British Journal of Dermatology (1975) 93, 229.
Vitiligo and jaundice H.NEERING Department of Dermatology, Free University Hospital, de Boelelaan 1117, Amsterdam, The Netherlands Accepted for publication 19 February 1975
Danzig (1953) described the absence of jaundice in the vitiligo patches of a woman with cirrhosis of the liver, and though several possible mechanisms were discussed, no satisfactory explanation was offered. A similar phenomenon was noticed by Pegum (1953) in a patient with vitiligo, treated with mepacrine. Here also the vitiligo patches did not seem yellow, but the fluorescing drug could be demonstrated in the vitiliginous skin, and the vitiligo patches did appear yellow when seen against a white background. Fitzpatrick & Mihm (1971) commented on both cases and wondered if indeed bilirubin is absent in the depigmented skin of patients with vitiligo and jaundice. We would like to describe such a patient in whom the vitiliginous skin was clearly jaundiced.
A 74-year-old housewife was admitted to hospital with severe jaundice, present for about 5 weeks, due to an obstructing pancreatic tumour. The total plasma bilirubin content was 230/imol/l (normally less than 9 ^mol/1). Vitiligo had been present for 34 years, and the patient's mother, brother and a son also had vitiligo. Localized to the face and on the trunk (around an appendicectomy scar), in the axillae, on the perineum, but mainly on the distal parts of the extremities the patient showed several nummular, partly confluent, patches of clear light yellow colour, contrasting vividly to the other parts of the body, which were dark yellow brown. The sclerae were yellow. The vitiligo patches on the back of the hands and the knees were less yellow than those on the rest of the body. In the following days the yellow colour increased, in parallel with the plasma bilirubin levels (up to 600 ;umol/l). After about 2 weeks an anastomosis between the bile duct and the duodenum was made, resulting in lowering of bilirubin levels and diminution of the jaundice. Just before discharge from hospital, when the bilirubin level had fallen to loo |imol/l, the yellow colour of the vitiligo patches, especially on the hands, had almost gone. However when the hands were compared with a sheet of white paper the yellow colour was still distinct. The yellow-brown discolouration of the rest of the body remained and the sclerae were still yellow. In this case we clearly saw that jaundice can exist in vitiligo patches. The difference between our observations and those of Danzig may have been caused by the fact that our patient had much higher levels of plasma bilirubin. Danzig mentioned only one bilirubin value, 6-2 mg/ioo ml (= 106 /imol/1), which was approximately the concentration noted in our patient, when her vitiligo patches were almost white. Jaundice is normally seen when the serum bilirubin level exceeds2-5-3-omg/iooml (about 60 ^mol/1) and so one might have expected to find the vitiligo patches of Danzig's patient and our patient at the 229
230
Brief communication
time of discharge to be clearly yellow. The relative absence diffusion or fixation of bile pigments in vitiliginous skin, but case of vitiligo and mepacrine, the phenomenon is an optical depigmented skin of the vitiligo patches and the surrounding
of jaundice could be due to impaired we feel it is more likely that, as in the effect due to the contrast between the hyperpigmented skin.
REFERENCES DANZIG, L . E . (1953) Vitiligo and jaundice. American Journal of Medical Science, 225, 76. FiTZPATRiCK, T.B. & MiHMj M.C. (1971) Abnormalities of the melanin pigmentary system. In: Dermatology in General Medicine (Ed. by T.B. Fitzpatrick, K.A. Arndt, W.H. Clark, A.Z. Eisen, E.J. Van Scott and J.H. Vaughan), p. 1602. McGraw-Hill, New York and London. PEGUM, J.S. (1953) Vitiligo treated with Mepacrine. British Journal of Dermatology, 65, 324.
Vitiligo and jaundice H.NEERING Department of Dermatology, Free University Hospital, de Boelelaan 1117, Amsterdam, The Netherlands Accepted for publication 19 February 1975
Danzig (1953) described the absence of jaundice in the vitiligo patches of a woman with cirrhosis of the liver, and though several possible mechanisms were discussed, no satisfactory explanation was offered. A similar phenomenon was noticed by Pegum (1953) in a patient with vitiligo, treated with mepacrine. Here also the vitiligo patches did not seem yellow, but the fluorescing drug could be demonstrated in the vitiliginous skin, and the vitiligo patches did appear yellow when seen against a white background. Fitzpatrick & Mihm (1971) commented on both cases and wondered if indeed bilirubin is absent in the depigmented skin of patients with vitiligo and jaundice. We would like to describe such a patient in whom the vitiliginous skin was clearly jaundiced.
A 74-year-old housewife was admitted to hospital with severe jaundice, present for about 5 weeks, due to an obstructing pancreatic tumour. The total plasma bilirubin content was 230/imol/l (normally less than 9 ^mol/1). Vitiligo had been present for 34 years, and the patient's mother, brother and a son also had vitiligo. Localized to the face and on the trunk (around an appendicectomy scar), in the axillae, on the perineum, but mainly on the distal parts of the extremities the patient showed several nummular, partly confluent, patches of clear light yellow colour, contrasting vividly to the other parts of the body, which were dark yellow brown. The sclerae were yellow. The vitiligo patches on the back of the hands and the knees were less yellow than those on the rest of the body. In the following days the yellow colour increased, in parallel with the plasma bilirubin levels (up to 600 ;umol/l). After about 2 weeks an anastomosis between the bile duct and the duodenum was made, resulting in lowering of bilirubin levels and diminution of the jaundice. Just before discharge from hospital, when the bilirubin level had fallen to loo |imol/l, the yellow colour of the vitiligo patches, especially on the hands, had almost gone. However when the hands were compared with a sheet of white paper the yellow colour was still distinct. The yellow-brown discolouration of the rest of the body remained and the sclerae were still yellow. In this case we clearly saw that jaundice can exist in vitiligo patches. The difference between our observations and those of Danzig may have been caused by the fact that our patient had much higher levels of plasma bilirubin. Danzig mentioned only one bilirubin value, 6-2 mg/ioo ml (= 106 /imol/1), which was approximately the concentration noted in our patient, when her vitiligo patches were almost white. Jaundice is normally seen when the serum bilirubin level exceeds2-5-3-omg/iooml (about 60 ^mol/1) and so one might have expected to find the vitiligo patches of Danzig's patient and our patient at the 229
230
Brief communication
time of discharge to be clearly yellow. The relative absence diffusion or fixation of bile pigments in vitiliginous skin, but case of vitiligo and mepacrine, the phenomenon is an optical depigmented skin of the vitiligo patches and the surrounding
of jaundice could be due to impaired we feel it is more likely that, as in the effect due to the contrast between the hyperpigmented skin.
REFERENCES DANZIG, L . E . (1953) Vitiligo and jaundice. American Journal of Medical Science, 225, 76. FiTZPATRiCK, T.B. & MiHMj M.C. (1971) Abnormalities of the melanin pigmentary system. In: Dermatology in General Medicine (Ed. by T.B. Fitzpatrick, K.A. Arndt, W.H. Clark, A.Z. Eisen, E.J. Van Scott and J.H. Vaughan), p. 1602. McGraw-Hill, New York and London. PEGUM, J.S. (1953) Vitiligo treated with Mepacrine. British Journal of Dermatology, 65, 324.
