Vitiligo is a chronic skin disease that presents with a change in skin pigmentation. It is characterized by the appearance of white patches on the epidermis , of variable size, due to the loss of melanocytes (the cells that produce melatonin). The causes are still unknown, but an autoimmune and genetic origin cannot be ruled out. Diagnosis is made with an objective examination of the affected areas and the most common treatments are based on the use of drugs and phototherapy . In severe cases, depigmentation or skin grafting can also be considered.
It can occur associated with other diseases, such as those related to the thyroid gland and diseases of the immune system . It affects about 1-2% of the world population, regardless of gender or ethnicity. It generally begins between the ages of 10 and 30, although it can occur at any time in life. The spots are permanent and treatments can only improve the appearance of the skin.
World Vitiligo Day is celebrated on 25 June.
What is Vitiligo
Vitiligo is a chronic skin disease whose causes are not yet known. It is a pigmentation disorder of the skin and / or mucous membranes due to a selective loss of melanocytes. The most accredited hypothesis is the autoimmune one . That is, it seems to be caused by an alteration of the immune system. The latter would mistakenly attack the cells (melanocytes) that produce the pigment (melanin) that gives the skin its natural color. This explains the presence of well circumscribed white spots (depigmented) on the epidermis.
Vitiligo is not painful, it is not contagious and it is not harmful to health. It can affect any area of the skin, although it most commonly occurs on the face, neck, hands, and skin folds .
The areas of the skin devoid of pigment (depigmented), are more vulnerable to sunlight, therefore, it is important to apply a cream with a very high protection factor when exposed to the sun.
The treatments are aimed at restoring the natural color of the skin. In fact, the aesthetic aspect caused by the disease can cause severe psycho-emotional discomfort.
A therapeutic approach can therefore support self-esteem and the resumption of a normal social life.
What melanin is and what it is used for
Melanin is the brownish pigment responsible for the color of the skin, hair and iris of the eyes. It is produced by cells called melanocytes . Hence, the color gradations of the skin depend on the amount of melanin produced.
Ultraviolet radiation, such as sunlight, stimulates the production of melanin. In fact, when the skin exposed to the sun is not protected, molecular signals are activated that trigger melanocytes, stimulating the formation of melanin. This mechanism protects the epidermis from damage from ultraviolet rays.
Melanin activating foods
- yellow melons
Vitiligo is the most common pigmentation disorder and affects approximately 1-2% of the world population, regardless of gender or ethnicity. Its incidence is quite variable: from 0.4% in Denmark, up to 8.8% in some regions of India.
In Italy, it is estimated that about 0.7-1% of the population is affected by vitiligo.
The age range in which it appears most frequently is between 10 and 30 years. However, onset before the age of 12 is documented in about 35% of cases. Development is generally gradual, although, in some cases, the course is rapid and then stops. The areas most commonly affected are those around the nose, mouth and eyes.
Vitiligo: what are the symptoms
Vitiligo symptoms are manifested by:
- very light spots on some areas of the skin
- hair, beard, eyelashes and eyebrows become prematurely white or gray (before age 35)
- tissues lining the inside of the mouth and nose (mucous membranes) appear depigmented
- loss, or change in color, of the membrane that lines the inner surface of the eye (retina).
The most affected areas are :
- contour of the mouth and eyes
- fingers and wrists
- back of hands
- genitals and anus
- navel and nipples
- inside of the mouth
The disease begins with the appearance of very light patches on the skin with the central area whiter than the surrounding area. The border can be smooth or irregular and surrounded by a darker area.
If there are blood vessels below the affected area, the patch may take on a slightly pink color.
However, Vitiligo develops differently from person to person. In some cases, the white spots are small and infrequent. Instead, in others they occupy large areas of the body. Sometimes the spots can itch and are usually permanent.
The psychological impact is particularly relevant in subjects with dark complexions.
Types of Vitiligo
Vitiligo is distinguished by the distribution of the spots. The two main types are:
- non-segmental vitiligo, also called bilateral or generalized vitiligo
- segmental vitiligo, also called unilateral or localized vitiligo.
It rarely involves the whole body. In this case it is called universal or complete vitiligo.
Non-segmental or bilateral vitiligo
This type of Vitiligo is the most common. The depigmented spots appear on both sides of the body symmetrically. They may affect:
- back of hands
- arms and elbows
- skin around the eyes, mouth, genitals and anus
- knees and feet.
