What Causes Vitiligo?
Exactly what is Vitiligo
Vitiligo is an autoimmune skin disorder that manifests itself as irregular white patches on the skin, regardless of the skin’s original colour. This makes it all the more noticeable when the person with vitiligo has a darker skin tone, but anyone of any skin colour can have it.
This particular skin disorder is a form of hypopigmentation and is estimated to affect around 1 per cent of the population and can be found in people of any age, any gender and any racial group. Hypopigmentation has two main types, vitiligo and albinism. Albinism is caused through a genetic defect whilst vitiligo is an autoimmune disorder with a genetic association with more than 30 per cent of vitiligo patients inheriting the disorder. Vitiligo has no cure, but it can be treated and depigmentation can be halted and even reversed in some cases.
Vitiligo (sometimes referred to as leukoderma) is a progressive condition, but it isn’t contagious, however, it does mean that it will spread to other parts of a sufferer’s body in time. It can be a very slow process and patients with vitiligo may not see any noticeable changes in their condition for quite a number of years. The condition isn’t life threatening or debilitating in a physical sense, but because it results in unsightly lighter patches of skin it can have social and psychological effects on a sufferer. These social and psychological effects are just as much a part of the symptoms of vitiligo as the white patches of skin are.
What To Look Out For
Vitiligo symptoms you should look out for are not only restricted to the obvious white patches that occur due to the depigmentation of the skin, although these represent the largest single symptom of the disorder. There are various stages of this progressive condition that are classified as generalized or localized vitiligo and these are split into further sub categories as listed below.
Of the generalized vitiligo category, patients will notice the following:
· At the onset of the disorder, it is common for patients to suffer from acrofacial vitiligo which is characterized by white patches of depigmented skin mainly on the face, head, feet and hands.
· On the other hand vulgaris vitiligo is when the depigmented skin areas appear on the torso and limbs.
· When a vitiligo patient has a combination of acrofacial vitiligo and vulgaris vitiligo, it is classified as mixed vitiligo which is a fair description as the two previously mentioned types manifest themselves together.
· Probably the most severe of the generalized vitiligo types would have to be universal vitiligo which is where the white patches have spread and covered almost all of the patient’s body.
Localized vitiligo, as the name suggests, relates to the condition when it affects smaller areas of the body and include the following:
· Mucosal vitiligo is when only the mucus membranes are affected with vitiligo, such as the tissue that lines the mouth.
· A type that is more commonly found in children and which only seems to affect one side of the body is called segmental vitiligo.
· When the condition affects a relatively small area of the patient’s skin it is commonly known as focal vitiligo.
Why does skin pigment change? The reason that vitiligo causes irregular white patches on a patient’s skin is because melanocytes, the cells which produce the pigment melanin that gives skin its colouring , are either neutralized or destroyed. This means that as well as making the affected skin appear white, it also makes the whiter area more susceptible to the sun’s rays and consequently sunburn. It is a good idea for vitiligo sufferers to use a high factor sunscreen for this reason.
Vitiligo lesions are recognized by their milky white appearance compared to the rest of the skin and they can manifest as circular, oval or linear shapes whose borders are convex. They show a marked contrast to the colour of darker toned skin, but may only be detectable under ultraviolet light for those patients with naturally lighter skin.
These lesions can appear absolutely anywhere on the body, but typically, they usually first appear on the patient’s extremities – face, hands, fingers and feet. They can also appear on the scalp, forearms and wrists in the initial stages of the condition.
The eyes and mouth are the usual sites for vitiligo when it affects a patient’s face and, sometimes, if the scalp is affected, then the hair in that area can also turn white. It is also not uncommon for a patient with facial vitiligo to have white eyebrows. Vitiligo that attacks the mucosal membranes of the body will tend to form in areas such as the lips, navel, rectum and genitals. The distribution of vitiligo lesions can be either localized or generalized as discussed earlier.
Although vitiligo is a progressive disorder, there are no rules governing how quickly it spreads in a patient’s body. The way an individual vitiligo patch progresses, however, does follow a pattern. A vitiligo patch will grow from the centre outwards both in shape and size. There are three different colour zones within a vitiligo patch with the centre part being white (called achromia), the area between the centre and the edge is a tan colour (this area is called hypochromia) and the edge is where depigmentation hasn’t taken place and the skin retains its natural colour (pigmented skin). As the patch expands, the tan area will become white and the previous edge of the patch will turn to a tan colour. It isn’t possible to predict the rate at which a vitiligo patch will expand and it could take several years before any noticeable growth takes place.
There are some occasions when there are extra coloured zones making up a patient’s vitiligo patch. Very rarely the edges of the vitiligo lesion are reddened and inflamed and are itchy. Redness can also be seen in a form of vitiligo known as the Koebner Phenomenon when the skin suffers a trauma such as cuts, abrasions or burns.
