Vitiligo

Vitiligo: Overview

Vitiligo: This skin disease often forms on both sides of the body as shown here on the knees.

Vitiligo (vit-uh-lie-go) causes the skin to lose color. Patches of lighter skin appear. Some people develop a few patches. Others lose much more skin color.

Vitiligo usually affects the skin, but it can develop anywhere we have pigment. Patches of hair can turn white. Some people lose color inside their mouths. Even an eye can lose some of its color.

Vitiligo: This skin disease often forms on both sides of the body as shown here on the knees.

Vitiligo is not contagious. It is not life-threatening. But, vitiligo can be life-altering. Some people develop low self-esteem. They may no longer want to hang out with friends or develop serious depression. Most people have vitiligo for life, so it’s important to develop coping strategies.

A coping strategy that helps many people is to learn about vitiligo. Another helpful strategy is to connect with others who have vitiligo.

Image used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

References:
Gawkrodger DJ, Ormerod AD, Shaw L et al. Guideline for the diagnosis and management of vitiligo. Br J Dermatol 2008; 159: 1051-76.
Nicolaidou E, Antoniou C, Stratigos A et al. Narrowband ultraviolet B phototherapy and 308-nm excimer laser in the treatment of vitiligo: a review. J Am Acad Dermatol 2009; 60: 470-7.
Whitton ME, Ashcroft DM, Gonzalez U. Therapeutic interventions for vitiligo. J Am Acad Dermatol 2008; 59: 713-7.

Vitiligo: It is common to have vitiligo on the hands.

Vitiligo: Signs and symptoms

Vitiligo causes loss of color. Your dermatologist may call this “loss of pigment” or “depigmentation.” We can lose pigment anywhere on our bodies, including our:

• Skin.
• Hair (scalp, eyebrow, eyelash, beard).
• Inside the mouth.
• Genitals.

Most people who get vitiligo lose color on their skin. The affected skin can lighten or turn completely white. Many people do not have any other signs or symptoms; they feel healthy.

Vitiligo can progress: With time, some people see their vitiligo cover a large area.

A few people say that the skin affected by vitiligo itches or feels painful.

Living with vitiligo can cause other symptoms such as low self-esteem and depression that is hard to beat. This can happen regardless of the amount of color loss or type of vitiligo.
 

Vitiligo has types and subtypes

If you are diagnosed with vitiligo, your dermatologist may tell you what type and subtype you have.

Types: Today, most doctors recognize two types:

Types of vitiligo: The child on the left has the most common type, non-segmental vitiligo. The child on the right has segmental vitiligo.

Subtypes: The subtype tells you how much vitiligo appears on the body. The vitiligo subtypes are:

• Localized: One or a few spots or patches appear, but these are limited to one or a few areas of the body.
• Generalized: Most people develop this subtype, which causes scattered patches on the body.
• Universal: Most pigment is gone. This is rare.

There is no way to predict how much color a person will lose. Color loss can remain unchanged for years. Some people see patches enlarge and new patches appear. On a rare occasion, the skin regains its lost color.

Images 1, 2, and 3 used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
Image 4 used with permission of Journal of the American Academy of Dermatology. (J Am Acad Dermatol 2010; 62:945-9)

References:
Halder RM, Taliaferro SJ. “Vitiligo.” In: Wolff K, Goldsmith LA, Katz SI, et al. editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. United States of America, McGraw Hill Medical; 2008. p.616-21.
Mazereeuw-Hautier J, Bezio S, Mahe E et al. “Segmental and nonsegmental childhood vitiligo has distinct clinical characteristics: a prospective observational study.” J Am Acad Dermatol; 62: 945-9.
Ortonne JP, “Vitiligo and Other Disorders of Hypopigmentation.” In: Bolognia JL, Jorizzo JL, Rapini RP, et al. editors. Dermatology, 2nd ed. Spain, Mosby Elsevier; 2008. p. 913-20.

Vitiligo can affect hair: The white hair near this 22-year-old man's part is due to vitiligo.

Vitiligo: Who gets and causes

Who gets vitiligo?

Millions of people worldwide have vitiligo. Nearly half get it before they reach 21 years of age. Most will have vitiligo for the rest of their lives. It is very rare for vitiligo to disappear.

Vitiligo occurs about equally in people of all skin colors and races. About half the people who get vitiligo are male and half are female.

