Estratégias terapêuticas e atualizações no tratamento de vitiligo / Therapeutic strategies and updates for treatment of vitiligo

O vitiligo é uma desordem dermatológica complexa, cuja patogênese ainda não é totalmente esclarecida. Apesar de não apresentar complicações funcionais no organismo dos pacientes acometidos, o vitiligo pode resultar em um grande impacto psicossocial. Desse modo, é importante que os médicos saibam como conduzir o tratamento dessa patologia. O objetivo deste estudo foi documentar as terapias disponíveis para o tratamento do vitiligo, assim como apontar pesquisas que relataram a utilização dessas opções terapêuticas e os dados resultantes. As terapias abordadas foram corticoides tópicos e sistêmicos, fototerapia e fotoquimioterapias, antioxidantes, imunomoduladores, fenilalanina, despigmentação, procedimentos cirúrgicos e novas abordagens. A monoterapia parece ser menos eficaz no tratamento do vitiligo. A associação de medicação tópica e/ou sistêmica com o uso da fototerapia ultravioleta B de banda estreita parece ser o padrão-ouro para a repigmentação da pele dos pacientes. Medicamentos novos estão em estudo, porém sua eficácia e o estudo dos possíveis efeitos colaterais, principalmente a longo prazo, têm que ser melhores investigados. É necessário que o médico dermatologista, em conjunto com o paciente, escolha a melhor terapia dentre as disponíveis, de acordo com critérios clínicos e a possibilidade de acesso ao tratamento pelo portador. O acompanhamento e a abordagem por uma equipe multiprofissional também são importantes. (AU)

Vitiligo is a complex dermatological disorder, whose pathogenesis has not yet been fully elucidated. Although it does not present functional complications in the affected patients' body, vitiligo can result in a great psychosocial impact. Therefore, it is important that physicians know how to conduct its treatment. This study aimed at documenting the available therapies for the treatment of vitiligo, as well as pointing out studies reporting the use of these therapeutic options and their resulting data. The therapies addressed were topical and systemic corticosteroids, phototherapy, and photochemotherapies, antioxidants, immunomodulators, phenylalanine, depigmentation, surgical procedures, and new approaches. Monotherapy appears to be less effective in the treatment of vitiligo. The combination of topical and/or systemic medication with the use of narrowband ultraviolet B phototherapy seems to be the gold standard for the patients' skin repigmentation. New drugs are under study, but their effectiveness and study of possible side effects, especially in the long run, have to be better investigated. It is necessary that the dermatologist, together with the patient, choose the best therapy among those available, according to clinical criteria and the possibility of access to treatment by the patient. Monitoring and approach by a multiprofessional team is also important. (AU)

Partial repigmentation of vitiligo with tofacitinib, without exposure to ultraviolet radiation

Abstract Vitiligo is a disease that causes macules and achromic and/or hypochromic patches, which can affect from small areas to the entire tegument. Treatment options are few and are generally ineffective. Recently, some case reports have appeared which show positive results with the use of Janus kinase inhibitors associated with phototherapy. This report details the case of a patient with rheumatoid arthritis associated with vitiligo in treatment for two years, whose condition partially improved initially after eight months of oral tofacitinib at a dose of 5 mg twice a day, without exposure to ultraviolet radiation and with continuous improvement during these two years of treatment.

Patrón cutáneo pigmentario de disposición lineal en un niño, vitíligo segmentario vs. hipomelanosis de Ito / Linear disposition pigmentary skin pattern in a child, segmental vitiligo vs. Hypomelanosis of Ito

Introducción: algunas enfermedades dermatológicas siguen disposición con patrones lineales. Con hipopigmentación en la infancia se encuentran el vitíligo segmentario, que sigue los dermatomas, aunque puede seguir las líneas de Blaschko y la hipomelanosis de Ito, que a su vez sigue las líneas de Blaschko. Estas dermatosis son infrecuentes en la práctica dermatólogica. Objetivo: profundizar en los elementos diagnósticos que permiten diferenciar dos dermatosis clínicamente caracterizadas por hipopigmentación segmentaria lineal de tipo blaschkoide y el tratamiento. Presentación del caso: a la consulta de Genodermatosis en Las Tunas acude un niño con máculas acrómicas en hemicuerpo izquierdo, sin otras alteraciones. Después de ser evaluado por varias especialidades (Dermatología, Genética, Pediatría, Oftalmología y Neurología), se determina que solo presentaba afectación cutánea, se le realizó biopsia de piel, que corroboró el diagnóstico de vitíligo segmentario. Conclusiones: se presenta el caso porque el vitíligo segmentario es infrecuente, sigue un patrón lineal que puede ser diferenciado de otra dermatosis infrecuente, como la hipomelanosis de Ito, y en el tratamiento es importante brindar apoyo psicológico al paciente para favorecer la obtención de mejores resultados con la Melagenina Plus(AU)