If a patient develops vitiligo following hyperpigmentation and inflammation of the skin, then they may develop blue vitiligo. Hyperpigmentation actually has an opposite effect to vitiligo inasmuch that too much melanin is produced making the skin colour darken. It can be caused by hormonal changes as well as exposure to ultraviolet radiation and when it also inflames the skin then the rare blue vitiligo can occur.
Other diseases that may be associated with vitiligo include:
· Skin cancer, or melanoma, can cause vitiligo in some patients, with the white patches appearing anywhere on the patient’s body; they do not necessarily appear near the site of the melanoma itself.
· A dysfunctional thyroid gland is one of the most commonly associated autoimmune disease with vitiligo. When vitiligo is diagnosed in a young patient they are usually automatically screened for thyroid dysfunction, because the vitiligo generally appears in advance of any thyroid problems.
· Some vitiligo patients may experience loss of pigment in the eye’s retinal pigment epithelium. A very small percentage of vitiligo patients may experience inflammation of the iris.
· Because melanocytes are destroyed in vitiligo patients, melanin is not produced and another function of this substance, besides pigmentation, is the conduction of sound signals within the inner ear. As many as 16 per cent of vitiligo suffers also have auditory problems.
So What Are The Causes Of Vitiligo?
Even today the root cause of vitiligo is not fully understood. The mechanics of the disease are well known, but why it happens is still the subject of extensive research. Some studies have identified the following as probable causes of the disorder and it is more than likely that several factors are behind the onset of the disease:
· Genetic defects can either be inherited through dna or can be acquired and they can have an influence on the development of vitiligo in a patient. Genes are responsible for everything about us and that includes the control of the autoimmune system. In some vitiligo patients, their autoimmune system functions perfectly well except for one tiny detail – they identify melanocytes as a potential threat and deal with them accordingly. Genes are responsible also for the production of melanocytes and melanin and any defects in this function could bring on vitiligo. In addition to these other things, genes are responsible for protecting against oxidative stress which may be a factor responsible for vitiligo.
· Oxidative stress occurs when there is a build-up of hydrogen peroxide and free radicals on the skin. These can be instrumental in increasing the destruction rate of melanin producing melanocytes. Vitiligo that is caused by oxidative stress can be recognized and diagnosed by using ultra violet light to detect yellowish green or blue fluorescence on the skin.
· It has been observed in some cases that the onset of vitiligo only occurred after there had been some nerve damage in a patient. Experts believe that vitiligo is caused in these cases when damaged nerve endings don’t release enough neurochemical mediators and this affects the production of melanin.
· When vitiligo is associated with such autoimmune disease as thyroid disorders, the autoimmune system identifies melanocytes as a possible danger and sets about destroying them even though, otherwise, the autoimmune system functions perfectly normally. Those melanocytes can then no longer produce melanin and depigmentation starts. These autoimmune attacks can also lead to other conditions such as psoriasis.
Other autoimmune diseases that are also associated with vitiligo are adult-onset type 1 diabetes, psoriasis and pernicious anaemia. Pernicious anaemia is caused by the failure of the body to absorb vitamin B12 properly and this is significant because studies have found that vitiligo sufferers have a vitamin B12 deficiency.
· It is far easier for melanocytes to be destroyed if they didn’t form properly to begin with. Whether it is through inheriting a faulty gene or damage caused to the melanocyte from some other disease or trauma, people with deformed melanocytes are at a much higher risk of developing vitiligo than people with normally formed melanocytes.
Although the root cause is still unknown, there has been sufficient research conducted into vitiligo to enable the condition to be treated effectively, halting the progression of the disease and, in some patients, repigmenting the skin.
So How Can Vitiligo be Treated Effectively?
The type of treatment a vitiligo patient receives will be dependent on how severe their condition is. The fact that vitiligo is a disease that leaves unsightly white blotches on a patient’s skin means that an important part of any treatment would involve counselling. Diseases like vitiligo not only attack the skin, but they can also attack the self-confidence and psychological welfare of a sufferer and being helped to cope with the condition is invaluable.
At the very onset of vitiligo, the patient may experience only very slight patches of white skin and this may be hidden by clothing. If the patch is visible, on the face say, it may be possible to hide it with some creative use of make-up or even a self-tanning application. More enterprising individuals experiment with homemade camouflage creams using things like food colouring and rubbing alcohol.
However, as the vitiligo progresses it may not be as simple to use these camouflage methods and steps can be taken to begin repigmentation of the skin. It should be noted that repigmentation, if it does occur, will take a considerable amount of time. There are several ways to tackle repigmentation and some of them are a little less expensive than others and some produce fewer if any side effects.
1. Steroid Creams (corticosteroid) – Care should always be taken when applying steroid creams, which are commonly used in the first instance of vitiligo attacks, owing to the various side effects that can occur with long-term usage, such as contact dermatitis and skin atrophy. There are some safer creams that can be used, like pimecrolimus and tacrolimus creams, which are typically prescribed for children because they have few if any side effects.
