Vitiligo (pronounced vit-ill-EYE-go) is a pigmentation disorder in which melanocytes (the cells that make pigment) in the skin are destroyed. As a result, white patches appear on the skin in different parts of the body. Similar patches also appear on both the mucous membranes (tissues that line the inside of the mouth and nose) and the retina (inner layer of the eyeball). The hair that grows on areas affected by vitiligo sometimes turns white.
The cause of vitiligo is not known, but doctors and researchers have several different theories. There is strong evidence that people with vitiligo inherit a group of three genes that make them susceptible to depigmentation. The most widely accepted view is that the depigmentation occurs because vitiligo is an autoimmune disease – a disease in which a person's immune system reacts against the body's own organs or tissues. People's bodies produce proteins called cytokines that, in vitiligo, alter their pigment-producing cells and cause these cells to die. Another theory is that melanocytes destroy themselves. Finally, some people have reported that a single event, such as sunburn or emotional distress, triggered vitiligo; however, these events have not been scientifically proven as causes of vitiligo.
How Is Vitiligo Diagnosed?
The diagnosis of vitiligo is made based on a physical examination, medical history, and laboratory tests.
A doctor will likely suspect vitiligo if you report (or the physical examination reveals) white patches of skin on the body – particularly on sun-exposed areas, including the hands, feet, arms, face, and lips. If vitiligo is suspected, the doctor will ask about your medical history. Important factors in the diagnosis include a family history of vitiligo; a rash, sunburn, or other skin trauma that occurred at the site of vitiligo 2 to 3 months before depigmentation started; stress or physical illness; and premature graying of the hair (before age 35). In addition, the doctor will ask whether you or anyone in your family has had any autoimmune diseases and whether you are very sensitive to the sun.
To help confirm the diagnosis, the doctor may take a small sample (biopsy) of the affected skin to examine under a microscope. In vitiligo, the skin sample will usually show a complete absence of pigment-producing melanocytes. On the other hand, the presence of inflamed cells in the sample may suggest that another condition is responsible for the loss of pigmentation.
Because vitiligo may be associated with pernicious anemia (a condition in which an insufficient amount of vitamin B12 is absorbed from the gastrointestinal tract) or hyperthyroidism (an overactive thyroid gland), the doctor may also take a blood sample to check the blood cell count and thyroid function. For some patients, the doctor may recommend an eye examination to check for uveitis (inflammation of part of the eye), which sometimes occurs with vitiligo. A blood test to look for the presence of antinuclear antibodies (a type of autoantibody) may also be done. This test helps determine if the patient has another autoimmune disease.
What Treatment Options Are Available?
The main goal of treating vitiligo is to improve appearance. Therapy for vitiligo takes a long time – it usually must be continued for 6 to 18 months. The choice of therapy depends on the number of white patches; their location, sizes, and how widespread they are; and what you prefer in terms of treatment. Each patient responds differently to therapy, and a particular treatment may not work for everyone. Current treatment options for vitiligo include medication, surgery, and adjunctive therapies (used along with surgical or medical treatments).
Medical Therapies
A number of medical therapies, most of which are applied topically, can reduce the appearance of vitiligo. These are some of the most commonly used]
* * * Topical steroid therapy – Steroid creams may be helpful in repigmenting (returning the color to) white patches, particularly if they are applied in the initial stages of the disease. Corticosteroids are a group of drugs similar to hormones such as cortisone, which are produced by the adrenal glands. Doctors often prescribe a mild topical corticosteroid cream for children under 10 years old and a stronger one for adults. You must apply the cream to the white patches on the skin for at least 3 months before seeing any results. Corticosteriod creams are the simplest and safest treatment for vitiligo, but are not as effective as psoralen photochemotherapy. Yet, as with any medication, these creams can cause side effects. For this reason, the doctor will monitor you closely for skin shrinkage and skin striae (streaks or lines on the skin). These side effects are more likely to occur in areas where the skin is thin, such as on the face and armpits, or in the genital region. They can be minimized by using weaker formulations of steroid creams in these areas.
* * * Psoralen photochemotherapy – Also known as psoralen and ultraviolet A (PUVA) therapy, this is probably the most effective treatment for vitiligo available in the United States. The goal of PUVA therapy is to repigment the white patches. However, it is time-consuming, and care must be taken to avoid side effects, which can sometimes be severe. Psoralen is a drug that contains chemicals that react with ultraviolet light to cause darkening of the skin. The treatment involves taking psoralen by mouth (orally) or applying it to the skin (topically). This is followed by carefully timed exposure to sunlight or to ultraviolet A (UVA) light that comes from a special lamp. Typically, you will receive treatments in your doctor's office so you can be carefully watched for any side effects. You must minimize exposure to sunlight at other times. Both oral and topical psoralen photochemotherapy are described below.
