by Stephen Holt, MD, MS

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    00:01 Next up, Vitiligo.

    00:04 A vitiligo is characterized by very well demarcated, hypopigmented macules that can certainly coalesce into large patches, as we're seeing in this gentleman.

    00:15 It's an autoimmune disease attack on the melanocytes.

    00:18 It has nothing to do with any fungal infections.

    00:21 And the risk factors are having other autoimmune diseases.

    00:25 Oftentimes, you'll see patients have a history of type 1 diabetes, which I believe our patient did report.

    00:31 Graves disease, maybe rheumatoid arthritis or pernicious anemia, you get the point.

    00:36 These lesions are non-puritic.

    00:38 You really shouldn't see any scale.

    00:41 And they're usually on the face, the genitals, and probably the most often location we see them is on the hands.

    00:49 The disease course, the natural history, is fairly unpredictable.

    00:52 We really don't have any curative therapies but we can use as steroids which you can inject into the skin.

    00:58 Phototherapy can help.

    01:00 And also there's evidence that calcineurin inhibitors like tacrolimus and pimecrolimus can be helpful as well.

    01:07 Well, I'm thinking that with her hypopigmented macules on the face and the neck as well as her history of type 1 diabetes, we're probably obligated to keep vitiligo on our list for now.

    01:18 This is going to be one of those instances where a KOH prep will be really helpful.

    01:22 And lastly, we should just mention Candida intertrigo.

    01:25 Again, she is diabetic.

    01:27 She is somewhat immunocompromised, and thus, potentially at higher risk.

    01:31 Are those lesions on her face, satellite lesions? Again, typically, with Candida you're going to see hyperpigmented or really erythematous lesions, which is not what we're seeing here.

    01:43 So I think we can safely take Candida intertrigo off of our list.

    01:48 All right, to confirm our diagnosis and to tease apart these last two items, we'll need to get a KOH prep, which I can tell you shows Malassezia globosa hyphae and spores the so called spaghetti and meatballs pattern.

    02:01 and so our final diagnosis is tinea versicolor.

    02:05 Now, like most tinea, this can be treated with topical antifungals like fluconazole or selenium sulfide shampoo.

    02:14 So, let's highlight a few points in our case.

    02:17 As I mentioned, she has well control type 1 diabetes, It puts us at risk for certain things like vitiligo, but in this case, that was not going to be the most salient feature.

    02:26 The rashes on her chest, her face, her neck, that's a very typical location, for these hypopigmented macules of tinea versicolor.

    02:33 Again, the tripdown to the tropics could increase the risk of these developing and these lesions ought not to be itchy.

    02:40 Multiple scaly hypopigmented macules, coalescing into large patches, that would be a very common presentation for this condition.

    02:49 All right, so let's highlight a few key points about fungal skin infections.

    02:53 We've talked about the tinea family, tinea corporis or ringworm, tinea capitis on the scalp, Tinea cruria in the called jock itch, oftentimes.

    03:04 Tinea pedis, which can be around a two different patterns either the moccasin type or the interdigital maturation type, and then tinea unguium, also known as onychomycosis.

    03:14 We talked about Candida albicans, which commonly can cause candidal intertrigo underneath the breasts, in the axilla, in the groin, or underneath penis.

    03:23 We talked about tinea or pityriasis versicolor caused by malassezia globosa.

    03:29 We talked about how you can diagnose all of those fungal infections by just doing a skin scraping and putting some of the scale onto a slide putting a drop of KOH prep on there and looking for the spagetti or meatballs hyphy and other features of a fungal infection.

    03:46 And lastly, you can treat most of these with either topical, or oral antifungals like the azoles or terbinafine.

    About the Lecture

    The lecture Vitiligo by Stephen Holt, MD, MS is from the course Skin Infections.

    Included Quiz Questions

    1. It occurs due to melanocyte destruction by an autoimmune attack.
    2. KOH preparations show pseudohyphae and spores.
    3. It should be treated by oral azoles.
    4. The upper chest is commonly affected by vitiligo.
    5. Pruritus is a common presenting symptom.
    1. Gout
    2. Rheumatoid arthritis
    3. Pernicious anemia
    4. Type 1 diabetes mellitus
    5. Graves' disease

    Author of lecture Vitiligo

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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