the aim of this report is to describe a single case of vitiligo induced by carbamazepine .
the case was a patient with bipolar i disorder whose medications were changed from valproate to carbamazepine and who developed vitiligo after a short while .
when depigmentation occurred , we immediately discontinued carbamazepine after which the depigmented areas improved gradually .
about three years later , he received carbamazepine again , but depigmentation did not recur .
carbamazepine - induced vitiligo is not an absolute contraindication for the prescription of carbamazepine if other choices fail to respond or are not tolerated .
the patient was a 34 -year -old male with a diagnosis of bipolar i disorder who was admitted to iran psychiatric hospital with a manic episode with psychotic features in september 2007 , and this was his first manic episode .
he received sodium valproate as well as antipsychotic medications for the active phase treatment and was stabilized on 600 mg of valproate . in the post - discharge follow up ,
the tremor was mainly of a postural type and was so severe that made eating , drinking and shaving very difficult for the patient .
propranolol was added and titrated up to 120 mg , but was not successful in controlling the tremor .
therefore , valproate was tapered and replaced with carbamazepine to a total dose of 800 mg / d .
nearly one month later , areas of depigmentation appeared on the patient s face ( figure 1 ) .
although depigmentation decreased gradually in the next two months , it could still be observed in an attenuated form in a close inspection .
then , lithium was tapered to discontinuation and a combination of lamotrigine ( up to 100 mg / d ) and olanzapine ( 10 mg / d ) was the next treatment choice . despite a mild tremor ,
the patient remained well for the following 18 months when he was admitted for one week in march 2011 for an episode of methamphetamine- induced psychotic disorder .
after discharge , the patient was visited by a physician unaware of his history of vitiligo who decided to change the medications from lamotrigine and olanzapine to carbamazepine and aripiprazole .
it seemed that the decision had been made to decrease the side effects of the drugs ( weakness , dryness of mouth , and tremor ) .
the patient continued to improve and vitiligo did not recur ( or was not aggravated ) after re - challenging the patient with carbamazepine for the following 6 months .
currently , the patient is receiving carbamazepine ( 800 mg / d ) and aripiprazole ( 20 mg / d ) and remains in remission and is trying to get a job ( figure 2 ) .
few case reports of medication - induced vitiligo have reported the following mechanisms for this condition : activation of t cd8 + cells against melanocytes , apoptosis of melanocytes as a direct effect of the drugs , and damage to sympathetic nerves(3 ) .
although a single case can not prove or rule out any of the proposed mechanisms , reviewing the history of this case could be informative .
the reversibility of vitiligo in this case shows that the involved mechanism should not be a totally irreversible cellular change like apoptosis of melanocytes or permanent damage in sympathetic nerves at least in the early stages of medication - induced vitiligo . on the other hand ,
non - recurrence of vitiligo with re - challenge of carbamazepine suggests that some kind of immunity or desensitization has developed .
the latter point is against the direct cytotoxic effects of medications on induction of vitiligo .
we would like to emphasize that the patient also used other medications when the skin condition appeared .
therefore , it is theoretically possible that these medications ( such as propranolol or antipsychotic drugs ) would be related to vitiligo .
however , the temporal relationship of vitiligo appearance and the used medication suggests that carbamazepine is the most probable culprit for inducing vitiligo .
the other limitation of the current report is that we did not use additional methods to confirm the diagnosis , like skin biopsy or wood s lamp examination . because the patient did not show any other signs or symptoms of other autoimmune diseases
finally , we would like to suggest that the appearance of carbamazepine - induced vitiligo is not an absolute contraindication for the prescription of carbamazepine if other choices fail to respond or are not tolerated .
 objectivevitiligo is a rare side effect of carbamazepine whose exact mechanism is unknown . 
 the aim of this report is to describe a single case of vitiligo induced by carbamazepine.methodsthe case was a patient with bipolar i disorder whose medications were changed from valproate to carbamazepine and who developed vitiligo after a short while . 
 we followed the case for about four years when he was rechallenged with carbamazepine.resultswhen depigmentation occurred , we immediately discontinued carbamazepine after which the depigmented areas improved gradually . 
 about three years later , he received carbamazepine again , but depigmentation did not recur.conclusioncarbamazepine-induced vitiligo is not an absolute contraindication for the prescription of carbamazepine if other choices fail to respond or are not tolerated . 
 the case has implications for the mechanism of medication induced vitiligo . 
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Case Report
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