koga M. Vitiligo: a new classification and therapy. Br J DermatoI1977; 97:255-
26l.
15. Jaisankar TJ, Baruah MC, Garg BR. Vitiligo in children. Int J Dermatol 1992;
31:621-623.
16. Holbrook K, Sybert V. Basic science. In: Schahner L, Hansen R, eds. Pediatric
Dermatology. New York: Churchill Livingstone, 1995:J7-18.
17. Pasricha JS, Khaitan BK. Oral minipulse therapy with betamethasone in vitiligo
patients having estensive or fast-spreading disease. Int J Dermatol 1993; 32:753-
757
18. Gibbs NK, Traynor NJ, MacKie RM, Campbell I, Johnson BE, Ferguson J.
The phototumorigenic potential of broad-band (270-350 nm) and narrow-band
(311-313 nm) phototherapy sources cannot be predicted by their edematogenic
potential in hairless mouse skin. J Invest Dermatol 1995; 104(3): 359-363.
340 Menchini et al.
19. Njoo MD, Spuls PI, Bos JD, Westerhof W, Bossuyt MM. Nonsurgical repig-
mentation therapies in vitiligo. Arch Dermatol1998; 134:1532-1540.
20. Brostoff H, Brostoff J. Vitiligo and steroids. Lancet 1978; 2:688.
21. Montes LF, Diaz ML, Lajous J, Garcia NJ. Folic acid and vitamin B12 in
vitiligo: a nutritional approach. Cutis 1992; 50:39--42.
22. Falabella R. Surgical therapies for vitiligo. Clin Dermatol 1997; 15:927-939.
113(2):102-108.
24. Menchini G, Tsoureli-Nikita E, Hercogova J, Lotti T. UV-B Radiation micro-
phototherapy in vitiligo vulgaris: results after one year of treatment in 528
patients. lnt J Immunopath Pharmacol 2002; 13(5):365-369.
25. Menchini G, Tsoureli-Nikita E, Hercogova J, Lotti T. Narrow-band UVB mi-
crophoto-therapy: a new treatment for vitiligo. J Eur Acad Dermatol Venereol
2003; 17(2):171-177.
30
Use of UVB in Vitiligo
Mario Lecha
University of Barcelona, Barcelona, Spain
INTRODUCTION
In the treatment of vitiligo, phototherapy has been the most successful ap-
proach, especially for patients with widespread lesions. There is a long ex-
perience in the use of photochemotherapy since the introduction of this
modality, usually with 8-MOP (PUVA), both oral and topical (1).
The evolution of phototherapy in the last decade with the appearance
of new modalities has prompted the use of these new modalities in the treat-
ment of vitiligo with the aim to improve the results obtained with PUVA and
avoid side effects, mainly of psoralen administration or application (2).
There has been long experience with PUVA UVB phototherapy and
especially narrowband UVB (NBUVB). The design of fluorescent tubes
emitting UVB around 311 nm (NBUVB) has been a consequence of the
results obtained in the study of therapeutic action spectrum for psoriasis (3).
The success of this modality in psoriasis led to its indication in other diseases
such as vitiligo. Previous experience in the treatment of vitiligo with UVB
compared with PUVA was minimal (4). Because the therapeutic action
spectrum in vitiligo is not known, all wavelengths may be used.
BACKGROUND, TREATMENT PROTOCOLS, AND RESULTS

The first data on UVB treatment of vitiligo (broadband UVB) appeared in
1990 when Koster and Wiskemann (4) reported their results. The first report
of treatment with NBUVB appeared in 1997 (2). In this study, Westerhofand
341
342 Lecha
Nieuweboer-Krobotova compared this modality of treatment with topical

psoralen plus UV A. The authors concluded that NBUVB was more effective
compared to topical PUV A, with faster repigmentation. It is also notable that
with NBUVB, the contrast between normally pigmented skin and depig-
men ted skin was less striking as reported by these authors.
In 1998 a first meta-analysis on nonsurgical treatments for vitiligo re-
pigmentation appeared (5). Several treatment modalities were compared by
the authors, including, for generalized vitiligo, UVA associated with methox-
salen, trioxsalen, bergapten, psoralen, phenylalanine, khellin, oral cortico-
steroids and one study with broadband UVB and another with NBUVB. The
conclusion of this report is that the best levels of repigmentation in generalized
vitiligo are obtained with UVB broadband or NBUVB and methoxsalen
plus UVA, although for UVB treatments data are still insufficient.
Subsequently, two other papers about NBUVB treatment for vitiligo
appeared in the literature, the first about treatment in children (6) and the
second including adults (7), both reporting good results. EI Mofty et al.
reported in 2001 (8) results of comparing PUVA with 8-MOP plus broad-
band UVB with 8-MOP, indicating a similar efficacy for both treatment
modalities.
The use of UVB in the treatment of vitiligo has been also considered
with combinations as topical application of pseudocatalase and calcium chlo-
ride or calcipotrioJ (9,10). Phototherapy with phenylalanine has been used
since 1985 with either UVA and UVB. The major drawback of this combi-
nation treatment is side effects from oral phenylalanine administration. This
protocol has been applied much more frequently with UVA than with UVB
(II). For segmental vitiligo UVB has also been considered with a specific
microphototherapy modality (12).
Although experience with UVB treatment for vitiligo is still limited,
most treatment series reported refer to NBUVB phototherapy. Treatment
protocols (Table I) show slight differences in initial doses, increments per
treatment, maximal dose per treatment, and treatment frequency. Treatment
TABLE 1 Treatment Protocols
Ref 2 Ref 6 Ref 17 Ref 7

2 2 2
Initial dose 0.075 J/cm 0.25 J/cm 0.200 J/cm 0.280 J/cm 2
Increments of dose after 20% 20% 0.050 J/cm 2 15%
each treatment
Highest dose per treatment 0.800 J/cm 2
No. treatments per week 2 2 2 3
Use of UVB in Vitiligo 343
results are summarized in Table 2. These results are for patients achieving
>75% repigmentation. Side effects in these cases were minimal, and no treat-
ment discontinuation was needed.
According to the results of Westerhof et al. (2), NBUYB seems to
produce faster repigmentation. In 48% of their patients, 25-75% repigmen-
tation was achieved after the first 3 months of treatment.
Taking into account that not all patients will show the same level of
repigmentation and considering that we may have at present a choice of
phototherapic modalities to apply, it could be of interest to establish what
type of patient would respond better to NBUYB or to PUYA. Parameters
that have been considered in outcome evaluations are sex, age, phototype,
years of onset of lesions, and extension. According to Scherschun et al. (7), in
a report on a small series of patients, a better response with NBUYB was
achieved in patients with phototypes IY and Y and short-lasting disease.
The major advantages of the use of UYB or NBUYB are systemic
psoralen side effects (i .e., no need for eye protection between treatments) and
low cumulative total doses of radiation. These treatment modalities may be
used in children and pregnant or lactating women. On the other hand, UYB
treatments produce less erythema, no photo toxic effects, no epidermal thick-
ening after long-term irradiation, and less contrast between normally pig-
mented skin and vitiligo patches. The ultraviolet radiation cumulative dose is
lower and treatments are shorter.
There is incomplete understanding of the mechanism of UYB repig-
mentation, but it appears that there may be no specific differences between
UYB and PUYA. An interesting report regarding the possible mechanisms of
UBY repigmentation by Imokawa et al. (13) indicated that human keratino-
cytes show increased expression of tyrosinase, endothelin-I, and IL-I a after
UYB irradiation. Synthesis of endothelin-l is stimulated by IL-la, has mela-
nogenic properties, and may be involved in UYB-induced repigmentation.
TABLE 2 Treatment Results with NBUVB
Ref. 2 Ref. 6 Ref. 7
Number of patients 51 51 7
Results (>75% 32 patients (63%) 27 patients (53%) 5 patients (71.4%)
repigmentation)
Side effects No side effects Itching xerosis Itching erythema
Treatment duration 12 months 12 months 12 months
(100 treatments)
Mean cumulative 32.34 J/cm 2 91.3 ± 46.6 J/cm 2 31.34J/cm 2
total dose (9.58-128.01) (7.4-77.0)
344 Lecha
Previous studies regarding mechanisms involved in vitiligo were related

to oxidative stress in lesions of this disease, with local accumulation of H202
associated with low catalase levels and vacuolation of melanocytes. This
phenomenon can be reversed by addition of catalase. These results prompted
the topical application of pseudocatalase and its activation by UVB as a
treatment approach for vitiligo. It has been used mainly in focal disease by
Schallreuter et a!. (14).
Other anecdotal treatment protocols have been suggested, but this fact
unfortunately only reflects that we are still far from a satisfactory treatment
for vitiligo. Even phototherapy, which gives the best possible results, is not
satisfactory and is associated, moreover, with possible long-term side effects.
This may also be the case for NBUVB, a phototherapy modality with very
good short-term results (15).
Evidence-based guidelines for the treatment of vitiligo indicate that for
generalized vitiligo UVB phototherapy is recommended, but no statistical
differences exist between PUVA, NBUVB, or broadband UVB regarding
success rates.
REFERENCES
I. Ortel B, Gonzalez S. Photo- und Photochemotherapie der Vitiligo. In: Krutmann
1, Honigsmann H, eds. Handbuch der dermatologischen Phototherapie und
Photodiagnostik. Berlin: Springer-Verlag, 1997: 111-135.
2. WesterhofW, Nieuweboer-Krobotova L. Treatment ofvitligo with UV-B radi-
ation vs topical psoralen plus UV-A. Arch Dermatol 1997; 133:1525-1528.
3. Parrish lA, laenicke KF. Action spectrum for phototherapy of psoriasis. 1 Invest
Dermatol 1981; 76:359-362.
4. Koster W, Wiskemann A. Phototherapie mit UV-B bei Vitiligo. Z Hautkr 1990;
65:1022-1029.
5. Njoo MD, Spuls PI, Bos lD, Westerhof W, Bossuyt PMM. Nonsurgical repig-
mentation therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol
1998; 134: 1532-1540
6 Njoo MD, BosJD, WesterhofW. Treatment of generealized vitiligo in children
with narrow-band (TL-OI) UVB radiation therapy. 1 Am Acad Dermatol 2000;
42:245-253.
7. Scherschun L, Kim JJ, Lim HW. Narrow-band ultraviolet B is a useful and well-
tolerated treatment for vitiligo. 1 Am Dennatol 200 I; 44:999-1003.
8. EI Mofty M, Zaher H, Esmat S, Youssef R, Shahin Z, Bassioni D, El Enani G.
PUVA and PUVB in vitiligo-are they equally effective? Photodermatol Pho-
toimmunol Photomed 2001; 17: 159- 163.
9. Schallreuter KU, Wood 1M, Lemke KR, Levenig C. Treatment ofvitilicro with a
topical application of pseudocatalase aand calcium in combination wi~h short-
Use of UVB in Vitiligo 345
term UVB Exposure: a case study on 33 patients. Dermatology 1995; 190:223-

229.
10. Parsad D, Saini R, Nagpal R. CaJcipotriol in vitiligo: a preliminary study.
Pediatr Dermatol1999; 16:317-320.
II. Cormane RH, Siddiqui AH, Westerhoff W. Treatment of vitiligo with phenyl-
alanine and light. Arch Dermatol Res 1985; 277:126-130.
elective treatment for segmental vitiligo. 1 Em Acad Dermatol Venereol 1999;
13:102-108.
13. Imokawa G, Miyagishi M, Yada Y. Endothelin-I as a new melanogen: coor-
dinated expression of its gene and the tyrosinase gene in UVB-exposed human
epidermis. 1 Invest Dermatol 1995; 105:32-37.
14. Schallreuter KU, Moore 1, Wood 1M, Beazley WD, Gaze DC, Tobin DJ,
Marshall HS, Panske A, Oanzig E, Hibberts NA. In vivo and in vitro evidence for
hydrogen peroxide accumulation in the epidermis of patients with vitiligo
and its succesful removal by a UVB-activated pseudocatalase. 1 Invest Dertmatol
15. Halder RM, Young CM. New and emerging therapies for vitiligo. Dermatol Clin
2000; 18:79-89.
16. Njoo MD, Westerhof W. Vitiligo. Pathogenesis and treatment. Am 1 Clin
Dermatol 2001; 2:167-181.
17. Zanolli MD, Feldman SR, Clark AR, Fleischer AB II'. Phototherapy Treatment
Protocols. New York: Parthenon Publishing, 2000:63-79.
31
Cover-Ups: The View of the
Cosmetologist
Alida DePase
Bergamo, Italy
A global approach to vitiligo by the patient should take all physical and
psychological aspects of the disease into consideration, and therefore the
dermatologist should not only try a therapy, but also suggest products that
can make the patient feel as normal as possible. Patients suffering from vitiligo
can use camouflage: an aid that can help them overcome the emotional stress
deriving from the uncomfortable relationship with their own appearance,
which changes to an undefined extent as a result of this disfiguring disease.
Three different types of cosmetic products can be used for camouflage or
corrective make-up specific for vitiligo: cover creams, instant self-tanning
creams and lotions, and stains and dye.
Dermatologists are currently focusing great attention and interest on
corrective make-up, because it can increase the patient's confidence and
improve his or her quality of life. In addition. it is readily accepted by women,
who, unlike children and men, are already accustomed to using make-up
products. Even men Jearn the technique easily when they feel the need for it.
The few dermocosmetic industries in the world that have focused on this
specific sector in recent years have developed a range of effective and user-
friendly products, with results very close to perfection.
Reliability is the one common feature that cover creams, self-tanning
creams and lotions, and stains and dyes specific for vitiligo must ha ve. In fact,
these products are applied for very long periods of time, for many years or
347
348 DePase
even for the patient's entire lifetime, until a safe and effective treatment can be
found to totaIIy resolve the problem of vitiligo.
Low toxicological effect is achieved thanks to tested formulas and
ingredients for which the toxicological effects are widely known using selected
substances. Formulas must be tested so as to guarantee perfect consistency
over time. The formulas for these specific products must take their function
into account; their specific features are represented by guaranteed stability
over time, being insensitive to temperature changes, adhesiveness, and natural
coloring, which should remain unchanged during the day.
These specific products should be capable of creating films of different
thicknesses, be waterproof, sweatproof, and heatproof. Cover techniques are
not easy to learn, especiaIIy for beginners; but with patience and commitment
using the right cosmetic products specific for vitiligo, results close to perfec-
tion can be achieved.
COVER CREAMS
Cover creams can be liquid, compact, or in a stick. Their texture is denser than
traditional foundation creams; in fact, this is necessary to provide effective
cover. Cover creams contain up to 50% mineral oils and wax. Their different
texture is due to titanium dioxide, used as a thickening and shielding agent.
The coloring is provided by iron oxides. In general, these products are weII
tolerated by patients. However, comedo phenomena, dermatitis and allergies
can occasionally occur. These reactions are mainly due (in two-thirds of the
cases identified) to fragrances and preservatives contained in these products.
Dermocosmetic industries producing cover creams for camouflage
provide us with a wide range of base colors, and in the majority of cases
these are identical to the patient's skin coloring.
SELF-TANNING PRODUCTS
People who do not suffer from vitiligo often use self-tanning products,
because they not only provide a healthy and bright coloring but also
moisturize and protect the skin. Self-tanning products have been marketed
for about 30 years, but they were not very successful at first due to the yel-
lowish and uneven coloring they provided; today's new formulas produce
exceIIent aesthetic results.
Self-tanning products are based on DHA (dihydroxy acetone), a sub-
stance that reacts with the proteins of the surface layer of the epidermis,
"coloring" the skin a few hours after application and simulating a tanning
effect. In the past, bergamot oil was also used to trigger a hyperactivation of
Cosmetic Approach 349
melanin synthesis and create a tanning effect. However, the use of bergamot
oil has been prohibited due to the high level of phototoxicity and the effects it
may have on DNA stability. Therefore, bergamot oil is no longer contained,
as was previously the case, in the formulas of self-tanning products intended
for use by the general public. The use of psora lens has now been limited to the
treatment of skin diseases such as vitiligo. With normal washing and natural
skin renewal, DHA coloring gradually fades away, and the products currently
on the market are safe and do not present any side effects.
It is necessary to adopt specific application techniques of self-tanning
products in vitiligo. The patient will choose from among colorless lotions with
different DRA concentrations, which can be used for pale-medium-dark skin
types. These lotions can be used throughout the year; they are waterproof and
do not stain clothes and sheets. Sun-shielding products can also be applied
after the desired color intensity has been obtained.
Before applying the self-tanning products, it is necessary to ensure that
the skin is adequately moisturized. It is also advisable to rub the skin with a
soft brush to eliminate dead cells and obtain an even skin coloring. It is
advisable not to apply the product during the hot hours of the day, because
excessive sweat can result in an uneven application. Only a small quantity of
the product should be applied at first; if the desired coloring is not achieved, it
is possible to intensify the color with additional applications after a few
minutes. If too much of the product is used, the result will be too dark or
produce stains. Use a cotton swab for small-sized vitiligo lesion, and dip the
tip in the selected product. Then spread the product working from the center
of the lesion towards the outside, up to 1-2 mm from the lesion edge. The
product can be spread over the entire skin area, including the naturally
pigmented areas. Subsequently, application can be repeated over the white
areas using a cotton swab dipped in the product. Avoid washing for 3 hours
after the product has been applied.
OTHER PRODUCTS
Vitiligo patients who do not like cover creams or self-tanning products can
use liquid or gel dyes, which are very easy to apply using a cotton ball or while
wearing gloves. Dyes immediately provide a natural, amber-like coloring,
which can be adjusted to the desired shade by applying a single layer to get a
lighter hue or additional layers to get a darker shade. A wide range of dyes
in different hues are currently available. Their only disadvantage is that they
fade away when washed with soap and water, but they are extremely easy to
use and provide a natural result; they do not stain clothing and they are not
greasy. The coloring agents are products normally used in the food industry
350 DePase
and therefore are nontoxic. In brief, there are many ways to conceal vitiligo
areas-even large ones-and give vitiliginous skin a natural color. The re-
sulting aesthetic effect is a natural appearance, and the patient feels more
confident. Coping with everyday life without having to face embarrassing
questions or indiscreet looks; enjoying the possibility of wearing a short-
sleeved shirt or shorts in the summer without being forced to hide hands
in pockets; greeting a person with a handshake without fearing repulsion:
this is what camouflage can do for vitiligo. The patient's life is definitely
improved.
32
Cover-Ups: The View of the
Dermatologist
Rossana Capezzera, Cristina Zane,

and Piergiacomo Calzavara-Pinton
Spedali Civili, Brescia, Italy
INTRODUCTION
Results of standard and experimental treatment options for vitiligo are often
disappointing, with no or only partial results. In addition, most therapies re-
quire treatment periods lasting months or years before repigmentation oc-
curs, if at all (I). In the mean time, irrespecti ve of the extent of the disease, the
cosmetic disfigurement of vitiligo may lead to emotional distress and loss of
self-image and impair considerably the patient's private and professional life.
The relevant psychological and social impact of the disease fosters the need
for palliative treatments. Therefore, practically all patients with vitiligo may
need adjunctive therapies for a short-or perhaps lifelong-period of time. A
broad and heterogeneous group of cosmetics can mask the white spots, tem-
porarily or permanently.
Permanent camouflage involves cosmetic tattoo, whereas cosmetic
makeup and skin dyes are a ready and practical, albeit temporary, solution
that masks totally or partially the hypopigmented areas and restores a nor-
mal-looking appearance. These have been used since ancient times.
The use of cosmetics does not improve or modify results of dermato-
logical therapies but generally enhances the compliance with treatment pro-
grams because patients enjoy the psychological benefits of looking better
while receiving specific medical care. Unfortunately, the psychological con-
351
352 Capezzera et al.
sequences of impaired appearance are not sufficiently appreciated by physi-

cians. Few dermatologists are fully aware of the benefits that can be obtained
by the skilled use of cosmetics, and, as a consequence, their knowledge re-
garding colored foundations, lotions, cleansers, bleachers, self-tanning prep-
arations, and tinted covers is often poor.
SKIN CAMOUFLAGE
Camouflage is a makeup technique for masking aesthetic damage. It can be
permanent (tattoos) or temporary (cosmetic camouflage).
Permanent Camouflage
Permanent camouflage is obtained with a cosmetic tattoo. The most effective
pigments have peculiar physical and cosmetic characteristics. Unlike pig-
ments used for ritual or symbolic tattoos, they are inert iron oxides that do not
migrate or appear "blotchy" over time. The color is implanted into the dermal
layer with specialized techniques and cannot be washed off. Very satisfactory
results are obtained when only small areas of the face, particularly in the
perioral area, and the dorsal hands are involved. Dark photo types are more
easily treated than people with fair skin.
Cosmetic results are strongly dependent on the doctor's or technician's
skill in matching perfectly the color of the tattoo with the color of the sur-
rounding skin area. Unfortunately, only a few have been adequately trained
in color theory and understand the role that the skin's natural undertones play
in the achievement of maximum uniformity.
The colors of the tattoo fade naturally over time, requiring periodic
maintenance, usually every 2-5 years.
Temporary Camouflage
The uniform applica tion of thin films of selected opaque cosmetics wi th light-
reflecting ingredients are very effective for covering, or at least reducing, the
visual impact of white patches. Products for covering vitiligo are specific and
quite different from other common cosmetic make-ups. Their main character-
istics include (2,3):
Varied colors for matching all ethnic skin tones and individual skin
nuances. This can be achieved by mixing several cream bases.
High opacity for concealing or masking achromic skin with the appli-
cation of a thin layer of cream.
High resistance against wash-off to ensure that they can be worn in the
rain or when active in sports.
Cosmetic Cover-Ups 353
Easy application, because cumbersome and time-consuming applica-

tion will discourage their use.
Persistence and adherence to ensure that they will be long wearing and
easily repaired if necessary.
Cosmetic products for camouflage are complex formulations of several com-
ponents, as described in the following paragraphs.
Pigments are colored substances that are chemically inert in regard to
perspiration and sebum secretion. They are contained as insoluble ingredients
in wet products (powders, compact cream, eye shadows) or suspended in a
vehicle (cover cream emulsion) through physical and chemical links. The
cover index (Cl.) identifies both chemical class and formulation. There are
two chemical classes: inorganic (mineral) and organic (lacq uer) compounds.
The former are more commonly used (Table I). Organic pigments are lac-
quering compounds obtained through the absorption and co-precipitation of
hydroxides or sulfates of calcium, strontium, barium, and soluble dyes. (4,5).
Natural or synthetic pearls give brightness to cosmetic products. Natu-
ral pearls are rarely used because of the very high cost, whereas synthetic ones
are less expensive. They contain crystallized bismuth oxychloride, which has a
metallic luster but poor light resistance, or titanium dioxide monomolecular
layers and other pigments over mica layers.
Ore charges have many functions: adhesion to the skin (calcium, mag-
nesium, and zinc stearates), improvement of compactness (wax, rice starch,
and modified starch), stickiness (talc), and transparency and absorption of
skin lipids (talc, calcium precipitate carbonate, magnesium carbonate, colloi-
dal kaolin, pyrogenic silica) Talc is most widely used, but it must be free of
chlorine and amianthus fibers as well as bacterial contamination.
Thyxotropic agents (purified organophilic bentonites, pyrogenic silica
in addition to polymethacrylate and modified celluloses) can modify the
TABLE 1 Inorganic (Mineral) Pigments Available for MakeUp Products
Chemical nature C.1. Color Composition
Iron oxide 77491 Red-ochre Fe203

Iron hydrate oxide 77491 Yellow-ochre FeO(OH)nH 20
Iron dioxide 77492 Brown-black FeOFe203
Titanium dioxide 77891 White Ti0 2
Zinc oxide 77947 White ZnO
Chromium oxide 77288 Green Cr203
Chromium hydrate oxide 77289 Green-blue Cr2034H20
Prussian blue 77510 Blue-green Cr4" 1 [Fe" (CN)6b
viscosity of cosmetic products in order to prevent precipitation of the pig-

ments. They are widely used for colored emulsions.
Waxy vehicles enhance the compactness of the powders. They can be of
animal (beeswax, lanolin wax), vegetable (carnauba, pedilanthus pavonis, rice
bran, wax), or mineral (microcrystalline wax) origin.
Fatty vehicles (e.g., vegetable glycerides, lanolin derivatives, hydrogen-
ate lanolin, hydrogenated coconut oil, oily alcohols, white vaseline, synthetic
glycerides) increase oiliness, softness, doughiness, and lubrification of cos-
metic products and have high emollient activity.
At room temperature, oily vehicles moisten and carry pigments because
of their fluidity and ability to penetrate into the pores of the polymers. They
can be of mineral (vaseline oil), vegetable (fluid glycerides, e.g., castor oil,
oryza sativa, zea mays), animal (distillate alcohol of lanolin), or synthetic or
semisynthetic (oleilic alcohol, silicone) origin.
Solvent and emulsion vehicles used in cover-tinted creams are usually
aqua and glyceryl stearate.
Antioxidative alimentary agents, particularly tocopherol acetate, vita-
min A, vitamin C, vitamin E, and lecithin, are natural moistening agents that
allow the skin to breathe and function naturally. In addition, some studies
claim they have reparative, antiaging, and antiphotoaging properties. The
time onset of rancidity is used to assess their resistance over time. The most
common cosmetic preservatives, parabens, have antifungal and antimicrobial
properties. A defilement test (challenge test) assesses the minimal dose that
ensures safety over a reasonable period of time.
Fragrances are aromatic blends of natural or synthetic essential oils.
Irritants as well as products with sensitizing and photosensitizing properties
must be carefully ruled out.
Sunscreens are added in order to avoid sunburn of white patches and
prevent tanning of the surrounding normal skin that would enhance any chro-
matic difference.
COVER-UPS FOR TEMPORARY CAMOUFLAGE

Several different make-up products are available, including conventional
compact and liquid foundations, stick foundations, pressed powders, fixing
sprays, cleansers and "self-tanning" preparations. The prescription is based
on the patient's individual needs and the location and size of the vitiligo areas.
Cosmetics specifically designed for application on the face, body, or limbs are
available. For example, tinted cover creams in a loose (liquid foundation) or
pressed (compact foundation) form as well as loose and pressed powders are
usually applied on the face (4,5).
Compact Foundation
Compact foundations have a high covering and masking ability and give
brightness, opacity, and transparence to the skin. They are usually hypoalIer-
genic and allow the makeup to be long lasting, water- and sweat-resistant, as
well as protecting the skin. In addition, they can filter partially or totally
ultraviolet rays. Application with a soft sponge is easy, and removal is done
with cleansing milk or makeup remover. These foundations are available in
various tinted shades, allowing a perfect match to normal skin color.
Liquid Foundation
Liquid tinted cover creams are available in various shades. Application is very
easy, and soon after, a thin, fixing, absorbent and water-resistant powder can
be applied. In addition to masking activity, they moisten, soothe, and soften
the skin.
Stick Foundation
Pink sticks are used for covering ivory vitiliginous areas. Colored stick
foundations must be covered with makeup fluid or compact creams.
Pressed Powder
Various pink shades of pressed powder, alone or in combination with colored
sticks, are available for mimicking all skin colors. They can be applied with a
small paint brush or a synthetic sponge for quick and easy retouch.
Fixing Spray
A fixing spray dries and maintains the cover all the day. It is formulated with
silicon and polymers, which create an elastic film on the makeup.
Self-Tanning Creams
Self-tanning creams may be considered camouflage products as well. They
allow the achievement of a coloration that mimics a tan (pseudo-tan) and
masks the achromic areas without the exposure to ultraviolet radiation. Var-
ious formulations-creams, emulsions and lotions-are available. They con-
tain 3-5% dihydroxyacetone, derived from sugar cane, which oxidizes the
keratin of the horny layer, producing colored compounds that vary from
yellow to brown. A natural-looking tan appears 4 or 5 hours after application
and disappears gradually within a few days. They are usually well tolerated
without relevant adverse effects. However, careful washing of hands and
nails is needed after application in order to avoid unwanted coloration of
the palms. Application is not recommended during phototherapy because

self-tanning products can filter UV rays.
Cleanser
Cleansers remove makeup products and residual skin impurities from the skin
Several different formulations-emulsions, lotions, soap-free foaming gel,
creams-are available.
METHODS OF APPLICATION
Several recommendations help to obtain optimal results:
Cover creams must be tested directly on vitiliginous skin in order to
closely match the color of the normal surrounding skin.
The skin must be washed with a cleanser and a synthetic sponge in order
to remove residual skin impurities and sebaceous secretions that
reduce the holding power of the cover cream.
The stick corrector must be applied before the makeup foundation to
neutralize discoloration.
Tinted cover creams must be applied with a foam rubber or synthetic
sponge in a patting motion. The patting motion uniformly applies the
product and avoids obstructing the pores.
FIGURE 1 Correct application of foundation.
FIGURE 2 Camouflage of perioral vitiligo.
A small amount of the selected shade is placed on the outer surface of

the hand before application to warm the foundation to body temper-
ature. The foundation is applied with a sponge over the skin area by
pressing to obtain maximum adherence. The setting powder should
be colorless and translucent so that the camouflage product does not
change color (Fig. 1).
The finishing pressed powder is spread generously, and 2-3 minutes are
needed for it to incorporate with the foundation. Brush off the excess
powder and settle by pressing a damp tissue or sponge onto the skin
surface.
The fixing spray must be vaporized from a distance of about 50 em. It
will become dry within a few seconds.
Camouflage products are best removed with a water-soluble makeup
remover. Alcohol- or acetone-based removers excessively dry and
irritate sensitive skin. Apply the remover liberally to emulsify the
camouflage makeup, wipe off with cotton pads, wash the areas with a
mild, glycerine soap, rinse off thoroughly with warm water and pat
dry, and, finally, apply the preferred moisturizer or emollient for
sensitive skin.
An example of camouflage of vitiliginous areas of the face is shown in Fig-
ure 2.
SIDE EFFECTS
Permanent tattoing of the perioral skin is sometimes followed by recurrences
of herpes simplex infection (2). Chronic granulomatous reactions to the im-
planted pigment are exceedingly rare.
Cosmetic products for temporary camouflage are generally well toler-

ated if applied correctly. Nevertheless, it is not advisable to use camouflage
products on chapped, dry, or inflamed skin. Allergic contact dermatitis to
fragrances and preserving agents has been described and, if suspected, must be
assessed with patch tests and photo patch tests.
CONCLUSIONS
The addition of cosmetics to dermatological treatment programs improves
the compliance to the treatment protocol because patients enjoy the psycho-
logical benefits of looking better while receiving specific medical care. If the
disease is refractory to all standard and investigative therapies, camouflage of
the skin disfigurement is even more important. It is hoped that dermatologists
will become more skilled in temporary and permanent makeup techniques
and increase their awareness of the psychological benefits of appearance-
enhancing cosmetic treatments.
REFERENCES
I. Radokovic-Fijan S, Fiirnsinn-Friedl AM, H6nigsmann M, Tanew A. Oral dexa-
methasone pulse treatment for vitiligo. 1 Am Acad Dermatol 2001; 44(5):814-
817.
2. Graham lA, Kligman AM. The psychological benefits of cosmetics in health care:
dermatologic perspectives. 1 Appl Cosmetol 1984; 2:7-18.
3. Westmore MG. Camouflage and makeup preparations. Clin Dermatol 2001; 19
(4):406-412.
4. Engasser PG, Maibach H. Cosmetics and dermatology bleaching creams. JAm
Acad Dermatol1981; 5(2):143-147.
5. Rigano L. Cosmetici decorativi: formulazioni e componenti. Cosmesi Dermatol 7:
I 1~21.
33
Depigmentation and Vitiligo
Christina Antoniou and Electra Nicolaidou

