Vitiligo

What is vitiligo?
Vitiligo or leucoderma is a disease of unknown cause characterized by an overactive immune system (the system of the body responsible for attacking outside invaders, such as bacteria or viruses and destroying cancer cells). In vitiligo, pigmented cells of the skin (melanocytes) are being destroyed by patient’s own abnormal immune system. Likely causes of vitiligo include combination of autoimmune, genetic, and environmental factors. Vitiligo affects about 1% to 2% of the population and may cause significant psychological problems for affected patients. The disorder affects all races and both sexes.

Presentation:
Half of patients develop vitiligo before the age of 20. The disorder presents with white patches surrounded by normal or darkened border. Both sides of the body usually have similarly distributed light patches (symmetrical involvement). Hairs in diseased areas also become white. Stress or trauma to the skin may provoke appearance of new patches.

Additional associations:
Since the immune system of patients with vitiligo is not working properly, it sometimes attacks tissues outside skin. If hair is attacked, patients present with patches of hair loss (alopecia areata). If thyroid gland is targeted, thyroiditis or Grave’s disease occurs. Additionally, pancreas, red blood cells, and adrenal glands can be rarely affected. That results in diabetes, anemia, and Addison’s disease respectively.

Treatment:
Treatment of vitiligo is difficult and sometimes frustrating. The course of vitiligo is chronic. Many areas successfully regaining color may become depigmented again. New white patches may appear during therapy. Yet, many patients get better with treatment, and regain their color.

If vitiligo involves a small area of the skin, topical corticosteroid preparations, tacrolimus ointment, or pimecrolimus cream may be tried first. The treatment is prolonged. First signs of success usually are not seen until after 3 months of use of a topical medicine. Corticosteroid creams have significant risk of glaucoma if used around the eyes. Additionally, they should not be used in the areas of thinner skin (e.g. genitals, groin). If these areas are involved, tacrolimus or pimecrolimus are safer. Your dermatologist should monitor skin for side effects (stretch marks, thinning, or appearance of blood vessels) if topical corticosteroids are used.

Phototherapy or light therapy (UVB and PUVA) is beneficial for many patients with vitiligo. This treatment is usually conducted in physician’s offices and therefore requires multiple visits per week. UVB therapy involves exposure to UVB light emitted by an artificial light source. Narrow band UVB (UVB with wavelengths 310-315 nm) is preferred to a broad band UVB (multiple wavelengths of UVB spectrum). PUVA first involves ingestion of a medication (psoralen) or topical application of psoralen solution. Psoralen prepares skin for a second phase of treatment – exposure to UVA light from the light box.

Surgical treatments, such as grafting or melanocyte transplantation can be tried on patches of stable vitiligo. In grafting, tiny pieces of person’s own normal skin are transplanted onto areas without pigment. Melanocyte transplantation involves cells cultured from the person’s unaffected skin and injected into blisters on the depigmented areas or directly into dermabraded skin. These treatment modalities are not widely available. Large dermatology departments in medical schools are more likely to be involved in surgical treatment of vitiligo then individual practicing dermatologists.

Cosmetic camouflage with various cosmetics is helpful if disease is not responding to treatment. If the disease involves large areas of the body, some patients choose to completely depigment (get rid of pigment) their whole skin.

Since areas with vitiligo lack pigmented cells, they also lack natural protection from sunlight. Therefore, broad-spectrum sunscreens should be used on affected areas at all times to protect from solar radiation.

References:
Whitton ME. Ashcroft DM. Barrett CW. Gonzalez U. Interventions for vitiligo. Cochrane Database of Systematic Reviews. (1):CD003263, 2006.
UI: 16437451.

Support organizations:

www.vitiligosupport.org
www.avrf.org
www.nvfi.org
www.vitiligoforum.com

Alexander Doctoroff, D.O., F.A.O.C.D.
Assistant Chief of Dermatology,
Veterans Administration Medical Center
East Orange, New Jersey

Assistant Clinical Professor of Medicine,
University of Medicine and Dentistry of New Jersey
www.metropolitanderm.com