Psoriasis Superimposed on Vitiligo: The Tricolored Vulva Kyi Saw Tin, James Scurry, FRCPA,1 and Delwyn Dyall-Smith, FACD2 1
Hunter Area Pathology Service, Faculty of Health Sciences, University of Newcastle, Newcastle; and 2Riverina Dermatology, Wagga Wagga, NSW, Australia
h Abstract This study aimed to describe 2 cases of vulvar psoriasis and vitiligo resulting in a striking clinical appearance. Materials and Methods. Case 1 was of a 41-year-old woman concerned about a dark pigmentation around the introitus. Case 2 was of an 80-year-old woman with vulvar itch and red, white, and brown areas. Results. The vulva in each case showed a tricolored appearance of well-demarcated red, white, and brown colors. Biopsies showed psoriasis superimposed on vitiligo in the red, vitiligo in the white, and normal skin in the brown areas. Conclusions. When psoriasis and vitiligo are colocalized, the redness of the psoriasis may mask the vitiligo resulting in a striking red, white, and brown tricolored appearance. h Objective.
Key Words: psoriasis, vitiligo, lichen planus, vulva
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itiligo and psoriasis are common skin diseases affecting 1% to 3% and 1% to 2% of the general population, respectively [1]. The 2 diseases have been occasionally reported together on nongenital skin [2]. Two patients with psoriasis superimposed on vitiligo on the vulva are presented. The well-demarcated red areas of psoriasis, white of vitiligo, and natural brown color of normal skin led to a striking 3-colored appearance, which we have termed ‘‘the tricolored vulva.’’
Reprint requests to: James Scurry, FRCPA, HAPS, Locked Bag No. 1, Hunter Region Mail Centre, NSW 2310, Australia. E-mail: jamespscurry@ gmail.com The authors have declared they have no conflicts of interest. Kyi Saw Tin is a medical student at the University of Newcastle, Newcastle, NSW, Australia.
Ó 2013, American Society for Colposcopy and Cervical Pathology Journal of Lower Genital Tract Disease, Volume 18, Number 1, 2014, E1YE3
CASE REPORTS Case 1 A 41-year-old Caucasian woman presented concerned about dark pigmentation around the vaginal introitus. She presented with a history of a diagnosis of oral and vulvar lichen planus 9 years earlier when she developed a very itchy and red vulva without discharge and peeling inside the mouth. Over the years, she had used betamethasone dipropionate in optomized vehicle (Diprosone OV ung; Merck, Sharp and Dohme Pty Ltd, NSW, Australia) intralesional corticosteroids and oral corticosteroids without apparent benefit. At times, she scratched during the night, waking with blood under her nails. This was associated with dysuria and dyspareunia. On general examination, she had cutaneous psoriasis and vitiligo, but no evidence of oral lichen planus. On the cutaneous aspect of the vulva, there was patchy erythema, white depigmentation, and brown pigmentation (see Figure 1A). Biopsies were taken from the 3 distinct clinical morphologies. In the red zone, the epidermis showed confluent parakeratosis, agranulosis, acanthosis with regular elongation of rete ridges, and basal mitoses. Compressed polymorphs were seen on the summits of mounds of parakeratosis (corneal abscesses; see Figure 1B). The dermis showed capillary dilatation and a superficial perivascular lymphocytic infiltrate. No fungi were seen on a PAS stain. Human melanoma black 45 (HMB-45) and microphthalmia transcription factor (MTIF) immunoperoxidase showed the absence of melanocytes at the dermoepidermal junction (see Figure 1B). The white zone showed an absence of basal layer pigmentation but was otherwise normal on routine stains. HMB-45 and MTIF showed absence of melanocytes (see Figure 1C). The brown zone was normal with junctional melanocytes
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
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Figure 1. A, Red (psoriasis), white (vitiligo), and brown (normal) skin on the vulva (case 1). B, Red skin of case 1 showing combined psoriasis and vitiligo. The routine histology (hematoxylin-eosin) shows parakeratosis, corneal abscess, and acanthosis of psoriasis (upper image), while the absence of melanocytes due to vitiligo is seen in the same skin in the lower image (HMB-45 immunoperoxidase). C, Brown skin and white skin of case 1. The brown skin (normal) shows normal numbers of melanocytes (upper image). The white skin (vitiligo) shows an absence of melanocytes (HMB-45 immunoperoxidase).
seen on HMB-45 and MTIF (see Figure 1C). There was no evidence of a lichenoid tissue reaction.
