Vitiligo is a condition in which white patches develop on the skin due to loss of pigment from those areas, giving it a distressing appearance. Recent advances in treatment have found ways of restoring pigment in some cases.

What is the anatomy of the skin?

It is important to understand the anatomy of skin to understand vitiligo. Skin is composed of two layers - the outer epidermis and the inner dermis.  Below the dermis lies a layer of fat, and deeper structures such as muscles and tendons.

The colour of the skin is due to pigment cells in the bottom of the epidermis called as melanocytes, which make a pigment called as melanin. This melanin is passed to the nearby skin cells, colouring the skin and protecting them from the sun's rays.Dark-skinned people have more active melanocytes.

What do you understand by vitiligo and who causes it?

Vitiligo is a condition where pale white patches appear on the skin, due to a lack of pigment (colour) in the affected areas of skin. People do not have feeling of illness, but are distressed due to the appearance.

The cause is due to destruction of melanocytes in areas which are affected, thus they are appear as white patches, as they don’t have any melanin in them. The main reason for destruction of melanocytes is immune mediated. The immune system (which normally protects the body from infections) does not work properly. Antibodies are produced that can destroy your skin cells that make melanin.

Who is more prone to develop vitiligo?

There is some genetic factor involved and vitiligo may run in the family. About 1 in 100 people develop vitiligo. Men and women are equally affected. It can develop at any age. However, it begins before the age of 20 in about half of cases. About 1 in 3 affected people have some other family member who is also affected. Vitiligo is not infectious and you cannot catch it from affected people. It is not more common in any racial or ethnic groups.

What areas of the body are affected more?

It can affect any area of the body, butsites more prone to develop vitiligo are the face, neck, and scalp. Other common sites include the backs of hands, front of knees, elbows and genitals. In the areas of the scalp that are affected, the hair too is affected, causing it to become grey or white.

It is often symmetrical in that patches may appear on similar places on each arm or leg.

Very rarely, vitiligo can affect your whole body. This is called universal or complete vitiligo.

How does vitiligo progress?

Small areas of milky-white skin usually develop first. The contrast between the vitiligo skin and normal skin varies. In fair-skinned people it may only be noticeable in summer when normal skin tans. The contrast is more noticeable in darker-skinned people.

The course and severity of vitiligo varies from person to person. Sometimes a few small patches develop slowly and progress no further. Sometimes a number of patches develop quite quickly and then remain static for months or years without changing. However, it is quite common for the white patches gradually to become bigger and for more patches to appear on other parts of the body. Large areas of the skin may eventually be affected.

There is no way of predicting how much of the skin will eventually be affected when the first patch develops. The white patches are usually permanent. Rarely, some patches of vitiligo may re-pigment and return to normal.

How do they present?

People with vitiligo do not have any illness, however they are distressed because of the appearance. Since the natural protection of the skin is lost, the affected skin easily can have sun burns when exposed to sunlight.

How do you treat vitiligo?

Since there is no illness involved, if the patient is not distressed no treatment is advised. The main treatment options fall into four groups:

  • Camouflaging the skin is carried out by using special coloured creams that are put on the white patches of vitiligo.  Though this does not alter the disease process but it improves skin appearance and hence increases confidence.
  • Treatments that aim to reverse the changes in the skin are many, but no single treatment works well. The response is variable and depends on the type of vitiligo. The various treatments advised are as follows:
    • Steroid cream is sometimes prescribed sometime for a limited period of time (initially 4-6 weeks) when a small patch of vitiligo first develops. It may prevent a smaller patch from getting bigger. Occasionally, skin colour may return over a treated area. Steroids work partly by suppressing the immune system (which probably attack the melanocytes). Long-term use of steroid creams can cause side effects, which include thinning of the skin and stretch marks. Steroid creams are not usually recommended to use on your face.
    • Tacrolimus cream is another immune system suppressing drug, an alternative to steroids which is most effective for vitiligo on the face. It can also be used on the skin of children.
    • PUVA treatment, which stands for psoralen and ultraviolet A light, involves taking a special medicine (a psoralen) which makes the skin very sensitive to light. The skin is then treated with ultraviolet A (UVA) light from a special machine in hospital. This treatment is very time-consuming. Treatment is needed twice a week for 6-12 months or more. PUVA may cause side effects such as sunburn-type reactions or skin freckling. If colour does return to the white patches there is still a chance that it may go white again at a later stage.
    • Narrowband UVB phototherapy is another light treatment, which is now used more commonly than PUVA. It uses ultraviolet B (UVB) light. As with PUVA, treatment is twice weekly but you do not need to take a medicine to sensitise the skin and the treatment sessions are much shorter. It is less damaging to the skin than PUVA.
    • Laser treatments, though are available for treatment of vitiligo,it has not yet been shown to be an effective treatment in clinical trials.
    • Skin grafting, of normal skin to small patches of vitiligo has been tried. It is time-consuming and not always successful or available.
    • Complementary treatments, which have currently insufficient evidence to recommend any complementary treatments for vitiligo.
      • Treatment to de-pigment the skin completelyin people with extensive vitiligo, as in these people it may be considered to make the remaining normal areas of skin go white. This makes all the skin an even white colour. This is done only after a full discussion with a specialist. The removal of all the skin pigment is permanent and it takes about a year to complete.

Note: the use of sun beds is not recommended. The ultraviolet radiation from sun beds can damage your skin and people who use tanning devices are much more like to develop skin cancer (melanoma) than average.

      • Sunblock and other means to protect the pale skin, with an factor 30 or above should be applied to all areas of vitiligo exposed to sunlight. Sunburn can easily occur if the skin is not protected. It is also important to cover affected areas of skin when the sun is strong, especially in the middle of the day. For example, by wearing a wide-brimmed hat and long-sleeved clothing.

What are the complications of vitiligo?

Vitiligo itself does not develop into any other condition. However, other autoimmune disorders (diseases caused by the immune system) are slightly more common in people with vitiligo. For example, thyroid problems, diabetes and pernicious anaemia. Most people with vitiligo do not have these but your doctor may suggest a blood test to rule them out.

Some people with vitiligo are embarrassed about their condition. This can lead to low self-esteem and even depression. Some people find that counselling can be beneficial.

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