The risk of getting vitiligo increases if a person has:

• A close blood relative who has vitiligo.
• An autoimmune disease, especially Hashimoto’s disease (a thyroid disease) or alopecia areata (causes hair loss).

What causes vitiligo?

Vitiligo develops when cells called melanocytes (meh-lan-o-sites) die. These cells give our skin and hair color.

Scientists do not completely understand why these cells die. One type of vitiligo, non-segmental vitiligo, may be an autoimmune disease. An autoimmune disease develops when the body mistakes a part of itself as foreign. If the body mistakes these cells as foreigners, it will attack and kill these cells.

Studies suggest that the other type of vitiligo, segmental vitiligo, has a different cause. This type seems to develop when something in the body’s nervous system goes awry.

References:
Gawkrodger DJ, Ormerod AD, Shaw L et al. Guideline for the diagnosis and management of vitiligo. Br J Dermatol 2008; 159: 1051-76.
Halder RM. “Vitiligo.” Forum presented at the 2011 American Academy of Dermatology Annual Meeting: New Orleans. February 2011.
Mazereeuw-Hautier J, Bezio S, Mahe E et al. Segmental and nonsegmental childhood vitiligo has distinct clinical characteristics: a prospective observational study. J Am Acad Dermatol; 62: 945-9.

Vitiligo: Diagnosis and treatment

How do dermatologists diagnose vitiligo?

If your dermatologist suspects that you have vitiligo, your dermatologist will:

• Review your medical history, and may ask specific questions such as whether anyone in your family has vitiligo.
• Perform a physical exam, looking carefully at the affected skin.

You also may need a blood test to check the health of your thyroid gland. People who have vitiligo often have an autoimmune thyroid disease. A blood test will tell whether your thyroid is healthy. If you have thyroid disease, treatment can successfully control it.

How do dermatologists treat vitiligo?

If you have vitiligo, you should discuss treatment options with your dermatologist. There are many treatment options. The goal of most treatments is to restore lost skin color.

Here are some key facts about treatment options to help you start a conversation with your dermatologist. The type of treatment that is best for you will depend on your preference, overall health, age and where the vitiligo appears on your body. Some people choose not to treat vitiligo.

1. No medical treatment (use cosmetics to add lost color):

• Cosmetic options include makeup, a self-tanner and skin dye.
• Offers safe way to make vitiligo less noticeable.
• Often recommended for children because it avoids possible side effects from medicine.
• Drawbacks: Must be repeatedly applied, can be time-consuming, takes practice to get natural-looking result.

2. Medicine applied to the skin:

• Several different topical (applied to the skin) medicines can repigment the skin.
• Prescribed for small areas.
• The most commonly prescribed medicine is a potent or super-potent topical corticosteroid. About half, 45 percent, of patients regain at least some skin color after 4 to 6 months.
• A topical corticosteroid may be combined with another medicine to improve results.
• Topical medicine works best in people with darkly pigmented skin.
• Topical medicines are most effective on certain areas of the body, such as the face. They are least effective on the hands and feet.
• Not all topical medicines should be used on the face.
• Drawbacks: These medicines have possible side effects, so patients must be carefully monitored. A possible serious side effect of using of a topical corticosteroid for a year or longer is skin atrophy. This means the skin becomes paper thin, very dry and fragile.

3. Light treatment:

• Uses light to repigment the skin.
• Patient may sit in a light box or receive excimer laser treatments.
• Light box used to treat widespread vitiligo; laser used to treat small area.
• Works best on the face; least effective on hands and feet.
• Effective for many patients; about 70 percent see results with excimer laser.
• Results can disappear. About half, 44 percent, see results disappear within 1 year of stopping treatment. After 4 years, about 86 percent lose some color restored by treatment.
• May cause patients with darkly pigmented skin to see areas of darker skin after treatment, but treated skin usually matches untreated skin within a few months.
• Requires a time commitment. Patients need 2 to 3 treatments per week for several weeks.
• May be combined with another treatment such as topical corticosteroid.

4. PUVA light therapy:

• Uses UVA light and a medicine called psoralen to restore skin color.
• Psoralen may be applied to the skin or taken as a pill.
• Can treat widespread vitiligo.
• About 50 percent to 75 percent effective in restoring pigment to the face, trunk, upper arms and upper legs.
• Not very effective for the hands or feet.
• Time-consuming, requiring treatment at a hospital or PUVA center twice a week for about 1 year.
• Psoralen can affect the eyes, so this treatment requires eye exams before starting treatment and after finishing treatment.
• To help prevent serious side effects, patients need to be carefully monitored.

