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Vitiligo

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What is Vitiligo?

Vitiligo is a human skin condition that turns patches of skin and hair white, and affects approximately 1% of the population. 

Vitiligo is not painful and does not have significant health consequences however, it can have emotional and psychological consequences.

Jon Hamm from TV’s Mad Men has it, as does model Chantelle Brown-Young on America’s Next Top Model.

Causes

Vitiligo is thought to be an autoimmune condition that affects males and females of all ages and races. Immune system cells usually fight infection but in vitiligo, a person’s own immune system cells start to attack the skin’s pigment cells (melanocytes).

The destruction of the pigment cells result in white spots on the skin and sometimes also the mucosa (lips and genitals) and hair, eyelashes and eyebrows.

It is not an infection, nor is it contagious, cancerous or caused by food. It is generally not passed down to children, and individuals that are affected are usually otherwise fit and healthy. 

Unfortunately, there is no way to determine if a person’s vitiligo will be progressive over time. The condition undoubtedly carries a significant psychological burden for many, which may impact on work, life and relationships. Education and increasing public awareness of vitiligo is the sure way to remedy this problem.



Vitiligo is best diagnosed by a dermatologist. Usually assessing the skin in the consulting rooms is all that is required but occasionally a skin biopsy (piece of skin) may be needed to confirm the diagnosis.

While there is no blood test to diagnose vitiligo, blood tests may be ordered to assess for other autoimmune conditions if deemed necessary.

Will my vitiligo keep spreading?

Like many skin conditions, it is not possible to predict in each individual when the vitiligo will eventually stop occurring. Without treatment most people with vitiligo will continue to notice their condition getting worse over several years.

For some people, this is a slow and gradual process affecting only small patches of the skin, but for others it is more rapid and extensive. While new patches of vitiligo are appearing, the condition is often said to be ‘active’. Eventually in most cases (often after more than 10 years) new spots stop developing. The condition is then said to be ‘stable’.

Can i treat my vitiligo?

While not all patients with vitiligo will want or need to treat their spots, others do – and for this group, treatments are available to try to regain pigment in affected areas. It is important to know that treatments often only stop the vitiligo from getting worse, rather than resulting in a full recovery, and, even if treatments do lead to the skin colour returning, they usually need to be used for many months or years and recovery may be partial rather than complete.

There are two types of vitiligo. The treatment of your condition will depend on the type of vitiligo you have.

  • Common Vitiligo
    Most people with vitiligo have this type. It starts as one or two pale or white spots and over time more and more of these ‘patches’ start to appear.
  • Segmental Vitiligo
    This uncommon form of vitiligo usually occurs during childhood. It only occurs in one segment of skin – most often it is no bigger than the size of an adult palm. Once it starts it may quickly enlarge to its full size, but then stops growing. It does not improve on its own but it also does not start appearing elsewhere.

What are the treatment options for vitiligo?

Non-cultured Epidermal Cellular Grafting

Non-cultured Epidermal Cellular Grafting is a technique that involves taking a thin piece of skin from a hidden area such as the thigh, placing the skin into a test tube or dish and adding a chemical (trypsin) to separate all of the skin cells. A laser is then used to remove the top layer of skin from the white area of vitiligo and the liquid suspension of cells is placed onto this site. The patient’s own skin cells then grow into the area and start to re-pigment the skin. As only the top layer of skin has been removed, it heals without scarring. Since the technique involves the patient’s own cells, the colour matches the patient’s own skin colour and it should tan normally.

Benefits

Epidermal Cellular Grafting can achieve good to excellent re-pigmentation rates for stable vitiligo. The re-pigmented area will match the patient’s own skin colour. 

Disadvantages

Unfortunately this technique is not yet widely used in Australia. The Vitiligo Clinic at the Skin & Cancer Foundation Inc is the first clinic in Victoria to offer this technique. The skin grafting technique is suitable only for those with smaller areas of white skin that have not improved with other treatments. 

