Early signs of vitiligo pictures

Vitiligo

Protection from the sun

If you have vitiligo, you must protect your skin 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. If you have vitiligo, there is not enough melanin in your skin, so it is not protected. Sunburn is a real risk.

Always apply a high-factor sun cream, ideally with sun protection factor (SPF) 30 or above, to protect your skin from sunburn and long-term damage. This is particularly important if you have fair skin.

Read more about sunburn.

Protecting your skin from the sun will also minimise tanning, which will make your vitiligo less noticeable.

Vitamin D

If your skin is not exposed to the sun, there is an increased risk of vitamin D deficiency. Vitamin D is essential for keeping bones and teeth healthy.

Sunlight is the main source of vitamin D, although it is also found in some foods, such as oily fish.

To avoid potential problems like rickets (known as osteomalacia in adults), you may need to take vitamin D supplements.

Skin camouflage

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

You can also get skin camouflage cream that contains sun block or has an SPF rating.

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

Topical corticosteroids

Corticosteroids are any type of medicine that contains a type of hormone called steroids. Hormones are chemicals produced by the body that have a wide range of effects. Topical means the medicine is applied to the skin, such as a cream or ointment.

Topical corticosteroids are unlicensed for the treatment of vitiligo, but they can sometimes stop the spread of the patches, and may restore some of your original skin colour. Your doctor may prescribe a topical corticosteroid cream to adults if:

  • you have non-segmental vitiligo on 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

Read more about topical corticosteroids.

Using topical corticosteroids

Your doctor may prescribe a cream or an ointment, depending on what you prefer and where it will be used. Ointments tend to be greasier. Creams are better in your joints – for example, inside your elbows. Possible corticosteroids that may be prescribed include:

  • fluticasone propionate
  • betamethasone valerate
  • hydrocortisone butyrate

Your doctor will tell you how to apply the cream or ointment to the patches and how much you should use (see below). You normally need to apply the treatment once a day.

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.
  • You can use the Patient UK guide, Fingertip Units for Topical Steroids, to find out how many FTUs to use to treat different areas of the body.

Follow-up

After one month your doctor will ask you to return so they can see how well the treatment is working and check for any side effects. If your vitiligo is not improving or the treatment is causing side effects, you may need to stop using the corticosteroids.

After another month, your doctor will see how much your vitiligo has improved. If there is no improvement, you may be referred to a dermatologist (see below). If your vitiligo has improved slightly, you may continue treatment but have a two-week break from treatment every three weeks. You may also be referred to a dermatologist.

If the vitiligo has improved, treatment will be stopped.

Your doctor may take photos of your vitiligo throughout your treatment to monitor any signs of improvement. If you have a camera, you may also want to take photos to keep an eye on your condition.

Side effects

Side effects of topical corticosteroids include:

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

Referral

You doctor may refer you to a dermatologist if:

  • they are unsure about your diagnosis
  • you are pregnant and need treatment
  • more than 10% of your body is affected by vitiligo
  • you are distressed about your condition
  • your face is affected and you want further treatment
  • you cannot use topical corticosteroids because of the risk of side effects
  • you have segmental vitiligo and want further treatment
  • treatment with topical corticosteroids has not worked

Children with vitiligo who need treatment will also be referred to a dermatologist, particularly if their parents are distressed about their condition.

In some cases, you may be prescribed strong topical corticosteroids while you are 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 that 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 if you drink alcohol

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 their quality of life

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

During phototherapy, your skin is exposed to ultraviolet A (UVA) or ultraviolet B (UVB) light from a special lamp. You may first take a medicine called psoralen, which makes your skin more sensitive to the light. You can take psoralen by mouth (orally), or you can add it to your bath water.

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

Phototherapy may increase the risk of skin cancer because of the extra exposure to UVA rays. Your dermatologist should discuss this risk with you before you decide to have phototherapy.

Although you may be able to buy special sunlamps to use at home for light therapy, these are not recommended. They are not as effective as the phototherapy you will receive in hospital. The lamps are also not regulated, so may not be safe.

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 in areas that are affecting your appearance if:

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

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

Depigmentation

Depigmentation may be recommended for adults who have vitiligo on 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 your original skin colour.

Other treatments

Your dermatologist may recommend trying more than one treatment, for example, 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, that has also been used with phototherapy, although it can cause side effects

Complementary therapies

Some complementary therapies claim to relieve or prevent vitiligo. But there is no evidence to support their effectiveness, therefore more research is needed before they can be recommended.

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.

If you decide to use herbal remedies, check with your doctor first, as some remedies can react unpredictably with other medication or make them less effective.

Counselling and support groups

If you have vitiligo, you may find it helpful to join a vitiligo support group. This can help you understand more about your condition and come to terms with your skin’s appearance.

