VITILIGO

Symptoms of vitiligo 

The main symptom of vitiligo is flat, white spots or patches on your skin. The first white patch usually develops where the skin has been exposed to the sun.

Initially, the vitiligo may start as a patch of skin that is paler than the rest. Gradually, the patch will become completely white. The centre of a patch may sometimes be white, with pale skin around it. In areas where there are blood vessels under the skin, the patch may be slightly pink, rather than white.

The edges of the patch may be smooth or irregular,  sometimes inflamed (red) or  with  hyperpigmentation (brownish discolouration of the skin).

Vitiligo does not cause discomfort, such as dryness, but patches may occasionally be itchy.

The hypopigmented patches are more vulnerable to sunburn.

The areas most commonly affected by vitiligo include:

• the skin around your mouth and eyes
• fingers and wrists
• armpits
• groin
• genitals
• inside your mouth

Vitiligo can sometimes develop on hairy areas, such as on your scalp. The lack of melanin can turn the hair in the affected area white or grey.

 

Types of vitiligo

There are two main types of vitiligo:

• non-segmental vitiligo
• segmental vitiligo

In rare cases, it’s possible for vitiligo to affect the entire body. This is known as universal or complete vitiligo.

Non-segmental vitiligo

In non-segmental vitiligo (also called bilateral or generalised vitiligo), the symptoms of vitiligo often appear on both sides of the body as symmetrical white patches. Symmetrical patches can appear on the:

• backs of your hands
• arms
• eyes
• knees
• elbows
• feet

Non-segmental vitiligo is the most common type of vitiligo, affecting up to 9 out of 10 people with the condition.

Segmental vitiligo

The white patches may only affect one area of your body. This is known as segmental, unilateral or localised vitiligo.

Segmental vitiligo is less common in adults, although it’s more common in children. Segmental vitiligo usually starts earlier and affects 3 in 10 children who have vitiligo.

How the symptoms of vitiligo develop

If vitiligo is present, it is difficult to predict whether the condition will spread from the original patch, or how fast it may spread, as it varies from person to person.

It’s likely that more white patches will appear. For some people, this can happen quickly. For others, the patches may stay the same for months or years.

If the white patches appear symmetrically on more than one part of the body, the condition may progress quite slowly, with periods when the patches do not change. If you have white patches on only one area of your body, the condition may progress more rapidly.

Diagnosing vitiligo 

Vitiligo is diagnosed through basic skin examinations. Further tests are rarely needed.

A complete assessment is done to estimate the surface body are affected..

The medical practitioner may ask the following:

• the presence of vitiligo in the family
• history of other autoimmune conditions in the family
• injuries to the affected area of skin – for example, sunburn or a severe rash
• tan easily in the sun
• any areas have got better without treatment, or whether they are getting worse
• tried any treatment

Questions regarding the impacts of vitiligo will also be asked. For example:

• how much it affects confidence and self-esteem
• whether it affects your job

Wood’s lamp

Examination of the skin under an ultraviolet (UV) lamp called a Wood’s lamp could be done to look at your skin in more detail. It is usually done in a dark room with the lamp held 10-13cm (4-5in) away from the skin.

Under the UV light, the patches of vitiligo will be easier to see. This can help differentiate vitiligo and other skin conditions, such as pityriasis versicolor (a yeast infection that causes a loss of pigment in small, round patches).

Other autoimmune conditions

Non-segmental vitiligo, the most common type of vitiligo, is closely associated with other autoimmune conditions. Other autoimmune conditions may be investigated, symptoms of some related conditions include:

• being tired and lacking in energy (signs of Addison’s disease)
• being thirsty and needing to urinate often (signs of diabetes)

A blood sample may also be needed to test the thyroid for conditions such as an overactive thyroid (hyperthyroidism).

 

Treating vitiligo 

Vitiligo is treated by improving the skin’s appearance by restoring its color. However, the effects of treatment are not usually permanent, and control of the spread of the condition is difficult.

