Vitiligo: Understanding the Loss of Skin Colour

This article was contributed by Dr. Lim Ai Wei, Consultant Dermatologist at Pantai Hospital Klang. To book an appointment or learn more about Dr. Lim Ai Wei and her clinic, click here.

What is Vitiligo

Vitiligo is a skin disorder that causes loss of skin colour leading to the development of white patches on the skin. It is caused by destruction of pigment cells (melanocytes) that results in impaired melanin (substance giving the colour of skin) production causing white patches on the body.

How common is Vitiligo

Vitiligo affects 1-2% of the population worldwide. It affects both genders and all races equally even though it is more noticeable in darker skin type. It can occur at any age but most commonly appears between the age of 10 to 30 years old.

What causes vitiligo

It is an autoimmune skin disorder in which the person’s own immune system develops antibodies that destroy the pigment-producing cells, causing loss of pigment of the skin. Both environmental and genetic factors play a role. 20% of individuals with vitiligo have a first- degree relative affected by this condition. This further explained by the involvement of genes associated with the synthesis of melanin, regulation of autoantibodies (antibodies that attacks the own cells) and response to oxidative stress. Environmental trigger includes physical or emotional stress, exposure to ultraviolet radiation, skin injury or trauma (Koebnerisation), exposure to certain chemicals, skin- whitening products or medications.

What are the signs and symptoms?

• Face
• Periorbital
• Perioral
• Hands and feet
• Genitals

What are the types of Vitiligo?

• Generalized Vitiligo: This is one of the most common types in which white patches are widespread over the body
• Focal Vitiligo: The white patch/patches are confined to one area of the body, for example face or hands.
• Segmental Vitiligo: When the white patches are confined to one area of the body, and only involves one side of the body (unilateral).
• Acrofacial Vitiligo: When the white patches confine to face and hands or feet.

What are the Risk Factors?

• Other members of your family (first-degree relative) have it.
• Having an autoimmune condition such as thyroiditis, pernicious anemia, Addison’s disease, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, alopecia areata and psoriasis
• Family history of autoimmune conditions.

Is Vitiligo Contagious?

No, vitiligo is not contagious or infectious. It cannot be transmitted via touch, saliva, blood, inhalation, sexual intercourse or the sharing of personal items (i.e. drink bottle, towels, etc).

Is Vitiligo caused by some food?

No. Vitiligo is an autoimmune disease and has no direct relation to food.

What problems are associated with vitiligo?

• More susceptible to sunburn: Because of a lack of melanin (the substance that absorbs UV rays, affected skin is more sensitive to sunlight/ultraviolet radiation than the normal skin.
• Higher incidence of other autoimmune diseases: such as as thyroiditis, pernicious anemia, Addison’s disease, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, alopecia areata and psoriasis
• Eye problems: there may be inflammation of the retina (retinitis) or iris (iritis). These may lead to light sensitivity, eye discomfort or vision loss
• Hearing loss: due to the loss of pigment in the inner ear (rare)
• Embarrassment
• Psychological distress (anxiety and depression)

Diagnosis

• Clinical diagnosis: Detailed History and Physical examination
• Wood’s lamp: It is an ultraviolet (UV) lamp that is used to look at your skin in more detail. It must be performed in a dark room and the lamp will be held in front of your skin by the doctor. If the patches are due to vitiligo, there will be a chalky white accentuation
• Blood Tests: To look for any other associated autoimmune disorders
• Skin biopsy: To confirm the diagnosis by looking for absence of melanocytes. However, it is rarely done because the Wood’s Lamp examination is a gold standard with high accuracy.

Is there a cure?

Although there is no cure for Vitiligo, prompt treatment might slow or stop the progression of the disease.

Treatment

Treatment goals include stabilization of the disease progression and to regain pigment (repigmentation) of the lesions. Long-term treatment is usually necessary due to the chronic disease course and high relapse rate.

Steroid creams

Steroid is known to suppress the specific immune system cells and hence reduce inflammation that further damage of pigment- producing cells. Potent to very potent steroid creams once to twice daily application for 3–6months is recommended for patients with less extensive skin involvement. Common side effects of prolonged use are skin thinning, acne eruptions and increased hair growth on the application site. These side effects can be reduced by intermittent treatment regime such as 2 weeks on and 2 weeks off treatment.

