DermatologyTier 2Disease (DEADMAN)

Pigmentary, inflammatory, and immune responses of the skin

Description

Pigmentary disorders (vitiligo, post-inflammatory hyper/hypopigmentation), inflammatory dermatoses, and immune-mediated skin conditions collectively represent a large share of dermatology practice - united by involvement of skin immune/pigmentary cell function rather than infection or malignancy

Vitiligo, the paradigm pigmentary autoimmune disorder, affects a small but significant proportion of the population, with a notable psychosocial burden particularly in darker-skinned individuals given the visibility of the pigment loss

Vitiligo - autoimmune (CD8+ T cell-mediated) destruction of epidermal melanocytes, producing well-demarcated depigmented macules/patches - associated with other autoimmune conditions (thyroid disease particularly)
Post-inflammatory hyperpigmentation/hypopigmentation - a non-specific consequence of skin inflammation of any cause, from altered melanocyte activity during the healing process, generally reversible over months though sometimes prolonged, particularly in darker skin types

Vitiligo is a clinical diagnosis (well-demarcated depigmented macules, Wood's lamp examination enhances contrast/visibility); screening for associated autoimmune thyroid disease is reasonable given the recognised association
Post-inflammatory pigmentary change is diagnosed by history (recent inflammatory skin event at the affected site) and typical clinical appearance

Vitiligo: topical corticosteroids/calcineurin inhibitors, phototherapy (narrowband UVB), and newer targeted agents (JAK inhibitors, e.g. topical ruxolitinib) for repigmentation; camouflage make-up and psychological support are valuable adjuncts given the significant cosmetic/psychosocial impact
Post-inflammatory pigmentary change: generally managed by treating the underlying inflammatory trigger and allowing time for resolution; sun protection reduces the risk of hyperpigmentation becoming more pronounced/persistent

Autoimmune thyroid disease (vitiligo association), alopecia areata (shares autoimmune mechanism), psychosocial impact of visible pigmentary change (particularly in darker skin types)

Vitiligo's psychosocial impact is often disproportionate to its purely medical significance (it causes no physical harm) but can be profound, particularly in darker-skinned individuals where the contrast is more visually striking - this should be actively acknowledged and addressed, not dismissed as a purely cosmetic concern

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