Vitiligo (also called “leukoderma”) is a skin condition in which there is loss of pigment from areas of the skin resulting in irregular white spots or patches, even though the skin has normal texture. Vitiligo may appear at any age. Although it is a progressive condition, many people experience years or decades without developing new spots. The cause of vitiligo is not greatly understood, and there may be many causes that result in the condition.
Vitiligo is not contagious in any way. Susceptibility to vitiligo is thought by many to be genetic, as it is often, though not always, seen in families. It is thought by many experts that Vitiligo is an autoimmune related disorder, meaning a condition in which the body’s immune system turns on its own cells to destroy the melanocytes (pigment cells which give the skin its color.) This does not necessarily represent a weak or deficient immune system, but rather one which is malfunctioning or misdirected.
New research has suggested that too much hydrogen peroxide in the skin of those with vitiligo may be at the root of the problem. Called “oxidative stress,” it is felt that people with vitiligo may not have the proper enzyme (or enough of it) to break down hydrogen peroxide, which naturally accumulates in the skin.
Topicals including psoralens, steroids, calcineurin inhibitors and pseudocatalase cream.
Narrow band UVB Therapy with or without needling
Red light emitting diode therapy with Pseudocatalase cream
Narrowband UVB – now considered the gold standard of treatment for vitiligo covering more than 20% of the body. Narrowband UVB (NB) uses the portion of the UVB spectrum from 311-313 nm. This region has been determined to help stimulate pigment cells to produce melanocytes in less time than it takes to burn the skin. Any kind of light therapy has a suppressive effect on the immune system, so it can possibly stop new areas from forming as well. NB can be done in the doctor’s office with a full-body cabinet or, with a doctor’s prescription, from home using a full-length panel or a handheld device. The handhelds are very convenient for small areas of vitiligo but are too tedious and cumbersome to use for larger percentages as they cover a very small area at a time.
NB is sometimes used in combination with other topical treatments, but is effective for many on its own. NB can be used on children old enough to stand still and keep goggles on. Results are often seen beginning between 30 and 60 treatments, and treatment is usually given 3 times a week. Potential side effects of NB include skin burning if used for too long. If using a full-body panel or box, the normal skin may tan, increasing the contrast. Only full sized body units provide the immune suppression needed for stabilization that may halt further pigment loss, as the handheld units only treat isolated areas. Eye protection is worn during treatment to protect the eyes, but isn’t necessary once the treatment is over.
PUVA – “Psoralen” plus “UVA” light. Formerly the gold standard of treatment, PUVA has mostly been surpassed by NB-UVB as NB-UVB is at least as effective and has fewer side effects.
The psoralens are typically taken orally, but can also be used topically. A UVA light box or sun may be used to provide the light component. Treatments are usually given 3 times per week. Side effects of PUVA include skin burning, stomach upset, liver issues, and cataracts. To prevent the possibility of cataract formation you must wear sunglasses, which protect your eyes against UVA, for 12- 24 hours after taking the tablets. Sunglasses labeled UVB/UVA protection 100% are recommended. PUVA is used less often in children because of the risk of side effects.
Narrow-Band UVB Comparison With PUVA– Narrow Band Ultra Violet B Light is a relatively new technology on the vitiligo front. In the past, most doctors have used the PUVA system, which involved the use of Ultra Violet A light exposure and the taking of Psoralen pills. However, side effects for many people were unbearable. Narrow Band UVB light panels and cabinets solve the problems of over-exposure to ultraviolet by maximizing delivery of narrow-band UVB radiation (in the 311-312 nanometer range, the most beneficial component of natural sunlight) while minimizing exposure to superfluous UV radiation.
This allows patients to receive photo-therapy treatments with less risk of severe skin burning or pathogenic exposure to UV in harmful ranges. (It also avoids the adverse side effects of the psoralens used in conventional PUVA therapy, since UVB treatment requires no supplemental drugs.) These benefits have made Narrow Band UVB systems increasingly popular with vitiligo patients and their doctors.
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Even better is that Narrow B UVB light systems are available in home-sized panel systems and cabinets, which many are finding far more convenient than frequent trips to their dermatologist’s office. Though many people buy complete surrounding cabinets, some doctors suggest that panels are actually more effective, and that the optimum distance from the bulbs for the area being treated is about 7 inches. Time exposures should be discussed with your dermatologist prior to using a light panel or cabinet, as the exposure times vary greatly depending on how long you will be having the treatment depending on your skin tone and the severity of disease.
Narrow band UVB eliminates superfluous and harmful UV by emitting only wavelengths of 311-312 nanometers. Conventional broad band UVB lamps emit a variety of wavelengths ranging from 280-330 nm. Clinical studies show the peak therapeutic effectiveness of UVB to be within the range of 295-313 nm, but wavelengths below 300 nm can cause erythema or severe burning and increase the risk of skin cancer. The 311-312 range is considered by many to afford optimum safety.
