Role of oxidative stress and autoimmunity in onset and progression of vitiligo

Vitiligo is an acquired depigmentation disorder characterized by the loss of functional melanocytes from the epidermis. Two major theories of vitiligo pathogenesis include autoimmunity and oxidative stress-mediated toxicity in melanocytes. The present study aimed to evaluate both the hypotheses in vitiligo patients and to investigate their role in the disease onset and progression. Antimelanocyte antibody levels and lipid peroxidation (LPO) levels were evaluated in 427 patients and 440 controls; antithyroid peroxidase (TPO) antibody levels were estimated in 102 patients and 72 controls. Patients showed a significant increase in LPO and antimelanocyte antibody levels compared to controls. Antimelanocyte antibody and LPO levels were higher in active vitiligo compared to stable. Only 9.8% of patients showed the presence of anti-TPO antibodies in their circulation. Oxidative stress may be the initial triggering event to precipitate vitiligo in Gujarat population, which is exacerbated by contributing autoimmune factors together with oxidative stress.

A retrospective study of 231 Japanese vitiligo patients with special reference to phototherapy

Although the outcomes of various treatment modalities for vitiligo have been studied extensively, the influence of the participant's characteristics on treatment response has not been thoroughly investigated. Therefore, we retrospectively investigated treatment effects and their association with clinical characteristics in Japanese patients with vitiligo. The charts of patients with vitiligo treated in our institution were reviewed. Clinical response was evaluated as a marked response rate, defined as repigmentation in >75% of the initial lesional area. 162 patients were treated with phototherapy, while 69 were treated with topical mono-therapy. The patients treated with phototherapy and those treated with both phototherapy and topical treatment demonstrated significantly higher clinical response rates compared to patients treated solely with topical mono-therapy (marked response rate: 19.1% vs. 5.8%, P<0.05; and 23.5% vs. 5.8%, P<0.01, respectively). Among the phototherapy-treated patients, younger subjects (≤15 years old) were more responsive to phototherapy compared to older patients (37.0% vs. 15.6%; P=0.015). The disease subtypes did not affect treatment response. In conclusion, phototherapy appears to have a therapeutic effect superior to topical mono-therapy on both focal and generalized vitiligo, especially in younger patients. Thus, any type of psychosocially devastating lesions in a pediatric patient may be a good target for phototherapy.

Association of NLRP1 genetic variants and mRNA overexpression with generalized vitiligo and disease activity in a Gujarat population

BACKGROUND

It has been suggested that NLRP1 is involved in susceptibility to a wide range of autoimmune diseases including generalized vitiligo (GV). Genetic polymorphisms in the gene encoding NLRP1 (previously known as NALP1) have previously been shown to be associated with GV and there is speculation about their involvement in the regulation of NLRP1 expression.

OBJECTIVES

To explore NLRP1 polymorphisms and investigate their association with NLRP1 mRNA expression and disease activity in patients with GV.

METHODS

Polymerase chain reaction (PCR)-restriction fragment length polymorphism and TaqMan single nucleotide polymorphism (SNP) genotyping techniques were used to genotype NLRP1 A/G (rs2670660), T/C (rs6502867) and A/T (rs12150220) polymorphisms in 537 patients with GV and 645 controls in Gujarat. NLRP1 mRNA levels were measured in the whole blood of 122 patients with GV and 175 controls using real-time PCR.

RESULTS

The NLRP1 rs2670660 and rs6502867 polymorphisms were found to be in significant association with GV, minor alleles of these SNPs being prevalent in active cases of GV. The rs12150220 polymorphism was found have a marginal association with GV. The frequency of susceptible haplotype 'GCT' was significantly higher in patients with GV and increased the risk of vitiligo twofold. A significant increase in NLRP1 mRNA expression was observed in patients with GV and patients with active GV. NLRP1 mRNA expression was increased in patients with GV with the susceptible GG (rs2670660) and CC (rs6502867) genotypes. Patients with the susceptible GG (rs2670660) and CC (rs6502867) genotypes had early age of onset of GV. Moreover, patients in the age at onset group of 1-20 years showed increased expression of NLRP1 mRNA compared with the older age groups. Female patients showed a significant increase in NLRP1 mRNA and early age at onset of GV compared with male patients.

CONCLUSIONS

Our results suggest that NLRP1 rs2670660 and rs6502867 polymorphisms may be genetic risk factors for susceptibility to and progression of GV. The upregulation of NLRP1 mRNA in patients with susceptible genotypes advocates the crucial role of NLRP1 in GV.

