Causes of Vitiligo
Vitiligo is a condition characterized by depigmentation which is the loss of the normal color of the skin.
Though the exact cause of vitiligo is not known, it is thought to develop when cells from the immune system destroy cells in the skin known as melanocytes which produce the pigment that gives it its color known as melanin.
Genes are also thought to play a role in the development of vitiligo since around 30% of all patients have relatives with vitiligo. Oxidative stress is another factor thought to contribute to its genesis.
Symptoms of Vitiligo
The main symptom of vitiligo is gradually enlarging white patches on the skin. These patches usually not painful, itchy or scaly.
Though vitiligo can affect skin on any part of the body, these white patches often begin in face, hands and feet. The tissues inside the mouth and the retina in the eye may also lose their normal color.
Other symptoms of vitiligo include premature whitening of the hair on the scalp, eyebrows, eyelashes and beard. The areas affected by vitiligo may also have increased sweating.
Vitiligo can also cause psychological effects like emotional stress, social anxiety, low self-esteem and depression especially when the depigmented patches develop on the face and private parts.
Vitiligo can be classified according to the pattern formed by the white patches on the skin. These patterns vary from person to person and there is no way of predicting how vitiligo will evolve in an individual.
Localized vitiligo affects one or a few areas of the body like one side of the face or one arm or leg.
Segmental vitiligo affects one side of the body. For example depigmented patches developing on the right arm and leg.
Generalized vitiligo affects both sides of the body and causes widely distributed hypopigmented (lighter than the surrounding skin) patches which are often symmetrical (on both sides of the body).
Universal vitiligo results in complete or almost complete loss of the normal skin color.
The diagnosis of vitiligo is made after the healthcare provider listens to the symptoms and examines the white skin patches. A Wood’s lamp, which provides ultraviolet light, can be used to differentiate the depigmented areas from other skin diseases which cause white spots on the skin like the fungal infection Tinea versicolor.
The doctor may also perform a skin biopsy by numbing the affected area with local anesthesia and taking a small piece of tissue to be examined in the laboratory under a microscope.
Blood tests like blood glucose, anti-nuclear antibodies (ANA) test and thyroid function tests (TFT) may also be requested to check for the presence of other autoimmune diseases in the body.
Vitiligo Differential Diagnoses
The differential diagnoses of vitiligo or conditions which resemble vitiligo by having white spots on the skin include:
1. Tinea versicolor
2. Confetti hypopigmentation
3. Post-inflammatory hypopigmentation
4. Idiopathic guttate hypomelanosis
Medical Treatment for Vitiligo
Not all patients who develop vitiligo need medical treatment since in some cases the condition spontaneously. For those patients with larger patches, the treatment can be quite challenging due to the lack of a medication that works on all patients. Most patients therefore have to try different treatment options before they discover one that works for them.
Medications used to treat vitiligo include:
1. Corticosteroid creams
Creams containing corticosteroids like Triamcinolone are applied to the skin to help with repigmentation or restoration of normal skin color. They are most effective if applied early in the disease process.
The application of steroids on the skin has to be monitored closely by the doctor since it can cause many side effects like thinning of the skin (skin atrophy), streaking of the skin (skin striae) as well as internal complications.
2. Immunomodulator creams
Creams which affect how the immune system functions like Tacrolimus and Pimecrolimus are also used to manage vitiligo. These medications are mainly used on the face and neck since they are much safer than corticosteroids.
3. Vitamin D analog creams
Vitamin D derivatives like Calcipotriol and Tacalcitol are also applied on the skin and they can be used in conjuction with corticosteroids.
4. Topical PUVA
Topical psolaren plus ultraviolet A (PUVA), which is also known as photochemotherapy, is used when the vitiligo affects less than 20% of the skin. The therapy involves the application of a chemical known as a psolaren on the skin to make it more sensitive to ultraviolet (UV) light. The skin is then exposed to UVA light after around 30 minutes.
5. Oral PUVA
If vitiligo affects more than 20% of the skin, oral psolaren plus ultraviolet A (PUVA) is used. This involves taking a tablet containing a psolaren to make the skin more sensitive to UV light and then it is exposed to UVA light after around 2 hours. Oral PUVA is not recommended for children aged less than 10 years.
