What is vitiligo?
Vitiligo is a persistent or chronic condition in which areas of skin lose their normal pigment (colour) and become very pale, white or light pink. Vitiligo is common, affecting about 1%, or one in a hundred people, of the world’s population. It can start at any age after birth, but in over half of the people affected it appears before 20 years of age. The amount of skin affected by vitiligo and the speed at which it spreads are unpredictable, varying from single small patches to a total loss of skin colour. In most people vitiligo tends to change slowly, with periods of stability often lasting several years. The pigment may return partially in some people, through treatment or sometimes without treatment. It is important to note that re-pigmentation (return of colour) is not guaranteed following treatment and the vitiligo may well return after treatment.
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What causes vitiligo?
The pigment that gives your skin its normal colour is called melanin and is made by cells known as melanocytes. In patches of vitiligo the melanocytes are inactive but still may be present. The reason for this is not fully understood. However, vitiligo is considered to be an ‘autoimmune’ condition in which the body’s immune system rejects some of its own cells (melanocytes in the case of vitiligo). Thyroid disease and other autoimmune conditions are more common in individuals with vitiligo.
Repeated trauma such as burns, cuts, repeated pressure, rubbing or scratching the skin may trigger new areas of vitiligo in some patients. This is called the “Koebner Phenomenon”.
Vitiligo affects men and women of all races equally but is more noticeable in people with skin of colour. It is not infectious. There is no medical evidence of any link between diet or smoking and vitiligo.
Is vitiligo hereditary?
Yes, vitiligo has a genetic basis, although less than half of those with vitiligo know of someone in their family who also has it. If you have vitiligo, it does not necessarily follow that your children will develop it.
What are the symptoms of vitiligo?
Vitiligo is not usually itchy or sore, but some people experience some itching sensation on the skin before a new vitiligo patch appears.
Sunlight may cause sunburn to exposed areas because there is no longer protective melanin in the vitiligo patches. In addition, some people may feel embarrassed by their vitiligo as it may stand out more obviously when the surrounding skin is tanned or richly pigmented.
Having vitiligo may affect you psychologically and you may experience anxiety, depression and low self-esteem. Please inform your doctor if this is the case, who will be able to recommend sources of self-help or referral to psychological services if needed.
What does vitiligo look like?
Vitiligo consists of irregularly shaped patches of skin that lack the normal melanin pigmentation and are very pale, pink or white. It is often symmetrical, affecting both sides of the body. The skin otherwise feels entirely normal. The most common sites for vitiligo are the hands and face, around body openings (the eyes, nostrils, mouth, belly button and genital regions), and within body folds such as the underarms and groin. When hair-bearing skin is involved, the hair may lose its pigment and appear white.
Re-pigmentation (return of colour) often commences around hair follicles (roots), initially giving the skin a speckled appearance.
How will vitiligo be diagnosed?
The diagnosis is usually easily made by either your GP (including GP with Enhanced Role) or dermatologist. Occasionally, examination under an ultraviolet lamp is helpful to confirm affected areas, especially in light-skinned people. Once the diagnosis of vitiligo has been made, your doctor will usually take a blood sample to check for thyroid disease and may also test for other autoimmune conditions.
If you are avoiding all sun exposure because of your vitiligo you should discuss with your doctor about Vitamin D replacement and whether you may need your serum Vitamin D levels to be checked.
Clinical photographs may sometimes be taken by your doctor to monitor your vitiligo and the effect of any treatment you receive.
Can vitiligo be cured?
There is no cure for vitiligo. Although treatment may be helpful in restoring your skin colour, it cannot prevent its spread or recurrence and re-pigmentation may not be permanent.
How can vitiligo be treated?
There are treatment options that can be discussed with your healthcare professional.
You may decide not to treat your vitiligo, after talking to your healthcare professional. You may choose to protect your skin with sunscreens and find a good cover-up product for when you choose to use it.
If you do decide to seek treatment for your vitiligo patches, the following options are available.