Learn more about the Vitiligo Clinic at the Skin & Cancer Foundation.

Steroid Creams

Steroids (cortisones) work by dampening down the immune system; i.e. they reduce inflammation. Remember it is an 'over active' part of the immune system that is causing vitiligo.

Benefits 

Steroid creams, including strong ones, are very safe, even if used regularly for many months or even years. This is their main benefit. They can be used together with UV therapy. 

Disadvantages

Unfortunately, steroid creams are often not successful in returning the skin colour in vitiligo. They are more successful if used early in treatment (i.e. within three months of the new patch arising), and generally, they are more effective in stopping vitiligo getting worse (although this is sometimes hard to assess) than making it better.

Side-effects from steroid creams are uncommon. If they occur, they only affect the skin (not the rest of the body) and are usually of cosmetic nuisance only. They usually only happen after using the creams every day for many months and in most cases they are 'reversible' (i.e. the skin usually returns to normal when the cream is stopped):

UV therapy

Ultraviolet therapy is currently the best treatment option for people with 'active' vitiligo. Natural sunlight can help improve vitiligo, although in some parts of the country the climate does not allow for all year round 'natural UV' therapy. Most dermatologists provide an artificial form of UV, in 'light boxes' which are specially designed to treat skin conditions, including psoriasis and eczema. These days most medical light boxes use so-called 'narrowband UVB', which is both safer and more effective than older machines (and different from the UVA light emitted from solarium machines). In the past a form of light therapy called PUVA was used, which also involved taking a capsule before standing in the light box.

UV therapy (including natural sunlight) has the effect of dampening down the immune system in the skin. It may also have the effect of 'stimulating' melanocytes to re-pigment the skin.

Phototherapy Clinic

Benefits

UVB therapy is very safe and for most people it can stop vitiligo from getting worse and lead to some degree of recovery in the skin colour. Unlike creams, it can prevent new spots of vitiligo from appearing by 'treating' areas of skin that appear normal but probably already have some inflammation.

Most dermatologists in Australia bulk bill this treatment, so it is essentially at no additional cost to the patient.

Disadvantages

Even if UVB therapy is effective, it works slowly. It is necessary to have two or three treatments each week and a three-month course is needed just to see if there is any benefit. If there is some improvement with this treatment, it may take up to a few years before the maximal benefit is obtained. Understandably, most patients get very tired of coming in for treatment week after week, for what appears to be very gradual improvement.

Other, less common, forms of treatment...
Immune-suppressive tablets

In some cases where the vitiligo is getting worse rapidly, dermatologists with expertise in treating vitiligo may prescribe oral medications that suppress the body’s immune system. They are used for a period of weeks or sometimes several months. These medications are generally stronger than creams or UV therapy, therefore more effective in treating rapidly progressing form of vitiligo. However, it can be difficult for the dermatologist to tell if they are assisting, since they may slow down or stop the vitiligo from progressing rather than causing the skin to re-pigment.

Excimer Laser

The Excimer Laser uses the same type of UVB as the light boxes, but creates a stronger ‘pulse’ of UV energy to the skin. This laser provides a more efficient way of delivering UV therapy (treatment may take only 4-6 weeks). However only very small areas of the skin can be treated at a time and only certain areas are able to be treated. The main problem with the Excimer Laser is that this form of treatment is not covered under the Medical Benefits Scheme (Medicare), so it is more expensive.

De-pigmentation (skin bleaching)

In people where vitiligo has affected more than 50% of the skin, bleaching the rest of the normal skin may provide a better outcome than trying to bring back the natural skin colour. A prescription cream called monobenzyl ether of hydroquinone is applied as a bleaching agent on a daily basis until sufficient whitening has occurred (this usually takes 3-6 months). Although this form of treatment can produce a natural cosmetic result in a short time frame for many, for patients who have African or Aboriginal features, the results are less acceptable.