6. Narrowband UVB therapy
This treatment involves exposing the skin to UVB light without applying a psolaren.
For patients who have vitiligo patches covering more than 50% of their skin, depigmentation or removing the remaining pigment is another option. This is usually done by the application of a medication known as monobenzone ether of hydroquinone twice a day to the normal colored skin until it also loses its color.
Surgical Treatment of Vitiligo
The surgical treatment of vitiligo involves the use of:
1. Autolgous skin grafts
In this procedure the doctor removes small pieces of normal, pigmented skin from the patient’s body and attaches them to the areas affected by vitiligo. This treatment is recommended for those with very small patches of vitiligo. Possible complications of these grafts include developing a cobblestone appearance, spotty pigmentation and scarring.
2. Blister grafting
In this procedure the doctor uses a suction device to create a blister on an area with normal, pigmented skin. The roofs of the blisters are removed and attached to blisters that have been created on depigmented skin. The risk of scarring is reduced in this grafting procedure though the skin may also develop a cobblestone appearance.
Tattooing or micropigmentation involves injecting pigment into the skin that is affected by vitiligo. This therapy produces the best results in people with dark skin and in the area around the mouth. The procedure is repeated once the pigments begin to fade.
Adjunctive Therapies for Vitiligo
Adjunctive therapies for vitiligo include:
1. Psychological treatment
Counseling and cognitive therapy is an important aspect of vitiligo treatment since it improves the coping mechanisms of patients who are psychologically affected by the presence of white patches on their body. Adolescents are prone to developing anxiety especially if the vitiligo is spreading and it is on the face, hands and genitals.
Joining support groups like the National Vitiligo Foundation, Vitiligo Support International and Vitiligo Society can also help the patient and their family understand and cope with the condition better.
Alternative Medicine for Vitiligo
Alternative medicine therapies for vitiligo include the use of:
1. Ginkgo biloba
A study done on patients with limited and slow-spreading vitiligo showed that taking 40 milligrams of ginkgo three times a day stop depigmentation (loss of normal skin color) and induced repigmentation (return of normal skin color).
Note that you should always consult your doctor before taking any herbs or supplements since some of them may react adversely with your medications.
Experimental Therapies for Vitiligo
Experimental therapies for vitiligo include the use of:
1. Autologous melanocyte transplant
In this procedure melanocytes (the cells which produce the skin’s pigment) are grown in the lab and then attached to the areas affected by vitiligo.
Vitiligo Self Help
Vitiligo self-help includes the use of:
Broadspectrum sunscreens that offer protection from UVA and UVB light should be applied on all areas affected by vitiligo because they are prone to sunburns and subsequently even developing skin cancer. Applying sunscreen also reduces tanning which can make the white patches more obvious. These sunscreens should have a SPF (sun protection factor) of at least 30.
2. Camouflage cosmetics
The use of camouflage cosmetics can be divided into using cover-up makeup and using self-tanning lotions.
a. Cover-up Makeup
Cover-up makeup usually comes as sets which include concealing creams and setting powder. To apply the cover-up makeup follow these instructions:
1. Clean the skin with soap and water.
2. Apply the concealing cream foundation to the white patches. This cream foundation should be 1 or 2 shades darker than the surrounding skin.
3. Lightly dust the area with loose powder.
b. Self-Tanning lotions
Self-tanning lotions which contain Dihydroxyacetone (DHA) are used medically to darken skin which has lost its normal color. They can be applied to any part of the body and their color changes begin to become apparent around 1 hour after application.
DHA self-tanning lotions are available in concentrations which range from 2.5 to 10%. It is advisable to begin with the lower concentrations, which are lighter in color, since it is easier to darken a lighter shade than to lighten a darker shade.
To apply self tanning lotions follow these instructions:
1. Clean the skin with soap and water.
2. Exfoliate it with a body scrub to make it smoother for more even coloration.
3. Wipe it with hydroalcoholic to neutralize alkaline compounds from the soap.
4. Moisturize the skin.
5. Wear gloves to avoid developing tanned palms.
6. Apply a thin layer of the DHA self tanner to the white areas on the skin using long, uniform strokes.
7. Wipe off any excess color to prevent uneven darkening with a damp cloth.
8. Wait for 60 minutes before bathing.
9. Reapply the color once it begins fading which is usually after around 3-7 days.