Vitiligo is an acquired cutaneous depigmentary disorder with a classical presentation of numerous or solitary well-defined depigmented patches or macules that can be localized, segmental, or non-segmental/generalized [1]. It affects approximately 0.1% to 3% of the population [2]. Its pathogenesis is not well understood; however, biochemical, neural, viral, genetic, and autoimmune causes have been proposed [3]. Vitiligo can cause psychosocial distress owing to the resulting cosmetic disfigurement, although it is not a detrimental disease.

Patient was a 46-year-old male Chinese accountant who visited my clinic presenting with a few white patches on his face for 2 years. The first lesion appeared on his forehead, and it was an irregular, tiny, whitish area. Later, it grew in size and spread to both sides of his face and to the right perioral area. The oral mucosa, legs, arms, body, and neck were not affected. These lesions were neither painless nor itchy. Patient’s biggest concern was facial disfigurement, which resulted in considerable stress during social activities. He felt embarrassed when people looked at him during conversations, and this negatively impacted his ability to enjoy social gatherings, including those with family members.

Patient had no known drug allergies and a good health history. No family history of thyroid disease, diabetes mellitus, or any other autoimmune diseases was present. He was not on any herbal or non-herbal supplements or drugs, and he was a non-drinker and non-smoker. As for his personal life, he had been living in his own property and had gotten divorced 1 year prior to the skin depigmentation. No significant mood changes were observed. His usual activities were indoor, and he did apply sunscreen when going outdoors.

Patient was diagnosed with vitiligo on his first visit to another family practice clinic. Topical steroid cream was prescribed, which he applied for only 4 days before discontinuation as a result of his friends indicating the side effects of steroids such as thinning of skin. He visited another clinic, and the family doctor suggested depigmentation. Patient did not follow this suggestion, as strict sun avoidance was difficult. In addition, owing to the potential side effects of psoralen with ultraviolet A treatment, he was reluctant to undergo phototherapy. He also refused oral medications owing to their side effects.

On physical examination, patient had Fitzpatrick type IV skin. More than 10 depigmented and well-defined macules and patches were observed on both sides of his face and his forehead (Fig. 1; we received the patient’s consent form about publishing all photographic materials). Owing to the patient’s request, photographs of other parts of his face have not been included. Scaling was not observed, and the oral mucosal area was not involved. No acanthosis nigricans, joint swelling, butterfly rashes, pallor, or goiters were observed. The nails, hair, and scalp were normal. No other similar lesions were observed in any other body parts. Patient did not show any signs of mood disorders.

Figure 1. Patient’s front facial area before the first round of intense pulsed light treatment.

Management

A Wood’s lamp was used to examine the hypopigmented lesions. They appeared well-defined with a sharp border. This finding supported the diagnosis of acrofacial vitiligo. I also performed the following blood tests for patient owing to the association of vitiligo with other autoimmune diseases: renal, liver, and thyroid (free thyroxine and thyroid stimulating hormone) function tests, fasting glucose (to rule out diabetes mellitus) and anti-nuclear antibody levels, and complete blood count (to rule out pernicious anemia). All blood test results were normal.

The patient was unwilling to take any oral or topical medication. Compliance was one of the main hurdles to overcome in this case; however, this was mitigated after he agreed to the application of light therapy. We treated the patient with intense pulsed light, once every 3 weeks. An eye shield was provided. The parameters of the intense pulsed light are shown in Fig. 2.

Figure 2. Intense pulsed light treatment parameters for vitiligo patient.

Fig. 3 shows patient’s forehead a month after 15 treatment sessions with intense pulsed light. He was satisfied with the treatment outcome. Re-pigmentation was observed from the lesion borders to the central area. Owing to financial concerns, patient discontinued his treatment after 15 treatment sessions with intense pulsed light.

Figure 3. Patient’s facial frontal area after 15 rounds of intense pulsed light treatment.

Patients with vitiligo may experience social embarrassment, stigmatization, and distress. Mechri et al. [4] reported a higher risk of anxiety-depression disorders in patients with vitiligo. Alghamdi et al. [5] interviewed 924 Saudi Arabians in a study; one-third believed that vitiligo was infectious, and more than 54% were unwilling to marry a patient with vitiligo. In addition to treating the patient’s skin problem, we also taught our patient the camouflage technique to conceal the lesions using concealer. The patient’s self-confidence improved with this measure.

Post et al. [6], in their literature review of laser-and intense pulsed-light-induced vitiligo patches, demonstrated that intense pulsed light can induce vitiligo.

For light therapy of vitiligo, only the effectiveness of monochromatic excimer laser in re-pigmenting vitiligo lesions is supported by evidence [7]. Our case report provides a new treatment option for patients with vitiligo by demonstrating that intense pulsed light can be effective in treating them. We do not know the mechanism of action, but we hypothesize it is similar to that causing post-inflammatory hyperpigmentation, which is usually regarded as a side effect of light treatment.

In this case report, we demonstrate that intense pulsed light can help induce re-pigmentation in patients with vitiligo. More research is needed on histological changes in post-IPL tissue and for the evaluation of long-term sustainable results and optimal treatment parameters. Furthermore, selection of patients is also important. Potential complications with intense pulsed light include post-inflammatory hyperpigmentation, burns, and pain [8].

The authors have nothing to disclose.