Charities, such as The Vitiligo Society, may be able to put you in touch with local support groups (you may need to become a member first). Your doctor may also be able to suggest a local group.

If you have psychosocial symptoms – for example, your condition is causing you distress – your doctor may refer you to a psychologist or a counsellor 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.

Read more about CBT.

PMC

Introduction

Vitiligo is a common and easily recognized disorder for all dermatologists, many physicians and some observant members of the general public. It is a disorder that is characterized by white spots typically first noted on the fingers, knuckles, around the eyes and mouth, and on the feet and genitalia . There are two basic mechanisms whereby the skin can become white. Melanin is synthesized by melanocytes within melanosomes that are transferred into the surrounding keratinocytes. The keratinocytes transport the melanin and melanosomes from the basal layer of the epidermis to the stratum corneum where they are desquamated into the environment. Some disorders inhibit or retard the production of melanin formation and the skin develops hypopigmentation. Such disorders include, among many others, oculocutaneous albinism, pityriasis alba, tinea versicolor and nevus depigmentosus. In these disorders, melanocytes are present in normal numbers in the epidermis but produce less than normal amounts of melanin. Typically, the skin exhibits mild to marked hypopigmentation.

Depigmentation of the fingers and dorsum of the hands, classical, early manifestations of vitiligo

Depigmentation around the eyes (partially blocked), the nares and mouth, all classical and early manifestations of bilateral vitiligo

Depigmentation of the feet, typical early manifestation of vitiligo

In contrast, other types of leukoderma are characterized by the absence of melanocytes and therefore, complete absence of melanin. Such disorders include piebaldism, the leukoderma of lupus erythematosus and other scarring disorders, and vitiligo. These types of leukoderma typically are totally depigmented. Vitiligo and lupus cause a destruction of melanocytes during postnatal life. Piebaldism affects the migration of melanocytes during embryogenesis and the infant is born with depigmentation of the hair and skin.

There seem to be three major factors involved in the destruction of melanocytes in patients with vitiligo. The first is that vitiligo patients inherit a set of three “vitiligo” genes which predisposes them to destruction of melanocytes. There probably are many different sets of three genes that can cause vitiligo so that not every individual would necessarily inherit the same three. The second abnormality relates to the melanocytes themselves. Melanocytes from patients with vitiligo differ from those obtained from a person without vitiligo. For example, vitiligo melanocytes require different and more fastidious culture conditions than those from normal individuals. Also, vitiligo melanocytes are much more sensitive to phenolic chemicals than normal melanocytes and readily undergo apoptosis when exposed to such agents. The third factor is an environmental agent(s) that activates (or inhibits) the genes involved, thereby setting in motion the process of destruction of the susceptible melanocytes. The vitiligo genes activated (inhibited) by the environmental agents seem to cause an excessive immune reaction that induces melanocytes to undergo apoptosis, and depigmentation of the skin results.

Vitiligo principally affects melanocytes. However, keratinocytes also manifest some damage, mostly a granular degeneration. It is not widely recognized that Merkel cells also are absent from depigmented skin. The significance of this absence and the impact it has on the function of the epidermis are not known. The cells of the epidermis, i.e., keratinocytes, Langerhans cells, melanocytes and Merkel cells, work closely together. It should be expected that loss of one or the other cells from the epidermis would alter its function. It is thought the Merkel cell functions as a neurosensory cell. It has been shown that sweating and bleeding times are altered in the depigmented skin of a patient with vitiligo. Alterations in cholinergic activity and morphology of sweat glands which are innervated by cholinergic sympathetic nerves have been observed by some investigators although not by all observers. The functional changes observed in depigmented skin might be related to the collateral damage to keratinocytes and/or Merkel cells. There are other functional abnormalities in vitiliginous skin which will be discussed later.

There are two main types of vitiligo, unilateral (often called segmental) and bilateral (usually termed generalized). Segmental vitiligo will be discussed later. However, the word “segmental” is often confused with the term “dermatomal”, the latter meaning the pattern of sensory innervation of the skin. Segmental is rarely, if ever, dermatomal, so unilateral is a better term to avoid confusion.

