vitiligo is the most common depigmenting disorder , with a worldwide occurrence of 0.1 - 2% in general population .
multiple conditions have been described colocalized in vitiligo patches , like psoriasis or lichen planus .
however , actinic granuloma has not been described in association with vitiligo lesions so far .
actinic granuloma was first described by o'brien in 1975 as an uncommon disease , most frequently presented in middle - aged women [ 6 , 7 ] .
some authors consider actinic granuloma a subtype of annular granuloma and others a different entity .
we report the case of a 50-year - old woman , who was referred to our dermatology department in 2006 with a diagnosis of lip - tip vitiligo .
the milky patches were located in the face , on the dorsum of the hands , and on the forearms and legs .
no diagnosis of lupus , sarcoidosis or other dermatologic diseases could be elucidated in her medical or family history .
she was treated with topical steroids ( clovate cream ) and topical tacrolimus ( protopic 0.1% ointment ) , with poor response in achral lesions . oral puva therapy with 8-mop was started in 2007 , obtaining a moderate repigmentation in distal areas .
in june 2009 , during a routine follow - up , the patient complained that non - pruriginous lesions had appeared in her hands 2 weeks ago . on physical examination
, she presented with multiple asymptomatic , erythematous , annular plaques and solitary papules 5 - 10 mm in diameter , located on the dorsum of both hands , strictly confined to vitiliginous lesions .
full blood count , liver and renal function and urine analysis were all in normal ranges . based on the clinical picture , presumptive diagnosis of coincident vitiligo and annular granuloma was made .
fibers phagocyted by the histiocytes were seen , too . besides , absence of melanocytes in fontana - masson staining was demonstrated .
several articles have suggested that annular and actinic granuloma are different conditions based on histopathological characteristics .
different terms have been used to designate this disorder : annular elastolytic giant - cell granuloma ( aegcg ) , o'brien granuloma , multiple [ 10 , 11 ] , actinic [ 7 , 8 ] or elastolytic   granuloma .
multiple granuloma was coined by leiker in 1964 , and it is clinically similar to actinic granuloma , being considered the same entity in some studies .
a photo - mediated etiology has been proposed in the literature for this subtype [ 10 , 11 ] .
o'brien suggested the role of infrared and ultraviolet actinic radiation [ 6 , 7 , 13 ] .
the importance of a granulomatous chronic inflammation in association with another systemic illness such as sarcoidosis or diabetes mellitus was proposed by hanke .
cd4 lymphocytes would act against the solar - damaged elastic fibers , which could be recognized as antigenic products [ 6 , 7 , 13 ] .
histological characteristics like sarcoidal granuloma or multinucleated giant cells suggest an inflammatory response to small products , like altered elastic fibers . the confinement of the inflammatory reaction to the superficial dermis , corresponding to the area of solar elastosis , supports the actinic theory .
this photo - mediated damage could be considered as a trigger factor in our patient and could explain the strict colocalization of elastolytic granuloma on vitiligo patches .
vitiliginous skin is more photo - sensible and the actinic damage is more intense than in the rest of the body . in this case , the affected skin on the dorsum of the hands was not only prone to photo - damage as a result of sun exposure , but it was also selectively exposed to puva therapy over the last 2 years in our patient . in this case , we present an uncommon clinical feature with strict colocalization of elastolytic granuloma in vitiliginous areas .
the location of the lesions strongly supports the photo - damage hypothesis in our patient .
moreover , the patient received puva and sun therapy as an important part of her treatment . to our knowledge , this is the first patient with coexistence and strict anatomical coincidence of actinic granuloma and vitiligo reported in the literature thus far .
we conclude that the actinic radiation played an important role in this form of granuloma in our patient
. however , further studies to clarify pathogenetic links between vitiligo and actinic granuloma would be necessary .
 vitiligo is the most common depigmenting disorder , with a worldwide occurrence of 0.1 - 2% in the general population . 
 multiple conditions have been described colocalized in vitiligo patches , like psoriasis or lichen planus . 
 however , actinic granuloma has not been described in association with vitiligo lesions so far . 
Introduction
Case Report
Conclusion