Vitiligo: the facts

Vitiligo is a relatively common, acquired loss of pigmentation of the skin affecting 1% to 2% of the population. Destruction of melanocytes or pigment cells occurs and the skin becomes white. The most common sites of pigment loss are body folds (like the groin or armpits ), around body openings and exposed areas like the face or hands. It can develop at sites of injury: cuts, scrapes and burns. Vitiligo can begin at any age, but in half of all affected patients, its onset is noted before the age of 20. It can be associated with a number of autoimmune conditions such as thyroid disease and diabetes. Most people with vitiligo are in good health and have no symptoms other than areas of pigment loss. Although the precise cause is unknown, genetic factors, autoimmune factors, trauma to the skin and anxiety/ stress can be associated. Vitiligo is not infectious and cannot be spread to other people. People with melanoma can occasionally develop vitiligo. Research on the cause continues.

The diagnosis is based on clinical examination. Asymptomatic white areas are present with well defined edges. Lesions can be localized or generalized and the distribution is usually symmetrical. White hairs can occur within an area of vitiligo and early graying or whitening of scalp hair, eyelashes, eyebrows and beard hair can occur. Eye involvement can also occur.

Vitiligo can remain localized and stable indefinitely, or it may progress slowly or rapidly. There is no way to predict this. Definitive factors that precipitate progression of the disease are speculative-emotional distress, physical illness, severe sunburn and pregnancy are often implicated. Depigmented areas may sometimes spontaneously repigment.

The cosmetic disfigurement, particularly in dark skinned people, can have profound psychological effects. Low self esteem , depression and job discrimination have been reported and vitiligo can therefore ultimately alter lifestyles, create social barriers and limit employment opportunities. There can be a considerable impact on their quality of life. It is therefore important to offer treatment to these individuals.

There seems to be a hereditary component to vitiligo. 10% have a family history. Many patients do not realise that anyone in their family has had vitiligo. Your children have a somewhat higher probability of developing vitiligo than do children from families with no history of the disease. This however does not mean that your children will definitely inherit vitiligo. In most cases of vitiligo , there is no family history of the disorder.

Your Dermatologist is the best person to assess and manage your vitiligo. There are basically 4 treatment options: 1. No Treatment 2. Camouflage 3. Active Repigmentation with a) Medical Treatment;  b) Surgical Treatment; or  c) Lasers 4. Depigmentation

This is achieved with make-up and topical dyes including self tanning lotions. Microtattooing can be useful for small stable areas of vitiligo such as face, lips and hands.

To repigment the skin, new pigment cells must be produced from existing ones. These pigment cells 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. Treatment includes topical corticosteroids, light therapy with photosensitising psoralen drugs applied topically or given systemically in conjunction with sunlight exposure or UVA phototherapy (PUVA ), narrow band UVB phototherapy, and other topical agents-calcipotriol, pimecrolimus and tacrolimus. Approximately 75% of patients who undergo light therapy respond to some extent. Even for these individuals, complete repigmentation rarely occurs. Patients initially look worse with light treatment since the contrast between light and tanned skin increases. With time, repigmentation begins, and the appearance of the skin will improve. If patients stop the treatment, most will retain the achieved repigmentation.

Surgical treatments should only be considered when medical therapies fail. They should only be performed on patients with stable non- progressive vitiligo, ideally localized or segmental. These procedures can be used in combination with medical therapies. A number of surgical techniques for repigmentation of vitiligo have been developed. They involve transfer of a patient’s own melanocytes from unaffected skin into vitiligo affected skin (autologous melanoycte transplantation). Techniques available include mini-grafting using for example punch grafts, non-cultured epidermal suspension, cultured melanocyte suspension and cultured epidermal grafts Very good results can be achieved with these procedures.

Lasers such as the 308nm xenon chloride excimer laser have been used to treat vitiligo. Excimer lamps producing UV light at 308nm (such as VTRAC, Excilite-µ and Quantel) are also being used.

Treatment with monobenzyl ether of hydroquinone can be used in patients with extensive vitiligo, involving more than 80% of the skin. This process may take 6 months to 2 years to achieve. Strict sun protection is required after depigmentation. Pigment removing lasers can also be used.

Vitiligo patients can experience indifference from their treating doctors in terms of pessimism regarding treatment outcomes and do not feel adequately supported by them. Patients are therefore not informed properly about their disease and the available treatment options. Some patients need help with the emotional and psychological aspects of vitiligo and referral to either a psychologist or psychiatrist should be considered. Vitiligo support groups and other patients with vitiligo can also offer support. The Vitiligo Association of Australia has recently been set up incorporating the various state based Vitiligo Support Groups.

The precise answer at this time is no. Vitiligo is probably caused by a variety of factors interacting in specific ways. Research has advanced the understanding of the physical and psychosocial aspects of vitiligo, but the cause and cure are unknown. The treatment of vitiligo is prolonged and progress is slow. Patients require motivation, encouragement and empathy and must be reassured that repigmentation can be achieved with treatment. The Future Pigment cell research as related to vitiligo is ongoing. Hopefully, this will lead to better treatment options in the future. Melanocyte transplants , where the dermatologist takes pigment cells from an unaffected area of the patient’s skin, grows them in culture to large numbers, and then transfers them back into vitiligo affected skin, is also promising. Gene therapy may also have a possible role.