Vitiligo

Vitiligo is an autoimmune skin disease in which there is a progressive destruction of the skin’s pigment-producing cells (melanocytes), resulting in areas of otherwise normal white skin devoid of melanin pigment. It is not unusual for hairs growing in areas of vitiligo to lose their normal color.

There are poorly understood environmental factors that seem to interact with genes which predispose one to vitiligo. There are numerous theories as to the origin of vitiligo. A condition indistinguishable from vitiligo can be induced in some individuals after topical exposure to certain phenol-like chemicals. Vitiligo is not contagious.

Although most cases of vitiligo seem to occur sporadically, as many as 20% of affected individuals seem to have a family history of this disease. Working in an industrial setting where there is significant exposure to phenolic chemicals may put individuals at risk.

Classical vitiligo can begin anytime after birth and often appears as a white spot without other symptoms on a background of normally pigmented skin. The only detectable change in affected areas is the loss of color, which can begin with lightening but will progress to complete loss of color. If vitiligo involves hair-bearing areas, it is not unusual to note the development of gray, pigment-free hair growing from involved follicles. There may be one or more of these patches that may gradually enlarge and rarely progress to involve the entire skin surface.

There are clinical subtypes of vitiligo that extend in a linear fashion down an entire limb (segmental vitiligo). Vitiligo often involves the genitalia and is predisposed to appear in areas of previous skin trauma. Obviously, completely depigmented skin can be much more cosmetically significant in those with racially darker pigmentation. Skin affected by vitiligo is particularly susceptible to sunburn and chronic sun damage.

Dermatologists specialize in treating pigmentation problems.

Generally, the diagnosis can be accurately made during a physical examination without the benefit of any further laboratory support.

• It is important to distinguish vitiligo from a variety of other skin conditions in which pigment loss (leukoderma) may be a part.
• Some of these conditions are present at birth and may have a well established genetic cause, like albinism.
• Others may have easily treated infectious etiology, like the fungus infection tinea versicolor.
• Occasionally, in order to distinguish these disorders, it may be necessary to perform a skin biopsy.

• If an area of pigment loss becomes apparent, it would seem prudent for any patient to have the diagnosis of vitiligo confirmed by a physician.
• In a minority of patients, vitiligo is associated with a variety of systemic diseases, many of which have an autoimmune origin. A complete history, physical examination, and possibly laboratory testing is necessary to rule out the presence of these complicating conditions.
• One should remember that treatment of such associated conditions is unlikely to have any effect on the course of vitiligo.
• When vitiligo develops in certain individuals, there can be a severely deleterious effect on their sense of well-being.
• It is vital that efforts be made to treat the condition itself as well as the associated psychological factors that can occur in severely affected patients.

Treatment of vitiligo is dependent on its extent of involvement. It is unlikely that if more than 5%-10% of the skin is involved that topical therapy would be feasible.

Topical medical therapy generally involves the application of medications that inhibit inflammation. Most commonly, potent topical steroids have been very useful in certain cases of limited vitiligo. Care must be taken to limit the use of such medications for a specific duration due to the side effects that stem from excessive use. Another popular approach is the application of topical calcineurin inhibitor, tacrolimus (Protopic ointment) or pimecrolimus (Elidel), for example. These types of medications can have a beneficial effect and may be somewhat safer to use for long periods of time. The use of certain types of lasers, the monochromatic excimer laser for example, which emit light in the UVB range (308 nm) can be effective.

In patients with more extensive disease, exposure to certain wavelengths of ultraviolet light can be effective (usually UVB light sources with outputs in the range of 290 nm-320 nm). Exposure to longer wavelengths of light in the UVA range (320 nm-400 nm) plus the ingestion of certain drugs called psoralens have induced pigment production in certain patients. Many exposures over a considerable period of time are often necessary to get optimal results. None of these treatments is likely to cure the basic problem, which can involve other areas of skin while the treated areas are improving.

Other options include cosmetic camouflages (Covermark or Dermablend), skin stains (artificial tanning chemical), and tattoos. In light-skinned individuals, avoiding the tanning of normally pigmented skin would decrease the contrast with vitiligo skin.

If a patient is unfortunate enough to become almost entirely depigmented, it may be cosmetically prudent to consider a medication, monobenzyl ether of hydroquinone, which is likely to destroy the few remaining melanocytes producing monochromatic white skin.

There are no universally effective treatments that work in all patients. When selecting a treatment plan, it is important to consider that most patients with vitiligo live normal healthy lives.

There are a variety of surgical options to treat vitiligo.

• They basically all involve transplanting the patient's normal melanocytes into areas of vitiligo. This can be accomplished by taking small "pinch" grafts or split thickness grafts of normal skin and placing them into suitably prepared recipient sites. If all goes well, the melanocytes gradually grow out of the grafts and repopulate the surrounding involved skin.
• At certain research institutions, melanocytes from normal skin can be harvested and grown in tissue culture and then placed in suitably prepared recipient sites. Although somewhat cosmetically acceptable, even successful surgical outcomes are nevertheless distinguishable from normal skin.

Patients ought to carefully consider how much time and money they are willing to devote to medical or surgical treatment. The answer to this question is dependent on the patient's psychological reaction to the disease as well as their financial situation.

There is no way to prevent vitiligo. Home remedies are unlikely to have any effect on the course of the disease.

Generally limited vitiligo involving the face and trunk in children of recent onset is most responsive. Extensive disease in adults and disease affecting the hands and feet is resistant to therapy.

Vitiligo Support International Inc.
http://www.vitiligosupport.org

Vitiligo Association of Australia
http://www.vitiligo.org.au

"Vitiligo," Medscape.com