University of Athens School of Medicine, "A. Sygros" Hospital,
Athens, Greece
Despite the several therapeutic options that we now have for the management
of vitiligo, depigmentation of the normally pigmented skin still remains, for
selected vitiligo patients, the only way to a uniform skin color. Depigmenta-
tion is a process that destroys the remaining cutaneous melanocytes in vitiligo
patients, enabling them to achieve the same very light complexion all over
their body. The U.S. Food and Drug Administration (FDA) has approved the
use of monobenzylether of hydroquinone (MBEH) for depigmentation in
patients with vitiligo involving at least 50% of their body surface area (BSA)
(1). Patients with less widespread vitiligo can, however, also benefit from
depigmentation therapy, and recently substances such as 4-methoxyphenol
(2) and modalities such as Q-switched ruby laser (2) and cryotherapy (3) have
also been used for depigmentation with promising results.
INDICATIONS FOR DEPIGMENTATION

Proper selection of patients is the most important step in depigmentation
therapy. The procedure usually leads to permanent destruction of melano-
cytes and leaves the patient for the rest of his/her life with a skin that has a
different tone than before and is extremely photosensitive. Not every patient
can cope with that. Furthermore, the possibility of future, more successful
therapies for vitiligo must be discussed with the patient.
As mentioned above, the main indication for depigmentation therapy
is widespread vitiligo that extends to more than 50% of BSA. The more
360 Antoniou and Nicolaidou
extensive the depigmentation, the stronger the indication for depigmentation

therapy. Some patients have only a few residual dark spots scattered over
their face and body. These patients are ideal candidates for depigmentation.
Another group of patients who can benefit from depigmentation are
those with less extensive disease (30-50% of BSA), which is very resistant to
treatment. These patients may have failed repeated courses of standard
therapeutic interventions and see depigmentation as their last resort. How-
ever, the risk/benefit ratio must be weighed more carefully for those patients.
Children are generaUy not good candidates for depigmentation, because
they cannot give their informed consent to the procedure. However, for
children who suffer in such a way from their disfigurement that they cannot
attend school in a normal fashion, depigmentation therapy of their exposed
skin is an option that must be discussed in great detail with both the parents
and teachers before being initiated.
METHODS OF DEPIGMENTATION
Chemical Agents
MBEH, a phenolic compound, is by far the most widely used agent for
depigmentation and, as mentioned above, the only one approved by FDA for
that indication. Recently, 4-methoxyphenol has also been used with good
results (2)
Monobenzylether of Hydroquinone (Monobenzone). The first observation
of the depigmenting properties ofMBEH was made in the 1930s, when work-
ers began to develop depigmented macules mainly-but not exclusively-in
areas of their skin that were in contact with some new rubber gloves (4). The
gloves were analyzed and found to contain an antioxidant known as agerite
alba, or MBEH. Patch testing with MBEH induced depigmentation, and
when the agent was removed from the gloves, repigmentation was observed
(5). Thus, the etiological association of MBEH and depigmentation was es-
tablished. The sites of distant depigmentation were at that time attributed to
contact with the gloves while perspiring.
Following its association with depigmentation, MBEH was initially
used for the treatment of hyperpigmentation disorders. Again, distant sites of
depigmentation were observed in some patients, but the tendency to blame
accidental contact with the cream still prevailed. Eventually it became evident
that the depigmentation caused by MBEH is not restricted to the sites of
application but can also occur at distant sites of the body. This side effect,
along with reports of leukome1anoderma with patients developing areas of
hyper-, hypo-, and depigmentation both on sites of application and at distant
Depigmentation and Vitiligo 361
sites (6), led to the limitation of MBEH's indications to depigmentation in

vitiligo patients.
MBEH is metabolized into reactive free radicals which are capable of
destroying melanocytes (7). This is why depigmentation is usually permanent.
However, follicular melanocytes very often survive. This explains why, after
depigmentation has been completed, some patients develop a few to many
perifollicular pigmented macules, either after exposure to the sun or even
spontaneously. Why epidermal melanocytes are more sensitive than follicular
ones is not very clear. One theory is that MBEH cannot penetrate down to the
level of the hair matrix (I), while another one states that there are two
populations of melanocytes in the skin, an epidermal and a perifollicular one
(8) and the epidermal is more sensitive to both the mechanism of vitiligo and
depigmentation therapy. That is why the presence of dark hair in vitiligo
patches is a good prognostic sign for repigmentation therapy but a bad one for
depigmentation.
MBEH is commercially available as a 20% cream. The patient usually
first treats a test spot (e.g., forearm) to exclude an allergic reaction. If there
is no reaction after one week, the cream is applied to pigmented skin once
daily for another week. If the patient tolerates the applications, the medi-
cation is then applied twice daily. Some patients may develop contact der-
matitis, more often irritant than allergic, at the sites of application, which is
usually restricted to pigmented and not to white skin. In such cases, MBEH
can be diluted to a 10% or even 5% concentration. Mild topical steroids can
also be applied simultaneously. If the dermatitis is more severe, applications
of MBEH are withheld until the dermatitis is treated and then resumed usu-
ally at a 5% concentration, which is increased gradually. The risk of irritant
contact dermatitis is the reason why some authors (9) prefer to start not with a
20% but with a 10% concentration of MBEH applied twice daily and in-
creased by 5% every I or 2 months until reaching the 20% level.
Depigmentation therapy of a particular site can last from months to 1-2
years. In one study (10), 8 out of 18 patients who used MBEH for up to 10
months achieved complete depigmentation. Most the patients who did not
depigment fully used the cream for less than 4 months, and one had to stop
therapy because of severe contact dermatitis. During therapy, the skin light-
ens gradually. It usually takes 1-3 months of therapy for a response to be seen.
If after a course of 3~ months with 20% MBEH some sites, such as the
elbows or knees, have failed to lighten, the concentration can be increased to
30% or even 40%. Application of the cream with occlusive plastic wraps can
also help. It is possible for a patient to use different concentrations of MBEH
at different sites of the body, according to their sensitivity and response. Areas
such as the eyelids or periocular skin are usually not treated at all, because
application of MBEH to these areas has been reported to cause conjunctival
melanosis and corneal deposits of pigment (II). Patients are also advised to
avoid direct contact of their treated skin with the skin of others for 2-3 hours
after application of the cream.
Most of the side effects of MBEH have already been mentioned. To
summarize them, short-term adverse effects include contact dermatitis, pru-
ritus, xerosis, depigmentation at distant sites, graying of the hair (12), and,
following application to periocular skin, conjuctival melanosis and corneal
deposits of pigment. Long-term side effects include leukomelanoderma and
exogenous ochronosis (13). These long-term side effects have, however, been
noticed only in patients being treated for hyperpigmentation disorders, not
in vitiligo patients undergoing depigmentation. Systemic side effects have
not been reported for MBEH. However, it is better not to prescribe it during
pregnancy and lactation.
4-Methoxyphenol (Mequinol or p-Hydroxyanisole or Monomethylether of
Hydroquinone). In many European countries (including Greece), MBEH is
no longer available, mainly because of its side effects. 4-Methoxyphenol (4-
MP), another phenol derivative with melanocytotoxic properties similar to
those of MBEH (14), has been used in one study (2) for depigmentation in
vitiligo universalis. Among 16 treated patients, 11 achieved total depigmen-
tation, a rate comparable to that of MBEH (10). However, the first signs
of depigmentation appeared after 4-12 months of therapy, whereas with
MBEH, depigmentation can start as soon as I month after initiation of
therapy (10). Contact dermatitis after application of 4-MP seems to be less
common and less severe, compared to MBEH, but reports about irregular
leukoderma have also been made (15), and, therefore, as with MBEH, the
indications of 4-MP include only depigmentation of vitiligo patients. A 36%
relapse rate was reported in the above study after a treatment-free period
that lasted between 2 and 36 months. Repigmentation occurred after sun
exposure, and its pattern was perifollicular, which implies that perifollicular
melanocytes are not as sensitive to 4-MP as epidermal ones and survive its
melanocytotoxic actions. Therefore as is also the case with MBEH, sun pro-
tection is essential for preservation of depigmentation.
Q-Switched Ruby Laser

The Q-switched ruby (QSR) laser beam can selectively destroy melanin and
melanin-containing structures in the skin (16) and has been used for depig-
mentation therapy in patients with vitiligo universalis (2,17). In one study (2),
9 of the 13 treated patients showed complete depigmentation. The depigmen-
tation started between 7 and 14 days after the laser treatment, faster than the
results achieved with creams. The number of treatments needed for total
depigmentation depended on the size of the treated areas and varied between
Depigmentation and Vitiligo 363
2 and lO treatments. The only side effect reported was that of pain, which be
managed with the application of an anesthetizing cream (EMLA) 2 hours
before the procedure. Of the 9 successfully depigmented patients, 4 showed a
return of pigmentation in a perifollicular fashion after a treatment-free
period, which varied from 2 to 18 months. The perifollicular pattern of repig-
mentation indicates that perifollicular melanocytes are not destroyed by the
laser therapy, as is also the case with both MBEH and 4-MP. All four patients
who showed repigmentation had reported a negative Koebner phenomenon,
in contrast to the five patients who remained depigmented and who had re-
ported a positive Koebner phenomenon. This indicates that a positive Koeb-
ner phenomenon is a favorable prognostic sign for the long-term results of
QSR laser depigmentation.
Cryotherapy
Cryotherapy, even though it is known to be melanotoxic (18), had not been
reported to be used for depigmentation in vitiligo patients until very recently
(3). In this study, five patients were treated with one to three sessions of
cryotherapy and all of them achieved complete depigmentation. No side
effects were reported. Within 8 months of follow-up, however, two patients
developed lentigo-like macules on sun-exposed skin, which were retreated
with cryotherapy or chemical peeling. Cryotherapy seems to be a safe, cost-
effective, and rapid method of depigmentation, but return of pigment is still a
problem, as is the case with all the other methods of depigmentation described
above.
REFERENCES
1. Bolognia JL, Lapia K, Somma S. Depigmentation therapy. Dermatol Ther 200 I;
14:29-34.
2. Njoo MD, Vodegel RM, WesterhofW. Depigmentation therapy in vitiligo uni-
versalis with topical4-methoxyphenol and the Q-switched ruby laser. J Am Acad
Dermatol 2000; 42:760-769
3. Radmanesh M. Depigmentation of the normally pigmented patches in universal
vitiligo patients by cryotherapy. J Eur Acad Dennatol 2000; 14:149-152.
4. McNally WD. A depigmentation of the skin. Indust Med 1939; 8:405-410.
5. Oliver EA, Schwartz L, Warren LH. Occupational leukodel111a. JAMA 1939;
113:927-928.
6. Canizares 0, Jaramillo FU, Kerdel Vegas F. Leukomelanoderma subsequent to
the application of monobenzylether of hydroquinone. Arch Dermatol 1958; 77:
220-223.
7. Westerhof W, Njoo MD. Bleaching agents. In: Katsambas AD, Lotti TM, eds.
European Handbook of Dermatological Treatments. Berlin: Springer, 1999:766-

777.
8. Tobin DJ, Bystryn Jc. Different populations of melanocytes are present in hair
follicles and epidermis. Pigment Cell Res 1996; 9:304-310.
9. Antoniou C, Katsambas A. Guidelines for the treatment of vitiligo. Drugs 1992;
43:490-498.
10. Mosher DB, Parrish JA, Fitzpatrick TB. Monobenzylether of hydroquinone. A
retrospective study of treatment of 18 vitiligo patients and a review of the lit-
erature. Br J Dermatol 1977; 97:669-679.
II. Hedges TR TIl, Kenyon KR, Hanninen LA, Mosher DB. Corneal and conjunc-
tival effects of monobenzone in patients with vitiligo. Arch Ophthalmol 1983;
101:64-68.
12. Katsambas AD, Lotti TM, Ortonne JP. Vitiligo. Tn: Katsambas AD, Lotti TM,
eds. European Handbook of Dermatological Treatments. Berlin: Springer, 1999:
617-623.
13. Snider RI, Thiel'S BH. Exogenous ochronosis. J Am Acad Dermatol 1993; 28:
662-664.
14. Riley PA. Mechanism of pigment cell toxicity produced by hydroxyanisole. J
Pathol 1970; 101:163-169.
15. Boyle J, Kennedy CTC. Leucoderma induced by monomethylether of hydro-
quinone. Clin Exp Dermatol1985; 10:154-158.
16. Spicer MS, Goldberg DJ. Lasers in dermatology. J Am Acad Dermatol 1996;
34:1-25
17. Kim YJ, Chung BS, Choi KC. Depigmentation therapy with Q-switched ruby
laser after tanning in vitiligo universalis. Dermatol Surg 200 I; 27:969-970.
18 Kuftik GE. Cryosurgery updated. J Am Acad Dermatol 1994; 31:925-944.
34
Vitiligo and the Internet
Giovanni Menchini and Torello M. Lotti

Jana Hercogovci
The internet has become the most important media source of information
thanks to its simplicity and speed. Using the internet is easy and inexpensive:
it is far more simple to publish data on a web page than via the normal edi-
torial procedure associated with a periodical publication (Table I). Thus, the
internet provides not only scientific information (often not peer-reviewed),
but also commercial product, advertisements patient recommendations,
information about scientific associations or organizations, and much more
(Fig. I).
In this "info-jungle," it can be very hard to find the information one is
looking for. The simplest way is to used a search engine (e.g., Altavista,
Google, Yahoo) (1-3), refining the search with terms that specify the kind
of information desired along with the subject (vitiligo and treatments and
UYB, etc).
The internet is now certainly the major working tool used in medicine in
all fields, from research activity to on-line teaching. The quantity of medical
information included in the web pages of the global network is enormous and
permits everyone access to detailed information about all kinds of patholo-
gies, updated with the latest news. Nevertheless, when the interest is in a single
365
366 Menchini et al.
TABLE 1 Web Pages and Scientific Publications Dedicated to Vitiligo and

Other Common Skin Diseases
Web pages Scientific publications Ratio
Vitiligo 67,000 1,351 50 to 1

Psoriasis 368,000 8,352 44 to 1
Herpes simplex 121,000 13,598 9 to 1
Acne 194,000 3,202 61 to 1
Vasculitis 69,500 4,839 14 to 1
Melanoma 402,000 23,919 17 to 1
Web pages about some dermatological disorders
160. 000-'/'
,
VI
,-
140. 000- vi
if
V if:
120. 000-
,/,
100. 000-
80. 000-
(i
- o University
/' - ---- .:;::l
Products
60. 000- ,/, "'~~
rtfl o Therapies
~
.0:::
d' -
40. 000-
T '"" b_
,........
,........
.;:
-
- I-
20. 000- ~ ii; ...,.. ::(
"
/f=.
.~
F;
I·;·" !:::i1),
WiJigo
;\
Psoriasis
,........
.. '.
Herpes
-,
1-""
Acne
it
o Ph_
Vasculitis
':'
I\felanoma
I-<.
"''
sirrplex
Diseases
FIGURE 1 Web pages dedicated to vitiligo and other common skin diseases.
Vitiligo and the Internet 367
pathology, such as vitiligo, it is advisable to utilize authorized websites of

worldwide scientific importance, such as those of international professional
organizations (e.g., European and/or American Academy of Dermatology,
International Society of Dertmatology) (4,5), medical journals (e.g., Archives
ofDermatology, Journal of the American Academy ofDermatology, Journal of
the European Academy of Dermatology and Venereology) (6-8), or medical
web portals (e-medicine, PubMed) (9 10).
Consulting websites of well-established dermatological professional
societies is of importance mainly when one is interested in therapeutic aspects
of a disease. "Treatment" and "therapy," used in conjunction with the
relative disease (e.g., vitiligo and treatment), seem to be two of the most
commonly used key words in internet searches. The amount of information
available is immense, and in addition to established scientific websites, many
commercial or even self-made websites contain questionable information.
This is true especially in the field of dermocosmetology, where websites
promote products that in some cases do not offer proper treatment of the
disease, but more of a cosmetic adjuvant use. Treatment of acute forms of
vitiligo, as well as chronic or maintenance treatment, should be accurately
researched on dermatological manuals on-line (e.g., Merck) (11-13), at sites
that include large clinical reviews of dermatological diseases, and/or the
websites of established journals or scientific publications. The internet must
be used carefully and critically. The enormous quantity of information
available must be carefully analyzed and checked before being exploited for
a research project or treatment protocol of any type.
To facilitate internet surfing and avoid the obstacles mentioned above,
we include here some addresses that, in our opinion, could be helpful for the
dermatologist and provide reliable, updated information:
Associations:
National Vitiligo Foundation: http://www.vitiligofoundation.org/
menu.htm
American Vitiligo Research Foundation: http://wwwavrf.org/
Products:
Sacha Cosmetics: http://www.sachacosmetics.com/camoufiage.htm
Vitiligosupport: http://www.vitiligosupport.com/
Therapies:
Vitiligo Switchboard: http://web.onramp.ca/cadd/vitiligo.htm
Bioskin: Narrowband UVB microphototherapy: www.vitiligo.it
REFERENCES
1. Altavista: www.altavista.com.
2. Google: www.google.com.
368 Menchini et al.
3. Yahoo: www.yahoo.com.
4. American Academy of Dermatology: www.aad.org.
5. European Academy of Dermatology and Venereology: www.eadv.org.
6. Archives of Dermatology: archderm. ama-assn.org.
7. Journal of American Academy of Dermatology: www.eblue.org.
8. Journal of European Academy of Dermatology and Venereology: www.
blackwell-synergy.com. www.eadv.orgjjournal.
9. E-medicine: www.emedicine.com.
10. PubMed: www.ncbi.nlm.nih.govjPubMed.
11. Merck Manual: www.merck.comjpubsjmmanual.
12. American Medical Association: www.jama.ama-assn.orgjissuesjv283nI2jffullj
jsc00054.html.
13. eHealth Code of Ethics: www.ihealthcoalition.orgjethicsjehealthcode0524.
html.
35
Halo Nevus
Demetris loannides
Aristotle University Medical School, Thessaloniki, Greece
INTRODUCTION
The halo nevus is a distinctive benign melanocytic nevus that occurs mainly in
childhood and adolescence (1). Clinically the nevus has a ring of depigmen-
tation (Fig. I). It was originally described by Hebra and made known by
Sutton as leukoderma acquisitum centrifugum in 1916 (2).
The term "halo phenomenon" describes the zone or margin of depig-
mentation occurring in association with a variety of both neoplastic and
inflammatory cutaneous lesions. The first description of the halo phenomenon
has been attributed to the artist Mathias Grunewald. In his masterpiece,
Wandelaltar (1512-1516), he depicts a bull-like monster with multiple halo le-
sions that are most likely nevi (3). The term halo phenomenon was particularly
used by Mescon in his pu blished discussion of an article by Kopf et al. (4).
EPIDEMIOLOGY AND CLINICAL PICTURE

The typical history of a halo nevus is that a ring of depigmentation forms
around a preexisting pigmented nevus. Most individuals are children and
young adults. In a study of 142 cases (5), the average patient age was 16 years.
The halo nevi may be located in any anatomical site, but there is a predilection
for the back (5). They are usually solitary, but authors have reported that 25-
50% of individuals present with multiple lesions, occurring either simulta-
neously or successively (6). The incidence of halo nevi has been estimated at
1% of the population (6).
370 loannides
FIGURE 1 A halo nevus on the thorax of a 20-year-old girl.
Familial occurrence can be rarely observed. Two sisters with halo nevi
were known to Ortonne et al. (6), and Chisa (7) reported a brother and a sister
with halo nevi. Two more sisters were included in a series of 35 patients
reported by Kopf et al. (4), and of 100 patients reported by Wayte and Helwig,
2 had a positive family history of similar lesions (8). There is also one report
with the simultaneous occurrence of such nevi in four members of one family
(9).
The time needed for the depigmentation of the halo to develop is not
known. Patients report that the halo phenomenon may take days to weeks to
fully evolve. The central nevus may remain unchanged or become less
pigmented over time. Sometimes the nevus involutes, leaving a localized area
of depigmented skin (8). Frank and Cohen declared that at least 50% of halo
nevi disappear spontaneously (10). The areas of depigmentation may persist
unchanged for months or years or repigment totally. Some authors (6,10)
describe four stages of nevus progression and regression. Stage I is the
appearance of a classic halo nevus, which is a brown nevus with a surrounding
rim of depigmentation. In stage II the central nevus may lose its pigmentation
and appear as a pin-colored papule with a surrounding halo, whereas in stage
III the central papule may disappear, leading to a circular area of depigmen-
tation. Finally, in stage IV the depigmented area may repigment leaving no
trace of its existence.
Whether a particular halo nevus will progress through all four stages of
regression is difficult to predict. It is even more difficult to predict the rate at
Halo Nevus 371
which the progression will occur. Moreover, there is a report in which

darkening rather than lightening of the central nevus was observed (II).
The distinctive feature in the patient described in this report is not only the
darkening of the central nevus, but also the pattern of hyperpigmentation. It
had a net-like appearance with perifollicular sparing (II).
HISTOLOGY AND PATHOPHYSIOLOGY

The microscopic criteria for the halo phenomenon include the obligate
presence of a band-like Iymphohystiocytic infiltrate and a diminution or
absence of melanin pigment at the dermoepidermal junction at the periphery
of the lesion. Especially in early lesions, lymphocytes may be seen around
damaged melanocytes in the halo. Later, more scattered nevus cells than nests
are observed. Even when melanin is still present in the nevus cells, these cells
often show evidence of damage to their nuclei and cytoplasm, and some
apoptotic nevus cells are commonly found (5,12).
The nevus is usually a benign melanoytic nevus, predominantly com-
pound in nature. It can be also junctional or intradermal nevus. Nevomela-
nocytic lesions associated with the halo phenomenon include congenital nevi,
blue nevi, neuroid nevi, Spitz nevi, and mongolian spots (5,12).
Some halo nevi may show some degree of atypia related to the intensity
ofinfiammation (I). Atypia, as a feature of halo nevus, is mentioned in several
textbooks. Okun and Edelstein stated that it has been suggested that halo
nevus may be a spontaneously regressing melanoma (13). In their description
of halo nevus, Clark et al. (14) commented that, in some cases, the hyperplasia
of melanocytes might be extensive with cytologic atypia. McGovern (15)
proposed that junctional nevus cells might assume a disturbing atypical
appearance. Lever and Schaumberg-Lever (12) refer to nevus cell nests, which
may appear as if they were atypical.
In a study of 142 cases of halo nevi, it was demonstrated that there is a
great deal of variation in the degree of atypia and that the spectrum of
nevi identified was similar to acquired nevi in general (5). Coperman and
Elliot (16) demonstrated a cytoplasmic antibody against melanoma cells in
patients with involuting halo nevi, but not in patients with ordinary nevi.
Cooke et al. reported (17) that melanoma specific protein is detected in the
urine of patients with actively developing halo nevi, but not in normal
controls.
In one report (18), the histological changes observed in a halo nevus
resembled those of epidermal erythema multiforme. Meyerson's nevus has
been described as a melanocytic nevus with an associated eczematous halo
reaction (19). Eczematous halo developing around atypical nevi has been also
reported in four patients (20).
372 loannides
In an interesting study (21), Lai et al. sent a questionnaire to 87 pediatric

dermatologists asking whether the physician had ever seen a child under 18
years who presented with a halo nevus that turned out to be melanoma. None
of the dermatologists from whom they received answers (90%) had ever seen a
typical halo nevus with melanoma. They concluded that a halo nevus in
childhood very rarely undergoes malignant transformation and therefore
very rarely, if ever, is a biopsy required (21). The congenital nevi with a halo
phenomenon were excluded from the study, because melanoma arising in
such nevus is a well-recognized pathobiologic event (22).
The underlying pathophysiology responsible for the halo phenomenon
is not well understood. During the formation and regression of halo nevi,
infiltrates composed ofT cells, in particular CD8 + cytotoxic suppressor cells,
have been observed (23). In addition, circulating activated lymphocytes were
seen in patients with halo nevi and their disappearance was documented
following surgical excision (24). It has been suggested that the mononuclear
inflammatory infiltrate of the halo phenomenon acts via a cytotoxic cell-
mediated immune response to cause regression of nevi (25). Bergman et al.
proposed (26) that the identical distribution of HLA-A,B,C antigens found
present on the melanocytes, and the composition of the inflammatory
infiltrate in both halo nevi and malignant melanoma, suggest a very similar
immune response operative in these conditions. Aside from whether a unique
antigen or several antigens are recognized by this family of T cells, the nature
of the halo nevi antigens remains unknown; however, it does not belong to the
proteins that are known thus far to be specifically expressed by melanoma
cells. The halo nevus antigen(s) might be an auto-antigen, part of the differ-
entiation program of the normal nevi to which the immune system is normally
tolerant (27).
The immunopathogenesis of halo nevus seems to overlap with that of
inflammatory vitiligo, in which T-cell infiltrates with elevated numbers of
CD8 + cells and CD25-expressing cells (a marker for T-cell activation) have
been observed (28). Patients with vitiligo were shown to have circulating skin-
homing autoreactive cytotoxic lymphocytes, and similar cells may be present
in those with halo nevi (29). However, the association of halo nevus and
vitiligo is not sufficiently common for halo nevus to be regarded as a form of
vitiligo (J 2). In an epidemiological case-control study in a population of
patients with unilateral and bilateral vitiligo, halo nevi were infrequent in the
total vitiligo group, and no difference was observed between vitiligo types
(30).
Besides the more common halo nevus with histologically apparent
inflammation, there are also cases of noninflammatory halo nevi, in which
no inflammatory infiltrate was shown in histological examination (12,31). In
such instances the nevus does not involute. In addition, there is the so-called
Halo Nevus 373
halo nevus without halo (32). In these instances, histological signs of in-
flammation are shown in the nevus, but clinically a halo around the nevus has
not been developed. Such nevi may involute (31,32).
Halo nevus may be difficult to differentiate from rare halo malignant
melanoma. The latter is usually asymmetrical, including the halo, and in
most cases some clinically obvious melanoma remains. With melanoma, the
perilesional pigment loss usually appears only along a portion of the pe-
rimeter rather than along the entire circumference, as is seen with typical halo
nevi (33).
Histologically, the inflammatory infiltrate in halo nevi is more pro-
nounced than in melanoma and extends diffusely through the lesion, rather
than being concentrated at the periphery as in most examples of tumorigenic
melanoma (12).
REFERENCES
I. Blessing K. Benign atypical nevi: diagnostic difficulties and continued con-
troversy. Histopathology 1999; 34: 189-198.
2. Sutton RL. An unusual variety of vitiligo (leukoderma acquisitum centrifugum).
J Cutan Dis 1916; 34:797-800
3. Borroni G, Vignati G. Should Sutton nevus really be called Grunewald-Sutton
nevus? Am J Dermatopathol 1993; 92: 14-15.
4. Kopf AW, Morrill SD, Silberberg 1. Broad spectrum of leukoderma acquisitul11
centrifugum. Arch Dermatol 1965; 92: 14-35.
5. Mooney M, Barr R, Buxton MG. Halo nevus or halo phenomenon? A study of
142 cases. J Cutan Pathol 1995; 22:342-349.
6. Ortonne JP, Mosher DB, Fitzpatrick TB. Vitiligo and Other Hypol11elanoses of
Hair and Skin. New York: Plenum Publishing Corporation, 1983:567-611
7. Chisa N. MUltiple halo nevi in siblings. Arch Derl11atol 1965; 92:404-405.
8. Wayte DM, Helwig BB. Halo nevi. Cancer 1968; 22:69-90.
9. Herd RM, Hunter JAA. Familial halo nevi. Clin Exp Derl11atol1998; 23:68-69.
10. Frank SB, Cohen HJ. The halo nevus. Arch Dermatol, 1964,367-371
11. Huynh P, Lazova R, Bologna J. Unusual halo nevi-darkening ather than
lightening of the central nevus. Dermatology 2001; 202:324-327.
12. Elder D, Elenitsas R. Benign pigmented lesions and malignant melanoma. In:
Elder D, Elenitsas R, Jaworsky C, Johnson B Jr, eds. Lever's Histopathology of
the Skin (8th ed.). Philadelphia JB Lippincott, 1997:652-654
13. Okun MR, Edelstein LM. Gross and Microscopic Pathology of the Skin. Boston:
Dermatopathology Foundation Press, 1975:942-944.
374 loannides
14. Clark WH Jr, Elder DE, Guerry D. Dysplastic nevi and malignant melanoma. In:
Farmer ER, Hood AF, eds. Pathology of the Skin. CT: Appleton and Lange,
1990:747-749.
15. McGovern VJ. Melanoma: Historical Diagnosis and Prognosis. New York:
Raven Press, 1983:87-89.
16. Coperman FWM, Elliot PG. Melanoma cytoplasmic humoral antibody test. Br J
Dermatol 1976; 94:565-568.
17. Cooke KB, Bennett C, Staughton RCD. Melanoma specific protein: occurrence
in the urine of patients with halo nevi and vitiligo. Br J Dermatol 1978; 98:663-
669.
18. Fabrizi G, Massi G. Halo nevus with histological changes resembling epidermal
erythema multiforme. Br J Dermatol 1999; 141:369-370.
19. Nicholls DSH, Mason GH. Halo dermatitis around a melanocytic nevus:
Meyerson's nevus. Br J Dermatol 1988; 118:125-127.
20. Elenitsas R, Halpern AC. Eczematous halo reaction in atypical nevi. J Am Acad
Dermatol 1996; 34:357-361.
21. Lai CH, Lackbart S, Mallory SB. Typical halo nevi in childhood: Is a biopsy
necessary? J Pediatr 200 I; 138:283-284.
22. Bouffard D, Barnhill RL, Mihm MC, Sober AJ. Very late metastasis (27 years) of
cutaneous malignant melanoma arising in a halo giant congenital nevus.
Dermatology 1994; 189:162-166.
23. Akasu R, From L, Kahn HJ. Characterization of the mononuclear infiltrate
involved in regression of halo nevi. J Cutan Pathol 1994; 21:302-311.
24. Baranda L, Torrez-Alvarez B, Moncada B, Portales-Perez D, de la Fuente H,
Layseca E, Gonzalez-Amaro R. Presence of activated lymphocytes in the
peripheral blood of patients with halo nevi. J Am Acad Dermatol 1999; 41:567-
572
25. Zeff RA, Freitag A, Grin CM, Grant-Kels GM. The immune response in halo
nevi. J Am Acad Dermatol 1997; 37:620-624.
26. Bergman W, Willemze R, De Graaf-Reitsma C, Ruiter DJ. Analysis of major
histocompatibility antigens and the mononuclear cell in.filtrate in halo nevi. J
27. Musette P, Bachelez H, Flaguel B, Delarbre C, Kourilsky P, Dubertret L,
Gachelin G. Immune-mediated destruction of melanocytes in halo nevi is
associated with the local expansion of a limited number of T cell clones. J
Immunol 1999; 162:1789-1794.
28. Le Poole IC, van del' Wijngaard RM, Westerhof W, Das PK. Presence ofT cells
and macrophages in inflammatory vitiligo skin parallels melanocyte disappear-
ance.AmJPathoI1996; 148:1219-1228.
29. Ogg GS, Dunbar PR, Romero P, Chen J, Cerundolo V. High frequency of skin-
homing melanocyte-specific cytotoxic T lymphocytes in autoimmune vitiligo. J
Exp Med 1998; 1881203-1208
30. Barona ML Arrunategui A, Falabella R, Alzate A. An epidemiologic case-
control study in a population with vitiligo. J Am Acad Dermatol 1997; 36:282-
283.
Halo Nevus 375
31. Brownstein MH. Halo nevi without dermal infiltrate. J Invest Dermatol 1978;
114:1718-1721.
32. HappJe R, Echternacht K, Scotola 1. Halonaevus ohne Halo. Hautartz 1975;
26:44-47
33. Bystryn J-C, Xie Z. Neoplastic hypomelanosis. In: Nordlund J, Boissy R,
Hearing V, King R, Ortonne J-P, eds. The Pigmentary System. New York:
Oxford University Press, 1998:647-662.
36
Alezzandrini's Syndrome
Fabrizio Guarneri and Mario Vaccaro

