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Diseases and Conditions
Vitiligo
From MayoClinic.com
Special to CNN.com

Introduction

Vitiligo is a condition in which your skin loses melanin, the pigment that determines the color of your skin, hair and eyes. If the cells that produce melanin die or no longer form melanin, slowly growing white patches of irregular shapes appear on your skin.

Vitiligo usually starts as small areas of pigment loss that spread and become larger with time. These changes in your skin can result in stress and worries about your appearance.

There is no cure for vitiligo. The goal of treatment is to stop or slow the progression of depigmentation and, if you desire, attempt to return some color to your skin.

Signs and symptoms

The main sign of vitiligo is pigment loss that produces milky-white patches (depigmentation) on your skin. Other less common signs may include:

  • Premature whitening or graying of the hair on your scalp, eyelashes, eyebrows or beard
  • Loss of color in the tissues that line the inside of your mouth (mucous membranes)
  • Loss or change in color of the inner layer of your eye (retina)

Although any part of your body may be affected by vitiligo, depigmentation usually first develops on sun-exposed areas of your skin, such as your hands, feet, arms, face and lips. Vitiligo generally appears in one of three patterns:

  • Focal. Depigmentation is limited to one or a few areas of your body.
  • Segmental. Loss of skin color occurs on only one side of your body.
  • Generalized. Pigment loss is widespread across many parts your body.

Although it can start at any age, vitiligo often first appears between the ages of 20 and 30. The white patches may begin on your face above your eyes or on your neck, armpits, elbows, genitalia, hands or knees. They're often symmetrical and can spread over your entire body. The disorder affects both sexes and all races equally.

Most people with vitiligo are otherwise healthy and have normal skin texture and sensation. However, the condition may be more common in people with certain autoimmune diseases — diseases in which your immune system reacts against your body's own organs or tissues — such as Addison's disease, vitamin B-12 deficiency anemia (pernicious anemia), or thyroid disorders, including hyperthyroidism and hypothyroidism.

The natural course of vitiligo is difficult to predict. Sometimes the patches stop forming without treatment. In other cases, pigment loss can involve most of the surface of your skin.

Causes

Your skin is composed of three layers — the epidermis, the dermis and the subcutaneous tissue. The outermost layer of your skin is the epidermis. Melanin, the pigment that determines the color of your skin, hair and eyes, is produced in the epidermis. Melanin provides the coloring of your skin and helps protect it from damage from ultraviolet light.

People of all races are born with approximately the same number of pigment cells (melanocytes). The rate at which melanin granules are formed in these cells and their concentration in the epidermis are inherited characteristics and major factors in skin color differences. When no melanin is produced, the involved patch of skin becomes white. When a white patch grows or spreads, the cause may be vitiligo.

The exact cause of vitiligo isn't known. Doctors and scientists have theories about what causes the disorder. It may be due to an immune system disorder. Heredity may be a factor because there's an increased incidence of vitiligo in some families. Some people have reported a single event, such as sunburn or emotional distress, to trigger the condition. However, none of these theories has been proved to be a definite cause of vitiligo.

When to seek medical advice

See your doctor if areas of your skin, hair or eyes lose coloring. Although there's no cure for vitiligo, treatments exist that may help to stop or slow the process of depigmentation and attempt to return some color to your skin.

Screening and diagnosis

If your doctor suspects you have vitiligo, he or she will ask about your medical history. Important factors in your medical history include:

  • A family history of vitiligo
  • A rash, sunburn or other skin trauma at the site of vitiligo within two to three months of the start of depigmentation
  • Premature graying of the hair (before age 35)
  • Stress or physical illness

In addition, your doctor will need to know whether you or anyone in your family has had an autoimmune disease. He or she will ask if your skin is sensitive to the sun. Your doctor will examine you to rule out other medical problems or skin conditions, such as dermatitis or psoriasis. Your doctor may take a small sample (biopsy) of your affected skin. He or she may take a blood sample to check your blood cell count and thyroid function. In some cases, your doctor may recommend an eye examination to check for inflammation in your eye (uveitis). A blood test to look for the presence of antinuclear antibodies (a type of autoantibody) also may be done to determine if you have an autoimmune disease.

