WHAT IS VITILIGO

Updated 22 June 2021

Vitiligo is a medical condition in which white skin discoloration appears on different parts of the body. It affects one in every one hundred people worldwide and is therefore not a rare condition. Vitiligo happens when Melanocytes, the cells responsible for skin color, stop producing skin pigment, also called melanin.

The white patches of Vitiligo can appear on any part of your body, and they may cover any amount of skin surface area. The condition is not contagious. 

How does vitiligo look?

The white skin patches seen in vitiligo can be as small as a coin, or large enough to cover a whole limb, and one or more areas can be affected at the same time. Most people with vitiligo have it on their hands, face, or skin folds, however, vitiligo can affect any region of your body, including your genitals, the inside of your mouth, and even the inside of your eyes and auditory system. Hair that’s on affected regions might also become grey from the lack of melanin.

Depending on the pattern of distribution of the patches, doctors classify vitiligo as either focal or generalized:

• Focal (or segmental): People who have smaller patches that are localized to one small region of the body, like the right arm, or left leg for example, are said to have focal vitiligo. Compared to generalized vitiligo, focal vitiligo progresses slower, usually over one year, and then halts.
• Generalized (or non-segmental): This is the more common pattern. People who have generalized vitiligo show white patches on both sides of the body, like on both legs or arms. The pattern of growth is less predictable with this type, and the patches tend to grow and cease many times during the person’s lifetime.

Who gets vitiligo?

Vitiligo is seen in 1-2% of the population, and it can affect all races and both genders equally. Nevertheless, the skin lesions are more noticeable in people with darker skin color. The patches usually appear early during one’s lifetime, and almost always before reaching the age of 40.

We are still not really sure why vitiligo happens. We know that melanocytes stop producing melanin, but we do not know why, and it doesn’t seem to be a hereditary problem. Nevertheless, people who have a family history of vitiligo are more likely to have it, suggesting a possible familial link.

People with vitiligo are also likely to have other autoimmune diseases, such as scleroderma, lupus, thyroiditis, psoriasis, alopecia, type 1 diabetes mellitus, and others. This has led to the belief that vitiligo is also an autoimmune disease. This means that your body’s immune system is attacking melanocytes and causing the problem, however, we still don’t know why.

What causes vitiligo?

The pathophysiology and mechanism of vitiligo are a little bit complex and not yet clearly understood. We know that melanocytes are destroyed in people with vitiligo, but we don’t know exactly why. One of the most accepted theories is that vitiligo is an autoimmune disease.

The autoimmune theory of vitiligo suggests that vitiligo happens when immune T-cells and B-cells start attacking melanocytes and destroying them. Researchers were able to find activated cytotoxic T-cells in the blood and skin of patients with vitiligo. Antibodies against melanocytes have also been discovered in these patients’ blood, further supporting the autoimmune explanation.

New research has also suggested the role of “memory” T-cells in the recurrence of vitiligo when stopping treatment. Memory T-cells are a form of immune cells that “saves” information related to their targets (in this case, melanocytes) to later activate the immune system against them. These cells were found in the skin lesions in vitiligo patients. The researchers theorized that once we stop treatment, these cells re-activate the immune systems, and cause the vitiligo lesions to show again.

Immune suppression and targeted immune therapy (JAK Inhibitors) aim to target the pathways that lead to the activation of T-cells and B-cells, and hopefully cure vitiligo.

How is vitiligo diagnosed?

A dermatologist can usually diagnose vitiligo by physical examination after obtaining a thorough medical history. They can order blood work to search for other related problems that are usually associated with vitiligo, such as anemia and diabetes. If your doctor is unsure of the diagnosis, they might take a small skin biopsy and send it to the lab for examination. This helps the doctor see if there are any melanocytes present in the diseased skin segment.

What are the treatment options?

Treatment of vitiligo depends on several factors, such as how extensive the patches are, their location and number, and your treatment response. Your doctor might suggest surgical treatment, medical treatment, or a combination of both. The goal of treatment is to achieve a homogeneous skin color.

Medical treatment: this refers to all forms of treatment that do not include surgery, and it includes oral and topical medications, as well as other forms of therapy.