Introduction: some dermatological diseases are still available with linear patterns. In childhood with hypopigmentation can be found segmental vitiligo (which follows the dermatomes although it can follow the lines of Blaschko), and Hypomelanosis of Ito (which in turn follows the lines of Blaschko). These dermatoses are infrequent in dermatological practice. Objective: to deepen into the diagnostic elements that allows the differentiation of two dermatoses clinically characterized by linear segmental hypopigmentation of blaschkoid type and treatment. Case presentation: a child attends to the consultation of Genodermatoses in Las Tunas presenting acromic macules in left half of the body, without other alterations. After being evaluated by several specialties (Dermatology, Genetics, Pediatrics, Ophthalmology and Neurology), it was determined that only skin affectation was present. A skin biopsy was performed, which corroborated the diagnosis of segmental vitiligo. Conclusions: The case is presented because segmental vitiligo is infrequent, it follows a linear pattern that can be differentiated from another uncommon dermatosis, such as Hypomelanosis of Ito, and in the treatment it is important to provide psychological support to the patient to favor obtaining better results with Melagenina Plus(AU)

A case series pilot study on the combination of 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) for treatment of vitiligo

Abstract: Background: To study the effective therapeutic concentration, drug application duration, irradiation duration and irradiation dosage of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) for treating vitiligo and observe its clinical efficacy. Objective: To assess the clinical efficacy of ALA-PDT for treating vitiligo. Methods: ALA with different drug concentrations, drug application durations, irradiation durations and irradiation dosages were adopted to treat skin lesions caused by vitiligo to determine the effective drug concentration, drug application duration, irradiation duration and irradiation dosage for treating three vitiligo volunteers and observe the therapeutic results. Results: The clinical trial suggested that ALA at a drug concentration of 1.5%, drug application duration for 3 hours, irradiation dosage of 80mw/cm2 and irradiation duration for 20 min was effective in treating vitiligo. Under these parameters, ALA-PDT was effective to the three vitiligo volunteers, with mild pain and feeling of burning but no other adverse reaction during treatment. Study limitations: Due to the small sample size in this study for the effectiveness of PDT in treating vitiligo and the potential variations in the efficacy for treating the disease at different areas, further studies shall be conducted for confirmation. Conclusions: ALA with a drug concentration at 1.5%, drug application duration for 3 hours, irradiation dosage of 80 mw/cm2 and irradiation duration for 20 min is effective in treating vitiligo. Therefore, ALA-PDT is safe and effective in treating the disease, with minor adverse events, providing a new method for treating vitiligo in the future.

Effectiveness and safety of topical tacrolimus monotherapy for repigmentation in vitiligo: a comprehensive literature review

Abstract Thus far, several small studies and case reports on the use of topical immunomodulators in vitiligo have been published. We undertook a comprehensive literature review, searching for studies evaluating clinical response to tacrolimus topical therapy for vitiligo. A search was performed on PubMed/Medline using the term “vitiligo”, combined with “topical” and “ointment”. Our inclusion criteria were: use of tacrolimus ointment as monotherapy to treat vitiligo. We found 29 studies from 2002 to 2014. Overall, 709 patients were treated in 29 studies. Pooling the lesions, 50% repigmentation of vitiligo patches was never achieved before 2 months of treatment, with a peak after 6 months of therapy. The best results were obtained on lesions of the cephalic region, especially the face, with tacrolimus 0.1% ointment two times daily. The percentage of non-responsive patients ranged from 0% to 14%. Treatment was generally well-tolerated; only localized adverse effects were reported. Our objective was to verify the effectiveness and safety of tacrolimus ointment monotherapy. It has good efficacy and tolerability. At present, only small trials and case series are available in the literature. Further, standardized investigations on a larger number of patients are needed.

