Vitiligo: Types, Causes, Symptoms, Investigations, Treatment, Surgery, Self Measures
Vitiligo is a medical condition of the skin where there is loss or absence of melanin, a pigment, which is responsible for the color of the skin, eyes and hair. The cause of vitiligo is destruction of the cells which produce melanin (melanocytes) or if these cells are not able to produce melanin. This results in irregular shaped white patches on the skin, which grow gradually in size. Vitiligo in individuals with darker skin is more noticeable; however, people from different races can also be affected by this condition.
Vitiligo begins as small areas of pigment loss which increases slowly. As of now, vitiligo has no cure. The aim of treatment is to stop or slow down the pigment loss and try to bring back some color to the skin.
Types of Vitiligo
It is difficult to predict the natural course of vitiligo. In some cases, the formation of patches stops without any treatment. However, in majority of the cases, pigment loss increases and ultimately involves the majority of the skin surface.
There Are Three Common Patterns Of Vitiligo:
- Generalized: This is the most common pattern where there is extensive de-pigmentation or pigment loss across various regions of the body, often in a symmetrical pattern.
- Segmental: In this type, the pigment loss occurs only on one side of the body. This type is commonly seen in people of younger age group. This type of vitiligo progresses for a couple of years before finally stopping.
- Focal: As the name itself suggests, in this type, de-pigmentation is restricted to one or some areas of the body.
Causes of Vitiligo
Vitiligo occurs when melanocytes, which are the cells which produce melanin, either fail to make melanin or if they are dead. Melanin is the pigment which lends color to the skin, hair and eyes. Any problem with the production of the melanin results in the affected patch of the skin turning white. Why this happens is not known. According to the experts, this could be due to an immune system disorder. Having a family history also puts you at an increased risk for having vitiligo. There are some cases, where vitiligo appeared after the patient suffered sunburn or some mental distress. Individuals with melanoma can also have pigment loss. However, no cause has been proved conclusively.
Symptoms of Vitiligo
- Primary symptom is the loss of pigment resulting in irregular, milky-white patches, which gradually grow in size.
- Premature graying/ whitening of the hair, eyebrows, eyelashes or beard.
- Loss or alteration of color in the retina.
- Loss of color in the mucous membranes which line the inside of the mouth.
Vitiligo or de-pigmentation often begins in those regions of the body which are exposed to sun the most, like hands, arms, feet, lips and face. Vitiligo is commonly seen in individuals aged 10 to 30 years; although people from any age can be affected by it.
Investigations for Vitiligo
- Certain tests are done to exclude other skin or medical problems, such as psoriasis or dermatitis.
- A device kwon as Woods lamp is used for diagnosis of vitiligo.
- Biopsy can also be taken for further confirmation and to rule out other problems, such as melanoma.
- Blood tests are done to check the blood cell count, thyroid function and to check whether anti-nuclear antibodies are present indicating an autoimmune disorder.
Medical history and physical exam is done. The doctor will ask many questions, such as whether the patient:
- Has a family history of vitiligo.
- Has some autoimmune disease.
- Has a history of other skin problems.
- Has developed a sunburn, rash etc. within a couple of months of de-pigmentation.
- Has a history of sun sensitivity.
- Has premature hair graying.
- Has a history of multiple, atypical moles or melanoma.
- Has any stress.
- Has any other medical problem or physical illness.
Treatment for Vitiligo
Treatment is done according to the number, location and size of the white vitiligo patches. In some cases, treatment may not be required and the patient gets his/her skin color back without any treatment. Self-measures like applying sunscreen and creams for camouflaging the white patches help in the overall appearance of the skin. In individuals who are fair-skinned, their patchy areas can be almost unnoticeable if they avoid tanning. Treatment for vitiligo comprises of balancing the skin tone by restoring color through pigmentation or by destroying the remaining color.
Treatment can take anywhere between 6 to 18 months. Patient needs to try multiple treatment modalities before finding the one treatment which benefits him/her.