Treatment

The goal in treating vitiligo is to attempt to restore color (pigment) to your skin and improve your appearance. Depending on the type of therapy, treatment for vitiligo may take from six to 18 months. Treatment choices are based on the number of white patches you have and how widespread they are. Each person responds differently to treatment, and a particular therapy may not work for you.

Medical therapies

  • Topical corticosteroid therapy. Corticosteroids may help return color to your skin (repigmenting), particularly if they're started early in the disease. These drugs, which include cortisone, are similar to the hormones produced by your adrenal glands. Your doctor may prescribe a mild topical corticosteroid cream or ointment for children younger than 10 years old or a stronger form for adults. You may need to apply the cream or ointment to the white patches on your skin for at least three months before you see any results. This treatment is simple and safe, but your doctor will monitor you closely for side effects, such as skin shrinkage and streaks or lines on your skin (skin striae). Calcipotriene (Dovonex), a vitamin D derivative, also may be used topically and is sometimes used with corticosteroids or ultraviolet light.
  • Topical psoralen plus ultraviolet A (PUVA). Topical PUVA may be a treatment option if you have a small number of depigmented patches (affecting less than 20 percent of your body). PUVA, also called photochemotherapy, is performed under artificial UVA light once or twice a week in your doctor's office. Your doctor or a nurse will apply a thin coating of psoralen to the depigmented patches of your skin about 30 minutes before UVA light exposure. You're then exposed to an amount of UVA light that turns the affected area of your skin pink. Your doctor may slowly increase the dose of UVA light over many weeks. Eventually, the pink areas of your skin fade and a more normal skin color appears.

    Potential short-term side effects of topical PUVA therapy include severe sunburn and blistering and too much repigmentation or darkening of the treated patches or the normal surrounding skin (hyperpigmentation). You can minimize your chances of sunburn by avoiding exposure to direct sunlight after each treatment. Hyperpigmentation is usually a temporary problem and eventually disappears when treatment stops.

  • Oral psoralen photochemotherapy (PUVA). Oral PUVA therapy may be used if you have extensive vitiligo (affecting more than 20 percent of your body) or if you haven't responded to topical PUVA therapy. Oral PUVA isn't recommended for children younger than 10 years of age because of an increased risk of damage to the eyes, such as cataracts. For oral PUVA therapy, you take a prescribed dose of psoralen by mouth about two hours before exposure to artificial UVA light or sunlight. Your doctor adjusts the dose of light until the skin areas being treated become pink. Treatments are usually given two or three times a week, with at least one day in between.

    If you don't have access to a PUVA facility, your doctor may prescribe psoralen to be used with natural sunlight exposure. Your doctor will give you careful instructions on carrying out treatment at home and monitor your progress with frequent office visits.

    Short-term side effects of oral PUVA may include sunburn, nausea and vomiting, itching, abnormal hair growth, and too much repigmentation or darkening of the treated patches or the normal surrounding skin (hyperpigmentation). If received for longer periods of time, this type of treatment may increase your risk of skin cancer. To avoid sunburn and reduce your risk of skin cancer, you'll need to apply sunscreen and avoid direct sunlight for 24 to 48 hours after each treatment. Wear protective UVA sunglasses for 18 to 24 hours after each treatment to avoid eye damage, particularly cataracts.

  • Narrow-band ultraviolet B (NBUVB) therapy. In recent years, NBUVB, a special form of ultraviolet B light, has been used as an alternative to PUVA. This type of therapy can be administered like PUVA and given up to three times a week. However, no pre-application of psoralen is required, thus simplifying the treatment process. NBUVB may be a safer long-term alternative to PUVA. However, more research is needed.
  • Depigmentation. Depigmentation involves fading the rest of the skin on your body to match the already-white areas. If you have vitiligo on more than 50 percent of your body, depigmentation may be the best treatment option. In this procedure, the drug monobenzone (Benoquin) is applied twice a day to the pigmented areas of your skin until they match the already-depigmented areas. Avoid direct skin-to-skin contact with others for at least two hours after applying the drug.