Case 2 An 80-year-old Caucasian woman presented with vulvar itch and pigment change. She had experienced a vulvar itch for many months and first noticed red, white, and brown areas on the vulva 7 months previously. During a pelvic ultrasound 1 year earlier, she was told her vulva was brown. Examination showed marked erythema of the cutaneous aspects of the labia majora and sharply defined
areas of brown and white pigmentation (see Figure 2). She had no history of psoriasis and no evidence of vitiligo elsewhere on examination with the Wood lamp. Biopsies were taken from all 3 areas. The histological changes were similar to those of case 1, except compressed polymorphs were not seen. No fungal elements were detected on the PAS stain. Diagnosis The diagnoses in both cases were psoriasis combined with vitiligo in the red zone, vitiligo alone in the white zone, and normal skin in the brown zone. Follow-Up After 2 months of treatment with methotrexate in case 1, the red areas on genital and nongenital skin faded to pink or white, leaving only vitiligo. Some areas of vitiligo appeared where previously only psoriasis was seen.
DISCUSSION
Figure 2. Red (psoriasis), white (vitiligo), and brown (normal) skin on the vulva (case 2).
A striking tricolored appearance of the vulva due to the superposition of psoriasis (red) on vitiligo (white) contrasted by normal skin (brown) was seen in both patients. The association of psoriasis and vitiligo is a manifestation of their common autoimmune pathogenesis. Recently, a common HLA locus, HLA-C/HLA-B rs9468925, has been found, providing precise evidence of the nature of their association [3]. The basis of their colocation has been suggested to be due to the Ko¨bner phenomenon, that is, dermatoses forming at the site of skin injury [4].
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Combined Vulvar Psoriasis and Vitiligo
The vulva is a site of predilection for minor injury due to friction. As in one of our patients, lichen planus, which is another autoimmune skin disease, may also be associated with vitiligo and psoriasis [5]. The colocation of psoriasis and vitiligo may be greater than first appears since psoriasis masks vitiligo. If psoriatic patches were to extend to or beyond the boundaries of vitiligo as seen in case 1, the vitiligo only becomes apparent with effective treatment of the psoriasis. In summary, clinicians should be aware that immunological skin diseases may be seen together on the vulva. A striking tricolored appearance of red, white, and natural brown color on the vulva may be due to psoriasis superimposed on vitiligo.
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REFERENCES 1. Torchia D, Terranova M, Fabbri P. Photosensitive psoriasis in a vitiligo patient. J Dermatol 2006;33:880Y3. 2. Wang WL, Lazar A. Lichenoid and interface dermatitis. In: Calonje E, Brenn T, Lazar A, McKee PH, eds. McKee’s Pathology of the Skin. 4th ed. Vol. 1. Philadelphia, PA: Elsevier Saunders; 2012:219Y58. 3. Zhu KJ, Lv YM, Yin XY, et al. Psoriasis regression analysis of MHC loci identifies shared genetic variants with vitiligo. PLoS One 2011;6:e23089. 4. Papadavid E, Yu RC, Munn S, Chu AC. Strict anatomical coexistence of vitiligo and psoriasis vulgarisVa Koebner phenomenon? Clin Exp Dermatol 1996;21:138Y40. 5. Ujiie H, Sawamura D, Shimizu H. Development of lichen planus and psoriasis on lesions of vitiligo vulgaris. Clin Exp Dermatol 2006;31:375Y7.