The following measures may be recommended by the doctor:

• sun safety advice
• a referral for camouflage creams
• topical corticosteroids

Treatment may not be necessary of only a small patch is affected or skin is very fair. Referral to a dermatologist (specialist in treating skin conditions) is done if further management is needed.

The various treatment methods are outlined below.

Protection from the sun

The risk for sunburn is increased in the presence of vitiligo. Skin must be protected from the sun and avoid sunbeds.

When skin is exposed to sunlight, it produces a pigment called melanin to help protect it from ultraviolet light. In vitiligo, not enough melanin is produced thus protection is inadequate.

A high factor sunscreen is recommended, one that has a sunprotection factor (SPF) of 30 or above. This is particularly important if you have fair skin.

Protecting the skin from the sun will also result in less tanning, making vitiligo less noticeable.

Vitamin D

An increase in the risk of vitamin deficiency occurs if skin is not exposed to sun. Vitamin D is important to maintain calcium balance keeping bones and teeth healthy.

Sunlight activates vitamin D in the skin, although other sources include some foods, such as oily fish.

To avoid potential problems like rickets (known as osteomalacia in adults), vitamin D supplements must be taken.

Skin camouflage

Skin camouflage involves applying coloured creams to the white patches on the skin. These creams are specially made to match natural skin colour. The cream blends in the white patches with the rest of the skin, making them less noticeable.

Camouflage creams are waterproof and can be applied anywhere on the body. They last up to four days on the body and 12-18 hours on the face.

Skin camouflage creams can contain sunblocks or has an SPF rating.

Self-tanning lotion (fake tan) may also help cover vitiligo. Some types can last several days. Self-tanning lotion is available from most pharmacies.

Topical corticosteroids

Corticosteroids are a type of medicine that contains steroids. Topical means that the medicine is applied to the skin, such as a cream or ointment.

Topical corticosteroids are not primarily used for the treatment of vitiligo, but they can sometimes control the spread of the patches, and may restore some of the original skin colour. But it is important not to self medicate and consult the medical practitioner for advice. Corticosteroid creams may be prescribed if:

• you have non-segmental vitiligo involving less than 10% of your body
• you want further treatment (sun protection advice and camouflage creams are enough for some people)
• the treatment is not for your face
• you are not pregnant
• you understand and accept the risk of side effects

Using topical corticosteroids

Topical corticosteroids may come in the form of creams or ointments, depending on preference and where it will be applied. Ointments tend to be greasier. Creams are better if it is applied to joints – for example, inside the elbows. Possible corticosteroids that may be prescribed include:

• fluticasone propionate
• betamethasone valerate
• hydrocortisone butyrate

How much topical corticosteroid to use

• Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU).
• One FTU is the amount of topical steroid squeezed along an adult’s fingertip.
• One FTU is enough to treat an area of skin twice the size of an adult’s hand.

Follow-up

Follow-up visit is usually done after one month of treatment, to evaluate the response to treatment and to monitor for any undesirable effects. If no improvement is noted or if side effects occurs, corticosteroids may be stopped.

After another month, improvement is again monitored. And if wtill with no improvement, referral to a dermatologist is necessary. If slight improvement occurs, treatment is continued but with a two-week break from treatment every three weeks.

If the vitiligo has improved, treatment will be stopped.

Side effects

Side effects of topical corticosteroids include:

• streaks or lines in the skin (striae)
• thinning of the skin (atrophy)
• visible blood vessels appearing (telangiectasia)
• excess hair growth (hypertrichosis)
• contact dermatitis (inflammation of your skin)
• acne

Referral

Referral to a dermatologist is done if:

• Diagnosis is not definite
• Patient is pregnant and treatment is needed
• more than 10% of the body is affected by vitiligo
• Face is affected
• Topical corticosteroids cant be used due to side effects
• Segmental vitiligo is present
• Topical corticosteroids was used but with no improvement

Children with vitiligo who need treatment will also be referred to a dermatologist.

In some cases, strong topical corticosteroids may be prescribed while waiting to be seen by a dermatologist.

Some treatments your dermatologist may recommend are described below.

Topical pimecrolimus or tacrolimus

Pimecrolimus and tacrolimus are a type of medicine called calcineurin inhibitors, which are normally used to treat eczema.

