Vitiligo

Vitiligo is a condition where white patches develop on the skin. It is due to loss of colour or pigment from areas of skin. The affected skin can lighten or turn completely white. Many people do not have any other signs or symptoms and they feel healthy.  It is not contagious and not a life threatening disease. However, Living with vitiligo can cause other symptoms such as low self-esteem and depression that is hard to beat. Its disfiguring signature often devastates the sufferers, specifically the dark-skinned type. For many, it is not just a cosmetic problem but a major social dysfunction that seriously curtail their ability to lead normal, professional, social or married lives. This can happen regardless of the amount of color loss or type of vitiligo.

Cause

The skin has two layers – the epidermis and the dermis. Melanocytes are special cells present in the bottom of the epidermis which make a pigment called melanin. The melanin is passed to the nearby skin cells, which colours the skin and protects them from the sun’s rays. Melanin causes the skin to tan in fair-skinned people. Dark-skinned people have more active melanocytes. The melanocytes are stimulated to make more melanin when exposed to sunlight.

Areas of skin with patches of vitiligo have no or very few melanocytes. The melanocytes are either damaged or destroyed in the body. Therefore, melanin cannot be made and the colour of the skin is lost. It is not known why the melanocytes go from affected areas of skin. They may be destroyed by the immune system or self-destruct for reasons not yet known. It is thought to be an autoimmune condition. This means that your own immune system (which normally protects your body from infections) causes damage. In the case of vitiligo, it destroys your skin cells that make melanin.

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

Who is affected by vitiligo?

Vitiligo affects people worldwide with an incidence of about 1 in 200. Men and Women are equally affected. Nearly half get it before they reach 21 years of age.  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), pernicious anemia or alopecia areata (causes hair loss).

Different Types Of Vitiligo

Localized

• Focal: This type is characterized by one or more areas of pigment loss in a confined area.
• Segmental: This type manifests as one or more areas of pigment loss on only one side of the body. It occurs most commonly in children.This type of vitiligo is not associated with thyroid or other autoimmune disorders.
• Mucosal: Mucous membranes alone are affected.

Generalized

• Acrofacial: Depigmentation occurs on parts away from the center of the body such as face, head, hands and feet.
• Vulgaris: This is characterized by scattered patches that are widely distributed.
• Mixed: Acrofacial and vulgaris vitiligo occur in combination, or segmental and acrofacial vitiligo and/or vulgaris involvement are noted in combination.
• Universal: This is complete or nearly complete depigmentation.

Treatment Options

-No treatment /Skin Camouflage:

Medical treatment may not be always necessary or welcome to the patient. Skin camouflage uses special skin-coloured cover creams that are put on the white patches of vitiligo. Skin camouflage does not alter the disease but temporarily improves the skin’s appearance. The aim is to find a colour to match the colour of your skin. The creams can disguise vitiligo very well which may greatly increase self-confidence. Drawbacks of camouflage products are that they must be repeatedly applied, can be time-consuming and they take practice to get natural-looking result. For large areas, self-tanning lotions which contain dihydroxyacetone (DHA) can be applied for providing tan on exposure to sunlight and can last several days before needing to be reapplied. However, they often do not provide an exact match for each skin colour.

-Topical Corticosteroids:

Corticosteroid creams or ointments may help return color to your skin (repigmentation) or prevent a smaller patch from getting bigger, particularly if the medication is started early in the disease. Milder topical corticosteroid cream or ointment may be prescribed for children and for people who have large areas of depigmented skin. Steroids work partly by suppressing the immune system (which probably attacks the melanocytes). It may take as long as three months of treatment before you begin to see any changes in your skin’s color. This treatment is easy and effective, but your doctor needs to monitor you closely for side effects, such as thinning of the skin (atrophy) and streaks or lines on your skin (skin striae).

-Topical Immunomodulators:

Tacrolimus or Pimecrolimus ointments are immunomodulators that have been shown to repigment vitiligo patches. They also work by suppressing cells of the immune system in the skin. This treatment may have fewer side effects than corticosteroids.

-Topical Psoralen plus Ultraviolet A:

This option, which is also called photochemotherapy, may be effective for you if less than 20 percent of your body has depigmented patches. You’ll have to visit the doctor once or twice a week for treatment. A thin coating of the topical psoralen is applied onto patches about 30 minutes before the light exposure. Psoralen makes your skin more sensitive to ultraviolet light. Your skin is then exposed to UVA light, which turns the treated areas pink. As the skin heals, a more normal skin color appears. Possible side effects include severe sunburn and blistering, though you can minimize your risk of complications by avoiding direct sunlight after each treatment. Hyperpigmentation — overdarkening of the skin — is usually temporary and eventually lightens when treatment stops.

