Vitiligo

What is vitiligo?

Vitiligo is a non-contagious, long-lasting, currently incurable skin disease with white patches on the skin. The cause of vitiligo is still unknown, but it is probably caused by an autoimmune reaction of our own immune system against the skin cells that produce skin color (medical name for those cells is melanocytes), which results in skin losing its color. The exact triggers for such a destructive immune reaction are still unknown. We can speculate that some viral infection acquired during the times when our immune system is weakened, such as during some stressful events, could be the trigger. Genetic factors play a role as well, but there is over 90% chance that you will NOT develop vitiligo, if someone in your family suffers from it. Also sometimes malignant melanoma, (a type of deadly skin cancer), can trigger our immune system to attack melanocytes (cells that produce the color of our skin, and that can get cancerous causing malignant melanoma) causing white patches on the skin.  Autoimmune theory is supported by the fact that vitiligo sometimes occurs with other autoimmune diseases such as Hashimoto’s thyroiditis, Graves’s disesase, diabetes mellitus, pernicious anemia, alopecia areata and Addison’s disease. About 1% of people have vitiligo. It can start at any age, but most commonly between 10 and 30 years of age.

How does vitiligo look and feel like?

Vitiligo shows up on the skin as areas of skin whitening or loss of skin color; usually around the eyes, nose, mouth, armpits, back of the hands, genitalia, anus and on areas of rubbing, such as elbows and knees. It is frequently symmetrical (i.e. it shows up in similar way both on the left and the right side of the body).  It usually does not have any abnormal feeling to it, but some patients complain, or recall some fine itchy sensation in the area of newly forming spots. Vitiligo frequently causes lots of social anxiety and even depression due to the skin appearance.

Should I see my health care provider?

Absolutely, since there are only very, very limited options available for over-the-counter treatment of vitiligo. In addition the vitiligo can be associated with other autoimmune diseases, anxiety and depression, so this should also be checked for, and treated if needed.

What will my health care provider do?

Your provider will perform full-body skin examination to check for possible melanoma – a skin cancer that can trigger loss of skin color in distant areas of the body. Also you will need to be checked for any associated diseases.

What is the treatment of vitiligo?

As of yet there is no cure; however, up to 25% of people with vitiligo experience spontaneous recovery of skin color. Vitiligo on the face recovers the best; in contrast, vitiligo on hands and feet has only about 20% chance of response to the treatment. Many people get at least partial benefit with the following treatment options:

  • Corticosteroid ointments, creams, lotions and gels such as 0.05% fluocinonide (only generic available), 0.1% fluocinonide  (brand name Vanos), 0.05% betamethasone dipropionate, clobetasol, halobetasol etc. These medicines weaken the immunity in areas where they are applied, and therefore they protect and shield the skin from our own immune reaction, enabling it to recover the color. However, these medicines must be used under close medical supervision as they can thin the skin, make capillaries visible on the skin, cause acne-like pimples, and stretch marks. Stronger corticosteroids (clobetasol, halobetasol) should be used in up to 2-3 months trials, while others up to 4-6 months. Face responds in up to 80% of cases, trunk in up to 40%, while hands and feet in up to 20% of cases.
  • Calcineurin inhibitor ointments and creams such as pimecrolimus (brand name: Elidel) and tacrolimus (brand name: Protopic). These medicines also weaken the immunity in areas where they are applied, and therefore protect and shield the skin from our own immune reaction, enabling it to recover the color. Compared to corticosteroids, they do not cause thinning of the skin, pimples, or stretch marks, but they have a black box warning mandated by the FDA stating that they can cause cancers.
  • Light therapy. The standard is a narrow band ultraviolet B light (nbUVB) twice weekly for several minutes. It may be used together with the medicines mentioned above, especially if vitiligo affects more than 10-20% of the skin surface. It is usually administered at doctor’s office (usually only dermatologists have these units), or if you have demonstrated improvement with this treatment, or if there is no such light unit in your area, your health care provider may work with your health insurance to obtain you a home nbUVB light unit for your personal use. The maximum results are achieved in about 9 months of continuous treatment. If no response happens in 3 months, the treatments should be stopped. About half of people will have a very good response on the face, trunk and arms, while only about quarter will have such good results on hands and feet. Only 1 in 20 of people who have over 20% skin surface with vitiligo will have complete recovery.
  • Excimer laser is actually a narrow band UVB light but much more concentrated. It is more suitable for localized disease, but wider areas can be treated as well.
  • Grafting is usually feasible only when small areas need to be treated and only for areas that have not changed in appearance for at least 6 months. It consists of taking small patches of normal-colored skin from one area of your body and fixing it over the area affected with vitiligo. It is not widely used in the US.
  • Cosmetic camouflage (cover up) such as with self-tanning lotions with dihydroxyacetone (brand names: Vitadye, Neutrogena Micromist Tanning Sunless Spray). There are also brands (Covermark, Dermablend, Dermacolor, Keromask, PerfectCover and  Veil Cover) that specialize in skin with pigment disorders such as vitiligo. If educated by an esthetician on proper use of these products, vitiligo can be completely covered making it invisible. To prevent rubbing the camouflage make-up off your skin, you may try applying Cavilon “No Sting Barrier Film” as a spray over the areas that you camouflaged with the make-up.
  • Complete bleaching (depigmentation) of the skin is an option suitable for people that have vitiligo over half of the skin surface. Since this step cannot be reversed (i.e. the color of the skin will be gone forever), you have to be 100% sure that you want to do this. We had excellent experience with monobenzone 20% cream (brand name: Benoquin) 20% which is applied twice to three times a day for 1-4 months to any area with remaining normal color of the skin. You may treat only areas that you want bleached out, but you must understand that loss of color may occur also on areas that have not been treated. Sometimes up to 10 months may be needed for good results. You may develop dermatitis at the areas where you apply this cream, but it is usually mild, and does not require stopping the treatment. Once the complete loss of skin color is achieved (i.e. there is no blotchy appearance of the skin anymore), the patients’ satisfaction with their appearance usually soars. Afterwards, you may use the cream only on occasion as maintenance. In addition, since your skin will be completely without color it will be prone to sunburns and skin cancers, therefore you will need to protect your skin from sun by using sunscreens, staying in the shade, wearing wide-brimmed hats, long sleeves and pants.
  • Alternative treatments. Some people have experienced improvement or resolution of vitiligo with various combinations of vitamins, minerals and various herbs; however, the randomized controlled trials published in peer-reviewed trials are lacking, so it is unsure if those treatments really helped, or it was just a coincidence as up to 25% of people may recover spontaneously. Also we cannot be sure what could be the side effects and adverse reactions of such alternative medicines without them being studied in larger randomized-controlled trials, and published in peer-reviewed scientific journals.
  • Psychological support. Majority of people, especially younger, are suffering from social anxiety and depression due to the blotchy appearance of their skin. You should not be ashamed to ask for help, and you should not suffer quietly- ask your health care provider to refer you for a psychological support to a psychologist. Please visit National Vitiligo Foundation web site (www.nvfi.org), Vitiligo Support International (www.vitiligosupport.org) and American Vitiligo Research Foundation (www.avrf.org) to learn more about the vitiligo, and to get the needed support.

Should I protect my skin from sun?

Absolutely, since skin without color is more prone to sunburns and therefore skin cancers. So, stay away from the sun and do not  tan.

  • Seek shade and stay out of the sun in the middle of the day (from 10 a.m. to 5 p.m.).
  • Wear a wide-brimmed hat, sunglasses, long-sleeved loose-fitting shirts, long loose-fitting pants, or long skirt outside.
  • Put on sunscreen with at least Sun Protection Factor (SPF) of 30. Look for sunscreens with titanium dioxide and zinc oxide. My family’s favorite is Banana Boat KIDS with SPF 50 that contains both titanium dioxide and zinc oxide.
  • Do not use tanning beds.

Worth of mentioning is an iconic Slip-Slop-Slap sun protection campaign in Australia during the 1980s.

It stands for:

Slip on a shirt,

Slop on the 30+ sunscreen,

Slap on a hat

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