* * * * * o Topical psoralen photochemotherapy – often used for people with a small number of depigmented patches affecting a limited part of the body and for children age 2 and older who have localized patches of vitiligo. Treatments are done in a doctor's office under artificial UVA light once or twice a week. The doctor or nurse applies a thin coat of psoralen to your white patches about 30 minutes before exposing you to enough UVA light to turn the affected area pink. The doctor usually increases the dose of UVA light slowly over many weeks. Eventually, the pink areas fade and a more normal skin color appears. After each treatment, you wash your skin with soap and water and apply a sunscreen before leaving the doctor's office.
* * * * * * There are two major potential side effects of topical PUVA therapy]* * * * * o Oral psoralen photochemotherapy – used for people with extensive vitiligo (affecting more than 20 percent of the body) or for people who do not respond to topical PUVA therapy. Oral psoralen is not recommended for children under 10 years of age because it increases the risk of damage to the eyes caused by conditions such as cataracts. For oral PUVA therapy, you take a prescribed dose of psoralen by mouth about 2 hours before exposure to artificial UVA light or sunlight. If artificial light is used, the doctor adjusts the dose of light until the skin in the areas being treated becomes pink. Treatments are usually given two or three times a week, but never 2 days in a row.
* * * * * * For patients who cannot go to a facility to receive PUVA therapy, the doctor may prescribe psoralen that can be used with natural sunlight exposure. The doctor will give you careful instructions on carrying out treatment at home and monitor you during scheduled checkups.
* * * * * * Known side effects of oral psoralen include sunburn, nausea and vomiting, itching, abnormal hair growth, and hyperpigmentation. Oral psoralen photochemotherapy may also increase the risk of skin cancer, although the risk is minimal at doses used for vitiligo. If you are undergoing oral PUVA therapy, you should apply sunscreen and avoid direct sunlight for 24 to 48 hours after each treatment to avoid sunburn and reduce the risk of skin cancer. To avoid eye damage, particularly cataracts, you should also wear protective UVA sunglasses for 18 to 24 hours after each treatment.
* * * Depigmentation – involves fading the rest of the skin on the body to match the areas that are already white. For people who have vitiligo on more than 50 percent of their bodies, depigmentation may be the best treatment option. Patients apply the drug monobenzyl ether of hydroquinone (monobenzone or Benoquin*) twice a day to pigmented areas until they match the already-depigmented areas. You must avoid direct skin-to-skin contact with other people for at least 2 hours after applying the drug, as transfer of the drug may cause depigmentation of the other person's skin. The major side effect of depigmentation therapy is inflammation (redness and swelling) of the skin. You may experience itching or dry skin. Depigmentation tends to be permanent and is not easily reversed. In addition, a person who undergoes depigmentation will always be unusually sensitive to sunlight.
*Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
Surgical Therapies
All surgical therapies must be considered only after proper medical therapy is provided. Surgical techniques are time-consuming and expensive and usually not paid for by insurance carriers. They are appropriate only for carefully selected patients who have vitiligo that has been stable for at least 3 years]
* * * Autologous skin grafts – The doctor removes skin from one area of your body and attaches it to another area. This type of skin grafting is sometimes used for patients with small patches of vitiligo. The doctor removes sections of the normal, pigmented skin (donor sites) and places them on the depigmented areas (recipient sites). There are several possible complications of autologous skin grafting. Infections may occur at the donor or recipient sites. The recipient and donor sites may develop scarring, a cobblestone appearance, or a spotty pigmentation, or may fail to repigment at all. Treatment with grafting takes time and is costly, and many people find it neither acceptable nor affordable.
* * * Skin grafts using blisters – In this procedure, the doctor creates blisters on your pigmented skin by using heat, suction, or freezing cold. The tops of the blisters are then cut out and transplanted to a depigmented skin area. The risks of blister grafting include scarring and lack of repigmentation. However, there is less risk of scarring with this procedure than with other types of grafting.
* * * Micropigmentation (tattooing) – This procedure involves implanting pigment into the skin with a special surgical instrument. It works best for the lip area, particularly in people with dark skin. However, it is difficult for the doctor to match perfectly the color of the skin of the surrounding area.
* * * The tattooed area will not change in color when exposed to sun, although the surrounding normal skin will. So even if the tattooed area matches the surrounding skin perfectly at first, it may not later on. Tattooing tends to fade over time. In addition, tattooing of the lips may lead to episodes of blister outbreaks caused by the herpes simplex virus.
* * * Autologous melanocyte transplants – In this procedure, the doctor takes a sample of your normal pigmented skin and places it in a laboratory dish containing a special cell-culture solution to grow melanocytes. When the melanocytes in the culture solution have multiplied, the doctor transplants them to your depigmented skin patches. This procedure is currently experimental and is impractical for the routine care of people with vitiligo. It is also very expensive, and its side effects are not known.
