25/06/2025
VITILIGO - CHALLENGES AND MANAGEMENT
By: Dr. Masroor Ahmad Wani, MD
E mail: masroorwani8@gmail.com
Vitiligo pronounced as vit-il-eye-go is a chronic autoimmune skin condition that causes the skin to lose its color or pigment. This causes the skin to appear lighter than the natural skin or turn completely white. Areas of skin that lose their pigment are called macule. . This happens usually when melanocytes – skin cells that make pigment – are affected and mostly destroyed, causing the skin to turn a white color.
History about Vitiligo
The Hebrew word "Tzaraath" from the Old Testament book of Leviticus approximately 1280 BC described a group of various skin diseases associated with white patches and a subsequent translation to Greek led to continued conflation of those with Vitiligo and leprosy.
Medical sources in the ancient world such as Hippocrates usually did not differentiate between Vitiligo and leprosy, often keeping these diseases in the same group. The name "Vitiligo" was first given by the famous Roman physician Aulus Cornelius Celsus in his classic medical text De Medicina.
Signs and Symptoms
The sign and symptom of Vitiligo is the presence of white patches which tend to occur on the extremities. Some people experience itching before a new patch appears. The patches are initially small, but often grow and change shape. When skin lesions occur, they are most prominent on the face, hands and wrists. The loss of skin pigmentation is particularly noticeable around body orifices, like mouth, around eyes and ge***alia. Some lesions may increase skin pigment around the edges. The persons affected by Vitiligo may experience sort of depression, frustration and anxiety.
Who is effected by Vitiligo?
Vitiligo affects all men and women equally. It’s more visible in people with darker or brown skin type. Although Vitiligo can develop in anyone at any age, macules or patches usually become apparent before age 30.A person might be at a higher risk of developing Vitiligo if having certain autoimmune conditions like: Addison’s disease, Diabetes, Psoriasis, Rheumatoid arthritis and Thyroid disease.
How does Vitiligo spread?
Vitiligo mostly starts with a small white macules or patches and then gradually spread over the body. Vitiligo typically begins on hands, forearms, feet and face, but can develop on any part of the body, including the mucous membranes and inner ears. Sometimes, larger patches continue to widen and spread, but they usually stay in the same place for years. Some people experience a few DE pigmented areas and other people experience a widespread loss of skin color.
Rate of Vitiligo worldwide
Vitiligo occurs in over 1% of the population throughout the world.
Is Vitiligo painful?
Vitiligo isn’t painful, however, one can get painful sunburns on lighter patches of skin affected by Vitiligo. It is necessary to protect against the sun with measures like using umbrella or sunscreen or wearing protective clothing.
Causes
Although many theories have been noticed about the Vitiligo but studies have shown that changes in the immune system are responsible for the condition. Vitiligo has been proposed to be a multifactorial disease with genetic and environmental factors both thought to play an important role. The National Institutes of Health states that sometimes an event, like a sunburn, emotional distress, or exposure to a chemical, can trigger or exacerbate the condition, Skin depigmentation in particular areas in Vitiligo can also be triggered by mechanical trauma: this is an example of the Koebner phenomenon. Unlike in other skin diseases, this can be caused by daily activities, especially chronic friction on particular areas of the body.
Autoimmune Associations
Vitiligo is sometimes associated with autoimmune and inflammatory diseases such as Hashimoto's thyroids, scleroderma, rheumatoid arthritis, Addison’s disease, type 1 diabetes mellitus, psoriasis, alopecia areata, systemic lupus erythematous, and celiac disease.
Pathophysiology
Melanocyte Destruction: studies have shown that the primary defect in Vitiligo is the loss or destruction of melanocytes in the skin. The mechanism behind this destruction is not clear but may involve autoimmune processes, where the immune system mistakenly may destroys melanocytes.
Diagnosis
Examination: A dermatologist can diagnose Vitiligo on clinical appearance and history. He/she will examine the skin and ask about the onset and progression of the patches. Wood’s Lamp examination can also help in deducting the Vitiligo. In some doubtful cases, a biopsy may be performed to rule out other conditions and confirm the loss of melanocytes.
Classification
Non-Segmental Vitiligo
In non-segmental Vitiligo, there is usually some form of symmetry in the location of the patches of depigmentation. New patches also appear over time and can be generalized over large portions of the body. Extreme cases of Vitiligo, to the extent that little pigmented skin remains, are referred to as Vitiligo universalis. Non segmental Vitiligo can come at any age .Non-segmental Vitiligo include the following:
Generalized Vitiligo is the most common type, mostly distributed areas of depigmentation2. Universal Vitiligo: Almost maximum part of body is affected with Vitiligo.3. Focal Vitiligo: one or a few scattered macules are seen in one area, children are seen, commonly affected.4. Acrofacial Vitiligo: Fingers and periorificial areas are seen affected with Vitiligo.
Segmental Vitiligo
Segmental Vitiligo differs in appearance, cause, and frequency of associated illnesses. Its treatment is different from that of Non segmental Vitiligo. This type of Vitiligo is unilateral and tends to affect areas of skin that are associated with dorsal roots from the spinal cord. Its association with autoimmune diseases appears to be weaker than that of generalized Vitiligo. Segmental Vitiligo usually does not improve with topical therapies, surgical treatments such as cellular grafting can be effective.
Other conditions look like Vitiligo:
Tinea versicolor: This fungal infection commonly seen on neck, chest, back and upper arm can sometimes create confusion. Albinism: This genetic condition means that have lower levels of melanin in the skin, hair and/or eyes. Pityriasis Alba: This condition starts with red and white scaly areas of skin, which fade into scaly lighter patches of skin, usually seen on face.
