Vitiligo

What is Vitiligo?

Vitiligo is a skin condition that leads to loss of color in patches, often resulting in white spots or patches on the skin. This happens because of the loss of pigment cells from the top layer of the skin, known as the epidermis. The direct cause of vitiligo is unknown, but it’s usually linked to some autoimmune disorders, and issues with the thyroid gland are the most common.

Vitiligo often shows up as white spots on the body that are symmetrically distributed, which means they appear similarly on both sides of the body. These white patches are most noticeable in individuals with darker skin tones. The white or colorless spots can come in various shapes such as oval, round, or linear, and they usually come with smooth, defined edges. These spots can range in size and often grow outward over time.

Vitiligo can come in different forms, including Trichrome, Marginal inflammatory, and Quadrichrome vitiligo. Sometimes, it can also appear on areas of the skin that have been injured, like a cut or burn; this is known as the Koebner phenomenon. The first spots often appear on the hands, forearms, feet, or face, particularly around the eyes or mouth.

Vitiligo is sorted into three types based on how the white patches are spread out: generalized, segmental, and localized. The seriousness of vitiligo is judged by the amount of skin affected. How the disease progresses can be unpredictable and the responses to treatment can vary. Often, the loss of skin color can lead to emotional stress, social stigma, and issues with self-confidence.

What Causes Vitiligo?

The exact cause of vitiligo, a condition that causes patches of skin to lose their color, is currently unknown. However, it’s often linked with several autoimmune diseases. Autoimmune diseases are conditions in which your immune system mistakenly attacks your own body. So, this connection suggests that the immune system might be playing a role in causing vitiligo.

It’s believed that a combination of various factors contribute to the development of this condition. It’s categorized by inconsistent inheritance patterns, diverse genetic factors, and multiple risk locations in the genes. In other words, vitiligo doesn’t show up in every generation of a family, doesn’t have a single, identifiable genetic cause, and seems to involve several gene locations that increase an individual’s risk of developing the condition.

Studies of families and twins have shown that both environmental and genetic factors are involved in inheriting vitiligo. It’s also thought that certain genetic factors influence when vitiligo starts appearing in a person’s life. The genetics of vitiligo may involve genes associated with the production of melanin (which gives skin its color), the regulation of autoantibodies (the proteins in the immune system that can cause autoimmune diseases), and the response to oxidative stress (an imbalance in the body that can damage cells).

Recent studies have not found any links with any particular type of human leukocyte antigen (HLA), which are proteins that help the immune system distinguish between the body’s own proteins and proteins from harmful substances like viruses and bacteria. However, there is a strong belief that two types of vitiligo, called segmental and nonsegmental, may be caused by unique genetic mechanisms. This could explain why different treatments work differently for different people having vitiligo.

Risk Factors and Frequency for Vitiligo

Vitiligo, a condition that causes loss of skin color, is the most common reason for this problem. It can affect people at any age, but it typically shows up most often when people are in their twenties or thirties. Interestingly, the age when vitiligo starts can be different in women and men. This disease affects around 0.1% to 2% of everyone worldwide, including both kids and adults. Importantly, it doesn’t favor any race and affects everyone with equal chances.

Signs and Symptoms of Vitiligo

Vitiligo is a skin condition that often can be diagnosed by simply looking at the skin. However, a detailed medical history and physical examination are important for assessing the severity of the disease. Certain pieces of information can be especially helpful for diagnosing vitiligo.

• When did the spots first appear?
• Has anything potentially triggered the start of the skin condition?
• Are there any symptoms associated with the spots?
• Have the spots spread or changed over time?
• Are there any other diseases present at the same time?
• What medications is the person currently taking?
• Is there any workplace exposure to chemicals or radiation?
• Is there a family history of vitiligo or other autoimmune diseases?

During a physical examination, doctors look for specific signs of vitiligo on the skin:

• Patches of skin that have lost their pigment, appearing as white spots or marks with clear borders, surrounded by normal skin.
• The spots are milky-white in color, have defined edges and can be various shapes like round, oval, or linear.
• They can be small or large, ranging in size from a few millimeters to a few centimeters.
• Commonly affected areas are the face, neck, back of hands, scalp, and torso. On the face, around the mouth and eyes are frequently affected.
• Spots can also appear on areas subjected to repeated stress or trauma, like knees and elbows.
• In 20% to 60% of vitiligo patients, new spots may appear in areas where the skin has been injured or traumatized (known as “Koebnerization”).
• Sometimes, signs of other associated diseases may also be present, such as an enlarged thyroid (goiter), anemia, generalized weight loss, premature grey hairs, patches of hair loss (alopecia areata), or weakness.

Testing for Vitiligo

Diagnosing vitiligo, a condition that causes loss of skin color, is usually based on a visual examination of the affected skin areas and involves the use of a special type of light called a wood light. Sometimes, a skin biopsy (a small sample of skin) is taken to help differentiate vitiligo from other conditions that cause changes in skin color.

Under the microscope, skin affected by vitiligo shows the absence of melanocytes, the cells that produce skin color, and complete loss of the protective skin color otherwise known as pigmentation. Surrounding an area of vitiligo, there can sometimes be a presence of immune cells, suggesting that the immune system is involved in the loss of pigmentation.

Some other findings under the microscope can include:

• Decay in both pigment cells (melanocytes) and skin cells (keratinocytes) at the edge of a vitiligo patch and adjacent skin
• An increased number of Langerhans cells, which are specialized immune cells in the skin
• Changes in the skin’s outer layer that cause it to appear hollow or filled with air pockets
• Thickening of the basement membrane, which is the layer that separates the top layer of skin from the deeper layers beneath it
• Loss of pigmentation, confirmed by using a special staining method during testing

Treatment Options for Vitiligo

Vitiligo, a skin condition where patches of skin lose their pigment, can be treated in various ways. The treatment options include medications applied on the skin, medications taken by mouth, light therapy, laser therapy, and even surgery.