Interleukin-4 genetic variants correlate with its transcript and protein levels in patients with vitiligo

BACKGROUND

Vitiligo is an acquired pigmentary disorder resulting from loss of melanocytes. Interleukin (IL)-4 has been shown to stimulate B-cell proliferation, to regulate immunoglobulin class switching (IgG1 and IgE) and to promote T-cell development. Polymorphisms in the IL4 gene are known to increase its expression, thereby implicating its role in vitiligo susceptibility.

OBJECTIVES

To explore intron 3 VNTR (IVS3) and -590 C/T (rs2243250) promoter polymorphisms in the IL4 gene and to correlate them with the IL4 transcript, serum IL-4 and IgE levels to achieve genotype-phenotype correlation in patients with vitiligo from Gujarat. A replication study was done in a North Indian population.

METHODS

The case-control study was performed to investigate these polymorphisms in 505 patients and 744 controls in Gujarat, and 596 patients and 397 controls in North India by polymerase chain reaction (PCR) and PCR-restriction fragment length polymorphism analysis. IL4 transcript levels were monitored by real-time PCR. Serum IL-4 and IgE levels were measured by enzyme-linked immunosorbent assay and electrochemiluminescence immunoassay, respectively.

RESULTS

The genotype frequencies differed significantly between patients with generalized vitiligo and controls for both the polymorphisms in both populations. Allele frequencies significantly differed between patients with generalized vitiligo and controls for both the polymorphisms in the population from Gujarat. Interestingly, genotype and allele frequencies for -590 C/T single nucleotide polymorphism were significantly different between patients with localized vitiligo and controls in both the populations. The study revealed significantly increased IL4 mRNA, serum IL-4 and IgE levels in patients from Gujarat. Age of onset analysis of disease in patients suggested that the TTR2R2, TTR1R2 and CTR2R2 haplotypes had a profound effect in the early onset of the disease.

CONCLUSIONS

Our results suggest that these polymorphisms of the IL4 gene may be genetic risk factors for susceptibility towards vitiligo and the upregulation of the IL4 transcript, protein and IgE levels in individuals with susceptible haplotypes reveal the crucial role of IL-4 in the pathogenesis of vitiligo.

HLA alleles and amino-acid signatures of the peptide-binding pockets of HLA molecules in vitiligo

Vitiligo is a depigmenting disorder of the skin that is characterized by the loss of functional melanocytes from the lesional sites. Although the exact etiology is not understood, autoimmunity is thought to be a crucial deterministic factor. A recurring theme of several autoimmune disorders is the aberrant presentation of self-antigens to the immune system, which triggers downstream perturbations. Here we examine the role of alleles of HLA class I and class II loci to delineate vitiligo manifestation in two distinct populations. Our studies have identified three specific alleles, HLA-A*33:01, HLA-B*44:03, and HLA-DRB1*07:01, to be significantly increased in vitiligo patients as compared with controls in both the initial study on North Indians (N=1,404) and the replication study in Gujarat (N=355) cases, establishing their positive association with vitiligo. Both generalized and localized vitiligo have the same predisposing major histocompatibility complex alleles, i.e., B*44:03 and DRB1*07:01, in both the populations studied, beside the differences in the frequencies of other alleles, suggesting that localized vitiligo too may be an autoimmune disorder. Significant differences in the amino-acid signatures of the peptide-binding pockets of HLA-A and HLA-B α-chain and HLA-DR β-chain were observed between vitiligo patients and unaffected controls.

Association of UVRAG polymorphisms with susceptibility to non-segmental vitiligo in a Korean sample

Autoimmune, self-destructive, oxidative stress and genetic theories have been proposed for the pathogenesis of vitiligo. Autophagy is essential for cellular homeostasis and is implicated in many pathophysiological conditions such as cancer, response to oxidative stress and autoimmunity. The ultraviolet (UV) radiation resistance-associated gene (UVRAG) activates the Beclin1-PI(3)KC3 complex, promoting autophagy. To evaluate whether UVRAG polymorphisms are associated with non-segmental vitiligo (NSV) patients in a Korean sample, we conducted a case-control association study of 225 NSV patients and 439 matched healthy controls. A total of five single nucleotide polymorphisms (SNPs) of UVRAG were selected for analysis. Among these, two SNPs (rs1458836, rs7933235) showed significant genotypic differences between the NSV patient group and the control group. These two SNPs were located within a strong linkage disequilibrium (LD) block. In addition, the haplotype of the UVRAG polymorphism was associated with NSV. This study suggests a possible association between UVRAG and NSV susceptibility.