University of Messina, Italy
Alezzandrini's syndrome is a oculo-cutaneous disease characterized by

hypomelanosis associated with retinic degenera tion and, sometimes, auditory
involvement. The first case of this extremely rare syndrome was described in
1959, by Casala and Alezzandrini (I). They reported the clinical history of a
12-year-old patient with unilateral retinitis pigmentaria, who successively
developed ipsilateral vitiligo and poliosis, in association with hypoacusia. In
1961 the same authors, together with Cremona, published another case report
(2) on a 22-year-old subject with similar clinical features, but not affected by
hypoacusia. In 1964, the observation of a third patient (3) led Alezzandrini
to propose the definition of a new syndrome, characterized by the onset, in
young subjects, of unilateral tapetoretinic degeneration, followed, in a varia-
ble time (3-13 years), by ipsilateral vitiligo and poliosis and inconstant audi-
tory involvement.
Because of the rarity of this syndrome, a new case was not reported until
1992, by Hoffman and Dudley (4): a diabetic (type I) patient developed
unilateral facial vitiligo and ipsilateral poliosis and, 9 years later, unilateral
retinal detachment. The latter sign, not included in the original definition by
Alezzandrini, was also observed, in 1994, by Shamsadini et al. (5). Their pa-
tient presented a unilateral retinal detachment, followed one year later by
ipsilateral poliosis and 3 years later by controlateral retinal detachment. Ac-
cording to Lorincz, retinal detachment has to be considered another criterion
for the diagnosis of Alezzandrini's syndrome.
377
378 Guarneri and Vaccaro
The etiopathogenesis is still unknown. No familial inheritance has been

evidenced: in the case described by Shamsadini et al. (5), some signs of the
disease were present in the family: a grandfather of the patient had become
blind at 19 years of age, but the cause of blindness was unknown, and the
brother presented with acral asymmetric vitiligo, but without any ophthalmo-
logical disorder or poliosis. Because of similarities with other multisystemic
syndromes, an autoimmune mechanism has been hypothesized by many
authors to explain the clinical manifestations of Alezzandrini's syndrome.
Differential diagnosis includes mainly Vogt-Koyanagi-Harada syn-
drome, a combination of Vogt-Koyanagi syndrome and Harada's disease
characterized by meningitic symptoms (in its first phase), generalized vitiligo
with destruction of basal melanocytes, poliosis, chronic bilateral uveitis, dys-
acusia, and alopecia areata (6). Lorincz proposed that Alezzandrini's syn-
drome and Vogt-Koyanagi-Harada syndrome could be different expressions
of a single disease (7).
Other syndromes and diseases can resemble some features of Alezzan-
drini's syndrome and should then be considered in differential diagnosis:
vitiligo, albinism, piebaldism, tuberous sclerosis, Waardenburg's syndrome,
Chediak-Higashi syndrome, Marfan's syndrome, Rubinstein-Taybi syn-
drome, hyperthyroidism, hypoparathyroidism, Addison's disease, hypopitui-
tarism, pernicious anemia, halo nevus (leukoderma acquisitum centrifu-
gum-Hyde and Sutton), nevus depigmentosus, leprosy-tuberculoid,
pityriasis alba, postinflammatory depigmentation, phenylketonuria (pigment
dilution), idiopathic guttate hypomelanosis, syphilitic leukoderma, and scle-
roderma/morphea (7,8).
The extremely limited number of cases, and their temporal and geo-
graphical distance, has not allowed studies on predisposing, causative, and
prognostic factors, and no specific therapy is therefore available. It must be
noted, however, that Alezzandrini's syndrome is largely unknown, and this
could lead to an underestimation of its low undoubtedly low incidence. Oph-
thalmologists and dermatologists should be aware of its existence and con-
sider it among possible diagnoses. This should provide researchers with more
data, contributing to the progress of medicine, better knowledge and a ther-
apy for this disease.
REFERENCES
l. Casala AM, Alezzandrini AA. Vitiligo y poliosis unilateral con retinitis pigmen-
taria y hipoacusia. Arch Argent Derm 1959; 9:449-456.
2. Cremona AC, Alezzandrini AA, Casala AM. Vitiligo, poliosis y degeneracion
macular unilateral. Arch onal B Aires 1961; 36:102-106.
3. Alezzandrini AA. Manifestation unilaterale de degenerescence tapeto-retinienne,
Alezzandrini's Syndrome 379
de vitiligo, de poliose, de cheveux blancs et d'hypoacusie. Ophtalmologica 1964;

147:409-419
4. Hoffman M D, Dudley C. Suspected Alezzandrini's syndrome in a diabetic patient
with unilateral retinal detachment and ipsilateral vitiligo and poliosis. JAAD
1992; 26:496-497
5. Shamsadini S, Meshkat M, Mozzafarinia K. Bilateral retinal detachment in Alez-
zandrini's syndrome. Int J Derm 1994; 33:885-886.
6. Barnes L, Nordlund 11. Vogt-Koyanagi-Harada and Alezzandrini's syndromes.
In: Clinical Dermatology. Philadelphia: Lippincott-Raven, 1988.
7. Lorincz AL. Disturbances of melanin pigmentation. In: Moschella SL, Hurley
JH, eds. Dermatology. Vol. 2. Philadelphia: WB Saunders, 1985:1297.
8. Monti M. La sindrome di Alezzandrini. In: Lotti TM, Bianchi B, Ghersetich I,
eds. La Vitiligine-Nuovi Concetti e Nuove Terapie. Milan: UTET Periodici
Scientifici, 2000: 120-121.
37
Acquired Hypomelanoses
R. Konkolova
Charles University, University Hospital Motol, Prague, Czech Republic
The occurrence of acquired hypomelanoses (hypopigmentation, depigmen-

tation, leukoderma) on human skin is more frequent than of vitiligo, albinism,
or other congenital hypomelanoses. In many cases the mechanism of origin
has not yet been fully clarified. They can be either reversible or permanent.
In a general sense, among the group of acquired hypomelanoses can be in-
cluded idiopathic guttate hypomelanosis, Vogt-Koyanagi-Harada syndrome,
halo nevus, leukonychia, and others. This list can be further supplemented
with hypopigmented mycosis fungoides, symmetrical progressive leukopathy,
a group of inflammatory and postinfectious hypomelanoses, chemical sub-
stances-induced hypomelanoses, hypomelanoses due to physical effects, and
hypomelanoses occurring in some internal diseases or disorders.
Hypopigmented mycosis fungoides is a rarely occurring form of myco-
sis fungoides. The incidence is significantly higher in persons with dark skin,
but it has also been reported in Caucasians. Depigmented macules are found
on the trunk, hips, and limbs. They usually respond readily to the most com-
monly used psoralen UVA (PUVA) therapy. Repigmentation occurs after the
treatment. Patients with this diagnosis require the same follow-up as those
diagnosed with mycosis fungoides (1,2).
Symmetrical progressive leukopathy is relatively frequent in young
adults (e.g., in Japan and Brazil). From a clinical viewpoint, it consists of
permanent symmetrical punctate hypopigmentations located above the ex-
tensors of the limbs, in the abdominal region, and interscapularly. Its etiology
is unknown (3).
381
382 Konkolova
POSTINFLAMMATORY AND POSTINFECTIOUS

HYPOMELANOSES
Almost any skin inflammation can heal with hypopigmentation or a hypo-
pigmented scar (depending on depth). The most frequent incidence is in
hypomelanotic nests in patients with healed psoriatic manifestations, lupus
erythematosus, lichen planus, and atopic dermatitis. A case of residual leuko-
derma following erythema multiforme has been also described (4), clinically
copying the original pathological manifestations (Fig. I). Other hypopig-
men ted lesions, macular as well as papular, can occur in sarcoidosis (5).
FIGURE 1 Postinflammat°[Jot;fjll{JJftl98W&terial
Acquired Hypomelanoses 383
Two clinical diseases are sometimes classified as pseudoleukoderma.

Pityriasis simplex alba is frequent in atopic children. The affected parts are
usually the face or the limbs, where the hypopigmented nest is clinically
found, sometimes with fine scaling on the surface. Its etiopathogenesis is
thought to involve blocked transition ofmelanosomes from melanocytes into
keratinocytes due to inflammation and edema of the involved area. The
manifestation is asymptomatic; it disappears with time. The recommended
therapy is lubrication with emolients with addition of antiseptics or mild
corticosteroids.
A frequent infectious cause of hypopigmentation is pityriasis versicolor.
The causative agent of the disease is MalasseziajUijur, a saprophyte of the
human skin that induces the disease only in predisposed individuals. Clinical
symptoms of the affected skin are whitish oval macules that can fuse into
larger patches. They are usually located on the back and in the presternal
region. They are probably a result of the inhibition of tyrosinase with lipids
originating during oleic acid metabolism (6) or a simple, so-called umbrella
effect, which reduces the penetration of sunlight. The usual treatment is local
application of imidazol-based topical preparations; general treatment is used
only in more severe cases.
Other infectious diseases associated with the onset of hypomelanotic
patches are syphilis with syphilitic leukoderma, leishmaniasis, onchocercosis,
leprosy, pinta (7), and herpes simplex.
CHEMICAL SUBSTANCE-INDUCED HYPOMELANOSES

Through their external effects on the skin or their systemic use, chemical
substances can lead to hypopigmentations. Of the substances with such effect,
the most common are those used for the therapy of hyperpigmentation. The
principle of their effect is usually irreversible melanotoxicity or reversible
blocking of melanogenesis. Such therapy may result in undesirable cosmetic
hypopigmentation. Among the bleaching agents used are the following:
Phenol and its derivatives (e.g., isopropylkatechol), used for their an-
tiseptic effects in germicide agents and for their melanotoxic and
caustic effects for the chemical peeling and bleaching of the skin.
They are also slightly anesthetic, nephrotoxic, hepatotoxic, and
cardiotoxic.
Hydroquinone and its derivative hydroquinone monobenzylether block
tyrosinase, the key enzyme in melanin synthesis. They can also be
components of substances used in industry.
Cojic acid, used as a component of bleaching creams. Its derivatives are
also used in the food industry and photography for their fungicide,
insecticide, and h~~'N/.aterial
384 Konkolova
Azelaic acid, which restrains tyrosinase activity and inhibits DNA syn-
thesis in keratinocytes and melanocytes. It has a selective effect on
hyperactive melanocytes and does not lead to formation of hypo-
pigmentation.
Oxidation substances result in the bleaching of the skin and hair via
melanin oxidation. These include hydrogen peroxide, benzoylperoxide, and
chlorates. The reduction agents change melanin into leukomelanin (e.g.,
acetic acid, citric acid). The principle of the bleaching effects of the mercury
compounds has not been fully clarified. Mild bleaching agents include cor-
ticosteroids and ascorbic acid (reduction agents). Mild bleaching effects also
occur in retinoids. Other substances having a bleaching effect include alde-
hydes present in cucumbers, arbutin and methylarbutin in other kinds of
vegetables, sandalwood oil, and unsaturated fatty acids (8).
Onset of hypomelanosis has been observed following contact with cer-
tain plants (e.g., primula, piperaceae) (9) or other contact allergens (e.g.,
chloroxylenol, paraphenylendiamin, nickel, dental acrylates) (10) and locally
administered medications (e.g., minoxidil) (II). Systematically administered
antimalarial agents may induce hypopigmentation of the skin or hair, and
following PUVA therapy reversible punctate leukoderma can be observed.
Other systemically administered substances that may induce hypomelanoses
are sulfonamides, phenytoin, barbiturates, or chronic arsenic intoxication.
HYPOMELANOSES AS SEQUELAE OF PHYSICAL EFFECTS

Any physical trauma of the skin (e.g., surgical interventions), the healing of
which is associated with an inflammation, can result in dyschromia and there-
fore also hypomelanoses. In heat-induced skin damage, hypopigmentation
occurs most often in second- and third-degree burns. In general, hypomela-
noses occur more frequently in subjects with darker skin, which applies also in
this case. Hypopigmentation on skin damaged with chronic UV exposure is
relatively common. It occurs on the parts of the body permanently or fre-
quently exposed to sunlight (head, dorsa of the hands, back) and is associated
with hypopigmentation and other signs of chronic solar damage. Actino-
therapy is also a relatively frequent cause of hypomelanoses at the site of its
action. A case of ionizing radiation-induced lentigo was described in indi-
viduals from the Chernobyl disaster area (12).
The importance of a number of surgical procedures leading to improve-
ment of skin conditions has increased. Such corrective dermatological and
surgical methods are, however, almost always associated with complications
in the terms of dyschromia. Hyperpigmentation can be avoided by means of a
proper selection of patients, thorough consequent photoprotection, or the use
of above-mentioned bleaching agents. The resulting hypopigmentation is

difficult to control. Its onset may be due to previous cryotherapy, chemical
peeling, or dermabrasion. Even periocular permanent depigmentation fol-
lowing the application of botulotoxin has been reported (13). The use of lasers
represents a certain risk of the incidence of hypomelanoses. In subjects with
darker complexion, the use of ruby laser for epilation may result in hypo-
pigmentation in the treated area (Fig. 2), but this is usuaJJy temporary (14).
FIGURE 2 Hypomelanosis after testing ruby laser for epilation.

386 Konkolova
The most frequent incidence of hypopigmentation is reported after CO 2 laser

treatment. This may be cosmetically insignificant, but on the other hand it
may result in the permanent appearance of alabaster skin (15-17). Erbium:
YAG laser treatment is less often associated with this complication (18). The
risk of hypopigmentation in the treatment of vascular lesions with the pulsed
dye laser is about 1% (19).
HYPOMELANOSES IN INTERNAL DISEASES

AND DISORDERS
Among the nutritional factors influencing the onset of hypomelanoses belong
chronic protein deficiency (kwashiorkor) with reversible hypomelanosis start-
ing in the face and with hair dyschromia, copper deficiency (hair hypopig-
mentation) (20), and pernicious anemia, as well as vagabond's leukoderma,
occurring in individuals with poor hygiene, insufficient nutrition, and chronic
alcohol abuse (21). Endocrinological disorders causing hypomelanoses in-
clude Addison's disease, thyroid gland disorders, and hypopituitarism. Dis-
seminated reticular hypomelanosis has been described in primary biliary
cirrhosis (22) and lightened hair and skin in hemodialyzed uremic patients
(23).
THERAPY OF HYPOMELANOSES
A number of hypomelanoses are reversible, and as such do not require any
treatment. Therapy of permanent hypomelanoses is, in contrast, very diffi-
cult and often unsuccessful. In cosmetically unfavorable sites, any surgical
procedure represents a high risk. Relatively good results were reported fol-
lowing tattoo techniques (dermatography, micropigmentation) (24), PUVA
therapy, and a combination of dermabrasion or the use of carbon dioxide
laser with subsequent transplantation of suspension of autologous kerati-
nocytes and melanocytes or thin skin grafts. In mild pigmentation shifts
(positive or negative), local tretinoin application can be tried (25). Local ap-
plication of dihydroxyacetone yields uneven results. Systemic use of f)-car-
otene in postinflammatory hypomelanoses has been recommended (26).
In differential diagnosis of acquired hypomelanoses, it is necessary to
mention at least two diseases of connective tissue. Morphea is a localized form
of scleroderma. In the central recession of the inflammatory phase it leaves
whitish-yellow, tough, atrophied patches Lichen sclerosus et atrophicus, which
is a chronic disease of unknown etiology, can be associated with autoimmune
diseases, morphea, lichen planus, diabetes mellitus, and vitiligo. It affects
females more frequently, possibly due to hormonal etiopathogenetic factors.
Certain areas (e.g., lateral parts of the neck, clavicular region, shoulders,
central part of the chest, flexural part of the forearm, external genitals,
mucosa) manifest porcelain white or blue-white macules with pinkish inflam-
matory borders, resulting in atrophy of the affected site,
REFERENCES
I, Epps RE, Kenney JA Jr. Diseases of black skin, In: Braun-Falco 0, Plewig G,
Wolff HH, Burgdorf WHC, eds, Dermatology, 2d ed, Berlin: Springer-Verlag,
2000: 1681-1691.
2, Amichai B, Grunwald MH, Avinoach I, Halevy S, Hypopigmented mycosis
fungoides in a white female, 1 Dermatol 1996; 23(6):425-426,
3. Bleehen SS, Ebling Fl, Champion RH, Disorders of skin colour, In: Rook A,
Wilkinson DS, Ebling FlG, eds. Textbook of Dermatology. 5th ed. Oxford:
Blackwell Scientific Publications, 1992: 1561-1622.
4. Fustes-Morales AJ, Soto-Romero I, Estrada Z, Duran-McKinster C, Orozco-
Covarrubias L, Tamayo-Sanches L, Ruiz-Maldonado R. Unusual leukoderma
after erythema multiforme: a case report. Pediatr Dermatol 200 I; 18(2): 120-122,
5, Handa S, Handa U. Sarcoidosis presenting as cutaneous hypopigmentation, Int
J Dermatol 1995; 34( II ):824,
6. Bose SK, Ortonne JP. Pigmentation: dyschromia. In: Baran R, Maibach HI,
eds, Cosmetic Dermatology. UK: Martin Dunitz Ltd, 1994:277-296,
7. Bolognia JL, Shapiro PE. Albinism and other disorders of hypo pigmentation. In:
Arndt KA, LeBoit PE, Robinson JK, Wintroub BU, eds. Cutanous Medicine
and Surgery. Philadelphia: W.B. Saunders Company, 1996:1219-1230.
8, Konkolova R, Korektivne dermatologick(: metody. Praha: Maxdorf Jessenius,
2001:65-74
9, Bhushan M, Beck MH. Allergic contact dermatitis from primula presenting as
vitiligo. Contact Dermatitis 1999; 41(5):292-293.
10, Kanerva L, EstJander T Contact leukoderma caused by patch testing with dental
acrylics, Am J Contact Dermat 1998; 9(3):196-198
II, Malakar S, Dhar S. Leucoderma associated with the use of topical minoxidil: a
report of two cases. Dermatology 2000; 201(2):183-184.
12. Peter RU, Gottlober P, Nadeshina A, Krahn G, Plewig G, Kind P. Radiation
lentigo. A distinct cutaneous lesion after accidental radiation exposure, Arch
Dermatol 1997; 133(2):209-21 L
13. Roehm PC, Perry JD, Girkin CA, Miller NR, Prevalence of periocular depig-
mentation after repeated botulinum toxin A injections in African American pa-
tients, J Neuroophthalmol 1999; 19(1 ):7-9,
14, Liew SH, Grobbalaar A, Gault D, Sanders R, Green C, Linge C. Hair removal
using the ruby laser: clinical efficacy in Fitzpatrick skin types I-V and histological
changes in epidermal melanocytes, Br J Dermatol 1999: 140(6):1105-1109,
15, Manuskiatti W, Fitzpatrick RE, Goldman MP, Long-term effectiveness and side
effects of carbon dioxide laser resurfacing for photoaged facial skin, JAm Acad
Derma tol 1999; 40(3):401-411,
16, Laws RA, Finley EM, McCollough ML, Grabski Wl, Alabaster skin after
388 Konkolova
carbon dioxide laser resurfacing with histologic correlation. Dermatol Surg 1998;
24(6):633-636
17. Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The short- and long-
term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997; 23(7):
519-525.
18. Zachary CB. Modulating the Er: YAG laser Lasers Surg Med 2000; 26(2):223-
226.
19. Wlotzke D, Hohenleutner D, Abd-EI-Raheem TA, Baumler W, Landthaler M.
Side-effects and complications of flashlamp-pumped pulsed dye laser therapy
of port-wine stains. A prospective study. Br J Dermatol 1996; 134(3):475-480.
20. Olivares M. Dauy R. Copper as an essential nutrient. Am J Clin NutI' 1996; 63(5):
79 IS-796S
2 I. Mosher DB, Fitzpatrick TB, Ortonne JP. Abnormalities of pigmentation. In:
Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg 1M, Austen KF, eds. Derma-
tology in General Medicine. New York: McGraw-Hill, 1979:568-620.
22. Viraben R, Couret B, Gorguet B. Disseminated reticulate hypomelanosis devel-
oping during primary biliary cirrhosis. Dermatology 1997; 195(4):382-383.
23 Hmida MB, Turki H, Hachicha J, Reygagne P, Rabier D, Zahaf A, Jarraya A.
Hypopigmentation in hemodialysis. Acquired bair and skin fairness in a uremic
patient undergoing maintenance bemodialysis: case report and review of tbe
literature. Dermatology 1996; 192(2):148-152.
24. Guyuron B, Vaughan C. Medical-grade tattooing to camouflage depigmented
scars. Plast Reconstr Surg 1995; 95(3):575-579.
25. Pagnoni A, Kligman AM, Sadiq I, Stoudemayer T. Hypopigmented mantles of
photodamaged skin and their treatment with topical tretinoin. Acta Derm Vene-
reo11999; 79(4):305-310.
26. Orfanos CE, Garbe C. Therapie der Hautkrankheiten. Berlin: Springer-Verlag,
1995:770-778.
38
Idiopathic Guttate Hypomelanosis
Michelangelo La Placa and Sabina Vaccari

Idiopathic guttate hypomelanosis (IGH) is a common disorder characterized

by multiple rounded hypopigmented macules of the extremities, first
described by Costa in 1951 as leucopalhie symetrique progressive des exlrem-
iles (I).
CLINICAL FEATURES
IGH usually appears in elderly individuals after the third decade of life, and
lesions tend to increase in number and size with advancing age (2-9). The
disorder is characterized by circular or angular maculae, from few to many in
number, measuring 2-6 mm in diameter. The spots are white-porcelain in
color, well circumscribed, usually without sign of atrophy or hyperkeratosis,
and mainly localized on the sun-exposed areas of the legs and the forearms
(Figs. I and 2). When IGH is found in younger patients (20 years), lesions
appear smaller (1-2 mm) and are fewer in number (less than five). Although
asymptomatic, these lesions can provoke an aesthetic concern that is cause for
dermatological consultation (5). IGH affects all individuals, with no gender-
or race-related differences. However, a slight prevalence in women and in
subjects with skin types II and III has been reported (5).
389
390 La Placa and Vaccari
FIGURE 1 Hypopigmented maculae of the legs in IGH.
PATHOLOGY
Histologically there is an evident hyperkeratosis of the horny layer with
typical "basketweave" appearance, atrophy of the epidermis, decreased
number ofmelanocytes and melanosomes, with a predominance of immature
forms. In sections stained with the Fontana-Masson method, the melanin
content in lesional skin is markedly less than in the perilesional epidermis.
FIGURE 2 Magnified view of Figure 1.

Idiopathic Guttate Hypomelanosis 391
Moreover, there is either a significant reduction in or an absence of dopa-

positive melanocytes (2,7). Within the hypomelanotic epidermis, the melanin
granules are irregularly distributed.
Electron microscopy examination shows rounded and less dendritic
melanocytes in lesional skin, with fewer melanosomes uncompletely mela-
nized (2,7). Immunochemistry studies, using a panel of melanocyte differ-
entiation antigens to compare normal and IGH skin, demonstrated again an
absolute decrease in the number of melanocytes (8).
PATHOGENESIS
The cause of this macular depigmentation is unknown, although actinic
influence has been suggested by many authors as a possible etiological factor.
In fact, the location of the lesions suggests that sun exposure plays an im-
portant etiological role (9). However. lesions can be observed less frequently
in unexposed areas, suggesting that other pathogenic mechanisms should be
considered (5). One study detected gastric parietal cell antibodies in three of
nine patients, indicating a possible autoimmune phenomenon (4). Genetic
factors could playa causal role because more than 60% of patients have a
family history of IGH, sometimes with diffuse skin xerosis (3). These data
support the idea that two types of IGH exist: an idiopathic form and an
inherited form.
TREATMENT
Therapeutic procedures include intralesional triamcinolone with or without
minigrafts of normally pigmented skin (5), cryotherapy (7), and PUVA ther-
apy. However, all these treatments remain unsatisfyng, and relapses are
common. In our opinion, it is most important to reassure patients of the
benign nature of this disorder. Lastly, the application of topical tretinoin gives
some cosmetic benefit (9).
REFERENCES
I. Costa OG. Leucopathie symetrique progressive des extremites. Ann Dermatol
1951; 78:452.
2. Ortonne JP, Perrot H. Idiopathic guttate hypomelanosis. Ultrastructural study.
Arch Dermatol 1980; 116:664-668.
3. Savall R, Ferrandiz C, Ferrer L Peyri J. Idiopathic guttate hypomelanosis. Br J
Dermatol 1980; 103:635-642.
4. Wilson PD, Lavker RM, Kligman AM. On the nature of idiopathic guttate hy-
po melanosis. Acta Den641pyeig/rl~lftj/2;62:301-306.
392 La Placa and Vaccari
5. Falabella R, Escobar C, Giraldo N, Rovetto P, Gil J, Barona MI, Acosta F,

Alzate A. On the pathogenesis of idiopathic guttate hypomelanosis. J Am Acad
Dermatol 1987; 16:35-44.
6. Gilhar A, Pillar T, Eidelman S, Etzioni A. Vitiligo and idiopathic guttate hypo-
melanosis Arch Dermatol 1989; 125:1363-1366.
7. Ploysangam T, Dee-Ananlap S, Suvanprakorn P. Treatment of idiopathic gut-
tate hypomelanosis with liquid nitrogen: light and electron microscopic studies.
J Am Acad Dermatol 1990; 23:681-684
8. Wallace ML, Grichnick JM, Prieto VG, Shea CR. Numbers and differentiation
status of melanocytes in idiopathic guttate hypomelanosis. J Cutan Pathol 1998;
25375-379.
9. Pagnoni A, Kligman AM, Sadiq I, Stoudemayer T. Hypopigmented macules
of photodamaged skin and their treatment with topical tretinoin. Acta Derm
Venereol 1999; 79:305-310.
39
Leukonychia
Aurora Tedeschi, Maria Rita Nasca,

and Giuseppe Micali
Clinica Dermatologica, Universita di Catania, Catania, Italy
Leukonychia is a chromatic anomaly of the nail which appears white in color

(1,2). Clinically, three main types of leukonychia are recognized: true leuko-
nychia and pseudoleukonychia, in which there is an alteration of the nail
plate, and apparent leukonychia, in which subungual tissue is involved (2).
Pseudoleukonychia and apparent leukonychia may be due to several factors
and usually disappear when the underlying local or systemic diseases are cor-
rected (Table I) (2). Some authors also include onycholysis and subungual
hyperkeratosis as forms of apparent leukonychia (1). Several clinical variants
of leukonychia have been described, making its classification controversial
because of poor knowledge about pathogenesis and histological features. Un-
usual clinical variants recently described include variegata and distal leuko-
nychias (2), as well as sporadic congenital leukonychia with partial phenotype
expression (3). The simultaneous occurrence of partial and total leukonychia
in different members of the same family or in single patients (1,4-6) has been
described. In such cases, partial leukonychia has sometimes been interpreted
as a phase of total leukonychia (5-7).
True leukonychia involves the nail plate (I) and is considered a kera-
tinization disorder. The structural abnormality is due to the persistence of
nuclei or nuclear debris in keratotic cells (parakeratosis) leading to decreased
transmission of incident light. With polarized light, the nail structure appears
disrupted due to disorganization of keratin fibrils (2). True leukonychia may
be complete (total leukonychia), when the nail is totally white; subtotal, when
393
W
lD
TABLE 1 Morphological Types and Causes of Leukonychia ""