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Hunter Area Pathology Service, Faculty of Health Sciences, University of Newcastle, Newcastle; and 2Riverina Dermatology, Wagga Wagga, NSW, Australia
h Abstract This study aimed to describe 2 cases of vulvar psoriasis and vitiligo resulting in a striking clinical appearance. Materials and Methods. Case 1 was of a 41-year-old woman concerned about a dark pigmentation around the introitus. Case 2 was of an 80-year-old woman with vulvar itch and red, white, and brown areas. Results. The vulva in each case showed a tricolored appearance of well-demarcated red, white, and brown colors. Biopsies showed psoriasis superimposed on vitiligo in the red, vitiligo in the white, and normal skin in the brown areas. Conclusions. When psoriasis and vitiligo are colocalized, the redness of the psoriasis may mask the vitiligo resulting in a striking red, white, and brown tricolored appearance. h Objective.
Key Words: psoriasis, vitiligo, lichen planus, vulva
V
itiligo and psoriasis are common skin diseases affecting 1% to 3% and 1% to 2% of the general population, respectively [1]. The 2 diseases have been occasionally reported together on nongenital skin [2]. Two patients with psoriasis superimposed on vitiligo on the vulva are presented. The well-demarcated red areas of psoriasis, white of vitiligo, and natural brown color of normal skin led to a striking 3-colored appearance, which we have termed ‘‘the tricolored vulva.’’
Reprint requests to: James Scurry, FRCPA, HAPS, Locked Bag No. 1, Hunter Region Mail Centre, NSW 2310, Australia. E-mail: jamespscurry@ gmail.com The authors have declared they have no conflicts of interest. Kyi Saw Tin is a medical student at the University of Newcastle, Newcastle, NSW, Australia.
Ó 2013, American Society for Colposcopy and Cervical Pathology Journal of Lower Genital Tract Disease, Volume 18, Number 1, 2014, E1YE3
CASE REPORTS Case 1 A 41-year-old Caucasian woman presented concerned about dark pigmentation around the vaginal introitus. She presented with a history of a diagnosis of oral and vulvar lichen planus 9 years earlier when she developed a very itchy and red vulva without discharge and peeling inside the mouth. Over the years, she had used betamethasone dipropionate in optomized vehicle (Diprosone OV ung; Merck, Sharp and Dohme Pty Ltd, NSW, Australia) intralesional corticosteroids and oral corticosteroids without apparent benefit. At times, she scratched during the night, waking with blood under her nails. This was associated with dysuria and dyspareunia. On general examination, she had cutaneous psoriasis and vitiligo, but no evidence of oral lichen planus. On the cutaneous aspect of the vulva, there was patchy erythema, white depigmentation, and brown pigmentation (see Figure 1A). Biopsies were taken from the 3 distinct clinical morphologies. In the red zone, the epidermis showed confluent parakeratosis, agranulosis, acanthosis with regular elongation of rete ridges, and basal mitoses. Compressed polymorphs were seen on the summits of mounds of parakeratosis (corneal abscesses; see Figure 1B). The dermis showed capillary dilatation and a superficial perivascular lymphocytic infiltrate. No fungi were seen on a PAS stain. Human melanoma black 45 (HMB-45) and microphthalmia transcription factor (MTIF) immunoperoxidase showed the absence of melanocytes at the dermoepidermal junction (see Figure 1B). The white zone showed an absence of basal layer pigmentation but was otherwise normal on routine stains. HMB-45 and MTIF showed absence of melanocytes (see Figure 1C). The brown zone was normal with junctional melanocytes
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
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TIN ET AL.
