European Academy of Dermatology and Venerology
Ended7 months ago More20 Oct 2011
Tattoo for vitiligo patches: when and how
Tattoo is currently adopted by the general population for ritual or symbolic reasons. It consists in introducing into the dermis micropigments, i.e. inert iron oxides that are considered unable to migrate. The micropigment implanted into the skin cannot be washed off, but the colors fade naturally in 24-36 months.
Cosmetic results are dependent on doctor’s or technician’s skill in matching the color of the tattoo with the color of the surrounding normal skin.
Dark skinned people usually have better results than faired skinned ones.
Adverse effects which have been reported include recurrences of herpes simplex infection, chronic granulomatous reactions to implanted pigments, allergic reactions, koebnerization, imperfect color matching and, in our experience, also cutaneous pseudolymphomas.
Question: What is vitiligo?
Vitiligo is an acquired disorder of the skin and mucous membranes that is characterized by well circumscribed, white macules and patches and that occurs secondary to selective destruction or inactivation of the cells which mainly produce the color of the skin, named melanocytes. It may appear at any age; cases have been reported as early as 6 weeks after birth and after 80 years of age.
Vitiligo can be rarely tolerated, being more often a psychologically devastating disease, especially in darker skinned individuals, in whom it is more easily noticeable. It appears to be inconsistently transmitted genetically, in a multifactorial manner. The actual cause of vitiligo is under debate and has been attributed to autoimmune causes, oxidative stress, and/or neurogenic disturbance. These terms will be explained later on.
In other terms, vitiligo is a skin and/or mucosal disorder characterized by white patches, often but not always symmetrical, which usually increase in size with time, corresponding to a substantial loss of functioning epidermal and sometimes hair follicle melanocytes. It may occur in a unilateral limited distribution or may be generalised.
Vitiligo lesions may rarely itch and have a high propensity to sunburn. Vitiligo is a chronic persistent and often progressive disorder; spontaneous repigmentation is uncommon and usually occurs around the hairs in a perifollicular pattern. Many patients are poorly educated about their illness. In one study, 51.3% of patients believed that their vitiligo was caused by poor medical care, 30% thought personal behavior played a major role, 25% wrong diet, 21.3% altered state of mind only, and 20% blamed only pollution or environmental alterations. All the above believes are considered by the scientific community “per se” unfounded and misleading, even if all of them may bring some true indications for understanding the disease and for finding the cure.
Vitiligo is not a contagious disease.
Vitiligo is a disease that presently cannot be cured, but successfully treated with many different approaches. Its progression can be halted in almost 90% of cases with appropriate therapy, most frequently by combining different treatments. More than 85% of subjects affected by vitiligo respond satisfactorily to the active treatments (medical or surgical).
Thus, it is not true that there is nothing to do for vitiligo. In fact, just the opposite is true.
Question: What does vitiligo look like?
Vitiligo appears as uneven white patches on the skin, that may vary from lighter tan to complete absence of pigment. Many people develop vitiligo bilaterally, in other words, if it appears on one elbow, it often appears on the other elbow. Researchers do not completely understand why this is. Others develop what is known as segmental vitiligo, where the patches develop in only one area or on only one side of the body.
Question: What is an autoimmune disorder?
An autoimmune disorder is any of a number of conditions in which a person's immune system reacts against the body's own organs or tissues, and the person's immune system produces antibodies to them. An autoimmune disorder is NOT an "immune deficiency". In the case of vitiligo, we believe that the immune system probably sees the person's own pigment cells as foreign bodies, and attacks them, destroying them or weakening them. Other examples of autoimmune disorders include thyroid disorders, alopecia areata, lupus, and pernicious anemia.
Question: What is a Melanocyte (Pigment Cell)?
A Melanocyte is a specialized cell located in the skin, which produces melanin (pigment). Surprisingly, all humans have roughly the same number of pigment cells in their skin. Those with darker toned skin, have pigment cells that are able to store more melanin within them. In the diagram below, the cell with the tendrils, marked "I" is the melanocyte. The brown color within the cell is the melanin. The cell uses the tendrils to distribute the melanin evenly throughout the skin.
Question: White Skin Patches
What is it?
White patches (depigmentation) on the skin are the foremost symbols of vitiligo. These patches are more common on the hands, feet, arms, face, and lips. Other common areas are the armpits and groin, and around the mouth, eyes, nostrils, navel, and genitals.
