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, tendons, etc.

The epidermis has three main types of cell.

• Basal cells. These are the bottom layer of cells in the epidermis.
• Keratinocytes. These cells are in layers above the basal layer. They make a substance called keratin which is a hard 'waxy' material. Keratinocytes are constantly dividing and a certain number are dying at any given time. The top 'horny' layer of the epidermis is made of dead keratinocytes which contain keratin. The top of the skin is constantly being shed and replaced by new dead cells which contain keratin.
• Melanocytes. These cells are dotted about at the bottom of the epidermis. They make a pigment called melanin. The melanin is passed to the nearby skin cells which colours the skin and protects them from the sun's rays. Melanin causes the skin to tan in fair skinned people. Dark skinned people have more active melanocytes. The melanocytes are stimulated when exposed to sunlight to make more melanin.

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. 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. 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. However, 2 in 3 affected people do not have other family members affected so it is not just an inherited problem.

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. Vitiligo is not infectious and you cannot 'catch' it from affected people.

Any area of skin can be affected. However, the most common sites involved are the face, neck, and scalp. Other common sites include the backs of hands, front of knees, and elbows. In the areas of the scalp that are affected, the hair too is affected. So, you may develop patches of hair with no colour - so the affected patches of hair look grey or white.

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 normally well. Vitiligo is not sore or itchy. However, the appearance of the skin can be distressing, particularly if the face or hands are affected.

Sunburn is a risk. There is no natural protection from the sun in affected areas of skin. Vitiligo skin burns much more easily than normal skin if exposed to sunlight.

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. However, many people prefer to do something to counter the problem. 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 cream 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 products available from pharmacies often called 'fake tans'. 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.

Treatments that aim to reverse the changes in the skin.

There is no once and for all 'cure' for vitiligo. However, some treatments have been shown to slow down the progression of the condition, 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. 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 when a patch of vitiligo first develops. It may prevent a smaller patch from getting bigger. Occasionally, skin colour may return over a treated area. However, steroid cream is usually only advised for a limited time as long-term use can cause side-effects.

Steroids work partly by suppressing the immune system. As one theory is that the melanocytes are destroyed by the immune system, this may explain why steroid creams may have some effect on improving the condition. (Steroid tablets such as prednisolone are sometimes used, but not often. There is a risk of serious side-effects from the long-term use of steroid tablets which is why they are not usually advised.)

Tacrolimus cream or ointment
This is a relatively new treatment. It has been used to treat eczema for a few years, but has also been shown to restore skin colour to some people with vitiligo. It seems to be most effective for vitiligo on he face. It works by suppressing cells of the immune system in the skin (which probably attack the melanocytes).

Currently, this treatment can only be prescribed by a skin specialist (a dermatologist). Although this treatment shows promise, further research needs to clarify just how good it is. For example, some research is being done to see if tacrolimus cream combined with Narrow Band UVB (see below) works even better. As with other treatments, it can take several months of treatment for improvement to be noticed on 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 works well in some people - perhaps in up to half of cases. However, it is very time consuming. Treatment is needed twice a week for 6-12 months or more.

PUVA may also cause side effects such as 'sunburn' type reactions or skin freckling. There is also an increased risk of skin cancer with this treatment. It is not normally advised for children. 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 that has recently been developed. 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. It seems to have good results.

Laser treatments
Newer types of laser treatments are being investigated.

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 sunblocks used for medical reasons such as for vitiligo are available on NHS prescription. However, dont rely mainly on sunblock. Try to cover affected areas of skin when the sun is strong. For example, by wearing a wide brimmed hat and long sleeved clothing.

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 than average. For example, thyroid problems and a type of anaemia called pernicious anaemia. Most people with vitiligo do not have these but your doctor may suggest a blood test to rule them out.

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: 0870 170 7000    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. Clinics are usually held in the Skin Departments of hospitals, in GP surgeries, or in British Red Cross Branch offices. A letter of referral from a GP or specialist is needed before an appointment can be made.

© EMIS and PIP 2005   Updated: September 2005