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Vitiligo

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Related Terms
  • Hypopigmentation, leucoderma, leukoderma, patchy skin, pigmentation disorder, skin disease, skin disorder, skin graft, skin pigmentation disorder, vitiligo vulgaris.

Background
  • Vitiligo (also known as leucoderma or leukoderma) is a condition in which irregular, pale or white patches form on the skin. The condition may also affect individuals' hair, eyes, and mucous membranes.
  • Skin develops color from a pigment called melanin. In vitiligo, melanocytes, or the cells that produce this pigment, are damaged, and skin loses its color in the areas where melanin production is dysfunctional.
  • The exact cause of vitiligo is unknown at this time; however, scientists have several different theories. One theory suggests that vitiligo is an autoimmune disease in which the body destroys melanocytes for no known reason. It is often tied to thyroid autoimmune diseases, such as Hashimoto's thyroiditis, primary myxedema, and Graves' disease. There may also be a genetic component, because some families have a higher prevalence of this disease. There are no known drug-induced causes of vitiligo.
  • Vitiligo affects approximately one out of every 100 hundred people of both sexes ad all ages and races in the United States. The onset of vitiligo is most common in individuals between 20 and 30 years old and is rare in individuals greater than 40 years of age. Approximately 30% of people diagnosed with vitiligo have a family history of the condition.
  • Approximately 30% of individuals with vitiligo will see repigmentation within the affected areas over time. The quality, speed, and extent of recoloration vary among these individuals. However, it is frequently considered inadequate, and treatment is still sought. Research appears to focus on determining the underlying causes of vitiligo and finding new therapies.

Signs and symptoms
  • Pale or white areas of skin develop over time or suddenly. These areas of skin feel normal. However, there is a definite, irregular border between the areas missing pigment and those that are normally pigmented. The areas of skin affected are typically small at first but may progress to encompass larger areas.
  • The areas of the body most commonly affected by vitiligo include the arms, elbows, face, feet, hands, knees, lips, and genitalia.
  • Rare signs of vitiligo include premature graying of hair and loss of color in the retina and/or inner mouth.

Diagnosis
  • Healthcare providers may perform a skin exam using a handheld UV light, called a Wood's light, to diagnose vitiligo.
  • Physicians may also perform a skin biopsy and blood tests to rule out other possible causes. For instance, thyroid hormone and autoantibody levels are frequently measured, because vitiligo seems to be highly correlated with autoimmune-related thyroid diseases.

Complications
  • In some instances, vitiligo progresses with time and may spread to other areas of the body. However, this progression is hard to predict and does not occur in all individuals affected by vitiligo.
  • Skin with less pigment is more prone to sun damage. It is important to remember to protect skin from the sun with sunscreen, protective clothing, sunglasses, and other sun safety measures (avoiding sun during peak times, seeking shade, etc.).
  • Concerns with appearance generally lead to emotional and social distress. Social and emotional distress is common in individuals with vitiligo, and many individuals find counseling and support groups beneficial.

Treatment
  • Treatments aim to slow the progression of vitiligo and return pigment to the areas of the body affected by vitiligo.
  • Corticosteroids: Topical and/or oral steroids are used to restore pigment, help make paler areas of skin more sensitive to phototherapy, and potentially slow the progression of the disease. When used for the long term, certain types of vitamin D, such as calcipotriene (Dovonex®), are sometimes given topically in combination with steroids to avoid specific adverse effects, such as thinning of the skin, and to increase response rates.
  • Cosmetics and skin dye: Cosmetics and cover-up may help disguise areas affected by vitiligo. Skin dyes may also be obtained from dermatologists to help cover under pigmented areas.
  • Depigmentation: Depigmentation, or the removal of remaining pigment, in the surrounding areas with monobenzyl ether of hydroquinone (Benoquin®) is often seen as a last resort, because it may take 1-4 years to see results and will ultimately turn the skin white. It is typically only performed when large areas of the body are affected by vitiligo.
  • Immunosuppressants: Topical immunosuppressants, such as pimecrolimus (Elidel®) and tacrolimus (Protopic®), may help if vitiligo has an underlying autoimmune component.
  • Light therapy (or phototherapy): Phototherapy is typically considered a first-line therapy and involves carefully exposing lighter areas of skin to ultraviolet light. This treatment may or may not be combined with medications that make the skin more sensitive to light. Subsets of light therapy include psoralen plus ultraviolet A (PUVA), broadband ultraviolet B (bbUVB), and narrowband ultraviolet B (nbUVB) therapy. Sapam et al. compared PUVA and nbUVB therapies, and, although statistically significant differences were lacking, UVB was associated with higher repigmentation rates after 18 weeks and few adverse events. Additionally, PUVA may not work as well on the hands and feet. Early reseach proposed a monthly, synthetic implant of a melanocyte-stimulating hormone called afamelanotide, in combination with light therapy, as a possibly effective treatment for vitiligo. More studies are needed.
  • Psoralen derivatives: Methoxsalen (Oxsoralen®) and other psoralen derivatives may be given topically or orally to help sensitize skin to phototherapy.
  • Surgical procedures: Surgical options include skin grafts in which normally pigmented areas of skin are used to replace areas that are underpigmented.