Manejo despigmentante de vitiligo generalizado con monobenzil eter de hidroquinona / Depigmenting management of generalized vitiligo with hydroquinone monobenzyl ether

El vitiligo es una patología crónica, recidivante y difícil de tratar. El objetivo primario del tratamiento es inducir la repigmentación, sin embargo, en casos extensos refractarios a tratamiento, se puede realizar despigmentación para corregir la discromía. Dentro de los tratamientos despigmentantes en vitiligo, a la fecha el único aprobado por la FDA es el Monobenzil éter de hidroquinona (monobenzona). Se expone el caso de una paciente con vitiligo extenso y refractario a tratamiento que fue manejado con monobenzona. El resultado fue exitoso durante tiempo prolongado, con recaída parcial al suspender el medicamento. La recaída remitió con el reinicio de la monobenzona. Sin nueva recaída actualmente con tratamiento de mantención 3v/semana. La monobenzona induce acromía secundaria a necrosis de los melanocitos. Se requiere su uso 1 a 2 veces al día por 6-12 meses para lograr la despigmentación. En pacientes adecuadamente seleccionados, es una alternativa válida para el manejo del vitiligo. Se presenta un caso exitoso de despigmentación con monobenzona. Actualmente, la paciente está muy satisfecha con los resultados.

Vitiligo is a chronic, recurrent pathology, difficult to treat. The primary goal of treatment is to induce repigmentation, however, in extensive cases refractory to treatment depigmentation of surrounding skin may be performed to correct the cosmetic misbalance. To date the only depigmenting treatment for vitiligo approved by the FDA is the hydroquinone monobenzyl ether (monobenzone). We report the case of a patient with extensive vitiligo refractory to treatment managed with monobenzone. The result was successful for a long time, with partial relapse when the drug was discontinued. The relapse ended with the restart of the monobenzone. No new relapse seen with maintenance treatment 3 times a week. Monobenzone induces acromy due to melanocyte necrosis. To achieve depigmentation, it is used 1 to 2 times a day for 6 to 12 months. In adequately selected patients, it is a valid alternative for the management of vitiligo. A successful case of monobenzone depigmentation in dyschromia due to extensive vitiligo. Patient currently very satisfied with the results.

The reservoir effect of topical steroids in vitiliginous skin: A cross-sectional study.

Background: Prolonged and frequent use of topical steroids may lead to decrease in effi cacy as well as many local adverse effects. Stratum corneum has a unique property of reservoir effect. Aims: To study the reservoir effect of topical steroids in a steroid-responsive condition which may enable a decrease in the dosing frequency of topical steroids. Methods: A cross-sectional study design was used. Patients with at least three vitiliginous patches of more than 2 cm2 present over the trunk or limbs were included. Exclusion criteria were topical or systemic corticosteroid use within the previous 4 weeks, antihistamine use within the previous 7 days, history of any allergy in the past and immunosuppression. Clobetasol propionate cream was applied on the fi rst vitiliginous area (site A) and fl uticasone propionate ointment was applied on the second vitiliginous area (site B). The third vitiliginous area, site C (control site) was left without applying any medication. Histamine-induced wheal suppression test was performed on each site, at the same time of the day, on every consecutive day following steroid application, until the values obtained at sites A and B approached those obtained at site C. SPSS software for Windows, version 16.0 was used for statistical analysis. The mean and standard deviation of the various studied parameters were calculated for various treatment groups and compared using analysis of variance (ANOVA) test. Results: Forty patients were included in the study. The average wheal volumes and average erythema sizes at sites A and B were signifi cantly smaller than the corresponding values at site C for up to 5 days after applying medication (P < 0.001). Limitations: The presence of a cutaneous reservoir of topical steroid was confi rmed based on its suppressive effect on the wheal and fl are response to histamine. It is not certain that the concentration that suppresses histamine-induced wheal and fl are is suffi cient for therapeutic effi cacy in vitiligo. Conclusion: The reservoir effect of topical clobetasol propionate and fl uticasone propionate persisted for 5 days in vitiliginous skin. Hence, it may be possible to reduce the frequency of topical steroid application in vitiligo.

Vitamin D and skin diseases: A review.

