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Vitiligo

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Vitiligo



Introduction 

Vitiligo is a long-term condition that causes pale, white patches to develop on the skin due to the lack of a chemical called melanin.

Vitiligo can affect any area of your skin, but most commonly occurs on skin exposed to the sun, such as your face, neck and hands.

The condition varies from person to person. Some people only get a few small, white patches, but others get bigger white patches that join up across large areas of their skin.

There is no way of predicting how much skin will be affected. The white patches are usually permanent.

 

Why does vitiligo happen?

Vitiligo occurs due to a lack of melanin in the affected areas of skin. Melanin, which is produced by specialised skin cells called melanocytes, gives your skin its colour and protects it from the sun.

It's not clear exactly what causes this lack of melanin, but it has been linked to problems with the immune system (autoimmune conditions) and nerve endings in the skin.

Certain things can increase your chances of developing vitiligo, such as a family history of the condition or having another autoimmune problem, like an overactive thyroid gland (hyperthyroidism).

Vitiligo is not caused by an infection and you cannot catch it from contact with someone who has it.

 

Who is affected?

In the UK, about 1 in 100 people develop vitiligo.

In around half of people affected it starts before the age of 20, although it can occur at any age. Men and women are equally affected, as are people of different ethnicities.

Diagnosis

Vitiligo can usually be identified by a GP after a physical examination. You may also be asked questions about your family's medical history and if the problem is affecting your confidence.

In some cases, an ultraviolet lamp may be shone on your skin to examine it in more detail and rule out other skin conditions.

You may also be checked for symptoms of other autoimmune conditions, such as diabetes. Blood tests are sometimes taken to check how well your thyroid gland is functioning.

 

How is vitiligo treated?

The white patches caused by vitiligo are usually permanent, although there are treatment options to improve the appearance of your skin.

If the patches are relatively small, skin camouflage cream may be used to cover them up.

In general, combination treatments, such as phototherapy (treatment with light) and medication, give the best results.

In some cases, treatment may restore pigment (colour) to your patches, but the effect doesn't usually last. Treatment cannot stop the condition from spreading.

 

Complications

Vitiligo can sometimes cause other problems.

Due to a lack of melanin, your skin will be more vulnerable to the effects of the sun. If it is not protected with a strong sunscreen, sunburn is likely.

Vitiligo may also lead to a lack of pigmentation in your eyes and a partial loss of hearing (hypoacusis).

Problems with confidence and self-esteem are common in people with vitiligo, particularly if the condition affects areas of frequently exposed skin.

Support groups can often help by putting you in contact with other people who have vitiligo. Your GP may suggest a group in your area, and charities such as The Vitiligo Society may be able to help.

 

Symptoms of vitiligo 

The main symptom of vitiligo is flat, white spots or patches on your skin. The first white patch usually develops where the skin has been exposed to the sun.

Initially, the vitiligo may start as a patch of skin that is paler than the rest. Gradually, the patch will become completely white. The centre of a patch may sometimes be white, with pale skin around it. In areas where there are blood vessels under the skin, the patch may be slightly pink, rather than white.

The edges of the patch may be smooth or irregular. The edges are sometimes inflamed (red) or there is hyperpigmentation (brownish discolouration of the skin).

Vitiligo does not cause discomfort to your skin, such as dryness, but patches may occasionally be itchy.

If you have vitiligo, the pale areas of your skin are more vulnerable to sunburn.

 

Areas commonly affected by vitiligo

The areas most commonly affected by vitiligo include:



the skin around your mouth and eyes 



fingers and wrists



armpits 



groin 



genitals



inside your mouth



Vitiligo can sometimes develop where there are hair roots, such as on your scalp. The lack of melanin in your skin can turn the hair in the affected area white or grey.

 

Types of vitiligo

There are two main types of vitiligo:



non-segmental vitiligo



segmental vitiligo



In rare cases, it's possible for vitiligo to affect your whole body. This is known as universal or complete vitiligo.

Non-segmental vitiligo

In non-segmental vitiligo (also called bilateral or generalised vitiligo), the symptoms of vitiligo often appear on both sides of your body as symmetrical white patches. Symmetrical patches can appear on the:



backs of your hands



arms



eyes



knees



elbows



feet



Non-segmental vitiligo is the most common type of vitiligo, affecting up to 9 out of 10 people with the condition.

Segmental vitiligo

The white patches may sometimes only affect one area of your body. This is known as segmental, unilateral or localised vitiligo.

