Bruce P.Robinson, MD
Vitiligo is a skin condition resulting from the loss of pigment which produces white patches. Any part of the body may be affected. Usually both sides of the body are affected. Common areas of involvement are the face, lips, hands, arms, legs, and genital areas.
Vitiligo affects one or two of every 100 people. About half the people who develop it do so before the age of 20; about 1/5 have a family member with this condition. It may be an autoimmune process (the body makes antibodies to its own pigment cells). Most people with vitiligo are in good general health, although vitiligo may occur with other autoimmune diseases such as thyroid disease
Melanin, the pigment that determines color of skin, hair, and eyes, is produced in cells called melanocytes. If these cells die or cannot form melanin, the skin becomes lighter or completely white
Typical vitiligo shows areas of milky-white skin. However, the degree of pigment loss can vary within each vitiligo patch. There may be different shades of pigment in a patch, or a border of darker skin may circle an area of light skin.
Vitiligo often begins with a rapid loss of pigment. This may continue until, for unknown reasons, the process stops. Cycles of pigment loss, followed by times where the pigment doesn't change, may continue indefinitely.
It is rare for skin pigment in vitiligo patients to return on its own. Some people who believe they no longer have vitiligo actually have lost all their pigment and no longer have patches of contrasting skin color. Although their skin is all one color, they still have vitiligo.
The course and severity of pigment loss differ with each person. Light-skinned people usually notice the contrast between areas of vitiligo and suntanned skin in the summer. Year round, vitiligo is more obvious on people with darker skin. Individuals with severe cases can lose pigment all over the body. There is no way to predict how much pigment an individual will lose.
Sometimes the best treatment for vitiligo is no treatment at all. In fair-skinned individuals, avoiding tanning of normal skin can make areas of vitiligo almost unnoticeable because the (no pigment) white skin, of vitiligo has no natural protection from sun. These areas are easily sunburned, and people with vitiligo have an increased risk to skin cancer. A sunscreen with a SPF of at least 30 should be used on all areas of vitiligo not covered by clothing. Avoid the sun when it is most intense to avoid burns.
Disguising vitiligo with make-up, self-tanning compounds or dyes is a safe, easy way to make it less noticeable. Waterproof cosmetics to match almost all skin colors are available. Stains that dye the skin can be used to color the white patches to more closely match normal skin color. These stains gradually wear off. Self-tanning compounds contain a chemical called dihydroxyacetone that does not need melanocytes to make the skin a tan color. The color from self-tanning creams also slowly wears off. None of these change the disease, but they can improve appearance. Micropigmentation tatooing of small areas may be helpful.
If sunscreens and cover-ups are not satisfactory, your doctor may recommend other treatment. Treatment can be aimed at returning normal pigment (repigmentation) or destroying remaining pigment (depigmentation). None of the repigmentation methods are permanent cures.
Aggressive treatment is generally not used in children. Sunscreen and cover-up measures are usually the best treatments. Topical corticosteroids can also be used, but must be monitored. PUVA, an ulta-violet therapy, is usually not recommended until after age 12, and then the risks and benefits of this treatment must be carefully weighed.
Topical Corticosteroids — Creams containing corticosteroid compounds can be effective in returning pigment to small areas of vitiligo. These can be used along with other treatments. These agents can thin the skin or even cause stretch marks in certain areas. They should be used under your dermatologist's care.
PUVA is a form of repigmentation therapy where a type of medication known as psoralen is used. This chemical makes the skin very sensitive to light. Then the skin is treated with a special type of ultraviolet light call UVA. Sometimes, when vitiligo is limited to a few small areas, psoralens can be applied to the vitiligo areas before UVA treatments. Usually, however, psoralens are given in pill form. Treatment with PUVA has a 50 to 70% chance of returning color on the face, trunk, and upper arms and upper legs. Hands and feet respond very poorly. Usually at least a year of twice weekly treatments are required. PUVA must be given under close supervision by your dermatologist. Side effects of PUVA include sunburn-type reactions. When used long-term, freckling of the skin may result and there is an increased risk of skin cancer. Because psoralens also make the eyes more sensitive to light, UVA blocking eyeglasses must be worn from the time of exposure to psoralen until sunset that day to prevent an increased risk of cataracts. PUVA is not usually used in children under the age of 12, in pregnant or breast feeding women, or in individuals with certain medical conditions.
This is a form of phototherapy that requires the skin to be treated two, sometimes three, times a week for a few months. At this time this form of treatment is not widely available. It may be especially useful in treating children with vitiligo.
Transfer of skin from normal to white areas is a treatment available only in certain areas of the country and is useful for only a small group of vitiligo patients. It does not generally result in total return of pigment in treated areas.
Other treatment options include a new topical class of drugs called immunomodulators. Due to their safety profile they may be useful in treating eyelids and children. Excimer lasers may be tried as well.
For some patients with extensive involvement, the most practical treatment for vitiligo is to remove remaining pigment from normal skin and make the whole body an even white color. This is done with a chemical called monobenzylether of hydroquinone. This therapy takes about a year to complete. The pigment removal is permanent.
At this time, the exact cause of vitiligo is not known, however, there may be an inherited component. Although treatment is available, there is no single cure. Research is ongoing in vitiligo and it is hoped that new treatments will be developed.