Vitiligo is a non-lethal, non-contagious disease and it does not cause any organic harm. It is not sore or itchy. Vitiligo itself does not develop into any other condition.
Complete knowledge of its etiology has been elusive for decades of intense research. During the past few years important findings started to shed light on its causes and pathogenesis of depigmentation.
What causes it?
According to the available data, it is likely that the loss of epidermal and follicular melanocytes in vitiligo
may be the result of several different pathogenic mechanisms. None of these hypotheses has been demonstrated yet.
Who is else affected by vitiligo? Estimates of the number of people affected by vitiligo disorder range from 2 to 8% of the world population. Vitiligo affects all races and both sexes equally and ninety-five percent of its victims are below the age of 40.
What are the treatment options?
Although there is no cure for vitiligo, there are now treatments available which can slow down vitiligo and also improve it. No single treatment for vitiligo works well in all cases. The response to the various treatments is variable and can depend on the type of vitiligo.
Question: Is vitiligo a common disease?
The prevalence of vitiligo is 0.5% to 2%. Large studies in China, India, and Denmark have found the prevalence to be 0.093%, 0.005%, and 0.38%, respectively. Gujarat, India is considered to have the highest prevalence in the world, at about 8.8%. Men and women are equally affected, but women are more likely to seek treatment.
In most studies 20% of vitiligo subjects report a first-degree relative suffering from vitiligo. The mean age of onset is earlier in those with a positive family history, which ranges from 7.7% to more than 50%. Vitiligo is significantly more prevalent in young women (≤ 30 years of age) than young men.
The peak in females occurs in the first decade of life.
Male peak prevalence is in the fifth decade of life.
Vitiligo is more frequently diagnosed in spring and summer (64.4%).
Question: Which is the cause of vitiligo?
It remains unclear what causes damage to melanocytes and their subsequent total inactivation and/or disappearance in vitiligo skin. There are several theories; the most prominent are autoimmune, neurohumoral, related to abnormal detachment of melanocytes from the epidermal layers and autocytotoxic. None are mutually exclusive, and it is likely that they each partially contribute to the disease formation.
The current thought is that vitiligo represents a group of different disorders with a similar outcome: the presentation of white patches on the skin. The convergence theory states that stress, accumulation of toxic compounds, infections, autoimmunity, genetic mutations, altered cellular environment, and impaired melanocyte migration can all contribute to the vitiligo initiation process. Autoimmune mechanisms likely underlie generalized vitiligo, while a more localized phenomenon (i.e., the altered activities of sensitive nerves in the skin) may be responsible for segmental or focal vitiligo. Site of a physical trauma may develop vitiligo ( his is named: Koebner phenomenon)
Question: I have vitiligo: will my children have vitiligo too?
Although most cases of vitiligo are sporadic, familial clustering is not uncommon, and up to 20% of patients report an affected relative. In whites, the lifetime frequency of vitiligo among patients’ siblings is 6.1%, an 18-fold increase over the studied population. The frequency of vitiligo among first degree relatives in white, Indo-Pakistani, and Hispanic populations is 7.1%, 6.1%, and 4.8%, respectively, compared to an estimated worldwide frequency of 0.14% to 2%.
Epidemiologic studies indicate that vitiligo is inherited in a multifactorial pattern, with incomplete penetrance. Monozygotic (i.e., identical) twins with identical DNA have only a 23% concordance in developing vitiligo, suggesting a significant non-genetic component in the disease.
Familial clustering of generalized vitiligo with other autoimmune diseases is compelling evidence for an autoimmune predisposition, a common underlying genetic susceptibility to an immunologic aberrancy. Among vitiligo patients, 20% report thyroid disease (an 8-fold increase over the general population), particularly hypothyroidism. Similarly, there is an increased frequency in other forms of autoimmune disease and autoimmune disorders of the endocrine system (see later on).
Question: Is it true that my quality of life will be affected by vitiligo?
It is true that vitiligo can be a psychologically devastating disease, especially in darker skinned individuals and in case of improper management provided by the dermatologist.