    The major side effect of depigmentation therapy is redness and swelling (inflammation) of the skin. You may experience itching, dry skin or abnormal darkening of the membrane that covers the white of your eyes. Depigmentation is permanent and cannot be reversed. In addition, if you undergo depigmentation you will always be extremely sensitive to sunlight.

Surgical therapies

  • Autologous skin grafts. This type of skin grafting uses your own tissues (autologous). Your doctor removes tiny pieces of skin from one area of your body and attaches them to another. This procedure is sometimes used if you have small patches of vitiligo. Your doctor removes sections of your normal, pigmented skin (donor sites) and places them on the depigmented areas (recipient sites). Possible complications of this procedure include infection at the donor or recipient site. The recipient and donor sites may develop scarring, a cobblestone appearance, spotty pigmentation, or may fail to repigment at all.
  • Blister grafting. In this procedure, your doctor creates blisters on your pigmented skin primarily by using suction. The tops of the blisters are then cut out and transplanted to a depigmented skin area where a blister of equal size has been created and removed. The risks of blister grafting include the development of a cobblestone appearance, scarring and lack of repigmentation. However, there's less risk of scarring with this procedure than with other types of skin grafting.
  • Tattooing (micropigmentation). Tattooing implants pigment into your skin with a special surgical instrument. For treatment of vitiligo, tattooing works best for the lip area, particularly if you have dark skin. However, it may be difficult for your doctor to match your natural skin color. Tattooing tends to fade over time, and when used on the lips it may lead to episodes of blisters caused by the herpes simplex virus.

Experimental therapies
In a procedure called an autologous melanocyte transplant, your doctor takes a sample of your normal pigmented skin and places it in a laboratory dish containing a special cell culture solution to grow melanocytes. When the melanocytes in the culture solution have multiplied, they're transplanted to your depigmented skin patches. This procedure is experimental and performed only in a few institutions where vitiligo research is conducted.

Self-care

Certain self-care tactics may help you care for your skin and improve its appearance:

  • Protect your skin. If you have vitiligo, particularly if you have fair skin, use sunscreen to protect your skin from the sun's harmful rays. Sunscreen helps protect your skin from sunburn and long-term damage. Sunscreen also minimizes tanning, which makes the contrast between normal and depigmented skin less noticeable.
  • Conceal imperfections. Cosmetics that cover the white patches on your skin may improve your appearance and help you feel better about yourself. These cosmetic products may be particularly effective if you have vitiligo that's limited to exposed areas of your body. You may need to experiment with several brands of concealing cosmetics, such as Dermablend or Chromelin, before finding a product that works best for you.

Coping skills

The change in appearance caused by vitiligo can affect your emotional and psychological well-being. You may experience emotional stress, particularly if vitiligo develops on visible areas of you body, such as your face, hands, arms or feet. You may feel embarrassed, ashamed, depressed or worried about how others will react. Young people, who are often particularly concerned about their appearance, can be devastated by widespread vitiligo.

Certain strategies may help you cope with vitiligo. Consider these tips:

  • Make a good connection. Find a doctor who's knowledgeable about vitiligo. A dermatologist is a doctor who specializes in the care of skin.
  • Learn all about it. Find out as much as you can about vitiligo and its treatment options so you can participate in making important decisions about your health care.
  • Communicate your feelings. Let your doctor know if you're feeling depressed. He or she can refer you to mental health professionals who specialize in helping people deal with depression.
  • Talk with others. Ask your doctor about support groups in your area for people who have vitiligo. Take your loved ones along with you.
  • Confide in loved ones. Seek understanding and support from your family and friends.

May 25, 2005

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