Understanding Vitiligo. Types, Symptoms, and Treatment

Vitiligo is a non-contagious, non-life-threatening condition that results in loss of color of the skin, hair, and mucous membranes. It can be present on any body part at any time. The goal of treatment is to improve skin color by camouflaging, restoring, or removing pigment.

Are there different types of vitiligo?

There are two main types of vitiligo: segmental and non-segmental.

1. Segmental vitiligo - This type causes loss of pigment on one side or part of the body. It usually presents at a younger age. 30% of children with vitiligo have this type. Segmental vitiligo lasts for about 1-2 years; then, it stops progressing.
2. Non-segmental vitiligo - This type leads to symmetric loss of pigment on both sides of the body. 90% of people with vitiligo have this type. There are three subtypes of non-segmental vitiligo: universal, generalized, and localized.
   1. Universal vitiligo - Nearly all of the body is affected by this type.
   2. Generalized - This is the most common type. It affects large areas of the body.
   3. Localized - This type of vitiligo is rare and will affect one or a few body areas. This type does not spread to involve large areas.

What are the signs and symptoms of vitiligo?

Vitiligo is characterized by the loss of pigment in the skin, hair, and mucous membranes leading to the appearance of white patches. It can appear at any age, but usually before 30. It can also appear on any body part, especially the hands, face, orifices, and genitals. Here are some signs and symptoms of vitiligo.

• White patches on the skin that may coalesce into large areas of involvement
• White hair on scalp, eyelashes, eyebrows, and beard
• White patches on the mucosa of the mouth and nose
• No symptoms
• Eye problems
• Hearing loss

What causes vitiligo?

The destruction of melanocytes, the cells that produce the pigment melanin, causes vitiligo. The exact reason is not known, but there are several theories. It is most likely a combination of genetic and environmental factors that destroy the melanocytes.

• Autoimmune - Our bodies attack the melanocytes that produce the pigment melanin.
• Inherited - There are about 30 separate genes responsible for vitiligo, including NLRP1 (regulates inflammation) and PTPN22 (modulates the immune system).
• Triggers - Triggers of vitiligo include stress, severe sunburns, tattoos, and exposure to chemicals.

Are other diseases associated with vitiligo?

Scientists believe vitiligo is an autoimmune condition because other autoimmune diseases are present with vitiligo. Here are some of the autoimmune diseases.

• Pernicious anemia
• Hyperthyroidism
• Addison's disease
• Diabetes mellitus, type 1
• Hypothyroid
• Alopecia areata
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Psoriasis

Are there risk factors for vitiligo?

Some factors may put you at risk of developing vitiligo.

• Family history of vitiligo - 30% of vitiligo cases run in families.
• Family history of autoimmune conditions
• Personal history of autoimmune diseases - 15-25% of people with vitiligo have other autoimmune conditions.
• Personal history of melanoma or non-Hodgkin's lymphoma

You cannot prevent vitiligo if you are genetically predisposed to getting it. The best you can do is avoid things that may trigger an event, such as sunburns, exposure to chemicals, trauma, and stress.

How is vitiligo diagnosed?

A patient's history, physical examination, and other interventions can help diagnose vitiligo.

• Personal history of autoimmune conditions, melanoma, or non-Hodgkin's lymphoma
• Family history of vitiligo or autoimmune conditions
• Triggers
• Examination of skin, hair, and mucous membranes
• Wood's lamp exam - A device that emits special light is shined on the areas of vitiligo. The areas of vitiligo will appear very bright white under a Wood's lamp.
• Labwork - This can diagnose other conditions associated with vitiligo.
• Skin biopsy

What treatments are available for vitiligo?

There are three goals for treating vitiligo.

1. Sun protection.
2. Evening out the color of the skin, hair, or mucus membranes involved, either by camouflaging, repigmentation, or depigmentation.
3. Diagnosing and treating any other autoimmune conditions.

Treatments for vitiligo include sun protection, camouflage agents, topical medications, systemic medications, surgery, and phototherapy.

Sun protection - Since the areas of vitiligo do not have protective pigment (melanin), you need to be extra careful to protect them from the sun. Vitiligo patients are at higher risk of developing skin cancers. Use a broad-spectrum sunscreen that protects against the sun's UVA and UVB rays. Apply it daily and reapply it every 1-2 hours you are outside or driving. Wear a wide-brimmed hat, sunglasses with UV protection, and UPF clothing to protect the skin. Limit the time you spend outdoors, especially 10 am-4 pm.

Camouflage creams - Camouflage creams are heavy, water-proof makeup that can last for hours to days to help even out the color discrepancies in the skin.

Hair dye - Hair dye works well at covering the white hairs. It can last 4-6 weeks, depending on how fast your hair grows.

Topical medications

• Steroids - Steroid creams decrease inflammation and calm the immune system, preventing your body from attacking the melanocytes. These work well for small areas (less than 10%) that you are trying to repigment. Long-term use is not recommended because steroids can cause thinning of the skin, acne, broken blood vessels, and red stretch marks.
• Calcineurin inhibitors - Calcineurin inhibitors (Elidel and Protopic) work like steroids but do not have the same long-term side effects. Some experience a burning sensation or redness from using these.
• Monobenzone - This is a hydroquinone-based topical that depigments the skin. It takes years to accomplish this and is used only for severe, widespread cases of vitiligo involving more than 50% of the body. Depigmentation is permanent.

Systemic medications - Systemic medications used to treat vitiligo include immunosuppressants, like prednisone or azathioprine. They suppress the immune system to prevent your body from destroying the melanocytes that make melanin and help repigment the skin. These are used in moderate to severe cases because they have many grave side effects, like infections or cancers.

Phototherapy - Phototherapy can be used alone or in combination with topical therapy. It helps in widespread cases of vitiligo to repigment the skin.

• UVA - UVA phototherapy is often combined with a photosensitizing agent, psoralen, to achieve better results. This combination of psoralen and UVA is called PUVA. The photosensitizer can be topical or oral. UVA treatments carry an elevated risk of skin cancer.
• UVB - This type of phototherapy has less risk of skin cancer because UVB does not penetrate as deeply as UVA.
• Excimer laser - This laser emits UVB light to help repigment the skin. It is used in cases with small areas to treat.

Surgery - Different types of grafting procedures can help repigment the skin. However, any surgical intervention can cause trauma to the skin and trigger a vitiligo flare. It is not recommended for active progressing vitiligo cases or those who get keloid scars.

• Skin grafts - Skin grafting involves removing pieces of skin and transplanting them to areas of the body affected by vitiligo to repigment them.
• Blister grafts - Blister grafting removes small pieces of the top layer of skin by causing a blister to form with a suction device and then transplanting this blistered tissue to the affected areas.
• Melanocyte grafts - In this technique, only the melanocytes are transplanted to the affected areas.

Complementary therapies - There are only anecdotal reports of the success of using Ginkgo Biloba, alpha-lipoic acid, folic acid, Vitamin C, and B12 to repigment the skin. More research is necessary.

With so many available options, it is best to see a board-certified dermatologist who can devise a treatment plan that is right for you and your particular case. Prompt treatment will prevent the worsening of vitiligo.