Vitiligo

1 - ACKNOWLEDGEMENTS

Chapter written with the help of the EADV, the Fondation René Touraine and the Therapeutics in Dermatology

2 - OVERVIEW

Vitiligo is a chronic depigmenting disorder that causes the loss of normal skin color, affecting 1 -5% of the world population, without sex or racial difference, but it may be more noticeable in people with darker skin. This condition can affect all age groups but in more than half occurs before 20 years of age.

The extent and rate of color loss from vitiligo is unpredictable, varying from single small patches to total loss of skin color. It can affect the skin on any part of the body.

The disease is not life-threatening, but it can cause many psychosocial problems related to the development of low self-esteem and depression. Most people have vitiligo for life, so it’s important to develop coping strategies.

3 - SYMPTOMS

Vitiligo manifests through irregularly shaped patches of skin that lack the normal melanin pigmentation, and are thus completely very pale, pink or almost white. Vulgaris vitiligo is often symmetrical, affecting both sides of the body. The most common sites affected are the hands and face, around body openings (the eyes, nostrils, mouth, umbilicus and genital regions), and within body folds such as the underarms and groin. The hair may lose its pigment and appear white. Itch is uncommon. Segmental vitiligo has unilateral distribution (asymmetric vitiligo) that may totally or partially match a cutaneous segment.

Sunlight worsen the contrast between tanned skin and vitiligo skin and people may feel embarrassed. Besides, sunlight may cause sunburn to exposed areas.

Repigmentation often commences around hair follicles, initially giving the skin a speckled appearance.

4 - CAUSES

Normally, the color of hair and skin is determined by melanin. Vitiligo occurs when the cells (melanocytes) that produce melanin stop functioning. The reason for this is not fully understood. However, vitiligo is considered an autoimmune condition, in which the body’s own immune system rejects melanocytes. Other autoimmune diseases, for instance, thyroid disease, can be appear associated to vitiligo. Both twin and family studies point the importance of genetic predisposition in the development of vitiligo, in addition to environmental factors.

Repeated trauma such as rubbing or scratching the skin may trigger vitiligo. This is called koebner phenomenon. There is no medical evidence about any link between smoking or diet and vitiligo.

5 - TREATMENT

There is no cure for vitiligo. Although treatment may be helpful in restoring the color, it cannot prevent its spread or recurrence and repigmentation may not be permanent. As the care often extends over a long period of time, patients are frequently frustrated by the failure of previous treatments. Psychological stress is common. The treatment plan should be discussed with the patient to obtain a high level of compliance. It must be remembered that some therapies are not licensed for vitiligo and can only be prescribed ‘off-label’.

There are a number of treatment options:

• Sunscreens. Areas of vitiligo will burn easily in the sun. The use of a sunscreen with a high sun protection factor (SPF) to all exposed areas helps to protect skin affected by vitiligo, and also, when applied more widely, reduces the contrast between the areas of vitiligo and the surrounding normal skin.
• Topical corticosteroids. The application of a potent or very potent corticosteroid anti-inflammatory cream or ointment (e.g. clobetasol) to areas of vitiligo may restore some pigment. There are potential local side-effects (skin atrophy, telangiectasia, hypertrichosis, acneiform eruptions and striae) of potent or very potent corticosteroids used for long periods.
• Topical calcineurin inhibitors They may also restore pigment in some patients. These topical treatments (e.g. tacrolimus/pimecrolimus) will help avoid the corticosteroid side effect of skin thinning.
• Phototherapy. This involves exposing affected skin to artificial ultraviolet light. Phototherapy may be helpful in a proportion of patients with vitiligo. However, treatment often needs to be prolonged (lasting at least several months). Full repigmentation is unusual and depigmentation after phototherapy can occur. Phototherapy may also be used in combination with topical or oral corticosteroid treatments. 
• Antioxidants. The occurrence of cellular oxidative stress during the progression of vitiligo is the rationale for the topical or systemic administration of antioxidants like pseudocatalase, vitamin E, vitamin C, ubiquinone, lipoic acid, Polypodium leucotomos, catalase⁄superoxide dismutase combination, and Ginkgo biloba. They have been used alone or in combination with phototherapy. However, there is a limited evidence of efficacy, and further confirmation is needed before recommending their prescription.
• Laser treatment. Some areas of vitiligo have improved from treatment with a laser called the Excimer laser. This treatment appears to work best on vitiligo that has not changed for a long time and affects relatively small areas of skin. Laser treatment can sometimes be used in combination with topical treatments. 
• Surgical treatment. This process involves transplanting small areas of normal skin into areas of stable vitiligo. This method of treatment is still being developed and is not yet in general use.
• Removing the remaining pigment. If vitiligo has spread very widely (more than 50% of the body) or involves large areas of the face or hands, it may in exceptional circumstances be reasonable to consider removing the small amounts of pigmented areas of skin using a bleaching chemical such as hydroquinone.
• Skin camouflage. Advice from experts about skin camouflage is now widely available. There is a wide choice of self-tanning agents, stains, dyes, whitening lotions, tinted cover creams, compact, liquid and stick foundations, fixing powders, fixing sprays, cleansers, semipermanent and permanent tattoos, and dyes for pigmenting facial and scalp white hairs. There are good quality camouflage products in a range of colours that are water resistant and less likely to rub off.
• Psychological treatments. Depigmentation exerts a negative impact on the patient’s appearance and self-esteem leading to social isolation in both personal and professional relationships. Professional help with developing coping mechanisms may be helpful for some patients.

6 - TIPS FOR MANAGING

• Protect your exposed skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
• Spend time in the shade between 11am and 3pm when it’s sunny. 
• When choosing a sunscreen look for a high protection SPF (SPF 50 or more) to protect against UVB and UVA.
• Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming, towel-drying and strenuous exercise. 
• It may be necessary to take Vitamin D supplement tablets as strictly avoiding sunlight can reduce Vitamin D levels. Ask your doctor about this.