A quality of life assessment should be made always during the first consultation, because there may be a difference between patient and physician assessment of severity, and it should be followed during treatment to assess patient satisfaction. Studies suggest that vitiligo imparts a mental and emotional burden comparable to chronic hand eczema or psoriasis, and that women tend to suffer more than men. In a study of 158 patients with vitiligo, black or white skin did not impact the degree of disturbance by the disorder. Vitiligo patients also experience sexual difficulties and a variety of psychological problems, such as adjustment disorder, sleep disturbance, depression, anxiety, and the so called “dysthymia”.
Clinical variables, such as duration, facial or chest involvement, unsuccessful previous treatment, darker skin type, and extent of disease may predict a poorer quality of life.
In fact, vitiligo may be, or may become, a psychologically devastating disorder. The fact that it typically occurs in exposed areas (face and hands) has a major impact on self-esteem and perception of self. In many societies, vitiligo is poorly understood and is believed to be a sign of leprosy or sexually transmitted infection. In these societies, women with vitiligo have difficulty getting married and finding educational and vocational opportunities independently on their skills. Many patients worry about the disease worsening, have their social life affected, and feel embarrassment, depression, and shame.
Correct information on vitiligo (extended to the non-affected subjects to the media system and to the Authorities) will rapidly change this outrageously and incredible discriminated attitude against the alteration of the colour of the skin. The vitiligo patient’s association active in the different communities and the VRF are committed to fight against all irrational feelings and behaviors which negatively impact on the quality of life of vitiligo patients all over the world.
Question: How can I be sure that I am really affected by vitiligo?
Discrete, uniformly white patches with convex borders and surrounded by normal skin, not painful and very rarely itching: this is the usual presentation of vitiligo. White hair can be associated or not with the white patches. Any kind of trauma of the skin may induce white patches of vitiligo in any part of the skin surface: this is named Koebner Phenomenon, and is quite common.
The diagnosis of vitiligo is usually made clinically and with the use of Wood’s lamp, a handled device emitting ultraviolet rays (at 365 nm) which makes the color of the white patches more and more white.
Vitiligo is usually discovered during the spring and summer moths in sun exposed areas: normal skin becomes tanned while vitiligo skin remains white, with tendency to sun burn. When presentation of vitiligo is atypical, a biopsy can be taken from the skin, in order to show the complete absence of melanocytes in the white patch. A full body examination is necessary to detect all skin areas affected, including mouth mucosal and genital depigmentation.
Question: I have vitiligo: which blood tests or other examinations are necessary?
After the diagnosis of vitiligo a full body skin examination is necessary in order to evaluate the specific form of the disease. Thyrotropin (thyroid-stimulating hormone) levels, antinuclear antibody titer, and a complete blood count should be considered, for all generalized forms of vitiligo, especially when prompted by signs or symptoms. Antithyroid peroxidase antibodies and/or antithyroglobulin antibodies may also be worthwhile. They are mandatory if signs of thyroid disease are present.
The evaluation of possible associated disorders is mandatory in all the generalized forms of vitiligo.
All autoimmune diseases should be screened, as well as atopic dermatitis, psoriasis, pernicious anemia and diabetes. Ophthalmologic and auditory investigations can be useful because melanocytes are present both in the eye and in the inner ear.
Question: Is it true that vitiligo can be a part of a most complex multisystem organ dysfunction of the human body?
There are subjects in whom vitiligo is part of , or associated with a wider group of signs and symptoms.
The expert Dermatologist in cooperation with an expert Genetist and/or with other specialists will treat properly all cases of vitiligo associated with specific disorders and syndromes.
Here is reported a list of disorders and syndromes possibly associated with vitiligo. This list is of great interest for experts in Dermatology and specialists of many other Disciplines.
Disorders and syndromes possibly associated with vitiligo (in alphabetical order), more common associations:
Addison disease
Alopecia areata
Atopic dermatitis
Autoimmune thyroid disease
Chronic urticaria
Diabetes mellitus
Halo nevi
Hypoacusis
Hypoparathyroidism
Ichthyosis
Morphea
Ocular abnormalities
Pernicious anemia
Psoriasis
Rheumatoid arthritis
Question: Does it exist a complete list of white patches on the skin, which are not consistent with vitiligo?
Not all what appears white on the skin is vitiligo. White patches not diagnosed as vitiligo are named leukodermas.
Here is a list of leukodermas for dermatologic use:
Differential diagnosis in vitiligo: the Leukodermas.