Clinical manifestations Transmission Association
True leukonychia
Total Hereditary: AD, AR (7), or Isolated associated Koilonychia
somatic mutation with with: Acrokeratosis verruciformis (Hopf)
gonadal mosaicism (7) Leopard syndrome
Knuckle pads and deafness
() Multiple sebaceous cysts and renal calculi
0
~ Pancreatitis
~. Duodenal ulcer and cholelithiasis
~ Palmoplantar keratoderma and atrophic
CD fibrosis
0..
S; Palmoplantar keratoderma and deafness
OJ Palmoplantar keratoderma and hypotrichosis
CD
Koilonychia, onychorrhexis, hypothyroidism,
~ cataracts, and dental alterations
KID's syndrome
Epiphyseal dysplasia, short stature, small
head, mental retardation, visual problems,
hypoplasia of the corpus callosum
Acquired Isolated associated Hemochromatosis
with: Trazodone -I
CD
Exposure to extremely cold temperatures Co
CD
(fl
Acanthosis nigricans 0
Leprosy ::r
Subtotal Hereditary (AD) Acquired Isolated associated
with:
exposure to: Nitric acid, Nitrite solution,
Concentrated sodium chloride
-
CD
~
Partial r-
CD
Punctate Hereditary (AD) Associated with: Pili torti c:
Acquired Isolated associated Traumas "o
:::l
with: Alopecia areata '<
(')
Acanthosis nigricans ::r
iii"
Striate (?)a Acquired Isolated associated Menstrual cycle, stress, chemical and physical
with: traumas, exposure to cold temperatures,
cachectic state
Cardiac disorders: stroke, cardiac
() insufficiency
.g Renal disorders: acute and chronic renal
~ failure, renal transplantation
'§: Infective disorders: leprosy, syphilis,
CD tuberculosis, amebic dysentery, malaria,
0.. rheumatic fever, rickettsiosis, herpes zoster,
~ measles, pneumonia, typhus, trichinosis
CD Skin disorders: erythema multiforme, exfoliative
~ dermatitis, erythropoietic porphyria
Metabolic disorders: gout, alkaline metabolic
disease
Hematological disorders: sickle cell anemia,
Hodgkin's disease
Gastrointestinal disorders: ulcerative colitis
Immunological disorders: lupus erythematosus,
cryoglobulinemia, glomerulonephritis
Endocrine disorders: hypothyroidism
Neoplastic disorders: abdominal neoplasia,
bronchial carcinoid
W
<0
<.n
w
(l)
Ol
()
o
~ TABLE 1 Continued
~.
:;jo
q;- Clinical manifestations Transmission Association
Q.
~
q;-
Striate (contd.) Drug reaction: cyclophosphamide,
5-f1uorouracil, doxorubicin, bleomycin,
~ pilocarpine, sulfonamide, emetine

hydrochloride, corticosteroids
Poisoning: antimony, arsenic, fluorosis,
thallium, CO, lead paraquat
Nutritional disorders and
deficiencies: pellagra, hypocalcemia, severe
hypoalbuminemia, hypoproteinemia, zinc
deficiency c;Co
Neurological disorders: peripheral neuropathy, CD
III
psychosis n
~
Longitudinal Hereditary Associated with: Darier's disease
Hailey-Hailey's disease !2.
Hemochromatosis ~
Acquired Associated with: Hypothyroidism ....
(tl
Gout c:
Neurological disorders "o
::J
Breast carcinoma '<
n
~
Pseudoleukonychia iii'
Expression of: SUbungual proximal onychomycosis
Superficial white onychomycosis
Nail varnish
Anemia
Apparent leukonychia
~ Associated with: Vasoconstriction (Raynaud)
~ Cirrhosis (Terry's nails)
~ Hypoalbuminemia and chemotherapy
~ (Muehrcke's type)
CD Renal disorders (half-and-half nails)
0..
~ a Only one case of congenital isolated striate leukonychia (11).
CD
~
to)
10
~
398 Tedeschi et al.
a pink area is present, usually close to the edge as an arch; or partial, when the
nail plate involvement is not uniform (2). Congenital and acquired forms for
each clinical variant have been described (2,8).
Total leukonychia (Fig. I) is a rare condition in which the nail may be
milky, chalky, bluish, ivory, or porcelain white in color (2). It is usually seen
at birth and may follow an autosomal dominant inheritance, although an
autosomal recessive transmission and a parental somatic mutation with go-
nadal mosaicism have also been hypothesized (8,9). Inherited totalleukony-
chia may be isolated or associated with other malformations listed in Table I
(1,2,8,10-12). Idiopathic acquired forms (4,13), as well as forms following
ingestion of trazodone, exposure to extremely cold temperatures, or associ-
ated with dermatoses such as acanthosis nigricans (I) and leprosy (2), have
also been described.
Total leukonychia may also be observed in association with various
systemic diseases. In these cases inheritance may vary according to the main
underlying disease.
Subtotal leukonychia, sometimes preceding a total leukonychia (2,4,7),
is characterized by a pink arch of about 2---4 mm width distal to the white area
(2). The presence of this pink arch can be explained by loss of keratohyalin
granules and by decreased parakeratotic cells as the nail plate approaches its
distal end (2). Subtotal leukonychia may be congenital, transmitted as an
autosomal dominant trait, or acquired following exposure to nitric acid or
concentrated sodium chloride solutions (14).
FIGURE 1 Hereditary/congenital total leukonychia of the fingernails in a 44-year-

old woman. The toenails were not affected. A similar condition was also present in
her son and daughter.
Leukonychia 399
Partial leukonychia is distinguished into punctate leukonychia (very

common), striate leukonychia (relatively common), and longitudinal or distal
leukonychia (very rare). Each variant may either be congenital or acquired.
Partial punctate leukonychia is characterized by white spots 1-3 mm in di-
ameter appearing on the nail proximal end. The spots grow distally with the
nail, disappearing in most cases during progression towards the free edge (2).
They are caused by a local or general fault in keratinization and/or air infil-
tration. Partial punctate leukonychia may be acquired, especially following
repeated trauma, or idiopathic (2,15,16). It is common in kids and in women
who practice excessive and traumatic manicuring. An association with alo-
pecia areata and acanthosis nigricans has been reported. A congenital form of
punctate leukonychia, transmitted as an autosomal dominant trait, has also
been described in association with pili torti (l,8, 17). Striate or transverse leu-
konychia shows transversal and parallel white streaks 1-2 mm wide involving
one or several nails. Mees' lines belong to this form (8). Although acquired
forms are considered more common, congenital forms may be observed.
Causes of acquired striate leukonychia include chemical (contact with 2-ethyl-
cyanoacrylate glue) and physical traumas (mechanical, thermic), psychophys-
ical stress, menstrual cycle, and systemic diseases (Table I) (1,2,8,18). Those
forms associated with a systemic disease are easily recognized, since they
usually involve all nails
Longitudinal or distal leukonychia is characterized by permanent
grayish-white longitudinal bands of about I mm width due to localized dam-
age of the nail matrix, sometimes following the development of benign tumors
or cysts proximally to the nail plate (2). Longitudinal leukonychia is a typical
feature of Darier's disease, a genodermatosis transmitted as an autosomal
dominant trait and characterized by the onset of red longitudinal streaks,
which in time turn white. Longitudinal leukonychia has also been described in
patients with Hailey-Hailey disease (19) and hemochromatosis (2), in both
cases transmitted as an autosomal dominant pattern.
The term pseudoleukonychia is used when fungal parasitization of the
ventral surface of the nail plate clinically appears as superficial white ony-
chomycosis. The nail becomes friable and can easily be removed by a curette.
Pseudoleukonychia associated with the use of nail polish has also been
reported (2).
Apparen't leukonychia is due to vasoconstriction and anemia, causing
pallor of the nail bed (1). It uniformly involves all nails and remains un-
changed as the nail grows (2). Terry's nails, formerly considered a typical
feature of hepatic cirrhosis, have recently been described also in healthy sub-
jects or in patients with cardiac insufficiency and/or type II diabetes. The nails
are an opaque white color, with persistence of a pink area of 1-2 mm width,
corresponding to the onychodermal band, in the distal edge (2). A variant of
400 Tedeschi et al.
Terry's nails is represented by Morey and Burke's nails in which the nail
whitening is limited exclusively to its central segment (2). Usually observed in
cases of hypoalbuminemia (albumin <2.2 gjdL) or in patients undergoing
chemotherapy, Morey and Burke's nails are characterized by multiple trans-
verse white bands, separated one from another and from the lunula by pink
streaks, which disappear pressing the distal phalanx. These alterations are
more evident in the second, third, and fourth fingernail and vanish when
serum albumin levels return to normal, reappearing when it falls again (2).
Their pathogenesis is probably due to edema of the connective tissue caused
by hypoalbuminemia, changing the compact arrangement of collagen fibrils
into a looser texture (2). Finally, Lindsay's half-and-half nails, occurring in
hyperazotemia, are sometimes considered a sign of chronic renal failure. In
most cases the nails appear white and opaque in their proximal half, and
reddish, pink, or brown (20-60% of the toal nail) in the distal area. The
brownish color of the distal part can be due to increase in either melanosomes
or capillar density.
REFERENCES
I. Grossmann M, Scher R. Leukonychia. Review and classification. lnt J Dermatol
1990; 29:535-541.
2. Baran R, Barth J, Dawber R. Nails Disorders. Common Presenting Signs, Dif-
ferential Diagnosis and Treatment. London: Martin Dunitz, 1991:146-149.
3. Brown PJ, Padgett JK, English JC III. Sporadic congenital leukonychia with
partial phenotype expression. Cutis 2000; 66: 117-119.
4. Stewart L, Young E, Lim HW. Idiopatic leukonychia totalis and partialis. JAm
Acad Dermatol 1985; 12:157-158.
5. Bettoli V, Tosti A. Leukonychia totalis and partialis: a single family presenting a
peculiar course of the disease. J Am Acad Dermatol 1986; 15:535.
6. Albright S, Wheeler SP. Leukonychia. Arch Dermatol 1964; 90:392.
7. Butterworth T. Leukonychia partialis: a face of leukonychia totalis. Cutis 1982;
29363-367
8. Stevens KR, Leis PF, Peters S, Baer S, Orengo 1. Congenital leukonychia. J Am
Acad Dermatol 1998; 39:509-5 J 2.
9. Frydman M, Cohen HA. Leukonychia total is in two sibs. Am J Med Genet 1993;
47:540-541.
10. Micali G. Knuckle pads-leukonychia-deafness. Birth Defects Encyclopedia.
Cambridge: Blackwell, 1990: 1019-1020.
II. Yamamoto T, Tohyama J, Koeda T, Maegaki Y, Takahashi Y. MUltiple epiph-
yseal dysplasia with small head, congenital nystagmus, hypoplasia of corpus
callosum, and leukonychia totalis: a variant of Lowry-Wood syndrome? Am J
Med Genet 1995; 56:6-9
Leukonychia 401
12. Basaran E, Yilmaz E, Alpsoy E, Yilmaz GG. Keratoderma, hypotrichosis and

leukonychia totalis: a new syndrome? Br J Dermatol 1995; 133:636-638.
13. Claudel CD, Zic JA, Boyd AS Idiopathic leukonychia totalis and partialis in a
12-year-old patient. 1 Am Acad Dennatol 2001; 44(suppl 2)379-380.
14. Zaun H. Leukonychias. Semin Dermatol1991; 10:17-20.
15. Mahler RH, Gerstein W, Watters K. Congenital leukonychia striata. Cutis 1987;
39:453-454
16. Dotz WI, Lieber CD, Vogt Pl. Leukonychia punctata and pitted nails in alopecia
areata. Arch Dermatol 1985; 121:1452-1454.
17. Giustina T, Woo TY, Campbell JP, Ellis CN. Association of pili torti and
leukonychia. Cutis 1985; 35:533-534.
18. Ena P, Mazzarello Y, Fenu G, Rubino C. Leukonychia from 2-ethyl-cyanoacry-
late glue. Contact Dermatitis 2000; 42: 105-106.
19. Kirtschig G, Effendy I, Happle R. Leukonychia longitudinalis as the primary
symptom of Hailey-Hailey disease. Hautarzt 1992; 43:451-452.
CQpyrighted Material
40
Vogt-Koyanagi-Harada Syndrome
Fabrizio Guarneri, Pasquale Aragona, and Mario Vaccaro

University of Messina, Messina, Italy
A rare multisystem inflammatory disease, Yogt-Koyanagi-Harada syndrome

is part of the group of melanocyte disorders. It was first described in 1906 by
Yogt, who described a patient with bilateral idiopathic uveitis, poliosis, and
alopecia (l). Four years later, a case of generalized vitiligo followed by bi-
lateral uveitis and optic neuritis was reported by Gilbert (2). In 1926, Harada
described five cases of bilateral posterior uveitis and retinal detachment, often
presenting after meningitis. He also studied the cerebrospinal fluid of these
subjects, showing the presence of increased protein levels and pleocytosis (3).
Clinical signs and symptoms of the syndrome were better defined 3 years later
by Koyanagi in a study on 16 patients with headache, fever, dysacusis, viti-
ligo, poliosis, alopecia, and anterior or posterior uveitis bilaterally, with oc-
casional exudative retinal detachment (4). The term Yogt-Koyanagi-Harada
(YKH) syndrome was suggested by Babel in 1939, in consideration of the
several similarities between clinical pictures ofYogt-Koyanagi syndrome and
Harada syndrome. Synonyms for Yogt-Koyanagi-Harada syndrome, used
particularly in the ophthalmological and neurological literature, include
uveoencephalitis, oculocutaneous syndrome, and idiopathic neuraxitis.
The prevalence and incidence of YKH syndrome are reported to be very
low. According to the literature, classic clinical manifestations are reported in
4-7% of patients with uveitis, a disease affecting approximately 15 out of
100,000 subjects. However, some authors noted that many patients with
common vitiligo, a more frequent disease, have subclinical manifestations of
sparse poliosis or uveitis and could be considered as cases of subclinical YKH
403
404 Guarneri et al.
syndrome. Males and females are equally affected; incidence seems to be

higher in people with pigmented skin, but no race is spared. The onset is
reported mainly between 10 and 52 years of age, with peak frequency in the
third and fourth decades; pediatric cases are rare. No familial inheritance was
found. Some HLA haplotypes (DR4, Dw53, LD-Wa) seem to be present in a
statistically significant number of patients.
Etiopathogenesis of VKH syndrome is still unknown. Its frequent
association with several well-known autoimmune diseases, like Hashimoto's
disease, nontuberculous Addison's disease, thyrotoxicosis, and mucocuta-
neous candidiasis, led many authors to hypothesize an autoimmune origin for
it. In vitro studies showed that lymphocytes from subjects affected by VKH
syndrome undergo blast transformation in the presence of bovine uveal pig-
ment cells and are cytotoxic against allogenic melanoma cells. In vivo, pres-
ence of activated CD4 + lymphocytes in depigmented skin areas of patients
affected by vitiligo (a frequent clinical sign of VKH syndrome) was demon-
strated, strengthening these theories. According to some authors, autoim-
mune reaction against melanocytes could be triggered by a viral infection, still
of undefined nature (5). Once activated, the inflammatory process causes
destruction of pigmented cells in all areas of the body.
The widespread presence of meJanocytes in the human body explains
the variety of clinical signs and symptoms typical of VKH syndrome. In ad-
dition to the skin and central nervous system, meJanocytes are, in fact, present
in eyes and ears.
In the eye, melanocytes localized in uvea and iris absorb part of the
incident light, improving the visualization of images on the retina, and playa
role in the catabolism of toxic substances produced in retinal photochemical
reactions, while melanocytes present in the retinal pigmented epithelium are
important in maintaining the functions of photoreceptors, and those situated
in ciliary bodies are involved in the production of aqueous humor.
The functions of melanocytes in the ear, in contrast, are still not clearly
defined, but it is well known that an altered development of ear melanocytes
(as in Waardenburg syndrome or piebaldism) results in hypoacusis. This
suggests a role for these cells in the transmission of electric signals from
receptors to central nervous system, demonstrated until now only in rats.
Moreover, some authors showed an increased number ofmelanosomes in ear
melanocytes after an acoustic trauma, and suggested that melanin could have
a protective role against damage caused by noise or toxic agents (6).
Considering the role ofmelanocytes in different organs, clinical features
ofVKH syndrome are easy to explain. Clinically, this disorder has a triphasic
evolution.
The first stage, the meningoencephalitic phase, often begins abruptly
and is characterized by headache, malaise, fever, nausea, and vomiting, of
variable intensity. Confusion, psychosis, hemiparesis, paraplegia, aphasia.
Vogt-Koyanagi-Harada Syndrome 405
syncope, and general muscle weakness can also be present. During this phase,
electroencephalographic abnormalities can be shown, as well as an increase in
the concentration of proteins and in the number of white blood cells in the
cerebrospinal fluid.
The second, or ophthalmic stage, of uveitis usually occurs several weeks
later and may last for 10 years or more. It is characterized by ocular and
supraorbital pain, photophobia, eye irritation, sudden or gradual decrease of
visual acuity (progressing in some severe cases to permanent blindness, due to
retinal detachment). Histological features in the affected areas resemble those
of a granulomatous uveitis, with close aggregation of lymphocytes around
melanocytes. Transient dysacusis, usually bilateral, occurs, according to
different authors, in 50-80% of patients during this phase. Headache and
slight fever can also be present.
The convalescent state, the third stage of the syndrome, begins when the
uveitis subsides, and its hallmarks are poliosis, alopecia, and vitiligo, occur-
ring in 90%,73%, and 63% of patients, respectively. Poliosis can involve the
scalp as well as eyelashes and eyebrows, with variable extension, and is usually
noted after the onset of alopecia. Alopecia in VKH syndrome can involve a
subtle diffuse loss of hair or may occur in patches, while alopecia totalis is only
sometimes observed. Histological features of involved skin-periappend-
ageal infiltrates of lymphocytes and plasma cells-are indistinguishable from
those of alopecia areata, but it is not clear if alopecia associated with VKH
syndrome can be classified as alopecia areata. Cutaneous depigmentation
observed in course ofVKH syndrome is clinically and histologically identical
to vitiligo. It usually consists of patches of hypomelanosis, symmetrical and
centrifugally enlarging, most commonly localized to the head and shoulders,
nape of the neck, and eyelids (as in segmental vitiligo), with rarely occurring
spontaneous repigmentation. Halo nevi were reported in some cases as the
first manifestation of VKH syndrome. Histologically, edema, vasodilatation
of the dermis, melanophages full of pigment, and the above-mentioned
lymphocytic infiltrate are visible in specimens of depigmented skin. Electron
microscopy shows absence of melanocytes, replaced by Langerhans cells and
indeterminate dendritic cells. Colloid-amyloid bodies are found at the dermo-
epidermal junction (5,7,8).
Diagnostic criteria for VKH syndrome specified by the American Uve-
itis Society during the 2nd Annual Meeting in Kansas City, Missouri, in 1978
(9) are listed in Table 1. These criteria have some limitations: patients may
present with incomplete or delayed appearance of the extraocular manifes-
tations, especially if treated early with steroids or immunosuppressive agents,
and the patterns of symptoms may vary between racial groups. In 1999 revised
criteria for diagnosis were proposed by the First International Workshop on
Vogt-Koyanagi-Harada Disease, held at the University of California at Los
Angeles (Table 2) (10). Copyrighted Material
406 Guarneri et al.
TABLE 1 Diagnostic Criteria for Vogt-Koyanagi-Harada Syndrome
1. Absence of previous ocular trauma or surgery

2. At least three of the following:
Bilateral iridocyclitis
Posterior uveitis (including exudative retinal detachment or sunset glow fundus)
Central nervous system problems: tinnitus, vertigo, dysacusis, meningism (with
fever, headache, nausea, vomiting), cranial nerve dysfunction, cerebrospinal
fluid pleocytosis
Cutaneous findings: alopecia, poliosis, vitiligo
Source: American Uveitis Society, 1978.
Some clinical signs of VKH syndrome are very similar to those of

vitiligo and AJezzandrini's syndrome, both of which should be considered in
differential diagnosis. Some authors, on the basis of many clinical, histopa-
thological, and immunological findings common to these three disorders,
proposed that they could be different expressions of a single etiopathogenetic
mechanism, but this very interesting hypothesis is yet to be clearly demon-
strated. Other diseases that could resemble some clinical features of VKH
syndrome are albinism, piebaldism, tuberous sclerosis, Waardenburg's syn-
drome, Chediak-Higashi syndrome, Marfan's syndrome, Rubinstein-Taybi
syndrome, hyperthyroidism, hypoparathyroidism, Addison's disease, hypo-
pituitarism, pernicious anemia, halo nevus (leukoderma acquisitum centrifu-
gum-Hyde and Sutton), nevus depigmentosus, leprosy-tuberculoid,
pityriasis alba, postinflammatory depigmentation, phenylketonuria (pigment
dilution), idiopathic guttate hypomelanosis, syphilitic leukoderma, sclero-
derma/morphea, alopecia (caused by various etiological agents), uveitis, bac-
terial or viral meningitis, tumors of the central nervous system, Lyme disease,
and sarcoidosis.
The ocular features are characterized by a sudden presentation of
bilateral granulomatous iridocyclitis, often asymmetrical, with the onset in
one eye followed by the involvement of the fellow eye 2-4 weeks later. Asian
patients may present with a perilimbal vitiligo known as the Sigiura's sign
(11). The cornea may show granulomatous or nongranulomatous deposits in
the endothelium. The iris may demonstrate nodules in the stroma or in the
pupil margin with possible posterior synechiae formation between iris and
lens capsule. This may lead to the development of a secondary glaucoma. The
ciliary body may also be involved in the disease with edema and inflammatory
cell infiltration. In this case the intraocular pressure tends to decrease due to
reduced aqueous humor production. Vitritis (Fig. 1) and exudative retinal
detachment may be present, most frequently in the inferior retina. Disc edema
TABLE 2 Revised Diagnostic Criteria for Vogt-Koyanagi-Harada Disease
1. No history of penetrating ocular trauma or surgery preceding the initial onset

of the uveitis
2. No clinical or laboratory evidence suggestive of other ocular disease entities
3. Bilateral ocular involvement, with findings dependent on stage of disease
when the patient is examined (see below)
4. History or presence of neurological andlor auditory findings (see below)
5. Integumentary findings occurring concurrent or after (not preceding) the onset
of CNS or ocular disease (see below).
Criteria present Diagnosis
1, 2, 3, 4, and 5 Complete Vogt-Koyanagi-Harada disease

1, 2, 3, and (4 or 5) Incomplete Vogt-Koyanagi-Harada disease
1,2, and 3 Probable Vogt-Koyanagi-Harada disease
Other Not Vogt-Koyanagi-Harada disease
Ocular involvement (earlv):

3E1. Diffuse choroiditis (with or without anterior uveitis, vitreous inflammatory
reaction or optic disc hyperemia) which may be manifested by one or both
of the following:
3E1 a. Focal areas of subretinal fluid
3E1 b. Bullous serous retinal detachments
3E2. With equivocal fundus findings, both of the following must be present as
well:
3E2a. Fluorescent angiography shows focal areas of delay in choroidal
perfusion, multifocal areas of pinpoint leakage, large placoid areas
of hyperfluorescence pooling within subretinal fluid and optic nerve
staining (in order of sequential appearance)
3E2b. Diffuse choroidal thickening without evidence of posterior scleritis
by ultrasonography
Ocular involvement (late):

3L1. History suggestive of prior presence of early ocular involvement, both 3L2
and 3L3, or multiple signs from 3L3
3L2. Ocular depigmentation, one or both of the following:
3L2a. Sunset glow fundus (pale choroidal pigmentation)
3L2b. Sigiura sign (perilimbal vitiligo)
3L3. Other ocular signs:
3L3a. Nummular chorioretinal depigmented scars
3L3b. Retinal pigment epithelium clumping andlor migration
3L3c. Recurrent or chronic anterior uveitis
(continued)
408 Guarneri et al.
TABLE 2 Continued
Neurological and/or auditory findings-one or more of the following:
4a. Meningismus (combination of malaise, fever, headache, nausea, abdominal
pain, stiffness of the neck and back. Headache alone is insufficient)
4b. Tinnitus
4c. Pleocytosis in the cerebrospinal fluid
Integumentary findings-one or more of the following:

5a. Alopecia
5b. Poliosis
5c. Vitiligo
Source: First International Workshop on Vogt-Koyanagi-Harada Disease, 1999.
FIGURE 1 Active vitritis with vitreal exudates.
is also a common feature (12). Nodular, yellow choroidal infiltrates, identi-

cal to the Dalen-Fuchs nodules of sympathetic ophthalmia, may be found in
the mid-periphery. Neovascularization of optic disc and the retina may lead
to vitreous hemorrhages (J 3) (Fig. 2). Choroidal neovascular membrane may
cause hemorrhagic macular detachment with consequent visual loss and poor
visual prognosis. The presence of subretinal neovascular membrane is usu-
ally associated with anterior chamber inflammation. Scleral melting may
occur due to an immune reaction against the melanocytes connected with the
scleral nerves.
When the clinical features resolve, the eyes are characterized by the
presence of a generalized pigment alteration that can be seen either as a
pigment rearrangement or as a pigment loss resulting in a blond appearance
of the fundus. Cataract and glaucoma occur in 35% of patients (11,12).
Glaucoma associated with VKH is difficult to control. Visual acuity may be
severely impaired by the retinal alterations consequent to the inflammation.
Fluorescein angiography and HLA typing can be useful in confirming
the diagnosis of VKH syndrome. It is often necessary to perform additional
radiographic, histopathological, and/or laboratory tests to exclude some of
the above-mentioned disorders in the differential diagnosis.
FIGURE 2 Granulomatous choroidal inflammation and area of choroidal atrophy.

410 Guarneri et al.
Early diagnosis of YKH syndrome is essential for an early start of

therapy that has proved effective in preventing the progression of uveitis, thus
avoiding blindness. The preferred drug is prednisone at an initial dose of 1
mg/kg/day, which can be increased in more severe cases. Duration of the
treatment depends on clinical response, but is usually around 6 months.
Widespread cutaneous depigmentation can be treated with psoralens and
ultraviolet light (PUYA), as described for vitiligo. However, a careful eval-
uation of the risk/benefit ratio should be made in each patient: in particular,
phototherapy might aggravate an eventually present anterior uveitis. More-
over, it has to be considered that repigmentation of relatively hair-free areas
(such as the eyelids) can prove difficult.
Clinical manifestations and prognosis ofYKH syndrome are extremely
variable. Frequently, not all signs are present (see Table 2). Relapses can be
present in the clinical course of the disease. Uveitis is the main problem be-
cause of its possible consequences. It is usually self-limiting, but can lead to a
variable reduction of visual acuity and, in some cases, to blindness. Hypo-
acusis is, in the majority of cases, only temporary, and auditory sequelae are
infrequent. Cutaneous manifestations, instead, tend to persist, especially
when widespread depigmentation is present (5,7).
In conclusion, disorders of cutaneous pigmentation are not only aes-
thetic problems involving skin and mucosae. Sometimes, as in the case of
Yogt-Koyanagi-Harada syndrome, they can be the exterior manifestation of
a multisystemic pathology of extracutaneous origin, possibly with severe
consequences; this reminds us once more, if needed, that a careful and com-
plete clinical examination of the patient is always to be performed, even in
apparently "simple" cases.
REFERENCES
1. Vogt A. Fri.ihzeitiges Ergraven der Zilien und Bemerkungen uber den soge-
nannten plotzlichen einentt dieser Veranderugn. Klin Monatsbl Augenheilkd
1906; 44:228-242.
2. Gilbert W. Vitiligo und Auge, ein Beitrag zur Kenntnis der herpetischen Auge-
nerkrankungen. Klin Monatsbl Augenheilkd 1910; 48:24-31.
3. Harada E. Clinical study of nonsuppurative choroiditis: a report of acute diffuse
choroiditis Acta Soc Ophtalmol Jpn 1926; 30:356-377.
4. Koyanagi Y. Dysakusis, Alopecia und Poliosis bei schwerer Uveitis nicht trau-
matischen Ursprunges. Klin Monatsbl Augenheilkd 1929; 82:194-21 L
5. Barnes L, Nordlund 1J. Vogt-Koyanagi-Harada and Alezzandrini's syndromes.
In: Demis 1, ed. Clinical Dermatology. Vol. 2. Philadelphia: 1 B Lippincott Com-
pany, 1991:unit 11-34.
6. Tosti A, Piraccini BM, Tosti G. Vitiligine: disturbi oculari e audiologici. In: Lotti
TM, Bianchi B, Ghersetich I, eds. La Vitiligine-Nuovi Concetti e Nuove

Terapie. Milano: UTET Periodici Scientifici, 2000:63-66.
7. Patrizi A, Trestini D. La sindrome di Vogt-Koyanagi-Harada. Ill: Lotti TM.
Bianchi B, Ghersetich J, eds. La Vitiligine-Nuovi Concetti e Nuove Terapie.
Milano: UTET Periodici Scientifici, 2000:137-140.
8. Immunopathologic study of Vogt-Koyanagi-Harada syndrome. Am J Oph-
thalmol 1988; 105(6):607-611.
9. Beniz J, Forster DJ, Lean JS, Smith RE, Rao NA. Variations in clinical features
of the Vogt-Koyanagi-Harada syndrome. Retina 1991; 11:275-280.
10. Read RW, Holland GN, Rao NA, Tabbara KF, Ohno S, Arellanes-Garcia L,
Pivetti-Pezzi P, Tessler HH, Usui M. Revised diagnostic criteria for Vogt-Ko-
yanagi-Harada disease: report of an international committee on nomenclature.
Am J Ophthalmol2001; 131:647-652.
II. Sigiura S. Vogt-Koyanagi-Harada disease. Jpn J Ophthalmol 1978; 22:99.
12. Nussenblatt RB, Palestine AG. Uveitis: Fundamentals and Clinical Practice.
Vol. 15 Chicago: Year Book Medical Publishers, 1989:274.
13. Harada T, Matsuzaki S, Okada H, Yumiyama A, Majima Y. Occurrence of op-
tic disc hemorrhage in the course of Vogt-Koyanagi-Harada syndrome. Klin
Monatsbl Augenheilkd 1991; 199(3):206-208.
41
Nevus Depigmentosus
Beatrice Bianchi and Torello M. Lotti

Jana Hercogova
Charles University, University Hospital Motol, Prague, Czech Republic
Nevus depigmentosus (NO), described first by Lesser in 1884 (I), is a well-

circumscribed hypomelanosis that is present at birth and remains stable in its
relative size and distribution throughout life (2,3). Some authors have
reported its initial presentation at various ages, probably because the infants
or young children have untanned skin and the color contrast of NO lesions
may not be readily visible. NO occurs sporadically and is of no medical
significance. There is no known pattern of inheritance or sex predominance.
Examination of NO by light microscopy, as well as electron microscopy, has
revealed the presence of either a normal or decreased number ofmelanocytes
(5), with stubby dendrites poorly developed and DOPA reduced reactivity.
Histological study on lesional skin compared with perilesional normal skin
shows in melanocytes a significant reduction in the density of the melano-
somes, which are aggregated and heteromorphic (4). Within the affected ke-
ratinocytes, small melanosomes tends to reunite in masses surrounded by a
limiting membrane and are present in reduced numbers.
NO pathophysiology is probably associated with a developmental
defect of the fetal melanocytes (4). In particular a defect has been reported
in the transfer of melanosomes from melanocytes to keratinocytes (2).
NO can clinically present in three different ways: (a) as an isolated
patch, circular, rectangular, or irregular in shape and size, with geographic
margins, involving a quite small segment of the body (Fig. I), (b) as a cir-
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FIGURE 1 Nevus depigmentosus, These congenital nonprogressive hypopigmented macules were
present since birth and stable in size. -
lD
I II
z(\)
TABLE 1 Differential Features of Nevus Depigmentosus, Hypomelanosis of Ito, Tuberous Sclerosis, and Segmental <
Vitiligo c:
In
C
Feature NO HI TS SV (\)
"'5!.
u::l
Age of onset Birth, rarely early Birth, early infancy, Birth Acquired from birth 3(\)
Localization
childhood
Unilateral trunk or
or childhood
Trunk and extremities Trunk, legs, arms

to old age, half
by age 20
Unilateral in a
-
;::,
0
In
c:
In
extremities, dermatomal or
()
lower abdomen quasidermatomal
0 distribution
"C Color of lesions Off-white Off-white Dull- to off-white Chalk- or milk-white
~ Shape Quasidermatomal Swirls, streaks, and Polygonal, thumbprint, Round, scalloped
'§: macules with patches lance-ovate margins
CD irregular margins
Q.
s:
Q)
Course Stable Evolves and often
tends to remit
Chronic Chronic progressive,
occasional
CD improvement
~ Wood's lamp Enhances contrast Enhances contrast Enhances contrast in Enhances contrast
fair-skinned infants
Special signs None Marble cake Ash-leaf spots None
Extracutaneous disorders None Neurological, mental, Mental retardation, Thyroid diseases,
associated ocular, dental, hair, cerebral calcification, diabetes mellitus,
musculoskeletal hamartomas, cardiac pernicious anemia,
abnormalities rhabdomyomas, Addison's disease
bone lesions
Treatment None None None Topical steroids,
topical UVA, oral
PUVA
.;.
NO, nevus depigmentosus; HI, hypomelanosis of Ito; TS, tuberous sclerosis; SV, segmental vitiligo. .....
U1
416 Bianchi et al.
cumscribed, unilateral band or streak arranged in a blocklike configuration

or along Blaschko lines, or (c) as a segmental variant. The segmental variant
is usually confined to one side of the body, more often on the trunk. A sys-
tematized pattern, consisting of multiple, irregular hypopigmented whorls or
streaks, without preceding vesicular or verrucous stages is also described (2).
The back and buttocks are the most commonly affected sites, followed by the
chest and the abdomen, the face, the neck, and the arms, in descending order
of frequency (4). The lesions are uniformly hypomelanotic but not amela-
notic, and they become more apparent with a Wood's lamp examination.
CLINICAL DIAGNOSIS
Clinical diagnostic criteria commonly accepted and proposed by Coupe (6) in
1976 are:
1. Leukoderma present at birth or onset early in life
2. No alteration in distribution of leukoderma throughout life
FIGURE 2 Segmental vitiligo.
Nevus Depigmentosus 417
3. No alteration in texture, or change of sensation, in the affected area

4. No byperpigmentation border around the achromic area
The differential diagnoses of ND include (7) (Table I): (a) segmental
vitiligo (Fig. 2), which is amelanotic and acquired and is milk-white in color
under Wood s lamp iJlumination; (b) hypomelanosis of Ito (incontinentia
pigmenti achromians), in which there are hypopigmented bands and whorls
occurring along Blaschko's lines, which tend to occur within the first year of
life, with a variability in clinical presentation and association with other con-
genital abnormalities predominantly neurological, leading to frequent char-
acterization as a neurocutaneous syndrome; (c) segmental tuberous sclerosis,
which is usually associated with other hypomelanotic lance-ovate-shaped
macules with other cutaneous findings and neurological involvement; (d)
nevus anemicus (Fig. 3), which is a localized vascular abnormality that pre-
sents as an area of pale skin and which lacks a flare response to rubbing or
heat.
FIGURE 3 Nevus anemicus.