Among the medications applied on the skin, there are corticosteroids (anti-inflammatory drugs), calcineurin inhibitors (drugs that reduce inflammation and skin reactions), and Vitamin-D analogs (compounds similar to Vitamin-D that promote skin health).

Light therapy or phototherapy is another common treatment. It’s usually recommended for the early stages of the disease or for patients who only have a few patches of vitiligo. The most common type of light therapy used is Narrowband UV-B, which uses a specific wavelength (311-312nm) of ultraviolet light. This treatment is usually done two to three times a week. It has become more popular than an older form of phototherapy called psoralen because it’s much less likely to cause harmful side effects.

The Excimer Laser is recommended for small, stable patches of vitiligo that don’t change over time. This treatment can also be combined with a medication called Tacrolimus and systemic corticosteroids (a type of drug that reduces inflammation) to treat a specific kind of vitiligo called segmental vitiligo, which is usually resistant to most treatments.

Emerging treatments in the fight against vitiligo include Afamelanotide and JAK inhibitor therapy. There’s also a topical drug called ruxolitinib that has been shown to be effective in a 2019 study.

Surgery is an option in cases of vitiligo that only affects a small area of the body. There are five basic ways to perform this surgery, all of which aim to restore pigmentation to the skin. These methods include grafting techniques that transfer healthy, pigmented skin to vitiligo-affected areas.

Surgical treatment is best suited for patients with the following characteristics:
* Have a form of vitiligo affecting only one side of the body (segmental vitiligo)
* Have vitiligo confined to a small area (localized vitiligo)
* Have vitiligo affecting parts of the body that typically don’t regain pigmentation easily (like hairline, back of the fingers, forehead, and ankles)
* The vitiligo affected lesion must be stable and not spreading

Keep in mind that everyone is different, and treatment plans can be tailored to fit individual needs and circumstances. Your healthcare provider can help determine which treatment might be best for you.

What else can Vitiligo be?

Here are some conditions that might look like vitiligo, but are actually different issues:

• Nevus depigmentosus: This is a defined area of skin that is lighter or has less pigment, which is usually present at birth.
• Pityriasis alba: Often seen as part of a range of conditions linked to atopic dermatitis, it is common in children and appears as white, scaly spots on the face and other areas exposed to sunlight.
• Idiopathic guttate hypomelanosis: This condition is marked by small, white spots on areas exposed to sunlight. It is typically seen in older people and doesn’t cause any symptoms.
• Tinea Versicolor: This is a skin infection caused by a fungus, which leads to loss of pigment. It appears as pale, scaly spots on the back and chest and may look yellow under a special kind of light called a Wood’s lamp.
• Halo nevus: This is a type of birthmark that is surrounded by an oval area of lighter skin.
• Progressive macular hypomelanosis: This condition shows up as lighter-colored patches on the trunk of young adults and doesn’t cause any symptoms.
• Drug-induced leukoderma: Sometimes powerful topical or injected corticosteroids can cause lightening of the skin where the medication is applied. This type of skin whitening can also be observed in patients treated with certain cancer medications.
• Hypopigmented mycosis fungoides: This is a type of skin lymphoma often seen in children and people with darker skin. It appears as widespread lighter patches of skin with thinning and scaling.

It’s crucial to get the right diagnosis, as each of these conditions requires different treatments.

What to expect with Vitiligo

Vitiligo is a long-term skin condition that behaves unpredictably. Some people with vitiligo may see their skin color return in certain spots on its own. How vitiligo progresses and the likelihood of skin color returning depends on the age when it first shows up and how much of the skin it affects. Vitiligo that starts at an early age typically involves larger areas of the skin and spreads more quickly.

Certain types of vitiligo and locations on the body may respond to treatment. However, some cases, especially when the person is under the age of 14 and has the segmental type of vitiligo, might not improve with treatment. It’s common for people being treated for vitiligo to go through cycles where their skin loses color and then stabilizes.

Possible Complications When Diagnosed with Vitiligo

Vitiligo can lead to a variety of issues beyond the visual appearance of the skin. These complications span from social issues due to appearing different, to mental stress caused by societal stigma. Moreover, vitiligo can cause problems with the eyes, such as irritation and inflammation, and can increase the risk of sunburn and skin cancer due to the loss of skin pigment. Hearing loss can also occur because of melanocyte damage in the ear—an effect of vitiligo. Lastly, using medication to manage vitiligo can lead to its own set of complications. For instance, using topical steroids for a long duration can lead to thinning of the skin.

Complications of Vitiligo:

• Social stigmatization and mental stress
• Eye problems like iritis
• Increased risk of sunburn
• Higher likelihood of skin cancer
• Hearing loss from the loss of cochlear melanocytes
• Skin thinness due to prolonged use of topical steroids

Preventing Vitiligo

Vitiligo is a condition that slowly causes loss of skin color, changing a person’s physical appearance over time. Since this change can be quite noticeable, it often affects patients both emotionally and socially. People with vitiligo, especially those with visible skin changes, may experience feelings of distress and stigmatization, which can significantly lower their quality of life. Therefore, mental health support such as psychiatric consultation can be very important in managing emotional wellbeing.

Furthermore, it’s crucial for patients to understand that the treatment for vitiligo can be a slow process and that results can vary greatly from person to person. In some cases, treatment may not work as expected. This understanding can help them set realistic expectations and alleviate potential frustrations during the treatment process.