Dermatology Online Journal

Inflammatory vitiligo with raised borders and psoriasiform histopathology
Shyam B Verma MBBS DVD FAAD
Dermatology Online Journal 11 (3): 13

Baroda, India. vermaderma@rediffmail.com

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A 43-year-old man presented with a 15-year history of depigmented macules mainly involving the extremities. He noticed severe itching associated with new vitiligo patches for the past 6 years. He said that he developed new lesions that had itchy and angry-red borders. On examination he had classic depigmented macules of vitiligo. The borders were raised and erythematous (Figs. 1 and 2). He said that the borders were very itchy initially and were associated with oozing in the beginning. Although the depigmented patches remained static the borders responded to topical steroids and flattened out over time.

There was nothing significant in his history except that he was atopic with a strong family history of the same.

Figure 1	Figure 2
Raised erythematous borders of Inflammatory vitiligo

Figure 3
Psoriasiform changes in raised border of a vitiligo lesion

A biopsy taken from the raised erythematous border, including some depigmented area, showed psoriasiform hyperplasia with a prominent parakeratotic mound (Fig. 3). There was acanthosis with regular elongation of rete ridges. Pigment in the basal layer was absent. The upper dermis showed a sparse lymphohistiocytic infiltrate. The papillary dermis showed dilated vessels.

Discussion

Although there are many clinical forms of vitiligo, there are few published reports of vitiligo with raised borders [1, 2, 3, 4, 5]. It can occur at any age and in both sexes. The elevated, erythematous border of inflammatory vitiligo may be present at the onset of the disease or may appear any time during the course of the disease. The inflammatory border responds to topical steroid therapy and, in some instances, it regresses spontaneously. There are reports of inflammatory vitiligo macules with edematous borders and slight scaliness in atopic individuals [4]. Our patient was atopic. His areas of active vitiligo were characterized by severe itching and oozing. The borders were inflamed, erythematous, scaly, but not edematous. Lee, Lazova and Bologna have reported psoriasiform histopathology in a patient of inflammatory vitiligo; they also noted similar reports in French and Japanese literature dating back 28 years [6, 7].

Very few histopathologic studies of vitiligo have been done and hence the microscopic features are not well appreciated. The frequently reported findings in vitiligo include absence of melanocytes, increased number of Langerhans cells, epidermal vacuolization, thickening of the basement membrane, and a lymphocytic inflammatory infiltrate [8]. Vitiligo is generally considered to be a non-inflammatory disease. However, some workers have found inflammatory element especially at the border of the vitiligenous lesions. That finding is present in less than 5 percent of vitiligo patients, Affected patients have a significant influx of lymphocytes in the area of amelanotic skin, histologically called inflammatory vitiligo [1, 9, 10, 11]. Some workers propose that vitiligo is an inflammatory disease and that the epidermal lymphocytic infiltration is actually the primary immunological event [12]. Histopathology of vitiligo with raised borders reveals eczematous change in the epidermis with absent or decreased melanin pigmentation and a fairly dense lymphohistiocytic infiltrate in the upper dermis [5, 13, 14]. There are also reports of lichenoid infiltrate, thickened stratum corneum and parakeratosis occurring in inflammatory vitiligo [6]. Our case showed parakeratotic mounds, psoriasiform hyperplasia, and regular elongation of rete ridges over and above the upper dermal lymphohistiocytic infiltrate and absence of melanocytes in the vitiligenous area.

In conclusion, inflammatory vitiligo with raised borders is not routinely included in discussions on vitiligo and hence can be a diagnostic dilemma for those who are not aware of such an entity. The confusion can be amplified with unusual histopathologic features such as psoriasiform changes that have been described in this case and also in few scattered reports in international literature. The spectrum of inflammatory vitiligo should be expanded to include psoriasiform histopathologic changes too.

References

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11. Boisy RE, Nordlund JJ. Biology of Vitiligo. In Cutaneous Medicine and Surgery: An Integrated Prgram in Dermatology Eds Arndt KA et al. pp 1210-18. WB Saunders Company, Philadelphia;1995

12. Sharquie KE, Mehenna SH, Naji AA, Al-Azzawi H. Inflammatory changes in vitiligo: stage I and II depigmentation. Am J Dermatopathol. 2004 Apr;26(2):108-12. PubMed

13. Abdel-Naser MB et al. (1991) Evidence for Primary Involvement of Keratinocytes in vitiligo. Archives of Dermatologic research-Archiv fur dermatologische Forschung 283,47 (Abstract)

14. Gokhale BB, Mehta LN. Histopathology of vitiliginous skin. Int J Dermatol. 1983 Oct;22(8):477-80. PubMed

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