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A-Z of Skin: Vitiligo

What is vitiligo?

Vitiligo is a relatively common, acquired loss of pigmentation of the skin, affecting 1% to 2% of the population.  Destruction of melanocytes, or pigment cells, occurs and the skin becomes white.  The most common sites of pigment loss are body folds (like the groin or armpits), around body openings, and exposed areas like the face or hands.  It can also develop at sites of injury: cuts, scrapes, and burns.

Vitiligo can begin at any age, but in half of all affected patients, its onset is noted before the age of 20.  It can be associated with a number of autoimmune conditions, such as thyroid disease and diabetes.  Most people with vitiligo are in good health and have no symptoms other than areas of pigment loss.  Although the precise cause is unknown, genetic factors, autoimmune factors, trauma to the skin and anxiety or stress can be associated.  Vitiligo is not infectious and cannot be spread to other people.  People with melanoma can occasionally develop vitiligo. Research on the cause continues.

What does vitiligo look like?

The diagnosis is based on clinical examination.  Asymptomatic white areas are present with well defined edges.  Lesions can be localised or generalised and the distribution is usually symmetrical.  White hairs can occur within an area of vitiligo and early graying or whitening of scalp hair, eyelashes, eyebrows and beard hair can occur.  Eye involvement can also occur.

Can vitiligo spread?

Vitiligo can remain localised and stable indefinitely, or it may progress slowly or rapidly.  There is no way to predict this.  Factors that have been suggested may precipitate progression of the disease include emotional distress, physical illness, severe sunburn, and pregnancy.  De-pigmented areas may sometimes spontaneously re-pigment.

The emotional impact of vitiligo

The cosmetic disfigurement, particularly in dark-skinned people, can have profound psychological effects.  Low self esteem, depression and job discrimination have been reported, and vitiligo can therefore ultimately alter lifestyles, create social barriers and limit employment opportunities.  It is therefore important to offer treatment to these individuals.

Can my children inherit vitiligo?

There seems to be a hereditary component to vitiligo – 10% have a family history.  Many patients do not realise that anyone in their family has had vitiligo.  Children of patients with vitiligo have a higher probability of developing vitiligo than children from families with no history of the condition.  This, however, does not mean that patients’ children will definitely inherit vitiligo.  In most cases of vitiligo, there is no family history.

Can vitiligo be treated?

A specialist dermatologist is the best person to assess and manage vitiligo.

  • No treatment
    This is a good option if the patient has very fair skin. Strict sun protection is important, with SPF30+ sunscreens, protective clothing and sun avoidance.

  • Camouflage
    This is achieved with make-up and topical dyes including self tanning lotions.  Micro-tattooing can be useful for small stable areas of vitiligo, such as the face, lips and hands.

  • Active Re-pigmentation
    a) Medical: to re-pigment the skin, new pigment cells must be produced from existing ones.  These pigment cells come from the base of hair follicles, from the edge of the lesion, or from the patch of vitiligo itself if de-pigmentation is not complete.

    Treatment includes topical corticosteroid creams, light therapy with photosensitising psoralen drugs (applied topically or given systemically in conjunction with sunlight exposure or UVA phototherapy (PUVA )), narrow band UVB phototherapy, and other topical agents, e.g. calcipotriol, pimecrolimus, and tacrolimus.

    Approximately 75% of patients who undergo light therapy respond to a variable extent.  Even for these individuals, complete re-pigmentation rarely occurs.  Initially, patients will look worse with light treatment, since the contrast between light and tanned skin increases.  However, with time, re-pigmentation begins, and the appearance of the skin improves.  If patients stop the treatment, most will retain the achieved re-pigmentation.

    b) Surgical: surgical treatments should only be considered when medical therapies fail. They should only be performed on patients with stable non- progressive vitiligo, ideally localised or segmental.  These procedures can be used in combination with medical therapies.

    A number of surgical techniques for re-pigmentation of vitiligo have been developed.  They involve the transfer of a patient’s own melanocytes from unaffected skin into vitiligo affected skin (autologous melanoycte transplantation).  Techniques available include mini-grafting using punch grafts, non-cultured epidermal suspension, cultured epidermal suspension, and suction blister grafting.  These treatments are relatively experimental at this stage.

    c) Lasers: lasers such as the 308nm xenon chloride excimer laser have been used to treat vitiligo with varying success.

  • De-pigmentation
    Treatment with monobenzyl ether of hydroquinone can be used in patients with extensive vitiligo involving more than 80% of the skin.  This process may take six months to two years to achieve.  Strict sun protection is required after de-pigmentation.  Pigment removing lasers can also be used.

Is there a cure for vitiligo?

The answer at this time is no.  Vitiligo is probably caused by a variety of factors interacting in specific ways.  Research has advanced the understanding of the physical and psychosocial aspects of vitiligo, but the cause and cure are unknown.

The treatment of vitiligo is prolonged and progress is slow.  Patients require motivation, encouragement, and empathy.

Some patients need help with the emotional and psychological aspects of vitiligo and referral to either a psychologist or psychiatrist should be considered.  Vitiligo support groups and other patients with vitiligo can also offer support.

The future

Pigment cell research, as related to vitiligo, is ongoing.  Hopefully this will lead to better treatment options in the future.  Melanocyte transplants, where the dermatologist takes pigment cells from an unaffected area of the patient’s skin, grows them in culture to large numbers, and then transfers them back into vitiligo affected skin, is also promising.  Gene therapy may also have a possible role in the future treatment of vitiligo.

 

 

This information was prepared by Dr Richard Wittal, MBBS, FACD (May 2006)