Vitiligo: Leukoderma, Sins Against the Sun…

Vitiligo is an acquired pigmentary anomaly of the skin manifested by depigmented milky white patches surrounded by a normal or a hyperpigmented border.  It is an ancient disorder, first described in 1550 B.C….the Ebers Papyrus mentioned two forms of depigmentation that could be interpreted as leprosy or depigmentation resembling vitiligo.  In 200 B.C. the Indian Manu Smriti described “Sweta Kushtha” meaning “white disease” probably referring to vitiligo.  Heredotus, the Greek historian (484-420 B.C.) claimed that foreigners had “sinned against the sun” and must leave the country.  Years later the term vitiligo was perhaps derived from the latin word vitelius used to describe the “white flesh” of caves…and finally use of the word vitiligo was attributed to Celsus in the classic Latin book De Medicina in the first Century A.D.  To read more about the history of vitiligo click HERE.

Vitiligo affeccts 0.5-1.0% of the population and occurs in all races.  It may be more common in India than elsewhere (8.8% of population).  In about half of all patients the pigment loss begins before the age of 20, and in about 80% it starts before the age of 30.  About 20% have other family members afflicted and males and females are equally affected.

Vitiligo is thought to be a systemic autoimmmune disorder, associated with a deregulated immune response.  There may be a genetic susceptibility, since it has been associated with rare disorders such as Vogt-Koyannagi-Harada syndrome.  The gene encoding the melanocyte enzyme tyrosinase is probably involved.  The depigmentation is the result of destruction of melanocytes, which are the cells that produce melanin.

The most common areas of involvement are exposed areas, such as the face, neck, eyelids, nostrils, lips, fingertips and toes (lips and tips), body folds (armpits and groin), nipples, navel, and genitalia.  There are 6 types of vitiligo reported:  localized or focal, segmental, generalized (frequently symmetric), universal, acrofacial and mucosal.  The generalized form is most common.

 

TREATMENT:  Many forms of treatment are available but  none of them provide a long lasting cosmetic result, except for total depigmentation.  Repigmentation occurs at the edges and from hair follicles producing a spotted or peppered pattern.  Spontaneous repigmetation occurs in less than 15-25% of cases.  Some but not all treatments available include:

  1. PUVA-topical applications or oral administration of 8-mthoxypsoralen (phototherapy)
  2. Narrow band UVB (phototherapy)
  3. Potent topical steroids alone or in combination with topical vitamin D
  4. Topical pimecrolimus
  5. Systemic (oral) steroids
  6. Surgical options such as punch grafts and suction blister transplants
  7. Cultured epidermal melanocyte transplantation (some techniques include surgical options)
  8. Laser therapy in combination with sun exposure
  9. Complete depigmentation by use of topical Benoquin or Q-switched laser
  10. JAK Inhibitors…the wave of the future…

There is excellent data coming out on use of topical and oral JAK inhibitors for treatment of vitiligo.  To read more about JAK inhibitors click HERE and HERE.

Although not a form of treatment there are some remarkable cosmetics available to camouflage the skin.  There is a excellent section on this on the Vitiligo Society website.

The image above is of a patient we treated very effectively with Benoquin and this is likely also the treatment Michael Jackson used to depigment his skin.  Total depigmentation is a serious consideration for dark toned individuals and psychological impact needs to be considered.  To read more about vitiligo click HERE, HERE and HERE.  To go to the Vitiligo Society website click HERE.