Bilateral or generalized vitiligo can begin at any age and tends to progress intermittently over the life of the patient. It produces depigmentation that is remarkably symmetrical in distribution . A patch on the right side of the body is matched by a patch in a similar location on the left side. The entire body can depigment although it rarely does so. The classical presentation of the depigmentation is a remarkably symmetrical distribution of depigmentation beginning on the fingers, feet, wrists, elbows, axillae and around the mouth and eyes. There is no explanation for this symmetry. Yet, it is so typical and common that symmetrical depigmentation is one criterion for the diagnosis of vitiligo. (Depigmented patches can be randomly scattered. This has been labeled atypical vitiligo.) Dr. RB Goudie, a Scottish pathologist, was intrigued by the symmetry that characterized vitiligo. He noted that the distribution of some autoimmune endocrine disorders such as thyrotoxicosis resembled in some ways the distribution of vitiligo. He also noted that malignant lymphomas often appeared as tumors symmetrically involving both sides of the body. He hypothesized that benign lymphocytes honed to specific sites in the skin where they might be responsible for the symmetry of vitiligo. Although his ideas are no longer popular, they are based on the known propensity of cutaneous lymphocytes to migrate to specific sites in the skin and the role of lymphocytes in causing depigmentation. His ideas are worthy of reconsideration.

Extensive depigmentation of a woman which illustrates the symmetrical distribution of classical bilateral vitiligo

Unilateral (segmental) vitiligo differs from generalized vitiligo in many important aspects. It more commonly begins in children and young adults and progresses for a limited period, usually 1–2 years, and then remains static for the life of the individual. It affects just one side of the body . In contrast to bilateral vitiligo, the distribution is asymmetrical on the skin. However, the patterns also are not random. The various sites affected by the depigmentation are repetitious. The patterns on the face have been classified. There are patterns affecting the neck and trunk which resemble each other in location and shape . It is important to note that a nevus depigmentosus 10] and a cafι-au-lait spot can have a similar shape, pattern and location as segmental vitiligo . These similarities of patterns and distribution for unilateral vitiligo and nevus depigmentosus suggest that unilateral vitiligo corresponds to embryological developmental patterns for melanocytes in their migration from the neural crest to the epidermis.

Unilateral (segmental) vitiligo affecting one side of the face of a young boy. Note that the depigmentation does not correspond to a dermatome

Unilateral depigmentation (segmental vitiligo) affecting the neck of a woman. Note the very similar distribution of depigmentation in the two men pictured in Figures ​Figures77 and ​and88

Unilateral depigmentation (segmental vitiligo) on the neck of a man with a distribution similar to that in Figures ​Figures66 and ​and77

Nevus depigmentosus on the neck of a boy. The pigmentary abnormality was present at birth in the patient

Nevus depigmentosus on the neck of a man. The pigmentary abnormality was present at birth in the patient

Unilateral depigmentation (segmental vitiligo) on the anterior chest and upper part of the right arm in a young woman. The distribution of pigment loss is very similar in this patient and the one given in Figure 12

A nevus depigmentosus in a young girl with a distribution of pigment loss similar to the unilateral vitiligo seen in Figures ​Figures1111 and ​and1212

Unilateral depigmentation (segmental vitiligo) of the neck of a man which is similar to the depigmentation seen in Figures ​Figures66 and ​and88

Unilateral depigmentation (segmental vitiligo) on the anterior chest and upper part of the right arm in a girl. The distribution of pigment loss is very similar in this patient and the one shown in Figure 11

Typically, bilateral vitiligo progresses over the life of the individual so that the person has partially normal and partially depigmented skin. This probably is the worst outcome. Of course, it is best to be one’s own color but it is the worst condition for most people to have two colors at least on visible skin such as the hands, face, neck and arms. To avoid this, for some patients, the treatment of choice is depigmentation of the normal skin by applications of monobenzone by which they achieve a single color. This is what Michael Jackson did to achieve a single white color. Occasionally, nature achieves the same end. A very small number of patients will develop over a period of a few months a very rapid depigmentation of the entire integument and also the hair . Dr. Aaron Lerner called it “veloce vitiligo” or rapid vitiligo. These individuals go from having dark skin to having totally depigmented skin and hair in a period of months. It can occur spontaneously but in my personal experience has followed in a few individuals generalized erythematous drug eruptions. How or why this happens is not known.

An Indian woman with veloce vitiligo. She lost almost all of her pigmentation on the skin and hair over a period of some months

The three cells of the epidermis, keratinocytes, Langerhans cells and melanocytes, form a troika so to speak and work together. As noted above, it should not be surprising that depigmented skin has some altered functions if one part of the troika is missing. Several Japanese workers noted that depigmented skin of vitiligo patients did not react to sensitization with dinitrofluoro benzene (DNFB) to produce contact dermatitis. In their experiments, DNFB was applied to normal skin to induce contact allergy. A challenge was applied to both normal and white skin. The white skin did not respond. In other experiments, the sensitizing dose of DNFB was applied to white skin and the challenge to both white and pigmented skin. The pigmented but not the white skin responded. These findings suggest that the afferent limb of the immune response is intact in the white skin, but the efferent limb is not so. In the same studies, Candida antigen was injected into the dermis of both white and pigmented skin and the dermal response was normal in both. The discrepancy between epidermal and dermal immune responses might be attributed to loss of the melanocytes which could have immune/inflammatory functions.

