Everything You Need To Know About Vitiligo
Vitiligo is a chronic skin condition characterized by hypopigmented white patches created as melanocytes (the skin’s melanin pigment producing cells) die off. The patches tend to lose color slowly over time, sometimes appearing pink due to underlying blood vessels. The depigmentation is relatively harmless, though it does make the skin more susceptible to sunburn. Vitiligo may be present all over the body or concentrated in specific areas.
According to the National Institutes of Health (NIH), vitiligo is estimated to affect between 0.2 and 1.8 percent of people worldwide. “Men and women are equally affected, although women are more likely to seek medical care,” says Samer Jaber, MD, a board certified dermatologist and founder of Washington Square Dermatology in New York City. While the onset can occur at any age, 70 percent of vitiligo patients develop it before the age of 30.
Here, we break down everything you need to know about living with and treating vitiligo.
Types of Vitiligo
Vitiligo takes several forms that are generally categorized as local or generalized and segmental or non-segmental. Because vitiligo is often progressive, lesser forms can morph into a more widespread pattern covering more areas of the body. Here’s a breakdown:
Local vitiligo refers to hypopigmentation isolated to one area of the body. From there, it can be broken down into focal or segmental:
- Focal: A few spots concentrated in a single area. Typical types of focal vitiligo include mucosal (affecting only the lips and genitals) and lip-tip (lips, genitals, and fingertips).
- Segmental: The rarest form, with affected areas focused on one side of the body and nowhere else.
The most common type, generalized vitiligo is characterized by many patches all over the body that are often symmetrical (i.e. like a mirror image). Depending on the body parts affected, it can be classified as:
- Acrofacial: Affects the face, hands, and feet
- Vulgaris: Patches on many parts of the body in a roughly symmetrical fashion
- Universal: Vitiligo covering most of the body
Causes of Vitiligo
Though no one knows for sure, many scientists believe that vitiligo is an autoimmune disorder that attacks the pigment producing cells (a.k.a. melanocytes) in skin. Exactly why this happens, however, remains unclear. “Vitiligo does not have one cause, as it is a multifactorial disorder,” Dr. Jaber notes. Genetics likely play a role, and research also shows some correlation between certain other health conditions (like hypothyroidism and pernicious anemia) and developing the condition.
Known risk factors include:
- Genetics: About 30 percent of people with vitiligo have a family history of either the disorder or premature hair graying (which is also a loss of pigment).
- Autoimmune Conditions: You are more likely to get vitiligo if you (or a family member) have another autoimmune disease like psoriasis, rheumatoid arthritis, and thyroid disease.
There is no known cure for vitiligo, and its path is unpredictable. Doctors generally consider vitiligo to be a lifelong condition that often — but not always — progresses. Some people with vitiligo experience hearing loss (though many don’t realize it) because the inner ear also contains melanocytes. Patients sometimes speak of the pale areas of skin waxing and waning, speculating that periods of stress might bring it on, whereas certain protocols may improve the skin’s appearance.
To determine if a patient has vitiligo, doctors perform a combination of physical exam, patient interview, and a Wood’s lamp test. American physicist Robert Wood developed this method of evaluating skin exposed to long-wave UV light (the same ‘blacklight’ of 1980s roller rink fame). Healthy skin appears as a bluish color under the Wood’s light, while patches of skin devoid of pigment cells glow white.
It should be noted that those white areas are not always vitiligo. Glowing spots might instead indicate idiopathic guttate hypomelanosis (IGH) — the tiny white sun damage spots often found on the arms and décolleté — so it’s important to get a dermatologist’s opinion. The Wood’s light test is useful in ruling out other possible causes of hypopigmented skin patches, including those caused by other inflammatory conditions, congenital abnormalities, infections, and an extremely rare form of lymphoma (which can be ruled out with a biopsy).
There are several factors that are known to bring on vitiligo symptoms that include:
- Stress: Mad Men actor Jon Hamm famously stated that he discovered his vitiligo — a small white spot on his neck — after wrapping the show’s pilot episode. He told reporter Lee Thomas in 2016 that it was brought on by stress.
- Skin Damage: Severe sunburn or cuts can trigger the appearance of autoimmune symptoms, including psoriasis plaques and vitiligo patches. This process is known as the Koebner Phenomenon.
