What is Vitiligo?
Patients with vitiligo develop white spots
on the skin that vary in size and location. The spots occur when pigment
cells, or melanocytes, are destroyed and the pigment melanin can no longer
be produced. Melanocytes normally occur throughout the skin, as well as in
the hair follicles, mouth, and eyes. In vitiligo, pigment cells can be lost
in any of these areas. Common sites of pigment loss are: Exposed areas:
hands, face, upper part of the chest Around body openings: eyes, nostrils,
mouth, nipples, belly button, genitalia Body folds: arm pits, groin Sites of
injury: cuts, scrapes, burns Hair: early graying of hair of the scalp, beard
or other areas Area immediately surrounding pigmented moles Back of the eye
Who gets Vitiligo
Vitiligo affects between 0.5-1% of the
population. About half of the people who develop this skin disorder
experience some pigment loss before the age of 20, and about one third of
all vitiligo patients say that other family members also have this
condition. Even though most people with vitiligo are in good general health,
they face a greater risk of having hyperthyroidism or hypothyroidism
(increased or decreased thyroid function), pernicious anemia (vitamin B12
deficiency), Addison's disease (decreased adrenal function), alopecia areata
(round patches of hair loss), and/or uveitis (inflammation of the eyes).
What determines skin color?
Melanin is the substance that normally
determines the color of skin, hair, and eyes. This pigment is produced in
cells called melanocytes. If melanocytes cannot form melanin or if their
number decreases, skin color will become lighter or completely white as in
vitiligo. Leukoderma is a general term that means white skin. Severe trauma,
like a burn, can destroy pigment cells resulting in leukoderma. Vitiligo is
just one of the forms of leukoderma.
What is the cause of Vitiligo?
The precise cause of vitiligo is not
known. A combination of genetic, immunologic and environmental factors is
involved in most cases. This means that certain people are predisposed (have
a greater tendency) to develop vitiligo upon exposure to the right trigger.
Many people report pigment loss shortly after a severe sunburn, while others
relate their onset of vitiligo to emotional trauma associated with an
accident, death in the family, or divorce.
How does Vitiligo develop??
The beginning of vitiligo and the severity
of pigment loss differs with each individual. Light skinned people usually
notice the pigment loss during the summer as the contrast between
depigmented skin and suntanned skin becomes distinct. People with dark skin
may observe the onset of vitiligo at any time. Individuals who have severe
cases may lose pigment over their entire body surface. There is no way to
predict how much pigment an individual will lose. Illness and stress can
result in more pigment loss. The degree of pigment loss can also vary within
each vitiligo patch, and a border of abnormally dark skin may encircle a
patch of depigmented skin. Vitiligo frequently begins with a rapid loss of
pigment, which may be followed by a lengthy period when the skin color does
not change. Later, pigment loss may resume, perhaps after the individual has
suffered physical trauma or stress. The loss of color may continue until,
for unknown reasons, the process stops. Cycles of pigment loss followed by
periods of stability may continue indefinitely. It is rare (but possible)
for a patient with vitiligo to repigment or regain skin color spontaneously.
Most patients who say that they no longer have vitiligo may actually have
become depigmented and are no longer bothered by contrasting skin color.
While such patients appear to be "cured", they really are not. People who
have vitiligo all over their bodies do not look like albinos because the
color of their hair may not change (or it can be dyed) and eye color does
Does Vitiligo have an emotional impact?
Many individuals with vitiligo are
distressed because of their uneven skin color. It is difficult for people
who do not have vitiligo to appreciate the significance of this problem.
Individuals with vitiligo benefit from talking to, and sharing experiences
with, other people with the disease.
What is the treatment for Vitiligo?
are two basic approaches to treatment: try to restore the normal pigment (repigmentation
therapy), or try to destroy the remaining pigment cells (depigmentation
therapy). Both are described below.
What is repigmentation theory?
For skin to be repigmented, new pigment
cells must be recruited from those that exist nearby. That means that new
pigment cells must come from the base of hair follicles, from the edge of
the lesion, or from the patch of vitiligo itself if depigmentation is not
complete. The maximum amount of repigmentation that can be expected in any
one spot in a year of treatment is an eighth to a quarter of an inch. If, in
a given area, most of the hair follicles provide pigment cells that radiate
to one eighth to a quarter of an inch, there may be substantial
repigmentation. However, if the hairs are white or if there are no hairs
present, repigmentation must occur from the edge of the depigmented area.
Hydrocortisone-type compounds (immunomodulators and immunosupressants), when
applied to the skin, slow the process of depigmentation and sometimes
enhance repigmentation. Cortisone ointments or creams sold over the counter,
such as 0.5% hydrocortisone, are too weak to be effective. More potent
cortisones are available by prescription. When potent cortisones are used
daily for a long time, they may produce side effects such as thinning of the
skin. Under the care of a dermatologist, it is usually possible to adjust
the treatment with topical hydrocortisones such that side effects are
minimized. Phototherapy methods can also be used to induce repigmentation of
the skin, either alone or in combination with hydrocortisone-type compounds.