Vitamin D, originally associated with rickets and osteomalacia, has recently been shown to have a role in a number of medical and dermatological diseases. It has been found that vitamin D receptors and the enzymatic machinery capable of converting circulating 25-hydroxyvitamin D [25(OH)D] to the active 1,25-hydroxyvitamin D [1,25(OH)D] is present in most cells in the body including the skin. It is well known that vitamin D analogs are effective in the treatment of psoriasis vulgaris because of their anti-proliferative and pro-differentiating effects on keratinocytes. However, new roles have been found for vitamin D in skin, such as immunomodulatory and anti-apoptotic effects thus raising a possibility of its use in conditions such as atopic dermatitis and infections. Increasing evidence now indicates that cutaneous vitamin D synthesis may help in prevention of skin malignancies and further, that cancer mortality may be reduced by oral supplementation of vitamin D. Various epidemiological studies have linked low levels of vitamin D to autoimmune diseases including vitiligo, and topical vitamin D has been used to treat vitiligo. This review focuses on a wide array of roles of vitamin D in various skin disorders with emphasis on both its well-established role as in psoriasis and the less characterized role in other disorders such as ichthyosis, tuberculosis or acne.

Abordagem clínica e terapêutica do vitiligo / Clinical and therapeutical approach of vitiligo

O vitiligo é uma leucodermia idiopática adquirida que resulta da perda de melanócitos na epiderme. A sua patogênese ainda não foi esclarecida, mas a teoria autoimune é a mais aceita, sendo a base de muitas modalidades de tratamento. Diante do grande impacto que esta doença provoca na qualidade de vida do paciente, é de extrema importância o conhecimento adequado do seu manejo clínico e das opções terapêuticas disponíveis.

Vitiligo is an acquired idiopathic leukoderma resulting from epidermal melanocytes loss. Its pathogenesis is not clear, but the autoimmune theory is the most accepted one, substantiating the basis of many treatment modalities. Given the great impact in life quality caused by this disorder, the knowledge of its appropriate clinical management and therapeutic options is of great relevance.

Photochemotherapy (PUVA) in psoriasis and vitiligo.

Phototherapy with photochemotherapy (PUVA) is a well‑known and well‑studied modality for the treatment of psoriasis, which involves systemic or topical administration of chemicals known as psoralens and administration of ultraviolet light in increasing dosages after requisite time gap. PUVA is also used in the treatment of widespread vitiligo with moderately good results, though it is being surpassed by ultraviolet B (UVB), which is equally or slightly more efficacious with fewer side effects. PUVA induces repigmentation by varying mechanisms such as stimulation of melanogenesis, immunomodulation and activation of growth factors, though the exact mechanism is still speculative. There are various studies evaluating the efficacy of PUVA in psoriasis as well as in vitiligo, either alone or in combination with other immunosuppressants like azathioprine and calcipotriene.

Randomized controlled study to evaluate the effectiveness of dexamethasone oral minipulse therapy versus oral minocycline in patients with active vitiligo vulgaris.

Background: Oral minocycline has been recently shown to halt disease progression in active vitiligo. Aims: The present study was planned to compare the efficacy and tolerability of oral minocycline with oral mini pulse (OMP) corticosteroids in active vitiligo. Methods: A total of 50 patients with actively spreading vitiligo were randomized to receive either minocycline 100 mg/day (Group I - 25 patients) or OMP 2.5 mg dexamethasone on 2 consecutive days in a week (Group II - 25 patients) for 6 months. These were followed-up at every 2 weeks interval. Mean vitiligo disease activity score (VIDA) and mean Vitiligo Area Scoring Index (VASI) were assessed in all patients in addition to the photographic comparison before and after treatment. Results: Both groups showed a significant decrease in VIDA from 4.0 to 1.64 ± 0.86 (P < 0.001) in Group I and from 4.0 to 1.68 ± 0.69 (P < 0.001) in Group II. However, the difference between the mean VIDA scores in the two groups was not statistically significant (P = 0.60) at the end of treatment period. The mean VASI declined from 1.71 ± 1.45 to 1.52 ± 1.43 Group I (P = 0.06) and from 1.39 ± 1.31 to 1.17 ± 1.34 in Group II (P = 0.05). The difference between VASI in Group I and II was not significant at the end of 24 weeks of treatment (P = 0.11). Conclusion: Both dexamethasone OMP and oral minocycline are effective drugs for managing the arrest of disease activity in vitiligo.

