VITILIGO

Vitiligo is a relatively common, sometimes familial disorder in which
depigmentation of the skin occurs. It may start at any age but often starts
in young adults. Lesions start as small white macules and become
progressively larger and confluent, leading to bizarre shapes. Common
localisations are the hands and feet and the skin around body openings,
e.g. around the eyes, nose, mouth and lips, the umbilicus, and around the
genitals and the anus. Vitiligo also occurs in traumatised skin and can
affect hair bulbs, leading to streaks of white hair. The condition is usually
slowly progressive and seldom regresses spontaneously. Vitiligo of the
genital area should be distinguished from lichen sclerosis, in which
depigmentation and atrophy are usually limited to this area.
Management of vitiligo
- There is no satisfactory treatment. Reassure the patient; there is only colour
change, vitiligo is not a sign of abuse.
- Sometimes the combination of topical steroids and sun exposure results in
repigmentation.

LICHEN PLANUS

Lichen planus presents with very typical itchy papules, which are small
(1-3 mm) and are demarcated by the natural skin lines, making them
polygonal. They have a sharp, elevated border, a flat surface (hence the
name "planus") and they shine by reflecting light. They are often a shade
of red, later reddish blue to purple and show "Wickham’s striae", a fine
milky-white network on the papule’s flat surface. Neighbouring papules
may join together to form plaques which resemble lichen growing on
trees, explaining the name "lichen". They may occur anywhere on the skin
but are most common on joint flexures (especially wrists), genitals, sacral
region and inner thighs. A Koebner phenomenon is present. The oral
mucosa and lips may be affected and show a network of white lines.
Actinic lichen planus occurs on sun-exposed areas. In hypertrophic lichen
planus there are thick, hyperkeratotic papules and nodules or thickened
wart-like plaques on the shins. Lichen planus is self-limiting, it will disappear
spontaneously, sometimes in months but it may take many years.
Management of lichen planus
Treatment can be very difficult.
- For severe itch: calamine lotion and/or antihistamines.
- Coal tar 2-6% ointment nightly.
- Strong topical steroids combined
with salicylic acid 5% once to twice
daily.
- Refractive lesions: Apply strong
steroid at night and cover with
plastic 2 nights a week (see lichen
simplex). This improves penetration
of the steroid.
- Widespread, severe forms: a short
course of prednisolone may be tried:
start with 30 mg daily for a week
then reduce to zero in two weeks

CHRONIC DISCOID LUPUS ERYTHEMATODES

Chronic discoid lupus erythematodes (CDLE) is a chronic scarring skin disease
which occurs on sun-exposed areas. The face is the commonest
site, but scalp, upper trunk and distal extremities may also be affected.
On the face there may be a "butterfly distribution" on the cheeks and
bridge of the nose, the lips may also be affected. The lesions are welldefined
reddish patches with thick or hyperkeratotic scaling and hyper-,
hypo- or depigmentation, they feel rough on palpation. They slowly increase
in size and form atrophic hypopigmented scars. Exposure to sunlight
aggravates the lesions and causes an increase in symptoms, such as itch
and irritation.
Management of chronic discoid lupus erythematodes
- Sunprotection! Wear a sunhat, protective clothing, and stay out of the sun as much
as possible. Use a sunscreen when outdoors (see albinism).
- Topical steroids e.g. betamethasone 0,1% once daily. If this is not effective after
2 months, this treatment should be stopped, as there is already a high risk of
skin atrophy.
- Chloroquine 150 mg/hydroxychloroquine 200 mg once daily for 6-8 weeks. If
improving continue until maximum improvement (i.e. no active lesions, scars will not
disappear), then slowly decrease the dosage (over months). If no improvement
occurs a double or triple dose may be tried for a short time. Do not use antimalarials
for more than 9 months at a time.
- Sometimes dapsone, with or without antimalarials is effective.

CHRONIC BULLOUS DERMATOSIS OF CHILDHOOD

This is a chronic blistering disease which occurs in children. It usually
starts before the age of 5 years. Small and large blisters appear predominantly
on the lower trunk, genital area and thighs, often also on the
scalp and around the mouth. They may spread all over the body. New
blisters form around healing old blisters, forming "a cluster of jewels".
There is often some itchiness. The course is chronic, spontaneous remission
usually occurs after an average of 3-4 years.
Management of chronic bullous dermatosis of childhood
- Dapsone in doses from 12,5 to 125 mg daily or Sulphapyridine 250 mg to 3 grams
daily usually control the eruption. After it clears you can slowly reduce the dosage to
a maintenance dose but you may need to increase it again when disease activity
flares up.
- Treat any superinfection with betadine, GV paint or if severe antibiotics.
- If there is no response to the above treatment, topical (strong) or systemic corticosteroids
may need to be added. Take care not to overtreat, especially regarding the
side effects of systemic steroids in children.

ALOPECIA AREATA

Alopecia areata occurs in adults and in children and generally presents
as one or more round or oval bald patches on the scalp or beard area. The
hair is lost suddenly, the bald patch extends until it is usually some centimetres
in diameter, and as a rule after weeks to months new hairs
begin to grow within the lesion. The skin remains normal, showing hairfollicle
openings without scaling or atrophy. The re-growing hair may be
white in colour, giving the impression of "turning white overnight" when
a large area is affected.
In progressive cases new bald patches develop as others heal, or patches
do not heal for years. In alopecia areata totalis there is baldness of the
whole head; in alopecia areata universalis all body hair including scalp,
beard, eyebrows, eyelashes, pubic and axillary hair falls out.
Management of alopecia areata
- Explain to the patient that the condition is not serious and that the hair is likely to
grow back after some time. This may take weeks or months and is different in each
individual.
- A topical irritant such as garlic may be tried.
- People with very extensive alopecia areata or alopecia which does not heal may be
referred to a skin specialist.