Yasir Radhi, Ali Almamoori
Facial depigmentation may remain clinically unrecognized when obscured by persistent erythema associated with steroid-induced rosacea-like dermatitis (SIRD). We report a 42-year-old woman with Fitzpatrick skin phototype IV and a history of prolonged facial topical corticosteroid use who presented with persistent centrofacial erythema. Clinical examination was consistent with SIRD. Multimodal VISIA imaging revealed findings that were not appreciable under standard visible light: red-channel (RBX®) imaging demonstrated increased vascularity and telangiectasia, while ultraviolet imaging identified patchy depigmentation with a speckled pattern and perifollicular pigment preservation. Linear depigmentation corresponding to prior eyebrow tattooing suggested a Koebner phenomenon. Although advised to discontinue corticosteroids, the patient was lost to follow-up and returned three years later with persistent erythema and progression of depigmentation. Repeat ultraviolet imaging demonstrated an increased extent and partial coalescence of the depigmented areas. The longitudinal evolution, imaging features, perifollicular pigment preservation, and trauma-induced depigmentation were most consistent with evolving vitiligo coexisting with SIRD. Following corticosteroid withdrawal, topical tacrolimus 0.1% ointment was initiated. This case highlights how persistent facial erythema can mask progressive depigmentation and demonstrates the value of multimodal VISIA imaging, particularly red-channel and ultraviolet modalities, in detecting subclinical pigmentary changes, differentiating overlapping disease processes, and documenting disease progression.