Segmental or unilateral vitiligo
White spots affect only one area of the body.
It is less common than bilateral vitiligo and accounts for approximately 10% of all forms of vitiligo. It mostly occurs in children.
Generally, vitiligo begins between 10 and 15 years of age, however a “late” form is increasingly common , that is, which occurs after the age of 40. These forms are frequently bilateral and affect:
They respond well to therapy, but relapse is quite common.
Causes and risk factors
The main cause is the lack of a pigment, melanin , which gives the skin its natural color and is produced by cells called melanocytes . It is therefore the lack of melanin that causes the white (depigmented) spots on the skin.
The origin of the disease is still unknown, although autoimmune factors and / or a genetic predisposition seem to play a relevant role. However, it is not yet possible to hypothesize with certainty the elements capable of triggering or favoring the disease.
The immune hypothesis, that is a reaction of the immune system that, by mistake, attacks the cells of its own body, is supported by the presence, in about 20% of subjects affected by vitiligo, of other autoimmune diseases (such as autoimmune thyroiditis, pernicious anemia, type 1 diabetes mellitus and Addison’s disease).
Another hypothesis is oxidative stress and the accumulation of free radicals and hydrogen peroxide which could interfere with the production of melanin. In this case, vitiligo would be caused by metabolic or endocrine gland disorders caused by the low amount of an enzyme, tyrosinase , which neutralizes hydrogen peroxide.
Although a genetic predisposition is present in about 30% of cases, vitiligo is not a strictly hereditary disease. So it is not certain that the children of parents with this disorder will also develop the disease. However, it is equally true that this type of pathology is found more frequently if a family member is already affected by it.
Stressful events and other risk factors
Even if not validated, some theories associate the appearance of vitiligo with particular situations such as:
- stressful events (e.g. childbirth)
- damage to the skin (severe sunburn or cuts)
- exposure to certain chemicals (e.g. in the workplace).
Generally, many people with vitiligo or autoimmune diseases report that severe psychic trauma, such as death in the family, financial setback, divorce, or physical trauma (such as a car accident, surgery, childbirth, severe sunburn, etc.), precedes the onset or worsens the disease.
These testimonies therefore highlight the role of stress on the immune system. Many studies also show how those who experience chronic stress (emotional and / or physical) get sick more often, even cuts and wounds heal more slowly because the immune system is weakened.
However, at a scientific level it is not yet possible to confirm the responsibility of stress as a trigger of vitiligo and autoimmune diseases.
Although the causes are not known, there are cases of drug-induced vitiligo, but the mechanisms still remain unknown.
Among them are drugs that:
- activate cytotoxic T lymphocytes (a type of white blood cell) that fight melanocyte antigens
- damage sympathetic nervous system fibers (including skin nerves) connected to melanocytes by specific synapses
- have a direct toxic effect on melanocytes.
Vitiligo related medications are:
- anticonvulsants such as carbamazepine, valproic acid, clonazepam and fentoin
- antimalarials such as chloroquine and quinine
- Parkinson’s medications such as tolcapone and levodopa
- medicines for alopecia areata such as dipheniprone
- drugs such as interleukin-2, interleukin-4, interferons, etc.
Diagnosis is mainly based on observation of the affected areas and family history. In fact, it is necessary to ascertain:
familiar with vitiligo;
- familiarity with autoimmune diseases;
- presence of wounds, rashes and sun burns in the affected skin areas;
- how the skin reacts to the sun (tans or burns);
- any treatments in progress or already used;
- if the affected skin areas improve or worsen without treatment.
Blood tests are also usually ordered to check for other autoimmune diseases related to vitiligo and to check the function of the thyroid and pancreas.
Differential diagnosis is performed with respect to other skin diseases such as:
- post-inflammatory hypopigmentation;
- piebaldism (rare genetic disease);
- morphea (localized scleroderma);
- lichen sclerosus;
- pityriasis alba;
- chemical leukoderma;
- leucoderma cause of melanoma.
Named after the American physicist Robert W. Wood, who invented it in 1935, it is an ultraviolet (UV) lamp, which allows you to examine the skin more accurately. UV light, in fact, allows the doctor to distinguish patches due to vitiligo from those caused by other skin diseases (fungal or skin infections such as, for example, pityriasis versicolor from Malasseziafurfur, a yeast present on the skin surface).
