Title: Case 1. Depigmentation therapy in vitiligo universalis with cryotherapy and 4-hydroxyanisole. Introduction: Vitiligo is a disease characterized by the loss of melanocytes, resulting in progressive depigmentation of skin. Residual normally pigmented patches in patients with vitiligo universalis are of cosmetic concern to patients. Treatment options are based on case series or case reports and include cryotherapy, laser and topical therapies. Aim and scopes: use a less toxic, but efficient depigmentation method for removing the residual pigmentation of a patient with generalised vitiligo, which was resistant to all other classical therapies modes. Material and methods: A 65-year-old man with a 45-year history of vitiligo after several unsuccessful attempts to restore his pigmentation with topical corticosteroids and phototherapy, he had begun the treatment of removing the remaining pigment. A 12-month course of topical hydroquinone 4% cream resulted in no improvement. The patient was treated with single-session cryotherapy, using a closed cryogenic system (Cry-Acl Brymill Corporation, Vernon, CT, USA) with an open probe mounted on the tip. Uniform freezing of the involved area was obtained by holding the orifice approximately 40 mm from the skin and slowly painting the surface with vaporized liquid nitrogen. Two freeze–thaw cycles were performed Then after 3 weeks, twice-daily treatment with topical mequinol (4-hydroxyanisole; 4-HA) 20% in an oil and water mixture was started. Results: During a 14-month course of treatment, the patient was clear of all pigment within the treated sites, with no side-effects. Six months after discontinuation of topical treatment, he began to develop small patchy areas of repigmentation, which were easily removed by single-session cryotherapy. Comments: In this case, when rapid depigmentation is desirable, physical treatment works faster than bleaching compounds (1). Cryotherapy is a widely available and cheap physical procedure that has been used successfully in patients with vitiligo universalis. Owing to the high sensitivity to cryodamage of melanocytes compared with other skin cell types, we preferred to use an open cryoprobe, which allows gentler and more superficial freezing, and the direct spraying of the skin permits treatment of larger areas in a shorter time. Indeed, although some authors claim that physical depigmentation is permanent (3) repigmentation does occur after laser treatment (1) and in our case it also occurred after cryotherapy. An explanation for this phenomenon is that the melanocytes might be not entirely damaged, especially the follicular population. This PPT is loaded as student material "as is", from the Vitiligo Master Class Barcelona November 2011; VRF does not endorse or otherwise approve it.