Cosmetic Camouflage

The use of camouflage products can work very well to hide the areas of vitiligo and can therefore be important to lessen the psychological impact of the condition. To obtain the best results a careful colour match needs to be obtained. Cosmetic camouflage is very safe and effective however, upon close inspection, it is usually apparent that a make-up has been applied. It can also be very time consuming and costly to apply the camouflage make-up every day.

Micro-tattooing

A form of micro-tattooing exists that can provide a good cosmetic camouflage that is 'semi-permanent'. It must be applied by a professional expert. The pigment, which is carefully matched to the natural skin tone, usually lasts for a few years and can then be re-applied again. This technique is less of a hassle than having to apply camouflage make-up every day however, it is only recommended for stable vitiligo. It can also be very expensive.

How successful are the treatments for vitiligo?

It is important to know that vitiligo can be treated and that safe and medically-proven treatments exist. However, treatment often only stops the vitiligo from getting worse, rather than resulting in a full recovery, and even if treatments do lead to the skin colour returning, they usually need to be used for many months or years and recovery may be 'partial' rather than 'complete'.

Furthermore, after successful treatment there is also a risk that the vitiligo may return again in the future. 

It is not possible to predict which treatments will work best for which patients, but in general treating vitiligo spots early (within the first three months after they first develop) is better. Also patients who develop spots slowly are more likely to be successfully treated compared with those with more widespread vitiligo which is worsening quickly.

The sites of involvement on the skin are important in terms of the likelihood of successful treatment. This depends on the number of hair follicles present in the skin. Parts of the skin with large numbers of hairs have a good chance of recovery (since the pigment cells in the hair root migrate to the surface to repigment the skin), whereas parts of the skin with small numbers of hairs often do not recover. 

Support

What steps should I follow to cope with vitiligo?

When you have vitiligo, you may feel upset or depressed about the change in your appearance. It is important to know that there are several things you can do to cope with this disorder.

  1. Find a dermatologist who knows how to treat vitiligo. The dermatologist should also be able to provide emotional support, as vitiligo can have psychological consequences.
  2. Learn as much as you can about your disorder and the treatment options. This can help you make decisions about the treatment that will best work for you.
  3. Talk with other people who have vitiligo. A vitiligo group can help you find a support group.

Research:

Scientists have gained a better understanding of vitiligo in recent years, especially through gene research. Current research includes studies that are investigating:

  • how trauma or stress to the skin can trigger vitiligo or the development of new white patches
  • new treatments and better understanding of vitiligo 
  • genes that may cause or contribute to having vitiligo
  • analysis of genes already known to be linked to vitiligo.

The Vitiligo Clinic at the Skin & Cancer Foundation Inc

The Vitiligo Clinic at the Skin & Cancer Foundation Inc offers a wide range of treatment techniques and support for its patients. 

The Clinic's multi-disciplinary approach hopes to offer dermatologists and their patients a comprehensive service encompassing expert opinion, patient support and education, and specialised treatments. 

As a centre of excellence, the Vitiligo Clinic will be well placed to provide training and research opportunities and to collaborate with similar centres overseas.

About the Vitiligo Clinic

Patient Support

The Vitiligo Association of Australia (VAA) was founded in September 2010 for patient support, public education and the promotion of research into vitiligo within Australia.  

Anyone with an interest in this condition, be they a person with vitiligo, a family member, a friend, a clinician, a scientist, an allied medical professional or a philanthropist can join this not-for-profit association and its affiliated Patient Support Groups.  Members have the added advantage of benefiting from international links and information resources through the World Alliance of Vitiligo Support (WAVS).

See their website for more information. 

The Vitiligo Clinic at the Skin & Cancer Foundation Inc urges those with this condition to consider seeking attention from a qualified dermatologist.

June 25 is World Vitiligo Day – visit the Vitiligo Association of Australia website for more information.

(This article, by Dr Michelle Rodrigues, was originally published on The Conversation and is reproduced with their permission. See that original article.)

Vitiligo: Truth, Hope and Change

This video was created by Vitiligo Working Group.

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