Sir,

Leukotrichia, the depigmentation of hair, commonly occurs in vitiligo patients due to melanocyte depletion in hair follicles, affecting approx. 9–46% of vitiligo patients. Vitiligo itself has a global prevalence of 0.1–2% in the general population, with pediatric cases representing up to 26% of all vitiligo patients. The condition demonstrates a female predominance in childhood, with most cases presenting before the age of 30 and often being associated with other autoimmune conditions [1–2].

A seventeen-year-old female with no previous autoimmune disorders presented to dermatology with a two-month history of progressive upper eyelash whitening. Physical examination showed symmetrical depigmentation of 90% of the upper palpebral cilia, while lower eyelids, eyebrows, and other body hair remained normally pigmented (Fig. 1). Mild vitiliginous changes were noted in the periorbital skin. Laboratory evaluations, including autoimmune markers and thyroid antibodies, were within normal limits. This isolated eyelash leukotrichia presentation aligned with typical vitiligo onset demographics. However, the isolated periorbital involvement without other autoimmune markers was noteworthy. The symmetrical pattern suggested a non-segmental vitiligo subtype, which typically exhibits a bilateral distribution of lesions. Treatment was initiated with topical tacrolimus 0.1%. While vitiligo treatments include topical corticosteroids, calcineurin inhibitors, and JAK-inhibitors, leukotrichia often shows a poor response to conventional therapies, and eyelash depigmentation has a poorer prognosis than eyebrow depigmentation. The pathogenesis of vitiligo-associated leukotrichia involves autoimmune mechanisms, including interferon-γ-mediated destruction of melanocytes and CXCL10 signaling (a type of immune system messenger). Studies show that melanocyte reservoirs within hair follicles become severely depleted in leukotrichous areas, making conventional therapies less effective. Leukotrichia typically indicates the exhaustion of the follicular melanocyte reservoir and correlates with a poor response to standard treatments such as topical corticosteroids and phototherapy [1–4].

Figure 1: Clinical photograph showing selective depigmentation of the upper eyelashes. Note the stark contrast between the affected (white) and unaffected (dark) cilia, with approx. 90% involvement of the upper eyelashes.

A recent systematic review on leukotrichia treatment included fifteen studies, most reporting on surgical treatment options. Surgical approaches for leukotrichia include a split skin graft after dermabrasion, suction blister transplantation, follicular unit extraction, and transplantation. Dermabrasion with a split skin graft and suction blister transplantation were particularly successful. Advances in topical therapy have also shown promise, particularly with JAK inhibitors. Topical tofacitinib 2% applied twice daily achieved complete repigmentation of eyelash leukotrichia after five months of treatment. This treatment works by blocking interferon-γ signaling pathways that cause melanocyte destruction. Topical bimatoprost 0.03%, a prostaglandin F2α analog, showed partial repigmentation in eyelash leukotrichia by stimulating melanocytes and enhancing melanin production. Combined approaches may be more effective, with studies showing bimatoprost plus narrowband UV-B phototherapy achieving better repigmentation than single treatments alone [5–7].

This case was notable for its isolated presentation in the eyelashes, emphasizing the importance of early recognition and treatment of localized vitiligo. It highlighted the need for dermatologists to consider newer therapeutic approaches, including topical JAK inhibitors and prostaglandin analogs, particularly in young patients in whom surgery may not be immediately feasible or desired. While traditional therapies often yield suboptimal results, emerging treatments offer new hope for achieving repigmentation. Future research should focus on optimizing combination therapies and identifying predictive factors for the treatment response in pediatric patients with isolated eyelash leukotrichia.