The lamp uses ultraviolet radiation with a specific wavelength. When a substance is hit by this radiation, it emits a fluorescence, i.e. a luminescence, which is typical for each substance (for example white for vitiligo and yellow for fungal infections).
Therapeutic evaluation of vitiligo
At the moment there is no clinical evaluation index of the disease.
The vitiligo activity index or VAI is based on the signs of repigmentation or depigmentation of individual spots, assigning a score to highlight the progress of the disease.
This allows to evaluate the course of vitiligo and to formulate and modulate the therapy more quickly.
Vitiligo: cures and therapies
There is still no definitive cure for vitiligo and the spots are usually permanent, but there are remedies that improve the appearance of the skin and restore its original color.
In people with fair skin , if tanning is avoided, the vitiligo spots may be barely visible. And if they are small, they can be “camouflaged” with a covering cosmetic cream ( camouflage creams) .
However, by combining phototherapy (light treatment) and medication, the results are often encouraging. Although it is possible to improve the color of the skin, the effect has a limited duration and does not block the spread of the spots.
Topical corticosteroid drugs
These are drugs that are applied to the skin in the form of creams and ointments . In some cases, they can stop the spread of spots and restore the skin’s original color.
The dermatologist can prescribe them if:
- bilateral vitiligo is present in less than 10% of the body;
- sun protection and the use of covering creams are not enough;
- you are not pregnant;
- side effects are accepted.
Among the most used corticosteroids are:
- fluticasone propionate
- betamethasone valerate
- hydrocortisone butyrate.
However, you need to carefully follow the medical directions. After a month of treatment, the doctor will evaluate its effectiveness and any unwanted effects, defining the best therapeutic strategy.
Side effects of corticosteroids
Side effects of corticosteroid medications are:
- streaks on the skin;
- thinning of the skin (atrophy);
- appearance of visible blood vessels (telangiectasia);
- increased hair and hair growth (hypertrichosis);
- contact dermatitis (inflammation of the skin);
Pimecrolimus and tacrolimus for local use , are the immunosuppressive drugs normally used for the treatment of atopic eczema . But, they can also be prescribed to restore the natural color of the skin in adults and children with Vitiligo.
However they can cause side effects including:
- burning or painful sensation after applying them to the skin;
- increased sensitivity of the skin to sunlight;
- facial redness and skin irritation if you drink alcohol.
Unlike corticosteroids, they do not cause skin thinning but must be used under close medical supervision .
Phototherapy (light therapy)
It can be used if local treatments have not worked, vitiligo is widespread or has a significant impact on quality of life.
When combined with drug treatments, it appears to have an overall positive effect.
During phototherapy, the skin is exposed to ultraviolet A (UVA) or ultraviolet B (UVB) rays emitted by a particular lamp. In this way the production of melatonin is stimulated.
UVA light treatment can be combined with the application of psoralens on the affected areas. These are substances that make the skin more sensitive to UV rays, that is, they have a photosensitizing and pigmentogenic action.
However, it is a treatment to be performed for a limited time , under strict medical supervision, as it can increase the risk of skin cancer.
With this procedure, it is possible to partially obtain the re-pigmentation of the skin.
This is a procedure that involves taking a small patch of healthy skin from an area of the body to cover the area where the skin has been damaged.
This procedure may be considered for adults if:
- no new spots have appeared in the last 12 months;
- the spots have not worsened in the past 12 months;
- Vitiligo was not caused by skin damage such as severe sunburn.
An alternative technique, on the other hand, consists in taking a sample of skin from which to extract melanocytes, to transplant them on the areas affected by vitiligo.
However, it is a non-definitive cure and can produce scars. Therefore, it is not suitable for children.
Depigmentation or whitening
It is recommended for adults affected by vitiligo on more than 50% of the body. It consists in the bleaching of healthy skin using a hydroquinone-based drug that makes the skin the same color (white) as the depigmented skin, creating uniformity.
However, with depigmentation, the skin is left without any protection from sunlight.
Hydroquinone can cause side effects such as:
There is no scientific evidence to support the effectiveness of natural herbal remedies for relieving or preventing Vitiligo. Among other things, some herbs can interact with medications and make them less effective.
Burns from exposure to the sun are to be avoided in case of vitiligo.
In fact, it is necessary to safeguard the skin by using creams with very high protection factors (50 or higher) . When the skin is exposed to sunlight it produces a pigment, melanin, which serves to protect it from ultraviolet rays. If you are suffering from Vitiligo, melanin is missing and therefore the skin lacks its own natural defense.