5. Surgery:

• May be an option when light therapy and medicines applied to the skin do not work.
• For adults whose vitiligo has been stable (not changed) for at least 6 months.
• Not for children.
• Not for people who scar easily or develop keloids (scars that rise above the skin).
• Different surgical procedures available. Most involve removing unaffected skin or skin cells and placing where need pigment.
• Can be effective for 90 percent to 95 percent of patients.
• Possible side effects include failure to work, cobblestone-like skin and infection.

6. Unconventional treatment:

• Some vitamins, minerals, amino acids and enzymes have been reported to restore skin color in people who have vitiligo.
• Most have not been studied, so there is no evidence to support these treatments and no knowledge of possible side effects.
• Ginkgo biloba, an herb, has been studied in a clinical trial. Results from this trial indicate that the herb may restore skin color and stop vitiligo from worsening.
• In the ginkgo biloba trial, 10 patients given ginkgo biloba had noticeable or complete return of skin color. Two patients taking the placebo (contains no active ingredient) also had noticeable or complete return of skin color.
• Because some patients taking the placebo regained their skin color, more study is needed.

7. Depigmentation:

• This treatment removes the remaining pigment from the skin.
• Very few patients opt for this treatment.
• Removing the rest of the pigment leaves a person with completely white skin.
• It may be an option for an adult who has little pigment left and other treatment has not worked. Removing the remaining pigment can be an effective way to get one skin color.
• To remove the remaining color requires you to apply a cream once or twice day. This cream gradually removes color from the skin.
• Depigmentation can take 1 to 4 years.
• Once treatment is finished, some people see spots of pigment on their skin from being out in the sun. To get rid of these spots, you can use the cream that removed your remaining skin color.

Outcome

It is not possible to predict how a patient will respond to treatment. It is important to keep in mind that no one treatment works for everyone. Results can vary from one part of the body to another. Combining two or more treatments often gives the best results.

Treatment Q&A

Q: Can a child with vitiligo be treated?

A: Yes, but some treatments are not appropriate for children. The following may be an option for a child:

• Medicine applied to the skin.
• PUVA that uses psoralen applied to the skin. PUVA therapy that uses the psoralen pill is usually not recommended until after 12 years of age. Even then, the risk and benefits of this treatment must be carefully weighed.
• For children with extensive vitiligo, a dermatologist may recommend narrowband UVB light treatments.

Q: Are researchers looking for more effective treatment?

Yes. They are studying the genes involved in vitiligo. Researchers believe that by identifying all of the genes involved in vitiligo, they will learn what destroys the cells that give skin its color. With this knowledge, it should be possible to develop better treatments. One of the key goals of this research is to develop a treatment that will permanently stop the skin from losing color.

References:
Gawkrodger DJ, Ormerod AD, Shaw L et al. “Guideline for the diagnosis and management of vitiligo.” Br J Dermatol 2008; 159: 1051-76.
Grimes PE, “Vitiligo.” In: Kelly AP and Taylor SC, editors. Dermatology for Skin of Color, China, McGraw-Hill; 2009. p. 317-23.
Halder RM, Taliaferro SJ. “Vitiligo.” In: Wolff K, Goldsmith LA, Katz SI, et al. editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. United States of America, McGraw Hill Medical; 2008. p.616-21.
Linthorst Homan MW, Spuls PI, de Korte J et al. “The burden of vitiligo: patient characteristics associated with quality of life.” J Am Acad Dermatol 2009; 61: 411-20.
Nicolaidou E, Antoniou C, Stratigos A et al. “Narrowband ultraviolet B phototherapy and 308-nm excimer laser in the treatment of vitiligo: a review.” J Am Acad Dermatol 2009; 60: 470-7.
Ortonne JP, “Vitiligo and Other Disorders of Hypopigmentation.” In: Bolognia JL, Jorizzo JL, Rapini RP, et al. editors. Dermatology, 2nd ed. Spain, Mosby Elsevier; 2008. p. 913-20.
Whitton ME, Ashcroft DM, Gonzalez U. “Therapeutic interventions for vitiligo.” J Am Acad Dermatol 2008; 59: 713-7.