Excimer laser – It is a targeted NB machine typically using the 308 nm portion of the spectrum. Laser can be very effective for smaller areas of stable vitiligo. As it treats a small area, it is inefficient for larger areas or percentages. Results from laser treatments frequently occur more quickly than with other treatments. Because laser treatments are expensive, it is typically only used on stable vitiligo because when the vitiligo is active there is a greater chance of pigment being lost afterwards. Hands and feet are often not treated with laser because it is less effective there. Treatments are generally 2-3 times per week. Potential side effects include skin burning.
Topical Therapies for Vitiligo
Immunomodulators suppress the immune system where applied, allowing the melanocytes to return. These are generally used twice a day, about 12 hours apart (typically morning and night). Only a thin layer is necessary and should be gently rubbed in – by the time you spread it around, it should be mostly absorbed.
Makeup or sunscreen can be applied on top of these immunomodulators. Studies have shown that in most cases these medications have very little systemic absorption. As with most treatments, they are most effective on the face and less so on the hands and feet. Side effects can include stinging, soreness, a burning feeling, or itching of the treated skin. These side effects are usually mild to moderate and are most common during the first few days of treatment.
Commonly prescribed steroids are clobetasol, betamethasone and fluocinonide. Mild steroids are sometimes used on more sensitive areas like the face while stronger ones are used for other parts of the body. Topical steroids suppress the immune system, but can have more systemic absorption than immunomodulators. They are typically used for short periods of time or are alternated with other medications like immunomodulators to decrease the potential for side effects. Potential side effects are skin thinning/atrophy,redness and possibly systemic immune suppression allowing infections to occur.
Topical Vitamin D Analogues
Typically Dovonex (calcipotriol), though other forms are sometimes used as well. Studies are mixed as to the efficacy of vitamin D applied topically to stimulate the melanocytes. There are no serious side effects of using vitamin D topically. Minor side effects can include dry skin, stinging, or burning. These can go away with continued treatment. These medications are typically used in combination with others like topical steroids or NB-UVB.
Pseudocatalase reduces epidermal hydrogen peroxide in vitiliginous skin within 2 minutes at a rate 15 times faster than natural catalase. It also prevents vacuolation in melanocytes and keratinocytes and increases the number of functioning melanocytes in the involved epidermis.
There are 2 forms of pseudocatalase (PCat) – They are PC-KUS, developed by Dr. Karin Schallreuter, and PCAT, available only through a few compounding pharmacies in the US and Canada. Dr. Schallreuter’s formula is only available through an initial consultation at her clinic in Griefswald, Germany. The two formulas are similar in nature, though Dr Schallreuter’s formula is specific to the individual’s needs.
PCat is typically applied to the affected area twice per day. NB-UVB or sunlight is used for a very brief period of 15 seconds or so to activate the medication. Studies are mixed, but some people have had success with both forms.
Due to the expiration date, the company standardly sends 100 gm depending on how bad the area is that is in question and how much is to be applied. Is it the whole body, the hands, the feet, etc. for a small area 100 grams will last about 3 months and for the whole body about a month.
The company typically does 100gm for $84.00 but it has to be shipped next day by air, due to the fact that it is a refrigerated item. So it has to be shipped in a cooler and on ice. So shipping can be costly depending on where it is shipped to. Mind you the company is in the U.S. and shipping internationally will be costly.
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Surgical Therapies for Vitiligo
Surgical therapies can be used for areas of stable vitiligo. There are a variety of grafting and transplant procedures used. Small grafts of skin can be removed from normal skin that is in an unseen area and grafted onto areas with vitiligo. Light is often used to stimulate the pigment to spread in the grafted area.
Some dermatologists are using small samples of normal skin and culturing either melanocytes or a combination of melanocytes and keratinocytes that are then spread over the areas of vitiligo that have been abrased to allow the cells to penetrate. The area is covered with a dressing for some period of time.
Surgical therapies can often be used with success on segmental vitiligo, as the vitiligo is usually stable after the initial spread. Due to the risk of the skin trauma activating the vitiligo, surgical therapies are rarely performed unless the patient has been stable for at least a year.
Surgical therapies include grafts and transplants:
- Mini-punch grafting takes small full-thickness grafts and places them in the depigmented area. Some form of light is often used to help stimulate the pigment to spread out. The main downside is a cobblestone effect.
- Thin split-thickness grafts take a thinner slice but are similar to the mini-punch grafting. They require general anesthesia and are often successful for the lips/hands. Scarring may occur in both donor and grafted areas.
- Suction blister grafting separates the epidermis from the dermis with a suction device that causes blisters. The epidermis is then placed on an abraded vitiligo area. Areas between the grafts may remain hypopigmented, but scarring is usually minimal.