Chemically-induced leukoderma (often occupational):
Arsenic
Phenols and other derivatives, cathecols
Infections:
Leishmaniasis (post kala-azar)
Leprosy
Onchocerciasis
Secondary siphylis
Tinea versicolor
Treponematoses (pinta and syphilis)
Genetic syndromes:
Hediac-Higashi syndrome
Hypomelanosis of Ito
Oculocutaneous albinism
Piebaldism
Tuberous sclerosis
Vogt-Koyanagi-Harada syndrome
Waardenburg syndrome
Postinflammatory hypopigmentation:
Atopic dermatitis/allergic contact dermatitis
Nummular dermatitis
Phototherapy- and radiotherapy-induced
hypopigmentation
Pityriasis alba
Posttraumatic hypopigmentation (scar)
Psoriasis
Sercoidosis
Systemic lupus erythematosus
Topical or systemic drug-induced depigmentation
Neoplastic:
Amelanotic melanoma
Halo nevus
Melanoma-associated leukoderma
Mycosis fungoides
Idiopathic:
Idiopathic guttate hypomelanosis
Lichen sclerosus et atrophicus
Lichen striatuselike leukoderma
Morphea
Melasma (caused by contrast between lighter and darker skin)
Progressive (or acquired) macular hypomelanosis
Malformations:
Nevus anemicus
Nevus depigmentosus/hypopigmentosus
Nutritional
Kwashiorkor
Selenium deficiency
Question: Whitish and depigmented patches on the skin: how can I know what they are?
No, not all white patches are vitiligo, but white patches resembling vitiligo are not unusual in the skin. They are named leukodermas. Chemical leukoderma has been induced by dyes, perfume, detergents, cleansers, insecticides, rubber condoms, rubber slippers, black socks and shoes, eyeliner, lip liner, lipstick, toothpaste, antiseptics with phenolic-derivatives, and mercuric iodide-containing ‘‘germicidal’’ soap.
Occupational vitiligo may occur in those who work with depigmenting substances like hydroquinone, paratertiary butyl catechol, paratertiary butyl phenol, paratertiary amyl phenol, hydroquinone monomethyl ether, and hydroquinone. Depigmentation has also been reported in shoemakers and from contact with arsenic-containing compounds. Nevus depigmentosus is a segmental hypopigmentation detectable in the first year of life and stable in size in proportion to the child’s growth. With a Wood’s lamp, the contrast between lesional and normal skin is less marked than in vitiligo. Piebaldism is an autosomal dominant disease presenting at birth with anterior midline depigmentation and a white forelock (poliosis). Many other types of leukodermas have been described. The diagnosis and treatment of leukodermas needs expert approach. The only way to know if a depigmented patch on the skin is vitiligo or not is to consult a Dermatologist with special interest in Pigmentary Disorders of the skin.
Question: How can I treat vitiligo?
Choosing a treatment for vitiligo can be difficult, sometimes overwhelming. In general, first-line therapy should be safe, effective, minimally invasive, and cost efficient. More complex, invasive, and time-consuming options should be reserved for subjects with recalcitrant disease. Each therapeutic modality should be tried for a sufficient period of time because the initiation of pigmentation varies and is in general rather slow. An effective therapy should be continued as long as there is improvement or the lesions completely repigment. We are in need of consistent data on maintenance regimens or the long-term persistence of pigmentation with any of the recommended therapies.
How to treat vitiligo:
First-line. There are many topical and some oral agents that are inexpensive, easy to administer, and effective at halting disease progression and inducing repigmentation. Corticosteroids (CSs) are consistently reported as the single most effective topical agent, with Calcineurine Inhibitors (CIs) being always a close second. Because local side effects of CSs are possible, scheduled drug holidays are recommended.
In our experience phocused micro-phototherapy (using 308 or 311 nm emission device) is the recommended treatment either when used alone and when adopted in combination with topical therapy. Topical CIs are effective as monotherapy in patients who do not tolerate topical CSs. They are also effective for recalcitrant lesions on the extremities when applied nightly under occlusion. Current data does not support monotherapy with topical vitamin D3 analogs, but Vitamin D3 can augment the effect of topical steroids even in previously steroid nonresponsive patients. Topical L-phenylalanine, topical antioxidants and mitochondrial stimulating cream, associated with natural sunlight with oral khellin have all been suggested as efficacious alternative first-line therapies.
