Depigmented/white macules and patches affecting skin and mucosa; hair within affected areas can also lose its color.

Two general categories

• Nonsegmental (most common): Generalized and acral/acrofacial most common.
  
  
  
  • Generalized: Usually symmetric, random distribution, pressure/friction/trauma sites, early childhood or adult onset, face, trunk, and extremities.
    
  • Acral/acrofacial: Distal extremities or face, can become generalized or confined to lips and tips of fingers/toes.
    
  • Mucosal: Oral/genital mucosa, with generalized or isolated.
    
  • Universal: Nearly complete to complete depigmentation, usually from progression of generalized.
  
  
• Segmental: Least common, childhood, typically dermatomal or quasi-dermatomal, commonly along trigeminal nerve distribution, rarely spreads, usually stabilize within a year, leukotrichia (depigmented hair).

Clinical variants

• Trichrome: patients with skin of color may have more obvious graded shading between the normal and depigmented skin.
  
• Marginal inflammatory: 5% may develop raised, pink to red border.
  
• Quadrichrome: Perifollicular or marginal hyperpigmentation.
  
• Koebnerization: Development of new areas of vitiligo following skin injury may occur on occasion as well as halo nevi with rings of depigmentation around pigmented nevi.

Associations: Thyroid disease (most common) in family members; may include retinal depigmentation, uveitis without eye color change, and hearing loss that is rare in children and does not require screening.

• Generalized presentation: Tinea versicolor, pityriasis alba, morphea, piebaldism, congenital hypopigmentation or depigmentation along lines of Blaschko, Waardenburg syndrome, postinflammatory hypopigmentation, and leprosy (Hansen disease).
  
• Segmental presentation: Nevus depigmentosus, nevus anemicus; localized Blaschkoid depigmentation.

• Counseling: Areas of vitiligo have no protection from UV radiation, aggressive sun protection but short periods of sun exposure before applying sunscreen may be helpful.
  
• Topical therapy: Calcipotriene, mid- to ultrapotent topical steroids (triamcinolone, clobetasol); topical calcineurin inhibitors (tacrolimus, pimecrolimus) may be effective particularly in sensitive areas where topical steroids should be avoided; once per day on weekdays with weekends off can reduce risk of side effects from ultrapotent steroids.
  
• Phototherapy: Narrow-band ultraviolet B (NBUVB) safer than UVA-1 or UVA; combination of topical and phototherapy likely more effective than monotherapy; erbium laser-assisted dermabrasion and fractional CO2 lasers with NBUVB; oral steroids may be helpful in halting progression but have significant side effects and not recommended; depigmentation therapy used only for patients with >75% body surface area refractory to other therapies.
  
• Janus kinase (JAK) inhibitors: Topical ruxolitinib 1.5% cream twice per day, selective JAK1/2 inhibitor, approved for age >12 years, maximum dose of 60 g per week.
  
• Other: Melanocyte keratinocyte transplantation via autologous punch and suction blister grafts, split thickness grafts, needling, and noncultured epidermal cell suspension shows promise, although they are complicated and not generally used in children.

• General presentation: slowly progressing, 5% may lose >20% body surface area of pigment, responsive to therapy, and rare spontaneous resolution.
  
• Segmental presentation: rapidly progressing to a stable affected area, less responsive to therapy than generalized disease, and rare risk for generalized disease.
  
• Facial vitiligo most responsive to therapy; associated with psychological distress in older children and adults.