Although they are unlicensed for the treatment of vitiligo, pimecrolimus or tacrolimus may be used for children or adults with the condition.

They can cause side effects, such as:

• burning or painful sensations
• making the skin more sensitive to sunlight
• facial flushing (redness) and skin irritation with alcohol intake

Phototherapy

Phototherapy (treatment with light) may be used for children or adults if:

• topical treatments have not worked
• the vitiligo is widespread
• the vitiligo is having a significant impact on the quality of life

Evidence suggests that phototherapy, particularly when combined with other treatments, has a positive effect on vitiligo.

During phototherapy, skin is exposed to ultraviolet A (UVA) or ultraviolet B (UVB) light from a special lamp. Premedication with psoralen, makes skin more sensitive to the light, is given. Psoralen can be taken orally or mixed in bath water.

This type of treatment is sometimes called PUVA (psoralen and UVA light).

Phototherapy may increase the risk of skin cancer because of the extra exposure to UVA rays. The dermatologist should discuss the risks before considering phototherapy.

Although special sunlamps are available to use at home for light therapy, these are not recommended. They are not as effective as the phototherapy. The lamps are also not regulated, and may be unsafe.

Skin grafts

A skin graft is a surgical procedure that involves removing healthy skin from an unaffected area of the body and using it to cover an area where the skin has been damaged or lost. To treat vitiligo, a skin graft can be used to cover the white patch.

Skin grafts may be considered for adults if:

• no new white patches have appeared in the last 12 months
• the white patches have not gotten worse in the last 12 months
• vitiligo is not triggered by any form of skin damage, such as severe sunburn (known as the Koebner response)

This type of treatment is time-consuming and is not widely available. It has a risk of scarring and will not be considered for children.

Depigmentation

Depigmentation may be recommended for adults who have vitiligo of more than 50% of their bodies, although it may not be widely available.

During depigmentation, a lotion is painted on to the normal skin to bleach away the pigment and make it the same colour as the depigmented (white) skin. A hydroquinone-based medication is used, which has to be applied continuously to prevent the skin from re-pigmenting.

Hydroquinone can cause side effects, such as:

• redness
• itching
• stinging

Depigmentation is usually permanent and leaves the skin with no protection from the sun. Re-pigmentation (when the colour returns) can occur, and may differ from the original skin colour.

Other treatments

The dermatologist may recommend trying more than one treatment, such as phototherapy combined with a topical treatment. Other possible treatments include:

• excimer lasers – high-energy beams of light that are used in laser eye treatment, but may also be used in phototherapy
• vitamin D analogues – such as calcipotriol, which may also be used with phototherapy
• azathioprine – a medicine that suppresses your immune system (the body’s natural defence system), which may be used with phototherapy
• oral prednisolone – a type of corticosteroid, which has also been used with phototherapy, although it can cause side effects

Complementary therapies

Some complementary therapies claim to relieve or prevent vitiligo. However, there is no evidence to support their effectiveness.

There is very limited evidence that Ginkgo Biloba, a herbal remedy, may benefit people with non-segmental vitiligo. However, there is currently not enough evidence to recommend it.

Before considering any herbal therapy, consult your medical practitioner first, as some remedies can react unpredictably with other medication or make them less effective.

Counselling and support groups

A vitiligo support group may help you understand more about the condition and come to terms with your skin’s appearance.

If psychosocial symptoms occur – for example, the condition is causing distress – referral to a psychologist or a counsellor is done for treatment such as cognitive behavioural therapy (CBT).

CBT is a type of therapy that aims to help you manage your problems by changing how you think and act.

Unlicensed medicines

Some of the mentioned medications are used off label for the treatment of vitiligo.

This means manufacturers of the medication have not applied for a licence for their medication to be used in treating vitiligo. In other words, the medication may not have undergone clinical trials (a type of research that tests one treatment against another) to see if it can treat vitiligo safely and effectively.

Many experts will use an unlicensed medication if they think the medication is likely to be effective and the benefits of treatment outweigh any associated risk.