When administered in patients with active disease, a short course of oral or intravenous steroids can arrest the vitiligo progression and induce repigmentation in the majority of patients. However, the optimal dose to maximize benefits and reduce the incidence of side effects has yet to be determined.
Second-line. Second-line treatment is considered when “first line” fails. Given the cost, time commitment required by patients and staff, and higher incidence of side effects, phototherapy is recommended as second-line therapy for patients who fail conservative first-line treatment(s). Phocused micro-phototherapy (308 or 311 nm) should be electively offered when cutaneous involvement is less than 10%. Narrow Band Ultra Violet type B (NBUVB) phototherapy produces the greatest clinical improvement compared to other forms of light therapy; combinations with topical therapy work better than either alone.
Topical CIs with NBUVB phototherapy have the best clinical outcomes compared to other topical adjuvant therapy. It is uncertain whether adding a vitamin D3 analog to NBUVB phototherapy enhances the effects. While inferior to NBUVB in terms of clinical response, both UVA and broadband UVB phototherapies with various adjuvant therapies are beneficial as alternative second-line treatments.
Third-line. Targeted phototherapy with the 308 nm Monochromatic Excimer Laser (MEL) is effective as monotherapy, and superior to NBUVB phototherapy when compared side by side. However, it should be reserved for patients who fail NBUVB phototherapy, except in very limited disease, or in patients who can afford the time and cost of therapy. MEL works best in combination with topical CSs or CIs.
Fourth-line. Surgery should be offered when lesions persist despite appropriate therapy. There are many different surgical techniques available. While the specific technique will depend on individual patient characteristics and the custom practice of the expert surgeon, it can provide excellent cosmetic results for limited lesions recalcitrant to other modalities.
Special populations. Although patients with Segmental vitiligo (SV) have been studied alongside those with Non-Segmental Vitiligo (NSV), it is unclear how applicable study results are to this population. SV tends to be more stable and recalcitrant to treatment. The He-Ne laser seems more effective in this population. Generalized/universal vitiligo may also require tailored treatment. The extent of disease can be so great that it may be nearly impossible to provide cosmetically pleasing repigmentation. For these patients, depigmenting agents should be offered and discussed extensively for their non reversible effects.
Considerations. At all stages of therapy, keep in mind that vitiligo can be a lifelong disease that may extensively damage one’s psychosocial sense of well being. Acknowledging this hidden impact of disease on quality of life and offering support for dealing with it will greatly improve the physician-patient relationship and promote a positive outcome. Camouflage can always provide temporary cosmetic relief, and psychotherapy should be offered to help patients deal with the psychological disease burden.
Question: Can we stop the progression of vitiligo?
Vitiligo is progressive in 73% of cases and regressive in 1.3%. We usually explain to the patients that progression depends on the modality of spreading: localized or generalized forms have different behavior. In 89% of the cases of localized vitiligo, disease activity ceases after 1-2 years of rapid spreading over the affected skin area, while generalized vitiligo shows less progression only when it starts on the face (52% of the cases).
In 89% of cases we can arrest patch extension in widespread vitiligo with oral minipulse corticosteroid therapy (5 mg betamethasone on 2 consecutive days per week). Administering the corticosteroid methylprednisolone 8 mg/Kg intravenously for 3 consecutive days in patients with generalized vitiligo led to temporary cessation to the disease progression in 85% of the cases and repigmentation in 71% of the cases. Other steroids administered intravenously showed a similar degree of limiting disease progression.
Thus, it is true that vitiligo progression could be stopped in 4 out 5 cases by the use of potent systemic corticosteroids. However, systemic corticosteroids might have possible relevant side effects, hence the decision of their use for limiting vitiligo progression must be taken by expert dermatologists and after careful evaluation of the individual clinical situation.
Question: Depigmentation: when and how?
Depigmentation is an option for the management of vitiligo that can be adopted when all repigmentation treatments failed. The scope of cutaneous depigmentation is to reach an uniform (white or very fair) skin color.
Depigmentation is a process that destroys the remaining cutaneous melanocytes in the skin: one must be aware that he/she will stay for the rest of the life a skin that is not “his/her skin”.
It may happen that one cannot cope with extreme photosensitivity.
The ideal candidates for depigmentation are adult patients with few residual dark spots scattered over the face or on other visible areas of the body.