These forms of therapy consist of narrow-band ultraviolet B (UV-B) light,
Excimer laser, and PUVA (Psoralen plus UV-A). Narrow-band UVB (also referred
to as narrowband and NB-UVB) is a relatively new vitiligo treatment option
that helps to repigment cells with minimal to no side effects. It involves
exposing the skin to a narrow-band UVB light source, which can be done in a
doctor's office or using home phototherapy units. Typically treatment is
done three times week for several months. Excimer laser treatment involves
exposing the skin to a beam of focused laser light. It is most commonly used
for small areas of depigmentation. The majority of patients with head and
neck depigmentation achieve substantial repigmentation in less than four
months. Treatment must be done by a doctor; no home units are available at
this time. In PUVA, a patient is given a Psoralen drug and is then exposed
to UV-A light. When Psoralen drugs are activated by the light, they
stimulate repigmentation by increasing the movement of pigments cells into
the vitiligo lesion. The response varies among patients and body sites. PUVA
therapy is no longer the first choice of phototherapy given the availability
and relative success of narrow-band UVB and excimer laser treatments. About
75% of the patients who undergo PUVA therapy respond to some extent. Even
for these individuals, complete repigmentation rarely occurs. After the
initial two to three weeks of exposure to sunlight, patients will look worse
since the contrast between their light and tanned skin increases. With time
repigmentation will begin, and the appearance of the skin will improve. If
therapy in stopped in winter, most people will retain at least half of the
they achieved during the summer months. People with vitiligo should
always protect their skin against excessive sun exposure by wearing
protective clothing, staying out of the sun at peak periods (except during
doctor-approved treatment times), and applying sunscreen lotions and creams.
Sun protection products are numbered according to the sun protection factor
(SPF), with the higher numbers giving more protection. Patients with
vitiligo should use a sunscreen with an SPF of 15 or higher, except during
times of treatment. During treatment, an SPF of 8 to 10 protects against
sunburn but does not block the needed UV-A light. Sunscreens should be
reapplied after swimming or perspiring, unless the sunscreen is formulated
to resist wash-off. To prevent potential damage to the eyes, special
sunglasses with protective lenses should be worn during sunlight exposure
and for the remainder of any day on which Psoralen drugs were taken.
Who is a good candidate for repigmentation?
Not all individuals with vitiligo are good
candidates for repigmentation therapies. Good candidates generally meet the
following requirements: Pigment loss of less than five years duration for
patients over 20 years of age. In general, children and young adults respond
better than older people. Patients should be at least 10 years old.
Treatment is safe for younger children, but because treatments may be
tedious to them, better results may be achieved when the child is interested
in treatment. An individual must be committed to the treatment because it is
a long process that requires a great deal of patience. Patients should be
healthy. Any associated illness, such as hyperthyroidism, should be treated
at the same time as the vitiligo. For PUVA therapy only, a pregnant woman
should not be treated because of the potential harmful effects of the drug
on her developing baby. WHAT IS DEPIGMENTATION THERAPY AND WHEN IS IT
WARRANTED? If a person has vitiligo over more than half of the exposed areas
of their body, he or she is not a good candidate for repigmentation. Rather,
such a person may want to try depigmentation of the remaining pigmented
skin. The drug for depigmentation is monobenzylether of hydroquinone (Benoquin).
Many patients with vitiligo are at first apprehensive about the idea of
depigmentation and are reluctant to go ahead. However, patients who achieve
complete depigmentation are usually satisfied with the end results. Some
people become allergic to the medication and must discontinue therapy.
Moreover, depigmentation is not always permanent. Some patchy pigmentation
may return. It can be re-treated under the advisement of a dermatologist.
Can cosmetics be used?
Most patients, even those who are
responding well to therapy, may want to make their vitiligo less obvious.
Many find that a combination of cosmetics effectively conceals their skin
disorder. Patients who are interested in dyes and stains should consult a
dermatologist for the names of suitable commercial products.
Is Vitiligo curable?
At present, the answer is no. Vitiligo
results from a variety of factors (genetic and environmental) interacting in
unknown ways. While research has advanced our understanding of the physical
and psycho-social causes underlying vitiligo, a cure for this disease does
not currently exist. More research is required to fully understand the
factors involved and to find ways to reverse or block them.
What does the future hold?
Research on vitiligo, defects of pigment
cells, autoimmune response, and the associated genes has increased
significantly in the past decade. Therapeutically, attempts to stop the
progression of vitiligo by the use of topical immunosuppressants/immunomodulators
and new phototherapy procedures appear promising. Skin transplantation
procedures, where a dermatologist removes a patch of normally pigmented skin
and grafts it onto a depigmented area, are progressing well. In addition,
melanocyte transplant therapy, where a dermatologist takes pigment cells
from an unexposed normally-pigmented patch of skin, grows them in culture to
large numbers, and returns them into a white patch of skin, is also being
Does anyone care?
There is much concern for the vitiligo
patient, but there is relatively little emphasis on funding clinical and
basic science research on this disease because it is not lethal and is often
considered cosmetic in nature. The National Institutes of Health (NIH)
awards about $500,000 annually toward pigment research programs. However,
this pales in comparison to money awarded to research on cancer, AIDS,
cardiovascular disease, etc. Despite this, research does continue in the
United States and around the world to various degrees. Universities such as
Denver, Loyola, Cincinnati, Howard, and Boston have active programs in
vitiligo research (we are creating a research roadmap that identifies these
and other research centers). But, for the reasons mentioned above, funds are
sparse. It is because of this that your contributions to Foundations such as
the NVF are so crucial for enabling research on better therapies and,
ultimately, a cure.
Text above borrowed with permission from
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