Depigmented, Hypopigmented, Teledermatology, Vitiligo



  1. Zikry, Joseph
  2. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a case of asymptomatic hypopigmented patches on a man.


Article Content

The store-and-forward feature of teledermatology allows patient medical information (including history and visual data) obtained from one provider's location to be electronically transferred to a provider in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.




Chief complaint: presenting for diagnosis and therapeutic options.


History of Present Illness

A 68-year-old gentleman presents with a loss of color on his torso, face, hands, and genital region that has progressively worsened over the last 6 months. He is known to have hypothyroidism and is currently on Synthroid 88 mcg/d. Prior treatment for skin condition: none. His primary symptom: none. He is concerned about his appearance. Prior biopsy: none.



Fully satisfactory.



There is one image provided with this consult. This image shows well-demarcated hypopigmented and depigmented patches and macules extending over most of the back and upper left arm (see Figure 1).

Figure 1 - Click to enlarge in new windowFIGURE 1. Well-demarcated patches and macules of depigmentation on the back and upper arm. The light brown patch of skin represents his normal (unaffected) skin color.


Lesion A


The presented lesions and history are most consistent with a diagnosis of vitiligo.



The patient must present to a dermatology clinic (face-to-face) to discuss diagnosis and treatment options. Given the extent of the skin involvement, if the lesions are continuing to progress, a trial of narrowband ultraviolet B light therapy may be indicated, for which she should be evaluated by a dermatology provider.



Vitiligo is a common disorder that causes macules and patches of hypopigmentation and depigmentation in patients. It is occurs with a frequency of 0.1%-2% across the world (Alkhateeb, Fain, Thody, Bennett, & Spritz, 2003). This depigmentation occurs because of immune-mediated melanocyte destruction, although the etiology of melanocyte destruction is not fully understood. It affects men and women equally as well as people of all races and ethnicities. Vitiligo has a peak incidence in the second and third decades of life, although it can arise anytime from childhood to adulthood. The hallmark of the disease is the development of asymptomatic depigmented patches, which lack physical signs of inflammation, with a distributional tendency to appear on the face, hands, and genitals. Interestingly, lesions commonly appear at sites of skin trauma, which is referred to as Koebnerization or Koebner's phenomenon.


Diagnosis is usually clinical without the need for skin biopsy. However, it is important to perform a thorough history and physical examination to rule out other etiologies of depigmentation (e.g., pityriasis alba, tinea versicolor, and idiopathic guttate hypomelanosis). In cases of uncertainty, a skin biopsy can be performed to help ascertain a diagnosis (Montes, Abulafia, Wilborn, Hyde, & Montes, 2003). It is important to biopsy the border of a lesion that includes both affected and normal skin. Histology shows an absence of melanocytes and loss of pigment in the epidermis (Alikhan, Felsten, Daly, & Petronic-Rosic, 2011).


Vitiligo is associated with autoimmune thyroid disease in approximately 20% of patients, which can be screened for with antithyroid peroxidase and antithyroglobulin antibodies (markers that often precede the onset of overt thyroid disease), thyroid-stimulating hormone, and T4 levels (Gawkrodger et al., 2010; Taieb et al., 2013). Repeat of appropriate diagnostic tests should be utilized based on presenting symptoms and signs. Although there is no cure for vitiligo, there are various treatments that can help prevent progression and induce varying degrees of repigmentation in patients. Unfortunately, results are variable, and patients should be educated to have realistic expectations given the chronic nature of the disease. Mainstay treatment options include topical corticosteroids, topical calcineurin inhibitors, narrow-band ultraviolet B phototherapy, excimer laser, and autologous skin grafts (Taieb et al., 2013; Whitton et al., 2015; van Geel et al., 2004). Of interest, suplatast tosilate, an immunoregulator, has been reported to be effective in a case series study (Nihei, Nishibu, & Kaneko, 1998).


In conclusion, this case of vitiligo is a valuable example of the benefits that teledermatology provides. Teledermatology proves to be a useful and powerful tool that allows dermatologists to remotely dictate the next step in patient care based on treatment urgency and the resources available.




Alikhan A., Felsten L. M., Daly M., Petronic-Rosic V. (2011). Vitiligo: A comprehensive overview: Part I. Introduction, epidemiology, quality of life, diagnosis, differential diagnosis, associations, histopathology, etiology, and work-up. Journal of the American Academy of Dermatology, 65(3), 473-491. [Context Link]


Alkhateeb A., Fain P. R., Thody A., Bennett D. C., Spritz R. A. (2003). Epidemiology of vitiligo and associated autoimmune diseases in Caucasian probands and their families. Pigment Cell Research, 16(3), 208-214. [Context Link]


Gawkrodger D. J., Ormerod A. D., Shaw L., Mauri-Sole I., Whitton M. E., Watts M. J., Young K. (2010). Vitiligo: Concise evidence based guidelines on diagnosis and management. British Journal of Dermatology, 86(1018), 466-471. [Context Link]


Montes L. F., Abulafia J., Wilborn W. H., Hyde B. M., Montes C. M. (2003). Value of histopathology in vitiligo. International Journal of Dermatology, 42(1), 57-61. [Context Link]


Nihei Y., Nishibu A., Kaneko F. (1998). Suplatast tosilate (IPD), a new immunoregulator, is effective in vitiligo treatment. The Journal of Dermatology, 25(4), 250-255. [Context Link]


Roman M., Jacob S. E. (2015). Teledermatology: Virtual access to quality dermatology care and beyond. Journal of the Dermatology Nurses' Association, 6(6), 285-287. [Context Link]


Taieb A., Alomar A., Bohm M., Dell'Anna M. L., De Pase A., Eleftheriadou V., Picardo V.; Vitiligo European Task Force (VETF); European Academy of Dermatology and Venereology (EADV); Union EuropeCenne des MeCdecins SpeCcialistes (UEMS). (2013). Guidelines for the management of vitiligo: The European Dermatology Forum consensus. British Journal of Dermatology, 168(1), 5-19. [Context Link]


van Geel N., Ongenae K., De Mil M., Haeghen Y. V., Vervaet C., Naeyaert J. M. (2004). Double-blind placebo-controlled study of autologous transplanted epidermal cell suspensions for repigmenting vitiligo. Arch Dermatol Archives of Dermatology, 140(10), 1203-1208. [Context Link]


Whitton M. E., Pinart M., Batchelor J., Leonardi-Bee J., Gonzalez U., Jiyad Z., Ezzedine K. (2015). Interventions for vitiligo. Cochrane Database of Systematic Reviews, (2), CD003263. [Context Link]


1The standardized teledermatology reader report format is available for authors on the journal's Web site ( and on the submissions website online at [Context Link]