Children should not be considered eligible for depigmentation treatments.
Question: Which are the individual factors associated with vitiligo disease propension?
It is well known that familiarity is an issue in vitiligo disease propensity. In fact, around 20% of people with vitiligo report a first degree relative as suffering of the same disorder. Children of a vitiligo subject have a 1.7-fold increased risk of developing vitiligo as compared with other family members. HLA haplotypes may contribute to generalized vitiligo susceptibility i.e. the HLAs -A2, -DR4, -DR7 and -DQB1 0303.
NALP-1 gene (NACHT leucine rich-repeat protein 1) is a major susceptibility gene that is epidemiologically linked to generalized vitiligo and other autoimmune diseases (i.e. thyroid disease, pernicious anemia, lupus erythematosus).
Patients already affected by the following disease are more prone to develop vitiligo (and vice versa):
Alopecia areata
Pernicious anemia
IgA selective defect
Thyroid autoimmune disease
Addison’s disease
Congenital melanocytic nevi
MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis, and
stroke episodes syndrome)
Stressful life events, probably interfering with the psycho-neuro-endocrine-immune system, and physical traumas of the skin, including solar burns, may easily start vitiligo in predisposed subjects.
Question: Surgical therapy for vitiligo: when and how?
The surgical option in vitiligo is always possible, at least on selected/limited depigmented areas.
Two mail conditions are required:
the white vitiligo lesion to be treated should be stable (i.e. avoid surgical procedures in lesions which are progressing – no progression of lesions or appearance of additional depigmentation must be evident during at least 2 years).
the white area should be recalcitrant to the main and most effective medical and physiotherapic UV-based treatments (lights or lasers).
Many surgical procedures are possible; among these:
punch grafting and mini-grafting
epidermal grafting
dermo-epidermal grafting
suction blisters grafting
autologous melanocyte suspension transplant
treatments with tissue-engineered skin
cultured epidermis with melanocyte
are considered the most popular procedures.
Neo-melanogenesis usually begins shortly after melanocyte graftings or transplantation and continues for some months at a slow rate.
UV exposure (with lamps or natural sunlight) induces faster and deeper repigmentation after surgery.
The surgical techniques offer a repigmentation that is not often comparable with the normally pigmented skin. They are always invasive procedures. The final results vary considerably from patient to patient.
The psychological aspect of the subject who requires the surgical/invasive procedure must be always evaluated and patient’s expectations must be clearly discussed.
Thus, the decision of starting a surgical procedure for vitiligo must be always a well balanced and informed decision.
Question: Should we take topical or oral antioxidants for vitiligo?
There is a clear inclination of the experts in the field of vitiligo research toward considering that appearance and progression of the white patches are related to a global unbalanced activity of the scavenger mechanism (s) which decrease the levels of the reactive oxygen species (ROS) both in the blood and in the skin of the vitiligo patients.
Thus, both the local and the systemic use of substances which are able to decrease the levels of the reactive oxygen species has been repeatedly proposed.
Most of these substances are mentioned in the Key points section of this paragraph.
In general, while some studies show remarkable good results in repigmentation after the use of local or systemic “natural antioxidants” , other studies show no benefits.
The Dermatological Scientific Community seems to encourage both the per os and the local use of the “natural antioxidants” for treating vitiligo.
Nevertheless, defined dosing parameters, double blind consistent studies on efficacy and safety profiles of these natural substances are not yet clarified.
A volume on “natural antioxidants in General Medicine and in Dermatology” co-edited by the present Authors will be available soon for the VRF audience.
Question: What does it mean “treating vitiligo with catalase and superoxide dismutase”?
Superoxide dismutase and catalase are substances well known for their antioxidant properties.
Most of them belong to the group of the oral and local antioxidants which have been listed and discussed in the previous chapters. They are exhaustively discussed in the volume “Natural Antioxidants in General Medicine and in Dermatology”, available as e-book for the VRF audience.
These substances are usually of natural origin and their use is combined with ultra violet irradiation of the skin.
The Dead Sea climatotherapy associated with topical pseudocatalase seems as effective as the use of potent local corticosteroids in inducing repigmentation.
Thus, this issue should be discussed by the patients with their dermatologist before staring any active treatment with chemical drugs, keeping in mind that unfortunately defined dosing parameters and possible side effects have not yet been elucidated fully for those substances provided with superoxide dismutase and catalase activities.