Vitiligo in North-Eastern China: An association between mucosal and acrofacial lesions

Vitiligo is a mucocutaneous pigmentary disorder with worldwide distribution. Little is known about the clinical profile of vitiligo in North-eastern China. Accordingly, we reviewed 692 vitiligo out-patients from seven government hospitals in North-eastern China via a questionnaire in a multi-centre study conducted between June 2007 and June 2008, and hence characterized the epidemiology of vitiligo in North-eastern China. The mean +/- standard deviation age of onset was 23.69 +/- 13.83 years (range < 1-77 years). No gender preponderance was seen. The back was the most common site of involvement (39.6%). Vitiligo vulgaris was the predominant form (53.5%). Mucosal lesions were associated with lesions on the feet (odds ratio (OR) = 3.177, p < 0.001), hands (OR = 2.228, p < 0.01), face (OR = 2.028, p < 0.05) and neck (OR = 0.454, p < 0.05); but were not associated with chest, abdomen, waist, arms, legs or scalp lesions. Mucosal vitiligo is probably a special form of acrofacial vitiligo.

Platelet-derived growth factor receptor alpha gene mutations in vitiligo vulgaris

Vitiligo vulgaris is an acquired depigmenting disorder resulting from the loss of melanocytes in the skin. Though several putative susceptibility loci of vitiligo have been identified in different populations, the pathogenesis of the disease remains poorly understood. Through genetic linkage analysis of a large Chinese family cohort of vitiligo, we identified a vitiligo linkage locus AIS4 within chromosome 4q12-q21, a region containing several possible candidate genes, including the platelet-derived growth factor receptor alpha (PDGFRA) gene. We postulated that PDGFR mutations may be linked with vitiligo. To test this hypothesis, we performed DNA sequencing on this gene in 143 multiplex families with familial vitiligo vulgaris, 480 patients with sporadic vitiligo vulgaris, and 480 healthy subjects. Mutations were found in 3.5% of familial vitiligo cases, which is significantly higher than for the general population (0.42%, p = 0.008, Fisher's exact test), and possibly higher than in sporadic vitiligo patients (1.0%, p = 0.053). To our knowledge, this is the first observation that PDGFRA mutations are linked with familial vitiligo vulgaris.

Vitiligo update

Vitiligo is an acquired dyschromia of the skin in which there is a loss of epidermal melanocytes. The prevalence of vitiligo is approximately 1% in the United States and 0.1-2% worldwide. The exact pathogenesis of vitiligo remains elusive and is likely multifactorial. After completing this update, participants should be able to discuss the epidemiology of vitiligo and summarize the proposed mechanisms for development of this disease. In addition, they should be able to discuss physical findings, approach to the patient, and some of the therapeutic modalities for this disorder.

Using a 308-nm excimer laser to treat vitiligo in Asians

BACKGROUND

Current vitiligo therapies require many months of treatment and often result in disappointing outcomes. Treatment with a 308-nm excimer laser has shown promising results in patients with vitiligo.

OBJECTIVE

This controlled prospective trial studied the effectiveness of the 308-nm excimer laser for treating vitiligo in Asians.

METHODS

Thirty-four patients (14 males and 20 females) with localized vitiligo were enrolled in the study. Vitiligo patches were treated using a 308-nm excimer laser. Lesions were treated twice weekly for 13 weeks. The treatment was started with 50 to 100 mJ/cm2 (according to site) and increased by 50 mJ/cm2 in every session until erythema appeared. Patients were treated for 25 sessions, or until 100% repigmentation, whichever was achieved first. The overall response rate was assessed clinically and by comparison of photographs before and after treatment by two independent investigators.

RESULTS

Twenty-nine patients (12 males and 17 females) completed the study. Lesions on the face responded better than elsewhere on the body. The least responsive areas were the hands and feet. The average number of treatment sessions prior to repigmentation was 11. Untreated control patches remained unchanged. In higher skin phototypes the response was more favorable. There was no significant correlation between the age of the patients and their response to treatment.

