(Leukoderma; Acquired leukasmus; Leukopathia; Achromia; Acquired piebald skin)
Definition. – An acquired disease, characterized by the progressive disappearance of normal pigmentation in variously sized and shaped white, smooth, sharply defined patches with hyperpigmented borders.
Symptoms. – This is a disorder of pigmentation, the texture and functions of the affected portions remaining undisturbed. It probably begins with a moderate increase of pigment which is only observed at the border after the atrophic process has occurred. It usually appears in small, milk-white, smooth, rounded areas which may enlarge symmetrically, irregularly or coalesce making irregular patches of bleached skin. Hairs in the affected portions become white but retain their vigor and life while the secretions and sensibilities are unchanged. The edges of the primary lesions are always convex and correspond to the concave border of hypertrophied pigment. The contrast in color is most apparent in the summer owing to a tanning of the normal skin. Hence it is that the return of winter shows a less conspicuous condition. The progress of the whitening process is slow, consuming years when it extends over large areas. When the surface is largely involved, the map-like distribution of white and dark color would make it seem as if the latter were the abnormal skin. In the negro and other colored races the absorption of pigment goes on progressively from one or many points until nearly the whole surface becomes white, but complete loss of pigment is rare in either race. The disease may start on any part of the surface and the spots may be singled or multiple with indefinite normal intervals between. The common sites are the back of the hands, neck, face, scalp and genitocrural regions. If there are many small patches the piebald look is present. The general health is unaffected by this order, although there may be present some associated nerve disturbance.
Fig. 114 – Vitiligo in a negro, with similar lesions on the scrotum and both knees.
Etiology and Pathology. – The cause is unknown but it is more frequent in tropical countries and in the dark races. It occurs in adults and affects equally both sexes. It has followed or been associated with malarial and eruptive fevers, such neurotic diseases as migraine, alopecia areata, scleroderma, Addison’s disease and Graves’ disease, exposure to extreme heat or cold, or local injuries. These factors have little in common except that they lead to a derangement of the nervous system leads to the assumption that vitiligo is pathologically a trophoneurosis. The earliest anatomic change is a hypertrophy followed by an atrophy of pigment in the whitish spots while the surrounding brownish discolorations show hyperpigmentation.
Fig.115 – Vitiligo extensive distribution, in a chinaman (courtesy of Dr. J.L. Keeler).
Diagnosis. – Macular leprosy in its later stages may be pale and anesthetic but structural changes and the general symptoms of the disease are present. Cholasma presents the concave lines of lighter surface surrounding its pigmented area, while vitiligo presents the convex outline of whitened surface surrounded by hypertrophied pigment. Circumscribed scleroderma or morphea is characterized by a change in the texture of the skin, first thickened, then atrophied. Tinea versicolor is a fungus affection presenting yellowish-brown patches and furfuraceous scales.
Prognosis and Treatment. – Cases rarely cease spontaneously and occasionally from treatment but the tendency is to persist and increase with age. While any treatment is unsatisfactory, it is often necessary to do something externally in an effort to relieve the disfigurement. Frictions of the affected surface sufficient to produce hyperemia. I have found beneficial in several cases and can recommend the following simple application:
Fig. 116 – Vitiligo in a white woman, on the dorsal aspect of both hands and wrists. Cured by the prolonged use of Silicea 6x and local frictions with a 10 per cent. solution of capsicum.
Cantharid, tinct., 3jv; 15@
Benzoin, tinct., 3j; 4@
Spts. vin. rect., @
Aq. rosae aa 3ij; 60@ M.
Hyperemia may also be produced by suction cups, combined with fairly large doses of the X-rays; by galvanism, placing over the affected areas the negative electrode with a current of 2 to 5 milliamperes; by photo-therapy; or by the high-frequency currents. To remove the excess of pigment about the patches of vitiligo, pure carbolic acid is the best of the acids or caustics, but a similar result may be accomplished by cataphoresis with a solution of mercuric chlorid (1 : 1000). Temporary relief from disfigurement may be obtained by staining the exposed patches with walnut juice, a weak solution of iodine or any appropriate staining substance. The chief reliance in curable cases is to be placed, however, on the long continued use of such remedies as Arsen, Ferrum phos., Nit. acid., Sul., and Zincum met. phos. and hygienic measures to improve the general health.