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A 26 year old young man presented with depigmented patches on face (below the eyes) and neck 2 yrs. Along with this, he also complained of eructation.

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Presentation on theme: "A 26 year old young man presented with depigmented patches on face (below the eyes) and neck 2 yrs. Along with this, he also complained of eructation."— Presentation transcript:

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2 A 26 year old young man presented with depigmented patches on face (below the eyes) and neck 2 yrs. Along with this, he also complained of eructation which was worse after food, incontinence of urine with sudden urging and sticky watery discharge from ears since 5 yrs which was worse after head bath. Lesions first appeared on forehead which disappeared of its own and then gradually appeared below eyes, on lips and on neck. The lesions were of progressing type. The patient did not receive any treatment for the above complaints prior to this visit. There was no family history of vitiligo. Childhood history was uneventful. He discontinued studies due to his lack of interest. He started working in a cloth shop from 15 yrs of age. A 26 year old young man presented with depigmented patches on face (below the eyes) and neck 2 yrs. Along with this, he also complained of eructation which was worse after food, incontinence of urine with sudden urging and sticky watery discharge from ears since 5 yrs which was worse after head bath. Lesions first appeared on forehead which disappeared of its own and then gradually appeared below eyes, on lips and on neck. The lesions were of progressing type. The patient did not receive any treatment for the above complaints prior to this visit. There was no family history of vitiligo. Childhood history was uneventful. He discontinued studies due to his lack of interest. He started working in a cloth shop from 15 yrs of age.

3 Patient had desire for sweets and fried food and cold climate; was intolerant to warm weather with profuse perspiration from soles. There was sudden urging for urination. He was mild, gentle and had a clear conception. He was dark and moderately built, weigh 60 kg. and height 160 cm; blood pressure maintained at 120/80 mm of Hg, Pulse rate of 75/minute and Respiratory rate 20/minute. On examination tenderness of left hypochondria on palpation, no other systemic abnormality was detected. Patient had desire for sweets and fried food and cold climate; was intolerant to warm weather with profuse perspiration from soles. There was sudden urging for urination. He was mild, gentle and had a clear conception. He was dark and moderately built, weigh 60 kg. and height 160 cm; blood pressure maintained at 120/80 mm of Hg, Pulse rate of 75/minute and Respiratory rate 20/minute. On examination tenderness of left hypochondria on palpation, no other systemic abnormality was detected.

4 hot patient Desires sweets Profuse perspiration from soles Sudden urging to urinate White discoloration of skin Eructations

5 - Pityriasis alba - Pityriasis versicolor alba - Chemical leukoderma - Leprosy - Nevus depigmentosus - Hypomelanosis of Ito - Nevus anemicus - Leukoderma associated with melanoma - Postinflammatory leukoderma - Mycosis fungoides

6 Hypomelanosis is a decrease of melanin in the epidermis. This reflects mainly two types of changes: ▪ No decrease of melanocytes but a decrease of the production of melanin only that is called melanopenic hypomelanosis (an example is albinism). ▪ A decrease in the number or absence of melanocytes in the epidermis producing no or decreased levels of melanin. This is called melanocytopenic hypomelanosis (an example is vitiligo)

7 Incidence: Common, worldwide. Affects up to 1% of the population. Sex : Equal in both sexes Age of Onset: begin at any age, but in 50% of cases it begins between the ages of 10 and 30 years. Race: All races, most common in India, Mexico, Japan, Egypt and other tropical countries. of vitiligo cases Inheritance: in about 30 % there is a positive family history.

8 Vitiligo is a chronic,acquired,idiopathic depigmentary condition The cause of vitiligo is not yet fully understood. Three principal theories have been presented about the mechanism of destruction of melanocytes in vitiligo - Autoimmune (activated Lymphocytes destroy melanocytes ) - neurogenic hypothesis - self-destruct hypothesis (destruction of melanocytes by a toxic subestance produced by normal melanocytes ) :causes onset of vitiligo - physical trauma (Koebner phenomenon) - Illness - emotional stress - Sunburn

9 The disease appears symmetrically, usually in the face, but also on the nape of neck, axillae, elbows, hands, knees and genitals. Vitiligo usually occurs in a localized or generalized pattern The “ lip-tip ” pattern involves the skin around the mouth as well as on distal fingers and toes; lips, nipples, genitalia and anus may be involved.