Figure 1. A, Red (psoriasis), white (vitiligo), and brown (normal) skin on the vulva (case 1). B, Red skin of case 1 showing combined psoriasis and vitiligo. The routine histology (hematoxylin-eosin) shows parakeratosis, corneal abscess, and acanthosis of psoriasis (upper image), while the absence of melanocytes due to vitiligo is seen in the same skin in the lower image (HMB-45 immunoperoxidase). C, Brown skin and white skin of case 1. The brown skin (normal) shows normal numbers of melanocytes (upper image). The white skin (vitiligo) shows an absence of melanocytes (HMB-45 immunoperoxidase).
seen on HMB-45 and MTIF (see Figure 1C). There was no evidence of a lichenoid tissue reaction.
Case 2 An 80-year-old Caucasian woman presented with vulvar itch and pigment change. She had experienced a vulvar itch for many months and first noticed red, white, and brown areas on the vulva 7 months previously. During a pelvic ultrasound 1 year earlier, she was told her vulva was brown. Examination showed marked erythema of the cutaneous aspects of the labia majora and sharply defined
areas of brown and white pigmentation (see Figure 2). She had no history of psoriasis and no evidence of vitiligo elsewhere on examination with the Wood lamp. Biopsies were taken from all 3 areas. The histological changes were similar to those of case 1, except compressed polymorphs were not seen. No fungal elements were detected on the PAS stain. Diagnosis The diagnoses in both cases were psoriasis combined with vitiligo in the red zone, vitiligo alone in the white zone, and normal skin in the brown zone. Follow-Up After 2 months of treatment with methotrexate in case 1, the red areas on genital and nongenital skin faded to pink or white, leaving only vitiligo. Some areas of vitiligo appeared where previously only psoriasis was seen.
DISCUSSION
Figure 2. Red (psoriasis), white (vitiligo), and brown (normal) skin on the vulva (case 2).
A striking tricolored appearance of the vulva due to the superposition of psoriasis (red) on vitiligo (white) contrasted by normal skin (brown) was seen in both patients. The association of psoriasis and vitiligo is a manifestation of their common autoimmune pathogenesis. Recently, a common HLA locus, HLA-C/HLA-B rs9468925, has been found, providing precise evidence of the nature of their association [3]. The basis of their colocation has been suggested to be due to the Ko¨bner phenomenon, that is, dermatoses forming at the site of skin injury [4].
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Combined Vulvar Psoriasis and Vitiligo
The vulva is a site of predilection for minor injury due to friction. As in one of our patients, lichen planus, which is another autoimmune skin disease, may also be associated with vitiligo and psoriasis [5]. The colocation of psoriasis and vitiligo may be greater than first appears since psoriasis masks vitiligo. If psoriatic patches were to extend to or beyond the boundaries of vitiligo as seen in case 1, the vitiligo only becomes apparent with effective treatment of the psoriasis. In summary, clinicians should be aware that immunological skin diseases may be seen together on the vulva. A striking tricolored appearance of red, white, and natural brown color on the vulva may be due to psoriasis superimposed on vitiligo.
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E3
REFERENCES 1. Torchia D, Terranova M, Fabbri P. Photosensitive psoriasis in a vitiligo patient. J Dermatol 2006;33:880Y3. 2. Wang WL, Lazar A. Lichenoid and interface dermatitis. In: Calonje E, Brenn T, Lazar A, McKee PH, eds. McKee’s Pathology of the Skin. 4th ed. Vol. 1. Philadelphia, PA: Elsevier Saunders; 2012:219Y58. 3. Zhu KJ, Lv YM, Yin XY, et al. Psoriasis regression analysis of MHC loci identifies shared genetic variants with vitiligo. PLoS One 2011;6:e23089. 4. Papadavid E, Yu RC, Munn S, Chu AC. Strict anatomical coexistence of vitiligo and psoriasis vulgarisVa Koebner phenomenon? Clin Exp Dermatol 1996;21:138Y40. 5. Ujiie H, Sawamura D, Shimizu H. Development of lichen planus and psoriasis on lesions of vitiligo vulgaris. Clin Exp Dermatol 2006;31:375Y7.
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