Accidental PUVA burns, vitiligo and atopic diathesis resulting in prurigo nodularis: a logical but undocumented rarity / Prurigo nodular induzido por queimaduras acidentais por PUVA, vitiligo e diátese atópica: uma raridade lógica, mas não documentada

Vitiligo is a dreaded disease in India due to its social and cultural consequences. PUVA and PUVAsol are the main treatment modalities for vitiligo vulgaris. To the best of our knowledge, this is the first case of accidental PUVA burns eventuating in prurigo nodularis lesions to be reported in a female patient who was undergoing home PUVA therapy. The itch is so prominent and disabling that the focus of the patient has shifted from treating her vitiligo to ameliorating the pruritus.

O vitiligo é uma doença temida na Índia por suas consequências sociais e culturais. As principais modalidades de tratamento do vitiligo vulgar são as terapias PUVA e PUVAsol. Pelo que sabemos, este é o primeiro relato de caso de prurigo nodular induzido por queimaduras acidentais por PUVA em paciente do sexo feminino em tratamento domiciliar com PUVA. O prurido é tão intenso e incapacitante que o foco da paciente passou do vitiligo à busca constante pela melhora do prurido.

Vitiligo y terapia con inmunoglobulina intravenosa: a propósito de un paciente con síndrome de Sjögren / Remission of vitiligo during treatment with intravenous immunoglobulin: Report of one case

Vitiligo is associated with other autoimmune diseases. We report a 52-year-old male with a Sjögren syndrome that was treated with monthly pulses of intravenous immunoglobulin for a chronicinflammatory demyelinating polyradiculoneuropathy. The neurological disorder responded adequately to the treatment and the patient also noted a marked remission of his vitiligo with almost compete re-pigmentation of the scalp and face and partial repigmentation of other areas.

Pomada de tacrolimo 0,1 por cento no tratamento de vitiligo: série de casos / Tacrolimus 0,1 percent ointment in the treatment of vitiligo: a series of cases

O vitiligo é dermatose de difícil tratamento e de significativo impacto psicossocial. O objetivo deste estudo foi avaliar a resposta do tacrolimo 0,1 por cento pomada no vitiligo. Dez pacientes completaram o estudo: seis com lesões nas regiões cefálica e cervical obtiveram mais de 75 por cento de repigmentação. Nas extremidades e no tronco, os resultados variaram de bons a excelentes em 27 por cento dos casos. A associação com outras formas de tratamento possivelmente aumentará a eficácia da terapêutica.

Vitiligo is a dermatosis of difficult treatment and significant psychosocial impact. The objective of this study was to evaluate the response to tacrolimus 0,1 percent ointment for vitiligo treatment. Ten patients took part in the present study: six patients with lesions on the cephalic and cervical regions had more than 75 percent of repigmentation. As for extremities and trunk results varied from good to excellent in 27 percent of the cases. The association with other therapeutic options could possibly increase the efficacy of the treatment.

Experiencia en el tratamiento del vitiligo utilizando UVB pulsado de banda ancha y tacrolimus tópico / Broad band targeted UVB and topical tacrolimus treating localized vitiligo: our experience

Introducción: El tratamiento del vitiligo es prolongado y los resultados suelen ser desalentadores. Existen terapias que se han utilizado con resultados aceptables, como PUVA (psoraleno asociado a radiación UVA) y UVB de banda angosta (UVBnb).Recientemente se ha comenzado a utilizar con éxito el excimer láser para el tratamiento del vitiligo localizado. Existe evidencia de que el UVB pulsado de banda ancha tendría efectos biológicos similares a este último. Material y método. Se realizó un estudio prospectivo, descriptivo y observacional con 15 pacientes, 12 con vitiligo generalizado, 2 con vitiligo localizado y un paciente con vitiligo segmentario. Todos ellos habían realizado tratamiento previo con tacrolimus tópico con escasa respuesta. Se inició tratamiento combinado con tacrolimus tópico dos veces por día y UVB de banda ancha pulsado dos sesiones por semana, durante 30 sesiones. Resultados. Todos los pacientes mostraron distintos niveles de repigmentación: 12 pacientes alcanzaron el 75% o más de repigmentación, 2 pacientes entre el 50 y el 75%, y un solo paciente no mostró ninguna mejoría (paciente con vitiligo segmentario).Conclusión. La combinación del tacrolimus tópico y el UVB de banda ancha pulsado es una buena alternativa para el tratamiento del vitiligo.

