What is Vitiligo

Vitiligo is an acquired skin disorder where loss of melanocytes leads to localized white spots or patches on the skin(1) . Melanocytes are cells that produce melanin, which normally give the color on the skin. While the occurrence of vitiligo is irrespective of age or ethnicity, it is generally more noticeable in darker-skinned individuals due to the nature of the condition. 

Its prevalence is about 1-2 million people in the United States, and between 0.1% to 8% worldwide(2) . Of those affected, about half begin to see symptoms before 20 years of age. However, it may occur at any age and in any part of the body(3). 

There are two types of vitiligo(4):

1. Segmental vitiligo occurs in one area of the body. It generally begins at an early age and commonly affects hair color.

2. Non-segmental vitiligo often occurs symmetrically in both parts of the body, such as both arms or both legs. 

What are signs and symptoms of vitiligo?

The most notable sign of vitiligo is loss of color of the skin, also known as depigmentation. Many patients do not report any symptoms other than the loss of color. Rarely, patients may report itching, and even painful sensations of those areas(4).

Commonly affected areas of depigmentation include the following areas(2):

• Skin

• Areas with hair (scalp, eyebrow, eyelash, beard)

• Armpits and groins

And less commonly affected areas of depigmentation include the following areas(2):

• Eyes

• Nose

• Inside the mouth

• Belly button

What causes vitiligo?

Vitiligo occurs due to loss of melanocytes, which are cells that give color to our skin and hair. The specific cause is yet undetermined but there are many theories. A major theory is that it may be correlated to autoimmune diseases, especially for non-segmental vitiligo. Autoimmune diseases are conditions in which the patient’s immune system attacks its own cells of the body, mistaking it as foreign(5). 

It may also be a hereditary factor, in which a close blood relative diagnosed with vitiligo may predispose one to developing the condition. Additionally, there may be triggers, such as severe sun-exposure, pregnancy, skin trauma, or emotional stress that may instigate development(3). 

Another contributing factor to vitiligo may be oxidative stress, which may cause unwanted melanocyte degeneration(6). This mechanism is the target of the treatment option pseudocatalase cream, which has antioxidant and catalytic properties(7). Additionally, recent studies have explored the correlation of low vitamin D levels with autoimmune diseases in the setting of vitiligo(8). Vitamin D is beneficial in regulating immune cells in vitro. Therefore, there may be benefit to screen for vitamin D levels and considering supplementation if necessary.

How is vitiligo diagnosed?

When vitiligo is suspected, the physician will examine both family and medical history, perform a physical examination, and run tests before making a diagnosis(2). Atypical signs and symptoms may require additional assessment by the dermatologist(9). Also, a blood test will test thyroid function to consider if the patient has an autoimmune disease(10). 

What are treatment options for vitiligo?

There are several treatments options to consider for patients with vitiligo. The treatment choice depends on the number of white patches, how widespread they are, and on patient preference(2). 

Pseudocatalase Cosmetic Cream

Pseudocalatase is of high interest concerning treatment of vitiligo. Dr. Karin Schallreuter and her colleagues created this highly effective topical cream to reverse the effects of H2O2-induced oxidative stress plus low catalase levels(11). Results have shown that this narrow-band activated pseudocalatase cream works to decrease levels of H2O2, which allows time for repigmentation to occur. 

Topical corticosteroids (applied to skin)

Topical medications such as corticosteroids are considered first-line and/or added therapy(7). Studies have shown that corticosteroid use can decrease the loss of melanocytes and increase repopulation of these cells in order to increase color on the skin(7). Favorable results have been recorded especially in children for patches on the head and neck. If there is no response in 3 months, other therapy options should be pursued(12). 

Topical calcineurin inhibitors (applied to skin)

Topical calcineurin inhibitors have fewer side effects than corticosteroids but are also less efficacious. This medication functions by altering the level of immune response. It is an option for patients who cannot tolerate topical corticosteroids and can be used intermittently for long-term use for small areas of the body(7).

Oral corticosteroid (taken by mouth)

Oral corticosteroids may be helpful in pulse doses in conjunction with PUVA therapy (listed below). However, due to the prevalence of side effects especially from long-term use, it is not considered to be conventional therapy(7). Long-term side effects include insomnia, acne, agitation, menstrual disturbances, weight gain, and abnormal hair growth, among others(7). 

Psoralen + Ultraviolet A light (PUVA)

Both UVA and UVB phototherapy promote growth or melanocytes and inhibit autoimmunity. UVA phototherapy a FDA-approved treatment indicated for vitiligo, and is given with topical or oral psoralen to enhance response rates. Psoralen is a photosensitizer that becomes active under light exposure. Upon administration of topical or oral psoralen, the patient is exposed to UV light one to three times a week. Short-term side effects of this therapy include itching, nausea, headache, severe sunburn, and too much coloring of the skin(7).

Ultraviolet B light (UVB)

In the past decade, the development of UVB has been proven to be more clinically effective and have therefore increased in use. This therapy does not require psoralen, has no major known side effects, and can be utilized at home(12). However, there are no long-term studies of this treatment option to date. Treatment frequency is about two to three times weekly with an average duration of ten weeks to two years(7). 

Vitamin D analogs

There is a potential role that the lack of vitamin D may lead to autoimmune diseases, which may in turn increase the risk of vitiligo development(13). Considering this correlation, topical vitamin D3 analog (calcipotriene) has shown to be effective in achieving repigmentation, especially when added to topical corticosteroids or light therapy(14). It is a safe therapy for both children and adults(7). Oral supplementation may also be an added therapy option for those with low vitamin D levels. 

Depigmentation

Depigmentation is removing color from pigmented areas. This option is reasonable for patients who have vitiligo in majority of their body, because it requires fading the rest of the skin in order to match areas affected by vitiligo(12). This is achieved by topical medications such as hydroquinone and monobenzone, both of which are FDA-approved for vitiligo(7). 

Skin graft

When nonsurgical therapy options are unsuccessful, surgical treatment is a viable option(7). This procedure involves taking skin from one part of the body and attaching it to a part of the body affected by vitiligo(2). It is appropriate for patients who have vitiligo in small areas of the body. Complications of this procedure involve infection or scarring(15).

Blister graft

Blister grafting uses suction to create a blister and laser cut an appropriate size to transplant it to depigmented areas. Complications include scarring and lack of pigmentation, though the risk of scarring is lower compared to other graft procedures(15).

Tattoo

Tattooing can cosmetically cover up patches on the body by color matching(7). 

Other Treatments

Counseling and support

Vitiligo may decrease quality of life by lowering self-esteem and cause social stress due to lack of knowledge by peers(7). Psychotherapy, or cognitive behavioral therapy, consists of developing coping mechanisms to improve body image and self-esteem in order to improve quality of life(7). Preliminary results of a study have shown that it can also improve disease progression(16).