Question: Which are the main side effects of vitiligo treatments?
Treatment of vitiligo is a complex issue which always requires a clear and exhaustive explanation of the side effects of both the systemic and the local treatments.
Each vitiligo patient should clearly ask the ermatologist on the length of the treatment (s) and on the possible side effects.
We have here limited the description of the most common side effects and safety profile of local treatments, which are presently the most used.
The discussion of any systemic treatments of vitiligo requires always a vis a vis discussion between the subject affected by vitiligo and her/his dermatologist in a most empathic and cooperative setting based on clear questions and clear answers.
This book will hopefully help the patient(s) in rising clear answers to the dermatologist for reaching the best understanding and treating vitiligo.
Question: Camouflage: when and how
Most therapies for vitiligo may require treatment periods lasting months or years before repigmentation eventually occurs.
Thus, palliative treatments could be used in the meantime, with considerable improvement in quality of life of the subject affected by vitiligo.
Sunscreens are usually added to most of those cosmetic products in order to avoid sunburn.
The vitiligo patients should know how many different topicals are available for them on the market, and should become familiar with the different methods of application and cleansers.
Cover creams, stick correctors , tinted cover creams and fixing sprays applications on the vitiligo areas require expert recommendations to obtain optimal results.
Permanent camouflage is obtained with cosmetic tattoo, usually performed implanting into the dermis iron oxides pigments.
The colors of the tattoos naturally fade over the years, thus requiring periodic maintenance, usually every 30 months.
The quality of life of vitiligo subjects is overall greatly improved by the cover-ups, which can temporarily cancel vitiligo areas and give vitiliginous skin a natural color.
Unfortunately, reliable clinics devoted to acknowledgeable application of camouflage in vitiligo are not always available.
Question: Psychotherapy: when and how
Vitiligo is often considered both by the affected subjects and by the doctors as emotionally triggered.
An incubation period of 2-3 weeks between the stress event and the clinical manifestation of the vitiligo patches is reported by over 70% of the patients.
Even the localization of the white patches has been anecdotally but significantly reported as related to specific affective relationships.
Thus, men who had been betrayed developed vitiligo on the genital areas, women who did not accept their pregnancy developed vitiligo on their abdomens, according to some reports.
It is illuminating the case of a woman who developed in a few hours vitiligo on the hands after cleaning the sheets where her son’s girlfriend had aborted.
These are obviously anecdotal reports in the medical literature which are of very limited “per se” value but are clearly disclosing possible general psycho-somatic pathways which could drive the researchers on the causes and on the cure of vitiligo in not yet explored psycho-neuro-immune endocrine territories.
Nobody ignore the burden of the somato-psychic rebound of the vitiligo into the psyche of the affected subject.
Vitiligo subjects may adopt (more or less consciously) different behaviors to cope with vitiligo.
Some will adopt the “mastery active” psychological mechanism consisting in reading, studying and actively researching over the causes of the disease.
Others will behave as “natural acceptors” showing good self-esteem and not trying to hide their skin lesions.
Others will instead make heroic attempts to hide the white spots, will be always embarrassed and often depressed. These subjects could limit the social contacts and could loose their job because of vitiligo.
In examining the vitiligo subject and in discussing the therapeutic options, each skilled dermatologist will try to understand both the psycho-somatic mechanism inducing the appearance of the vitiligo patches (if any) and the somato-psychic rebound of the disease over the self-esteem and the quality of life of each individual subject.
Thus, should the dermatology always or often refer each and every vitiligo patient to the psychologist or the psychiatrist?
Hard to say always no, but more hard to say yes.
If the vitiligo patient has chosen the dermatologist for “superficial and deep” assistance regarding the understanding of his or her surface and depths, the dermatologist cannot give up.
The dermatologist must always respond to the request of the patient by giving the complete full care which has been requested, including supplying proper counseling.
To “force” the patient to go to visit another (non skin) specialist is in fact dangerous.
Immediate insensitive referral of skin patients to a psychiatrist can even lead to suicide ideas in especially delicate subjects, as already reported in the literature.
Thus, when a psycho-intervention will be considered “necessary” the dermatology should enter the “liaison consultation” practice of approaching the patient in close collaboration with the psychiatrist-psychologist. It will be a direct contact two to one: the vitiligo subjects, the dermatologist and the psychiatrist.
