What's causing these pale patches of skin?

Speedy skins: The next in our series of quick quizzes in dermatology asks – what is the diagnosis in this case involving pale patches of skin affecting the hands and axillae?

The Case

A 25-year-old man presents with symmetrical pale patches affecting his hands. He has similar lesions in both axillae. There is no itch and he is otherwise well. He has been seen previously and treated with antifungal creams, but there has been no improvement.

Picture

What’s the diagnosis?

SHOW THE ANSWER 〉

Fast Facts: Vitiligo

Presentation:

Depigmented or hypopigmented macules or patches of skin, typically well‑defined, with loss of normal skin pigment (melanin).
The borders may be discrete; sometimes an inflammatory border or ‘confetti’ depigmentation may indicate active disease.
Course can be chronic, progressive and relapsing; spontaneous repigmentation is uncommon.

Symptoms:

Itching is uncommon.
Main impact is cosmetic and psychosocial – distress, impact on self‑image, social avoidance.
Hair (including scalp hair, eyebrows, eyelashes) can show premature greying or depigmentation (‘poliosis’).

Affected areas:

Commonly involves the face (particularly peri‑orificial areas such as around the eyes and mouth), dorsal hands, wrists, forearms.
Also frequently seen in the axillae, groins, areolae, genital region and skin creases.
Distribution is often symmetrical (in non‑segmental vitiligo) but segmental/unilateral forms also occur.

Epidemiology

Estimated prevalence in the UK is approximately 1 in 100 people, with around 85‑90% having the non‑segmental type.
Onset can occur at any age, but about half of cases begin before age 20 years.
No strong sex predilection in many series, though disease is more visible and impactful in those with darker skin tones.
Frequently associated with other autoimmune disorders (notably thyroid disease).

Diagnosis

Clinical evaluation:

Take history of onset, progression (rapid or slow), family history of vitiligo or autoimmune disease, and psychosocial impact.
Examine skin broadly: face, hands, creases, genitalia, hair (scalp, eyebrows) and look for symmetry, Koebner phenomenon (lesions in sites of trauma) and any inflammatory border.
Assess for signs of other autoimmune disease (e.g., thyroid, type 1 diabetes, pernicious anaemia) and ask about psychosocial impact.

Investigations:

Routine investigations are not required for the diagnosis of vitiligo.
Consider thyroid function tests and thyroid auto‑antibodies, especially if other autoimmune features present.
Photograph documentation may help monitoring over time.

Differential diagnosis

Pityriasis alba – hypopigmented rather than fully depigmented macules, typically in children on the face.
Piebaldism – congenital depigmented patches, often with white forelock of hair.
Post‑inflammatory hypopigmentation – following eczema or other inflammation, often less sharp borders.
Leprosy – hypopigmented (rather than fully depigmented) patches with sensory loss and thickened nerves in endemic context.
Hypopigmented cutaneous T‑cell lymphoma – rare, but consider in persistent hypopigmented patches especially in skin of colour.

Red flags

Rapidly progressive disease (many new patches over a short time) – may indicate active aggressive vitiligo and merits dermatology referral.
Segmental vitiligo with hair follicle involvement (poliosis) – may have a different prognosis and management.
Significant psychosocial distress, especially in visible areas (face, hands) or in skin of colour – requires holistic management including psychological support.
Suspected other autoimmune disease (e.g., new thyroid disease, type 1 diabetes) – coordinate care.
Diagnostic uncertainty – e.g., irregular pigment loss, lack of typical distribution, presence of scale or inflammatory signs – refer to dermatology.

Management

First‑line (primary care / early intervention):

Sun protection is essential: patches are vulnerable to sunburn due to lack of melanin. Advise sunscreen (SPF 50+), protective clothing, avoidance of indoor sunbeds.
Skin camouflage may help improve the appearance and reduce psychosocial impact.
For limited, early non‑segmental vitiligo: consider potent or very potent topical corticosteroids once daily (e.g., for up to 6‑12 weeks) with intermittent holiday‑break regimen (e.g., 1 week on, 1 week off) until review.
In facial involvement (or sensitive sites) consider topical tacrolimus 0.1% ointment twice daily (unlicensed) particularly where corticosteroids are less preferred. bpg.org.uk+1

When to refer:

Disease involving >10% body surface, or face/hands significantly, or impact on quality of life – refer to dermatology.
Patients who fail to respond to topical therapy or have widespread disease – dermatology may offer narrow‑band UVB phototherapy or other interventions.
For very extensive disease (>50% body surface) where repigmentation unlikely, depigmentation therapy may be discussed (e.g., monobenzyl‑ether of hydroquinone) in adult patients – specialist only.
Consider early referral dermatology in children and adolescents, given impact and differing management.

Patient education

Understanding the condition:

Vitiligo is an autoimmune pigment‑loss condition: it is not contagious, malignant, or due to infection.
Emphasise the long‑term nature: regimentation of lifestyle, skin protection and realistic treatment goals (stabilisation versus repigmentation).
Explain that early treatment may improve outcomes but full repigmentation cannot always be guaranteed.

Triggers and associations:

Explain associations with other autoimmune conditions (especially thyroid disease) and the importance of monitoring.
Discuss psychosocial implications: encourage open discussion about emotional impact, self‑esteem, social avoidance and support groups (e.g., Vitiligo Society).
Advice on sun protection, vitamin D supplementation (if limited sun exposure) and camouflage options.