CONCLUSION

The use of the 308-nm excimer laser for the treatment of vitiligo is effective, relatively safe, and more convenient compared to other available modalities of treatment for stable vitiligo with small patches. However, similar to other modalities of treatment, the therapeutic effect is mainly dependent on the location of vitiligo lesions.

Genetic variations in NALP1 are associated with generalized vitiligo in a Romanian population

Generalized vitiligo is a common, multifactorial, polygenic disease in which autoimmune loss of melanocytes results in depigmented spots of skin, overlying hair, and mucous membranes. In Caucasian families from the United States of America and United Kingdom, susceptibility to generalized vitiligo and associated autoimmune diseases is genetically associated with variants of NALP1, encoding NACHT leucine-rich repeat protein 1. Here, we describe a population-based case-control association analysis of single-nucleotide polymorphisms (SNPs) distributed through the NALP1 region in Caucasian generalized vitiligo patients and controls from Romania. This study confirms genetic association of generalized vitiligo with variation in NALP1, which contains at least two independent risk signals, one tagged by SNP rs6502867 and another tagged by SNPs rs2670660 and rs8182352. Individuals carrying high-risk alleles of both rs6502867 and rs2670660 had an odds ratio of 4.20 compared with individuals carrying a high-risk allele from only one signal. These findings support the involvement of NALP1 in predisposition to generalized vitiligo.

Evidence for two susceptibility loci on chromosomes 22q12 and 6p21-p22 in Chinese generalized vitiligo families

Vitiligo is an acquired depigmentation disorder of the skin and hair caused by the selective destruction of melanocytes from the epidermis that gives rise to well-defined depigmented patches. Strong genetic predisposition has been well recognized. Previous reports have described five significant vitiligo susceptibility loci spread over five different chromosomes, 1p31 (AIS1), 7q (AIS2), 8p (AIS3), 4q13-q21 (AIS4), and 17p (SLEV1). In addition, our previous genome-wide scan of 106 Chinese vitiligo families presented suggestive linkages on five additional chromosome segments, 1p36, 6p21-p22, 6q24-q25, 14q12-q13, and 22q12. To clarify the significance of these suggestive loci, we have now extended this study to a total of 143 Chinese vitiligo families and increased the marker density. Two linkage signals on 6p21-p22 and 22q12 that were previously only suggestive now meet genome-wide criteria for significant linkage, establishing their importance as major vitiligo susceptibility loci. Linkage signals on 1p36 and 6q24-q25 did not improve our previous findings, but on 14q showed negative in the 143 family cohorts. The results presented here further demonstrate the genetic complexity of vitiligo pathogenesis and point to new chromosomal locations for further research to identify the specific genes involved in this process.

[ssociation of HLA class I and II alleles with generalized vitiligo in Chinese Hans in north China]

OBJECTIVE

To investigate the association of HLA class I and II alleles with generalized vitiligo in ethnic Han Chinese in north China.

METHODS

By employing polymerase chain reaction sequence-specific primer (PCR-SSP) procedure 34 generalized vitiligo patients in north China were studied for HLA I and II alleles and were compared with 102 healthy controls.

RESULTS

The allelic frequencies of HLA-A*30, Cw*06, DRB1*07, and DQB1*0201 were increased significantly in generalized vitiligo and especially in the patients without family history compared with the controls.

CONCLUSION

These alleles positively associated with generalized vitiligo in Chinese Han patients in north China, might provide clues to reveal the susceptibility gene(s) of vitiligo in Chinese and as well as the immunnogenetic mechanisms of disease.

Association of HLA loci alleles and antigens in Saudi patients with vitiligo

HLA complex is composed of several closely linked loci, each containing several alleles, yielding a high expression of polymorphism. Vitiligo, a commonly acquired dermatological disorder, has been associated with different HLA antigens in different ethnic groups. In this study, HLA classes I (HLA-A, B, and C) and II (HLA-DR, DQ) antigens/alleles were analyzed in a group of 80 Saudi subjects consisting of vitiligo patients (40) and matched controls (40). The frequency of antigens of various HLA loci was tested using two-stage microcytotoxicity assays, while the frequency of alleles of HLA-DR was screened by polymerase chain reaction/sequence specific primers (PCR/SSP) method. The frequencies of HLA-B7, B15, Bw6, Cw6, Cw7, and DRB4*010101 were found to be significantly higher in vitiligo patients compared to controls [P = 0.029, 0.015, 0.033, 0.009, 0.043, and 0.015, respectively, with relative risk (RR) > or = 3, etiologic fraction (EF) > or = 0.4]. On the other hand, HLA-A9, B5, DQ1, and DRB3*010101 were significantly decreased in vitiligo patients compared to healthy Saudis [P = 0.008, 0.004, 0.028, and 0.04, respectively, with RR < 1 and preventive fraction (PF) < 0.5]. Among the patients, the highest allele frequency was noted for DRB4*010101(70%), while in controls it was for DRB3*010101 (72.5%). These results for antigens and allele frequency of various HLA Loci in vitiligo patients and control subjects suggested that HLA-B7, Bw6, Cw6, Cw7, and DRB4*010101 could be susceptible to vitiligo, while HLA-A9, B5, DQ1, and DRB3*010101 might be negatively associated with the development of vitiligo in Saudis.