Leucodermia punctata após tratamento com Puvasol tópico / Leukoderma punctata following topical PUVAsol treatment

Duas adolescentes e uma menina com vitiligo clinicamente diagnosticado foram tratadas com 8-metoxipsoraleno a 0,2 por cento em creme Lanette com subsequente exposição solar. Um ano após, apresentaram máculas acrômicas na área do vitiligo. A biópsia de pele em um dos casos revelou melanócitos com escassa pigmentação melânica. Os achados clínicos e histológicos sugerem o diagnóstico de leucodermia punctata.

Two adolescent females and a girl, all with clinically diagnosed vitiligo, were treated with 0.2 percent 8-methoxypsoralen cream followed by exposure to solar ultraviolet light. One year later, they developed hypopigmented and achromic spots on the areas affected by the vitiligo. Biopsy of skin tissue taken from one of these cases showed a marked reduction in melanin. Clinical and histological findings point to a diagnosis of leukoderma punctata.

Efectividad de un extracto de placenta humana con Calcio (Melagenina Plus) en el tratamiento del vitiligo / Effectiveness of a human placental extract with calcium (Melagenina Plus) for the treatment of vitiligo

Introducción: Extractos alcohólicos de placenta humana han demostrado que poseen acción sobre la melanogénesis y sobre la proliferación de los melanocitos. Tales extractos producen un incremento en la densidad de los melanocitos así como de los gránulos de melanina cuando son aplicados tópicamente sobre las orejas y colas de ratones negros. Objetivo: Evaluar la acción de un extracto alcohólico de placenta humana con calcio (Melagenina Plus) en el tratamiento del Vitiligo, por ser esta una enfermedad en la que se pierden los melanocitos y por ende el pigmento melánico. Material y Método: Se realizó un estudio retrospectivo con 300 pacientes de vitiligo cubanos que fueron seleccionados por haber realizado de forma correcta la aplicación del extracto alcohólico de placenta humana con calcio sobre sus áreas despigmentadas. La selección se realizó con pacientes que se incorporaron al tratamiento con Melagenina Plus en los Servicios Clínicos del Centro de Histoterapia Placentaria entre los años 1998 hasta el 2003. Resultados: Al final del estudio 231 pacientes mostraron repigmentación completa o notable, 28 repigmentación parcial, 24 ninguna repigmentación y 17 nuevas lesiones. Conclusiones: Nuestros resultados demuestran que el extracto alcohólico de placenta con adición de calcio puede ser un eficaz e inocuo tratamiento del Vitiligo.

Introduction: Human placental alcohol extract have been successfully used on melanogenesis and melanocyte proliferation. Such extracts cause an increase in the number of melanocytes and melanin granules when applied topically on the ears and tails of black mice. Objectives: Assessment of the effectiveness of a human placental alcohol extract with calcium (Melagenina Plus) for the treatment of vitiligo, since this disease is characterized by melanocyte loss and consequently of melanine pigment. Material and methods: A retrospective study was carried out with 300 cuban vitiligo patients which were chosen because of their correct application on their depigmented areas of the human placental alcohol extract with calcium. Patients selection was made among those involved in the treatment with Melagenina Plus from the Clinical Service of the Placental Histotherapy Center since 1998 to 2003. Results: At the end of the study, 231 patients showed total or marked repigmentation, 28 moderate repigmentation, 24 no repigmentation and 17 new lesions. Conclusions: Results demonstrate that placental alcohol extracts with calcium added can be very effective and innocuous for the vitiligo treatment.

Estudo clínico dos pacientes portadores de vitiligo no Serviço de Dermatologia do HU-UFJF / Clinical study of patients with vitiligo in the dermatology department of HU-UFJF

Os autores apresentam um estudo clínico dos pacientes portadores de vitiligo no Serviço de Dermatologia do Hospital Universitário da UFJF. Foram cadastrados 40 pacientes, no período compreendido entre março de 2000 a março de 2001. Foram avaliados dados referentes à idade do início da enfermidade, característica inicial, doenças associadas, fatores precipitantes, peliose, fenômeno de Koebner, história familiar, classificação e terapêutica.