418 Bianchi et al.
TREATMENT
No effective treatment is available.
REFERENCES
1. Lesser E. In: von Zeimssen H, ed. Handbuch der Hautkrankheiten. Leipzig:
Vogel,1884:183.
2. Bolognia JL, Pawelek JM. Biology of hypopigmentation. J Am Acad Dermatol
1988; 19:217-247.
3. Orlow SJ. Congenital and genetic disorders associated with hypopigmentation.
Curr Probl Dermatol1994; 6:157-184
4. Lee HS, Chun YS, Hann SK. Nevus depigmentosus: clinical features and histo-
pathologic characteristics in 67 patients. J Am Acad Dermatol 1999; 40:21-26.
5. Ogunbiyi AO, Ogunbiyi JO. Nevus depigmentosus and inflammatory linear
epidermal nevus. An unusual combination with a note on histology. Tnt J Der-
matol 1998; 37:600-602.
6. Coupe RL. U nila teral systematized achromic naevus. Dermatologica 1976; 134:
19-35.
7. Mosher DB, Fitzpatrick TB, Ortonne JP, Hori Y. Hypomelanoses and hyper-
melanoses In: Freedberg 1M, Eisen AZ, Wolff K, et aI., eds. Fitzpatrick's
Dermatology in General Medicine. 5th ed. New York: McGraw-Hili, 1999:945-
1017.
42
Hypomelanosis and Tuberous Sclerosis
Complex
A. Patrizi and I. Neri

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder where

the term "complex" emphasizes the multisystemic involvement of this disease
and its genetic heterogeneity. TSC is characterized by seizures, mental
retardation, and development of multiple cutaneous and visceral hamartomas
mainly located in the brain, eyes, kidneys, and heart. TSC hamartomas are
benign and rarely progress to malignant tumors. TSC affects 1 in 6,000-
10,000 subjects in the general population, and 50-75% of affected patients are
sporadic cases caused by a de novo mutational event (1--4). TSC shows a high
penetrance and variable expressivity (1--4). Males and females are equally
affected, and there is no racial predilection.
GENETICS
TSC is the result of the mutation of two different genes: TSCI and TSC2 (5,6).
TSCI, cloned in 1997, is a gene located on chromosome 9 at 9q34.3,
producing a messenger RNA of 8.6 kb and encoding for a 1164-amino-acid
protein named hamartin. TSC2 is a gene located on chromosome 16 at
16p 13.3, producing a messenger RNA of 5.5 kb and encoding for a 1784-
amino-acid protein named tuberin. The functions of hamartin and tuberin are
not well defined, but in vivo they form a complex, and the inactivation of this
complex leads to TSC (7). As a consequence, mutations to either gene result in
the same phenotypic spectrum. Much evidence would appear to indicate that
419
420 Patrizi and Neri
TSC genes are tumor suppressor genes. Screening oflarge numbers of patients
reveals that the majority of cases carry TSC2 mutations (80%). In familial
cases the ratio of TSC 1 to TSC2 mutations is approximately I: 1, while in
sporadic cases the disorder results from a new dominant mutation occurring
in the TSC2 gene in two-thirds of patients and TSCI in the other third. There
may also be germline mosaicism when thoroughly evaluated parents with no
features ofTSC have two or more affected children (8). If parents or siblings
of an affected individual wish to ha ve children, a meticulous screening should
be made for genetic counseling. The widespread distribution of both TSCI
and TSC2 mutations hinders the development of a simple molecular com-
mercial diagnostic test on account of the many different mutations reported in
patients with familial or sporadic TSC.
DIAGNOSTIC FEATURES
In the past the disease was diagnosed on the basis of the Vogt triad-mental
retardation, epilepsy and facial angiofibromas-but recently this triad has
been found in less than one-third of patients, and in some children none of the
features are evident (9). Gomez first proposed diagnostic criteria for TSC
(10,11), and in 1992 the National Tuberous Sclerosis Association proposed a
long list of diagnostic criteria for TSC, divided into primary, secondary, and
tertiary features (12). Hypomelanotic mantles and "confetti" skin lesions
were encompassed in the tertiary criteria.
In July 1998, in the TSC Consensus Conference in Annapolis, Mary-
land, the diagnostic criteria for TSC were revised on the basis of new infor-
mation from clinical and genetic studies, and a new panel of revised diagnostic
criteria was proposed (Table 1), divided into two groups of features: major
and minor (8). There are 11 major features, 4 of which are cutaneous: facial
angofibromas or forehead plaque, nontraumatic ungual and periungual
fibroma, hypomelanotic macules (more than 3), and shagreen patch (con-
nective tissue nevus). The only cutaneous feature of the 9 minor features is
that of the so-called confetti skin lesions. All the cutaneous features may be
diagnosed clinically, and histological confirmation is not necessary. Derma-
tological manifestations are crucial in this panel of diagnostic criteria, and the
diagnosis of TSC is often made by dermatologists, as 96% of patients with
TSC have one or more typical skin lesions which are often the first sign to
draw attention to the disorder.
CLINICAL FEATURES OF TSC

In very small children the most frequently observed clinical signs are epileptic
seizures, mainly as infantile spasms. They affect more than 60% of affected
infants (9,13-15). Subependymal nodules are the most frequently observed
Hypomelanosis and Tuberous Sclerosis Complex 421
TABLE 1 Revised Diagnostic Criteria for Tuberous Sclerosis

Complex
Major features
1. Facial angiofibromas or forehead plaques
2. Nontraumatic ungual or periungual fibrome
3. Hypomelanotic macules (three or more)
4. Shagreen patch (connective tissue nevus)
5. Multiple retinal nodular hamartomas
6. Cortical tuber
7. Subependymal nodule
8. Subependymal giant cell astrocytoma
9. Cardiac rhabdomyoma, single or multiple
10. Lymphangiomyomatosis
11. Renal angiomyolipoma
Minor features
1. Multiple, randomly distributed pits in dental enamel
2. Hamartomatous rectal polyposis
3. Bone cysts
4. Cerebral white matter radial migration lines
5. Gingival fibromas
6. Nonrenal hamartoma
7. Retinal achromic patch
8. Confetti skin lesions
9. Multiple renal cysts
Definite tuberous sclerosis complex
Either two major features or one major feature plus two minor features
Probable tuberous sclerosis complex
One major plus one minor feature
Possible tuberous sclerosis complex
Either one major feature or two or more minor features
Source: Ref. 8.
cerebral lesions, detected by computed tomography or by magnetic resonance

imaging. Cardiac rabdomyomas are present in up to more than 50% of in-
fants (J3-IS). The first observed cutaneous changes include hypomelanotic
macules, present in more than 80% of patients, and forehead fibrous plaques,
whereas facial angiofibromas (Fig. I), shagreen patches (Fig. 2), periungual
fibromas, and gingival fibromas usually appear later in life.
CLINICAL FEATURES OF HYPOMELANOTIC MACULES

Hypomelanotic macules (HM) ofTSC appear very early in infancy or may be
already present at birth ~~ertJll.0a6waJpresentthe earliest cutaneous
FIGURE 1 Facial angiofibromas.
sign ofTSC (2,16). Moreover, at birth and in children less than 2 years of age,
HM are the most frequent lesion ofTSC (16-19). The etiopathogenesis ofHM
is still unknown. In 2000 Chudnow et al. reported that in most HM ofTSC the
eccrine sweat glands produce less sweat than normal skin when stimulated
with pilocarpine. They suggested that focal abnormal postganglionic sym-
pathetic innervation may be responsible for both impaired sudomotor
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function and decreased pigmentation (20). HM of TSC vary remarkably in

size, shape, morphology, site, and number (16-19).
Size and Shape

HM of TSC have been reported as typically lance-ovate macules (Fig. 3)
called "ash leaf spots" due to their resemblance to the shape of a mountain
ash leaf, but they may present many differences in size and shape, and the
most frequently observed lesions are polygonal (16,21) (Fig. 4). They may also
be round, oval, or linear, and the largest may be segmental with a dermatomal
pattern of distribution. The latter type of HM, similar to a nevus depigmen-
tosus, is generally considered the rarest clinical aspect of HM in TSC and
usually appears only in association with other types of HM (9). The most
frequently found HM have a diameter of 1-5 cm in children under 5 years, but
they may vary from 4 mm to several cm.
HM more rarely occur as a group of numerous macules, often sym-
metrical and 1-3 mm in diameter, named confetti spots (Fig. 5).
Morphology
Hypopigmented macules show a smooth surface with absence of scale and are
not as white as suggested by their former name, ash leaf-shaped white spot.
The adjective "hypomelanotic" or "hypopigmented" is due to the fact that
these lesions are somewhat clearer than the surrounding skin. In Caucasian
patients, in particular fair-skinned individuals, they may be not readily visible
under normal room light but become evident with the use of a Wood's lamp.
The use of a Wood's lamp is mandatory in screening of each individual for
hypopigmented lesions, particularly for small lesions such as confetti skin
lesions, which are easily missed without such an examination. The borders of
HM ofTSC may be well demarcated or not, and, although the majority show
a smooth contour, some may have irregular outlines. Morphologically they
may be indistinguishable from hypopigmented macules of normal individu-
als, as the latter are also hypochromic and not achromic (16-19,22).
Site
Hypomelanotic macules of TSC are distributed neither symmetrically nor in
crops; they are scattered over the entire skin surface, except for the palms and
soles. The Wood's lamp examination should therefore be made in a totally
undressed state. The macules are situated mainly on the trunk and buttocks
but may also be present on the limbs alone (16-19,21). The head and neck are
more rarely involved, but on the scalp HM may produce tufts of hypopig-
men ted hairs (poliosis), which more rarely occur in the eyebrows and eye-
FIGURE 3 A typical lance-ovate macule, named "ash leaf spot," on the right
buttock.
FIGURE 4 A polygonal hypopigmented macule.
lashes. Only rare and isolated white hairs may be seen, and leukotrichia of
body and pubic hair may also be observed. No HM are usually found on the
mucous membranes.
Confetti skin lesions are usually spread over the lower legs and fore-
arms, where they are often symmetrically distributed and may involve the full
circumference of the lim b.
FIGURE 5 Confetti skin lesions on the leg.
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HM are usually about 3-6 in number but may sometimes be more than 25
(Fig. 6). In rare cases they may only be 1 or 2 in number. Some HM may
totally disappear with age, and for this reason the number of HM is
frequently reported as higher in young children than in adults (14).
HISTOPATHOLOGY OF HYPOMELANOTIC MACULES

HM are lighter than the surrounding skin but are not completely lacking in
pigment. At electron microscopic examination the melanocytes appear
normal or slightly decreased in number and size, but their melanosomes are
few or absent, smaller in diameter, and with reduced melanization (21).
DIFFERENTIAL DIAGNOSIS OF HYPOMELANOTIC

MACULES
HM of TSC are clinically indistinguishable from hypochromic macules of
normal people. In 1996, in a large study of 423 white individuals younger than
45 years of age, screened with ambient light and Wood's lamp, 20 subjects
(4.7%) showed at least one HM but none had more than 3 (22). In 1998, on
the basis of this study, HM numbering 3 or more were included in the major
diagnostic features of TSC, while confetti skin lesions remained in the group
of minor diagnostic features (8).
Differential diagnosis ofHM includes: patches of vitiligo, where there is
a complete lack of pigmentation and sometimes hyperpigmented borders;
nevus anemicus, which is not a pigmentary abnormality and does not redden
when rubbed; nevus depigmentosum, which is usually larger, sometimes
segmental, and is congenital. Pytiriasis alba and areas of postinfiammatory
hypopigmentation usually appear later and often have fine scale.
Congenital achromic patches of piebaldism contain some normally
pigmented areas and are always associated with poliosis. In Waardenburg's
syndrome, however, there is congenital leukoderma, poliosis, and many other
clinical features such as dystopia canthorum, broad nasal root, heterochro-
mia irides, and deafness.
Idiopathic guttate hypomelanosis and multiple endocrine neoplasia
type I may be considered in differential diagnosis of confetti skin lesions.
TREATMENT AND EVOLUTION

There is no treatment for the HM of TSC apart from the use of sun blocks to
prevent sunburn. Moreover, HM frequently become more pigmented and less
obvious with age, and so~tffi!aIM~i113pear.
REFERENCES
I. Kwiatkowski Dl, Short P. Tuberous sclerosis. Arch Dermatol 1994; 130:348-
354
2. Harper 11. Genetics and genodermatoses. In: Champion RH, Burton lL, Burns
DA, Breathnach SM, eds. Rook/Wilkinson/Ebling Textbook of Dermatology.
Oxford: Blackwell Scientific Publications, 1998:384--388.
3. Osborne lP, Fryer AE, Webb D. Epidemiology of tuberous sclerosis. Ann NY
Acad Sci 1991; 615:125-127.
4. Webb DW, Clarke A, Fryer A, Osborne lP. The cutaneous features of tuberous
sclerosis: a population study. Br 1 Dermatol 1996; 135:1-5.
5. Van Slegtenhorst M, de Hoogt R, Hermans C, Nellist M, lanssen B, Verhoef S ,
et al. Identification of the tuberous sclerosis gene TSCI on chromosome 9q34.
Science 1997; 227:805-808
6. The European Chromosome 16 Tuberous Sclerosis Consortium. Identification
and characterization of the tuberous sclerosis gene on chromosome 16. Cell 1993;
75:1305-1315.
7. Nellist M, van Slegtenhorst M, Goedbloed M, van den Ouweland AMW, Halley
DJJ, van del' Sluijs P. Characterization of the cytosolic tuberin-hamartin com-
plex. 1 Bioi Chem 1999; 274(50)35647-35652.
8. Roach ES, Gomez MR, Northrup H. Tuberous Sclerosis Complex Consensus
Conference: revised clinical diagnostic criteria. 1 Child Neuro11998; 13:624-628.
9. Jozwiak S, Schwartz RA, lanniger CK, Michalowicz R, Chmielik 1. Skin lesions
in children with tuberous sclerosis complex: their prevalence, natural course and
diagnostic significance. Int J Dermatol 1998; 37:911-917.
10. Gomez MR. Tuberous Sclerosis. New York: Raven Press, 1979.
II. Gomez MR. Phenotypes of the tuberous sclerosis complex with a revision of
diagnostic criteria. Ann NY Acad Sci 1991; 615: 1-7.
12. Roach ES, Smith M, Huttenlocher P, Bhat M, Alcorn D, Hawley L. Diagnostic
criteria: tuberous sclerosis complex. 1 Child Neurol 1992; 7:22 I-224.
13. Ellis SS, Bayliss Mallory S. Hypopigmentation disorders. In: Eichenfield LF,
Frieden IJ, Esterly NB, eds. Textbook of Neonatal Dermatology. Philadelphia:
W.B. Saunders Company, 2001:362-364.
14. Sybert VP. Selected hereditary diseases. In: Eichenfield LF, Frieden IJ, Esterly
NB, eds. Textbook of Neonatal Dermatology. Philadelphia: W.B. Saunders
Company. 2001 :454-457
15. Jozwiak S, Schwartz RA, lanninger CK, Cymermann lB. Usefulness of diag-
nostic criteria of tuberous sclerosis complex in pediatric patients. J Child Neurol
2000; 15:652-659.
16. Fitzpatrick TB, Szabo G, Hori Y. et al. White leaf-shaped macules. Earliest
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78:419-420
43
Inherited Hypomelanotic Disorders
Nicoletta Cassano
Istituto Dermopatico dell'lmmacolata, Rome, Italy
Gino A. Vena
University of Bari, Rome, Italy
Numerous advances have been made in the field of inherited hypomelanosis

thanks to genetic and molecular studies. The study of mouse mutant models
has provided insight into the biology of melanin formation and the mecha-
nisms underlying abnormalities of melanin synthesis. A great variety of loci
that affect the pigment system has been identified in the mouse; some homol-
ogous genes have been found in the human genome and correlated with clin-
ical phenotypes and with specific biological functions.
ALBINISM
Albinism is a heterogeneous group of inherited disorders in which the syn-
thesis of melanin is absent or reduced, despite the normal distribution of
melanocytes. It can be divided into a generalized form, oculocutaneous albi-
nism COCA), which involves the skin, hair, and eyes, and a localized form,
which mainly involves the eyes, ocular albinism (OA). Albinism affects people
from all races with variable prevalence; OCA is more frequent than OA.
Analysis of mutations has shown that the phenotypic spectrum of al-
binism is broad and complex (1-3); for this reason, it is currently preferred to
classify albinism on the basis of the specific gene involved (Table I) rather
than clinical appearance.
433
434 Cassano and Vena
TABLE 1 Variants of Albinism and Affected Genes in Humans
Involved gene
Variant (chromosome) Heredity
Type 1: Tyrosinase-related Tyr (11q21) Autosomal

recessive
Type 1A: Tyrosinase-negative
Type 1B: Phenotypes: yellow
mutant, temperature-:>ensitive
minimal pigment, platinum
Type 2: Tyrosinase unrelated P gene (15q11.2-q12)
Tyrosinase positive
Brown
Type 3: Rufous/red TYRP1 (9p23)
Type 4 MATP (5p)
Type I HPS1 (10q23.1-q23.3)
Type II HPS2 or AP3B1 (5)
Type III HPS3 (3q24)
Type IV HPS4 (22q11.2-q12.2)
Chediak-Higashi syndrome CHS1 (1q42.1-42.2)
Ocular albinism type 1 OA1 (chromosome Xp22.3) X-linked
Oculocutaneous Albinism
OCA affects approximately I in 20,000 people worldwide. It was traditionally
categorized as two major variants, tyrosinase-positive or tyrosinase-negative,
based on the ability of hair bulbs to produce pigment or not when incubated
with tyrosine or dopa. Ultrastructural examination of hair and skin reveals
stage 1 and stage 2 melanosome in tyrosinase-negative albinos without mela-
nization, whereas other types may show up to stage 3.
It is now known that type 1 (tyrosinase-related) OCA is caused by dif-
ferent mutations of the gene encoding tyrosinase, the enzyme that catalyzes at
least the first two steps of melanin biosynthesis. Mutations can lead to a
complete inactivation of tyrosinase, thus causing a total absence of the pig-
ment (type I A or tyrosinase-negative), or to a reduced activity of the enzyme
capable of producing variable amounts of melanin (type 1B). Individuals with
OCA I B appeared tyrosinase-negative at birth but subsequently developed
some pigment in the hair or skin. In general, the color of eyelashes is darker
than that of the scalp hair; some patients can also tan with sun exposure.
Among OCA I B phenotypes are included "yellow mutant" OCA, so named
Inherited Hypomelanotic Disorders 435
for the yellow-blond or golden color of the hair described in Amish com-
munities of North America (4), and temperature-sensitive OCA, in which
tyrosinase activity is low at 35°C but is absent in body areas with higher
temperatures (scalp, axillae) (5). OCAI accounts for approximately 40% of
OCA worldwide. OCA2 (tyrosinase-positive) accounts for approximately
50% of OCA worldwide and has a high prevalence in sub-Saharan African
blacks (1/3900). In this form, some pigment is produced and may be found in
the skin, iris, and hair. OCA2 is associated with mutations of the P gene; the
encoded protein is a transmembrane polypeptide with possible transport
functions. Mutations at this locus are also responsible for the milder pheno-
type seen in individuals with brown OCA (6,7).
OCA3 is a rare form ofOCA, also known as rufous/red albinism, which
seems to affect more commonly southern African blacks (1/8500). Patients
present unusual red skin color, ginger to reddish hair color, low susceptibility
to sun damage, and minimal visual problems. OCA3 is linked to mutations in
TYRPI (encoding tyrosinase-related protein I) (8). In contrast to the murine
system, human TYRPI does not express DHICA-oxidase activity (9). Its role
in humans is still obscure, although it was suggested that TYRPI can modu-
late the stability and activity of tyrosinase, melanosome ultrastructure, and
melanocyte proliferation/survival (10).
Recently, the mouse underwhite gene (uw) and its human orthologue,
involved in a new form of human OCA (OCA4), has been identified. The en-
coded protein, MATP (mem brane-associated transporter protein), may func-
tion as a transporter (3).
All types of OCA are associated wi th ocular signs of varia ble severity:
photophobia, reduced visual acuity, foveal hypoplasia (more common in
OCA-IA), congenital nystagmus, albinotic fundi, translucent irides, errors of
refraction (more frequent in OCA-IA), lack of stereopsis, and strabism sec-
ondary to misrouting of the optic axons (II). A direct correlation has been
found between stereopsis and both visual acuity and amounts of pigment in
the iris and macula (12). In type 2, visual acuity and nystagmus may improve
with age.
Cutaneous hypopigmentation leads to diminished photoprotection and
increased risk for skin cancers. In sun-exposed regions of the skin, localized
pigmentary lesions (nevi, freckles, and lentigines) can develop, especially in
tyrosinase-positive OCA. UV-induced cutaneous tumors are common in
patients with albinism, with squamous cell carcinoma being the most fre-
quent. Although dysplastic nevus and melanoma are less common, they create
great diagnostic difficulties in these patients because of their hypopigmented
appearance (13).
The medical approach to albinism includes photoprotective measures
and regular skin examination for the early detection and treatment of pre-
malignant and malignant conditions. Low vision devices and glare filters are
helpful in correcting ocular problems (14).
Prenatal diagnosis of OCAI is available using histological and electron
microscopic examination of fetal skin biopsies or even molecular genetic
techniques (15).
Ocular Albinism
OA type I (OAI) is an X-linked recessive disorder characterized by a severe
reduction in visual acuity, hypopigmentation of the retina that leads to
nystagmus, strabismus, varying degrees of corneal astigmatism, and photo-
phobiajphotodysphoria. Ultrastructural studies show the presence of macro-
melanosomes in skin melanocytes and retinal pigment epithelium, suggesting
that there can be a defect of melanosome biogenesis.
The OA I gene product can act as an intracellular G-protein-eoupled
receptor (16). Some findings indicate that OA I and X-linked OA with late-
onset sensorineural deafness may be allelic variants or may be caused by
contiguous gene defects (17). Autosomal recessive OA is now regarded as
OCAIB or OCA2 with absent or minimal changes in skin pigmentation.
ALBINOIDISM
Albinoidism is a name applied to a condition in which there is some hypo-
pigmentation of the skin and hair-less marked than in OCA-and minimal
ocular changes (18). A diffuse, punctate pattern of iris is revealed by trans-
illumination. Eyes are usually normal, although there may be photophobia
and severe myopia. This variant is regarded as tyrosinase-positive and in-
heritable in an autosomal dominant or recessive fashion. The genetic bases
and the relationship with true albinism have not yet been defined.
HERMANSKI-PUDLAK SYNDROME
Hermansky-Pudlak syndrome (HPS) results from defects in melanosomes,
platelet granules, and lysosomes responsible, in turn, for tyrosinase-positive
OCA, prolonged bleeding, and lysosomal deposition of ceroid lipofuscin de-
position in many tissues. In the mouse, the disorder is multigenic and can
cause several phenotypes (19). In humans four genes have been identified, two
of which (HPSI and HPS2) have been more widely studied. HPSI gene en-
codes an ubiquitous protein of unknown function; HPS2 gene encodes the
beta-3 subunit of the adaptor protein 3 (AP-3) complex, which is implicated
in the vesicular formation (20,21). HPS is a rare syndrome throughout the
world, with the exception of Puerto Rico, in which the prevalence is high,
especially in the northwestern quarter of the island (1/1800) (22). The pig-
mentary phenotype of HPS patients resembles that of other types of OCA.
Ocular findings in HPS include reduced visual acuity, congenital nystagmus,
strabismus, and cataract (23).
Ceroid Iipofuscinosis can lead to fibrotic restrictive lung disease, com-
monly between the ages of 20 and 44 years, and granulomatous enteropathic
disease, which usually has its onset after 13 years (24,25). Moreover, renal
failure and degenerative cardiac disease can occur. Hemorrhagic diathesis has
been attributed to storage pool-deficient platelets. In some patients low levels
of plasma von Willebrand factor have also been detected, which were, how-
ever, unrelated to history of bleeding (26). The major causes of death are
pulmunar fibrosis, hemorrhagic episodes, and seq uelae of granulomatous en-
teropathic disease.
The most reliable method of diagnosing HPS is by a deficiency of plate-
let dense bodies observed by electron microscopy. Measures apt to prevent or
minimize bleeding (trauma, surgical intervention, use of aspirin and NSAIDs)
are mandatory.
CHEDIAK-HIGASHI SYNDROME
Chediak-Higashi syndrome (CHS) is a rare disorder which shares with HPS
some clinical findings, represented by variable degrees of OCA and easy bru-
isability and bleeding due to platelet storage pool deficiency. The two diseases
may also have similar pathogenic mechanisms linked to vesicle anomalies at
the lysosomal level; in particular, it is thought that CHS may result from a
defect in vesicle trafficking (27) The only known CHS-causing gene, CHSI or
LYST, codes for a large protein of unknown function that shows similarities
with proteins associated with cellular signal response coupling (28). The
hallmark of CHS is the presence of huge cytoplasmic granules in circulating
granulocytes and many other cell types. These granules are peroxidase-posi-
tive and contain lysosomal enzymes, suggesting that they are giant lysosomes
or, in the case of melanocytes, giant melanosomes.
There are severe immune defects (neutropenia, impaired chemotaxis
and bactericidal activity, and abnormal natural killer cell function) that are
responsible for the high susceptibility to recurrent infections. Neurological
involvement is variable and progressive and often includes peripheral neuro-
pathy. Most patients developed an "accelerated phase," which is a nonmalig-
nant Iymphohistiocytic infiltration of multiple organs resembling lymphoma.
Death often occurs in the first decade from infection, bleeding, or develop-
ment of the accelerated phase unless patients are treated by bone marrow
transplantation. About 10-15% of patients exhibit a milder phenotype and
survive longer, but they can undergo severe and often fatal neurological dys-
functions (29,30).
GRISCELLI-PRUNIERAS SYNDROME (PARTIAL ALBINISM

WITH IMMUNODEFICIENCY)
This is a rare autosomal recessive disorder distinct from CHS. Two genetic
loci have been isolated on chromosome l5q2l, one of which colocalizes
with the myosin-Va gene (31). Pigmentary dilution mainly affects the hair,
which has a silver-metallic color; hair shafts show large clumped melano-
somes, and stage 4 melanosomes are contained in skin melanocytes. Immu-
nological abnormalities include reduced natural killer (NK) and helper T-cell
functions, defective cell-mediated immunity, hypogammaglobulinemia, and
impaired response to mitogens. Patients are prone to develop neurological
disturbances, accelerated phases, and hemophagocytic syndrome related to
viral infections, especially Epstein-Barr virus (EBV). The prognosis is poor
without bone marrow transplantation (32,33).
ELEJALDE SYNDROME (NEUROECTODERMAL

MELANOLYSOSOMAL DISEASE)
This is a rare autosomal recessive disease characterized by silvery hair and
neurological involvement (seizures, severe hypotonia, and mental retarda-
tion), often fatal. Skin becomes bronze after sun exposure. Large granules of
melanin unevenly distributed in the hair shaft are observed. Abnormal mela-
nocytes and melanosomes and abnormal inclusion bodies in fibroblasts may
be present. It should be differentiated from CHS and Griscelli syndrome.
Despite the similarities between Elejalde syndrome and Griscelli syndrome,
the possibility that they are two different entities, although probably allelic
related, has been suggested (34).
CROSS SYNDROME (OCULOCEREBRAL SYNDROME WITH

HYPOPIGMENTATION)
This is a rare syndrome determined by an autosomal recessive gene, with
ocular and cutaneous hypopigmentation, mental and psychomotor retarda-
tion, with spasticity and atheto is. The mixed pattern of hair pigmentation
seems very typical (35). The clinical spectrum can include microphthalmos,
opaque corneas, iris atrophy, dental defects, and multiple-site malformations
(36,37).
VICI SYNDROME
Several reports (38,39) indicate a new syndrome, probably with autosomal
recessive inheritance, characterized by OCA, agenesis of corpus callosum,
and primary immunodeficiency leading to repeated infections. Cardiomyop-
athy has been also described.
PRADER-WILLI AND ANGELMAN SYNDROMES

Loss of the 2-Mb domain of human chromosome 15qll-ql3 on the paternal
or maternal allele results in Prader- Willi syndrome (PWS) or Angelman syn-
drome (AS), respectively (40). Other modalities of inheritance are unipar-
ental disomy or translocation and biparental inheritance. Different genetic
mechanisms are responsible for variable phenotypes (41,42). The two syn-
dromes present with mental retardation, abnormal behavior, and hypopig-
mentation. The hypopigmentation has been associated with OCA2 and is
characterized by light skin, reduced retinal pigment, low hair bulb tyrosinase
activity, and incomplete melanization of melanosomes (43). Other clinical
findings are hyperphagia, obesity, hypogonadism, small hands and feet in
PWS, and developmental delay, microcephaly, ataxia, hyperactivity, inap-
propriate laughter, EEG abnormalities, and seizures in AS (44,45).
PIEBALDISM
This is an autosomal dominant disorder of melanocyte development in which
the major clinical features are patchy hypopigmentation of the skin (leuko-
derma), often localized in the frontal median or paramedian area, and polio-
sis (white forelock). Piebaldism is quite rare but widely distributed among
racial groups. The presence of lesions from birth and the static course help
to differentiate piebaldism from vitiligo. With age, hyperpigmented mac-
ules within depigmented and normal skin can be observed. Ultrastructurally,
the hypomelanosis results from the absence of functional meJanocytes; in
the hypermelanotic areas melanocytes contain abnormal as well as normal
melanosomes (46). Uncommon associations were described with Rubinstein-
Taybi syndrome, congenital deafness (Woolf's syndrome), and neurofibro-
matosis type I (47--49). The molecular basis of piebaldism involves several
mutations of the human KIT gene (chromosome 4q 12), encoding c-kit recep-
tor, a tyrosine kinase transmembrane receptor for mast cell growth factor
(steel factor, stem cell factor, or c-kit ligand). This factor plays a crucial role in
migration, differentiation, and proliferation of melanoblasts (50).
WAARDENBURG'S SYNDROME
Waardenburg's syndrome (WS) is a rare syndrome inherited in a variably
penetrant autosomal dominant fashion (51). It has an estimated frequency of
1 in 20,000 in Kenya and I in 40,000 in the Netherlands. The frequency of
deafness is lower, estimated at I in 50,000-212,000. WS actually comprises
different clinical and genetic variants (Table 2) (51-54) The affected genes
ha ve pleiotropic effects on the development of melanocytes and other neural
crest-derived lineages and can be hierarchically related to each other (e.g.,
MITF expression can be regulated by SOXIO and PAX3) (55,56). Hypo-
pigmentation of WS is quite similar to that of piebaldism, with absence of
melanocytes and stable course throughout the lifetime although an atypical
TABLE 2 Variants of Waardenburg's Syndrome
Type of WS Phenotype (frequency) Gene (chromosome) Gene product: function
WS-I Dystopia canthorum (99%) PAX-3 (2q35) PAX-3 transcription factor:

Synophrys (17-69%) neural tube development
Broad nasal root (78%)
Depigmentation of hair
and/or skin (17-58%
with white forelock)
Heterochromia/hypochromia
of iris (> 20%)
Congenital deafness
(9-38%)
WS-II Similar to WS-I, without MITF (3p14.1-p12.3) Microphthalmia-associated
dystopia canthorum transcription factor:
melanocyte survival and
differentiation
WS-lIl a Similar to WS-I, but PAX-3 (2q35) PAX-3 transcription factor:
with associated neural tube development
musculoskeletal
abnormalities of limbs
WS-IV b Similar to WS-I, with EDN3 (20q13.2-q13.3) Endothelin 3: melanocyte
associated bowel EDNRB (13q22) development
aganglionosis SOX10 (22q13) Endothelin receptor B:
(Hirschsprung disease) melanoblast differentiation
SRY-related transcription
factor: transcription
activation
a Klein-Waardenburg syndrome.
b Waardenburg-Shah syndrome or Hirschsprung disease type II.
TABLE 3 Most Relevant Characteristics of Tuberous Sclerosis and Phenyketonuria
Tuberous sclerosis
(Bourneville's disease) Phenyketonuria
Heredity Autosomal dominant with Autosomal recessive

variable expression
(new mutations are
however common)
Gene (chromosome) TSC-1 (9q34) PAH (12q22-q24.1)
TSC-2 (16p13.3) + other loci (rarely)
Gene product/function Hamartin (TSC-1 )/regulation of Phenyalanine hydroxylase/
cell proliferation formation of tyrosine
Tuberin (TSC-2)/regulation from phenylalanine
of cell growth and differentiation
Type of Ash-leaf-shaped hypopigmented Decreased pigmentation
hypopigmentation macules (trunk or limbs) (pigment dilution) in
(tertiary features) skin, eyes, hair
Possible segmentary or guttate
hypomelanosis
Hypopigmented iris spot
Punched-out chorioretinal
depigmentation
UItrastructu ral Abnormal melanocytes with Reduction of keratinocytes
findings reduced tyrosinase activity; containing melanin and
defective melanization of of melanosomes in
melanosomes melanocy1es
Mechanism of Hypofunctioning melanocy1es Reduced melanin formation
hypopigmentation with reduced transfer of due to the inhibition of
melanosomes to keratinocytes tyrosine-tyrosinase
and decrease of the overall reaction by phenylalanine
melanin content in the (darkening of the hair
affected skin towards normal color with
tyrosine treatment)
Focal abnormalities of
sympathetic innervation (7)
Main additional Mental retardation, epilepsy, Mental retardation, epilepsy,
clinical findings skin lesions (facial hyperactivity, psychomotor
angiofibromas, multiple delay, extrapyramidal
periungual fibromas, shageren symptoms, long eyelashes,
patch, and others), ocular and eczema, dermographism
pulmonary signs, cardiac, renal
and gastrointestinal tumors
Clinical features are divided Syndrome rarely observed
in three groups according thanks to the early recognition
to the Diagnostic Criteria and treatment (restriction of
Committee of the National phenylalanine intake)
Tuberous Sclerosis
Association (1992)
spontaneous pigmentation was described in some cases affected with WS-I

(51). Premature greying of hair can occur.
TIETZ SYNDROME
This syndrome is determined by an autosomal dominant gene with complete
penetrance. Clinical hallmarks are congenital severe deafness and generalized
hypopigmentation of the skin. There can be hypoplasia of the eyebrows; eyes
are normal. Interestingly, the gene affected appears to be the same as for WS
type II (MITF) (57).
YEMENITE DEAF-BLIND HYPOPIGMENTATION SYNDROME

(WARBURG'S SYNDROME)
In 1990, Warburg and co-workers described two Yemenite siblings with
microcornea, colobomata of the iris and choroidea, nystagmus, severe early
deafness, and patchy hypo- and hyperpigmentation. Melanocytes were absent
in leukoderma I areas. They proposed the disorder as a new syndrome with
autosomal recessive inheritance. Subsequently, a mutation in the SOX 10 gene
was associated with a milder phenotype (58).
ZIPRKOWSKI-MARGOLIS SYNDROME
In 1962 Ziprkowski et al. (59) reported an Egyptian-Jewish family with deaf-
mutism, heterochromia of iris, diffuse poliosis, and piebald-like leukoderma
associated with hypermelanotic patches. An X-linked gene seemed to be
implicated.
OTHER HEREDITARY CONDITIONS

The most important conditions that can be associated with the presence of
peculiar hypomelanotic lesions are tuberous sclerosis (46,60-65) and phenyl-
ketonuria (66-69) (Table 3). In other diseases, such as Menkes' disease or
disorders of methionine metabolism, the color dilution results from defective
keratinization and not from disturbances of melanin synthesis.
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44
Piebaldism
Giovanni Maria Palleschi

Piebaldism or partial albinism is a rare congenital stable leukoderma with

autosomal dominant inheritance, characterized by the presence at birth of
achromic skin vitiligo-like patches with islands of normal or hyperpigmented
skin, associated with frontal poliosi. The disease is rare, with an incidence of I
in 20,000, but it is widely distributed and there is no any sex prevalence.
Piebaldism was well known by the Greek and Romans but its familiar nature
was only described by Morgan in 1786 (J ,2).
CLINICAL FEATURES
Typically the macules or patches of piebaldism are present at birth and do not
modify during life. Cases that arise after the first sun exposure are reported,
but probably this depends on tanning, which shows up the lesions. The color
is matte chalk-white, the border can be feathered, normally containing smal]
macules of normal or hyperpigmented skin (Fig. ]). The disorder is classically
associated with poliosis due to locahzed loss of hair pigment (Fig. 2). The
patches are bilateral but not symmetrical (Fig. 3). The distinctive localization
that represents the typical pattern in 90% of the cases is on the frontal region
median or paramedian with a white forelock (Figs. 4 and 5). This character-
istic path is triangular and is extended to the eyebrows but rarely to the eye-
lashes, which can be white. Occasionally on the face the chin can be affected.
The areas affected on the trunk are the lateral regions, the abdomen extending
to the upper chest (Fig. 6), and the back, although normally the paravertebral
450 Palleschi
FIGURE 1 Classical matte chalk-white leukodermic area, with feathered border

containing small macules of normal or hyperpigmented skin.
region is spared. The four limbs are affected in the upper areas (Figs. 7 and 8).
The periorificial regions are spared (1-5). Mucosae are normally spared, and
their involvement is rarely reported (6).
The areas of hyperpigmented skin within the amelanotic macules or
patches and less often on normal skin appear during life. They do not have a
uniform color and may be more evident after sun exposure. Some cases of
depigmentation during life are reported (1,6).
Piebaldism is occasionally related to mental retardation. In two cases
reported in the literature it is associated with the interstitial deletion of
chromosome 4 (I). Other rare associations are heterochromic irides or sen-
sorineural deafness. The association of piebaldism with perceptive deafness is
named Woolf syndrome, and it represents a distinct autosomal recessive syn-
drome (1,7). The X-linked occipital white forelock is a variant of piebaldism.
Piebaldism 451
FIGURE 2 Detail of leukodermic patch with hyperchromic maculae within and

outside of the border and leukotrichia.
The association of piebald-like maculae with sensorineural deafness, con-

genital megacolon, a characteristic face, and ocular abnormalities is known as
Waardenburg syndrome (Table 1 and Box I) (8,9).
PATHOLOGY
In lesional skin the epidermis appears normal but melanocytes and melano-
somes are totally absent or greatly reduced. In one case mast cells have been
identified in the epidermis. Atypical large melanocytes are sometimes visible
FIGURE 3 Bilateral but not symmetrical patches on the calves.

452 Palleschi
FIGURE 4 Typical localization on the median frontal region with white forelock.
in hair follicles. In the hyperpigmentated maculae the melanocytes produce

abnormal melanosomes (large, spherical, and granular), which are fused into
the keratinocytes (6,9~11).
PATHOGENESIS
Studies on animals, dominant white-spotting (Ws) mice (equivalent to human
piebaldism), and humans revealed that piebaldism is due to several genetic
FIGURE 5 White forelock on forehead.

Piebaldism 453
FIGURE6 Large patch localized on abdomen, with feathered margins, containing

numerous hyperchromic maculae.
mutations of the proto-oncogene (c-kit). This gene is implicated in the encode

of tyrosine kinase transmembrane receptor of melanocytes, mast cells, and
other cells. The ligand of this receptor is represented by the steel factor, also
called mast stem cell growth factor or stem cell growth factor (12-14). The
result is a modification of the normal migration or differentiation during
em briogenesis of melanoblasts from the neural crest to the skin and other
organs such as the inner ear (15).
FIGURE 7 Leukodermic rrf3opj¥~rM3~fJf with figurated border.

454 Palleschi
FIGURE 8 Large leukodermic patch on lower limb with widespread leukotrichia.
In the Ws mouse the proto-oncogene c-kit is mapped on chromosome 5,

and in humans on chromosome 4. There are 14 known types of mutation of c-
kit on chromosome segment 4q 12. Point mutation, frame-shift and splice-
junction are the most frequent in humans (16-19). Piebaldism is an autosomal
dominant disorder, and the mutation in one of the two copies of the gene
produces the disease. For the dominant-negative effect there is no relation
between a mild or severe phenotype and the grade of genetic mutation (9). The
association of piebaldism with mental retardation is related to a deletion of
chromosome segment 4q 13.
The most important differential diagnosis is vitiligo (Table I) in which mac-
ules appear during life with generally symmetrical, acroloca ted, and/or
periorificial distribution, with a hyperpigmented border and with little peri-
follicular pigmented maculae within the patches. The lesions can also arise
following scratching (Koebner phenomenon) or have a unilateral dermato-
mal arrangement in segmental form. The involvement of mucosae is possi-
ble. The course is chronic, with temporary partial remission, but is generally
TABLE 1 Differential Diagnosis
"ll
(ii'
Piebaldism Vitiligo Waardenburg syndrome C"
III
Age of onset Congenital autosomal dominant All ages acquired Congenital autosomal dominant 0:
iii'
Course Chronic stable Chronic progressive, Chronic stable (regressed in 3
temporary regression two cases)
Shape and From a few millimeters to many Rounded, oval, figurate From some millimeters to
dimension centimeters; irregular, segmental many centimeters; irregular
of maculae feathered margins
Disposition Symmetrical Symmetrical Asymmetrical
() Distribution Forehead, trunk with sparing Eyelids, genital and Forehead, face, neck, trunk,
0 of paravertebral regions, periorificial areas, extensor limbs, dorsal hands
~~, upper arms and legs limbs, terminal digits
<g. Characteristic Hyperpigmented macules in Hyperpigmented border Piebald-like
CD features leukodermic macules or, pigmented perifollicular
0..
rarely, on normal skin spots, segmental
~ Other skin Poliosi, leukotrichia Halo nevus or Sutton nevus, Synophrys, graying of hair,
CD alterations scattered leukotrichia, leukotrichia
~ areata alopecia
Pathology Absent melanocytes, atypical Absent melanocytes, Absent melanocytes
large melanocytes, spherical lymphocytic infiltrate
atypical melanosomes in in early lesions
hyperpigmented macules
Extracutaneous Deafness in S Woolf Diabetes, autoimmune Heterochromic iridies, broad
manifestations thyroiditis, Addison's nasal root, deafness,
disease, myasthenia gravis, congenital megacolon,
pernicious anemia Hirschsprung disease,
dystopia canthorum
Diagnostic Audiometry Glycemia, thyroid function, Audiometry
.j:o
evaluation autoantibody ophthalmological U1
U1
examination, audiometry
456 Palleschi
BOX 1 Waardenburg Syndrome
Rare disorder due to abnormal development of neural crest, with autosomal dom-
inant inheritance and variable penetrance (formes frustes). The incidence is 1 in
42,000. It represents approximately 0.9-2.8% of people with perceptive deafness
(1,6).
The syndrome is based on the original description of dystopia canthorum,
broad nasal root, synophrys (confluent thick eyebrows), massive jaw, hetero-
chromia and/or hypopigmentation of the iris, which determine a characteristic
face, associated with congenital deafness and piebaldism (8). In about half of the
cases a depigmentation of the ocular fundal is present without any alteration of
visual acuity (1). Leukoderma is similar to piebaldism, but the forehead, neck, and
dorsum of the hands are affected and a premature graying of the hair is present.
Two cases with spontaneous remission were reported by Chang in 1993 (24).
The syndrome is divided into Types I, II, and III [also known as Klein-Waarden-
burg syndrome, a result of association with other anomalies described by Klein
(25)].
Type I: presence of dystopia canthorum, white forelock, leukoderma,

synophrys, broad nasal root.
Type II: absence of dystopia canthorum, increased frequency of deafness,
heterochromia irides.
Type III: characterized by presence of musculoskeletal abnormalities of the
upper limbs, such as fusion or hypoplasia of carpal bones, contractu res,
syndactyly (26)
In Types I and III mutations of the PAX-3 gene on chromosome 2q35-37 are de-
scribed. In Type II, a mutation of the MITF (microphthalmia transcription factor)
gene on chromosome 3p13 (cc) has been reported (9,27).
progressive. Life stress events can cause the illness to break out. Another dif-
ferential diagnosis is the rare Waardenburg syndrome suggested by hetero-
chromic irides, neurosensorial deafness, and facial dysmorphism (Table land
Box 2).
TREATMENT
There is no specific therapy. Sunscreen should be applied on the area of leu-
koderma. There are reports of successful transplantations of unaffected skin
into areas ofJeukoderma (20-22). PUVA therapy has been used with poor re-
ults (23).
Piebaldism 457
BOX 2 Deafness and Leukodermic Syndromes
The relationship between leukodermic syndromes and deafness can be explained

by the importance of melanocytic cells for inner ear development and function.
In the inner ear, melanocytes were observed in the vestibular dark cells,
endolymphatic sac, and stria vascularis of the mammalian cochlea (28). The stria
vascularis is composed of three types of cell. Marginal cells line the lumen of the
cochlear duct and are of ephithelial origin. Basal cells that form a continuous layer
derive from the neural crest or from the mesoderm. Intermediate cells derive from
the neural crest and show cytological characteristics almost identical to those of
melanocytes (29). The marginal cells form extensive interdigitations with the inter-
mediate (melanocyte-like cells) and basal cells.
Alteration of the melanocytes could be responsible for ear function defects.
Melanocytes appear to be vital for normal stria vacularis development and func-
tioning. In mutant mice with an absence of melanocytes and in albino mice, there is a
lack of interdigitation between basal cells and marginal cells. The stria vascularis is
abnormally thin and lacking intermediate cells. This morphological aspect is cor-
related to stria dysfunction evaluated by electrophysiological studies (28-30). A
relationship between the production of melanosomes and the process of interdigi-
tation of melanocytes with the marginal cells was demonstrated comparing pig-
mented rats with albino rats (15).
The functioning of stria vascularis depends on melanocytes or melano-
somes, which prevent damage to the hair cells by ototoxic agents (15,31). These
data are supported by the finding that black-skinned persons are less commonly
affected by noise-induced hypoacusis than are white-skinned persons.
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17. Fleischman RA, Gallardo T, Mi X. Mutations in the ligand-binding domain of
the kit receptor: an uncommon site in human piebaldism. J Invest Dermatol
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18. Schinzel A, Braegger CP, Brecevic L, et al. Interstitial deletion, del(4) (q 12q21.1),
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45
Albinism
Giovanni Menchini and Torello M. Lotti
H. Grossman
Regional Dermatology Training Center, Moshi, Tanzania
INTRODUCTION
Albinism includes a heterogeneous group of genetically determined diseases
characterized by diffuse skin hypopigmentation and ocular disorders, result-
ing in oculocutaneous albinism (OCA). If the skin and hair are normally
pigmented and just the eye pigmentation is affected, the condition is called
ocular albinism (OA). The word "albino" derives from the Latin albus, which
means white, used once by African populations to describe white people. The
prevalence of albinism is approximately I :20,000 in the world population and
rises in Africans.
Nine different types of clinical and genetic variants of oculocutaneous
albinism are inherited as autosomal recessive and one only rare type as auto-
somal dominant (Table I).
In OCA there is partial or complete failure of melanin production,
leading to a marked dilution of the pigmentation of the skin, hair, and eyes
(1). The melanocytes that originate in the neural crest produce melanin, pro-
viding pigment for the skin (including eyelids, hair, uvea, conjunctiva, stroma
of the iris, ciliary body, and choroids), which act as a photoprotective pig-
ment. The biosynthesis of melanin begins with the hydroxylation of the amino
461
462 TSQureli-Nikita et a!.
TABLE 1 Hypomelanotic Disorders Due to Genetic

and Nevoid Factors
Oculocutaneous albinism
Tyrosinase negative (type IA) Recessive
Yellow mutant (type IB) Recessive
Platinum Recessive
Tyrosinase positive (type II) Recessive
Brown Recessive
Rufous (type III) Recessive
Chediak-Higashi Recessive
Hermansky-Pudlak Recessive
Minimal pigment Recessive
Autosomal dominant Dominant
Ocular albinism X-linked
With deafness X-linked
Recessive
Dominant
Albinoidism
Cross syndrome Recessive
Piebaldism Dominant
Waardenburg syndrome Dominant
Vitiligo Polygenic
Phenylketonuria Recessive
Tuberous sclerosis Dominant
Achromic nevus
Incontinentia pigmenti achromians
acid L-tyrosine to dihydroxylphenylalanine (DOPA) and the oxidation of

DOPA to DOPAquinone by the copper-containing enzyme tyrosinase, re-
sulting in either black-brown eumelanin or the presence of sulf11ydryl com-
pounds, red-yellow pheomelanin. The resulting pigment polymer is deposited
on a protein matrix within the melanosome. In the skin and hair follicles,
the melanosome is then transferred to keratinocytes via the dendrites of the
melanocyte. In white persons, the synthesis of pheomelanin derives from the
ammino acids tyrosine and cysteine, while in blacks, tyrosine is the only pre-
cursor for the biosynthesis of eumelanin (Fig. I). Skin color depends on the
dimensions and not on the number of the melanocytes. In fact, blacks have
larger melanosomes than whites.
The gene encoding tyrosinase has been localized in chromosome 11, and
many different mutations are connected to the variants of oculocutaneous
albinism. The majority of these mutations lead to the production of tyrosinase
enzyme that is inactive ("null" mutations), so the two initial conversions in
Albinism
463
OCA1
TyrosinOlls.
OCA3
Eumelanins
FIGURE 1 Melanogenesis pathway. OCA1 is due to "null" or "leaky" mutations

of the tyrosinase gene leading, respectively, to complete or partial inactivity of
tyrosinase (ty-ve albinism). In OCA3, the mutation involves tyrosinase-related
protein 1, and only the production of eumelanins is blocked ("rufous," or red
phenotype).
the melanin pathway (tyrosine---+dopa---+dopaquinone) (Fig. 1) are not made

and no melanin forms. Other tyrosinase gene mutations called "leaky" muta-
tions lead to the production of a tyrosinase enzyme that has some activity not
approaching normal. Some melanin is formed, for example, in OCAIB "yel-
low albinism" and in the minimal pigment type ofOCA.
OCA has been divided into two different groups according to the under-
lying biological defect. When a mutated tyrosinase gene produces inactive,
less active, or temperature-sensitive tyrosinase, its phenotype is described as
tyrosinase-negative (ty-ve) (type IA), yellow-mutant (type lB), or tempera-
ture-sensitive (type I-TS) OCA, respectively. Mutation of the P gene that
encodes the tyrosine-transporting membrane protein may occur in tyrosinase-
positive (ty + ve) OCA (type 2). In this case, the enzyme is present but the
production of type III and type IV melanins is insufficient. Tyrosinase-
TABLE 2 Genes Related to Different Phenotypes

of Albinism
Gene Type of albinism
Tyrosinase gene OCA1 (OCA1A and OCA1B)

P gene OCA2
TRP1 gene OCA3
HPS gene Hermansky-Pudlak syndrome
CHS gene Chediak-Higashi syndrome
OA1 gene X-linked ocular albinism
positive albinism is characterized by hair bulbs which, after plucking and

incubation with tyrosine, produce darkening. In tyrosinase~negative albin-
ism, the hair bulbs do not darken, although the precise metabolic defects have
yet to be ascertained (2). Ultrastructural studies of the skin and hair of tyro-
sinase-negative types show that most of the melanosomes are in stage I or
stage 2, without any melanization (2,3). Albinism is found in all races with
variable prevalence. The incidence in the United Kingdom is estimated at I
in 20,000. In some countries it is more common, especially where there is a
tendency towards inbreeding and in isolated comunities. The highest inci-
dence (63 per 10,000) of albinism in the world is found on the coast of Pan-
ama, in the Cuba Indians nation on the San Bias islands. Table 2 summarizes
the genes related to various types of albinism.
CLINICAL FEATURES
OCA1A
OCAlA (ty-ve), occurs in approximately I in 40,000 individuals in most pop-
ulations. It is an autosomal recessive disorder characterized by absence of
pigment in hair, skin, and eyes and does not vary with race or age. The most
important distinguishing characteristic of OCA I is the presence of marked
hypopigmentation at birth. The skin appears pink, the hair white, and pa-
tients show a red reflex and blue eyes at birth (4,5). The irides are usually very
light blue and translucent, so that the whole iris can appear pink or red in
ambient or bright light. During the first two decades of life, the irides usually
become a darker blue. Sun exposure produces erythema and a burn if the skin
is unprotected.
The eyes need melanin to develop normal vision. People with albinism
have vision defects because the eyes do not have a normal amount of melanin
pigment during development. Hence, the albinotic macula is always hypo-
Albinism 465
plastic and the albinotic patient has reduced acuity. This maldevelopment
of the macula explains the pendular nystagmus of the albino patient, as the
albino eye constantly searches for a clear image. Research indicates that there
is a disorganization of reticulogeniculate projections in the albino patient,
with 20% of temporal fibers decussating at the optic chiasm. The abnormal
crossings of the temporal fibers in the optic chiasm can also cause errors
of refraction, head nodding, photophobia, variable visual acuity, and, fre-
quently, strabismus in both oculocutaneous and ocular albinism. Foveal
hypoplasia can also occur. In contrast, the lack of pigmentation does not
obstruct the normal growth and development of the skin or hair.
In OCAIB (yellow mutant type), the patient resembles a tyrosinase-
negative type at birth, but at the age of I year the hair becomes yellow-red. It is
now known that the hair color is the result of pheomelanin synthesis, related
to the reduced tyrosinase function. The incubation of tyrosine plus cysteine
in the hair bulbs of these patients produces an intensification of the yellow-
red pheomelanin. This type is common in Amish communities in the United
States (7).
Another type ofOCAIB is temperature-sensitive OCA, which is caused
by a mutation of the tyrosinase gene that produces an enzyme that does not
work at regular body temperature (scalp and under the arms) but does work in
cooler parts of the body (arms and legs). During development, some of the
body hair becomes darker. The hair under the arms and the scalp hair remain
white, and with time may develop a slight yellow tint. Hair on the arms and
legs slowly develops light to dark pigment. The eyes remain blue and the skin
white without tanning.
OCA2
OCA2 (ty + ve) is the most common type of albinism, especially frequent
among African Americans and Africans. The estimated frequency ofOCA2 in
the African American population is 1 in 10,000, in contrast to a frequency of I
in 36,000 in Caucasian Americans (6), whereas in certain isolated commun-
ities, such as the Hopi Indians in Arizona, it is I in 277 (5). The tyrosinase-
positive type tends to be a little darker with straw-colored hair. Some pigment
is formed which can be found in the iris (which appears less translucent), skin,
and hair with increasing age. Localized (nevi, freckles, and lentigines) skin
pigment can develop, often in sun-exposed regions of the skin, but tanning is
usually absent. Since the eyes are slightly pigmented, the affected subjects'
eyesight is not as severely compromised.
In Caucasian individuals with OCA2, the amount of pigment present at
birth varies from minimal to moderate. The hair can be very lightly pigmented
at birth, having a light yellow or blond color, or more pigmented with a blond,
golden blond, or even red color. With time, pigmented nevi and lentigines may
develop and some pigmented freckles can be seen in exposed areas after
repeated sun exposure. The hair in these individuals may slowly turn darker
through the first two decades of life.
African individuals have white skin but the hair is blonde or yellow.
Some affected individuals develop lentigoes and pigmented moles, especially
in the sun exposed areas. Almost all albinos in Tanzania belong to this group.
The irides of these patients are blue/grey, green, or hazel (17). Interestingly,
the hair of these subjects can turn lighter in older individuals; this probably
represents the normal graying with age. This phenotypic pigment variation
probably reflects genetic admixture in this population and may result from
different mutations of the P gene and their effects on the function of the P
protein.
In tyrosinase-positive individuals, the visual acuity may improve as they
get older and nystagmus may become less severe.
Brown OCA
Brown OCA is a type of albinism that is recognized, for the time being, only in
the African and the African American populations. In these individuals, the
hair and skin color are light brown, and the irides are gray to tan at birth.
Affected individuals are recognized because they have all the ocular defects of
albinism. The iris is punctated translucent, and moderate retinal pigment is
present. The skin can tan modestly with sun exposure (6,7).
Brown OCA is part of the spectrum ofOCA2, resulting from alterations
of the P gene associated with the development of yellow or red pheomelanin
and a lack of development of brown or black eumelanin. Brown OCA, like
OCA 1B, probably arises from a "leaky" mutation, which reduces the func-
tion of the P gene product.
OCA3 TRP1-Related OCA

The first connection between mutations of the TRP 1 (tyrosinase-related pro-
tein 1) gene and variations in human pigmentation came from the descrip-
tion of an African American newborn twin boy with light brown skin, light
brown hair, and blue irides, while his fraternal twin brother had normal pig-
mentation. This and other similar cases have been described from then on in
the literature as "red," "rufous," or "xanthous" albinism. The pigment
phenotype in South African individuals includes red or reddish-brown skin,
ginger or reddish hair, and hazel or brown irides. The ocular features are not
fully in accordance with the diagnosis ofOCA; many subjects do not have iris
translucency, strabismus, nystagmus, or foveal hypoplasia or misrouting of
the optic nerves. This suggests either that this is not a true type of albinism or
Albinism 467
that the hypopigmentation is not sufficient to alter the development of the

optic nerve (7,8). Presently, the phenotype for TRP1-related OCA in Asian
and Caucasian populations is unknown.
Ocular Albinism
In ocular albinism, only the eyes are clinically involved, although melanocytes
of the skin seem to show some changes. Four different types exist: two are X-
linked, one dominant and one recessive. The X-linked and recessive types
present an association with deafness, since the melanocytes apparently fail
to playa protective role in the ear. Ocular albinism type I, also known as
Nettleship-Falls type, is the most common X-linked form of ocular albinism.
Affected males show all the ocular typical defects of albinism, including
reduction in visual acuity, strabismus, nystagmus, retina hypopigmentation,
foveal hypoplasia, and loss of stereoscopic vision due to misrouting of the
optic tracts. Eye color may be normal, but examination of the back of the eye
(retina) through the pupil shows that there is no pigment in the retina. Female
carriers, on the contrary, have normal vision but may show after examination
a patchy hypopigmentation of the retinal pigment epithelium due to a mosaic
inactivation of the affected X chromosome. The clinical severity of ocular
albinism type I is believed to depend on the race of the patient, being more
severe in those of racial groups exhibiting very light constitutive pigmentation
than in those more darkly pigmented (1).
Although this type of albinism is categorized as a type of ocular albi-
nism, the melanocytes in the skin and hair follicles are also involved and
contain abnormally large melanosomes (9).
HERMANSKY-PUDLAK SYNDROME
The Hermansky-Pudlak syndrome is very rare. Only 250 cases have been re-
ported so far, mostly of Puerto Rican origin (11). Tyrosinase-positive oculo-
cutaneous albinism occurs in association with bleeding tendency and deposits
of ceroid-like pigment in the reticuloendothelial cells. The bleeding is attrib-
uted to a storage-pool platelet defect. No defect has been found in circulating
lymphocytes or neutrophils. Association with lupus nephritis, granulomatous
colitis, and pulmonary fibrosis has been posited. The primary genetic defect is
still unknown.
CHEDIAK-HIGASHI SYNDROME
In this rare syndrome, inherited as an autosomal recessive disorder, there is
hypopigmentation of the skin and eyes, and abnormal inclusions are found in
many cell types, including melanocytes, leukocytes, and platelets (12). Giant
pigment granules, arising by autophagocytosis and fusion of large degraded
melanosomes, are present in melanocytes. Similar granule defects can be also
seen in leukocytes and platelets. These patients demonstrate a high suscept-
ibility to infections.
CROSS SYNDROME
This syndrome, probably determined by an autosomal recessive gene, is
characterized by albinism-like hypopigmentation, ocular defects, and mental
retardation. Blood tyrosine levels are normal and light-colored hair pigment
poorly in tyrosine solution. Microphthalmos, smal1 opaque cornea, and
coarse nystagmus are the major clinical defects at birth, while spacicity and
mental retardation become evident soon (13).
ALBINOIDISM
The term "albinoidism" is used to describe families in whom are found partial
defects in melanin production in the skin, but only minimal changes in the
eyes (5). Slight tanning may occur, while the hair bulb test is positive. A
punctate pattern of iris translumination is seen. Although the eyes are usual1y
normal, there may be photophobia. The disorder seems to be transmitted as
an autosomal dominant. Its biochemical basis remains unknown (14).
ALBINISM-GRISCELLI SYNDROME
Griscelli syndrome is a form of partial albinism associated with immuno-
deficiency. It is a rare disorder that involves a lack of pigment production and
a variable degree of immunodeficiency. Mature melanosomes appear in skin
and hair follicle melanocytes, with sparse pigmentation of adjacent keratino-
cytes. The associated immunodeficiency often involves impaired natural killer
cell activity, absent delayed-type hypersensitivity, and poor cell proliferation
response to antigenic challenge. Bone marrow transplantation from a com-
patible donor seems to be the only treatment with some success (15).
Recent studies have begun to reveal the molecular links between im-
munodeficiency and albinism. Chediak-Higashi, Griscelli, and Hermasky-
Pudlak syndromes are all characterized by a combination of immunological
and pigmentation defects. New key proteins, such as Rab27a protein, have
been recently identified as responsible for the secretion of specialized granules
found in immune cells and in melanocytes. These granules, believed to be
Albinism 469
modified Iysosomes ("secretory Iysosomes"), are not found in any other cell
type, which explains the selective effects present in these diseases (16).
QUALITY OF LIFE OF PERSONS AFFECTED WITH ALBINISM