Vitiligo and comorbidities
According to an American study published in the Journal of the American Academy of Dermatology , people with vitiligo are also often affected by other autoimmune diseases. Based on a sample of around 1,000 people, the researchers found that 19.8% had at least one autoimmune comorbidity, while 2.8% had more than one.
The two most common autoimmune diseases found are those affecting the thyroid gland (12.3% of patients) and alopecia areata (3.8% of patients).
Other autoimmune diseases found are:
- discoid lupus;
- Guillain-Barré syndrome;
- linear scleroderma;
- myasthenia gravis;
- Atopic dermatitis;
- pernicious anemia;
- Sjogren’s syndrome;
- systemic lupus erythematosus (SLE).
Women with vitiligo had a higher prevalence of comorbid thyroid disease than men (18.5% vs 5.1%; p <0.001), but no other relevant gender differences emerged.
Additionally, subjects with at least one autoimmune comorbidity tended to have more extensive vitiligo than those who did not have autoimmune diseases.
Hence, these data underline the need for a multidisciplinary approach to the disease.
Diet and Vitiligo
Diet is certainly important, but not essential. In fact, the disease has more or less the same incidence in different countries with different eating habits.
According to some research, the intestinal and cutaneous microbiota (the set of bacteria and fungi that inhabit the mucosa of our intestine and skin) play an important role in the development and treatment of vitiligo.
In fact, the microorganisms present in the intestine and in the skin perform functions necessary for the regulation of the immune system. The hypothesis is that these microorganisms induce an autoimmune response towards melanocytes triggering vitiligo. Since the gut microbiota is heavily influenced by diet, it is safe to assume that an improper diet can facilitate the autoimmune reaction.
In the case of vitiligo, the skin must therefore be protected by the sun , but the risk is a lack of vitamin D, an essential element for the health of bones and teeth. In fact, this vitamin is mostly synthesized by our body through exposure to sunlight. It is also contained in some foods, but the amount introduced with food may not be sufficient.
The use of supplements, therefore, could be beneficial.
Foods rich in vitamin D.
- Cod liver oil
- fatty fish
- milk and derivatives
Living with Vitiligo
Vitiligo is not an infectious disease and does not cause damage to the body.
However, it is more exposed to erythema and sunburn. But the most obvious consequence is on an aesthetic level. Vitiligo, in fact, changes the appearance of the skin, creating embarrassment and discomfort in social and work relationships.
The most relevant disorders are therefore on a psycho-emotional level, such as stress and shame. For this reason, it may be useful to undertake supportive psychotherapy.
- do blood tests once a year
- perform a specialist visit
- act promptly: the sooner you start, the less skin needs to be treated
- do not traumatize the skin with sun burns, chemicals, piercings, etc
- maintain a regular and healthy lifestyle
- keep stress under control
- correctly follow therapies with confidence and perseverance
- monitor the condition of the patches with your doctor
- do not change the therapy with the first improvements but always consult the referring doctor
- in case of skin recoloration, however, carry out checks once a year for 2 years.
From the Latin vitius (defect) or vitilius (calf, perhaps due to the light color of the calves), vitiligo is described for the first time in the fifteenth century BC in the Ebers papyrus, where it speaks of two diseases that cause the color of the skin. One could be leprosy, the other seems to be vitiligo.
From the same period, but in India, similar indications are also found in ancient Vedic texts such as the Atharva Veda.
For the treatment of these disorders, on the other hand, both in ancient Egypt and in India, psoralea corylifolia was used , which was applied on the white patches followed by sun exposure.
Even in ancient Greece there is talk of vitiligo. Herodotus in 400 BC writes that foreigners suffering from this disease must leave the country immediately because they have sinned against the sun.
Also in the Bible there are references to some skin disorders with the Hebrew word ” tzara ” (white spots). But it will be Celso, in his De Medicina, to distinguish vitiligo from other conditions, even if in the Middle Ages all skin diseases were then traced back to leprosy.
The definitive distinction of vitiligo as a specific pathology dates back to 1832 with the publication of the Monographie des dermatoses by Jean-Louis-Marc Alibert, which includes vitiligo in dermatoses and dyschromic disorders of the skin.
Famous people with vitiligo
- Andy Warhol
- Michael Jackson
- Kasia Smutniak
- Winnie Harlow.