Vitiligo (White Skin Patches)
What is vitiligo?
Vitiligo is a skin condition which causes white patches on the skin. It is a chronic (long-term) condition in which occurs the destruction of melanocytes (cells responsible for making pigments). The areas of skin affected have very little or no melanin and this is why they are white in colour. Melanocytes in the skin, mucous membranes and the retina can be affected, meaning that patches can develop on various areas of the body. In most cases the hair which grows within patches of affected skin also become white.
The reason for the development of vitiligo isn't fully understood but experts have come up with several possible causes: one hypothesis is that melanocytes are destroyed as part of an autoimmune response, while a separate premise is that the cells destroy themselves. There has also been a suggestion that vitiligo may be triggered by an incident such as emotional stress or severe sunburn. However, there is little scientific evidence to support this notion.
Who is susceptible to vitiligo?
It is estimated that between 1 and 2 per cent of the population is affected by the condition. In the UK around 1 in 100 people develop vitiligo, with most people developing symptoms during early adulthood, although it can affect people of all ages. Men and women are both affected by the condition and it affects all ethnicities.
Vitiligo tends to be more frequent in people who have autoimmune disorders, which are conditions that cause the body's immune system to attack healthy tissue when mistaking it for a harmful threat. Autoimmune diseases which may be linked to vitiligo are hyperthyroidism (overactive thyroid gland) and adrenocortical insufficiency, which occurs when there is a shortage of the corticosteroid hormone that is made by the adrenal glands. Other conditions which may be associated with a heightened chance of vitiligo include pernicious anaemia, a form of anaemia that occurs as a result of an inability to absorb vitamin B12, and alopecia areata, which causes hair loss. The connection between autoimmune conditions and vitiligo is not fully understood by scientists.
Vitiligo can pass through families but this often isn't the case. The majority of children will not develop vitiligo even if they have a parent with the condition.
Melanoma, a type of skin cancer, can also heighten the chances of vitiligo.
Vitiligo is not contagious and it cannot be spread by contact with an affected person.
Symptoms and signs of vitiligo
The major symptom of vitiligo is white patches on the skin (depigmentation). Patches tend to develop in areas that are most exposed to the sun, such as the arms, legs, lips, hands, feet and face. Other general areas include the armpits, groin, navel (tummy button), genitals, eyes and mouth.
There are three main patterns of depigmentation. The first, known as focal depigmentation, is restricted to a single or small number of areas on the skin. The second, known as segmental pattern, occurs when patches develop on a single side of the body. The third, known as general pattern vitiligo, affects many sections of the body and is the most common type of vitiligo.
Additional symptoms of vitiligo include premature greying of the hair on the scalp and beard, as well as the eyelashes and eyebrows. People who have darker skin may also notice that the tissue within their mouths appears lighter.
Do the depigmented patches spread?
It is not possible to calculate if depigmented patches will spread across the body or not. In some cases the patches don't spread, but in most cases they will gradually extend to other sections of the body, as the condition is progressive. The speed of the spread of depigmentation varies; some people experience gradual spreading over the course of several years, while other people find the patches spread very quickly. Some people who suffer with vitiligo claim that triggers, such as anxiety and stress, can cause patches to spread more rapidly.
Diagnosing vitiligo
If a doctor believes that you may have vitiligo they will ask you questions about your symptoms and medical history. They will ask if you have any relatives with vitiligo and if you have experienced any kind of skin trauma, such as severe sunburn or skin rashes. They will also ask if you have any autoimmune disorders or a family history of autoimmune conditions. Other questions may be whether you have premature greying of the hair or if you have experienced any emotional stress or trauma during the last few months before the patches started to appear.
Your doctor will perform an examination to rule out other skin conditions and they may remove a small tissue sample (known as a biopsy) to be sent away for analysis. Your doctor will acquire a blood sample to verify thyroid function and blood cell count. In some cases an eye test is also carried out to test for uveitis, a condition which causes eye inflammation. A blood test to identify antinuclear antibodies may be ordered if an autoimmune condition is suspected.
Coping with the emotional aspects of vitiligo?
Vitiligo affects the appearance of the skin and can have negative implications on self-confidence and esteem. Individuals with vitiligo may feel embarrassed around other people, especially when parts of their body affected by vitiligo are exposed. In severe cases this may have an impact upon the ability to keep a job and maintain an active social life. Teenagers can be particularly affected by vitiligo, as they are likely to be conscious about their appearance. Vitiligo can cause emotions such as stress, anxiety, shame, embarrassment and depression.
There are various ways of coping with vitiligo and you should make use of your doctor and the knowledge they have about the condition. Your GP will be on hand to discuss your symptoms and condition, so that you are able to gain a better understanding of vitiligo and identify ways of coping if you are worried or unhappy about the way you look. If you are suffering from depression your doctor will be able to refer you for help; for example, seeing a trained counsellor. It is also important to talk to people close to you about how you feel, and many people find it beneficial to chat to other people in the same situation. There are support groups and charities and the Internet has made it possible for vitiligo sufferers to get in contact with people with the same condition easily.
Some people find it beneficial to use cosmetics to cover their patches, although this approach is not for everyone.