The epidermis is composed of three main cell types that work together like a troika

Others have noted that depigmented skin does not respond to contact allergens. Monobenzone as noted above is used to depigment skin for those with depigmentation too widespread to repigment. Some individuals applying monobenzone develop a contact allergy to the medication .17]. However, the allergic dermatitis is manifested only in the pigmented skin. In separate studies, investigators observed that the inflammatory response to irritants was abnormal in white skin compared to pigmented skin. It seems especially fascinating that graft versus host skin disease in one individual with piebaldism affected preferentially the white skin, emphasizing again that the three cells of the epidermis work together and that melanocytes likely play a role in inflammation.

A woman treated with monobenzone, who developed a contact allergy. The dermatitis is exclusively confined to the pigmented skin

A man treated with monobenzone, who developed a contact allergy. The dermatitis is exclusively confined to the pigmented skin

A muted response to contact allergens is not unique to humans. There is a species of mice that has an acquired form of depigmentation resembling vitiligo, called the mi/mivit/vit mouse . The skin and follicles of the mouse have normal numbers of Langerhans cells in both the pigmented and depigmented stages. However, the response of the mouse to potent contact allergens is highly muted after the skin and pelage have lost their melanocytes. This aberrant response might be due to inability of depigmented skin to express intercellular adhesion molecule 1 (ICAM-1). Humans with vitiligo show altered expression of ICAM-1 in the epidermis. ICAM-1 is critical to a normal immune response.

Mice with mivit/mivit gene. The mouse on the left has a piebald band on the leg but a normal pigmented pelage in early life. The mouse on the right is undergoing depigmentation with loss of melanocytes from the epidermis and hair follicles

One of the most mysterious features of vitiligo is the resistance of skin depigmented by vitiligo to producing skin cancers. It is a common worry for physicians and patients with vitiligo that they might get a melanoma. It is possible for a patient with vitiligo to get a melanoma but only in their normally pigmented skin. The white skin is devoid of melanocytes and thus unable to generate a melanoma. It is baffling that the white skin is also highly resistant to formation of keratinocyte malignancies, i.e., basal and squamous cell carcinomas.

Vitiligo skin is totally depigmented. The color is similar to that of albinism. Albinos are known to have a high incidence of skin cancer, especially in Africa where most albinos have oculocutaneous albinism type 2, a disorder caused by mutations in the p-gene. Most of these are squamous cell carcinomas. Interestingly, few individuals with other forms of oculocutaneous albinism, types I, III and IV, have been reported to have skin cancer. There are many possible explanations for this, the most obvious being that those living in Africa have little access to sufficient sun protection. In contrast, it has been suggested the mutations in the p-gene are related to melanomas as well as causing oculocutaneous albinism II. Similar studies on the p-gene and skin cancer have not been done for non-melanoma cancers but it is a project which may be worth doing. It must be stated that melanomas are very infrequent in albinos of any type.

Patients with vitiligo can get skin cancer of any type in their normal skin but there is a paucity of reports of non-melanoma skin cancer in the white skin. This observation is particularly puzzling because the treatments for vitiligo include both ultraviolet B and psoralen-ultraviolet A (PUVA), both carcinogenic forms of light. Of interest is a recent report in which the incidence of skin cancer was studied in a cohort of 477 vitiligo patients. Half of these were Caucasians and the other half were dark skinned (Fitzpatrick skin types IV, V, VI). There with six patients with skin cancers, all with light colored skin (Fitzpatrick types I, II, III). Four of the six occurred in normal skin and only two affected the depigmented skin. Several points are worth noting. No individuals with type IV skin or darker had a skin cancer. Depigmented skin is of the same color in individuals of all ethnic backgrounds, i.e., totally white. One would expect that the cancers affected individuals of all skin color equally. The other point is that the cancers were most common (four of the six) in the normally pigmented skin. One would expect a majority to be in the depigmented skin. This is consistent with the idea that vitiligo skin is resistant to formation of skin cancers.

It is of note that actinic damage also is less visible in white skin than in the pigmented skin of those with vitiligo . Several studies on patients with vitiligo treated with PUVA showed no increase in skin cancer incidence. In contrast, albinos exhibit sun damage from early childhood. Some white skin caused by the absence of melanocytes from other causes seems susceptible to carcinogenesis. Thermal scars or depigmented skin of patients with discoid lupus are susceptible to formation of cancers. Of particular interest are patients with piebaldism caused by defects in the c-kit oncogene. As noted above, piebald skin reacts differently from normally pigmented skin to a graft versus host immune reaction. In my own series of three families with piebaldism, actinic damage is common and seems to have a predilection for the white skin rather than the pigmented normal skin . This seems to be the reverse of our observations for vitiligo skin. That the melanocytes have some role in inflammation, carcinogenesis and other processes seems probable.