In temperate climates, the quality of life and the prognosis for albinos is
better than in tropical regions, with visual defects being the greatest disabil-
ity. In the tropics, by contrast, the fate of albinos is inversely related to the
distance from the equator, exposing them to more or less intense sunlight and
putting them at risk of sun damage and developing skin cancer. The most
frequent form of albinism in sub-Saharan Africa is tyrosinase-positive
oculocutaneous albinism (OCA2). The estimated frequency of OCA2 in
Dar-Es-Salaam (Tanzania) was I in 1429. In Zimbabwe the prevalence in
schoolchildren in Harare was found to be 1 in 2833, and nationwide 1 in 4728.
In Soweto, South Africa, the prevalence of OCA2 among the black popula-
tion was estimated to be I in 3900 and in schoolchildren in Swaziland I in 1634
(J 9). Albinos is sub-Saharan Africa are often not accepted by their families. In
Tanzania they are sometimes called Zeru zeru (ghost) or I17zungu (white Euro-
pean). In East Africa albino babies have been known to be killed at birth.
Although 50% of albinos have another albino in the family, many local
people still do not realize that it is hereditary disease (20). This situation
contributes to the prevailing stigmatization, alienation, and discrimination.
The continuous and inevitable solar exposure provokes precocious skin
photoaging, with solar elastosis and formation of many actinic keratoses
from an early age and development of basal and squamous cell carcinomas.
Malignant melanomas are extremely rare in patients with albinism (J 7).
Albinos have a lack of melanin and therefore no suitable protection
against UV irradiation. The most frequently observed malignant tumor that
occurs in albinos is squamous cell carcinoma, which is often very disfiguring
and finally leads to death. Many studies have shown that few albinos in sub-
Saharan Africa survive beyond the third decade (17).
Another major problem of albinos in sub-Saharan Africa is poor
eyesight. The reduction of melanin in the iris, the poor retinal pigment, and
the existing hypoplastic fovea lead to a marked reduction in visual acuity.
Albino patients may therefore suffer from poor central vision and refractive
errors like myopia or hyperopia, nystagmus, strabismus (squint), and photo-
phobia. A misrouting of the optic fibers results in loss of stereoscopic per-
ception and nystagmus (19).
The International Society Dermatology (lSD) has recently taken up a
project supporting the albinos of Africa by cooperating with the Regional
Dermatology Training Centre (RDTC) in Moshi, Tanzania, a joint venture
by the Ministry of Health of Tanzania in collaboration with the International
Foundation For Dermatology (IFD), which serves under the aegis of the
International League of Dermatological Societies (ILDS) and the Kiliman-
jaro Christian Medical Centre (KCMC). The primary aim of this project,
which is financially supported by the Italian Rotary Clubs, is to support the
Mobile Albino Skin Care Clinic, initially launched by Lookingbill and Lep-
pard in 1993 to provide a clinical advisory service to albinos in the Kiliman-
jaro region (I7). This project seeks to prevent skin cancers and subsequent
early death by providing health education such as sun protection counseling,
and guidance to persons affected with albinism, their relatives, community
leaders and teachers, and by regular examination and monitoring of those
affected with treatment of early and/or advanced lesions. Patients are pro-
vided with sunscreens, protective broad-brimmed hats, long-sleeved shirts,
and sunglasses and are constantly reminded that only by strict adherence to a
protective lifestyle can UV damage be confined. To overcome prejudice,
stigmatization, and discrimination, large-scale educational programs for the
community at large by means of radio, television, newspapers, and magazines
are in the planning phase.
REFERENCES
I. Shen B, Samaraweewa P, Rosenberg B, Orlow Sl. Ocular albinism type I: more
than meets the eye. Pigment Cell Res 2001; 14:243-248.
2. Bologna lL, Pawelwk 1M. Biology of hypopigmentation. 1 Am Acad Dermatol
1988; 19:217-255.
3. Boissy RE, Nordlund JJ. Molecular basis of congenital hypopigmentary dis-
orders in humans: a review. Pigment Cell Res 1997; 10(1-2):12-24.
4. King RA, Hearing Vl, Creel DJ, Oetting WS. Albinism. In: Scriver CR, Beaudet
AL, Sly WS, Valle D, eds. The Metabolic and Molecular Basis of Inherited
Disease. New York: McGraw-Hill, 1995:4353-4392.
5. Witkop CJ, Quevedo WC, Fitzpatrick TB, et a!. Albinism. In: Scriver CR, et aL
eds. The Metabolic Basis ofInherited Disease. 6th ed. New York: McGraw-Hill,
1989.
6. Bleehen SS. Albinism. In: Champion RH, el a!., eds. Disorders of Skin Color.
6th ed. Oxford: Blackwell Science, J998.
7. Ortonne J-P, Mosher DB, Fitzpatrick TB. Vitiligo and Other Hypomelanosis of
Hair and Skin. New York: Plenum Medical, 1983:129-310.
8. Lyle WM, Sangster 10, Williams TD. Albinism: an update and review of the
literature. J Am Optom Assoc 1997; 68(10):623-645.
9. Garner A, lay BS. Macromelanosomes in X-linked ocular albinism. Histopa-
thology 1980; 4:243-254.
10. Russel-Riggel I. Albinism. Ophthalmol Clin North Am 200J; 14(3):533-546.
II. Shanahan F, Randolph L, King R, et a!. Hermansky-Pudlak syndrome and
immunologic asseSSment of IS cases. Am 1 Med 1988; 85:823-828.
Albinism 471
12. Acquiron L. Human albinism: clinical, genetic, cellular, biochemical and molec-
ular aspects. Med Trop 2000; 60(4):331-341.
13. Cross HE, McKusick VA, Breen W. A new oculocerebral syndrome with hypo-
pigmentation. J Pediatr 1967; 70:398-406.
14. Guarera M. Albiniso e Albinoidismo. In: Lotti T, ed. UTET Periodici Scientifici
2000; 159-162.
15. Mancini AJ, Chan LS, Paller AS. Partial albinism with immunodeficiency:
Griscelli syndrome: report of a case and review of the literature. J Am Acad
Dermatol 1998; 38(2 pt 2):295-300.
16. Griffiths GM. Albinism and immunity: what's the link? Curr Mol Med 2002;
2(5):479--483.
17. Lookingbill DP, Lookingbill GL, Leppard B. Actinic damage and skin cancer in
albinos in northern Tanzania: Findings in 164 patients enrolled in an outreach
skin care programme. J Am Acad Dermatol 1995; 32:653-658.
18. Leppard B. Management of albino children in a tropical climate. Postgrad Doc-
tor 1998; 20:112-116.
19. Doe PT. Educational and social problems of albinism in the Kilimanjaro region
of Tanzania-a community-based case study of educational and social problems
facing patients with albinism in Kilimanjaro region. Dissertation for the Degree
of Masters of Medicine by the TUMAINI University, April 2000
20. Simona B. Albinism in Africans as seen at the Regional Dermatology Training
Centre, Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Personal
communication, 2001.
46
Chediak-Higashi Syndrome
Benedetta Brazzini and lIaria Ghersetich

DEFINITION
Chediak-Higashi syndrome (CHS), described for the first time in 1943
by Begnez, is a rare autosomal recessive disorder characterized by partial
oculo-cutaneous albinism, recurrent infections with neutropenia, abnormal
natural killer cell function, impaired chemotaxis and phagocyte bactericidal
activity, easy bleeding due to deficiency of storage, and/or release of platelet
dense bodies, and neurological abnormalities (I). A similar disorder occurs in
the beige mouse, the Aleutian mink*, and albino Hereford cattle. Parental
consanguinity is often reported.
CHS affects all races. Symptoms ofCHS usually appear soon after birth
or in children before the age of 5. Most children die during infancy (first
decade) as a result of infections, bleeding, or the development of the accel-
erated lymphoma-like phase. Survival into the second and third decades has
been reported; these patients usually die from a malignant lymphoma.
* Aleutian mink disease is a slow progressive disease of mink caused by the Aleutian mink
disease virus, characterized by poor reproduction, weight loss, autoimmunity. hypergamma-
globulinemia, increased susceptibility to bacterial infections, and death from renal failure.
Mink that are homozygous recessive for the Aleutian gene for light coat color are particularly
susceptible.
474 Brazzini and Ghersetich
PATHOGENESIS
In 1996 Nagle et al. (2) identified the CBS locus as the LYST or CHSI on
chromosome lq42-43 and performed a mutation analysis (Table 1). The CBS
locus encodes a lysosomal trafficking regulator expressed in the cytoplasm of
many tissues. The CBS gene mutation causes an abnormal membrane fluidity
with a consequent uncontrolled granule membrane fusion and the formation
of giant cytoplasma tic granules in various types of cells.
During the early stage of neutrophil maturation (myelopoiesis in the
bone marrow), azurophilic and specific granules tend to coalescence forming
megagranules, while in the later stage (myelocyte stage) normal granules are
formed. The formation of megagranules results in death of the myeloid pre-
cursors in the bone marrow (neutropenia), defective chemotaxis, degranula-
tion and bactericidal activity of the remaining neutrophils with increased
susceptibility to infections (especially gram-positive and gram-negative bacte-
ria). A similar phenomenon occurs in lymphocytes, monocytes, macrophages,
platelets, and melanocytes. Lymphocytes become defective in antibody-
dependent cell-mediated cytolysis of tumor cells, while platelets become
unable to concentrate serotonin and ADP, resulting in platelet aggregation
defect with normal platelet concentration but prolonged bleeding time.
Melanosomes in melanocytes are larger in size and irregular in morphology
due to a failure to dispense pigment, which causes partial albinism of the
hair and skin. In melanocytes, autophagocytosis of melanosomes also oc-
curs (3,4).
Other affected cells are Schwann cells with consequent central and
peripheral neuropathies and retinal cells with sequelae like photophobia,
nystagmus, and altered red reflex.
CLINICAL FEATURES
In CBS the skin is very pale (similar to albinos, but with dyschromic lesions in
patchy distribution) and slate-colored areas may be present. Sunlight expo-
TABLE 1 Mutation Analysis of the CHS Gene
Phenotype Mutation Basechange Classification
CHS Ala 40 insG GCA-GGCA Homozygous

CHS Arg 1103 ter CGA-TGA Homozygous
CHS Glu 489 delG GAGCAA-GA_CAA Homozygous
Source: Ref. 1.
Chediak-Higashi Syndrome 475
sure may stimulate a slight tanning, but usually causes severe sunburns. The
hair is light blond or silvery grey and frizzy. The irides are translucent, bluish,
gray, or light brown. Usually the patients present with extreme photophobia,
rotary nystagmus, and increased red reflex (5).
Recurrent infections occur frequently and involve the skin, the mucous
membranes (severe gingivitis, oral ulcerations, and periodontal disease), and
the respiratory tract. Skin infections range from superficial pyoderma to deep
subcutaneous abscesses and ulcers that heal slowly, leaving atrophic scars.
Staphyloeo eus aureus is the most frequently involved agent (6).
Neurological manifestations usually have their onset in adulthood and
consist of abnormal gait, clumsiness, seizures, ataxia, muscular weakness,
paresthesia, mental retardation, and peripheral neuropathy. In most cases
neurological dysfunctions appear in the Iymphoproliferative lymphoma-like
phase.
Progressive neurological deterioration is common in patients who sur-
vive early childhood. Generally, these patients enter the acceleration phase of
the disease, which is characterized by a lymphoma-like picture with fever, gen-
eralized lymphoadenopathy, hepatosplenomegaly, pancytopenia, and sepsis
(7).
The adult form ofCRS is characterized by onset in early adulthood and
marked by neurological sequelae such as parkinsonism, dementia, spinocer-
ebellar degeneration, and peripheral neuropathy (8).
LABORATORY INVESTIGATIONS
Laboratory findings include neutropenia, hypergammaglobulinemia, normal
platelet count, but prolonged bleeding time. Pancytopenia is present in the
accelerated phase. Light microscopy of a routine blood smear reveals the
characteristic giant granules in neutrophils and eosinophils, while bone mar-
row smears reveal giant inclusion bodies in leukocyte precursors. Granules
are peroxidase posi tive and contain lysosomal enzymes. Cytochemistry
(Wright stain) of cellular granularity and surface molecules offers useful diag-
nostic information. A prena tal diagnosis can be made by examining hair from
fetal scalp biopsies or leukocytes from fetal blood.
TREATMENT
A multidisciplinary approach is important (pediatrics, dermatologists, neu-
rologists, ophthalmologists, etc.). Regular monitoring is necessary. The skin
must be washed two times a day with disinfectants to avoid infection. Bone
marrow transplantation (BMT) (9, lO) is the treatment of choice and is
476 Brazzini and Ghersetich
indicated before the accelerated phase of the disease develops. However,

BMT corrects the immunological status but does not affect the pigment
disorder. In the stable phase ascorbic acid may improve the clinical status and
phagocytic function; management of infections and seizures is important, but
prophylactic antibiotics are not indicated. In the accelerated phase, admin-
istration of corticosteroids and microtubulytic drugs (vincristine, vin blastine,
and colchichine) and cyclophosphamide seem to partially arrest the Iympho-
histiocytic infiltration of the reticuloendothelial system but is not effective in
arresting the progression of the disease. Acyclovir (II), high doses of gamma-
globulins (12), and methylprednisolone provide a temporary improvement in
fever and pancytopenia and decrease the bleeding time. Interferon-ex 2a and
2b has been demonstrated to partially restore the function of natural killer
cells.
REFERENCES
1. Braun-Falco 0, Plewig G, Wolff HH, Burgdorf WHC. Chediak-Higashi syn-
drome. Dermatology. 2d ed. Berlin: Springer-Verlag, 2000: I029.
2. Nagle DL, Karim MA, Woolf EA, Holmgren L, Bork P, Musini D1. McGrail
SH, Dussault B1, Perou CM, Boissy RE, Duyk GM, Spritz RA, Moore KJ.
Identification and mutation analysis of the complete gene for Chediak-Higashi
syndrome. Nat Genet 1996; 14:307-311.
3. Introne W, Boissy RE, Gahl WA. Clinical, molecular and cell biological aspects
of Chediak-Higashi syndrome. Mol Genet Metab 1999; 68(2):283-303.
4. Zhao H, Boissy YL, Abdel-Ma1ek Z, King RA, Nordlund 11, Boissy RE. On
the analysis of the pathophysiology of Chediak-Higashi syndrome. Defects ex-
pressed by cultured melanocytes. Lab Invest 1994; 7l( I):25-34.
5. Carnide EM, 1acob CM, Pastorino AC, Bellinati-Pires R, Costa MB, Grumach
AS. Chediak-Higashi syndrome: presentation of seven cases. Rev Paul Med
1998; 116(6):1873-1878.
6. Kapoor A, Munjal S, Arya R. Chediak-Higashi syndrome: a case report. In-
dian 1 Pathol Microbiol 2000; 43(3):373-375.
7. Rubin CM, Burke BA, McKenna RW, McClain KL, White JG, Nesbit ME 1r,
Filipovich AH. The accelerated phase of Chediak-Higashi syndrome: an ex-
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47
Melanoma and Vitiligo
Dan Forsea
University of Bucharest, Bucharest, Romania
Vitiligo or vitiligo-like leukoderma associated with melanoma has been ob-

served by several investigators in the past. Melanoma and vitiligo also have
been observed together in animals. The association in some ways is a paradox,
because melanoma is an uncontrolled proliferation of malignant melano-
cytes, and vitiligo is the result of destruction of normal pigment cells (1).
The worldwide prevalence of vitiligo has been estimated as 1-2%. The
relative rates of association between vitiligo and melanoma have been quite
controversial, ranging from 1.4 to 20% (2).
Genetic factors have been discussed for both disorders (4). There is
considerable evidence that vitiligo and melanoma involve a genetic predis-
position. About half of the patients with ordinary vitiligo have a family his-
tory of vitiligo that suggests an autosomal dominance for a few families with
the disorder and a polygene for others. Approximately 6% of patients with
melanoma have one or more family members with melanoma. Lerner et al. (4)
reported 12 families with melanoma who had close family members with halo
nevi, early graying of hair, a halo primary melanoma, or ordinary vitiligo. It is
known that the most common condition associated with halo nevus is vitiligo,
occurring in 18-26% of cases (8).
A number of clinical observations suggest the relationship between viti-
ligo and melanoma (3):
Patients with melanoma have been observed to develop vitiligo or de-
pigmented spots on the skin.
480 Forsea
The appearance of vitiligo improves the prognosis of melanoma in both

animals and humans. The association of the two disorders has been
well documented in animals. Several animal models have been studied
in which genetic factors, presumably oncogenes, influence the
development of vitiligo and melanoma. All gray Arabian horses de-
velop melanocytic tumors, and independent of whether these tumors
are malignant or benign, the horses always develop loss of pigment
that resembles vitiligo. It is not known whether loss of pigment or
development of tumor occurs first, but the horses survive for many
years with their tumors. These animals sometimes develop total viti-
ligo in conjunction with a dramatic regression of their tumors. It has
also been postulated that melanoma patients with vitiligo have a
better prognosis. It is possible that the melanocytes of people with
vitiligo or with a genetic background for vitiligo are predisposed to
undergo a malignant transformation, but that presence of vitiligo
suppresses the growth of malignant melanocytes. It is knows that
patients with metastatic melanoma who develop vitiligo tend to sur-
vive longer than those who do not have depigmentation.
Immunization of animals to melanoma cells can induce vitiligo.
It is important to know the clinical aspects of vitiligo and the kinds of

pigment loss that occurs in patients with melanoma (4). Although some ob-
servers have termed the widespread leukoderma seen in melanoma patients as
vitiligo, this condition is not strictly identical to vitiligo in terms of epidemi-
ology, clinical appearance, body distribution, or histological features. The age
range is 30-61 years, whereas classical vitiligo occurs in patients 10-30 years
of age with a positive family history of 30-50%. The onset and course of de-
pigmentation in patients with melanoma differ from those of classical vitiligo
not associated with melanoma. In the latter, depigmentation most often be-
gins on the hands, face, and feet and spreads centripetally to the trunk. In
patients with melanoma, depigmentation begins more commonly on the
trunk and spreads centrifugally to involve the neck, face, and extremities.
Four patterns of hypomelanosis have been observed in melanoma
patients: (a) areas of depigmentation confined to the primary lesion, suggest-
ing spontaneous regression; (b) halos of depigmentation about the primary
tumor; (c) coexistent halo nevi; and (d) widespread hypomelanosis occurring
at sites distant from the primary site (5).
It is of special interest to examine the time of onset of vitiligo in rela-
tion to the onset of melanoma, since the development of vitiligo in patients
with this malignancy has been claimed to be of prognostic significance by
several investigators (2). Most authors have published case reports describ-
ing the onset of vitiligo: (a) after first diagnosis of melanoma, (b) after tu-
Melanoma and Vitiligo 481
mor progression into regional lymph nodes with some cases of widespread
metastatic disease, (c) after chemotherapy, irradiation, or immunotherapeu-
tic approaches, and (d) preceding the diagnosis of melanoma. Onset broadly
extends over a period of 2-60 years, whereas vitiligo following melanoma oc-
curs in the majority of cases in the first few years after tumor diagnosis; there-
fore, premelanoma vitiligo may indeed present as a distinct disorder and may
be, after all, of different etiology than postmelanoma vitiligo.
The mechanism responsible for the association between melanoma and
vitiligo is not known. Since both vitiligo and melanoma represent disorders
involving melanocytes, more recently there has been much speculation as to
the possible clinical connections, especially in regard to immunological fac-
tors. In both diseases, researchers have implicated the immune system re-
sponses. Clinicopathological support for the immune implication for vitiligo
includes the presence of lymphocytes in the dermis of early lesions, the pres-
ence of circulatory autoantibodies in many patients, the association with halo
nevi and certain autoimmune diseases, and the therapeutic effect of PUYA,
which is known to act on T lymphocytes (8). Abnormalities of both humoral
and cell-mediated immunity have been also described. The presence of cir-
culatory melanoma-specific cytotoxic T lymphocytes (CTLs) and the small
but reproducible incidence of regression of disseminated disease, either spon-
taneous or after treatment with cytokines such as interleukin-2 (IL-2), are
the clinicopathological evidence for the relevance of cell-mediated immunity
in melanoma.
The rationale for an autoimmune connection between vitiligo and
melanoma has emerged from the animal models where melanoma precedes
vitiligo followed by tumor regression (2). Sinclair pigs may provide an animal
model because melanocytic tumor associated with metastatic disease in these
animals is similar to human melanoma, and regression to tumors is associated
with surrounding depigmentation as a concomitant event that follows an
inflammatory cellular infiltrate in tumors. The mechanism of regression of
melanocytic nevi and the depigmentation of halo nevi has been shown to be
related to an immunological action mediated by cytotoxic T lymphocytes.
Approximately 80% of patients with generalized vitiligo were found to have
circulating antibodies to cell surface antigens on normal human melanocytes;
these antibodies were cytotoxic to normal melanocytes and melanoma cells in
tissue culture (8).
Both types of T lymphocytes, CD8 + and CD4 +, appear to playa
major role in antitumor response; the tumor antigen-specific CTL (CD8 +)
is the important effector cell involved in recognition of tumor rejection anti-
gen. On recognition of the peptide MHC complex, CTLs (CD8 +) can secrete
IL-2, IF-)', or TNF or can kill a tumor cell directly. Precursors of mature
CD 4 + lymphocytes can differentiate into two types of cytokine-secreting cell:
482 Forsea
one produces cytokines important for generating CD8 + cellular response

(CD8 + T HI)' the other produces cytokines that help prime B cells for anti-
body production (CD4 + T H2) (6).
The induction of vitiligo in the setting of immunotherapy for melanoma
has been observed (9). In a small series of patients treated with sequential
chemotherapy (combination chemotherapy with carmustine, dacarbazine,
cisplatin, and tamoxifen followed by IL-2 and interferon-ex immunotherapy)
for metastatic melanoma, 56% developed extensive de novo vitiligo, par-
ticularly on the trunk. This phenomenon, when it occurs spontaneously in
patients with metastatic melanoma, may be an example of autoimmunity com-
plicating antitumor immunity. Presumably, the mechanism of vitiligo in this
setting may represent an immune response against melanoma antigens that
are shared by normal melanocytes, with cytotoxic T lymphocytes and/or anti-
bodies being the effector mechanism. Circulating antibodies in vitiligo pa-
tients with active disease are directed to melanocyte antigens with molecular
weights of approximately 40-45, 75, and 90 kDa. Likewise, patients with
melanoma can develop antibodies to melanoma antigens of similar size. These
observations suggest that the clinical links between vitiligo and melanoma
result from the presence of immune responses to common pigment cell anti-
gens in both diseases.
Management of melanoma continues to present a challenge to derma-
tologists, particularly in advanced cases. Immunotherapy remains of interest
because of the minimal toxicity and improved prognosis correlated with
specific humoral and cellular immune responses. Based on the idea that viti-
ligo may be an autoimmune disorder, much more clinical interest was focused
on the possibility that antibodies to melanocytes in vitiligo may be important
to the immune defense system in metastatic melanoma (2). Whether clinical
links between these two diseases are simply by chance or an interplay between
genetics and immunological factors remains to be determined, but it is of note
that both vitiligo and melanoma are associated with immune responses to
identical antigens expressed by melanocytes and melanoma cells. Metastatic
spread of melanoma may provoke an immune response that proceeds to
attack both normal pigment cells and tumor cells, e.g., by the action of cyto-
kines, and leading to leukoderma. The selective destruction of pigment cells
that occurs in vitiligo is the therapeutic goal sought in melanoma.
REFERENCES
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Dermatol 1983; 9:689-696.
Melanoma and Vitiligo 483
2. Schallreuter KU, Levenig C, Berger J. Vitiligo and cutaneous melanoma. Der-

matologica 1991; ] 83:239-245.
3. Cui J, Bystryn Jc. Melanoma and vitiligo are associated with antibody responses
to similar antigens on pigment cells. Arch Dermatol 1995; 131 :314-318.
4. Lerner AB, Kirkwood JM. Vitiligo and melanoma: Can genetically abnormal
melanocytes result in both vitiligo and melanoma within a single family? J Am
Acad Dermatol 1984; 11:696-70l.
5. Koh HK, Sober AJ, Nakagawa H, Albert DM, Mihm MC, Fitzpatrick TB.
Malignant melanoma and vitiligo-like leukoderma: an electron microscopy study.
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6. Curiel-Lewandrowski C, Demierre MF. Advances in specific immunotherapy of
malignant melanoma. J Am Acad Dermatol 2000; 43: 167-185.
7. Kovacs SO. Vitiligo. J Am Acad Dermatol 1998; 38:647-666.
8 Mosher DB, Fitzpatrick TB, Ortonne JP, Hori Y. Hypomelanosis and hyper-
melanosis. In: Freedberg 1M, Eises AZ, Wolff K, et a!., eds. Dermatology in
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9. Gaspari AA. Autoimmunity as a complication of interleukin-2 immunotherapy.
Arch Dermatol 1994; 130:894-897.
48
Vaccines and Vitiligo
Silvia Moretti and Paolo Fabbri

Several findings support the concept of vitiligo as an autoimmune disease in

which destruction of melanocytes occurs. Most patients with active vitiligo
have cytolytic antimelanocyte antibodies (1-3), and accumulation of acti-
vated T cells at the margin of the depigmented lesions has been demonstrated
(4). Vitiligo is associated with other autoimmune diseases such as primary
hypothyroidism or type 1 diabetes mellitus (5). Therefore, humoral and cel-
lular immune mechanisms as well as a genetic predisposition (so that suscep-
tibility of melanocytes is enhanced toward apoptotic stimuli) may play an
important role in vitiligo pathogenesis.
An increased frequency of vitiligo in patients with metastatic melanoma
has been described by several authors (6). In addition, the presence of vitiligo
in melanoma patients seems to correlate with a better prognosis (7,8). In fact,
it was speculated that an immune reactivity against a growing melanoma re-
sulted in some destruction of tumor cells as well as normal melanocytes. With
the advent of immunotherapy, in which the regression of the tumor is asso-
ciated with a stimulation of the immune system against the tumor itself, this
association was observed more specifically. In fact, upon treatment with
interleukin-2 (IL-2, T-lymphocyte growth factor), approximately 20% of re-
sponding melanoma patients developed vitiligo, and the relationship between
vitiligo and melanoma regression was considered highly significant (9). Al-
though melanoma regression could be observed without vitiligo, every patient
who developed vitiligo showed at least a partial tumor regression (9). In ad-
dition, no renal cancer patient treated with IL-2 developed vitiligo, suggesting
486 Moretti and Fabbri
that tumor-derived "self" antigens were required for the induction of vitiligo
(9). These results suggest that "normal" antigens expressed on both melano-
cytes and melanoma cells could be the targets of the immune response. In fact,
T lymphocytes specific for melanoma cells were able to recognize antigens
expressed by normal melanocytes (10).
Techniques of biochemistry and molecular biology have made it pos-
sible to identify peptides that can be considered tumor-associated antigens.
Among tumor antigens, one large class is represented by the so-called shared
tumor antigens that, unlike mutated proteins, are expressed in unaltered form
on cancer cells from many patients (11,12). One group of these antigens con-
sists of the cancer testis antigens, exclusively expressed in tumors of different
histologies as well as normal testis. The main proteins of this group belong to
the MAGE family, some antigens of which are found also in melanoma (11).
A second group of shared antigens includes the melanocyte differentiation
antigens (MDA), mostly enzymes of the cascade of the synthesis of melanin
pigment (12). These antigens are expressed by melanoma cells as well as by
normal melanocytes and include gpJOO/pmel-17, MART-I, tyrosinase, tyro-
sinase-related protein (TRP)-I/gp75, and TRP-2 (12-15). Tyrosinase and
TRP-I have been identified as targets for antibodies in autoimmune vitiligo
(2, I6). In addition, most melanoma-reactive T lymphocytes obtained from
tumors recognize MDA, and in many melanoma patients antibodies and/or
T lymphocytes that are specific for one or more of these five antigens have
been found (17). These findings suggest that autoreactive T cells escape thy-
mic deletion and reach the periphery, where they can in some instances be
activated and involved in antitumor immune responses (18). It is generally
believed that these autoreactive T cells display relatively low avidity (9) but
can be effective when activated under the proper circumstances (10,12). The
understanding of the requirements for proper T-cell activation has provided
possible explanations for the absence of tumor-specific immunity. Full acti-
vation of naive T cells requires stimulation of the T-cell receptors by cor-
responding peptide-major histocompatibility complex (MHC) complexes as
well as co-stimulation through engagement of CD28 molecule by B7.1 or B7.2
molecules on the antigen-presenting cells (19). Stimulation of T cells by anti-
gen in the absence of co-stimulatory signals can result in unproductive T-cell
stimulation or T-cell toleration (20). The lack of expression of B7 molecules
by tumor cells seems to be one factor that can contribute to their failure to
elicit productive immune responses (21,22).
It seems important to identify the antigens in cancer patients for which
specific T cells are present and to activate these cells and expand them to the
point where they can affect tumor regression. As for the supposed lack of
immunogenicity of self tumor antigens, such as MDA, lymphocytes isolated
from melanoma specimens and grown in vitro with no other stimulation than
Vaccines and Vitiligo 487
autologous whole melanoma cells and IL-2 consistently recognize MDA in a

great majority of cases (23). For these reasons, various attempts have been
made to target MDA with cancer vaccines in melanoma, both in animal
models and in humans.
More recently, the immunogenicity of self antigens was studied and the
therapeutic effect of autoimmune responses to these proteins in mouse mela-
noma models was explored (24). Such studies on mouse models revealed a
clear antitumor effect of autoimmunity against mouse TRP-I, and evaluating
the contribution of MHC class I and II, using knockout mice as well as in vivo
depletion ofCD8 + and CD4 + T lymphocytes, it was found that both mouse
TRP-I-induced vitiligo and melanoma destruction relied cri tically on CD4 +
T lymphocytes (24). The understanding of the role of CD4 + lymphocytes
in antitumor immunity was accompanied by the identification of new molec-
ular mechanisms through which CD4 + T lymphocytes help the initiation and
maintenance of the antitumor immune response (24-26). CD4 + T lympho-
cytes can activate antigen-presenting cells through engagement of CD40,
secrete proinftammatory cytokines such as tumor necrosis factor (TNF)-~,
interferon (IFN)-'Y, and IL-2, and induce the production of chemokines to
attract and activate a large number of other cells to the site of inunune re-
action (27,28). Such cells are represented by CD4 + and CD8 + T lympho-
cytes, B cells, and nonspecific leukocytes (eosinophils and macrophages)
(29,30). Furthermore, some melanoma patients also exhibit significant levels
ofIgG-type antibodies against melanosomal proteins in the serum, suggesting
activation of melanocyte-specific CD4 + T lymphocytes in humans (31,32).
MDA, frequently identified as the principal targets of T lymphocytes grown
from melanoma lesions in melanoma-bearing mice and patients (17) and ofT
lymphocytes in vitiligo lesions in spontaneous vitiligo patients (33), reside in
the melanosome. Various observations suggest a close relationship between
melanosomes and endosomes/lysosomes, indicating that the endocytic com-
partment may well intersect with the transport routes of proteins targeted to
the melanosome, so that a fraction of MDA may localize to the endocytic
compartment (34) and be transported along with proteins destined for the
dense endocytic compartment for peptide loading, to the site where MHC
class II molecules associate with peptides in melanoma or antigen-presenting
cells (34-36).
The results of this process may be the availability of high levels of mela-
nosomal proteins for processing and loading on MHC class II molecules when
the expression of MHC class II is induced on melanoma cells or melanocyte,
e.g., for some stimuli such as IFN-'Y (37). These data suggest that MDA are
antigens expressed in a relatively small cell population (i.e., melanocytes).
resulting in low levels of antigen during central and peripheral T-cell selection
and thus affecting relatively mild tolerization (38). Large amounts of MDA
can be presented together with MHC class I and class II by melanocytes or

