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Skin: Vitiligo

Vitiligo is a skin disorder that occurs in people of color, in which the cells that make melanin pigment (melanocytes) are destroyed. The destruction results in the appearance of white patches on the skin, in the hair, and on mucous membranes (lips and genitals). Vitiligo can occur at any age, but usually occurs before the age of 20 in about 50% of patients. Vitiligo affects approximately 1% to 2% of the world’s population. It is believed to be a hereditary disorder with 30% of patients having a first-degree relative with vitiligo.

Although vitiligo occurs equally in all racial and ethnic groups, it is significantly more noticeable in individuals with brown skin because of the dramatic contrast between the normal brown skin and the vitiliginous white areas. Because of its visibility, vitiligo can be an emotionally devastating disorder in individuals with skin of color. In fact, in India, the original term for vitiligo was ven kushtam….white leprosy. As the name implies, Indians with vitiligo are sometimes treated like lepers, having difficulty obtaining jobs or even finding a partner to marry.

There are five main types of vitiligo, which are based upon the location of the white patches and the pattern of involvement: focal, generalized, acrofacial, segmental and universal.

• Focal vitiligo: minimal involvement with only one or a very few white patches scattered on the skin
• Generalized vitiligo: the most common type with symmetrical patches on any location on the skin including the trunk and/or extremities
• Acrofacial vitiligo: white patches limited to the fingers and around the mouth and eyes
• Segmental vitiligo: white patches on one side of the body and in a linear or line-like distribution (dermatome)
• Universal vitiligo: Widespread patches involving almost the entire body

The cause of vitiligo is not well understood. It is believed to be an autoimmune, disorder which means that certain blood cells in your body, lymphocytes, turn against and attack the melanocytes. Another theory is that vitiligo is caused by an interaction between the body’s nerve cells and melanocytes.

Vitiligo may be associated with other immune disorders. They include Addison disease (an adrenal gland disorder), alopecia areata, diabetes mellitus, thyroid disease, parathyroid disease, melanoma, chronic mucocutaneous candidiasis (yeast infection), pernicious anemia, and uveitis (eye disorder). If you are affected with vitiligo, ask your doctor if you should also be evaluated for these immune disorders.

Treatment
Vitiligo is a difficult disorder to treat and no form of treatment is entirely successful. A small number of people with skin of color may experience spontaneous repigmentation (without treatment) of their vitiligo. For others, there are several therapies that may be effective. If one treatment does not work, do not give up, but ask your dermatologist to try another treatment. Since vitiligo can effect self-esteem and be emotionally devastating, consider becoming involved in a support group (www.nvfi.org) or seeking a psychologist with whom to discuss your feelings. This is an important component of treatment for some individuals. Other common treatments for vitiligo include:

• Camouflage: cosmetics (Dermablend, Covermark)
• Topical creams: corticosteroids, tacrolimus
• Injections: corticosteroid
• Phototherapy: PUVA (oral or topical), narrow-band UVB
• Laser: 308-nm excimer laser
• Surgical: skin grafts
• Depigmentation: Monobenzylether of hydroquinone

For small areas of vitiligo or patches involving the face, camouflage with cosmetics is the easiest treatment with which to begin. However, matching the color cosmetic to normal brown skin may be difficult. It is important to identify an aesthetician or store sales associate who will take the time to find the shade closest to your skin hue. It is also important for that person to teach you how to apply the cosmetic so that it may be done quickly and efficiently daily.

Another approach to treatment of small areas of vitiligo is the use of topical creams. These include corticosteroid creams or the topical immunomodulator, tacrolimus. Using medium and high strength topical corticosteroids for 1-4 months has been found to be the most effective and safest therapy for localized vitiligo. Steroid injections have also been used for the treatment of vitiligo. Steroids can be used twice daily for limited periods of time. Repigmentation of the vitiliginous area with topical corticosteroids is most likely to occur on hair bearing areas of the skin. However, corticosteroids should not be used for long periods of time, since they may lead to thinning of the skin, growth of blood vessels, and rashes.

The non-steroid containing ointment, tacrolimus has been demonstrated to be an effective alternative treatment to topical steroids. In children treated twice daily for three months, at least partial response was noted on the head and neck area in 89%, and on the trunk and extremities in 63%. In adults, one study demonstrated that 17 of 19 subjects (89%) achieved varying levels of repigmentation with topical tacrolimus, with 68% having greater than 75% repigmentation of face and/or neck lesions.

Phototherapy (ultraviolet light) has been used successfully in the treatment of vitiligo. There are two primary types of light treatments available 1) ultraviolet B (UV-B) and 2) PUVA therapy, ultraviolet A (UV-A) combined with the chemical psoralen, either in pill form or topicallyapplied.

The theory behind ultraviolet light therapy is that the light, as well as the psoralen, stimulate the melanocytes in the hair follicle to repigment the skin. Repigmentation often begins as small brown dots of pigmentation around the follicle that then spread to fill in the patch.

Ultraviolet light therapy is a slow process, however, requiring treatment over 12 to 24 months. PUVA therapy is associated with a variety of side effects. Narrow-band UVB is a new alternative to PUVA without the side effects associated with PUVA. In one study, the highest success rates for repigmentation of vitiligo were achieved with narrowband UV-B (63%), broadband UV-B (57%), and oral PUVA therapy (51%). The areas that responded most favorably with PUVA were the face and trunk.

Vitiligo has been treated using a 308-nm xenon-chloride excimer laser. Patches were treated 3 times a week for a maximum of 12 treatments. Some repigmentation occurred in 57% - 82% of the treated patches, in one study.

Surgical treatment of vitiligo with grafts is another treatment. Minigrafts or suction-blister grafts of skin taken from an area of normal skin pigmentation are placed in the vitiliginous patch. The area then slowly repigments over a 3 to 6 month period of time. Melanocyte transplantation is another technique that has the potential to treat large areas of vitiligo but is not widely available.

If the patches of vitiligo are widespread and there are only a few remaining areas of normal brown skin tone, depigmentation of the remaining pigmented areas is sometimes considered. However, the bleaching is permanent and it is achieved with the cream, monobenzylether of hydroquinone.

Bottm Line
Although vitiligo does not occur more often in individuals with brown skin as compared to those with white skin, it clearly can be more devastating psychologically. There are several very good treatments available for vitiligo and new research offers the hope of even more effective treatments in the future.

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