Vitiligo

Overview

Vitiligo (vit-ih-LIE-go) is a disease that causes loss of skin color in patches. The discolored areas usually get bigger with time. The condition can affect the skin on any part of the body. It can also affect hair and the inside of the mouth.

Normally, the color of hair and skin is determined by melanin. Vitiligo occurs when cells that produce melanin die or stop functioning. Vitiligo affects people of all skin types, but it may be more noticeable in people with brown or Black skin. The condition is not life-threatening or contagious. It can be stressful or make you feel bad about yourself.

Treatment for vitiligo may restore color to the affected skin. But it doesn't prevent continued loss of skin color or a recurrence.

Symptoms

Vitiligo signs include:

• Patchy loss of skin color, which usually first appears on the hands, face, and areas around body openings and the genitals
• Premature whitening or graying of the hair on your scalp, eyelashes, eyebrows or beard
• Loss of color in the tissues that line the inside of the mouth and nose (mucous membranes)

Vitiligo can start at any age, but usually appears before age 30.

Depending on the type of vitiligo you have, it may affect:

• Nearly all skin surfaces. With this type, called universal vitiligo, the discoloration affects nearly all skin surfaces.
• Many parts of the body. With this most common type, called generalized vitiligo, the discolored patches often progress similarly on corresponding body parts (symmetrically).
• Only one side or part of the body. This type, called segmental vitiligo, tends to occur at a younger age, progress for a year or two, then stop.
• One or only a few areas of the body. This type is called localized (focal) vitiligo.
• The face and hands. With this type, called acrofacial vitiligo, the affected skin is on the face and hands, and around body openings, such as the eyes, nose and ears.

It's difficult to predict how this disease will progress. Sometimes the patches stop forming without treatment. In most cases, pigment loss spreads and eventually involves most of the skin. Occasionally, the skin gets its color back.

When to see a doctor

See your health care provider if areas of your skin, hair or mucous membranes lose coloring. Vitiligo has no cure. But treatment might stop or slow the discoloring process and return some color to your skin.

Causes

Vitiligo occurs when pigment-producing cells (melanocytes) die or stop producing melanin — the pigment that gives your skin, hair and eyes color. The involved patches of skin become lighter or white. It's unclear exactly what causes these pigment cells to fail or die. It may be related to:

• A disorder of the immune system (autoimmune condition)
• Family history (heredity)
• A trigger event, such as stress, severe sunburn or skin trauma, such as contact with a chemical

Risk factors

Anyone can develop vitiligo. But you may be more likely to develop it if you:

• Have a family history of the condition.
• Have frequent direct contact with phenol-containing chemicals, such as those found in some detergents.

Complications

People with vitiligo may be at increased risk of:

• Social or psychological distress
• Sunburn
• Eye problems
• Hearing loss

Diagnosis

Your health care provider will ask about your medical history and examine your skin, possibly with a special lamp. The evaluation might also include a skin biopsy and blood tests.

Treatment

The choice of treatment depends on your age, how much skin is involved and where, how quickly the disease is progressing, and how it's affecting your life.

Medications and light-based therapies are available to help restore skin color or even out skin tone, though results vary and are unpredictable. And some treatments have serious side effects. So your health care provider might suggest that you first try changing the appearance of your skin by applying a self-tanning product or makeup.

If you and your health care provider decide to treat your condition with a drug, surgery or therapy, the process may take many months to judge its effectiveness. And you may have to try more than one approach or a combination of approaches before you find the treatment that works best for you.

Even if treatment is successful for a while, the results may not last or new patches may appear. Your health care provider might recommend a medication applied to the skin as maintenance therapy to help prevent relapse.

Medications

No drug can stop the process of vitiligo — the loss of pigment cells (melanocytes). But some drugs, used alone, in combination or with light therapy, can help restore some color.

• Drugs that control inflammation. Applying a corticosteroid cream to affected skin might return color. This is most effective when vitiligo is still in its early stages. This type of cream is effective and easy to use, but you might not see changes in your skin's color for several months. Possible side effects include skin thinning or the appearance of streaks or lines on your skin.

  Milder forms of the drug may be prescribed for children and for people who have large areas of discolored skin.

  Corticosteroid pills or injections might be an option for people whose condition is progressing rapidly.

• Medications that affect the immune system. Calcineurin inhibitor ointments, such as tacrolimus (Protopic) or pimecrolimus (Elidel) might be effective for people with small areas of depigmentation, especially on the face and neck. The U.S. Food and Drug Administration (FDA) has warned about a possible link between these drugs and lymphoma and skin cancer.

Therapies

• Light therapy. Phototherapy with narrow band ultraviolet B (UVB) has been shown to stop or slow the progression of active vitiligo. It might be more effective when used with corticosteroids or calcineurin inhibitors. You'll need therapy two to three times a week. It could take 1 to 3 months before you notice any change, and it could take 6 months or longer to get the full effect.

  Given the FDA warning regarding possible risk of skin cancer with use of calcineurin inhibitors, talk with your health care provider about the risks and benefits of using these drugs with phototherapy.

  For people who can't go to a clinic for treatment, smaller portable or handheld devices for narrow band ultraviolet B therapy are available for home use. Talk with your health care provider about this option as well if needed.

  Possible side effects of narrow band ultraviolet B therapy include redness, itching and burning. These side effects usually clear up within a few hours after treatment.

• Combining psoralen and light therapy. This treatment combines a plant-derived substance called psoralen with light therapy (photochemotherapy) to return color to the light patches. After you take psoralen by mouth or apply it to the affected skin, you're exposed to ultraviolet A (UVA) light. This approach, while effective, is more difficult to administer and has been replaced in many practices by narrow band UVB therapy.