Segmental vitiligo is less common than non-segmental vitiligo, although it's more common in children. Segmental vitiligo usually starts earlier and affects 3 in 10 children who have vitiligo.

How the symptoms of vitiligo develop

If you have vitiligo, it is difficult to predict whether your condition will spread from the original patch, or how fast it may spread, as it varies from person to person.

It's likely that more white patches will appear. For some people, this can happen quickly. For others, the patches may stay the same for months or years.

If the white patches appear symmetrically on more than one part of your body, the condition may progress quite slowly, with periods when the patches do not change. If you have white patches on only one area of your body, the condition may progress more rapidly.

 

Causes of vitiligo 

Vitiligo is caused by the lack of a skin pigment called melanin.

Melanin, which is produced by skin cells called melanocytes, gives your skin its colour.

If you have vitiligo, you do not have enough working melanocytes, so not enough melanin is produced in your skin. This causes white patches to develop on your skin or hair. It's not clear exactly why the melanocytes disappear from the affected areas of skin.

The causes of non-segmental and segmental vitiligo may be slightly different (read about the symptoms of vitiligo for more information about these types).

 

Autoimmune conditions

Non-segmental vitiligo, the most common type of vitiligo, is thought to be an autoimmune condition. This means that your immune system (the body’s natural defence system) does not work properly.

Instead of attacking foreign cells, such as viruses, your immune system attacks your body’s own healthy cells and tissue.

If you have non-segmental vitiligo, your immune system destroys the melanocyte skin cells that make melanin.

Vitiligo is associated with other autoimmune conditions, such as an overactive thyroid gland (hyperthyroidism).

 

Neurochemicals

Segmental vitiligo, the less common type of vitiligo, is thought to be caused by chemicals released from the nerve endings in your skin. These chemicals are poisonous to the melanocyte skin cells.

Increased risk

You may be at higher risk of developing non-segmental vitiligo if:



someone in your family has it – around 20% of people with vitiligo know another family member who has it 



you have a family history of other autoimmune conditions – for example, one of your parents has pernicious anaemia (an autoimmune condition that affects your stomach)



you have another autoimmune condition 



you have melanoma (a type of skin cancer) or cutaneous T-cell lymphoma (a type of cancer of the lymphatic system) 



you have particular changes in your genes that are known to be linked to non-segmental vitiligo



Triggers

It's possible that the vitiligo may be triggered by particular events, for example:



stressful events – such as childbirth



damage to your skin – such as severe sunburn or cuts (this is known as the Koebner response)



exposure to certain chemicals – for example, at work



Vitiligo is not caused by an infection and you cannot catch it from someone else who has the condition.

 

Diagnosing vitiligo 

Vitiligo can usually be diagnosed by your GP, based on a skin examination. Further tests are rarely needed.

Your GP will need to see all your patches to estimate how much of your body area is affected. They will also ask how long you have had the patches.

Your GP may ask whether:



there is a history of vitiligo in your family



there is a history of other autoimmune conditions in your family 



you have injured the affected area of skin – for example, you have had sunburn or a severe rash there



you tan easily in the sun, or whether you burn 



any areas have got better without treatment, or whether they are getting worse



you have tried any treatments already



Your GP may also ask about the impact that vitiligo has on your life. For example:



how much it affects your confidence and self-esteem



whether it affects your job



 

Wood’s lamp

If one is available, your GP may use an ultraviolet (UV) lamp called a Wood’s lamp to look at your skin in more detail. You will need to be in a dark room and the lamp will be held 10-13cm (4-5in) away from your skin.

Under the UV light, the patches of vitiligo will be easier to see. This can help your GP tell the difference between vitiligo and other skin conditions, such as pityriasis versicolor (a yeast infection that causes a loss of pigment in small, round patches).

Other autoimmune conditions

Non-segmental vitiligo, the most common type of vitiligo, is closely associated with other autoimmune conditions. You may be assessed to see if you have any symptoms that could suggest an autoimmune condition, such as:



being tired and lacking in energy (signs of Addison’s disease)



being thirsty and needing to urinate often (signs of diabetes)



A blood sample may also be needed to test your thyroid for conditions such as an overactive thyroid (hyperthyroidism).

 

Treating vitiligo 

Treatment for vitiligo is based on improving your skin’s appearance by restoring its colour. However, the effects of treatment are not usually permanent, and it cannot always control the spread of the condition.