• Ointments and creams: these are topical agents used to either slow the progression of vitiligo or reverse its effects. These agents might weaken your skin and cause some local irritation.
• Oral drugs: your doctor might prescribe steroids or other oral medications that can treat vitiligo.
• Photochemotherapy: also known as psoralen and ultraviolet A (PUVA) therapy, is a treatment modality that combines oral or topical psoralen (a drug) and ultraviolet light therapy. After applying or ingestion the drug, the ultraviolet light is applied to your skin to activate it.
• Narrow-band ultraviolet B (NB-UVB) therapy: This is another form of light therapy that has been used in treating vitiligo for some time, and it might have fewer side effects than PUVA.
• Laser therapy: It can be beneficial in treating localized lesions, and requires several sessions depending on your response.
• Depigmentation: If more than half of your skin surface area is affected by vitiligo, it might be easier to remove the pigment from the unaffected half and obtain a homogeneous color. This treatment is however reserved as a last choice, since it is permanent and can lead to skin inflammation, and it will make your skin more sensitive to sunlight. Depigmentation is done by using certain topical creams that remove pigment from your skin. The process takes around two years to complete.

Surgical Treatment

This is usually the last resort in treating vitiligo, and can only be attempted if your vitiligo has been stable and not growing for at least one year. There are several types of vitiligo surgeries:

• Miniature punch grafting: This is a skin grafting technique used to treat vitiligo. It involves the removal of very tiny pieces of healthy malanocyte-rich skin from donor sites (like your buttocks) and inplanting them into the vitiligo-affected areas. Each “punch” of removed skin is around 2 mm in diameter
• Split thickness skin grafting: This is another skin grafting technique that can be used to treat vitiligo. This surgical procedure involves harvesting a large patch of skin from a donor site and implanting it in hypopigmented areas. This technique has the advantage of being able to uniformly treat large 
• Melanocyte transplant (MKTP): Also known as melanocyte-keratinocyte transplantation or MKTP. It is an advanced technique in which the doctor removes normal melanocytes and sends them to be grown in the lab, and then re-implants them in the affected areas. Results start appearing 2 months after melanocyte transplant. It is currently one of the most promising surgical treatments for vitiligo. One study done at the Henry Ford Hospital showed that the results of MKTP were sustained in most patients nearly 5 years after the procedure.

Emerging Treatments

These future treatments of vitiligo have shown much promise and are expected to be the long-awaited solution for the chronic skin condition:

• Ruxolitinib: Ruxolitinib is a JAK inhibitor. JAK (Janus Kinase) is a family of enzymes that mediate certain inflammatory processes, some of which are thought to be involved in vitiligo, alopecia, and other skin conditions. Researchers presented very promising study results during the annual American Academy of Dermatology (AAD) meeting held earlier in 2021. This potential new vitiligo treatment was tested in two recent clinical trials. It was able to completely cure vitiligo and restore color to facial and body skin. The results were sustainable and were unaffected even 104 weeks after therapy. Ruxolitinib is expected to be a groundbreaking treatment for vitiligo, especially since it can be taken orally or applied as a cream applied twice daily.
• Afamelanotide: This is another new treatment for vitiligo that’s undergoing heavy investigation. Afamelanotide stimulates pigment cells (melanocytes) and encourages their proliferation. The drug is delivered as an extended-release implant inserted under the skin. The implant releases the drug over several days. Data from an ongoing study of 55 patients showed that afamelanotide combined with NB-UVB can speed up repigmentation and heal vitiligo more effectively compared to NB-UVB alone.
• Prostaglandin E2: Prostaglandin is a chemical mediator produced by the body to serve numerous physiologic roles. It has been studied as a potential new treatment for vitiligo for the past 2 decades. Some studies have shown promising results with excellent skin repigmentation rates.

Vitiligo is not an uncommon skin condition, and it might be both a physical and psychological burden. If you have vitiligo and it’s causing you cosmetic concerns, you can discuss any of the available treatments with a dermatologist.

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Sources:

• mynvfi.org/about_vitiligo
• vitiligosociety.org.uk/phocadownload/mv-suncare.pdf
• ncbi.nlm.nih.gov/pmc/articles/PMC5017284/
• dermnetnz.org/topics/vitiligo
• niams.nih.gov/Health_Info/Vitiligo/default.asp
• nih.gov/news-events/news-releases/scientists-implicate-gene-vitiligo-other-autoimmune-diseases
• https://pubmed.ncbi.nlm.nih.gov/28502377/
• https://www.hcplive.com/view/ruxolitinib-cream-could-become-novel-treatment-vitiligo
• https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2008.08923.x

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