Care and Treatment of Vitiligo


" Vitiligo is a skin condition that is characterized by the appearance of white skin patches. The white color is caused by the immune system interfering with normal skin cell function and the Melanocytes, the cells responsible for skin color.

There are several hypotheses regarding what causes the condition such as an autoimmune problem, the neural hypothesis where the nervous system is interfering with the melanocytes and a toxin hypothesis (autocytotoxic)  from the use of phenols in common household products such as air fresheners, deodorants, and acne medications. Each is explained in the video below. 

Usually, the white color is the only symptom. It is more noticeable in darker skinned people. The irregularly shaped white patches usually appear on the face and other sun-exposed parts of the body but are not associated with other symptoms. Other areas that could be involved include the inner ears, eyes, and the mucous membranes (lines body cavities). All ages and races are affected, but most cases start between age 10 and 30. 30% of cases have a genetic background.

The cause is unknown and the treatment goal is to slow down the loss of skin pigmentation. The white skin patches can spontaneously clear for no known reason. The condition is not contagious or harmful in healthy individuals. It can spread to other parts of the body in a limited number of cases. 

Treatment can last for an extended period, lasting from months to years. Treatment cannot cure vitiligo, but it can help to repigment the skin. Treatment includes light therapy, topical treatments, vitamin D supplementation, skin grafts, and depigmentation. Other studies show that antioxidants, Folic acid and Vitamin B12 combined with sun exposure can help with repigmentation."

Video: Miliaria Rubra Rash on the Body


Video by Dr. John Bergman on what causes Vitiligo, how to prevent it and how to reverse it. Dr. Bergman reviews the side effects of each prescription Vitiligo medication. Dr. Bergman claims that the Vitiligo Cure is a natural approach where you remove exposure to toxins in common household products, optimize your gut flora via diet, correct mineral deficiency and detox the body. He also recommends reducing chronic stress.

Types of Vitiligo

  • Localized or Generalized Vitiligo (GV): a skin melanocyte-specific autoimmune-mediated inflammation. Also called segmental Vitiligo (SV). Believed out of neural mechanisms where there is an interaction of melanocytes (what gives skin color) and nerve cells. It usually occurs in one location.
    - Symmetric
    - Frequently occurs where there is skin injury or friction
    - Can change over time

  • Acrofacial Vitiligo: involvement of the fingers and toes, tissues around the mouth and the head

  • Universal Vitiligo: color loss on 80% to 90% of the body
vitiligo picturesVitiligo Pictures of White Patches on Dark and Light Skin

Causes

About one out of a hundred people in the United States has vitiligo. What exactly causes vitiligo is unclear, but it appears to be linked to an autoimmune process of destruction of melanocytes, which are cells that produce the brown pigment in the skin. The skin problem is also associated with other autoimmune disorders such as hyperthyroidism, pernicious anemia, and Addison’s disease. A hereditary factor may be involved because some have reported that there is an increased incidence within families. 

There is also a theory called the neurogenic hypothesis which believes the problem is due to an interaction between nerve cells and melanocytes.

Another hypothesis believes that the melanocytes are actually destroyed by toxins that result from normal melanin biosynthesis or exposure to Phenols that are found in common household products.

vitiligoThe skin condition Vitiligo causes white skin spots or patches. The disease is not age specific and starts as a small area that grows.
Source: Meisenheimer Clinic

Many people attribute the onset of vitiligo to a specific event such as emotional stress, injury, death in the family or sunburn.

Diagnosis

The sudden or gradual appearance of irregularly shaped white skin spots or patches in the face, arms, hands, other exposed body parts and even the genitals are characteristic of vitiligo. The doctor may ask about a family history of any autoimmune disorder, a previous history of skin sensitivity or sunburn, premature hair graying, and physical or emotional stress.

A Woods lamp may be used to show the white patches of skin that glow under the handheld ultraviolet light. Blood tests may be done to look for signs of autoimmune disease such as autoantibodies or thyroid dysfunction. A skin biopsy may also be helpful in ruling out other disorders such as melanoma (skin cancer).

Vitiligo is associated with thyroid disease (30% of cases) and Diabetes (5%).

Conditions that need to be ruled out when diagnosing Vitiligo include:

  • Pityriasis alba
  • Pityriasis Versicolor
  • Chemical leukoderma
  • Leprosy
  • Nevus depigmentosus
  • Hypomelanosis of Ito
  • Nevus anemicus
  • Tuberous sclerosis

Symptoms

Milky white patches on the skin that feels normal are more noticeable in dark-skinned people because of the contrast in skin color. However, vitiligo can occur in any race and at any age, more commonly between 10 and 30 years.

Loss of pigmentation of the skin (depigmentation) occurs initially on sun-exposed areas but may spread rapidly or gradually to other areas including the back, armpits, and genitals. Depigmentation may occur in a focal, segmental, or generalized pattern, affecting small or large areas of skin.

Affected individuals do feel any other symptoms or discomfort related to the skin changes except for premature graying of the hair, eyebrows, eyelashes, or beard and depigmentation of the inner lining of the mouth.

In some people, loss of skin color may halt or slow down for some time, but the original skin color does not come back. However, in a few, skin color may return without treatment.

