Vitiligo

Understanding the skin

To understand the cause of vitiligo, it is useful to have a basic understanding of the skin. The skin has two layers - the epidermis and the dermis. Beneath the dermis is a layer of fat, and then the deeper structures such as muscles and tendons.

What is vitiligo and what causes it?

Vitiligo is a condition where pale white patches develop on the skin. It is due to a lack of pigment (colour) in the affected areas of skin. Vitiligo does not make you feel ill. However, the appearance of vitiligo can be distressing. This is particularly so for darker skinned people where white patches are more noticeable.

Areas of skin with patches of vitiligo have no or very few melanocytes. The melanocytes are either damaged or destroyed in the body. Therefore, melanin cannot be made and the colour of the skin is lost. It is not known why the melanocytes go from affected areas of skin. They may be destroyed by the immune system or 'self-destruct' for reasons not yet known. It is thought to be an auto-immune condition. This means that the immune system (which normally protects the body from infections) mistakenly attacks itself.

Who gets vitiligo?

About 1 in 100 people develop vitiligo. Men and women are equally affected. It can develop at any age. However, it begins before the age of 20 in about half of cases. There is some genetic factor involved and vitiligo may 'run in the family'. About 1 in 3 affected people have some other family member who is also affected. Vitiligo is not infectious and you cannot 'catch' it from affected people. It is not more common in any racial or ethnic groups.

What areas of skin are affected with vitiligo?

How does vitiligo progress?

Small areas of milky white skin usually develop first. The contrast between the vitiligo skin and normal skin varies. In fair skinned people it may only be noticeable in summer when normal skin tans. The contrast is more noticeable in darker skinned people.

The course and severity of vitiligo varies from person to person. Sometimes a few small patches develop slowly and progress no further. Sometimes a number of patches develop quite quickly and then remain static for months or years without changing. However, it is quite common for the white patches to gradually become bigger and for more patches to appear on other parts of the body. Large areas of the skin may eventually be affected.

There is no way of predicting how much of the skin will eventually be affected when the first patch develops. The white patches are usually permanent. Rarely, some patches of vitiligo may re-pigment and return to normal.

What are the symptoms of vitiligo?

People with vitiligo are usually well. Vitiligo is not sore or itchy. However, the appearance of the skin can be distressing and embarrassing, particularly if the face or hands are affected. There is no natural protection from the sun in affected areas of skin. This means that skin affected by vitiligo burns much more easily than normal skin if exposed to sunlight.

What are the treatment options for vitiligo?

Although there is no cure for vitiligo, there are now many different treatments available which can slow down vitiligo and also improve it. Some people may not be concerned about the white patches of skin if they are in areas not noticeable to others. In fair-skinned people, avoiding tanning of normal skin can make patches of vitiligo much less noticeable. Treatment options generally fall into four groups:

• Skin camouflage - measures to cover or camouflage the affected skin.
• Treatments that aim to reverse the changes in the skin.
• Treatment to completely de-pigment the skin.
• Sunblock and other means to protect the pale skin.

Skin camouflage

Skin camouflage uses special coloured cover creams that are put on the white patches of vitiligo. Skin camouflage does not alter the disease but improves the skin's appearance. The aim is to find a colour to match the colour of your skin. Some special cover creams can be prescribed on the NHS. The creams can disguise vitiligo very well which may greatly increase self confidence. The British Red Cross provide a free Skin Camouflage Service (see below).

There are also self-tanning lotions available from pharmacies. These may also hide the vitiligo and can last several days before needing to be reapplied. However, they often do not provide an exact match for each skin colour. They may be most useful for large areas of vitiligo where matching the colour exactly to nearby skin is not needed so much. Fake tans can also be useful for areas where camouflage is less effective (for example the back of the hands).

Treatments that aim to reverse the changes in the skin

Some treatments have been shown to slow down the progression of vitiligo, and some treatments cause affected skin to regain pigment and colour in some cases. No single treatment for vitiligo works well in all cases. The response to the various treatments is variable and can depend on the type of vitiligo. Your doctor will advise on treatments that may be worth trying. The following just gives a brief overview of current treatment options.

Steroid cream

This is sometimes prescribed for a limited period of time (3-6 months) when a small patch of vitiligo first develops. It may prevent a smaller patch from getting bigger. Occasionally, skin colour may return over a treated area. Long-term use of steroid creams can cause side-effects which include thinning of the skin and stretch marks. Steroids work partly by suppressing the immune system (which probably attack the melanocytes).

Tacrolimus cream

This can be used as an alternative to steroid cream. It has been shown to restore skin colour to some people with vitiligo. It seems to be most effective for vitiligo on the face. Tacrolimus also works by suppressing cells of the immune system in the skin.

PUVA treatment

PUVA stands for Psoralen and Ultra Violet A light. It involves taking a special medicine (a psoralen) which makes the skin very sensitive to light. The skin is then treated with ultra violet A light (UVA) from a special machine in hospital. This treatment is very time consuming. Treatment is needed twice a week for 6-12 months or more. PUVA may cause side effects such as 'sunburn' type reactions or skin freckling. If colour does return to the white patches there is still a chance that it may go white again at a later stage.

Narrowband UVB phototherapy

This is another 'light' treatment which is now used more commonly than PUVA. It uses ultaviolet B light (UVB). As with PUVA, treatment is twice weekly but you do not need to take a medicine to sensitise the skin and the treatment sessions are much shorter. It is less damaging to the skin than PUVA.

Laser treatments

Laser treatment for vitiligo is currently not available under the NHS as it has not yet been shown to be an effective treatment in clinical trials.

Skin grafting

Grafting of normal skin to small patches of vitiligo has been tried. It is time consuming and not always successful or available.

Treatment to completely de-pigment the skin

In some people with extensive vitiligo a treatment may be considered to make the remaining normal areas of skin to go white. This makes all the skin an even white colour. This is done only after a full discussion with a specialist. The removal of all the skin pigment is permanent and it takes about a year to complete.

Sunblock

A high protection sun-block (factor 20 or above) should be applied to areas of vitiligo exposed to sunlight. Sunburn can easily occur if the skin is not protected. Some brands of sunblocks are available on NHS prescription. It is also important to cover affected areas of skin when the sun is strong, especially in the middle of the day. For example, by wearing a wide brimmed hat and long sleeved clothing.

Are there any complications of vitiligo?

Vitiligo itself does not develop into any other condition. However, other 'auto-immune' disorders (diseases caused by the immune system) are slightly more common in people with vitiligo. For example, thyroid problems, diabetes and pernicious anaemia. Most people with vitiligo do not have these but your doctor may suggest a blood test to rule them out.

Many people with vitiligo are embarrassed about their condition. This can lead to low self-esteem and even depression. Some people find that counselling can be beneficial.

Further help and information

Vitiligo Society

125 Kennington Road, London, SE11 6SF
Tel: 0800 018 2631 Web: www.vitiligosociety.org.uk
Includes information and support for people with vitiligo and their families.

Red Cross Skin Camouflage Service

British Red Cross Association, British Red Cross, 44 Moorfields, London, EC2Y 9AL
Tel: 0844 871 11 11 Web www.redcross.org.uk
Aims to teach how to apply camouflage creams effectively and to enable people to feel more confident about their appearance. The service is available nationally.