Only later on, the two experts will have the full right to treat separately the same patient, with expected excellent results.
In this context, it seems that the cognitive behavior therapy will give fair results versus different psycho approaches.
Thus, at the horizon of vitiligo therapy and possibly of vitiligo cure we see a complex interaction of different overlapping ingredients including the identification of the specific form of vitiligo (classification and genetics) , the evaluation of the inherent biological pathways that have produced the white skin patches in the individual case (pathophysiology) and finally the selection of the proper treatment (treatment and hopefully cure).
This last issue is already (and will be probably more in the future) showing how cost and accessibility of therapy must be considered in front of a (presently) lifelong disease which affects “democratically” all populations in the world.
Most of affected subjects will probably have financial limitations for the proper treatment/cure of “their“ vitiligo.
At the horizon of vitiligo therapy and cure we see a complex puzzle with some essential bricks already well positioned and installed in the right place.
For the rest, the Scientific Community, the Vitiligo Patients Associations and the Foundations devoted to vitiligo are requested to coordinate and harmonize their strategies and efforts for winning the battle against vitiligo, by completing the puzzled image.
The Vitiligo Research Foundation (www.vrfoundation.org ; www.vitinomics.net ) is committed to keep you always informed on the ongoing research and on treatments available for vitiligo.
The VRF is committed to find the cure for vitiligo and to bring the needing of the vitiligo subjects to the attention of the Natinal Health Sysems and Spra National organizations.
For this, the VRF needs the help of all those who have interest in the vitiligo field.
Question: New concepts in treating vitiligo
This is the only section of this booklet in which all questions are followed by a question mark.
The statement “the cause of vitiligo still remains unknown” should always be followed by the sentence “because in each single vitiligo patient a different process may be involved in the production of the white patches onto his/her skin”.
In other terms, the same white spots on the skin of different subjects , which will be diagnosed by the dermatologist as “vitiligo”, most probably are related to several different mechanisms affecting the melanin production, release and removal in the skin. Vive la difference!
According to this there will be not one form of “vitiligo”, but more forms of “vitiligos”, affecting different subjects, and all manifesting similarly or identically as white patches on the skin and/or on the mucosal areas. This concept excludes the “leukodermas” , i.e. those white patches of the skin of known origin.
It is implicit that the different forms of vitiligo will require different treatments and, eventually, a different cure.
It is also implicit that for the present time the “combined treatments” are the most rationale choice for treating any individual case.
The Cloud Medical Research Management (MRM) , already adopted by the VRF will create individual communication bridges to accommodate the array of personal and institutional data sources thus realizing quick links to a comprehensive disease and gene database. This will be instrumental for developing analytical tools with the ability to test complex combinations of therapies for vitiligo with further development of its care and extended services, the Cloud MRM will greatly hep to find solutions to vitiligo and possibly other orphan diseases.
It is hard to say if genetic studies will bring to the direct discovery of the vitiligo cure. Most probably this will not happen soon. Identical twins with identical DNA have only 23% concordance in developing vitiligo, suggesting a significant environmental and non genetic component of the disease.
Genetics will probably help us in identifying the different subpopulations of the subjects affected by “white patches on the skin and/or mucosal areas” and diagnosed by the dermatologist as “vitiligo” which will need different investigations, different treatments and probably a completely different cure. This could be the best present goal of genetic testing in vitiligo subjects, with excellent perspective
The cost and accessibility of therapy must be considered when choosing a treatment plan for vitiligo. Presently, the vast majority of the vitiligo subjects have heavy financial limitations for being treated properly, according to the already existing treatment protocols.
This problem will probably become more acute in the nearest future, due to the progressive recession in the economy of many countries and to the relative increase of the cost of the effective treatments for vitiligo.
Become a contributor
The non-profit VR Foundation accepts a variety of contributed material on vitiligo, melanoma and pigmentary disorders for possible inclusion on the website www.Vitinomics.net.
More...25 JUNE INITIATIVE
The 25June Initiative aims to increase awareness of vitiligo and raise funds for research, national vitiligo associations and support groups. Led by the VR Foundation, this year’s goal is to mark World Vitiligo Day on June 25 a date to be observed annually by the United Nations.
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