Review Question - QID 109181

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Vitiligo Introduction Associated conditions QID: 109181 (M2.DM.17.4799)

QID 109181 (Type "109181" in App Search)

A 22-year-old woman arrives to your clinic complaining of a worsening rash. She reports the rash first appeared one year ago on her hands, but she had been too stressed with her final semester of classes to see a dermatologist. Since she first noticed it, the lesion has increased in size. The patient denies pain or pruritis, but notes that sometimes her hands are dry. Her past medical history is significant for seasonal allergies. Her current medications include only an oral contraceptive. Her family history is significant for a cousin with systemic lupus erythematous. She works part-time as a hair-dresser, which she started 6 months ago. She denies tobacco use, but has 3-4 glasses of wine on the weekend. Figure A shows a photograph of the patient’s hand. On physical exam you also note well-demarcated, de-pigmented patches in her armpits and a similar patch on her chest. Which of the following may be associated with this patient’s condition?

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Glossitis

47%

7/15

Dorsocervical fat pad

1/15

Exposure to para-phenylene diamine

20%

3/15

Post-exertional wheezing

13%

2/15

White forelock (poliosis)

13%

2/15

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This patient is presenting with non-pruritic, hypopigmented patches on her hands and armpits, suggesting the diagnosis of vitiligo. Vitiligo can be associated with pernicious anemia, for which a characteristic symptom is glossitis.

Vitiligo is an autoimmune disorder caused by the destruction of melanocytes. This causes hypo-pigmented lesions to appear, especially in sun-exposed areas (e.g., hands, feet, around the mouth and nostrils), armpits, and the groin. These lesions will often spread over time. These can be precipitated by sun-burn, trauma, or stress. Vitiligo is associated with other autoimmune disorders, including Grave’s disease, Hashimoto’s thyroiditis, type I diabetes mellitus, primary adrenal insufficiency, and pernicious anemia.

Figure A shows a photograph of a patient's hand with a sharply demarcated, depigmented patch covering her fingertips.

Incorrect Answers:
Answer 2: A dorsocervical fat pad or buffalo hump is associated with Cushing’s syndrome/disease. High cortisol levels in Cushing's causes a weakened immune system, increasing the risk for fungal infections, such as pityriasis (tinea) versicolor. Pityriasis versicolor is characterized by small, hypo-pigmented, scaling macules on the face and trunk with mild pruritis.

Answer 3: Exposure to para-phenylene diamine, such as in hair dyes, can cause contact/chemical leukoderma. This can present as white patches of skin, usually at the site of application.

Answer 4: Post-exertional wheezing is a symptom of asthma, which may be associated with eczema. Eczema can present as dry patches or plaques. Normally there will be underlying erythema and possible pruritus. Skin lesions occur most commonly near skin creases.

Answer 5: White forelock or poliosis can be associated with Waardenburg syndrome. This is an autosomal dominant condition that leads to congenital deafness, widely spaced eyes, and white patches of skin on the ventral midline (piebaldism).

Bullet Summary:
Vitiligo presents with hypo-pigmented patches often in sun-exposed areas and the groin, and is associated with other autoimmune disease (e.g., Grave’s disease, Hashimoto's thyroiditis, pernicious anemia, type I diabetes mellitus, and primary adrenal insufficiency).

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