The neck of an African woman who had vitiligo for over 20 years. She was a farmer and worked in the sun daily. Note the elastosis of the neck, but the normal overlying white epidermis

The hands of the African woman shown in Figure 19, who had vitiligo for over 20 years. She was a farmer and worked in the sun daily

The arms of a woman with piebaldism (c-kit). She has marked sun damage and many actinic keratoses, mostly in the depigmented patches on her arms

There is no doubt that skin color and susceptibility to skin cancer are related. Lighter skin has a high propensity for all forms of skin cancer compared to darker skin. It has been enigmatic to me that my students from Asia, China, Korea and Japan have a skin color not that much darker than mine with a European ancestry (Swedish and Hungarian). Asians are not so pigmented as Africans, Indians or Middle Easterners. Yet, their risk for skin cancers is low. My conclusion is that skin color is just one factor related to skin cancer risk. Other factors related to repair of damage, resistance to mutation and/or other factors play as big or bigger role in defense against skin cancer as skin color. This point is made clear, especially from the data on vitiligo and albino patients and skin cancer and the types of skin cancer identified in albinos, mostly squamous cell carcinomas. Why don′t albinos get more basal cell carcinomas and/or melanomas?

Finally, it is well known among those who are interested in vitiligo that treatment is difficult and frustrating. Some of the areas of depigmentation are especially difficult to repigment, such as the hands and feet. It seems mysterious to many. However, it has been shown that the hair follicle is the reservoir for repigmentation. Nature, for reasons not clear, evolved skin on the fingers, ventral surface of the wrist, the feet and genitalia that is hairless, i.e., glabrous. Such skin or skin with white hairs cannot respond to medical treatment 23] but only to surgical treatments which are a means to make a reservoir where there was none.

The leg shows repigmentation from the hair follicles

The leg has all white hairs and no repigmentation is visible except in one spot (arrows and circle)

Clearly, these are the musings of an old person thinking over the decades about vitiligo. Most of the interest by investigators is focused on an immune basis for melanocyte destruction. These studies are important to understand the cause of vitiligo. Little has been done to study the defects in the melanocytes which make them susceptible to destruction. There is so little interest in the melanocyte as a member of the inflammatory response because the prevalent bias about the melanocyte is that it is exclusively a protection against sun damage, a role it plays as part of a much larger function in the skin. There must be an important message in the fact that skin cancer is unusual in vitiligo skin but common in albino skin, the obvious difference being the presence of dysfunctional melanocytes in the latter patients. It is my hope that a younger student will not only study these phenomena and find the causes of vitiligo but also find the answer to other important questions about the epidermis and pigmentation.

Patients with at least one comorbid autoimmune disease tended to have more extensive vitiligo, compared with those who had no comorbid autoimmune disease.

“This builds on the theory pointing to an autoimmune pathogenesis for vitiligo,” Dr. Hamzavi says. “Most patients with vitiligo will not develop autoimmune disease, but a significant minority will develop hypothyroidism. Patients with vitiligo should be regularly screened yearly for thyroid disorders.”

“Also the rates of other autoimmune diseases like alopecia areata, inflammatory bowel disease, Guillain Barre, SLE (lupus), and others were observed at a much higher rate than one would expect,” Dr. Hamzavi says. “Patients should be asked if they have symptoms of these diseases when evaluated by their physicians.”

“We need better treatments for vitiligo which target the cause of the disease,” Dr. Hamzavi adds. “We hope that this work can be used by patients, physicians and researchers toward that end.”

“Prospective studies of vitiligo with a control group are needed to confirm the significance of our findings and may help uncover the sequence of development of these conditions,” the authors conclude.

Dr. Katia Boniface from Universite de Bordeaux in France, who was not involved in the new work, has studied the immune mechanisms of vitiligo. She told Reuters Health by email, “It is an interesting clinical study supporting previous findings demonstrating that an important proportion of vitiligo patients display at least one other comorbid autoimmune disease, in favor of the autoimmune theory to explain melanocyte disappearance in this disease.”

Understanding the symptoms of vitiligo

The American Academy of Dermatology (AAD) describe vitiligo as “more than a cosmetic problem.” It is a health issue that needs medical attention.

A number of remedies can help decrease the visibility of the condition.

Using sunscreen

The AAD recommend using a sunscreen, because the lighter patches of skin are especially sensitive to sunlight and they can burn easily. A dermatologist can advise on a suitable type.