Vitiligo Treatment Includes:
- Topical corticosteroid application works by restoring the skin color, i.e. re-pigmentation. Corticosteroid therapy especially works if it's started early on in the disease. For children, mild topical corticosteroid cream/ointment is prescribed. It may take some months before the results of this treatment are seen. Topical corticosteroids are an effective treatment which is also easy to use, but the patient needs to be monitored closely for side effects, which include skin thinning, skin striae etc.
- Vitamin D derivatives, such as calcipotriene can also be used topically and also along with corticosteroid therapy or UV light.
- Topical Immunomodulators which have pimecrolimus or tacrolimus are beneficial if the de-pigmentation areas are small, particularly on face and neck. The side effects are lesser than corticosteroid treatment. This treatment can also be used in conjunction with ultraviolet B treatment; however, there is no data to support if this treatment is effective. There is also a risk of skin cancer and lymphoma with this treatment.
- Topical PUVA or Psoralen Plus Ultraviolet A, also known as photochemotherapy, is also an option especially if the de-pigmented patches on the body are less than 20 %. This treatment makes skin more sensitive to the UV light. There is also a variation of this treatment, which is known as water bath PUVA, where the patient lies in a tub of water for 15 minutes, which has psoralen in it, after which the patient is exposed to light. Potential side effects of this treatment are acute sunburn, blistering. These side effects can be minimized by avoiding direct sunlight after the treatment.
- Oral PUVA or Oral psoralen photochemotherapy is used when the de-pigmented areas are more than 20 % of the body. In this treatment, oral psoralen is taken around two hours before UVA light exposure. Natural sunlight can also be used. Short term side effects include: Sunburn, itching, nausea, vomiting, skin over-darkening and abnormal hair growth. If this treatment is used for prolonged periods of time, then it increases the risk of skin cancer. This treatment is not recommended for children below 10 years, as there is an increased risk of eye damage, such as cataracts.
- Narrowband UVB (ultraviolet B) therapy utilizes a special type of UVB light with a specific wavelength of UV- B. This treatment can be used instead of PUVA. There is no need of psoralen pre-application, thus making this treatment more simple and easy. Research is being done to find out if its effectiveness surpasses the PUVA treatment and the long-term safety of this treatment.
- Excimer laser comprises of controlled beams of UVB light with a specific wavelength directed at the skin. This treatment can be used for mild cases of vitiligo and is usually done along with topical drugs.
- Side effects include blistering and redness.
- De-pigmentation therapy is used for vitiligo present over more than half of the skin. De-pigmentation treatment works by lightening the unaffected areas of the skin, so that it matches the affected areas, which have lost its natural color. Application of monobenzone ether of hydroquinone to the pigmented or unaffected areas is done twice a day and this treatment is continued until the unaffected areas of the skin match the vitiligo covered patches on the skin. Potential side effects of this treatment include swelling, redness, dry skin and itching.
Surgical Treatment for Vitiligo
- Autologous skin graft is a type of skin grafting where the body's own tissues are used. Small pieces of skin are removed from one area of the body and these are attached to another area. This type of procedure is beneficial for small vitiligo patches. Potential complications are scarring, spotty pigmentation, cobblestone appearance or failure of re-pigmentation in the grafted skin.
- Blister grafting is a procedure where the surgeon creates blisters on the pigmented skin usually with the help of suction. The upper portion of blisters is removed and they are transplanted to an area where an equal sized area blister has been made and removed in a region which has no pigmentation. There is a risk of scarring, cobblestone appearance and failure of re-pigmentation with blister grafting. The risk of scarring is lesser when compared to other types of skin grafting.
- Micropigmentation or tattooing is a procedure where the pigment is implanted into the affected skin using a special surgical instrument. This treatment is effective if the vitiligo is around the lips and in individuals with darker skin. There are instances when the color of the tattoo does not match the exact skin color. Tattoo color also tends to fade and they do not tan.
Self-Measures for Vitiligo
- Patients with vitiligo, especially those who are fair skinned, must use a sunscreen with a minimum SPF of 30 before stepping out in the sun.
- The vitiligo patches can be camouflaged by using concealing cosmetics to give a normal appearance to the skin. Self-tanners/ sunless tanning products can also be used to conceal the patches by adding color to the affected areas. This color won't wash off; however, it tends to gradually fade when the dead skin cells get replaced.