Calcineurin inhibitor creams (non-steroids)

Calcineurin inhibitor creams such as tacrolimus and pimecrolimus are non-steroidal cream which suppressed the specific immune system cells and thus reduce inflammation, without causing skin thinning. It is proven to be as effective as steroid creams. It is preferred in vitiligo involving areas of thinner skin such as the face, neck and body folds such as armpits and groin. Common side effects are burning and stinging sensation.

UV Light Therapy (Phototherapy)

This involves exposing the skin to special UV light under controlled conditions, to stimulate the production of melanin by the pigment-producing cells. A specific wavelength (narrowband UVB of 311-312 nm) is used. This is the preferred first-line therapy for widespread or rapidly progressive disease.

Starting dose and dose increments need to be adjusted according to the patient's skin colour (phototype) and response. The most common side effects are redness (erythema) and skin dryness (xerosis). There has been no significant association between UV light therapy and skin cancer as to date.

Phototherapy should be stopped if there is no improvement after 3 months.

Excimer lasers

Excimer lasers are equally effective compared to UV light therapy. Intense beam of UVB (wavelength of 308 nm) is targeted to the white patch, to stimulate the production of melanin. This will prevent the darkening of the surrounding normal skin. It is suitable for localized disease as it is excessively time-consuming when treating large areas. Safety and tolerability of excimer laser therapy are comparable to UV light therapy, but the cost of therapy is often higher.

Oral steroid mini-pulse therapy

For the treatment of rapidly progressive vitiligo, oral mini-pulses of betamethasone or dexamethasone 0.1 mg/kg/day twice weekly on 2 consecutive days per week for 3 months then with tapering dose for another 3 months to stop disease progression. Prolonged steroid use should be avoided in view of the side effects.

Other immunomodulating agents

Methotrexate, cyclosporine, azathioprine and minocycline can be used in patients with progressive vitiligo, although strong evidence for efficiency is lacking.

Janus kinase inhibitors

JAK inhibitors are drugs that block the enzymes called Janus kinases (JAKs), which play a role in the immune system, hence reducing inflammation and preventing further damage to the pigment-producing cells.

Ruxolitinib cream is the only FDA approved JAK inhibitor. It has been showed to be effective in treating vitiligo. However, this is not available in Malaysia yet. Side effects include redness, itching and irritation at the application site. Oral JAK inhibitors showed promising results for vitiligo and currently under clinical trials, can be considered as a potential treatment once approved.

Supplements

Vitamin B12, vitamin C, vitamin E, folic acid, zinc, flavonoids, Ginkgo biloba and green tea polyphenols are antioxidants that have been proposed with the aim of achieving stabilization and repigmentation of vitiligo lesions, however studies are lacking.

Camouflage

Specialized camouflage makeup products, such as concealer creams and foundations are available to cover vitiligo patches. These products are waterproof and provide long-lasting coverage. There are various range of shades to match different skin tones.

Surgical interventions

Surgery should be reserved for patients with localized and stabilized forms of vitiligo that is unresponsive to medical treatment and who remain distressed by the condition. These includes transferring healthy skin (skin grafting) or transferring pigment-producing cells to the white patches.

Removal of pigment (Depigmentation)

If vitiligo is non-responsive to treatment and extensive to nearly complete (vitiligo universalis), patients may wish to remove the colour of normal skin to even out their skin tone.

Monobenzyl ether of hydroquinone (MBEH) is the only agent approved for skin pigment removal for vitiligo and its effect is permanent. It is applied as a cream under guidance of a skin specialist. MBEH is associated with side effects such as skin irritation, redness, burning sensation and sun sensitivity.

Lifestyle and Psychological support

Use of sunscreen (SPF 50 and above) and sun protection is important to protect affected skin from sunburn and reduce tanning of surrounding skin. While no specific diet recommended for vitiligo, a balanced diet is necessary for overall good skin health.

Vitiligo has significant impact on mental health and self-esteem. Psychological support such as counselling and support group are beneficial. Vitiligo Association Malaysia is a support group that is dedicated to create awareness and advocating on vitiligo in Malaysia.

Early diagnosis and treatment of vitiligo is crucial to halt the disease progression. Dermatologist referral is necessary where there is diagnostic dilemma, vitiligo unresponsive to initial treatment and progression of the disease. Consultation with a skin specialist is essential to develop and effective and personalised treatment plan for vitiligo.

**Take part in World Vitiligo Day on June 25th and help to raise awareness on the nature of this disorder and helping to fight against bias and stigma.