- Chemical Exposure: Exposure to products containing phenol (a.k.a. phenic or carbolic acid) may provoke vitiligo. While you probably already avoid it’s most well-known incarnation, BPA, phenols are also found in products like antiseptic spray, mouthwash, deodorant, sunscreen, herbicides, fungicides, and more.
This is not an exhaustive list and symptoms look different depending on the patient. Consulting with your dermatologist can help shed light on what may be exacerbating the condition for you.
How to Treat Vitiligo
Now that we’ve covered the causes and triggers of vitiligo, it’s important to understand treatment options. “The most common treatments for vitiligo are topical steroids and topical calcineurin inhibitors,” Dr. Jaber explains, noting they are particularly helpful for mild cases.
- Calcineurin Inhibitors: This class of topical drugs act on the immune system to reduce skin inflammation. One medication, tacrolimus, is derived from a soil fungus found only in Japan. FDA-approved to treat eczema, it is highly effective in some vitiligo patients (particularly for treating the face) without the side effects of steroids.
- Corticosteroids: These creams are FDA-approved to reduce skin inflammation. According to JAMA Dermatology, topical corticosteroids are most effective on “small, newly depigmented areas.” Prolonged use can result in skin thinning and stretch marks.
- Bleaching Agents: Usually considered a last resort, bleaching chemicals like monobenzone can be used by patients whose vitiligo affects more than half their body or face. Rather than attempting to prevent depigmentation, the treatment lightens the surrounding pigmented skin.
When vitiligo is more widespread, Dr. Jaber says narrowband UVB phototherapy and the excimer laser can both be effective.
UV Light Therapy
- Psoralen UV-A (PUVA): The treatment has historically been recommended to treat extensive vitiligo vulgaris. Patients take psoralen (either orally or topically), a drug which increases sensitivity to UV-A rays, before being exposed to long-wave UV-A light. It’s effective about 50 percent of the time, though approximately 75 percent of patients relapse within two years. Side effects range from nausea to increased skin cancer risk.
- Narrowband UVB (nbUVB): This newer light therapy shows promise as a safer, more effective alternative to PUVA. Not only are there fewer side effects, but there is also a better color match between affected and non-affected areas.
- Excimer Laser: Similar to nbUVB, the laser uses just one wavelength and can be very effective on smaller areas of vitiligo. It’s often used in conjunction with nbUVB to address spots that remain after more widespread treatment.
There are a variety of skin grafting modalities available to treat vitiligo, depending on the part of the body and the goals of the patient. It does not, however, have a high success rate because the immune cells often attack the newly transplanted melanocytes. In order for surgery to be effective, a patient’s vitiligo must be stable (read: not continuing to progress) for one or two years. Even then, it only works about half the time and the patches could return if the vitiligo becomes active again. Research shows patients with segmental vitiligo (where the affected skin is limited to one side of the body) often see the best results.
Medical treatment for vitiligo is not required, and, as Dr. Jaber notes, it is a difficult condition to treat successfully. There are, however, some advancements that show promise. ”Fortunately, there are some newer immune-based medications on the horizon, which are currently being studied in clinical trials,” he says. In the meantime, dermatologists suggest vigilant sun protection and skincare for all vitiligo patients to protect the melanin-deprived skin patches.
The Psychology of Vitiligo
Vitiligo isn’t life-threatening or physically harmful (though some patients report minor itching and discomfort), but it can impact a patient’s social and emotional wellbeing. “The psychosocial effects of vitiligo are well studied,” Dr. Jaber says. “Unfortunately, those with vitiligo have a higher risk of depression and anxiety, resulting in low self-esteem and social isolation.”
Increased understanding of the condition has, however, helped to normalize it. While Michael Jackson famously struggled to accept his vitiligo, public figures today are increasingly comfortable not only discussing but flaunting their skin. Model Winnie Harlow (above), for example, has covered magazines like Vogue, Elle, and Glamour and boasts some 8.4 million Instagram followers. “Winnie Harlow is an amazing role model for those with vitiligo,” Dr. Jaber says. “Especially for a child or a teenager, seeing someone with a condition that you have achieve such success is truly a game changer.”
Ultimately, it’s all about education. “By increasing awareness of what vitiligo is, she has increased acceptance of the condition, decreasing the stigma associated with it,” he concludes.