Integrative therapies
  • Strong scientific evidence:
  • Light therapy: Light therapy may be used alone or in combination with other agents or treatments for vitiligo. Narrowband UVB is considered a first-line option for this disease. Combination therapy may be more effective than UVA, broadband UVB, and narrowband UVB alone.
  • It is recommended that people use light therapy under the supervision of a qualified professional, rather than attempting to self-medicate. Experts suggest that people wear eye protection when undergoing light therapy. People may need to wear special clothing to protect sensitive areas, such as the genitals, from being burned during light therapy. Light therapy is likely safe when used to treat conditions for which studies or a long history of use have been shown to be safe and effective under a doctor's care, such as psoriasis, seasonal affective disorder (SAD), and neonatal jaundice. Light therapy is possibly safe when used in combination with a psoralen agent taken by mouth or applied to the skin prior to undergoing psoralen-ultraviolet A (PUVA) phototherapy. Nontargeted phototherapy used alone is possibly safe during pregnancy and breastfeeding. Avoid using PUVA during pregnancy. Avoid taking retinoids by mouth in combination with phototherapy for the treatment of psoriasis in pregnant women. Use cautiously in people with autoimmune disorders, changes in bowel habits, dementia, eating disorders or changes in appetite, headaches or migraines, human immunodeficiency virus (HIV), light sensitivity disorders, muscle pain and weakness, nausea, Parkinson's disease or other movement disorders, psychiatric disorders, risk of dehydration, risk of eye problems, sexual dysfunction, skin cancer, stomach disorders, stomach pain, or weak immune systems. Use cautiously in elderly people. Use cautiously in combination with cyclosporine, as combined use may increase the risk of cancer (squamous cell carcinoma), high blood pressure, kidney problems, and liver toxicity. Use cautiously in combination with hydroxychloroquine, methotrexate, melatonin, and retinoids applied to the skin. Use home phototherapy systems cautiously for the treatment of psoriasis. Medical supervision is recommended. Light therapy may interact with agents that affect the immune system, agents that affect movement, agents that increase light sensitivity, antibacterials, antibiotics, antidepressants, antiretrovirals, antivirals, depressants, cyclosporine, hydroxychloroquine, immunoglobulins, khellin, melatonin, metalloporphyrins, methotrexate, phenobarbital, Picrorhiza kurroa, Polypodium leucotomos, retinoids, sedatives, vitamin A, vitamin B12, vitamin C, vitamin D, vitamin D analogs, vitamin E, and herbs or supplements with similar effects.
  • Good scientific evidence:
  • Phenylalanine: Several studies suggests that L-phenylalanine, in combination with exposure to ultraviolet A light or sunlight, may help treat vitiligo. According to another study, a combination product containing phenylalanine, Cucumis melo extract, and acetyl cysteine (Re-Pigmenta® gel) was combined with ultraviolet B light therapy for the treatment of vitiligo. The study showed a nearly 74% satisfactory repigmentation rate and outperformed topical steroid therapy alone. Additional studies are needed in this area.
  • Use cautiously in people with blood pressure disorders, anxiety disorders, psychiatric disorders, or sleep disorders, or in those taking monoamine oxidase inhibitors (MAOIs) or drugs that affect blood pressure. Avoid in people with Parkinson's disease, tardive dyskinesia, or phenylketonuria (PKU). Avoid with known allergy or hypersensitivity to D-phenylalanine, DL-phenylalanine, or L-phenylalanine.
  • Unclear or conflicting scientific evidence:
  • Bishop's weed: Early research suggests that 8-methoxypsoralen (8-MOP), a compound found in bishop's weed, may help treat vitiligo. However, high-quality human studies are needed before a conclusion may be made.
  • Use with caution in patients with bleeding disorders or those taking agents that may increase the risk of bleeding, those taking agents that are broken down by the liver's cytochrome P450 enzyme system, those with photosensitivity (light sensitivity), or those with eye disorders. Avoid in pregnant or breastfeeding women, due to a lack of available scientific evidence. Avoid in individuals with known allergy or sensitivity to bishop's weed, its constituents, or members of the Apiaceae family.
  • Canthaxanthin: Using canthaxanthin to treat vitiligo has produced mixed results. More research is needed in order to make any conclusions.
  • Canthaxanthin is likely safe when taken in amounts normally found in food. Avoid if allergic or sensitive to canthaxanthin or other carotenoids. Use cautiously if pregnant or breastfeeding.
  • Folate: According to preliminary data, folic acid and vitamin B12 may improve the symptoms of vitiligo. Further research is needed to confirm these results.
  • Avoid if allergic or hypersensitive to folate or any of the product ingredients. Use cautiously in those receiving coronary stents and in those with anemia and seizure disorders. It is suggested that pregnant women consume 400 micrograms daily in order to reduce the risk of the fetus developing a defect. Folate is likely safe if breastfeeding.
  • Ginkgo: Early research using oral Ginkgo biloba extract has reported that ginkgo appears to arrest the progression of this disease. Better-designed studies are needed to confirm these results.
  • Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy, oak, or cashews, then allergy to ginkgo is possible. Avoid with blood thinners (like aspirin or warfarin (Coumadin®)), due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.
