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Histopathologic Features in Vitiligo You Chan Kim, MD,* Yun Jeon Kim, MD,* Hee Young Kang, MD,* Seonghyang Sohn, Phd,† and Eun-So Lee, MD*

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Histopathologic Features in Vitiligo You Chan Kim, MD,* Yun Jeon Kim, MD,* Hee Young Kang, MD,* Seonghyang Sohn, Phd,† and Eun-So Lee, MD* ORIGINAL ARTICLE Histopathologic Features in Vitiligo You Chan Kim, MD,* Yun Jeon Kim, MD,* Hee Young Kang, MD,* Seonghyang Sohn, PhD,† and Eun-So Lee, MD* characterized by melanocyte loss in the epidermis.8–10 Le Abstract: Nevus depigmentosus is a congenital disorder charac- Poole et al8 reported that melanocytes were lost in vitiligo in terized by a nonprogressive hypopigmented lesion, which may not be their study, which used 18 antibodies against melanocytes. In apparent at birth. Thus, it is sometimes difficult to differentiate contrast, Husain et al11 discovered dihydroxyphenylacetic acid vitiligo from nevus depigmentosus only by clinical features. We pos- (DOPA)-positive melanocytes in vitiligo. Lesional skin in tulated that the histologic changes in lesional and perilesional skin vitiligo may not always be devoid of melanocytes, and melanin might be different in the 2 conditions. We took biopsies from both pigmentation may remain for a period of time after the lesional and perilesional skin of 100 cases of vitiligo to assess the development of vitiligo.12 Also, melanocytes and melanin number of melanocytes, the amount of melanin, dermal inflammatory pigment may be observed in the border areas around lesions of infiltrate, and other changes. We compared them with 30 cases of nevus vitiligo.13 Therefore, differential diagnosis of vitiligo from depigmentosus. Histologically, lesions of vitiligo showed more basal other depigmented disorders can be difficult even when hypopigmentation and dermal inflammation than perilesional normal a biopsy is performed. For example, the lesions of nevus skin. With Fontana–Masson staining, 16% of cases of vitiligo showed depigmentosus still contain some melanocytes. Thus, there is the presence of melanin. The ratio of pigmented area to epidermal a need for accurate histological investigation. Nevus depig- area was 0.06% in vitiligo, whereas 17% in perilesional normal skin mentosus is generally known to be a congenital disorder and 8.9% in nevus depigmentosus. In NKI/beteb staining, 12% of characterized by a hypopigmented macule or patch that vitiligo showed the presence of melanocytes, and their average num- remains stable over time. It may develop at various ages, which ber was 7.68 per square millimeter. The number of melanocytes was often makes the differential diagnosis of vitiligo challeng- also decreased in nevus depigmentosus but not as much as in vitiligo. ing.14,15 It is important to distinguish vitiligo from nevus We also confirmed the presence of melanocytes in 1 of 3 cases of depigmentosus because the prognosis and treatment of these 2 vitiligo by electron microscopy. In conclusion, there are a few mela- entities differ. Vitiligo is progressive and requires treatment, nocytes and melanin in some cases of vitiligo. Therefore, the diag- whereas nevus depigmentosus is stable and generally does not nosis of vitiligo should be made considering these points. require treatment. The misdiagnosis of nevus depigmentosus Key Words: immunohistochemistry, melanocytes, vitiligo as vitiligo may lead to tremendous psychologic trauma and economic loss, whereas the misdiagnosis of vitiligo as nevus (Am J Dermatopathol 2008;30:112–116) depigmentosus may also lead to the failure of treatment at the appropriate time.14 We investigated the number of melanocytes, the amount of melanin pigment, the dermal inflammatory infiltrate, and other changes between lesional skin in vitiligo, adjacent normal- INTRODUCTION appearing skin, and nevus depigmentosus skin to delineate the Vitiligo is a common acquired disorder characterized by histopathologic features that are important in differentiating patches of depigmentation. Its etiological factors include the vitiligo from nevus depigmentosus. contribution of a genetic predisposition, the nervous system, autoimmunity, and oxidative stress.1–4 A convergence theory combining all these pathogenetic hypotheses has also been suggested.5 In the majority of patients with vitiligo, the diag- MATERIALS AND METHODS nosis is established by direct clinical inspection followed by Subjects examination of the depigmented areas under Wood light. We examined 100 patients with vitiligo who presented Therefore, there are only a few reports on histopathological to the Department of Dermatology, Ajou University Hospital, changes in vitiligo.6,7 Vitiligo is generally known to be Suwon, Korea, between January 2003 and December 2004. There were 43 men and 57 women. Their mean age was 24.8 From the *Department of Dermatology; and †Laboratory of Cell Biology, years, and the mean duration of vitiligo was 13.3 months. We Ajou University School of Medicine, Suwon, Korea. also included 30 patients with nevus depigmentosus patients Supported by 2004 grant from Department of Medical Sciences, The Graduate (12 men and 18 women) for comparison. The mean age of the School, Ajou University. patients was 15.4 years, and the mean duration was 12.5 Reprints: You Chan Kim, MD, Department of Dermatology, Ajou University School of Medicine, 5 Wonchon-dong, Yeongtong-ku, Suwon, 443-721, months. Two-millimeter punch biopsies from lesional and Korea (South) (e-mail: maychan@ ajou.ac.kr). perilesional normal-appearing skin were obtained from all Copyright Ó 2008 by Lippincott Williams & Wilkins patients. 