MUDr. Lucie Polák: Vitiligo – causes, symptoms and treatmentsArticle
15. 06. 2022 Dermatovenerology
Vitiligo is an acquired non-infectious skin disease manifesting in white patches on the skin or mucous membranes. The spots most commonly appear on the face, around the eyes and mouth, on the fingers, knuckles and groin. The disease affects 0.5-2% of the population, and half of the cases present with first symptoms before the age of 20, regardless of gender or race. This article will discuss the suspected causes of vitiligo, how it manifests, and the different treatment options available.
What is vitiligo?
Vitiligo is a condition that causes patchy depigmentation of the skin or mucous membranes. Vitiligo spots are chalky white in colour, sharply demarcated from healthy skin, and if hair or pubic hair grows from them, this too is usually without pigmentation. The name vitiligo comes from the Latin word vitium (blemish, defect) or vitelis (white colour).
Pigment cells (melanocytes) are responsible for the production of pigment in our skin, and so vitiligo is thought to be a disorder of these cells (see more below under Causes of vitiligo).
Vitiligo does not hurt and is more of a cosmetic than a health problem for the patient - the appearance of the affected skin can also cause psychological problems. However, other unpleasant complications can also be associated with the disease. There are also cases where the disease occurs together with other autoimmune diseases.
Causes of vitiligo
Vitiligo is a multifactorial disease with a complex and not fully understood pathogenesis. Thus, there are several possible proposed mechanisms responsible for its manifestation.
The autoimmune theory - cells of our immune system attack melanocytes, wherein both humoral and cellular immunity are thought to be involved. This theory is supported by increased levels of activated lymphocytes in the blood of patients and in lesions of the affected skin, as well as by the frequent occurrence of associated autoimmune diseases such as thyroid disease, diabetes, rheumatoid arthritis or systemic lupus erythematosus.
Neutral theory - according to another hypothesis, melanocytes can be destroyed by substances that serve to transmit signals between nerve cells and are toxic to melanocytes.
Self-destructive theory - the role of toxic metabolites that are produced during melanin synthesis, i.e. a state in which melanocytes destroy themselves, is also considered.
However, genetics is also an important factor to consider in the development of the disease - the risk of an outbreak in a first-degree relative is 7-10 times higher. So far, the genes that could be the cause have not been clearly identified. So-called polygenic inheritance is being considered.
Manifestations and types of vitiligo
The typical manifestation of vitiligo is a patch of chalky white skin, well-circumscribed by healthy skin, which can be several millimetres to tens of centimetres in size. If hair or hairs grow from the surface of this patch, they are also discoloured. These spots are not sensitive, and do not itch or bother the patient in any other way apart from their aesthetic irregularity.
The initial symptoms appear on the hands, forearms and feet.
In patients with fair skin, the manifestations of vitiligo may be more subtle and harder to detect. In these patients, the patches can be better detected with a special Wood's lamp examination.
The course of the disease can vary from person to person and is very difficult to predict. Without treatment, the disease is progressive. Spontaneous repigmentation and spontaneous return of pigment is described in 10-20% of cases.
This disease is characterised by the Koebner phenomenon, i.e. the appearance of symptoms at the site of physical irritation, such as scratches, burns, or after therapeutic procedures. The affected skin is more sensitive to UV radiation as it loses its natural protection.
As already mentioned in the introduction, due to its appearance-altering manifestation, confidence and self-esteem issues are common in people with vitiligo, particularly if it affects areas of skin that are frequently exposed.
Vitiligo is most commonly classified according to the extent of the affected skin:
Segmental vitiligo - affects one area of the body
Local- this involves one or more patches in one area.
Segmental - here we are talking about one or more spots in a stripe (follows one dermatome).
Mucosal - affecting the mucous membranes.
- Generalised - affecting more than one area. Most often, it is an affection of the acral parts of the body (fingers, toes,...).
- Universal vitiligo affects the entire skin cover and is more often accompanied by other autoimmune disorders.
Vitiligo and associated diseases
Vitiligo may be accompanied by pathologies of other organs and body parts:
- eyes - choroidal abnormalities are described in up to 30% of vitiligo patients, iris defects in 5% of vitiligo patients.
- ears - in vitiligo, melanocytes, which are found in the labyrinth of the inner ear, may also be affected, thus causing hearing impairment - dysacusis.
A number of other autoimmune diseases are associated with vitiligo. The most common are thyroid disorders (thyroidopathy), which are present in up to 40% of cases. Other disorders may include hair loss (alopecia areata), diabetes mellitus (type 1 diabetes mellitus), non-specific intestinal inflammation or pernicious anaemia.
Treatment for vitiligo
Vitiligo is not yet a curable disease. However, it can be managed very well with symptom control. Depending on the severity, several types of treatment are used, but it is always necessary to first rule out associated general diseases with blood tests carried out by a GP. The treatment of vitiligo belongs under the expertise of a dermatologist.
Treatment is categorized into the following forms:
This is the foundation of all therapy for vitiligo and is particularly suitable for vitiligo affecting less than 20 per cent of the skin surface.
- Topical medications - corticosteroids and topical immunomodulators (calcineurin inhibitors) are mainly used.
- Light therapy (phototherapy) - uses UV light, the most effective wavelength is 308 to 314 nm. Sometimes phototherapy is combined with drugs that make the skin more receptive to radiation (PUVA).
- Surgical treatment - surgical methods aim to replace missing melanocytes in non-pigmented areas of the skin with melanocytes derived from normally pigmented skin. These methods are recommended for stable disease. It can be combined with phototherapy.
Total treatment is appropriate for the treatment of vitiligo with extensive skin involvement.
- Light therapy (phototherapy) - This uses whole-body emitters (tanning booth-like machines) that emit UVB 311 nm or UVA (320 to 400 nm) along with pre-radiation tablets that make the skin more sensitive to radiation (PUVA).
- Systemic drugs - total treatment with these is rarely given due to the high incidence of side effects (prednisone tablets).
- Cosmetic therapies
Other treatment options include:
Cosmetic agents - used as adjuncts to treatment. These are protective sunscreens etc., or various cosmetic camouflages such as special resistant make-up or self-tanning cosmetic products to darken the affected areas.
Spa treatment - this is offered by some Czech and Slovak spas that treat psoriasis. This option is not covered by insurance, of course.
Psychotherapy - this is often a very important part of the treatment, as vitiligo can significantly impact the quality of life.
Depigmentation - removal of pigment from the rest of the body to achieve a uniform skin colour, used primarily in patients with a darker phototype.
Interesting fact: The most famous vitiligo patient was undoubtedly Michael Jackson. However, even today there are many celebrities, models and models who break the taboo of this otherness, they do not camouflage vitiligo in any way - on the contrary, they see it as their unique mark, or something that sets them apart from the masses.
Prevention, care and protection
"Vitiligo is a chronic disease with an unpredictable course. Every patient with vitiligo should know that vitiligo symptoms occur at the sites of mechanical irritation and it is not advisable to undergo cosmetic procedures where skin damage occurs (e.g. piercing, tattoo, permanent make-up, etc.)," says Lucie Polák, MD, dermatovenerologist at Canadian Medical.
Patients suffering from vitiligo are advised to undergo regular laboratory blood tests for the possibility of associated diseases and regular skin examinations for increased risk of skin cancer. It is important to remember that vitiligo treatment belongs in the hands of a skin doctor (dermatologist).