Clinical Challenge: White Spots on Hands and Arms


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A 43-year-old Hispanic woman presents for evaluation of white spots that were first noted on the back of her hands approximately 3 months prior to evaluation and have spread to her arms and face. She states that the extremity sites were preceded by the appearance of tiny white dots that progressively enlarged. All sites have remained asymptomatic. Her medical history is significant for thyroid disease and hypertension. Examination reveals depigmented macules of the affected areas.

Vitiligo is a common skin disorder that affects up to 1% of the world’s population.1 The prevalence of vitiligo does not differ by sex or race and starts before the age of 20 years in approximately half of all patients.1 Vitiligo classically...

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Vitiligo is a common skin disorder that affects up to 1% of the world’s population.1 The prevalence of vitiligo does not differ by sex or race and starts before the age of 20 years in approximately half of all patients.1 Vitiligo classically manifests as well-demarcated depigmented macules that usually increase in size over time. This acquired depigmenting disorder commonly affects the hands, forearms, feet, and face.2,3

Two main types are identified: segmental and nonsegmental.2 Nonsegmental vitiligo is more common, involves multiple body parts, and is often symmetrical in distribution.2 Segmental vitiligo is focal in nature, often unilateral, has a rapid onset, and involves the hair follicle pigmentary system.2 Features of both types (mixed vitiligo) may be seen in the same individual.1,2 A recently described variant, as exhibited by this patient, is the initial appearance of confetti-like macules at the border of lesions.4 These signal a poor prognosis with rapid extension of depigmentation.

Diagnosis is usually made based on clinical features. If necessary, biopsy of a lesion may be used to differentiate vitiligo from other hypopigmented or depigmented disorders.1-3 Histopathologic examination will show absence of melanocytes and complete epidermal pigmentation loss.3 Patients with vitiligo are at increased risk for other autoimmune diseases, particularly thyroid disease, and should undergo screening for these disorders periodically.1,2,3

Vitiligo is most apparent in patients with darker skin and may negatively impact quality of life.5 The disorder is an autoimmune disease linked to cytotoxic CD8+ T cells that induce suppression of melanocytes.6 Traditional therapies include ultraviolet light as well as topical steroids and calcineurin inhibitors, although results are often suboptimal.2 Recently both topical and oral Janus kinase inhibitors have demonstrated efficacy and offer a promising therapeutic option.7,8

Brittany Spinosa-Weber, PA-C, is a physician assistant at DermDox Dermatology Centers in Leola, Pa. Stephen Schleicher, MD, is director of DermDox Dermatology Centers in Pennsylvania, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.


1. Ezzedine K, Lim HW, Suzuki T, et al; Vitiligo Global Issue Consensus Conference Panelists. Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference. Pigment Cell Melanoma Res. 2012;25(3):E1-13. doi:10.1111/j.1755-148X.2012.00997.x

2. Taieb A, Alomar A, Böhm M, et al; Vitiligo European Task Force (VETF); European Academy of Dermatology and Venereology (EADV); Union Europe´enne des Me´decins Spe´cialistes (UEMS). Guidelines for the management of vitiligo: the European Dermatology Forum consensusBr J Dermatol. 2013;168(1):5-19. doi:10.1111/j.1365-2133.2012.11197.x

3. Ahmed jan N, Masood S. Vitiligo. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Updated August 11, 2021. Accessed September 2, 2021.

4. Sosa JJ, Currimbhoy SD, Ukoha U, Sirignano S, O’Leary R, Vandergriff T, Hynan LS, Pandya AG. Confetti-like depigmentation: a potential sign of rapidly progressing vitiligoJ Am Acad Dermatol. 2015;73(2):272-5. doi:10.1016/j.jaad.2015.05.014

5. Grimes PE, Miller MM. Vitiligo: patient stories, self-esteem, and the psychological burden of disease. Int J Womens Dermatol. 2018;4(1):32-37. doi:10.1016/j.ijwd.2017.11.005

6. Frisoli ML, Essien K, Harris JE. Vitiligo: mechanisms of pathogenesis and treatmentAnnu Rev Immunol. 2020;38:621-648. doi:10.1146/annurev-immunol-100919-023531

7. Hamzavi I, Rosmarin D, Harris JE, et al. Efficacy of ruxolitinib cream in vitiligo by patient characteristics and affected body areas: Descriptive subgroup analyses from a phase 2, randomized, double-blind trial. J Am Acad Dermatol. 2021 Jun 2:S0190-9622(21)01043-4. doi:0.1016/j.jaad.2021.05.047

8. Komnitski M, Komnitski A, Komnitski Junior A, Silva de Castro CC. Partial repigmentation of vitiligo with tofacitinib, without exposure to ultraviolet radiation. An Bras Dermatol. 2020;95(4):473-476. doi:10.1016/j.abd.2019.08.032