Vitiligo Explained

Why the loss of colour shouldn’t mean loss of confidence

Of the many skin conditions which could affect any of us, few cause anxiety as Vitiligo(vit-ih-LIE-go). However, it is important to note that the condition is nothing but harmless discolouration of the skin, which usually gets bigger with time. The condition can affect the skin of any part of the body, including hair and the inside of the mouth. It would be helpful to gain a closer understanding to dispel some of the myths and fears surrounding vitiligo and arrive at a realistic acceptance of the condition.

What is Vitiligo?

Vitiligo is a long term auto-immune disease in which the skin loses its normal colour resulting in depigmentation and pale white patches. Additionally, the hair in these regions also loses pigment and turns white. This could occur anywhere on the body, and most people with vitiligo have white patches in multiple areas.  Vitiligo can be localized to a few body areas or generalized as a widely distributed loss of colour, but the size and the number of patches can vary from person to person. The onset of vitiligo happens in the early mid-twenties before the age of 30 though it can appear at any age and tends to progress over time with larger areas of the skin losing pigment.

Vitiligo is classified into two main types:  segmental and non-segmental. Most cases are non-segmental, affecting both body sides, and typically increase in coverage over time. About 10% of cases are segmental, meaning they mostly involve one side of the body and do not typically grow with time.  Segmental vitiligo is far more prevalent in the teenage years.

The following are the types of vitiligo, and they affect different parts of the body,

• Universal vitiligo can affect nearly all skin surfaces
• Generalized vitiligo is the most common type of vitiligo, which can affect many parts of the body leading to symmetrical progress of the discoloration of the patches
• Segmental vitiligo is when only a side or part of the body is affected. It tends to happen at a younger age, progress for a year or two, and then stop.
• Focal or localized vitiligo is when one or only a few areas of the body are affected.
• Acrofacial vitiligo affects the skin on the face and the hands and around body openings like the eyes, the nose, and the eyes.

It’s difficult to predict how this disease will progress. Sometimes the patches remain stable in some cases, or stop forming without treatment and improve in others. Pigment loss spreads and eventually involves most of the skin in most cases. Occasionally, the skin gets its color back.

How Does Vitiligo Occur?

Hair and skin colour are determined by melanin. Our skin normally contains melanocytes, or pigment cells, which are more or less evenly distributed and produce the melanin that gives the skin its characteristic colour. In vitiligo, melanocytes are destroyed, resulting in the loss of colour, leaving the area white.

What causes vitiligo?

The exact cause of vitiligo is not known. Some attribute it to the lack of melanin, which is the pigment in the skin. Medical research has not yet put the finger on what precisely sets off the destruction of melanocytes. However, multiple theories exist – a prominent one being that it is an autoimmune disease. In this case, your body’s immune system mistakenly attacks some part of your body, setting out to destroy the melanocytes.

It is believed that some individuals happen to be genetically more susceptible to autoimmune diseases, which could then be triggered by environmental factors.

“Am I at risk for vitiligo?”

Globally, about 1% of people are affected by vitiligo.  In most cases, vitiligo develops early in life, between the ages of 10 and 30 years.  Ninety-five percent of those affected will develop it before 40.   Vitiligo doesn’t discriminate by gender or by race, can affect any skin type, and is more noticeable in people with darker skin. While vitiligo is not contagious or life-threatening, it can be a constant source of anxiety and stress for those afflicted in terms of self-image and self-esteem.

Risk factors include the presence of an autoimmune disease, such as thyroid disease (hyper and hypothyroidism), alopecia areata, or pernicious anemia. Family history is a factor, too, although it does not follow that children of a parent with vitiligo will necessarily develop it.

Vitiligo can affect any part of your skin, but mostly, it happens on the face, neck, hands, and in skin creases.

Pale areas of the skin are typically vulnerable to sunburn, and vitiligo commonly affects sun-exposed areas, body folds (such as armpits), previous sites of injury, areas around moles, or areas around body openings.  Vitiligo can also affect the eyelids, hair, and mucous lining inside the mouth and nose.

Symptoms of vitiligo

Symptoms often include rapid pigment loss on several areas of the skin, especially the hands, face, and any area around body openings and the genitals. There is also premature graying of the hair on the scalp, eyelashes, eyebrows, or beard. There is a loss of colour in the tissues that line the inside of the mouth and nose. A stable period may follow without any progression of the condition. Later on, further cycles of pigment loss and stability may be observed. Typically, both sides of the body are involved.  It is rare for melanin pigment to spontaneously return once the white patches have developed.

Clinical diagnosis of vitiligo is initially made by physical examination and confirmed by histo-pathological examination of a skin biopsy.

Not all cases of pigmentation loss are instances of vitiligo. Differential diagnosis includes multiple skin conditions with similar symptoms.

How is vitiligo treated?

Vitiligo has no cure. The goal of vitiligo treatment may restore colour to the affected skin and create a uniform skin tone, but it cannot and does not prevent any further progress of the condition or a recurrence. There is no known way to prevent or arrest the process of melanocyte destruction and pigmentation loss. However, several methods can be used to improve the appearance of skin severely affected by vitiligo, including topical corticosteroid and calcineurin inhibitors to darken the light patches, camouflage therapy,  re-pigmentation using ultraviolet light therapy, and skin grafting, which is a form of surgery. At a non-clinical level, skin camouflage with make-up and other cosmetics is always available. For those with light skin, sunscreen and makeup can be all that is typically recommended. A combination of treatments generally has better outcomes, including counseling.

Another approach is to even out skin tone by depigmenting unaffected skin areas with hydroquinone to lighten them. A permanent and vigorous removal of all the skin pigment can be achieved with monobenzone.  Sun safety must be adhered to for life to avoid severe sunburn and melanomas.  Depigmentation takes about a year to complete. Yes, this is what Michael Jackson underwent.

New biological treatments are currently under investigation and look promising.  Janus kinase inhibitors are emerging as a potential treatment option for alopecia areata, eczema, and vitiligo.  However, they have not yet been approved for use in dermatologic conditions.

While, as dermatologists and skin specialists, we do our best to intervene and manage the visual appearance of vitiligo, we have observed that there is no better approach than confidence, information about the condition, and a realistic approach to take vitiligo for what it is: a pigmentation condition that is not infectious and does no harm whatsoever. In fact, in the world of fashion, some models with vitiligo, like Winnie Harlow, are flaunting it beautifully. And so should everyone else.