What is vitiligo?
Vitiligo is a persistent or chronic condition in which areas of skin lose their normal pigment and become very pale or pink. It is common, affecting about 1% of the world’s population. It can start at any age after birth, but in more than half of people affected it does so before 20 years of age. The extent of the condition is unpredictable, varying from single small patches to total loss of skin colour. In most people, it tends to change slowly, with periods of stability often lasting several years. The pigment may return in some patients, but is not guaranteed, and seldom returns completely.
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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 inactive but still present. The reason for this is not fully understood. However, vitiligo is considered to be an ‘autoimmune’ condition in which the body’s own immune system rejects some of its own cells (melanocytes in the case of vitiligo). As a result, thyroid disease and other autoimmune conditions are more common in individuals with vitiligo.
Repeated trauma such as rubbing or scratching the skin may trigger vitiligo.
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 irritation of the skin before a new vitiligo patch appears.
Sunlight may cause sunburn to exposed areas. Some people may feel embarrassed by this as it will stand out more obviously when the surrounding skin is tanned or in naturally dark-skinned individuals.
What does vitiligo look like?
Vitiligo consists of irregularly shaped patches of skin that lack the normal melanin pigmentation, and are thus completely very pale, pink or almost white. It is often symmetrical, affecting both sides of the body, although less commonly, it can be localized to one part 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, umbilicus 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.
Repigmentation (recovery) often commences around hair follicles, initially giving the skin a speckled appearance.
How will vitiligo be diagnosed?
The diagnosis is usually easily made by either your GP or specialist. 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 may take a blood sample to check for thyroid disease and for other autoimmune conditions. Clinical photographs may sometimes be taken by your doctor to monitor 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 the colour, it cannot prevent its spread or recurrence and repigmentation (recovery) may not be permanent.
How can vitiligo be treated?
There are a number of treatment options that can be discussed with your GP or dermatologist. Often no treatment may be required other than good sun protection, especially in pale-skinned individuals, and skin camouflage creams and powder.
Areas of vitiligo will burn easily in the sun. The use of a sunscreen with a high sun protection factor (SPF) of 30 or higher to all exposed areas helps to protect skin affected by vitiligo, and also, when applied more widely, reduces the contrast between the areas of vitiligo and the surrounding normal 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. Short courses of oral steroids can sometimes be considered but may be associated with side effects such as weight gain, skin thinning, mood changes and cataracts.
Other topical preparations
Other types of anti-inflammatory creams and ointments, such as calcineurin inhibitors and vitamin D analogues, may also restore pigment in some patients. These topical treatments will help avoid the corticosteroid side effect of skin thinning.
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 (lasting at least several months). Full repigmentation is unusual and depigmentation after phototherapy can occur. Areas such as the fingertips and the skin around the lips are less likely to improve (see Patient Information Leaflet on Phototherapy). Phototherapy may also be used in combination with topical or oral corticosteroid treatments.
This process involves transplanting small areas of normal skin into areas of stable vitiligo. This method of treatment is still being developed and is not yet in general use.
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 can sometimes be 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 pigmented areas of skin using a bleaching chemical such as hydroquinone. The emotional, social and medical implications must be carefully discussed before this treatment is used and it should only be undertaken with specialist supervision.
Professional help with developing coping mechanisms may be helpful for some people with vitiligo or their carers e.g. parents.
Advice from experts about skin camouflage is now widely available. There are good quality camouflage products in a range of colours that are water resistant and less likely to rub off. Your GP or dermatologist can advise or refer you to a camouflage service for this. Careful use of fake suntans can be effective to make areas of vitiligo less noticeable.
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’s sunny.
- When choosing a sunscreen look for a high protection SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 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.
This information is provided by the British Association of Dermatologists.
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