  • Khella: Several studies have investigated the use of khellin, a constituent of khella, for the treatment of vitiligo. However, the evidence of the efficacy of khellin is conflicting. Further research is warranted in order to draw a firm conclusion.
  • Avoid if allergic to members of the Apiaceae family (flowering plants such as carrot, celery, fennel, parsley, etc.). Khellin may cause liver damage in high doses. Use cautiously in those with liver problems or asthma. Avoid prolonged exposure to sunlight or ultraviolet radiation. Avoid if pregnant.
  • Polypodium: A combination of Polypodium and narrowband UVB (NB-UVB) light therapy may help treat vitiligo, especially on the head and neck. Additional research is needed in this area.
  • Avoid if allergic or hypersensitive to ferns from the Polypodiaceae family (such as maiden hair ferns, Holly fern, Boston fern, etc.). Use cautiously in those with heart disease or with blood pressure drugs. Avoid operating any heavy machinery when taking Polypodium. Avoid if pregnant or breastfeeding.
  • Vitamin D: The effectiveness of vitamin D analogs for vitiligo is controversial, and data are limited. Additional research is needed before a conclusion can be made.
  • Vitamin D is generally well tolerated in recommended doses; doses higher than those recommended may cause toxic effects. Vitamin D is considered safe in pregnant and breastfeeding women when taken in recommended doses. Use cautiously in those with hyperparathyroidism (overactive parathyroid), diabetes, low blood pressure, kidney disease, liver disease, or granulomatous disorders (a type of immune disorder), or in mothers who are receiving vitamin D supplements and who are breastfeeding. Avoid in those allergic or hypersensitive to vitamin D or any of its components or in those with vitamin D hypersensitivity syndromes. Avoid in patients with hypercalcemia (high blood calcium levels).
  • Traditional or theoretical uses lacking sufficient evidence:
  • Caffeine: Caffeine has been reviewed as a theoretical treatment for vitiligo. More research is needed.
  • People who are prone to heat-related fatigue or injury (such as firefighters), those who do not regularly consume caffeine (including athletes), those who have a heightened sensitivity to caffeine, or those whose bodies process caffeine quickly may be at an increased risk for side effects. Use cautiously over long periods of time. Use cautiously in people with a history of abnormal heart rhythms, bleeding disorders, breast disease, diabetes or low blood sugar, eating disorders, glaucoma, growth hormone deficiency, heightened caffeine sensitivity, high blood lipids, high blood pressure, high-grade inflammation, kidney stones, lowered immune system activity, movement disorders, osteoporosis (bone loss), risk of kidney or breast cancer, seizure disorders, sleep disorders (including insomnia), stomach disorders, or urologic disorders (including an overactive bladder). Use cautiously when combined with adenosine, agents that affect dopamine, agents that affect the liver's cytochrome P40 enzyme system, agents that depress the central nervous system, agents that mimic the effects of the sympathetic nervous system, agents that narrow or widen blood vessels, antidepressants, antipyrine, calcium, corticosteroids, creatine, fluconazole, geranium, iron, lithium, magnesium, or potassium. Use cautiously in children and the elderly. Use cautiously in preterm infants for periods longer than four weeks. Use cautiously in breastfeeding women in amounts greater than three cups of coffee daily. Avoid amounts greater than 200 milligrams daily in pregnant women. Avoid in people with autosomal recessive polycystic kidney disease (a genetic kidney disease), Marfan syndrome (a connective tissue disorder), or rosacea (enlarged facial blood vessels). Avoid combined use with alcohol, caffeine-containing herbs, or central nervous system (CNS)-stimulating agents. Avoid before adenosine, cardiac, or dipyridamole stress testing. Avoid in those with known allergy or sensitivity to caffeine.
  • Gardenia: Gardenia has been used historically for vitiligo. High-quality clinical research is needed.
  • Avoid if allergic or sensitive to gardenia, its parts, or any member of the Rubiaceae family. Avoid in children and pregnant or breastfeeding women, due to lack of information. Use cautiously in people who have autoimmune disorders or diarrhea. Use cautiously in people who are taking immunosuppressants or sedatives.
  • Guggul: Guggul has been used traditionally in Ayurveda for vitiligo. High-quality clinical research is needed.
  • Use cautiously in patients with gastrointestinal disorders. Use cautiously in patients using agents that affect the cardiovascular system, agents that are processed by the liver's cytochrome P450 system, agents that increase the risk of bleeding, agents that lower blood sugar, antiarthritics, antibacterials, antibiotics, anticancer agents, anti-inflammatory herbs, antiobesity agents, antioxidants, cholesterol-lowering agents, hormonal agents, lipid-lowering agents, osteoporosis agents, red yeast rice, and thyroid agents. Avoid in large amounts in patients using estrogens. Avoid if pregnant or trying to become pregnant. Guggul is not suggested for use in breastfeeding women, due to a lack of available scientific evidence. Avoid in those with known allergy or sensitivity to guggul (Commiphora mukul), any of its components, or other members of the Burseraceae family. Skin reactions and shortness of breath have been reported.