Phototherapy with UVB light

Exposure to ultraviolet B (UVB) lamps is a common treatment option. Home treatment requires a small lamp and allows for daily use, which is more effective.

If the treatment is done in a clinic, this will need 2 to 3 visits a week and the treatment time will be longer.

If there are white spots across large areas of the body, UVB phototherapy may be used. This involves full-body treatment. It is done in a hospital.

UVB phototherapy, combined with other treatments, can have a positive effect on vitiligo. However, the result is not totally predictable, and there is still no treatment that will fully re-pigment the skin.

Phototherapy with UVA light

UVA treatment is usually conducted in a health care setting. First, the patient takes a drug that increases the skin’s sensitivity to UV light. Then, in a series of treatments, the affected skin is exposed to high doses of UVA light.

Progress will be evident after 6 to 12 months of twice-weekly sessions.

In cases of mild vitiligo, the patient can camouflage some of the white patches with colored, cosmetic creams and makeup. They should select tones that best match their skin features.

If creams and makeup are correctly applied, they can last 12 to 18 hours on the face and up to 96 hours for the rest of the body. Most topical applications are waterproof.

Depigmenting

Share on PinterestA range of treatments are available for vitiligo, although many people choose not to treat it.

When the affected area is widespread, covering 50 percent of the body or more, depigmentation can be an option. This reduces the skin color in unaffected parts to match the whiter areas.

Depigmentation is achieved by applying strong topical lotions or ointments, such as monobenzone, mequinol, or hydroquinone.

The treatment is permanent, but it can make the skin more fragile. Long exposure to the sun must be avoided. Depigmentation can take 12 to 14 months, depending on factors such as the depth of the original skin tone.

Corticosteroid ointments are creams containing steroids. Some studies have concluded that applying topical corticosteroids to the white patches can stop the spread. Others have reported total restoration of the original skin color. Corticosteroids should never be used on the face.

If there is some improvement after a month, the treatment should be paused for a couple of weeks before starting it again.

If there is no improvement after a month, or if side effects occur, treatment should stop.

Calcipotriene (Dovonex)

Calcipotriene is a form of vitamin D used as a topical ointment. It may be used with corticosteroids or light treatment. Side effects include rashes, dry skin, and itching.

Drugs affecting the immune system

Ointments containing tacrolimus or pimecrolimus, drugs known as calcineurin inhibitors, can help with smaller patches of depigmentation. However, the United States (U.S.) Food and Drug Administration (FDA) warn of a connection between these drugs and skin cancer and lymphoma.

Psoralen

Psoralen may be used with UVA or UVB light therapy, as it makes the skin more susceptible to UV light. As the skin heals, a more normal coloration sometimes returns. Treatment may need to be repeated two or three times a week for 6 to 12 months.

Psoralen increases the risk of sunburn and skin damage, and therefore also skin cancer in the long term. It is not recommended for children under 10 years.

In a skin graft, a surgeon carefully removes healthy patches of pigmented skin and uses them to cover affected areas.

This procedure is not very common, because it takes time and can result in scarring in the area where the skin came from and the area where it is placed.

Blister grafting involves producing a blister on normal skin using suction. The top of the blister is then removed and placed on an area where pigment has been lost. There is a lower risk of scarring.

Tattooing

Surgery is used to implant pigment into the skin. It works best around the lips, especially in people with darker skin.

Drawbacks can include difficulty matching the color of skin and the fact that tattoos fade but do not tan. Sometimes, skin damage caused by tattooing can trigger another patch of vitiligo.

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Whether fair, dark, or any shade in between, most kids have skin that is generally the same color all over their body. But this isn’t the case for those with vitiligo.

Vitiligo is a loss of skin pigment, or color, that causes white spots or patches to appear on the skin. No one knows exactly why this happens, but we do know it affects people of both sexes and all races. In the United States alone, an estimated 1 to 2 million people have the condition, and more than half of them are kids and teens.

The good news is that vitiligo — upsetting as it can be to those who are living with it — isn’t medically dangerous. It’s not a form of skin cancer, it’s not an infection like MRSA, and it’s definitely not contagious. In fact, most kids who have it are every bit as healthy as everyone else.

About Vitiligo

Vitiligo (vih-tih-LY-go) is a skin disorder that affects the melanocytes, cells deep within the epidermis (the outermost layer of the skin) whose function is to produce melanin. Melanin is the pigment that gives skin its color and helps protect it from the sun.

Our skin color is determined not by how many melanocytes we have (we’re all born with a similar amount), but rather by how active they are. Dark-skinned people have cells that naturally produce a lot of melanin, while light-skinned people produce much less.