112 Am J Dermatopathol Volume 30, Number 2, April 2008 Am J Dermatopathol Volume 30, Number 2, April 2008 Histopathologic Features in Vitiligo Stains RESULTS A hematoxylin and eosin stain was used to study the general histopathological changes such as hyperkeratosis, General Histopathologic Features of Vitiligo acanthosis, exocytosis, spongiosis, basal hypopigmentation, In 78 of 100 (78%) cases, vitiligo skin showed more basal dermal melanophages, dermal inflammatory infiltrate, rete hypopigmentation compared with perilesional normal skin, ridge elongation, and telangiectasia in the vitiligo skin. Mel- whereas only 7 of 30 (23%) cases of nevus depigmentosus skin anin pigment was visualized with the Fontana–Masson stain, did (P , 0.05). The vitiligo skin showing mild dermal inflam- performed by the usual methods. mation accounted for 41% of the cases, which was more frequent than the 23% of cases of the perilesional normal skin (P , 0.05). Other features such as hyperkeratosis, acanthosis, Immunohistochemistry exocytosis, spongiosis, melanophages, rete ridge elongation, The melanocytes and inflammatory cells were stained and telangiectasia were observed in the vitiligo skin but were by immunohistochemistry using the standard technique.16 We not statistically significant in comparison to the perilesional used the following antibodies: NKI/beteb (1:20, Monosan, Uden, normal skin (P = 0.28) or the nevus depigmentosus skin (P = the Netherlands), MART-1 (1:100, Neomarker, Fremont, CA) to 0.74) (Table 1). visualize melanocytes, and CD1a (1:100, Novocastra, New castle upon Tyne, Tyne and Wear) to visualize Langerhans Quantitative Analysis of Melanin Pigment and cells. We also used CD3 (Novocastra), CD20 (Dako), and the Number of Melanocytes CD68 (Dako) to analyze dermal inflammation. In the stains for With the Fontana–Masson staining, 16 of 100 (16%) inflammatory cells (CD3, CD20, CD68, and CD1a), each com- cases of vitiligo skin showed remaining melanin pigment. ponent of the inflammatory cells was expressed as a percentage PA/EA was significantly decreased in the epidermal layers of of all inflammatory cells. vitiligo skin (0.06 6 0.00) compared with perilesional normal skin (17.25 6 5.56) or nevus depigmentosus skin (8.94 6 1.17, P , 0.05). The PA/EA of nevus depigmentosus skin was Image Analysis also decreased in lesional skin as compared with perilesional Quantification was performed with a computerized normal skin (14.11 6 4.79), but the amount of decrease was image analyzer (Image Pro Plus Version 4.5, Media Cybertics much smaller than in vitiligo skin (Fig. 1). Co., Silver Spring, MD) as described previously.16 The ratio of Remaining melanocytes were found in 12 of 100 (12%) pigmented area to epidermal area (PA/EA) was measured in vitiligo skin cases. The MC/EA was 7.68 6 24.43, and MC/1R lesional and control skin with Fontana–Masson staining. With was 0.35 6 1.16, whereas MC/EA and MC/1R were 384.36 6 the immunohistochemical stains for melanocytes (NKI/beteb 161.71 and 72.62 6 43.42, respectively, in perilesional normal and MART-1), the number of melanocytes was estimated using skin with NKI/beteb staining (P , 0.001). MART-1 staining 2 methods: the number of melanocytes per millimeter rete showed findings similar to the NKI/beteb staining (P = 0.01). ridge length (MC/1R) and the ratio of melanocytes to Nevus depigmentosus lesional skin showed a decreased MC/ epidermal area (MC/EA). Each melanocyte was counted as EA and MC/1R both for NKI/beteb and MART-1 staining com- 1 cell when its nucleus was confirmed. All morphometric pro- pared with that of the perilesional normal skin. But the amount cedures were performed by manually tracing the borders of the of decrease was greater in vitiligo than in nevus depigmentosus epidermis and rete ridges, and the epidermal area that con- (P , 0.05) (Table 2, Fig. 2). We then examined the rela- tained hair follicles was excluded from this tracing. tionship between duration of vitiligo and the number of Electron Microscopic Evaluation TABLE 1. Comparison of Histologic Features of Lesional and For electron microscopic evaluation, 3 pairs of lesional Perilesional Normal Skin in Vitiligo and Nevus Depigmentosus and normal skin specimens were processed as previously Nevus described.16
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