10 Skin Lesions - Macules, 5 mm to 5 cm - “Chalk” or pale white - sharply marginated - Margins are convex Trichrome vitiligo (three colors: white, light brown, dark brown) Inflammatory vitiligo has an elevated erythematous margin and may be pruritic. Inflammatory vitiligo has an elevated erythematous margin and may be pruritic.

11 Vitiligo: face Extensive depigmentation of the central face. Involved vitiliginous skin has convex

12 Vitiligo: knees Depigmented, sharply demarcated macules on the knees.

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15 The focal type : is characterized by one or several macules in a single site Generalized vitiligo: is more common and is characterized by widespread distribution of depigmented macules, often in a remarkable symmetry vitiligo universalis : extensive generalized vitiligo may leave only a few normally pigmented areas of skin Segmental Vitiligo : usually develops in one unilateral region; usually does not extend beyond that initial onesided region Mucosal Vitiligo: depigmentation of only the mucous membranes Acrofacial Vitiligo: fingers and periorificial areas

16 Universal vitiligo Vitiliginous macules have coalesced to involve all skin sites with complete

17 General Examination : Associated with thyroid disease: (Hashimoto thyroiditis, Graves disease) diabetes mellitus pernicious anemia Addison disease Multiple endocrinopathy syndrome Ophthalmologic examination healed chorioretinitis or iritis Vision is unaffected The Vogt-Koyanagi-Harada syndrome: is vitiligo + poliosis + uveitis + dysacusis + alopecia areata.

18 - Wood Lamp Examination - Dermatopathology - Electron Microscopy - Laboratory Studies Thyroxine (T 4 ) TSH FBG CBC ACTH stimulation test

19 Normally, diagnosis of vitiligo can be made readily on clinical examination of a patient with progressive, acquired, chalk-white, bilateral (usually symmetric), sharply defined macules in typical sites.

20 Sunscreens : - protection from acute sunburn reaction - limitation of tanning of normally pigmented skin. Cosmetic Coverup : (called self-tanning agents, which contain Dihydroxyacetone) The objective is to hide the white macules so that the vitiligois not apparent Repigmentation : The objective is the permanent return of normal melanin pigmentation. Topical glucocorticoids Topical calcineurin inhibitors Topical photochemotherapy Systemic photochemotherapy Narrow-band UVB Excimer laser (308 nm)

21 Minigrafting: may be a useful technique for refractory and stable segmental vitiligo macules. - PUVA may be required after the procedure to unify the color between the graft sites Depigmentation: The objective of depigmentation is “one” skin color in patients with: - extensive vitiligo - failed PUVA - who cannot use PUVA - who reject the PUVA option. Bleaching of normally pigmented skin with monobenzylether of hydroquinone 20% (MEH) cream is a permanent, irreversible process. note that the depigmentation achieved is permanent !!

22 Vitiligo: therapy-induced repigmentation This 20-year-old Indian female is being treated with photochemotherapy (PUVA). Before After

23 In the above case of Vitiligo, initially a medicine was selected (Merc.sol.) basing upon the totality of symptoms and analyzing the case but the patient did not show any improvement after taking that medicine. The patient discontinued treatment thereafter and again came back after one year with depigmented patches but this time it was found intensified although he did not use any other medicine and medication during this period. The case was re-analysed taking the presenting totality and Sulphur was the medicine selected. Sulphur in 30C potency, single dose was prescribed. The patient improved markedly with this remedy withvery few repetitions (2 doses of Sulphur 30) followed by placebo in a very short period. The depigmented spots on his face were almost completely disappeared and regimentation marked on the neck. The patient has been continuing Placebo till date with steady improvement In the above case of Vitiligo, initially a medicine was selected (Merc.sol.) basing upon the totality of symptoms and analyzing the case but the patient did not show any improvement after taking that medicine. The patient discontinued treatment thereafter and again came back after one year with depigmented patches but this time it was found intensified although he did not use any other medicine and medication during this period. The case was re-analysed taking the presenting totality and Sulphur was the medicine selected. Sulphur in 30C potency, single dose was prescribed. The patient improved markedly with this remedy withvery few repetitions (2 doses of Sulphur 30) followed by placebo in a very short period. The depigmented spots on his face were almost completely disappeared and regimentation marked on the neck. The patient has been continuing Placebo till date with steady improvement

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