Prevention
  • Since skin with less pigment is more prone to sun damage, it is important to protect affected areas from the sun. Individuals with vitiligo should apply sunscreen before going outdoors, wear protective clothing and sunglasses, avoid sun during peak times, and seek shade when possible.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Academy of Dermatology. Vitiligo. .
  2. American Vitiligo Research Foundation. .
  3. Bacigalupi RM, Postolova A, and Davis RS. Evidence-based, non-surgical treatments for vitiligo: a review. Am J Clin Dermatol. 2012 Aug 1;13(4):217-37.
  4. Buggiani G, Tsampau D, Hercogovà J, et al. Clinical efficacy of a novel topical formulation for vitiligo: compared evaluation of different treatment modalities in 149 patients. Dermatol Ther. 2012 Sep-Oct;25(5):472-6.
  5. Chan MF and Chua TL. The effectiveness of therapeutic interventions on quality of life for vitiligo patients: a systematic review. Int J Nurs Pract. 2012 Aug;18(4):396-405.
  6. Colucci R, Lotti T, and Moretti S. Vitiligo:an update on current pharmacotherapy and future directions. Expert Opin Pharmacother. 2012 Sep;13(13):1885-99.
  7. Gawkrodger DJ, Ormerod AD, Shaw L et al. Guideline for the diagnosis and management of vitiligo. Br J Dermatol. 2008 Nov;159(5):1051-76.
  8. Grimes PE, Hamzavi I, Lebwohl M, et al. The efficacy of afamelanotide and narrowband UV-B phototherapy for repigmentation of vitiligo. JAMA Dermatol. 2013 Jan;149(1):68-73.
  9. National Vitiligo Foundation. Vitiligo Basics. .
  10. Natural Standard: The Authority on Integrative Medicine. .
  11. Sapam R, Agrawal S, and Dhali TK. Systemic PUVA vs. narrowband UVB in the treatment of vitiligo: a randomized controlled study. Int J Dermatol. 2012 Sep;51(9):1107-15.
  12. Sawicki J, Siddha S, and Rosen C. Vitiligo and associated autoimmune disease: retrospective review of 300 patients. J Cutan Med Surg. 2012 Jul-Aug;16(4):261-6.

Causes
  • Melanocytes, the cells that produce skin pigment, stop working for unknown reasons. Scientists hypothesize an underlying genetic or autoimmune component. However, the exact cause is still unknown.

Risk factors
  • Autoimmune disorders: Addison's disease, autoimmune thyroid conditions, hyperthyroidism, hypothyroidism, and pernicious anemia are five autoimmune disorders that seem to be linked with vitiligo.
  • Family history: A family history of vitiligo may place individuals at a 10% higher risk for the skin disorder. A family history of diabetes and/or thyroid disorders may also place individuals at higher risk.
  • Precipitating factors: Although it is unconfirmed, some individuals believe that episodes of distress, anxiety, physical trauma, illness, and sunburn may prompt the onset of vitiligo.

Types of the disease
  • Focal (or localized) vitiligo: Color loss occurs in only one or a few places on the body.
  • Generalized (or bilateral, nonsegmental) vitiligo: Color loss is extensive and present throughout the body. This subtype is most common and is also referred to as vitiligo vulgaris.
  • Segmental (or unilateral) vitiligo: Color loss occurs in one portion or hemisphere of the body.
  • Universal vitiligo: Color loss is present over at least 80% of the body's surface. This subtype is the rarest and does not affect 100% of the body, as does albinism.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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