• Removing the remaining color (depigmentation). This therapy may be an option if your vitiligo is widespread and other treatments haven't worked. A depigmenting agent is applied to unaffected areas of skin. This gradually lightens the skin so that it blends with the discolored areas. The therapy is done once or twice a day for nine months or longer.

  Side effects can include redness, swelling, itching and very dry skin. Depigmentation is permanent.

Surgery

If light therapy and medications haven't worked, some people with stable disease may be candidates for surgery. The following techniques are intended to even out skin tone by restoring color:

• Skin grafting. In this procedure, your doctor transfers very small sections of your healthy, pigmented skin to areas that have lost pigment. This procedure is sometimes used if you have small patches of vitiligo.

  Possible risks include infection, scarring, a cobblestone appearance, spotty color and failure of the area to recolor.

• Blister grafting. In this procedure, your doctor creates blisters on your pigmented skin, usually with suction, and then transplants the tops of the blisters to discolored skin.

  Possible risks include scarring, a cobblestone appearance and failure of the area to recolor. And the skin damage caused by suctioning may trigger another patch of vitiligo.

• Cellular suspension transplant. In this procedure, your doctor takes some tissue on your pigmented skin, puts the cells into a solution and then transplants them onto the prepared affected area. The results of this repigmentation procedure start showing up within four weeks.

  Possible risks include scarring, infection and uneven skin tone.

Potential future treatments

Treatments being studied include:

• A drug to stimulate color-producing cells (melanocytes). Called afamelanotide, this potential treatment is implanted under the skin to promote the growth of melanocytes.
• A drug that helps control melanoctyes. Prostaglandin E2 is being tested as a way to restore skin color in people with vitiligo that isn't widespread or spreading. It's applied to the skin as a gel.

Self care

If you have vitiligo, the following self-care tactics may help you care for your skin and improve its appearance:

• Protect your skin from the sun and artificial sources of UV light. Use a broad-spectrum, water-resistant sunscreen with an SPF of at least 30. Apply sunscreen generously and reapply every two hours — or more often if you're swimming or sweating.

  You can also seek shade and wear clothing that shields your skin from the sun. Don't use tanning beds and sunlamps.

  Protecting your skin from the sun helps prevent sunburn of the discolored skin. Sunscreen also minimizes tanning, which accentuates the vitiligo patches.

• Conceal affected skin. Makeup and self-tanning products can help minimize the differences in skin color. You may need to try several brands of makeup or self-tanners to find one that blends well with your normal skin tone. The coloring of self-tanning products doesn't wash off, but it gradually fades over several days. If you use a self-tanner, select one that contains dihydroxyacetone, as it is approved by the U.S. Food and Drug Administration.
• Don't get a tattoo. Damage to your skin, such as that caused by a tattoo, may cause a new patch of vitiligo to appear within two weeks.

Alternative medicine

Limited studies show that the herb Ginkgo biloba may return skin color in people with vitiligo. Other small studies show that alpha-lipoic acid, folic acid, vitamin C and vitamin B-12 plus phototherapy may restore skin color for some people.

As with any nonprescription treatment, check with your health care provider before trying alternative medicine therapies to be sure they won't interfere with other treatments you're using.

Coping and support

The change in your appearance caused by vitiligo might make you feel stressed, self-conscious or sad. These self-care approaches can help you cope with vitiligo:

• Make a good connection. Find a doctor who knows a lot about the condition. A dermatologist is a doctor who specializes in the care of skin.
• Learn about your condition. Find out as much as you can about vitiligo and your treatment options so that you can help decide what steps to take.
• Communicate your feelings. Let your health care provider know if you're feeling depressed. You might benefit from a referral to a mental health provider who specializes in helping people with depression.
• Talk with others. Ask your health care provider about psychotherapy or support groups in your area for people with vitiligo.
• Confide in loved ones. Seek understanding and support from your family and friends.

Preparing for your appointment

You're likely to start by seeing your primary care provider. You may then be referred to a specialist in skin disorders (dermatologist).

Here's some information to help you prepare for your appointment.

What you can do

• Review your family medical history. Find out if anyone in your family has vitiligo, a thyroid condition or a disease in which the immune system attacks healthy tissues in the body (autoimmune disease).
• List relevant personal information, such as recent major stressful events, life changes, sunburns and rashes.
• List any medications, vitamins and supplements you're taking, including doses.
• Make note of questions you'd like to ask your health care provider, which will help you make the most of your limited time together.

Some basic questions to consider include:

• What's the most likely cause of my symptoms?
• What are other possible causes?
• Do I need any tests?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• What side effects can I expect from treatment?
• Can I do anything to help, such as avoid the sun at certain times or wear a specific sunscreen?
• Can you recommend a product to conceal the discolored patches?
• Do you have brochures or other printed material I can take home? What websites do you recommend?

What to expect from your doctor

Your health care provider is likely to ask you a few questions, such as:

• When did you begin noticing light patches on your skin?
• Did you have a sunburn or skin rash before you noticed the patches?
• Are you sensitive to the sun?
• Do the discolored patches itch or cause any other symptoms?
• Have you ever had this type of skin change before?
• Does anyone in your family have vitiligo, a thyroid condition or an autoimmune disease?
• What is your occupation, and what are your hobbies? Are you exposed to any harsh chemicals in either?
• Does this condition affect your quality of life?
• Are you taking any medications or supplements?

What you can do in the meantime

While you're waiting to see your health care provider, limit your sun exposure and use a broad-spectrum sunscreen with an SPF of at least 30. If you're feeling self-conscious about the changes in your skin, use makeup or a self-tanning product to cover the affected areas.