Is Vitiligo genetic?
There is evidence suggesting a genetic predisposition to Vitiligo triggers. Certain genes may increase susceptibility to the condition, although it often requires additional environmental. Research is ongoing and we learn more about the causes of Vitiligo, studies show that about 30% of Vitiligo cases are genetic which indicates that the condition is hereditary and one can potentially inherit Vitiligo from the biological family.
Is Vitiligo contagious?
Vitiligo isn’t contagious. It doesn’t spread from person to person through physical contact.
Psychological and Social Impact on Vitiligo patient
Vitiligo can have a significant impact on a person’s self-esteem and emotional health due to changes in appearance, thus mental health can be affected. Addressing the psychological aspect of the condition is crucial but often overlooked in treatment plans.
Support
Psychological support, family and friends support, counseling, and support groups can be beneficial for individuals coping with the social and emotional aspects of the condition.
Management
As we understand Vitiligo is a chronic condition and may fluctuate over time. Treatments aim to manage symptoms and improve appearance but may not completely cure the condition. Regular follow-ups with the concerned doctor can help manage the condition.
As we know, there is no complete cure for Vitiligo but several treatment options are available. The best treatment is application of topical steroids and ultraviolet light in combination .We must also know that due to the higher risks of skin cancer, the phototherapy be used only if primary treatments are ineffective. Lesions located on the hands, feet, and joints are the most difficult to repigment; those on the face are easiest to return to the natural skin color as the skin is thinner.
Tofacitinib newly discovered molecule used to treat the autoimmune conditions has shown promise as a treatment for Vitiligo. Clinical studies and trials have demonstrated that Tofacitinib can lead to significant repigmentation in some patients with Vitiligo. However, it's important to note that while the results are encouraging, the drug is still considered an off-label use for this condition, meaning it is not yet formally approved FDA, specifically for Vitiligo treatment.
Other treatment Options
Topical Corticosteroids: Often used to reduce inflammation and may help repigment the skin in some cases.
Topical Calcineurin Inhibitors: These can be used as an alternative to steroids, especially for sensitive areas.
Phototherapy: UVB light therapy can help stimulate melanocyte activity and repigmentation.
Systemic Medications: For more extensive or resistant cases, oral medications like levomisol tablet may be prescribed.
Surgical Options: Skin grafting or melanocyte transplantation might be considered for stable Vitiligo that does not respond to other treatments.
Phototherapy
Phototherapy is considered a second-line treatment for Vitiligo. Exposing the skin to light from UVB lamps is the most common treatment for Vitiligo. The treatments can be done at home or in clinic with an UVB lamp. The exposure time is managed so that the skin does not suffer overexposure. Treatment can take a few weeks or months if the spots are on the neck and face and if they existed not more than 3 years. If the spots are on the hands and legs and have been there for more than 3 years, it can take a few months.
Phototherapy sessions are done 2–3 times a week. Spots on a large area of the body may require full body treatment in a clinic or hospital. UVB broadband and narrowband lamps can be used, but narrowband ultraviolet peaked around 311 nm is the choice. It has been constitutively reported that a combination of UVB phototherapy with other topical treatments improves re-pigmentation. However, some people with Vitiligo may not see any changes to skin or re-pigmentation occurring. A serious potential side effect involves the risk of developing skin cancer, the same risk as an overexposure to natural sunlight.
Ultraviolet light (UVA) treatments are normally carried out in a hospital or clinic. Psoralen and ultraviolet A light (PUVA) treatment involves taking a drug that increases the skin's sensitivity to ultraviolet light, then exposing the skin to high doses of UVA light. Treatment is required twice a week for 6–12 months or longer. Because of the high doses of UVA and Psoralen, PUVA may cause side effects such as sunburn-type reactions.
Narrowband ultraviolet B (NBUVB) phototherapy has less side-effects caused by Psoralen and is as effective as PUVA. As with PUVA, treatment is carried out twice weekly in a clinic or at home, and there is no need to use Psoralen. Longer treatment is often recommended, and at least 6 months may be required for effects to phototherapy. NBUVB phototherapy appears better than PUVA therapy with the most effective response on the face and neck.
Skin Camouflage
In mild cases, Vitiligo patches can be hidden with makeup or other cosmetic camouflage solutions. If the affected person is pale-skinned, the patches can be made less visible by avoiding tanning of unaffected skin.
Biologics
Researchers are exploring biologic therapies, such as monoclonal antibodies that target specific immune system pathways. These treatments aim to modulate the immune response more precisely and reduce side effects.
Combination Therapies
Combining treatments, such as using JAK inhibitors with phototherapy, some herbal preparations has shown enhanced efficacy. This approach leverages the benefits of multiple treatment modalities to improve outcomes.
How do dermatologists treat Vitiligo in children?
Vitiligo can begin at any early age. This makes treatment options for children important. Many treatments described above are used to treat children. Before creating a treatment plan for the child, dermatologist thinks about the child’s age, how Vitiligo is spreading, other medical conditions the child has, and many other considerations
Counseling
People diagnosed with Vitiligo find counseling or visiting a professional psychologist beneficial to help improve their self-esteem or depression that can be associated with their skin conditions. Vitiligo can cause psychological distress and thus affects a person’s outlook.
DE Pigmenting
In cases of extensive Vitiligo the option to DE pigment the unaffected skin with topical drugs like monobenzone, may be considered to render the skin an even color. The removal of all the skin pigment with monobenzone is permanent. Sun-safety must be considered to for life to avoid severe sunburn and melanomas. Depigmentation takes near about a year to complete.