- Transplant therapies include transplantation of pure melanocytes or melanocytes and keratinocytes together. In either technique the area with vitiligo that is to receive the transplant is roughed up or abraded, sometimes with a laser, then a dressing with the melanocyte mixture is placed on the site and covered until the area heals. Some form of light is often used to help stimulate the pigment to spread out.
Transplantation of pure melanocytes requires a growth medium, which can lead to inconsistent results depending on the growth medium used and could possibly lead to malignant development of melanocytes. An area of donor skin is removed and the melanocytes are separated, then cultured on the growth medium.
Transplanting melanocytes and keratinocytes together is a much easier technique that does not require the use of growth factors since the keratinocytes help produce more melanocytes.
Sunlight & Vitiligo
Sunlight can be used if the prescription light sources are not available. Some doctors allow patients to combine sunlight with topical psoralens, immunomodulators or topical steroids, while others do not. Moderation must be used, however, as burning the skin can damage it and possibly cause the vitiligo to spread. When using sun as a therapy, it is important to start slowly and gradually build up time. A pink color (not red) in the vitiligo areas a few hours after sun exposure is the desired effect. As the skin becomes accustomed to the sun, it can take longer to achieve pinkiness. Like any other treatment, sunlight would need to be used at a therapeutic level consistently for it to be beneficial.
Safety – It should be noted that NB-UVB is safer for the skin than sunlight. Sunlight contains the UVA rays which penetrate the skin more deeply than the UVB rays. Recently, scientists have learned that UVA rays while not contributing to sunburns, damage deeper layers of the skin and probably play an important role in wrinkling, spotting, lost elasticity and the dangerous skin cancer melanoma. UVB are the burning rays. By using Narrow Band-UVB you can achieve a therapeutic level of treatment in just a few minutes as opposed to the longer times required by sunlight, reducing your overall exposure to these potentially damaging rays.
There is growing evidence that vitamin D levels are often low in those with autoimmune disease; whether this is a cause of the disease or a result of it is as yet unknown. Sunlight in moderation (15 minutes a day 3 days a week) can help build up the vitamin D level and support the immune system, while also stimulating pigment cells. Vitamin D supplements can also be used.
Vitiligo & Diet
There is no ‘vitiligo diet.’ A healthy diet with balanced nutrition from a variety of sources is a good way to support the immune system. Vegetables are very good, as is fruit like apples and bananas. Citrus fruits can cause problems for some people, though not for others. Blueberries and pears contain natural hydroquinones, which are depigmenting agents, and should thus be limited or avoided. Some people recommend dairy or red meat or other foods be avoided, but there is no evidence of these impacting vitiligo unless there is some underlying allergy to the products. Turmeric, often used as a seasoning, has caused problems for some people, so one might consider limiting or avoiding its use.
Herbs & Autoimmune Disease
People with autoimmune diseases, including vitiligo, must be cautious in the use of herbs. Many herbs, like Goldenseal, Astragalus, Echinacea and Spirulina are immune boosters. If the immune system is attacking your melanocytes, boosting it further with these types of herbs could be problematic.
Immunostimulatory herbal supplements may exacerbate preexisting autoimmune disease or precipitate autoimmune disease in persons genetically predisposed to such disorders.
Some studies have shown that Echinacea may worsen the effects of autoimmune disorders. Studies looking at this issue are few in number and largely inconclusive. However, until sufficient evidence emerges, it is recommended that echinacea supplements should not be used by those suffering from autoimmune diseases.
At least one study has shown that ginkgo biloba could be helpful in those with vitiligo, though some that have tried it have not found it helpful, and in fact it appeared to worsen the vitiligo in a few people.
When therapies for repigmentation have failed and/or the vitiligo has become extensive (generally over 50% coverage), some opt for depigmentation of the remaining ‘normal’ pigment.
Monobenzyl ether of hydroquinone, commonly called monobenzone or mono, is used to kill the remaining pigment cells, leaving the entire body pigment free. Like treatments for repigmentation, use of monobenzone requires patience and consistency. The process can take up to 2 years to complete, though some are done sooner depending on the initial amount of remaining pigmentation and the strength of the medication used.
This medication is only available in compounding pharmacies, and can be ordered in a 20%, 30% or 40% strength. Typically, people start with a lower percentage and work up to stronger levels as their skin adjusts to the monobenzone. Potential side effects are dry skin, itching, or a rash.This medication has a systemic effect, so even areas where it is not applied will still depigment. Since no pigment will be left in the skin, people who have depigmented skin must be very cautious about sun exposure due to the risk of skin burning. According to doctors, however, since the melanocytes are gone, there is very little risk of melanoma, which is a dangerous cancer of the melanocytes.