Stigma experience in skin disorders: an Indian perspective

Dermatologic disorders generally have a major impact on patients' daily activities, psychologic and emotional state, and social relationships. The intensity of impact of skin disease on an individual person is extremely variable, however, and depends on natural history of the disorder; the patient's demographic characteristics, personality, character, and value; the patient's life situation; and the attitudes of society. Social stigma toward dermatologic disorders in the Indian society is quite widespread, especially toward leprosy. Dermatologists are expected to consider quality of life issues along with social aspects, nature of disorder, efficacy, and tolerability of various therapeutic options to optimize relief and comfort to their patient.

Ophthalmic assessment in black patients with vitiligo

The objective of this study was to describe and estimate the prevalence of pigmentary disturbances occurring in the eyes of patients presenting with vitiligo in a teaching hospital in Ibadan, Nigeria. Patients presenting with vitiligo to the dermatology clinic of the University College Hospital between March and December 2001 were referred to the eye clinic of the same hospital for ophthalmic evaluation. Patients were assessed by visual acuity, intraocular pressure, refraction, slit-lamp biomicroscopic evaluation of the anterior segments and funduscopic examination of the two eyes. Visual fields estimation was done using the Goldman's perimeter. A total of 26 patients were referred to the eye clinic. Of these, only 17 patients were considered evaluable for the study. There were seven males and eight females. The age range was 5-30 years. The largest extent of vitiligo recorded in the study population was 25% of the body surface area. The duration of the vitiligo was two months to 3 1/4 years. None of the patients complained of any visual disturbance. All ophthalmologic assessment profiles were normal for all patients. One of the patients had poliosis. No pigmentary disturbance of the eyes was noticed in any of our patients. Pigmentary changes were not seen in these groups of blacks with vitiligo.

Clinical and immunological studies in vitiligo in the United Arab Emirates

OBJECTIVE

To determine the clinical and immunological changes encountered in patients with vitiligo in Al-Ain population, United Arab Emirates (UAE).

DESIGN

This is a prospective descriptive hospital-based study.

SETTING

Al-Ain Medical District, Al-Ain Hospital, United Arab Emirates.

SUBJECTS

Patients who were seen at Al-Ain hospital for skin diseases during 1996.

RESULTS

The study was based on 65 patients. The sample consisted 32 (49%) males and 33 (51%) females. The mean and standard deviation of age for males were 38.6 +/- 13.5 years and for females were 35.1 +/- 15.9 years. Most of the patients were UAE, Omani and Pakistani nationals. Positive family history of vitiligo was found in 19% of the patients. Association with other immune diseases was found in 6% of the patients while one or more organ specific antibodies, all of whom were females, most of them had positive history of autoimmune diseases.

CONCLUSION

Vitiligo is more common among UAE nationals since the UAE community including a multi-national society.

Study of HLA class I/IL and T lymphocyte subsets in Kuwaiti vitiligo patients

HLA polymorphisms of class I and class II MHC were investigated in 40 Kuwaiti vitiligo patients and in 40 controls using microcytotoxicity assay. HLA-B21, Cw6 and DR53 were increased significantly in patients compared to controls (P = 0.00001, 0.00001 and P = 0.0053 respectively) while HLA-A19, DR52, were significantly decreased (P = 0.00236, 0.05, respectively). Total T-cells, T4 and T8 were measured as CD2, CD4 and CD8 respectively by flow cytometry. Vitiligo patients showed significant increase in CD4 compared to controls (P = 0.03). Our findings suggest that HLA-B21 and Cw6 and DR53, are susceptible genes of vitiligo, while A19 and DR52 are protective genes in the Kuwaiti population.

