Vitiligo

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What is Vitiligo?


The term Vitiligo refers to a skin condition presenting as white patches on the body.   The patches vary from a few millimetres to many centimetres in size. Significantly, there is no change in texture of the involved skin ie. the skin is not scaly, thickened or red.   Furthermore, there are no symptoms eg. itch, burning, stinging or pain.  The only sign of its existence is a visible change in colour.   Vitiligo cannot be felt.


How is Vitiligo caused?


In Vitiligo patches, there is a complete absence of melanocytes (pigment cells). The cause of Vitiligo is unknown. As in any condition where the cause is unknown, several theories exist. These include:


1.      The autoimmune hypothesis:  

The body's immune system destroys its own pigment cells.  It is thought that immune cells are manufactured to get rid of some unknown invading substance eg. a virus.  These immune cells confuse the body's pigment cells for the virus and destroy them (the pigment cells) instead. The actual trigger factor remains unknown. Support for this theory comes from the fact that Vitiligo is sometimes seen in association with other diseases in which there is over-active immunity eg. Anaemia, Diabetes and Thyroid disease.

2.      Neurogenic hypothesis:

Nerve endings release substances which destroy pigment cells.

3.      Self destruct theory of Lerner:

The pigment cells destroy themselves by releasing toxins.

 

Vitiligo is thought to be an inherited disease.   Forty per cent of affected individuals have a family history. The condition affects 1% of the world's population.

Vitiligo may start at any age although over 50% of individuals are below the age of 20 years. Any part of the body may be involved.   The Koebner phenomenon may sometimes be seen in Vitiligo.   In this situation, white patches develop at sites of injury eg. scratch marks.  Usually pigment cells in the upper part of the skin are involved (epidermis).  Occasionally, however, pigment cells in the deeper part of the skin, around the hair follicles (roots of the hair), may be involved, in which case emerging hairs appear white.


Spontaneous repigmentation is seen in 20% of patients with Vitiligo.  In the rest, the condition is gradually progressive.   However, with treatment, up to 80% can expect some improvement in their condition.  Treatment involves the stimulation of pigment cells around the hair follicles and their movement upwards into the epidermis. It can take up to three months before the effects of treatment is appreciated. The success of treatment is measured by the appearance of small pigmented spots around hair follicles within the white patch. These spots gradually enlarge and join up until the patch becomes completely covered.  It stands to reason that parts of the body not populated by hair follicles are difficult to treat eg. the lips, palms and soles, and the tips of the fingers.


How is Vitiligo treated?


1.  Topical corticosteroids:   These are applied followed by sun exposure for half an hour daily, ideally before 10am or after 3pm in order to avoid sunburn in the white patches.

2.  Photosensitisers:   Topical psoralens (applied form of the medication) or Eau de Cologne can be used to make the skin sensitive to sunlight.   Sun exposure following application stimulates repigmentation.  Blister formation is not uncommon with this type of treatment. 

3.  Oral trisoralens followed by Sun exposure. Tablets are taken followed by Sun exposure.  Blister formation is a common side effect.

4.  PUVA (Psoralens and Ultra Violet A light): A promising treatment utilising ingestion of Trisoralen tablets followed by exposure to Ultra Violet A light from a special UVA machine.   Special spectacles have to be worn during treatment and for 24 hours thereafter in order to protect the eyes from Ultra Violet damage. With this treatment, it could take up to six months to a year for successful re-pigmentation to occur, if treatment is administered once a week.









5.  Narrow band UVB:    Treatment with this machine does not require the ingestion of Psoralen capsules prior to exposure.  Although special goggles need to be worn whilst in the machine, no glasses have to be worn after treatment.  Treatment time is much shorter than with PUVA.  There is also no age limit with this machine and young children from the age of two months may be treated. 






6.  Bleaching:   If Vitiligo is very extensive, it is not unreasonable to depigment (remove pigment) from remaining pigmented areas using 20% Monobenzyl ether of Hydroquinone, making the entire skin surface white in colour. One has to consider this form of therapy very carefully, as pigment removal is permanent.

7.  Tattooing:  Ferrous oxide tattooing is offered in some centres to cover up areas of Vitiligo.  Colour mismatch is a potential problem with this method.