2. Natural Remedies – As with many other conditions, patients find that natural remedies are far more attractive because not only are they effective, but they are also less likely to produce any side effects. Natural remedies commonly used in the treatment of vitiligo include:
a. Vitamins – Studies in the 1990s linked vitiligo with deficiencies in the two B vitamins, Folic Acid (Vitamin B9) and vitamin B12. In a test involving 100 patients, results proved very effective when vitamin B12 and Folic Acid were introduced together with exposure to sunlight (or UVB light as an alternative to sunlight). The results showed that 64 per cent of the vitiligo patients reported a halt to depigmentation altogether, whilst 52 per cent experienced repigmentation in varying degrees. In fact, 6 per cent of the patients involved in the study were shown to have experienced almost total repigmentation.
Vitamin B12 and Folic Acid (Vitamin B9) can be taken as supplements or found in a normal healthy diet. A good source for both folic acid and vitamin B12 is meat (particularly liver), dairy products, eggs, milk, leafy vegetables (preferably raw because the washing and cooking processes dispose of the majority of the available vitamin B12 in leafy vegetables), breakfast cereals, shellfish and fish.
b. Minerals and Herbal Extracts – These are typically found to have antioxidant properties as well as ingredients that modulate the immune system. Callumae would be a good example of this type of treatment.
3. Light Treatments – Although these treatments are costly and can take a long time to complete, they are quite effective in the treatment of vitiligo. They are as follows:
a. PUVA Treatment (which stands for psoralen and ultraviolet A therapy) – This used to be the most popular light therapy in the treatment of vitiligo, but it was quite a lengthy process.
b. Narrow band UVB Treatment (a treatment using ultraviolet B light)- This has proved to be a safer option than PUVA because it has a shorter treatment time with fewer complications than UVA light. Also, there is no need to use photosensitizing drugs like psoralen.
c. Excimer Laser Treatment (this is also known as an exciplex laser) – This is a comparatively new and quite an expensive form of light therapy. The excimer laser is an ultraviolet laser which is commonly used for eye surgery procedures.
4. Surgical Procedures – Vitiligo can be treated surgically in two ways
a. Autologous skin grafting.
b. Autologous melanocyte grafting.
Autologous means that the patient is both the donor and recipient of the skin or melanocyte graft. Healthy skin is removed from one site on the patient’s body and grafted onto the white patch. When melanocytes are grated, they first have to be taken from the patient and then they are multiplied and grown in a laboratory before being transplanted back into the patient.
If the vitiligo patches have progressed to such a stage that more than half the body has been affected, then total or full body depigmentation may be recommended. This treatment attacks the problem from the other angle. It removes the white patches, by making the whole body white. Mononbenzone is applied to the body to bring about full body depigmentation and once the depigmentation is complete it cannot be reversed.
Whilst vitiligo is a very common disorder (affecting almost 1 per cent of the world’s population) it is not contagious, nor does it have any real physical effects on the body. One of the biggest effects it has is to make the sufferer feel a lack of self-confidence owing to the unsightly patches of white skin that develop on the body.
This can be tackled initially, to some extent, through the constructive use of make-up and self-tanning products to camouflage the affected area. Of course, this is all very well whilst the affected area remains small and localized. Once the vitiligo patches start spreading and growing, hiding them through the use of make-up and self-tanning products becomes less viable and topical corticosteroid creams can be employed. Long-term usage of steroid creams are not really recommended because of the different side effects.
Patients suffering from vitiligo should really consider the use of vitamins to help them as the disease progresses, particularly in light of the very favourable findings of the study investigating the benefits of B12 and folic acid as an effective treatment. It’s very difficult not to take notice of a study that puts the success rate of stopping further depigmentation of the skin at over 60 per cent by using a combination of Vitamin B12, folic acid and plenty of sunshine.
Should a dietary and supplementary intake of Vitamin B12 and Folic Acid prove to be insufficient then vitiligo sufferers should consider other means of redressing the balance and might even consider surgery.
The surgical procedures used for vitiligo patients consist of taking normal healthy skin and grafting it onto the affected area or taking normal healthy melanocytes and growing them in the laboratory and then grafting them onto the area that needs them.
Other methods of repigmenting the skin include three different kinds of light treatment that employ ultraviolet light in different intensities and although this light treatment is quite effective it can prove to be quite expensive and the treatment takes a considerable amount of time to complete.
Vitiligo patients can take encouragement from the knowledge that it is possible for their condition to be treated over time and this should help to minimise the social and psychological stress that they will be experiencing. However, it is recommended that the patient should be given some counselling and they will also need the support of their friends and families.
Although on-going research is needed to discover the root cause of vitiligo, there is sufficient evidence already to show that the disorder is treatable by identifying some of the reasons for the lack of melanin due to destruction of the melanocytes.
As biomedical and genetic technologies improve, it is possible that treatment for vitiligo could become cheaper and much quicker which can only be good news for those people who suffer from the condition.