With regard to stable vitiligo lesions, sparse and moderate degrees of infiltrates were demonstrated in the upper dermis in 66 of 72 (91.7%) and six of 72 stable lesions (8.3%), respectively, with the absence of marked inflammatory infiltrates, epidermotropism and vacuolated keratinocytes in all stable biopsy specimens. Meanwhile, melanophages were identified in six of 72 stable vitiligo lesions (8.3%) (Table 2). All control biopsy specimens from healthy volunteers showed sparse infiltration only.
There was a statistically significant increase in moderate inflammatory infiltrates and melanophages in active than in stable vitiliginous lesions (P=0.0001). With regard to sparse infiltration, there was a statistically significant increase in either stable vitiligo (P=0.0001) or control normal biopsies (P=0.0001) compared with active vitiligo. Meanwhile, there was no statistically significant difference in sparse inflammatory infiltration between stable vitiliginous patches and control normal biopsy specimens (P=0.08).
All immune-stained biopsy specimens were positive for CD3 and CD68, but negative for CD20 (Fig. 4).
Assessment of the activity status of vitiligo lesions is mandatory to make therapeutic decisions. During activity, one of the main targets is to stop propagation through halting the immunological process using appropriate therapy 7,8. Accordingly, missing the time of activity may lead to a loss of opportunity of using the appropriate drug in its due time to stop disease progression. In contrast, activity is a main contraindication to surgical management of vitiligo as the use of grafting techniques during activity may lead to the development of new lesions at both the donor and the recipient sites 9,10.
Possible assessment of stability and activity may rely on a combination of history, serial digitized photographs and clinical scoring 4, which are time consuming and complicated processes. Accordingly, we are in need for simple clinical methods to assess the activity of vitiligo lesions.
The clinical changes recorded in this study are possible clues for a dermatologist to decide whether vitiligo is in activity or not. Among the most frequent findings during activity were the depigmented convex festooning edges (84.7%) and pigmented spikes (82.4%). Normally, the melanocyte is known to be in contact with 36 keratinocytes in basal and suprabasal layers through its dendrites forming ‘the epidermal melanin unit’ 11. Accordingly, the central existence of melanocytes within its functioning pigmenting areas may explain the appearance of the convexity and the festooning in active vitiligo patches as centrifugal depigmentation may occur when the melanocyte vanishes during macule progression. The remaining melanin between the two convex depigmenting areas will provide the pigmented spikes.
In contrast, repigmenting vitiligo patches under treatment showed pigmented convexity and festooning directed towards the depigmented areas (100%). This is because the newly formed melanocytes, evolving from hair bulge areas, provide melanin, which spreads centrifugally to neighboring keratinocytes, leading to the appearance of perifollicular pigmentation 12. With subsequent obliteration of depigmentation, a convex pigmented edge, which is demonstrated at the periphery due to melanization from nondestroyed marginal melanocytes, appeared with the pigmented perifollicular islands spreading centrifugally with another convex edge. Finally, both convex edges meet each other obliterating the white areas. Hence, the spikes are hypopigmented or depigmented, projecting towards the pigmented areas.
We also observed vitiligo patches with poorly defined borders in 76.5% of active vitiligo lesions, which were not found in any stable lesions. Instead, sharp delineated borders were found during stability in all lesions (100%).
Generally, melanosomes, containing melanin, are actively transported along melanocytic dendrites to neighboring keratinocytes, and then they move outward within the keratinocytes with gradual degradation till they are exfoliated through the stratum corneum 13. Accordingly, the concentration of melanin decreases in superficial layers with its higher concentrations within basal keratinocytes, which have very low mitotic activity. Meanwhile, the constitutive level of melanin production and delivery is in equilibrium with melanin loss through upper keratinocytes shedding 14. This equilibrium is lost in vitiligo when melanocytes are destroyed; hence, melanin concentration in the epidermis decreases, and subsequently hypopigmentation can be seen during activity (17.6%). The clinical finding of hypopigmented vitiliginous patches was described before by Sharqui 15.
Reticulated pattern of pigmentation or Chinese letter appearance was detected during activity (55.3%) and this is explained by an overlap of the remaining melanin in areas supplied by several groups of melanocytes.
Trichrome and quadrichrome vitiligo lesions were found in 36.5 and 1.2% of active vitiligo patients, respectively, demonstrating the decrease in epidermal melanin levels during activity, with sharp lines between the color differences. This was clinically described previously 16,17. Parsad et al.18 reported another possible explanation for the color changes, in which a decrease in the tyrosinase activity leads to death/inactivation of melanocytes, resulting in a switch in melanin formation from dark eumelanin towards pheomelanin with its lighter hue.
Vitiliginous lesions are asymptomatic, although itching may precede or accompany the onset of lesions in a few patients 19. In the current study, itching was elicited in five cases, who complained of it before the initial appearance of depigmentation.
Histopathologically, this study showed a statistically significant increase in moderate inflammatory infiltrates in active (65.9%) than in stable (8.3%) vitiliginous patches, which was mostly associated with absent marked infiltrates in stable lesions. These results are similar to those of previous studies 20–22, which reported a greater increase in inflammatory infiltrates in active than in stable vitiligo. In the current study, all immune-stained biopsy specimens of active vitiligo were positive for CD3 and CD68, but negative for CD20, indicating the presence of T lymphocytes and histiocytes, respectively, with the absence of B lymphocytes.
In this study, there was no statistically significant difference in sparse infiltrates between stable vitiliginous patches and control normal biopsies, indicating that there was no histopathological difference regarding inflammatory infiltrates between stable and control biopsies. This finding is in agreement with some authors, who failed to detect frank inflammatory changes in stable vitiligo patches 23.
Among histopathological signs of activity were epidermotropism (100%) and vacuolated keratinocytes (78.8%), which were absent in biopsy specimens of stable vitiligo lesions. This is similar to the findings of Le Poole and Norris 24. Meanwhile, these two findings were evident with all active vitiligo lesions showing sparse inflammatory infiltrates.
With regard to melanophages, there was a statistically significant increase in active (72.9%) than in stable (8.3%) vitiliginous lesions. The melanophages that are still present in stable lesions may be due to remaining melanin in vitiligo lesions. To the best of our knowledge, this study is the first one to mention that melanophages were present during activity. Vacuolar degeneration of basal cells leads to drop of melanin before their upward epidermal movement. After that, dermal histiocytes engulf the dropped pigment leading to the appearance of these melanophages. A previous literature described vitiligo with blue hue, which was not found in this study; yet it may be explained by the Tyndall phenomenon after dermal melanin drop 25.
We suggested that the morphology of the edge and the color of a vitiliginous patch can reflect the actual activity of the disease and can be used as clues to start immune-suppressor drugs and to avoid introduction of unneeded surgical procedures. Vitiligo patches with depigmented convex and festooned edges, pigmented spikes, a poorly defined border, a reticulated pattern, a trichrome pattern, hypopigmentation, an inflammatory raised edge and a quadrichrome pattern, in this sequence of frequency, could be considered as markers of clinical activation. Meanwhile, amelanotic vitiligo lesions with sharply demarcated borders could indicate the stability status of a lesion. Histopathologically, epidermotropism, vacuolated keratinocytes, and melanophages in a descending frequency may be considered as diagnostic clues for the disease activity.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2014 Egyptian Women's Dermatologic Society
active; regressing; stable; vitiligo