Your GP may begin treating your condition with:



sun safety advice



a referral for camouflage creams



topical corticosteroids



No further treatment may be necessary if, for example, you only have a small patch of vitiligo or have very fair skin anyway. You may be referred to a dermatologist (specialist in treating skin conditions) if further treatment is needed.

You can also see a summary of the pros and cons of these treatments, which allows you to easily compare your treatment options.

 

Protection from the sun

Sunburn is a real risk if you have vitiligo. You must protect your skin from the sun and avoid sunbeds.

When skin is exposed to sunlight, it produces a pigment called melanin to help protect it from ultraviolet light. If you have vitiligo, there is not enough melanin in your skin, so it is not protected.

Always apply a high-factor sunscreen, ideally with a sun protection factor (SPF) of 30 or above, to protect your skin from sunburn and long-term damage. This is particularly important if you have fair skin.

Protecting your skin from the sun will also mean you don't tan as much. This will make your vitiligo less noticeable.

 

Vitamin D

If your skin is not exposed to the sun, there is an increased risk of vitamin D deficiency. Vitamin D is essential for keeping bones and teeth healthy.

Sunlight is the main source of vitamin D, although it's also found in some foods, such as oily fish.

To avoid potential problems like rickets (known as osteomalacia in adults), you may need to take vitamin D supplements.

 

Skin camouflage

Skin camouflage involves applying coloured creams to the white patches on your skin. These creams are specially made to match your natural skin colour. The cream blends in the white patches with the rest of your skin, making them less noticeable.

For advice about skin camouflage, your GP may refer you to the Changing Faces skin camouflage service.

You need to be trained in using the camouflage creams, but the service is free (although donations are welcome).

Camouflage creams are waterproof and can be applied anywhere on the body. They last up to four days on the body and 12-18 hours on the face.

You can also get skin camouflage cream that contains sun block or has an SPF rating.

Self-tanning lotion (fake tan) may also help cover vitiligo. Some types can last several days before you need to reapply them. Self-tanning lotion is available from most pharmacies.

 

Topical corticosteroids

Corticosteroids are a type of medicine that contains steroids. Topical means that the medicine is applied to the skin, such as a cream or ointment.

Topical corticosteroids are unlicensed for the treatment of vitiligo, but they can sometimes stop the spread of the patches, and may restore some of your original skin colour. Your GP may prescribe a topical corticosteroid cream to adults if:



you have non-segmental vitiligo on less than 10% of your body



you want further treatment (sun protection advice and camouflage creams are enough for some people) 



the treatment is not for your face



you are not pregnant



you understand and accept the risk of side effects



 

Using topical corticosteroids

Your GP may prescribe a cream or an ointment, depending on what you prefer and where it will be used. Ointments tend to be greasier. Creams are better in your joints – for example, inside your elbows. Possible corticosteroids that may be prescribed include:



fluticasone propionate



betamethasone valerate 



hydrocortisone butyrate



Your GP will tell you how to apply the cream or ointment to the patches and how much you should use (see below). You normally need to apply the treatment once a day.

 

How much topical corticosteroid to use



Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU).



One FTU is the amount of topical steroid squeezed along an adult's fingertip.



One FTU is enough to treat an area of skin twice the size of an adult's hand.



 

Follow-up

After one month, your GP should ask you to return, so they can see how well the treatment is working and check for any side effects. If your vitiligo is not improving or the treatment is causing side effects, you may need to stop using corticosteroids.

After another month, your GP will see how much your vitiligo has improved. If there is no improvement, you may be referred to a dermatologist (see below). If your vitiligo has improved slightly, you may continue treatment, but have a two-week break from treatment every three weeks. You may also be referred to a dermatologist.

If the vitiligo has improved, treatment will be stopped. 

Your GP may take photos of your vitiligo throughout your treatment to monitor any signs of improvement. If you have a camera, you may also want to take photos to keep an eye on your condition.

 

Side effects

Side effects of topical corticosteroids include:



streaks or lines in your skin (striae)



thinning of your skin (atrophy)



visible blood vessels appearing (telangiectasia)



excess hair growth (hypertrichosis)



contact dermatitis (inflammation of your skin)



acne



 

Referral

You GP may refer you to a dermatologist if:



they are unsure about your diagnosis



you are pregnant and need treatment 



more than 10% of your body is affected by vitiligo 



you are distressed about your condition 



your face is affected and you want further treatment 



you cannot use topical corticosteroids because of the risk of side effects 



you have segmental vitiligo and want further treatment 



treatment with topical corticosteroids has not worked



Children with vitiligo who need treatment will also be referred to a dermatologist.