8.  Surgical methods involve the removal of skin from the normally pigmented parts of the body and inserting it into areas of pigment loss. Several surgical methods are currently performed for the treatment of Vitiligo.


     Suction blister grafting involves the creation of blisters on a donor site such as the thigh.  The upper layer of skin (epidermis) is removed from the Vitiligo area being treated.  The roof of the blister is then carefully removed and placed on the prepared Vitiligo area.  Pigment cells from the graft begin moving into the Vitiligo area within a week.  Re-pigmentation is usually complete within three months. 




Successful repigmentation following suction blister grafting one month after grafting.




·     Punch grafting is another popular surgical technique.  Tiny bits (1,5mm diameter) of full thickness skin are removed from a donor area such as the thighs, using a device called a biopsy punch.  At the same time, equal sizes of holes are made in the recipient area, about 0,5cm apart.  The puched out pieces of skin from the donor area are then transplanted into the recipient area.  About 30 grafts can be easily inserted at one sitting.  The process may be repeated to treat larger areas




A punch being used to remove vitligo skin from the hand,  in preparation for punch grafting from a donor site on the thigh.


    Needling


A novel surgical method of repigmentation of vitiligo skin takes the form of needling.  With this technique, the edges of the vitiligo patch are repeatedly needled using a 30 G needle.  The area is first prepared with EMLA - a local anaesthetic which is applied on the skin.  The treatment is perfomed weekly and combined with ultraviolet light either in the form of narrow band UVB or excimer laser/ excimer light.  There may be pin point bleeding which stops in a few minutes. 




·        Ultra-thin epidermal sheet grafts can be removed using an instrument called a             dermatome.  These sheets are transferred onto denuded Vitiligo areas.

·        Autologous cultured epidermal cell grafting is a technique where epidermis grown in the laboratory is grafted onto areas of pigment loss, after surgically removing the epidermis from the involved area.  With this technique, pigment cells are grown from skin obtained from a punch biopsy specimen usually behind the ear.   The facilities for culture however are expensive, available at few centres, and need technical support.

·        Non-cultured melanocyte rich epidermal cell suspensions may be made up from epidermis removed from a donor area.  These cells are grafted directly onto denuded epidermis in a Vitiligo area.

     The excimer laser is the most recent addition to the armamentarium of treatments for Vitiligo.  This laser emits light in the same spectrum as the narrow band UVB machine (308nm).  The number of treatments is shortened to about one third compared to narrow band UVB.  Areas like the eyelids can be treated in as few as 5 treatments.  This type of treatment is useful only for small areas of Vitiligo.





After 5 sessions of treatment with the excimer laser

© Dr N Raboobee 2008. 

 

10.  Topical Tacrolimus (Protopic) ointment has been recently launched in South Africa.  This preparation has been shown to be effective in the treatment of vitiligo.


Study with tacrolimus (J Am Acad Dermatol 2004;51:760-6)

57 paediatric patients treated with topical tacrolimus for 3 months
At least partial response seen in head and neck Vitiligo in 89% of the patients
and 63% in Vitiligo affecting the trunk and extremities
Tacrolimus was applied once or twice a day in 0,1 and 0,03%. No difference in response between different strengths but twice daily treatments did better than daily applications.

 

11.    Finally, one must not forget the benefits of using cosmetic camouflage creams to cover the white areas. This is a painless form of treatment and results in instantaneous improvement.  Camouflage creams could be used even while other forms of treatment are used.

 

Further resources


The Vitiligo Society of South Africa


The Vitiligo Society of South Africa has just been formed and will function under the umbrella of the Dermatological Society of South Africa.  The aim of this society is to offer support to Vitiligo sufferers and increase understanding of the condition.  Notices will be placed on this site once enrollment of members begins.   The web address of the Vitiligo Society is www.vitiligosociety.co.za


The National Vitiligo Foundation of USA


The National Vitiligo Foundation Inc. welcomes members from all parts of the world. Their address is: PO Box 6337, Tyler, Texas 75711, USA.   Their web address is:  http://www.nvfi.org/

Vitiligo Support - USA


The web address of the Vitiligo Support Group is http://www.Vitiligosupport.org/