What is vitiligo?
Vitiligo is a harmless but often cosmetically distressing condition in which the skin — and sometimes the hair — loses its pigment. This happens because the pigment cells in the skin disappear. Vitiligo can be an important and burdensome problem for the patient, and in some cases can affect self-image and confidence. About 1% of the world’s population has vitiligo.
How does it develop?
The precise cause of vitiligo is still unknown. Several theories about the mechanism have been proposed; the most important is the autoimmune theory. In autoimmune diseases the immune system is directed against the body’s own tissues, and this “defence against oneself” leads to disease. In vitiligo, this immune reaction is thought to cause the destruction of the pigment cells.
Other autoimmune diseases are known to occur more often in patients with vitiligo, such as certain thyroid diseases, diabetes and alopecia areata. Vitiligo also frequently runs in families, and identical twins often prove similarly susceptible to developing the white patches. Certain factors can trigger vitiligo, but only in people who already have a predisposition. Known factors include serious illness, surgery, pregnancy, childbirth, sunburn and skin damage from injury. Emotional stress may also trigger or worsen vitiligo.
How does it look?
Vitiligo patches are white: all pigment has disappeared. A characteristic feature is a sharp border with the normal skin. The patches are naturally most noticeable on tanned or naturally darker skin. Although they can occur anywhere on the body, there are certain preferred sites: the face, the hands and the genital area. People with a predisposition can also develop new depigmented patches where the skin is damaged. Hairs growing within vitiligo patches are usually white.
Who gets it?
Vitiligo can begin at any age and in people of any skin colour. Its course is difficult to predict: sometimes it remains limited to a few small patches, sometimes it spreads rapidly over large areas of skin. Vitiligo can improve spontaneously, but sometimes worsens again after such an improvement. Spontaneous improvement is seen mainly on skin areas regularly exposed to the sun. Because they lack the protective pigment, vitiligo patches can burn easily in the sun.
How is it treated?
Several treatments for vitiligo exist, but they do not work for everyone, and even when a treatment is effective, complete restoration of pigmentation usually does not occur.
Corticosteroids. Treatment with corticosteroid creams (“hormone creams”) is successful in some cases, especially in early vitiligo. The cream is applied once a day to the vitiligo patches. If this therapy has not been successful after about a month, it is better to stop, because a possible side effect is thinning of the skin.
Calcineurin inhibitors. Tacrolimus ointment and pimecrolimus cream are prescribed by dermatologists for (not too extensive) vitiligo. Like corticosteroids, these anti-inflammatory medicines are available only on prescription.
PUVA. Ultraviolet A (UVA) light is part of natural sunlight and penetrates fairly deep into the skin. It influences the inflammation in the skin and probably also the movement of pigment cells in normal skin at the edge of the vitiligo patches. UVA alone is insufficient in vitiligo, so a medicine that enhances its effect, called psoralen, is added. Usually the psoralen is taken as tablets 1–2 hours before the light exposure; patients are typically treated twice a week for several weeks to a few months. In some day-treatment centres “bath PUVA” is possible, in which the psoralen is dissolved in bath water instead of being swallowed. Disadvantages: frequent light treatments increase the long-term risk of skin cancer; the psoralen tablets can cause nausea; and PUVA is not suitable during pregnancy or breastfeeding.
UVB. Ultraviolet B is also part of natural sunlight. It has a more powerful effect than UVA and is therefore used without additional oral medicines such as psoralen (although PUVA is more powerful than UVB). Newer narrow-band UVB lamps are almost as effective as PUVA. Advantages: a proven, effective method that can, if needed, be used during pregnancy. Disadvantage: frequent light treatments increase the long-term risk of skin cancer.
Skin grafting. Small pieces of the patient’s own normal skin can be transplanted into vitiligo patches, usually as small “islands”, with the aim that pigment cells migrate from the healthy skin into the vitiligo skin. This is combined with light therapy. A condition for the treatment is that the vitiligo has not spread for some time. It is still fairly experimental and only carried out in certain specialised centres.
Calcipotriol. This is a vitamin D3 derivative applied as a cream, registered for psoriasis. Some publications suggest calcipotriol may also have a favourable effect on vitiligo, both alone and in combination with light therapy.
Depigmentation (bleaching). In patients with very extensive vitiligo, it can be cosmetically preferable to lighten the remaining normal skin so that the skin becomes evenly pale. This is done with a hydroquinone-containing cream.
What can you do yourself?
Camouflage. Camouflaging depigmented patches with a skin-coloured make-up is a good method for masking disfiguring vitiligo patches, particularly on the face, and is always worth considering for facial patches. A specialist skin therapist (camouflage therapist) can explain the options and give instructions; after that, the method can be applied at home.
Sun protection. Vitiligo skin lacks the pigment that protects against the harmful effects of sunlight, so the patches burn easily. The skin should always be well protected against sun by clothing or a sunscreen. This has the added benefit that the healthy, pigment-forming skin tans less and therefore contrasts less with the white, unpigmented skin.
When to see a doctor
See a doctor if white patches appear or spread, for advice on treatment options, and because vitiligo is sometimes associated with other (for example thyroid) conditions that a doctor can check for.