Areas of vitiligo will burn easily in the sun. You should use a sunscreen with 4* or 5* UVA rating and SPF 50 and apply it to affected patches and surrounding skin before going outdoors into the sun on exposed areas to help protecting your skin. Other standard sun protection measures, such as appropriate protective clothing and sun avoidance should also be employed (see the ‘top sun safety tips’ below for more information).
The application of a potent or very potent corticosteroid anti-inflammatory cream or ointment to areas of vitiligo may restore some pigment. Side effects, such as thinning of the skin and stretch marks, are a risk with continued use.
There is another type of anti-inflammatory cream and ointment called a calcineurin inhibitor, which may also restore pigment in some patients. This topical treatment will help avoid the corticosteroid side effect of skin thinning and may in particular be used for facial vitiligo. Calcineurin inhibitors may be prescribed in alternation with a topical corticosteroid cream or ointment, to avoid the skin thinning side effect of the topical corticosteroid on its own.
Short courses of oral corticosteroids can sometimes be considered if you have rapidly spreading vitiligo. This treatment may be associated with a wide range of side effects including but not limited to; weight gain, skin thinning, mood changes and cataracts.
This involves exposing affected skin to artificial ultraviolet light. Phototherapy may be helpful in a proportion of patients with vitiligo. However, treatment often needs to be prolonged, comprising of hospital visits two to three times a week for several weeks (usually at least 12 weeks and in some cases up to one year). Before the start of phototherapy and during the course of treatment, medical photographs of your vitiligo are usually taken in order to monitor progress. Full re-pigmentation is unusual and depigmentation (loss of colour) again after phototherapy can occur. Areas such as the fingertips and feet are less likely to improve (see Patient Information Leaflet on Phototherapy). Phototherapy may also be used in combination with topical or oral corticosteroid or calcineurin inhibitors as a treatment programme for you.
Professional help with developing coping mechanisms may be helpful for some people with vitiligo or their carers e.g. parents. Your doctor should direct you to self-help resources to support. If vitiligo is causing severe distress, you may be offered a referral to psychological services for individual or group talking therapy to help manage vitiligo.
There are a number of options for covering up or blending in your patches. First, advice from experts about skin camouflage is available by referral through your dermatologist or online via the charity Changing Faces. There are good quality camouflage products in a range of colours that are water resistant and less likely to rub off during the day or on your clothing.
You may also find some make-up brands identified as ‘long lasting’, or sunless-tanning products useful for day-to-day use. Patient Support Groups can often help with lists of available products or members’ personal recommendations.
In addition to the treatment options mentioned above, the following treatment options are not widely available on the NHS but in a limited number of centres with specialist interest only.
This process involves transplanting small areas of normal skin into areas of stable (unchanged for over a year) vitiligo. This method of treatment is not in general use or routinely available in NHS.
CO2 laser and 5-Fluorouracil cream
This combination can sometimes be used in adults on hands and feet only.
Excimer laser treatment
Some areas of vitiligo have improved from treatment with a laser called the Excimer laser. This treatment appears to work best on vitiligo that has not changed for a long time and affects relatively small areas of skin. Laser treatment is usually used in combination with topical treatments.
Removing the remaining pigment
If vitiligo has spread very widely (more than 50% of the body) or involves large areas of the face or hands, it may in exceptional circumstances be reasonable to consider removing the small amounts of remaining pigmented areas of skin using a bleaching chemical such as hydroquinone. The emotional, social and medical implications of this treatment must be carefully discussed with before this treatment is used and it should only be undertaken with specialist supervision.
Self care (What can I do?)
Top sun safety tips
- Protect your exposed skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
- Spend time in the shade between 11am and 3pm when it is sunny.
- When choosing a sunscreen look for a high protection SPF (SPF 50 or more) to protect against UVB, and 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen on all sun-exposed areas 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming, towel-drying and strenuous exercise.
- Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection. Keep babies and young children out of direct sunlight as far as possible. It may be necessary to take Vitamin D supplement tablets as strictly avoiding sunlight can reduce Vitamin D levels. You should ask your doctor or dermatologist about this.
Vitamin D advice
The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.
Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.