-Oral Psoralen plus UVA:

If you have depigmented areas that cover more than 20 percent of your body, your doctor may recommend oral psoralen. For this treatment, you take the oral psoralen about two hours before exposure to UVA light. You’ll have to visit the doctor two or three times a week, allowing for at least a day in between treatments. As with topical psoralen, the treated skin becomes pink after UVA exposure, and then eventually fades to a more normal skin tone. This treatment can also be done using natural sunlight if you don’t have access to a doctor’s office with the proper equipment. Your doctor will let you know how much exposure you need and will want to monitor your skin changes frequently.

Sunburn, nausea, vomiting, itching, abnormal hair growth and overdarkening of the skin are potential short-term side effects of this treatment, whether it’s done in the doctor’s office or using natural sun. The use of sunscreen can also help reduce your risk of cutaneous side effects. To protect your eyes from serious damage, such as cataracts, wear UV-protective sunglasses for up to 24 hours after each treatment when you’re exposed to the sun.

-Narrowband ultraviolet B (UVB) therapy:

Narrowband UVB, a special form of UVB light that uses a more specific wavelength of ultraviolet B, is an alternative to PUVA. This type of therapy can be administered like PUVA and given up to three times a week. However, no pre-application of psoralen is required, which simplifies the treatment process. Because it is simpler to administer, this type of phototherapy is gaining wide acceptance.

-Depigmentation:

Depigmentation may be an option for you if you have vitiligo that covers more than half of your skin. Depigmentation therapy lightens the unaffected parts of your skin to match the areas that have already lost color. For this treatment, you apply a medication called monobenzyl ether of hydroquinone twice a day to the areas of your skin that still have pigment. Treatment continues until the darker areas of your skin match the already-depigmented areas.

Redness and swelling are potential side effects of depigmentation therapy, and you have to be careful to avoid skin-to-skin contact with other people for at least two hours after you’ve applied the drug, so you don’t transfer it to them. Other potential side effects include itching and dry skin. Depigmentation is permanent and will make you extremely sensitive to sunlight permanently.

-Surgical Methods:

These are done when disease is absolutely stable for atleast 6 months – 1 year (No new lesions + No increase in size of old lesions). Excessive scarring tendency should also be ruled out.

• Tattooing: Tattooing implants pigment into your skin with a special surgical instrument. For the treatment of vitiligo, tattooing is most effective around the lips and in people with dark skin. Sometimes the tattoo color doesn’t match skin color closely enough. Additionally, tattoo colors fade and they don’t tan.
• Mini-punch grafting: Small punch shaped grafts from normal skin are taken and implanted on the vitiliginous patch.  Gradually, pigment from these punches spread and merge. Drawbacks are Cobblestone effect and Polka-Dot appearance.
• Split-thickness grafting: A thin piece of skin is harvested from a normally pigmented donor site and is placed onto the recipient vitiligo patch where it is incorporated with healing of skin. Drawbacks are chances of colour mismatch and scarring.
• Suction Blister Grafting:
• This method separates the epidermis from the dermis with a suction device that produces blisters. The epidermis is then placed on an abraded vitiligo patch. Areas between the grafts may remain hypopigmented, but scarring is usually minimal.
• Melanocyte Keratinocyte transplant / Non-Cultured Epidermal Suspension transfer: This is a highly specialized procedure where after harvesting; the normally pigmented piece of donor skin is treated in certain substances through a definite process. By this process, a concentrated suspension rich in melanocytes and keratinocytes present at bottom of the epidermis is obtained. Vitiliginous patches are abraded mechanically or sometimes with the help of a laser device and the suspension is applied on them. Dressing is done by specialized dressing material containing collagen. After healing the operated site appears red for a while. Pigmentation slowly starts to appear by one month but may occasionally take long. Keratinocytes in suspension produce certain growth factors which help in survival and proliferation of melanocytes. Collagen dressing provides a scaffold for melanocytes to survive, proliferate & produce melanin and promotes vascularization. This method is highly efficacious, generally provides very good colour match giving excellent results and can cover large areas by a small graft. Disadvantages are that it sometimes takes long to repigment.

Transplantation of pure melanocytes:This method requires special growth media, which can lead to inconsistent results depending on the growth medium. There is also a theoretical risk of uncontrolled proliferation and malignant transformation of the melanocytes. Moreover, studies do not show any additional benefit of transplantation of cultured melanocytes over transplantation of non-cultured epidermal suspension.