In some cases, you may be prescribed strong topical corticosteroids while you are waiting to be seen by a dermatologist.

Some treatments your dermatologist may recommend are described below.

Topical pimecrolimus or tacrolimus

Pimecrolimus and tacrolimus are a type of medicine called calcineurin inhibitors, which are normally used to treat eczema.

Although they are unlicensed for the treatment of vitiligo, pimecrolimus or tacrolimus may be used for children or adults with the condition.

They can cause side effects, such as:



burning or painful sensations 



making the skin more sensitive to sunlight



facial flushing (redness) and skin irritation if you drink alcohol



 

Phototherapy

Phototherapy (treatment with light) may be used for children or adults if:



topical treatments have not worked 



the vitiligo is widespread



the vitiligo is having a significant impact on their quality of life



Evidence suggests that phototherapy, particularly when combined with other treatments, has a positive effect on vitiligo.

During phototherapy, your skin is exposed to ultraviolet A (UVA) or ultraviolet B (UVB) light from a special lamp. You may first take a medicine called psoralen, which makes your skin more sensitive to the light. You can take psoralen by mouth (orally), or you can add it to your bath water.

This type of treatment is sometimes called PUVA (psoralen and UVA light).

Phototherapy may increase the risk of skin cancer because of the extra exposure to UVA rays. Your dermatologist should discuss this risk with you before you decide to have phototherapy.

Although you may be able to buy special sunlamps to use at home for light therapy, these are not recommended. They are not as effective as the phototherapy you will receive in hospital. The lamps are also not regulated, so may not be safe. 

 

Skin grafts

A skin graft is a surgical procedure that involves removing healthy skin from an unaffected area of the body and using it to cover an area where the skin has been damaged or lost. To treat vitiligo, a skin graft can be used to cover the white patch.

Skin grafts may be considered for adults in areas that are affecting your appearance if:



no new white patches have appeared in the last 12 months 



the white patches have not gotten worse in the last 12 months 



your vitiligo was not triggered by damage to your skin, such as severe sunburn (known as the Koebner response)



This type of treatment is time-consuming and is not widely available in the UK. It has a risk of scarring and will not be considered for children.

 

Depigmentation

Depigmentation may be recommended for adults who have vitiligo on more than 50% of their bodies, although it may not be widely available.

During depigmentation, a lotion is painted on to the normal skin to bleach away the pigment and make it the same colour as the depigmented (white) skin. A hydroquinone-based medication is used, which has to be applied continuously to prevent the skin from re-pigmenting.

Hydroquinone can cause side effects, such as:



redness



itching 



stinging



Depigmentation is usually permanent and leaves the skin with no protection from the sun. Re-pigmentation (when the colour returns) can occur, and may differ from your original skin colour.

 

Other treatments

Your dermatologist may recommend trying more than one treatment, such as phototherapy combined with a topical treatment. Other possible treatments include:



excimer lasers – high-energy beams of light that are used in laser eye treatment, but may also be used in phototherapy 



vitamin D analogues – such as calcipotriol, which may also be used with phototherapy



azathioprine – a medicine that suppresses your immune system (the body’s natural defence system), which may be used with phototherapy 



oral prednisolone – a type of corticosteroid, which has also been used with phototherapy, although it can cause side effects



 

Complementary therapies

Some complementary therapies claim to relieve or prevent vitiligo. However, there is no evidence to support their effectiveness, so more research is needed before they can be recommended.

There is very limited evidence that Ginkgo Biloba, a herbal remedy, may benefit people with non-segmental vitiligo. However, there is currently not enough evidence to recommend it.

If you decide to use herbal remedies, check with your GP first, as some remedies can react unpredictably with other medication or make them less effective.

 

Counselling and support groups

If you have vitiligo, you may find it helpful to join a vitiligo support group. This can help you understand more about your condition and come to terms with your skin’s appearance.

Charities, such as The Vitiligo Society, may be able to put you in touch with local support groups (you may need to become a member first). Your GP may also be able to suggest a local group.

If you have psychosocial symptoms – for example, your condition is causing you distress – your GP may refer you to a psychologist or a counsellor for treatment such as cognitive behavioural therapy (CBT).

CBT is a type of therapy that aims to help you manage your problems by changing how you think and act.


Vitiligo