Additional Therapies
In addition to medical and surgical therapies, there are many things you can do on your own to protect your skin, minimize the appearance of white patches, and cope with the emotional aspects of vitiligo]
* * * Sunscreens – People who have vitiligo, particularly those with fair skin, should minimize sun exposure and use a sunscreen that provides protection from both UVA and ultraviolet B light. Tanning makes the contrast between normal and depigmented skin more noticeable. Sunscreen helps protect the skin from sunburn and long-term damage.
* * * Cosmetics – Some patients with vitiligo cover depigmented patches with stains, makeup, or self-tanning lotions. These cosmetic products can be particularly effective for people whose vitiligo is limited to exposed areas of the body. Dermablend, Lydia O'Leary, Clinique, Fashion Flair, Vitadye, and Chromelin offer makeup or dyes that you may find helpful for covering up depigmented patches. Self-tanning lotions have an advantage over makeup in that the color will last for several days and will not come off with washing.
* * * Counseling and support groups – Many people with vitiligo find it helpful to get counseling from a mental health professional. People often find they can talk to their counselor about issues that are difficult to discuss with anyone else. A mental health counselor can also offer support and help in coping with vitiligo. In addition, it may be helpful to attend a vitiligo support group.
What Research Is Being Done on Vitiligo?
In the past two decades, research on the role that melanocytes play in vitiligo has greatly increased. A variety of technical advances, such as gene mapping and cloning, have permitted relatively rapid advances in knowledge of melanocytes at the cellular and molecular levels.
Much of the research that holds promise for understanding, treating, and possibly preventing vitiligo is supported by NIAMS. Current NIAMS-supported research includes the following]
* * * examination of the mechanism by which trauma or stress to the skin can trigger vitiligo or the development of new lesions
* * * development of a mouse model of vitiligo that not only would help scientists better understand the disease but also would allow them to test treatments for it
* * * identification of genes that play a role in and predispose people to vitiligo.
Melanotan One/afamelanotide to be trialled as novel repigmentation therapy
A drug initially developed to protect skin from light and UV will soon be tested as a repigmentation therapy in vitiligo, a common disorder which causes skin to gradually lose its pigment or tone. Melanotan, a new drug developed in Australia, will be evaluated for its ability to reactivate melanin in the whitened, depigmented skin patches caused by vitiligo.
If approved by US and EU regulators, Melbourne-based Clinuvel Pharmaceuticals Ltd will commence trials in October.
"Our vitiligo program is a potential breakthrough for patients and testament to Clinuvel's expertise in the field of dermatology and skincare]
Afamelanotide works by mimicking the body's own response to ultraviolet light; activating melanin in the skin to protect against damage. The drug is delivered as an subcutaneous inject and biologically activates melanin for up to 60 days.
In vitiligo the pigment producing cells of the skin (melanocytes) are absent or inadequate. As a result, lighter patches of skin appear in different parts of the body due to a lack of melanin. Vitiligo doesn't cause physical impairment but does cause significant psychological and emotional distress. The disorder affects up to 2% of the population. Nonsegmental vitiligo (NSV), the most common subtype, affects over 45 million people globally.
Clinuvel discovered that the drug may help vitiligo patients.
"For a long time we were unsure of the potential of the drug in vitiligo," explained Clinuvel's Chief Scientific Officer, Dr Hank Agersborg. "But, since the scientific reports came through on the effects of phototherapy in vitiligo, we understood afamelanotide's ability to assist with repigmenting skin lesions."
Melanotan One will be tested in a pilot NSV study on its own and in combination with an existing therapy called narrowband ultraviolet B (NB-UVB), which uses UV light to activate pigment and restore melanocytes. It is expected that Melanotan will enhance this therapy as well as activating melanin independently by stimulating specific melanocytes which exist in hair follicles within the skin.
"Vitiligo is a disorder that has a considerable impact on the lives of patients worldwide," Dr Wolgen said. "To be able to evaluate a potential therapy that could help improve quality of life for these people is a vastly rewarding prospect for Clinuvel.
"We are excited to be able to commence this trial and work with the vitiligo community to determine the drug's effect."
To date, SCENESSE? has been safely administered to approximately 550 patients and is in late stage confirmatory clinical trials in the US and Europe for the rare light intolerance porphyria (EPP).
I suffered from vitligo too, but I was cured now. It was bad, and makes me very unhappy. I live in China. Here we use Traditional Chinese Medicine to treat skin problems, I went to many hospitals like this and tried many different treatments, but the effect is not very good until I went to a hospital in the North of China. It works, and now I am a happy person again, I am glad to share this with you, you may not able to go there, but you can talk to their doctors for advice. you can find more information on the website of vitiligotcm.
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