Sometimes, though, skin cells suddenly stop producing melanin. At first, this might cause a spot, called a macule, whose color is much lighter than the skin around it. But in time these light patches may spread and grow to cover a larger portion of the body. Sometimes the spread happens quickly, and then remains stable for a number of years; other times it happens slowly, over a longer period of time.

Dermatologists label the types of vitiligo according to the amount and location of the patches:

  • focal vitiligo happens when there are just a few spots in a single area
  • generalized vitiligo is associated with many spots all over the body that tend to be symmetrical (they affect the right and left sides of the body like a mirror image). This is the most common form of the condition.
  • segmental vitiligo is characterized by spots only on one side of the body and usually nowhere else. This type of vitiligo is relatively uncommon.

Although vitiligo can appear anywhere on the body, it’s more likely to happen in:

  • areas that are exposed to the sun, such as the face or hands
  • skin that has folds, such as the elbows, knees, or groin
  • skin around orifices (body openings), such as the eyes, nostrils, belly button, and genital area

Although kids of all races are affected equally, spots tend to be more visible on those with darker skin.

Sometimes kids with vitiligo have other symptoms, such as premature graying of the hair or a loss of pigment on the lips, since pigment cells are found in these places, too.

Causes

Theories vary on what causes vitiligo. Some experts think it is an autoimmune disorder (in which the immune system mistakenly attacks healthy melanocytes). Others think it is a genetic condition, since over 30% of affected kids have a family member who also has it.

What is known is that the risk of developing vitiligo increases in kids with a family or personal history of thyroid disease, diabetes, and certain conditions like alopecia (an autoimmune disease that causes hair loss). And vitiligo is never contagious — kids can’t “catch” it from someone else.

Diagnosis

A dermatologist usually can make a diagnosis of vitiligo just by looking for the telltale white patches on the skin. On kids with very fair skin, a special tool called a Woods lamp might be used. This lamp uses ultraviolet light in a dark room to illuminate areas of affected skin that would otherwise be hard to see with the naked eye.

The doctor will also ask lots of questions about your child’s medical history, including whether anyone in the family has had skin conditions or autoimmune problems in the past; whether your child recently has had a rash or sunburn; or whether he or she has had any other illnesses or been under stress. A blood test may be done to check for thyroid problems and diabetes, as these can increase the risk of vitiligo.

Very rarely, the doctor may do a biopsy (where a small piece of the affected skin is removed to be analyzed in the lab). A biopsy lets the doctor check for pigment cells in the skin. If the biopsy shows there are no pigment cells, this may confirm a case of vitiligo.

Treatment

There is no “cure” for vitiligo. Some patches will clear up without treatment. For those that don’t, treatments can help to even out the skin tone. You can try some at home; others require treatment by a doctor. Just remember that results can vary — what works for one person may not work for another, and no treatment is likely to be 100% effective at making the spots disappear.

Here are ways to help if your child has vitiligo:

  • Sunscreen. One of the most important things your child can do is wear sunscreen every day to protect against skin cancer. And because vitiligo spots can’t tan (they have no melanin), they may burn and scar. Getting a tan on the rest of the body will only highlight white patches even more, especially if a child has light skin.
  • Cosmetics. Different kinds of over-the-counter concealers are available. Ask your doctor for recommendations and try different brands until you find the one that works best for your child.
  • Corticosteroid creams. Corticosteroids are a type of medication which, when applied to white patches very early in the disease, may help to “repigment” the skin. They reduce the inflammation that causes a loss of pigment so that pigmented cells can return to the skin. Some non-steroidal creams also produce a similar effect.
  • Photochemotherapy with ultraviolet A (also known as PUVA). PUVA has two steps: first, a medicine called psoralen is either applied to the white patches of skin or taken orally; then, the skin is exposed to ultraviolet light, sometimes from the sun but usually from an artificial source, like a UVA lamp. This turns the affected skin pink, which in time tends to fade to a more natural (often slightly darker) color. There are side effects, which may include severe sunburn and skin blistering. Other side effects may be more serious, so talk to your doctor about the risks involved.
  • Narrow-band ultraviolet B (UVB) therapy. This treatment is more widely used than PUVA. It’s similar to PUVA, except that the ultraviolet light used is UVB instead of UVA. Also, no psoralen is required beforehand, which eliminates some of the side effects.

Researchers are also looking into a new procedure called a melanocyte transplant. It works by removing a sample of normally pigmented skin and using it to grow new melanocytes in the lab. These can then be transplanted back into the depigmented skin to return some of the missing color.

When deciding which, if any, treatment to try, be wary of quick-fix “miracle” remedies you might see advertised. If it seems too good to be true, it probably is. Always work with your child’s doctor to help you decide what’s best for your son or daughter.

