Twenty seven years old female patient two years ago after delivery has noticed appearance of irregular hypo- and achromic macules on her trunk, extremities and face. Two months ago she has seen on her trunk and extremities oval gray-blue hyperpigmented macules which are accompanied from a slight pruritus. She has common complains of weight reduction of 5-6 kg, palpitation, sleep disturbance, fatigue and some joint pain. Clinically our patient is IV phototype. She has two different type of exanthema. First type - vitiligo is presented from symmetrical distributed over the trunk, extremities and face hypopigmented and achromic macules from 0,5 cm to 20 cm in diameter. The second type exanthema has symmetrical distribution and involves abdomen, back and proximal part of extremities. The lesions are gray-blue macules with oval shape and size from 0,5 cm to 2 cm in diameter. There is no change in mucous membrane. Deviations of the investigations include slight elevated ECR, reduced HGB, HCT, MCV, MCH, MCHC, monocytosis, reticulocytosis, low serum Fe, increase TIBC, decrease LDH, positive serological test for H. pylori, increased Tg-Ab and TSH-RAb, very low TSH, elevated FT4, nasal smear – S. aureus, vaginal smear – S. agalactiae. Ultrasound of thyroid gland shows normal topic, size, structure and enhanced blood flow. Conducted by the clinical laboratory research fund and consultative examinations are specified comorbidities Grave’s disease, iron deficiency anemia, bacterial colpitis, and chronic gastritis. Histopathological examination of the edge or the hyperchrome lesion show minor hydropic degeneration of basal layer, sparce, superficial, perivascular lymphocyte infiltrat, and macrophages containing melanin (incontinentia pigmenti). Differentially were discussed lichen planus, postinflammatory hyperpigmentation, contact dermatitis, fixed drug reaction. Based on the anamnesis, clinical picture, laboratory results and conducted histological examination answer the question what is this second type exanthema is Erythema dyschromicum perstans. Conducted treatment for accompanying diseases is with Ciprofloxacin, Ferrous sulfate, Vitamins, Thiamazol, eradication therapy for H. pylori and local application of Mupirocin nasal ointment. We have made 7 procedures UVB 311 nm narrow band with slight improvement. There are only few previously described cases of Erythema dyschromicum perstans & vitiligo in the same patient. These cases include patients with darker skin. In both diseases there is HLA-DR4 association in the pathogenesis. There are some common features between two diseases which include predominance of cytotoxic T-cell and almost the same ratio of CD4/CD8, Ia antigen positivity in the dendritic cells in epidermis and dermis and increased number of epidermal Langerhans cells. - Disclaimer- This PPT is loaded as student material "as is", from the VRF Vitiligo Master Class Barcelona November 2011; VRF does not endorse or otherwise approve it.

1. Vitiligo in association with Erythema dyschromicum perstans Violina Todeva 1 E. Hristakieva, D. Karshakova, D. Gancheva 1 S. Yordanova 2 1 University Clinic Stara Zagora, Bulgaria Department of Dermatology and Venereology 2 Medical Institute - Ministry of Interior, Bulgaria Department of Endocrine Diseases

7. Comorbidities Grave’s disease Iron deficiency anemia Bacterial colpitis Chronic gastritis

16. Autoimmune polyendocrine syndromes type III Betterle C.; Zanchetta R., Update on autoimmune polyendocrine syndromes (APS). Acta Biomed Ateneo Parmense 2003;74:9-33 AUTOIMMUNE POLYENDOCRINE SYNDROMES TYPE 3 AUTOIMMUNE THYROID DISEASES Hashimoto’s thyroiditis Idiopathic Myxoedema Asymptomatic thyroiditis Endocrine exophthalmus Grave’s disease Endocrine Diseases 3 A Gastrointestinal Apparatus 3 B Skin / Hemopoietic system/ Nervous system 3 C Collagen Diseases/ Vasculitis 3 D Type 1 DM Hirata’s syndrome Premature ovarian failure Lymphocitic hypophysitis Neurohypophysitis Atrophic gastritis Pernicious anemia Coeliac disease Chronic inflamm. bowel diseases Autoimmune hepatitis Primary biliary cirrhosis Sclerosing cholangitis Vitiligo Alopecia Autoimmune thrombocytopenia Autoimmune hemol. anemia Anti-phospholipid syndrome Miastenia gravis Stiff-mann syndrome Multiple sclerosis LES LED Mixed connectivitis Rheumatoid arthritis Reactive arthritis Sclerodermia S ö gren`s syndrome Vasculitis + + + +

20. Conclusion Alter immune regulation TRICHROME VITILIGO VULGARIS & GRAVE’S DISEASE & ERYTHEMA DYSCHROMICUM PERSTANS Immune cell participation Autoimmune pathogenesis

21. Thank you for your attention !