Here, we present two patients with generalized vitiligo who had absent or delayed repigmentation over lower extremity varicose veins, despite generalized repigmentation elsewhere after narrowband ultraviolet B (nbUVB) radiation therapy. Patient A received endovenous laser therapy to the greater saphenous vein and sclerotherapy of the superficial veins, which ultimately led to subsequent repigmentation of the overlying skin with continued nbUVB therapy.

Patient A was a 52-year-old woman with hypercholesterolemia, hypertension, and autoimmune hypothyroidism with a 40-year history of generalized vitiligo and a 15-year history of progressive, uncomfortable varicose veins. She presented for evaluation having failed multiple topical therapeutic agents (Figure 1A). After evaluation, the patient was started on nbUVB therapy three times weekly with substantial improvement after 2 months. However, no repigmentation was noted in the skin overlying the varicose veins. She received endovenous laser therapy to the greater saphenous vein and sclerotherapy of the superficial veins due to significant lower extremity discomfort. With 3 additional weeks of continued nbUVB to the overlying skin after the endovenous laser therapy and sclerotherapy treatments, the patient noticed substantial repigmentation over the calf and has experienced continued improvement since that time (Figure 1B).

FIGURE 1. Vitiligo. Generalized depigmentation of the left leg of Patient A. (A) Baseline depigmentation before initiation of nbUVB therapy. (B) Four months after varicose vein treatment, near-complete repigmentation with 7 total months of nbUVB therapy.

Patient B was a 58 year-old woman with a 3-year history of generalized vitiligo (Figure 2A) with little improvement on topical steroids or intramuscular triamcinolone. She presented for evaluation, seeking additional vitiligo treatment options. She began nbUVB therapy three times weekly. After 6 months, the skin of her legs had largely repigmented. However, there was only minimal repigmentation over the varicose veins in her thigh, calf, and feet (Figure 2B). After noting increasing discomfort related to varicose veins, the patient is considering referral to interventional radiology for treatment.

FIGURE 2. Vitiligo. Generalized depigmentation of the left leg of Patient B. (A) Baseline depigmentation before initiation of nbUVB therapy. (B) Large areas of repigmentation after 6 months of nbUVB therapy with lack of repigmentation over symptomatic varicose veins.

There have been previous reports in the medical literature involving cases of linear vitiligo developing along a varicose vein, possibly as an association with the Koebner phenomenon (Batalla & Feal, 2010). The Koebner phenomenon was first described in association with psoriatic skin lesions but has also been shown to lead to the skin depigmentation seen in vitiligo, with hypopigmentation often occurring along areas of trauma and surgical incisions and at locations exposed to other environmental stressors (Sagi & Trau, 2011). In varicose veins, venous hypertension is hypothesized to lead to a chronic inflammatory response with leukocyte infiltration, ultimately resulting in venous insufficiency and vein wall remodeling (Nicolaides, 2005). In fact, the more common skin changes overlying these varicosities, such as hyperpigmentation and fibrosis, are thought to be due to the underlying inflammatory process of chronic venous insufficiency (Nicolaides, 2005). It is plausible that the chronic inflammatory response within the symptomatic varicose veins of our patients is a form of the Koebner phenomenon, a condition which could explain the lack of response to nbUVB therapy. Patient A's rapid repigmentation after sclerotherapy and further nbUVB therapy supports this notion, because destruction of the offending vein may have eliminated the chronic inflammatory response and allowed for skin repigmentation.

There is a suggested association between the Koebner phenomenon and the occurrence of vitiligo (van Geel et al., 2012). The patients presented here also indicate that decreased response to vitiligo phototherapy could be due to the Koebner phenomenon as well. Future study of varicose veins as a potential impediment to skin repigmentation in the setting of vitiligo may further elucidate the Koebner phenomenon relationship seen in patients with vitiligo. This could ultimately alter prognostics and treatment decisions for this disease, as early referral for varicose vein treatment and sclerotherapy in patients with symptomatic varicose veins and vitiligo may improve treatment response.

REFERENCES