HLA antigens in Omani patients with vitiligo

Fifty native Omanis with vitiligo were studied to compare the incidence of HLA ABC and DR antigens with a control population. HLA Bw6 was found in 82% of patients compared with 49% controls (Pc = 0.0009 RR = 4.56) and HLA DR7 occurred in 40% of patients and 9% in controls (Pc = 0.00075 RR = 6.17). HLA DR7 was significantly increased in those patients with acrofacial, compared to focal disease (57% vs. 24% P = 0.038). Sixty-six per cent of the patients in this study had parents who were consanguineous and a positive family history was only found in this group with an incidence of 32%. HLA Bw4 segregated 100% with patients with a positive family history compared with 48% in consanguineous patients without a positive family history (Pc = 0.011 RR = 23). Vitiligo appears to be associated with different HLA antigens in different ethnic groups.

Increased incidence of antismooth muscle antibody in Korean vitiligo patients

To evaluate the incidence of autoimmune disorders and organ-specific autoantibodies in Korean vitiligo patients, antibodies to nuclear, mitochondrial, smooth muscle, gastric parietal cell, thyroglobulin, and microsomal antigens were screened in 226 vitiligo patients and 120 controls. Of the 226 vitiligo patients, three (1.3%) had thyrotoxicosis and two (0.8%) had diabetes mellitus. The vitiligo patients had an increased incidence of antinuclear (12.4%), antimicrosomal (7.1%), and antismooth muscle antibodies (25.7%). The increased incidence of antismooth muscle antibody was correlated with early onset (less than 15 years), a positive family history of vitiligo, and long duration of vitiligo. These results support an autoimmune origin of vitiligo and suggest that the high incidence of antismooth muscle antibody is a distinctive feature of laboratory findings in Korean vitiligo patients.

HLA associations in vitiligo patients in the Dutch population

This study characterizes the HLA class I and class II antigens in a group of patients with vitiligo and a control group, both of Dutch descent. Earlier reports had shown a significant positive association with DR4 and a significant negative association with DR3. We found that, after correction for the broad antigens studied, only Cw7 and DR6 were significantly associated with vitiligo. The significant positive association of DR6 with vitiligo is interesting since vitiligo has an autoimmune component in its pathogenesis and DR6 may be a marker for high immune responsiveness.

Peripheral blood lymphocyte imbalance in Koreans with active vitiligo

BACKGROUND

An immune-mediated destruction of melanocytes is the most popular current theory of vitiligo. There have been a few published reports on the assessment of lymphocyte population in vitiligo, and they showed mixed results. The purpose of our investigation was to assess peripheral lymphocyte subpopulations in Koreans with actively spreading vitiligo.

METHODS

Fifty patients with actively spreading vitiligo and 30 normal persons were studied for peripheral blood lymphocyte imbalance using flow cytometry. The percentages of total T-lymphocytes, B-lymphocytes, helper T cells, suppressor T cells, and natural killer cells were evaluated with the use of CD3, CD19, CD4, CD8, and CD16 monoclonal antibodies, respectively.

RESULTS

The mean value of helper T cells showed a significant difference between the two groups with the value being 38.2% in patients and 43.5% in control subjects. Seventeen of the 50 patients showed reversed helper/suppressor T cell ratio, whereas only 1 of 30 control subjects showed reversed ratio. There was a statistically significant difference in the mean percentage of helper T cells and suppressor T cells between generalized vitiligo patients and control subjects. The percentage of B cells in patients with recent onset less than 1 year was higher than control subjects and patients with late onset. The mean percentage of natural killer cells was increased significantly in patients with negative autoantibody test.

CONCLUSIONS

The present data show that immunologic abnormalities, both cellular and humoral, are involved in the pathogenesis of vitiligo.

Vitiligo

Vitiligo is a disease that affects from 1 to 3 per cent of the population. It is characterized by cutaneous white macules that often develop in cosmetically important areas such as the face, the dorsal hands, and the arms. It may be accompanied by ocular abnormalities and a number of associated disorders such as thyroid disease, diabetes, pernicious anemia, and alopecia areata. There is increasing evidence that vitiligo is an autoimmune disease. Although there is as yet no definitive cure, many patients have obtained respectable repigmentation by the use of topical or oral psoralen plus ultraviolet light. When large areas of skin are involved or when the patient is unresponsive to therapy, serious consideration should be given to depigmentation with monobenzone (Benoquin).