Vitiligo: Tips for managing

Dermatologists share the following tips with their patients who have vitiligo.

Protect your skin from the sun

Everyone who has vitiligo can benefit from sun protection. Here’s why:

• Skin that has lost its color sunburns very easily.
• A bad sunburn can worsen vitiligo.
• If you have fair skin, avoiding a tan usually makes the vitiligo barely noticeable.
• If you chose to treat vitiligo with depigmentation, that is removing the remaining color from your skin, the sun can cause spots of color to form on your skin. You will need to depigment your skin again to remove these spots of color.

To protect your skin from the sun, dermatologists recommend:

1. Use sunscreen.

Generously apply sunscreen every day to skin that will not be covered by clothing. Use a sunscreen that offers:

• UVA/UVB protection (label may say “broad spectrum”)
• A sun protection factor (SPF) of 30 or more
• Water resistance

2. Apply sunscreen every day.

Be sure to apply it at least 15 minutes before going outdoors.

3. Reapply sunscreen when outdoors.

If you will be outdoors, be sure to reapply the sunscreen:

• Every 2 hours, even on cloudy days.
• After being in water or sweating.

4. Wear clothing that protects your skin from the sun.

Skin covered by clothing that has a high SPF does not need sunscreen. Not all clothing offers high SPF. A long-sleeve denim shirt has an SPF of about 1,700. A white t-shirt only has an SPF 7, and a green t-shirt has about an SPF 10.

You can boost the SPF of clothing, by adding a product that increases the SPF of clothing during the wash cycle. You add this product to the wash machine. The increase in SPF is usually good for about 20 washings.

5. Seek shade.

This is especially important when your shadow is shorter than you are. That’s when the sun’s damaging rays are at their strongest and you are likely to sunburn.

Do not use tanning beds and sun lamps.

These are not safe alternatives to the sun. These, too, can burn skin that has lost pigment.

If you want to add color to your skin, consider using a cosmetic.
Cosmetics can safely add color to your skin if you want to add color without undergoing treatment. Cosmetics that can add color are self-tanners, dyes, and makeup. Here are some tips that dermatologists offer their patients:

• Select a water-proof product.
• Self-tanners and dyes last longer than makeup.
• Dyes work best for white spots.
• When looking for a self-tanner, choose a product that contains dihydroxyacetone.
• With practice, most people can achieve a natural look with a concealing cream or self-tanner.

Do not get a tattoo.

Getting a tattoo can cause something called Keobnerization or the Koebner phenomenon. What this means is when you wound your skin, which getting a tattoo does, a new patch of vitiligo can appear about 10 to 14 days later.

Learn about vitiligo.

Knowledge often improves a person’s quality of life. It helps to know about treatment options so that you know what is possible. Learning more about vitiligo can help you decide what feels right for you. You may want to treat it, camouflage with cosmetics, or just let it be. Only you can decide what’s right for you.

If you decide not to treat vitiligo, it’s still important to see a dermatologist for an accurate diagnosis and physical. Vitiligo is a medical condition, not just a cosmetic concern.

Connect with others who have vitiligo.

The emotional aspects of having vitiligo are often overlooked, but they are real. If a child has vitiligo, other children may tease and bully. People can stare. Studies conclude that many people who have vitiligo have a decreased quality of life.

Connecting with others who have vitiligo can help. You will find links to support groups below:

Support groups

Vitiligo Support International
Message boards for major cities, local support groups that meet monthly giving you the opportunity to meet others living with vitiligo, and the chance to share support and experiences in person.

Vitiligo Friends
An online community where people living with vitiligo, their family, and their friends can share information and stay in touch. Can meet people worldwide.

Vitiligo support group
Discussions and articles on the DailyStrength website.

Learn more:

• Is vitiligo a medical condition?
• Vitiligo discomfort stops with sunscreen use

Related resources:

American Vitiligo Research Foundation

References:
American Academy of Dermatology. “Dermatologists encourage consumers to be “clothes” minded when it comes to selecting summer wardrobe.” News release issued May 2, 2005.
Halder RM. “Vitiligo.” Forum presented at the 2011 American Academy of Dermatology Annual Meeting: New Orleans. February 2011.
Linthorst Homan MW, Spuls PI, de Korte J et al. “The burden of vitiligo: patient characteristics associated with quality of life.” J Am Acad Dermatol 2009; 61: 411-20

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