Dealing With the Emotional Impact

If your child has vitiligo, you know that even though it isn’t dangerous to his or her physical health, it can still be a big deal. Any condition that makes kids look different from their peers can be emotionally tough, especially during the preteen and teen years when everyone’s trying so hard to fit in.

Some kids are naturally more resilient and do just fine against these challenges. But others need a bit more help. As a parent you can do a lot to arm your child with confidence and self-esteem. Here are a few tips:

  • Don’t focus on the vitiligo or put pressure on your child to cover it up. He or she needs to know your love and acceptance are unconditional.
  • Remind your child of all the things at which he or she excels — and how they have nothing to do with skin color.
  • Teach your child to be comfortable explaining what vitiligo is — and isn’t — to other kids. Once the mystery is taken away, most kids will stop staring and asking questions.
  • Encourage your child to say yes to play dates, pool parties, trips, and any other experiences he or she might be tempted to pass on because of the vitiligo.
  • Urge your son or daughter to volunteer or get involved in the community. Giving back makes kids feel powerful.

Finally, get emotional support if your child needs it — especially if you see any signs of withdrawal, depression, or anxiety. Counselors, therapists, and vitiligo support groups can help.

Reviewed by: Patrice Hyde, MD Date reviewed: August 2016

3 Vitiligo Symptoms to Watch For—Other Than White Patches of Skin

The skin condition vitiligo causes people to lose pigment in patches of skin in different areas of their body. In many cases, these light or white areas of skin are the only symptom of vitiligo.

“There’s a complete loss of pigment,” Henry W. Lim, MD, former chair of dermatology at Henry Ford Hospital in Detroit, tells Health. “In patients with fair skin, it’s not going to be all that noticeable, but with dark skin it’s very noticeable—and it can be quite bothersome.”

But vitiligo can affect more than just your skin. Other vitiligo symptoms include:

  • Premature whitening or graying of your hair, eyelashes, and eyebrows
  • Whitening on the inside of your mouth and nose
  • Lightening of the retina of your eye

The bleaching is caused by destruction of melanocytes, the cells that produce melanin, which is the pigment that gives your skin and hair its color. No one knows exactly why the cells stop working, but experts believe it’s often related to autoimmunity. That’s when your immune system turns on your body’s own tissue and starts destroying it.

Many people with vitiligo also have other autoimmune diseases, commonly autoimmune thyroid disease, says Daniel J. Aires, MD, director of dermatology at the University of Kansas Health System in Kansas City.

RELATED: 5 Things That Might Cause Vitiligo

Early on, the symptoms of vitiligo begin gradually. Areas affected by vitiligo “are lighter than the surrounding skin,” says Dr. Lim, who is also a past president of the American Academy of Dermatology, “and as time goes by, it will become white.” The lighter-colored patches start as small, round areas that grow into different and bigger sizes. The centers of the patches may be white with your normal skin color around them. The borders are sometimes smooth and sometimes ragged.

How fast vitiligo progresses (and which parts of the body it affects) is highly individual. Although vitiligo symptoms can appear on any part of the body, the white patches often start on areas that have been exposed to a lot of sun—aka your hands, feet, arms, face, and lips. But signs of vitiligo can also appear on your neck, elbows, armpits, knees, and even your genitals, and once the spots appear, they almost never go away.

Very occasionally, says Dr. Lim, some people may have another vitiligo symptom: itchiness.

RELATED: How These 7 Women With Vitiligo Are Embracing Their Skin

Vitiligo symptoms also vary depending on which type you have. There are two main kinds of vitiligo: segmental, which is limited or localized, and non-segmental, which is more widespread. “Vitiligo can cover a very small percentage of the body’s surface, or it can be widespread and affect multiple different regions,” says Dr. Aires.

Almost all cases of vitiligo are non-segmental vitiligo. Usually the symptoms appear symmetrically on both sides of your body. The arms, backs of hands, elbows, knees, feet, and areas around body openings (like the eyes) are frequent locations for non-segmental vitiligo signs. “It does have a predilection for the orofacial area—eyes, nose, around the mouth,” says Dr. Aires.

With segmental vitiligo, the light patches of skin only appear on one segment of your body. But even if the vitiligo only covers a small percentage of your skin, if it’s on your face or another visible area, it can be hugely distressing.

Rarely, people have a third type of vitiligo—universal or complete vitiligo—which affects the whole body.

No matter the type of vitiligo you have, the disease can be active (meaning it is still spreading or growing) or stable (meaning there’s been no change in the course of a year). If you’re noticing any signs and symptoms of vitiligo, it’s worth bringing it up with a doctor. “I personally think if you have a loss of pigment,” says Dr. Aires, “it’s not a bad idea to see a health care provider.”

Get more on skin conditions here.

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