A case of vitiligo associated with paraffin injection.

Abstract

Dear Editor: Vitiligo is an acquired depigmentation disorder characterized by a progressive loss of melanocytes. The exact pathologic mechanism has not been clarified yet; however, the autoimmune hypothesis is the most widely accepted explanation. In some case reports, vitiligo was induced by trauma such as tattooing, eyebrow plucking, and intense pulse light treatment1,2,3. A 51-year-old woman presented with a 5-month history of multiple depigmented patches on both hands and the right foot. Importantly, she had received a paraffin injection on the dorsum of both hands, which had been performed by an unlicensed person 2 years ago. This was complicated by foreign body reaction accompanied by painful swelling of the injection sites, 1 month after the procedure. She had undergone partial removal of the granulomatous lesions and had been treated with oral corticoste intermittently for episodes of recurrent painful swelling. Five months ago, she began to notice numerous depigmented patches on both hands, including the paraffin injection sites, which were followed by new depigmented patches on the dorsum of the right foot, a month later. There was no personal or family history of vitiligo. Physical examination revealed multiple well-demarcated depigmented patches on the dorsum of both hands and on the dorsum of the right foot (Fig. 1A, B). Histopathological examination of the lesion showed aggregations of multiple clear vacuoles and lipophages in deep dermis (Fig. 2A, B). Additionally, Fontana-Masson and Melan-A staining demonstrated the loss of melanin pigments and melanocytes (Fig. 2C, D). Given the patient's history, clinical characteristics, and histopathologic findings, we diagnosed this case as vitiligo associated with paraffin injection. Fig. 1 Multiple well-demarcated depigmented patches on the dorsum of both hands (A) and of the right foot (B). Fig. 2 Biopsy specimen from the dorsum of the hand. (A, B) In the deep dermis, there is aggregation of multiple clear vacuoles and lipophages (HE A: ×40, B: ×400). (C) Absence of melanin pigments in the basal layer (Fontana-Masson, ... Our patient presented with hypopigmentation on the same locations of the paraffin injection sites, which began to develop 2 years after the injection. However, the lesions were also detected on the fingers and foot dorsum, which are frequently occurring sites of vitiligo. There have been case reports on the concurrence of vitiligo and chronic inflammatory disease such as psoriasis. For each associated diseases, several hypotheses have been suggested to explain a common pathogenesis, such as autoimmunity, Koebner phenomenon, involvement of neuropeptides, or decreased melanocytes and melanin4. In our case, the role of paraffin injection in the induction of vitiligo remains uncertain; however, the prolonged inflammation against paraffin had most likely damaged the melanocytes at the injection sites. To the best of our knowledge, this is the first report of vitiligo associated with paraffin injection. Although the foot lesion is remote from the injection site, we suggest that it is also possibly associated with the paraffin injection. The patient might have a vitiligo diathesis; thus, prolonged inflammation induced vitiligo, and then the autoimmunity caused the depigmentation on the foot. However, we cannot rule out that the vitiligo in this case is just a coincidence of paraffin injection. In conclusion, we report a rare case of vitiligo associated with paraffin injection. It is important that clinicians are aware of the potential pigmentary changes after paraffin injection.