Treatment options
The main aims of treatment for vitiligo are to improve the aesthetics of the skin and maintain or restore the full function of the skin. Treatment for vitiligo is usually long-term (at least 6 months). The selection of treatment depends on a number of factors, including the distribution and amount of patches and the patient's treatment preference. People respond differently to different therapies and it can sometimes take a few trials to find the best treatment. Treatment options include:
- Medical therapies.
- Surgical therapies.
- Adjunctive therapies (therapies that are used in conjunction with medical or surgical therapies).
Medical therapies
Topical steroid therapies: steroids can help to restore colour to the skin (known as repigmentation), especially if treatment is administered shortly after symptoms develop. Corticosteroids are medicines that are comparable to the hormones created by the adrenal glands. Clinicians usually set a mild dose for children under the age of 10 and a stronger dose for adults, and treatment should be administered for the minimum of 3 months. Topical steroid therapies are the safest treatment but they are not as efficient as photochemotherapy. Because steroids can lead to side-effects doctors will monitor patients to check for symptoms like skin shrinkage.
Oral psoralen phototherapy (PUVA): phototherapy is a form of treatment which uses light. The patient takes medicine called psoralen (in tablet form) and then UVA or UVB light is exposed to the skin using a special lamp; psoralen makes the skin more sensitive to light. This treatment is recommended if topical treatments have failed or vitiligo is widespread. There is an increased threat of skin cancer associated with treatment due to exposure to harmful UV rays. However, the risks will be weighed up against the benefits and your doctor or dermatologist will explain this before treatment. Oral psoralen phototherapy is not advised for children below the age of 10 years old due to an augmented risk of eye problems. By-products of oral psoralen therapy include nausea and sickness, sunburn and hyperpigmentation (darkening of the skin around the affected patches). The danger of skin cancer is also increased due to exposure to UV light. Patients are advised to protect their skin and wear sunglasses to prevent damage to their eyes after treatment.
Topical phototherapy (photochemotherapy): this is often recommended for people who suffer with small areas of depigmentation. It can also be used for young children (younger than 2 years old). Psoralen is applied to the affected patches of skin and the skin is then exposed to UV light under a special lamp; psoralen is usually applied around 30 minutes before the lamp is switched on. Over the course of time the amount of UVA is increased and gradually skin colour is restored. Sessions are usually carried out once or twice each week for several weeks.
There are two main side-effects to phototherapy: these include sunburn or damage to the skin and darkening of the skin close to the patches of vitiligo (hyperpigmentation). It is important for patients who are undergoing phototherapy to take steps to protect their skin from sun exposure between treatment sessions. This will help to lower the threat of sunburn and skin cancer.
Depigmentation: involves fading other parts of the skin so that they are the same as the affected patches. This may be the most successful treatment option for those with widespread vitiligo (at least 50 per cent of their body). Depigmentation involves patients applying drugs to their pigmented (normal coloured) skin twice a day until the skin is all the same colour. Patients are advised to avoid skin on skin contact with others for a minimum of 2 hours after administering the medicine. The main by-product of depigmentation is inflammation affecting the skin. It is also possible for treatment to cause itchiness, dry skin and darkening of the whites of the eyes. Depigmentation is a permanent treatment which cannot be reversed. It increases sensitivity to light so patients must be careful when exposed to sunlight.
Surgical therapies
Autologous skin grafts: this is a type of skin graft which involves using the patient's own skin. The procedure involves taking skin from one part of the body (where skin is pigmented) and grafting it to another part (where the skin is depigmented). This form of treatment is occasionally employed for people with small patches of vitiligo, which are restricted to one or two sections of the body. There are risks involved with this procedure and it is usually carried out when other therapies have failed. Possible complications include infection at recipient or donor sites, scarring, spotty pigmentation or failure to repigment.
Skin grafts using blisters: this procedure involves the doctor creating blisters in the person's pigmented skin. The tops of the blisters are cut and then transplanted to an area of depigmented skin. Risks associated with this procedure are scarring and repigmentation failure.
Micropigmentation (tattooing): this procedure involves tattooing pigmentation into the skin using a special instrument; this is best for treating the lips. Tattooing is most effective for dark-skinned people but the effects tend to become paler over time. Tattoos can also cause blisters as a result of the herpes simplex virus.
Autologous melanocyte transplant: this procedure involves taking a sample of the patient's pigmented skin and placing it in a special dish in a laboratory to culture melanocytes. When the melanocytes have multiplied they are transplanted to the patient's skin patches. This treatment is still at an experimental stage and is not usually recommended for the routine treatment of vitiligo.
Additional therapies
Sunscreen: it is important for people who suffer with vitiligo to wear protective sun cream when they are exposed to sunlight. Sun cream should protect from both UVA and UVB rays. It will help to reduce the threat of sunburn and skin cancer and reduces tanning, which makes the difference between pigmented and depigmented skin more perceptible.
Cosmetics: cosmetics can be used to cover affected patches of skin. This is usually only beneficial for patients who have small areas of depigmentation.
Support groups and counselling: many people who suffer from vitiligo find it useful to talk to others about their condition and meet or chat to people who are in a similar situation. Many people find it easier to open up to a counsellor rather than somebody they know well. Your doctor can arrange counselling sessions for you and give you details of any support groups in your local area.