melanoma cells stimulated by inflammatory cytokines such as IFN--y, allow-
ing recognition by those T cells that escaped tolerance (l7).
Induction of vitiligo in metastatic melanoma patients undergoing spe-
cific vaccina tion has been reported associa ted wi th vaccine made of allogeneic
genetically modified IL-2-producing melanoma cell line (39) or of autologous
IL-2-transfected melanoma cells (40), but in both cases it concerned very few
patients and was not clearly correlated with good clinical response. In these
cases IL-2 probably acts by evoking an inflammatory tissue response at the
injection site, which leads to the fragmentation of melanoma cells and sub-
sequent presentation of tumor antigen released (41,42). In human malignant
melanoma the cloning and characterization of melanoma-associated antigen-
derived peptides, such as MDA, recognized by cytotoxic T lymphocytes in a
MHC class-I-restricted fashion, has opened new possibilities for vaccine ap-
proach, particularly using antigenic peptides, plasmid DNA, or recombinant
viruses encoding tumor-associated antigens (43--45). However, several such
approaches have thus far met with little or no success in the clinic (46--48).
In the induction of peptide-specific cytotoxic T lymphocytes, the dominant
role of antigen-presenting cells has been demonstrated (49), and it was shown
that the in vivo cytotoxic T Iymphocyte-tolerizing potential of some peptides
can be converted to specific immunostimulation depending on the nature of
antigen-presenting cells (50). Dendritic cells (DC) are antigen-presenting cells
specialized to initiate and regulate immune responses (51). They were used in
human melanoma vaccines by the development of methodologies to generate
large numbers of these cells in culture from blood monocytes of CD34 +
progenitors (52,53). Two recent vaccine trials carried out in stage IV mela-
noma patients were based on antigen-bearing CD34-derived DC pulsed with
a mixture of MDA-derived peptides (MetanA, gp I00, tyrosinase) and/or with
peptides of the MAGE family (54,55). Progressing vitiligo was described in I
of 14 patients and in 2 of 18 patients, respectively. This clinical effect is a
demonstration that the DC vaccine may enhance immunity to MDA, al-
though no clear correlation with clinical response was observed, because only
temporary good prognostic serum markers were described in one patient (54).
In conclusion, we can say that in melanoma patients responding to spe-
cific vaccines, the same mechanism can media te both regression of melanoma
cells and development of vitiligo. In fact. based on the concept that normal
self proteins such as MDA can function as tumor antigen (12), specific T
lymphocytes and antibodies may be able to recognize both melanocytes and
melanoma cells. The whole mechanism acting in this process needs to be fur-
ther elucidated, especially in humans, and new insights into the immune
mechanisms concerning MDA in both vitiligo and melanoma will possibly
suggest more specific immunotherapeutic approaches in melanoma patients.
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44. Rosenberg SA, Yang JC, Schwartzentruber DJ, et al. Immunologic and thera-
peutic evaluation of a synthetic peptide vaccine for the treatment of patients with
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45. Rosenberg SA, Zhai Y, Yang JC, et al. Immunizing patients with metastatic
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46. Gilboa E. The makings ofa tumor rejection antigen. Immunity 1998; 9:757-763.
47. Pardoll DM. Cancer vaccines. Nat Med 1998; 4:525-531.
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54. Mackensen A, Herbst B, Chen JL, et al. Phase 1 study in melanoma patients of a
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Index
Acquired hypomelanoses, 381-388 Alternative treatments for vitiligo,

chemical substance-induced, 383-384 285-292
in internal disease/disorders, 386 Ayurvedic medicine, 289-290
postinfectious, 382-383 balneological therapy, 290-291
postinftammatorY,382-383 climatological therapy, 290-291
as sequelae of physical effects, homeopathy, 289
384-386 khellin, 286-288
therapy, 386-387 L-phenylalanine, 285-286
Adrenergic system, calcium and, 128 melagenina, 288
Albinism, 433-436, 461-472 minoxidil, 288-289
albinism-Griscelli syndrome, ultraviolet A, 286-288
468-469 Analytical epidemiology, vitiligo,
albinoidism,468 28-29
brown OCA, 466 Ancient references to vitiligo, 15-17
Chediak-Higashi syndrome, 467-468 Ancient treatments of vitiligo, 18-19
clinical features of, 464-467 Angelicine, 267
Cross syndrome, 468 Angelman syndrome, 439
Hermanski-Pudlak syndrome, 467 Anthropological aspects of vitiligo
OCA 1A, 464-465 implications of, 22-23
OCA2, 465-466 self-image, 20-22
OCA3 tyrosinase-related protein-I- Antibody action in vitiligo, 81-82
related OCA, 466-467 Antigens, targeted by autoimmune
ocular, 436, 467 reactions in vitiligo, 83-86
oculocutaneous, 434-436 Antioxidant system, components of,
partial, with immunodeficiency. See 125
Griscelli-Prunieras syndrome biopterin metabolism, 126-127
phenotypes, 464 calcium, adrenergic system, 128
quality of life with, 469-470 catecholamine synthesis, 128
Albinoidism, 436, 468 epidermal behavior modification, 129
Alezzandrini's syndrome, 377-380 H202 in epidermis, 126

494 Index
[Antioxidant system, components of] [Biology of hypopigmentation]

MSH, 128-129 pathogenesis. See Pathogenesis
thioredoxin red uctase, 126 white patches, dermatological
Anti-pigment cell immune responses, diseases characterized by, 36-37
melanocytes and, 86-87 Biopterin metabolism, 126-127
Application methods, cover-ups, Bleaching agents, 244-245
356-357 Blue vitiligo, 171
Audiological disorders in vitiligo, Broadband ultraviolet-B, 238-239
201-206. See also Deafness
A utocytotoxic hypothesis, 103-105 Calcium, adrenergic system and, 128
factors supporting, 103 Camouflage, skin, 352-354. See also
Autoimmunity, 79-92, 189-200 Cover-ups
autoimmune disease, 191-194 permanent, 352
cutaneous abnormalities, 180-190 temporary, 352, 354-356
endocrine disorders, autoimmune, cover-ups for, 354-356
in healthy relatives of vitiligo Cancer risk, with phototherapy,
patients, 56 239-240
genetic susceptibility to autoimmune Catecholamine metabolism, 70
disorders, 53-54 Catecholamine synthesis, 128
hypothesis of pathogenesis of Cellular immunity, 111 pathogenesis of
vitiligo, 7-8, 46-47, 99-102.138 vitiligo, 83
organ disorders, 190-191 Chediak-Higashi syndrome, 437-438,
rare associations, 194-195 467-468,473-478
Autologous transplantation, 241-244 clinical features, 474-475
Ayurvedic medicine, 289-290 definition, 473
genetic mutation analysis, 474
Balneological therapy, 290-291 laboratory investigations, 475
Biblical references to vitiligo, 18 pathogenesis of vitiligo, hypotheses,
Bilateral segmental vitiligo, 163-165 473
Biology of hypopigmentation, 33-50 treatment, 475-476
congenital alteration of Chemical agents for depigmentation,
pigmentation, 33-42 360-362
etiological factors, 34-35 4-methoxyphenol, 362
melanocyte development, disorders monobenzylether of hydroquinone,
of,40 360
melanosome biogenesis, disorders oC Chemical leukoderma, in differential
38 diagnosis for vitiligo, 211-213
melanosome melanization, disorders Chemical substance-induced
of,39 hypomelanoses, 383-384
melanosome transport/transfer, Children, vitiligo in, 173-178
disorders of, 37 clinical features, 174
110ncongenital alteration of differential diagnosis, 174
pigmentation, 42 prognosis, 177
vitiligo, 42-43 trea tmen t, 174-177
immunological abnormalities in, 47 Cleansers, 356
metabolic abnormalities in, 43 Climatological therapy, 290-291
Index 495
Clinical variants of vitiligo, 159-172 Deafness, 457

bilateral segmental vitiligo, 163-165 Definitions of vitiligo, 18
blue vitiligo, 171 Depigmentation, 80, 244-245, 359-364
raised borders, vittligo with, chemical agents, 360-362
170-171 4-methoxyphenol, 362
segmental vitiligo, 160-163 monobenzylether of
trichrome vitiligo, 165-170 hydroquinone, 360
"Cobblestoning," 308 cryotherapy, 363
Compact foundation, use as cover-up, indications for, 359-360
355 methods, 360-363
Congenital alteration of pigmentation, pattern, in vitiligo, 4-7
33-42 Q-switched ruby laser, 362-363
Corticosteroids, 240-241, 271-280, Dermatologist view of cover-ups,
336-337 351-358
combination therapies, 277 Differential diagnosis for vitiligo,
intralesional steroids, 274 207-224
systemic steroids, 274-277 chemical leukoderma, 211-_13
topical, 271-274, 336-337 cutaneous scleroderma, 216-217
Cosmetologist view of cover-ups, halo nevus, 213-214
347-350 idiopathic guttate hypomelanosis,
Cover creams, 348 213
Cover-ups leprosy, 217-219
application methods, 356-357 lichen sclerosus et atrophicus, 217
cleanser, 356 mycosis fungoides, 217
compact foundation, 355 nevus anemicus, 215-216
cosmetologist view, 347-350 nevus depigmentosus, 214-215
cover creams, 348 piebaldism, 221
dermatologist View, 351-358 pinta, 219-220
fixing spray, 355 pityriasis alba, 211
liquid foundation, 355 postinflammatory
pressed powder, 355 hypopigmentation, 209-210
self-tanning products, 348-349, sarcoidosis, 217
355-356 tinea versicolor. 209
side effects, 357-358 Doppler flowmetry, 94-95
skin camouflage, 352-354 use of in vitiligo, 95-98
permanent, 352
temporary, 352, 354-356 Ear, in vitiligo, 204-205
stick foundation, 355 Ear melanocytes, 204
Cross syndrome, 438, 468 Eclectic hypothesis, 106-114
Cryotherapy, for depigmentation, 363 pathogenesis of vitiligo, 106-114
Cutaneous diseases, vitiligo and, 8-MOP, topical, systemic, 266
182-183 Elejalde syndrome, 438
Cutaneous oxidative stress in vitiligo, Emotions in vitiligo, 225-234
124-129 Endocrine disorders, vitiligo and,
Cutaneous scleroderma, in differential 180-182
diagnosis for vitiligo, 216-217 polyglandular syndrome, 181
496 Index
[Endocrine disorders, vitiligo and] [Free radical damage]

thyroid disease, 180-181 cutaneous oxidative stress in vitiligo,
Epidemiology of vitiligo, 20-30, 27-32 124-129
analytical epidemiology, 28-29 systemic oxidative stress,
clinical epidemiology, 20-30 experimental evidence, 129-130
descriptive epidemiology, 27-28
pathological conditions associated Genetics, vitiligo, 51-64, 73-74, 102-103
with, 29 Grafting
Epidermal behavior modification, 129 cultured autologous melanocytes,
Epidermal calcium homeostasis, 71-72 243-244
Epidermal catalase, H 2 0 2 accumula- epidermal blisters, 243
tion in vitiligo, 66-67 follicular melanocytes, 247
Epidermal cytokines noncultured melanocyte suspension,
in achromic lesional skin, semi- 244
quantitative expression of, 108 tissue-engineered skin, 315-317
in perilesional skin, semiquantitative Griscelli-Prunieras syndrome, 438
expression of, 108 Guttate hypomelanosis, idiopathic,
Epidermal metabolic abnormalities in 389-392
vitiligo, 43 clinical features, 389
Epidermal receptors, expression of, 109 pathology, 390-391
Etiological factors in hypopigmentary treatment, 391
disorders, 34-35 vitiligo pathogenesis, hypotheses,
Excimer laser, 263 391
Experimental evidence, systemic
oxidati ve stress, 129-130 H 20 2 accumulation in vitiligo, 44-46,
Eye, in vitiligo, 202-204 126
consequences of, 66-72
Family history of vitiligo, 51, 54-57. epidermal catalase, 66-67
See also Genetics glutathione peroxidase, 66-67
5-MOP, topical, systemic, 266 pterins, 67-70
Fixing spray, 355 Halo nevus, 369-376
Fluticasone propionate, with clinical picture, 369-371
ultraviolet-A therapy, 245-246 differential diagnosis, 373
Focused microphototherapy, 246. See in differential diagnosis for vitiligo,
also Microphototherapy 213-214
Free radical damage, 123-136 epidemiology, 369-371
antioxidant system, components of, histology, 371-373
125 pathophysiology, 371-373
biopterin meta bolism, 126-127 Hansen's disease. See Leprosy in
calcium, adrenergic system, 128 differential diagnosis of vitiligo
catecholamine synthesis, 128 Healthy relatives of vitiligo patients,
epidermal behavior modification, disorders in, 51-64
129 association of vitiligo with other
H 2 0 2 in epidermis, 126 disorders, 51-53
MSH,128-129 autoimmune disorders, genetic
thioredoxin red uctase, 126 susceptibility to, 53-54
Index 497
[Healthy relatives of vitiligo patients, [Hypomelanotic disorders, inherited]

disorders in] ocular, 436
autoimmune endocrine disorders in, oculocutaneous,434-436
56 variants of, 434
family history, 51,54-57 albinoidism,436
incidence of various disorders in, 55 Angelman syndrome, 439
laboratory findings, 57-58 Chediak-Higashi syndrome, 437-438
Hematological diseases, vitiligo and, Cross syndrome, 438
182 Elejalde synd rome, 438
Hermanski-Pudlak syndrome, 436-437, Griscelli-Prunieras syndrome, 438
467 Hermanski-Pudlak syndrome,
Histopathology, vitiligo, 145-158 436-437
Historical overview of vitiligo, 15-26 piebaldism, 439
achromic disorder, knowledge of, 3 Prader-Willi syndrome, 439
ancient references to vitiligo, 15-17 Tietz syndrome, 442
ancient treatments of vitiligo, 18-19 Vici syndrome, 439
biblical references to vitiligo, 18 Waardenburg's syndrome, 440-442
definitions of vitiligo, J8 variants of, 440
nineteenth century, knowledge of Yemenite deaf-blind
vitiligo, 19 hypopigmentation syndrome,
Homeopathy, 289 443
Hydrosoluble vitamins, 282 Ziprkowski-Margolis syndrome, 443
Hyperpigmentation, 308 Hypomelanotic macules
of nonaffected skin, during treat- clinical features of, 42J-429
ment, 336~337 histopathology of, 429
Hypomelanosis, 419-432. See also morphology, 424
Hypomelanotic disorders, number, 429
inherited shape, 4_4
acquired, 381-388 site, 424-428
chemical substance-induced, size, 424
383-384 Hypopigmentation
in internal disease/disorders, 386 biology of, 33-50
postinfectious, 382-383 congenital alteration of
postinfiammatorY,382-383 pigmentation, 33-42
as sequelae of physical effects, etiological factors, 34-35
384-386 etiological factors of, 34-35
therapy, 386-387 melanocyte development, disorders
diagnostic features, 420 of,40
genetics, 419-420 melanosome biogenesis, disorders of,
hypomelanotic macules, differential 38
diagnosis of, 429 melanosome melanization, disorders
treatment, 429 of, 39
Hypomelanosis ofIto, 415 melanosome transport/transfer,
Hypomelanotic disorders, inherited, disorders of, 37
433-448 noncongenital alteration of
albinism, 433-436 pigmentation, 42
498 Index
[Hypopigmentation] [Inherited hypomelanotic disorders]

vitiligo, 42-43 Chediak-Higashi syndrome, 437-438
autoimmune pathogenesis, 46-47 Cross syndrome, 438
hypothesized pa thogenetic Elejalde syndrome, 438
mechanisms, 43 Griscelli-Prunieras syndrome, 438
immunological abnormalities in, Hermanski-Pudlak syndrome,
47 436-437
metabolic abnormalities in, 43 piebaldism, 439
metabolic pathogenesis of, 43-46 Prader-Willi syndrome, 439
white patches, dermatological Tietz syndrome, 442
diseases characterized by, 36-37 Vici syndrome, 439
Hypotheses regarding pathogenesis of Waardenburg's syndrome, 440-442
vitiligo. See Pathogenesis of variants of, 440
vitiligo Yemenite deaf-blind hypopigmenta-
Hypounpigmented alterations, with tion syndrome, 443
ocular diseases, 203 Ziprkowski-Margolis syndrome, 443
Internal disease/disorders,
Idiopathic guttate hypomelanosis, hypomelanoses in, 386
389-392 Internet, vitiligo resources available,
clinical features, 389 365-368
in differential diagnosis for vitiligo, Intralesional steroids, 274
213 Intrinsic/genetic hypothesis,
pathology, 390-391 pathogenesis of vitiligo, 102-103
treatment, 391
vitiligo pathogenesis, hypotheses, Keloids, 308
391 Khellin, 286-288
Immune system. See also topical, oral, 266-267
Autoimmunity; under specific
disorders of Laser-doppler ftowmetry, 94-95
abnormalities of, with vitiligo, 47, 83, in vitiligo, 95-98
87 Laser therapy, 245
immunoneuroendocrine system LDF. See Laser-doppler ftowmetry
involvement, 93-94 Leprosy in differential diagnosis of
mechanisms of, in vitiligo, 86-88 vitiligo, 217-219
Immunoneuroendocrine system Leukodermic syndromes, 457
involvement in vitiligo, 93-94 Leukonychia, 393-402
Infection with surgery, 308 Lichen sclerosus et atrophicus, in
Infectious diseases, vitiligo and, differential diagnosis for vitiligo,
183-184 217
Inherited hypomelanotic disorders, Liposoluble vitamins, 282
433-448 Liquid foundation, use as cover-up, 355
albinism, 433-436 L-phenylalanine, 72, 285-286
ocular, 436 LS&A. See Lichen sclerosus et atrophicus
oculocutaneous,434-436
variants of, 434 Melagenina, 288
albinoidism,436 infrared and/or ultraviolet radiation
Angelman syndrome, 439 with,247
Index 499
Melanization, disorders of, 39 [Nevus depigmentosus]

Melanocyte clinical diagnosis, 416-417
anti-pigment cell immune responses, in differential diagnosis for vitiligo,
86-87 214-215
development, disorders of, 40 differential features, 415
ear, 204 hypomelanosis of Ito, differential
growth, factors modulating, 107 features, 415
immune damage to, 87-88 segmental vitiligo, differential
Melanocyte antibodies, association features, 415
with, 81 treatment, 418
Melanoma, vitiligo and, 479-484 tuberous sclerosis, differential
Melanosome fea tures, 4 I 5
biogenesis of, disorders, 38 Nineteenth century
melanization of, disorders, 39 knowledge of vitiligo during, 19
transport/transfer of, disorders, 37 Nitric oxide in pathogenesis of vitiligo,
Metabolic pathogenesis of vitiligo, 137-144
43-46 Noncongenital alteration of
H 2 0 2 accumulation, 44-46 pigmentation, 42
Methoxyphenol, 362
Microphototherapy, 263, 337 Ocular albinism, 436, 467
Microvessels, 93-98 Ocular disorders in vitiligo, 201-206
immunoneuroendocrine system Ocular melanocytes, 20 I-202
involvement, 93-94 Oculocerebral syndrome with hypopig-
Minigrafting, 241-242 mentation. See Cross syndrome
Minoxidil, 288-289 Oculocutaneous albinism, 434-436
Monobenzone. See Monobenzylether Organ disorders with vitiligo, 190-191
of hydroquinone Oxidative stress, 71-72
Monobenzylether of hydroquinone, Oxygen burst, 70-7 I
360
MSH,128-J29 Partial albinism with immunodeficiency.
Mycosis fungoides, in differential See Griscelli-Prunieras syndrome
diagnosis for vitiligo, 2 I7 Pathogenesis of vitiligo
autocytotoxic hypothesis, 9,103-105
NADPH oxidase, 70-71 factors supporting, 103
Narrowband ultraviolet-B, 235-237, autoimmune hypothesis, 7-8,
262-263, 325-334 99-102, 138
doses, 327 factors supporting, 100
equipment,327-328 confusion regarding, 1-3
microphototherapy, 329-333, 337 eclectic hypothesis, 106-114
Natural history of vitiligo, 20-30 epidermal cytokines in achromic
Neural hypothesis, 105-106 lesional skin, semiquantitative
factors supporting, 105 expression of, 108
pathogenesis of vitiligo, 105-106 epidermal cytokines in perilesional
Neurological diseases, vitiligo and, 182 skin, semiquantitative
Nevus anemicus, in differential expression of, 108
diagnosis for vitiligo, 2 15-216 epidermal receptors, expression of,
Nevus depigmentosus, 413-4 I8 Copyrighted MatelMJ
500 Index
[Pathogenesis of vitiligo] Postinflammatory hypopigmentation,

free radical damage in, 123-136 in differential diagnosis for
idiopathic guttate hypomelanosis vitiligo, 209-210
hypothesis, 391 Prader-Willi syndrome, 439
intrinsic/genetic hypothesis, 8-9, Present knowledge of pathogenesis of
102-103 vitiligo, 3. See also Pathogenesis
mechanisms of, 43 of vitiligo
melanocyte growth, factors Pressed powder, use as cover-up, 355
modulating, 107 Prognosis of vitiligo, 20-30
metabolic, 43--46 in children, 177
H 2 0 2 accumulation, 44--46 Pseudocatalase, ultraviolet-B therapy
neural hypothesis, 9-10, 105~106 and,246
factors supporting, 105 Psoralen photochemotherapy, 253~260
nitric oxide in, 137-144 combination therapy, 255-256
present knowledge of, 3 efficacy of, 256-258
surgical solutions, 294 pretreatment assessment, 254
Pathological conditions associated with side effects, 258-259
vitiligo, 29 treatment protocols, 254-255
Perilesional skin, epidermal cytokines ultraviolet-A,237-238
in, semiquantitative expression Psycho-anthropological aspects of
of,108 vitiligo
Permanent skin camouflage, 352 implications of, 22-23
Personality in vitiligo, 225-234 self-image, 20~22
Phenylketonuria, characteristics of, 441 Pterins, H 2 0 2 accumulation in vitiligo,
Phenylalanine, oral, 267-268 67-70
Phototherapy, 240, 246, 262-265, 325-
334,337. See also Ultraviolet; QSR. See Q-switched ruby laser
specific type of phototherapy Q-switched ruby laser, for
agents used in, 264 depigmentation, 362-363
cancer risk with, 239-240
psoralen, 253-260 Raised borders, vitiligo with, 170-171
Piebaldism, 439, 449--460 Research studies, 65-78
clinical features, 449--451 catecholamine metabolism, 70
in differential diagnosis, 221,454--456 epidermal calci um homeostasis, 71-72
pathology, 451--452 H 2 0 2 accumulation in vitiligo, 66
treatment, 456-457 consequences of, 66-72
Pigmentation epidermal catalase, 66~67
congenital alteration of, 33--42 glutathione peroxidase, 66-67
noncongenital alteration of, 42 pterins, 67-70
Pinta, in differential diagnosis for L-phenylalanine turnover, 72
vitiligo, 219-220 NADPH oxidase, 70-71
Pityriasis alba, in differen tial diagnosis oxidative stress, 71-72
for vitiligo, 211 oxygen burst, 70-71
Postinfectious hypomelanoses, skin cancer, 73
382-383 tyrosinase-related protein- I, 71
Postinflammatory hypomelanoses, viral infections, 72-73
382-383 C ' ht d M t vitijigo gene, 73-74
opyng e a ena
Index 501
Sarcoidosis, in differential diagnosis for (Therapeutic guidelines]

vitiligo, 217 cultured autologous melanocytes,
Scan'i ng, 308 243-244
Scientific publications, dedicated to epidennal bJisters, 243
vitiligo. 366 follicular melanocytes, 247
Segmental vitiligo, 160-163,415 noncul tured melanocyte
Self-image, vitiligo and, 20-22 suspension, 244
Self-tanning products, 348-349, 355-356 laser therapy, 245
Skin camouflage, 352-354. See also melagenina, infrared and/or
Cover-ups ultraviolet radiation with, 247
permanent, 352 minigrafting, 241-242
temporary, 352, 354-356 narrowband ultraviolet-B, 235-237
Skin cancer, 73 nonsurgical repigmentation
Steroids. See also Corticosteroids therapies, 235-241
intralesional, 274 novel therapeutic approaches,
systemic, 274-277 245-247
Stick foundation, use as cover-up, 355 phototherapy. 240
Substance-induced hypomelanoses, cancer risk of, 239-240
383-384 pseudocatalase, ultraviolet-B
Surgical treatment of vitiligo. See also therapy and, 246
under specific surgical procedure psoralen plus ultraviolet-A, 237-238
artificial ultraviolet exposure, systemic antioxidant therapy, 247
following treatment, 306-307 thin split-thickness skin grafting,
candidate selection, 295-299 242-243
difficult-to-treat areas. 299 Thin split-thickness skin grafting,
methods, 299-306 242-243
repigmentation process, 295 Thioredoxin reductase, 126
side effects, 307-308 Tietz syndrome, 442
sunlight exposure, following Tinea versicolor, in differential
treatment, 306-307 diagnosis for vitiligo, 209
surgical combination therapy, 299 Tissue-engineered skin. 313-322
Systemic antioxidant therapy, -47 cultures, 314-315
Systemic steroids, 274-277 grafting procedure, 315-317
TMP, 265-266
Temporary skin camouflage, 352 Topical corticosteroids, 271-274,
cover-ups for, 354-356 336-337
Therapeutic guidelines, 235-252 Trichrome vitiligo, 165-J 70
autologous transplantation methods, TRP-I. See Tyrosinase-related protein-I
241-244 Tuberous sclerosis, 415, 419-432
bleaching agents, 244-245 characteristics of, 441
broadband ultraviolet-B, 238-239 clinical features of, 420-42J
corticosteroids, 240-241 diagnostic criteria, 421
depigmentation therapy, 244-245 diagnostic features, 420
fluticasone propiona te, with differential features, 415
ultraviolet-A therapy, 245-246 genetics, 419-420
focused micro phototherapy, 246 treatment. 429
grafting CopyrighteJM~llf?1tm-relatedprotein-I, 71
502 Index
Ultrastructural features of vitiligo, [Vitiligo]

145-158 personality and, 225-234
Ultraviolet A, 286-288 photosensitizing substances, 261-270
Ultraviolet B, 341-346 prognosis, 20-30
in children, 177
Vaccines, 485-492 psoralen photochemotherapy in,
Vici syndrome, 439 253-260
Viral infections, 72-73 psycho-anthropological aspects of,
Vitamins, 281-284 15-26
Vitiligo, 42-43 rare associations, 189-200
alternative treatments, 285-292 surgery, 293-312
audiological disorders in, 201-206 therapeutic guidelines, 235-252
autoimmunity, 79-92, 189-200 tissue-engineered skin treatment,
in children, 173-178 313-322
clinical associations, 179-188 ultrastructural, 145-158
clinical varia nts, 159-172 ultraviolet, 261-270
corticosteroids, 271-280 ultraviolet A, 286-288
cover-ups for, 347-350, 351-358 ultraviolet B, 325-334, 341-346
depigmentation, 359-364 vaccines and, 485-492
differential diagnosis, 207-224 vitamins, 281-284
disorders in healthy relatives, 51-64 Vitiligo gene, 73-74
emotional aspects of, 225-234 Vogt-Koyanagi -Harada synd rome,
epidemiology, 27-32 403-412
free radical damage, 123-136 diagnostic criteria, 406
histopathology, 145-158 revised, 407-408
historical overview of, 15-26
immunological abnormalities in, 47 Waardenburg's syndrome, 440-442, 456
internet, 365-368 variants of, 440
melanoma and, 479-484 Warburg's syndrome. See Yemenite
metabolic abnormalities in, 43 deaf-blind hypopigmentation
microvessels, 93-98 syndrome
narrowband, 235-237, 262-263, Web pages, dedicated to vitiligo, 366
325-334, 337 White patches, dermatological diseases
nature of, as disease, symptom, characterized by, 36-37
1-15
nitric oxide in, 137-144 Yemenite deaf-blind hypopigmentation
nonsurgical solutions, 335-340 syndrome, 443
ocular disorders in, 201-206
pathogenesis of. See Pathogenesis of Ziprkowski-Margolis syndrome,
vitiligo 443

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Copyrighted Material iii

Series Inlroduction iii

1. Vitiligo: Disease or Symptom? From the Confusion

9. Pathogenesis of Vitiligo: Evidence for a Possible

10. Free Radical Damage in the Pathogenesis of Vitiligo 123

II. Possible Role of Nitric Oxide in the Pathogenesis of Vitiligo 137

12. Histopathological and Ultrastructural Features of Vitiligo 145

14. Vitiligo in Children 173

15. Vitiligo: Focusing on Clinical Associations with

16. Clinical Associations: Focusing on Autoimmune

17. Ocular and Audiological Disorders in Vitiligo 201

18. Differential Diagnosis for Vitiligo 207

19. Vitiligo: Emotional Aspects and Personality 225

20. Therapeutic Guidelines for Vitiligo 235

21. Efficacy and Adverse Effects of Psora len

22. Treatment of Vitiligo with UV and

26. Vitiligo: Problems and Surgical Solutions 293

30. Use of UVB in Vitiligo 341

33. Depigmentation and Vitiligo 359

34. Vitiligo and the Internet 365

Andrea Andreassi Arezzo's Hospital and University of Siena, Siena, Italy

Maria Lucia Dell'Anna San Gallicano Dermatological Institute, Rome,

Wennie Liao University of Cincinnati, Cincinnati, Ohio, U.S.A.

Daniela Massi University of Florence, Florence, Italy

G. Primavera San Gallicano Dermatological Institute, Rome, Italy

Torello Lotti and Giuseppe Hautmann

THE ANCIENT CONFUSION

twentieth century, different approaches were developed to the treatment of

PRESENT (PARTIAL) KNOWLEDGE: THE DARK SIDES

VITILIGO BEYOND THE SKIN

THE SPECIAL DEPIGMENTATION PATTERN OF VITILIGO

FIGURE 1 Histological picture of vitiligo: a mild diffuse and follicular hyperkera-

FIGURE 2 Immunohistochemical staining of 8-100 reactivity in vitiligo: presence

PATHOGENESIS OF VITILIGO: DISEASE OR SPECTRUM?

injury. It is possible that phenols are one environmentally responsible agent.

Aberrations in f?,-endorphins and met-enkephalin secretion have been

ocytes related to an excess accumulation of7-tetrahydrobiopterin within the

CONCLUSIONS: IS VITILIGO A DISEASE OR A SYNDROMIC

patient might have many features of vitiligo vulgaris, such as depigmented

31. Puri N, Mojamdar M, Ramaiah A. Growth defects of melanocytes in culture

The other seems to simply involve a lack of pigmentation; it is likely to be

VITILIGO IN THE NINETEENTH CENTURY

VITILIGO AND SELF-IMAGE

FIGURE 1 Vitiligo major in an Eritrean patient. MUltiple depigmented macules

FIGURE 2 Vitiligo major in an Ethiopian child. Such depigmentation in dark-skinned

PSYCHO-ANTHROPOLOGICAL IMPLICATIONS OF VITILIGO

complexes, become aggressive, feel shame, and sometimes become isolated

23. Panconesi E, Cossidente, Giorgini S, et al. A psychosomatic approch to der-

The main objective of epidemiology is to find a means to prevent disease onset

CLINICAL EPIDEMIOLOGY: NATURAL HISTORY

TABLE 1 Pathological Conditions Associated with Vitiligo

Segmental vitiligo, which in many series accounts for 10-20% of the

Giovanni Menchini and Torello Lotti