Snapshot A 45-year-old woman presents to her dermatologist for further management of her vitiligo. In the past few months she has been very stressed with trouble at work, home, and recent deaths in the family. Her vitiligo has spread from her hands to her arms, face, chest, back, and legs. Given the widespread nature of her disease, she is started on phototherapy with pulses of oral steroids. Introduction Clinical definition autoimmune disease characterized by absent pigmentation due to loss of functioning melanocytes Epidemiology demographics onset between 10-30 years of age risk factors family history of vitiligo Pathogenesis exact mechanism is unknown theories include autoimmune attack on melanocytes stress leading to neurogenic factors that affect melanocyte survival reactive oxygen species attack on melanocytes Associated conditions vitamin D deficiency thyroid disease alopecia areata Prognosis chronic disease that waxes and wanes Presentation Symptoms asymptomatic Physical exam depigmented patches (not just lack of a tan or hypopigmentation) sharply demarcated white lesions Wood lamp can highlight these areas fluorescence Studies Biopsy rarely needed only done when clinical diagnosis is unclear Histology absence of melanocytes on tissue slide loss of epidermal pigmentation Differential Tinea versicolor Pityriasis alba Treatment Conservative cosmetic camouflage indication for patients who wish to camouflage the vitiligo patches modalities temporary makeup to color skin tattoo bleaching skin to produce uniform color sunscreen indication to protect against sunlight Medical topical corticosteroids indication for localized disease topical calcineurin inhibitors indication for localized disease phototherapy indications for widespread disease used often with topical vitamin D analogs or oral corticosteroids modalities narrowband ultraviolet B psoralen with ultraviolet A oral corticosteroids indication used either alone or with phototherapy Complications Poor quality of life and psychologic burden