Vitiligo is caused by the loss of melanin in the affected areas of skin. Melanin is a pigment that gives skin its colour and protects from the sun’s rays. Both fair and dark-skinned people have melanin, although darker skinned people produce more melanin. Melanin is produced by specialised cells in the skin, known as melanocytes. In vitiligo, some melanocytes are destroyed, leading to a loss of melanin pigment and the development of white patches in the affected regions.

The process by which melanocytes are destroyed is unclear. Some studies suggest it may be an autoimmune process, whereby the body’s immune system attacks the melanocyte cells. Other studies suggest that melanocytes are destroyed by toxic chemicals released from nerve endings.

Vitiligo is characterised by flat patches of pale, white skin.

The patches are not scaly and are not normally associated with other symptoms such as pain or itchiness. Patches may occur on any part of the body, although they most commonly occur on the:

• Fingers and wrists
• Neck
• Genitalia
• Skin around eyes and mouth
• Skin in body folds e.g. armpits or groin.

Vitiligo can also affect the scalp. When the scalp is involved, hair in the affected region may become grey or white.

Patches of skin affected by vitiligo are also more prone to sunburn. This is due to the loss of the pigment melanin, which ordinarily protects against sunlight.

Types of vitiligo

Vitiligo may be divided into two main types:

• Non-segmental vitiligo – which accounts for the vast majority of cases (85 – 90%) of vitiligo
• Segmental vitiligo

The distribution of white patches depends on the type of vitiligo. In non-segmental vitiligo, the patches are often found on both sides of the body and are symmetrical. In segmental vitiligo, white patches are usually restricted to a specific area on one side of the body.

Development of vitiligo

Vitiligo can develop at any age, but, in about 50% of people, it develops before the age of 20. Initially, the white patches are usually small. Over time, the patches become larger and more numerous.

The way the condition progresses is different from person to person: some people may develop patches very quickly, whereas others may notice little change over time.

Segmental vitiligo tends to present earlier in life and is more common in children.

A GP can diagnose vitiligo based on a simple examination of the skin. Blood tests, skin biopsies and other further investigations are rarely required to diagnose vitiligo.

The GP will need to see all of the white patches on your skin in order to accurately diagnose the type of vitiligo and ensure the best treatment.

In some cases, the GP may wish to look at your skin using an ultraviolet (UV) lamp, known as a Woods lamp. The UV light allows the GP to visualise the white patches more clearly and can also help exclude other diagnoses e.g. fungal infections of the skin.

The GP may also ask further questions in order to ascertain, for example:

• when you first noticed the white patches
• whether the white patches have spread
• whether you have family history of vitiligo
• whether you have other conditions, including autoimmune conditions
• whether you have already tried any treatments.

In order to investigate any possible autoimmune condition associated with vitiligo, the GP may require further tests. For example, if the GP wants to investigate autoimmune thyroid disease, a blood test known as a thyroid function test may be needed.

Referral to a dermatologist

In some cases, your GP may need to refer you on to see a dermatologist. You may be referred to a dermatologist in the event:

• the GP requires a second opinion on your condition
• you have segmental vitiligo requiring treatment
• you are pregnant and require treatment for vitiligo
• greater than 20% of your body area is affected
• your face is affected
• your current treatment is ineffective.

There is currently no permanent cure for vitiligo, but there are various treatments available that can help restore normal skin colour. The response to different treatments varies from person to person and there is no single best treatment for all cases of vitiligo. A GP or dermatologist may decide to combine more than one treatment.

The different treatment options on offer are outlined below.

Skin camouflage

Skin camouflage refers to creams that match normal skin colour and are applied on top of the white patches. They aim to make white patches less visible but do not alter the disease process – that is, they do not prevent the loss of melanocytes and melanin.

Skin camouflage creams may be prescribed on the NHS. A GP may also refer a person to the Changing Faces Skin Camouflage Service – a free service which helps people find the best cream to match their normal skin colour.

Self-tanning or fake tan lotions may also help to disguise vitiligo patches. They are available to buy from most pharmacies.

Topical corticosteroids / steroid creams

Topical corticosteroids are creams or ointments that contain steroids. They include creams such as: betamethasome valerate, fluticasone propionate and mometasone.

Steroids work by suppressing the immune system, thereby reducing the autoimmune destruction of melanocytes that occurs in vitiligo. Topical corticosteroid cream is applied to white patches when they first develop and can prevent patches from enlarging. Due to side effects (such as thinning of the skin and stretch marks) they are only prescribed for a maximum of 2 months and are not recommended for use on the face.

Tacrolimus or pimecrolimus cream

Tacrolimus and pimecrolimus creams are part of a group of drugs known as calcineurin inhibitors. Similar to steroids, they work by suppressing the immune system and preventing the destruction of melanocytes. They have been demonstrated to restore normal skin colour in some people with vitiligo.