Treatment

vitiligo cureNarrow Band UVB is a phototherapy Vitiligo Cure that results in 75% repigmentation in 63% of patients (9)

The condition is not a threat to health and is not contagious. The goal of treatment is to slow down depigmentation and to improve the appearance of the skin.

Self-care treatments are available such as:

  • Applying protective sunscreen (greater than SPF 30)
    - prevent sunburn on skin that normally has a pigment
    - decrease contrast
    - decrease the chance of Koebnerization (skin plaque formation)(3)
  •  Self tanners
    - ProTan 
    - Clinique Self Sun
  • Camouflage cosmetics to use makeup to hide the white skin macules (patches)
    - Olay Regenerest 
    - Clinique Even Better
    -
     Cover FX
    -
     Dermablend
  • Cosmetic tattoo (generally not recommended due to color mismatching with skin tanning and pigment migration)

Fair-skinned individuals should avoid tanning to make the white patches less noticeable.

Individuals who want to restore their skin color or lighten the remaining dark areas in order to even out the skin tone may seek medical treatment. This may last for 6-18 months and may involve more than one type of treatment, including:

  • Topical corticosteroids (4)
    - more effective when used with light therapy
    - may have side effects such as skin thinning (atrophy), stretch marks, easy bruising and tearing of the skin, enlarged blood vessels and localized hair thickness
    - If not effective in 2 months, will probably not work
  • Topical calcineurin inhibitors (5)
    - shown good therapeutic efficacy without the side effects of
    corticosteroids
    - in pediatric cases, the topicals tacrolimus and clobetasol show equal effectiveness
    - Side effects include severe burning, itching, stinging and soreness, swollen glands, sore throat, fever, chills
  • Vitamin D3 (6)
    - still being researched
    - repigmentation is faster when used in combination with calcipotriol  and betamethasone
    - A number of studies have recently reported that the treatment with vitamin D compounds or their combination with ultraviolet light enhances repigmentation in vitiligo (source: Medical Research Reviews)
  • Topical Calcipotriene (synthetic form of vitamin D)
  • Oral corticosteroids (7)
    - Used to stop rapid disease progression
  • Afamelanotide: melancyte stimulating hormone (8)
    - Improved response when combined with light therapy
  • Ruxolitinib (Janus kinase inhibitor JAK) (12)
    - Some cases with 51% repigmentation of face
    - Regained pigment regresses when treatment stops
    - High cost ($10,600)
  • Tofacitinib (Janus Kinase inhibitor JAK)(11)
    - Off-label use
    - One case saw substantial repigmentation at 5 months
  • Phototherapy
    - Narrow Band UVB achieved greater than 75% repigmentation in 63% of patients
    - Works slowly and requires 2 to 3 treatment sessions per week for several months.
  • Photochemotherapy
  • Depigmentation: for patients that have lost most skin color. Depigmentation removes the remaining color from the skin. Accomplished with a topical prescription cream applied 1x to 2x a day for 1 to 4 years.
  • Repigmentation: goal is return of normal color
    - Take 1 to 4 months and may take 1 to 2 years
    - Not always successful
    - Multiple methods
  • Surgery
    - skin grafts: Healthy skin that has not lost color is removed and replaced over skin that has lost color.
    - punch transplants
    - blister grafting
    - cellular grafting
    - melanocyte transplants
vitiligo phototherapyVitiligo Targeted Phototherapy is administered via the Excimer. Treatment is needed 2x per week for 6 months. Result in 75% repigmentation in 49% of patients (10)

Vitiligo Support Groups

Vitiligo can take an emotional toll on patients causing psychological disorders, sexual difficulties, anxiety, and depression. 

There are several support groups available that can help patients:

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References

(1) Mayo Clinic

(2) ADAM Medical Encyclopedia

(3) Hercogová J et. al., Dermatol Clin, 2007; 25:383-392 Ezzedine K et. al., Lancet, 2015; 386:74-84

(4) Njoo MD et al. Arch Dermatol. 1998 Dec;134(12):1532-40 Whitton ME et al. Cochrane Database Syst Rev. 2015 Feb 24;(2)

(5) Gutfreund K et al. Postepy Dermatol Alerogl 2013 June;30(3): 165-169

(6) Khullar G et al. J Eur Acad Dermatol Venereol. 2015 May;29(5):925-932

(7) Majid I et al. Indian J Dermatol. 2013  Mar;58(2):113-116 and Taieb A et al. Br J Dermatol. 2013 Jan;168(1):5-19

(8) Lim HW et al. JAMA Dermatol. 2015 Jan;151(1):42-50

(9) Njoo MD et al. J Am Acad Dermato 2000;42:245-53 Westerhof W et al. Arch Dermatol.1997;133:1525

(10) Esposito M. Clin Exp Dermatol 2004;29:133-37, Leone G et al. J Eur Acad Dermatol Venereol. 2003;17:53

(11) Craiglow BG et al. JAMA Dermatol. 2015 Oct;151(10):1110-1112

(12) Harris JE et al. J Am Acad Dermatol. 2016 Feb;74(2):370-371