Synopsis
Recognise true depigmentation across skin tones, distinguish segmental from non-segmental vitiligo, screen thoughtfully for associated autoimmunity, and match treatment to site, activity and patient priorities.
- Vitiligo is acquired loss of functioning epidermal melanocytes, producing sharply demarcated depigmented rather than merely pale skin; hair within a patch may also become white.
- Non-segmental vitiligo is commonly bilateral and symmetrical around hands, face, body openings and friction sites, whereas segmental disease is usually unilateral and follows a more localised distribution.
- Examine in good neutral light and compare with normally pigmented skin; erythema may be less conspicuous in deeply pigmented skin, but complete pigment loss and border definition remain informative.
- A Wood lamp can accentuate depigmentation and reveal subtle extent, especially where contrast is low, but it does not replace history, full skin examination or appropriate differential diagnosis.
- Ask about thyroid symptoms and personal or family autoimmunity; British dermatology guidance supports thyroid function and antithyroid-antibody screening because autoimmune thyroid disease is an important association.
- Treatment choices include camouflage, sun protection, a site-appropriate topical corticosteroid, off-label topical tacrolimus on selected sites, and specialist phototherapy for suitable extensive or progressive disease.
- Repigmentation is slow and often begins around follicles; acral areas and patches with white hairs generally respond less reliably than face and trunk.
- Discuss psychological, cultural and occupational impact directly. Visible difference can be highly distressing even when affected body-surface area is small.
Key red flags
Rapid pigment loss after chemical exposure, new neurological or systemic symptoms, extensive inflammation, ocular symptoms, or features of untreated thyroid or adrenal disease require prompt cause-specific assessment rather than routine cosmetic review.
Investigation priorities
Confirm extent, distribution, activity clues and follicular pigment reserve.
Management branches
New pale patches could represent vitiligo or a mimicking pigment disorder.
- Ask about onset, progression, trauma, preceding rash, chemical exposure, medicines, family history and autoimmune symptoms, then examine the entire skin and hair in neutral light.
- Use a Wood lamp when extent or complete pigment loss is uncertain, and sample scale or biopsy only when a specific alternative remains plausible.
- Classify segmental versus non-segmental pattern, record active spread and leucotrichia, and obtain consented baseline photographs using consistent lighting and camera settings.
Key medicines
Site-appropriate potent topical corticosteroidApply a thin layer once daily to selected nonfacial patches for a defined specialist or primary-care course, then review before continuing or stepping down.Match potency to site and avoid prolonged unsupervised use on face, folds or genital skin; monitor atrophy, telangiectasia, striae, acneiform change and total treated area.
Tacrolimus 0.1% ointment for selected adult sitesApply a thin layer twice daily under an explicitly off-label vitiligo plan, with interval review and avoidance of unnecessary ultraviolet exposure.Vitiligo use is off-label. Explain transient burning, infection precautions and sun protection; avoid use over suspected infection and seek specialist advice in immune compromise, pregnancy or extensive disease.