Tacrolimus and pimecrolimus creams have the advantage of being able to be applied to the face and are also suitable for use in children.

Phototherapy

Phototherapy involves exposing the skin to ultraviolet light using a special lamp. Exposure to UV light in controlled settings may stimulate the skin to produce more melanin and thus restore skin colour.

There are two types of phototherapy for vitiligo:

• Narrow Band Ultraviolet B (UVB) phototherapy
• Psoralen and Ultraviolet A (PUVA) phototherapy

Both phototherapies require treatment from a health professional on a twice-weekly basis. Treatment normally lasts between 6 and 24 months.

In PUVA (Psoralen and Ultraviolet A), people with vitiligo take a medication called psoralen, before being exposed to the UV light. Psoralen sensitises the skin for treatment with UV light. It can be taken orally or applied to the skin as a cream or by soaking in a bath.

Skin grafts

Skin grafting is a surgical procedure in which normal, unaffected skin is removed from one part of the body and transferred to cover the white patches of vitiligo.

Skin grafting is a time-consuming treatment and is not widely available on the NHS.

Depigmentation

Depigmentation involves removing the pigment from normal, unaffected areas of skin in order to match the white colour of vitiligo patches. This allows the whole skin to have the same colour.

The treatment involves applying a hydroquinone-based cream to unaffected skin. The cream acts to destroy melanocytes in the skin, thereby causing a loss of pigment. It takes between 1 and 4 months for the skin to become adequately depigmented. Following this, cream will still need to be applied regularly, to prevent repigmentation of the skin.

Depigmentation may be considered as a treatment in those with extensive vitiligo, where greater than 50% of body area is affected. Discussion with a dermatologist is required before starting treatment. Depigmentation is often permanent and leaves the skin with little protection from the sun. Lifelong sun protection is therefore required after treatment.

Other treatments

There are other treatments for vitiligo which are less frequently used.

• Laser treatment – involves exposing patches to high-energy beams of UV light (known as excimer lasers). The treatment aims to stimulate the production of melanin. Laser therapy for vitiligo is not available on the NHS and the evidence for its effectiveness is mixed.

• Oral corticosteroids – include steroid drugs (such as prednisolone) which are taken by mouth (orally). They may be considered in cases where vitiligo patches spread quickly. Oral steroids have many side-effects and not commonly prescribed.

• Azathiaprine – is another drug that suppresses the immune system to prevent the autoimmune destruction of melanocytes. It is not commonly used.

• Complementary medicines – include traditional Chinese medicines and herbal remedies such as Gingko Biloba. There is currently not enough evidence to recommend these medicines and they are not available on the NHS.

A person may be at increased risk of developing vitiligo if they have:

• a family member with vitiligo

• an autoimmune condition such as diabetes, thyroid disease, Addison’s disease or pernicious anaemia

• a family member with an autoimmune condition (such as diabetes, thyroid disease, Addison’s disease or pernicious anaemia)

• a melanoma (a type of skin cancer)

• a cutaneous T cell lymphoma (a type of cancer of the lymphatic system that affects the skin).

Race, ethnicity or the colour of a person’s skin do not affect the risk of developing vitiligo, although white patches may be more noticeable in people with dark skin.

Vitiligo affects men and women equally.

Certain events may trigger the onset of vitiligo, including:

• Emotional stress
• Childbirth
• Damage to the skin e.g. from a cut or burn
• Exposure to certain chemicals.

Use sun protection

Owing to the loss of melanin pigment, white patches of vitiligo are not protected from sunlight. Affected regions of skin may burn easily. People with vitiligo are therefore advised to:

• cover white patches with clothing
• always apply a high-factor sun cream. High-factor creams have an SPF (Sun Protection Factor) of 30 or above. Some sun creams may be available on prescription.
• avoid being in the sun at the hottest times of day – usually between 10am and 4pm
• avoid sunbeds.

Consider refraining from tanning

White patches do not tan in sunlight, but unaffected normal regions of skin will tan. Fair-skinned people may find that white patches become less contrasting and noticeable, when normal skin is left untanned.

Consider Vitamin D supplements

The skin uses sunlight to produce Vitamin D. Although Vitamin D is also found in foods (e.g. oily fish and dairy products), reduced exposure to sunlight may put a person at risk of vitamin D deficiency.

People with vitiligo may consider taking daily 10 microgram vitamin D supplements and should discuss this with a GP.

Avoid injury to the skin

Cuts and burns to the skin may trigger the development of further white patches. People with vitiligo should take care to avoid injuring their skin.

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http://bestpractice.bmj.com/best-practice/evidence/background/1717.html

Ezzedine et al (2015). Seminar: Vitiligo. The Lancet, Vol 386; 74-84.

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Vitiligo. NHS Choices. Available online at: http://www.nhs.uk/Conditions/Vitiligo