What is Vitiligo - Pathogenesis, Diagnosis, Types, Symptoms

Vitiligo

Authored by DesiMD Team

What is Vitiligo?

Vitiligo is a patchy loss of color of the skin and is an acquired depigmentation of skin which results from the destruction of the melanocytes.

Vitiligo, a benign cosmetic problem with no racial and gender bias is a common, acquired, primary, progressive, chronic depigmentory disorder of obscure etiology, manifesting clinically as patchy, circumscribed achromic macules sometimes associated with leucotrichia (white hair) of the involved skin.

Vitiligo and similar conditions

Albinism: Albinism is a congenital (by birth) condition in which there is complete absence of melanin pigment in the skin, hair, and eyes

Leukoderma is a combination of two words one is “leuko” means “white” and second is “derma” means “skin” any white patch of varied pathology, it could be infectious like in Alopecia areta, Petriaresis alba, Granuloma annulare, Sutton’s halonaevus, Post-inflamatory hypopigmentation, Idiopathic gutteate hypomelanosis, Pitiariasis, lichen chronic, Mycosis fungoides, Sarcoidosis, Leucoplaqia, Infection, Leprosy, Pityriasis versi colour, Pinta, Post Kala azar, Lupus vulgaris, Hansons disease angular stomotitis. Leucoplaqia is a precursor to malignancy.

What is its pathogenesis?

There are three plausible hypothesis which attempts to explain the pathogenesis of Vitiligo

Autoimmunity in which, though the immune system is normal but misdirected sensing pigment cells as foreign bodies and destructing them, a battle within the body

Neural hypothesis postulates a neurochemical mediator which is secreted from the nerve endings, destroys the melanocytes (pigment cells)

Auto Cytotoxicity or melanocytes self destruction. The cell destruction hypotheses implicate an intermediate in melanin metabolism that causes melanocyte destruction

How is it diagnosed?

Vitiligo is diagnosed through

A.      Clinical examination: Most of the cases are diagnosed only by way of clinical examination

B.      Wood’s lamp examination

C.      Histopathology with special strains

 

What is its incidence and prevalence?

Incidence: 0.5 – 1% of global population. In India, it is estimated to be 0.4 to 2.5%. Gujarat and Rajasthan states have the highest prevalence in terms of seeking treatment however disease prevails more in coastal areas of Kerala, Tamil Nadu, Andhra Pradesh, West Bengal, etc.

The incidence of Vitiligo is around 1% of the total population in USA, 1.64% in Japan, 0.14% in Russia, 0.24% in London, 0.39% in Switzerland and 1% in Egypt.

According to the various studies in different cities of India can be anything between 2.9% in Goa to 8.8% in Delhi and 1.2% in Hyderabad. However, most authors say that its incidence is around 4% which is definitely more as compared to the world’s population of 1%.

Prevalence: The prevalence among the dermatology outdoor patients is estimated to be between 3-4%. It affects both the genders equally regardless of social and racial background.

What are the types of Vitiligo?

Vitiligo is categorized according to the extent of involvement and the distribution of depigmentation there are three broad classification of Vitiligo:

Depending on the distribution pattern and area wise involvement, Vitiligo is commonly classified as follows:

Vitiligo Vulgaris: The most common presentation with bilaterally symmetrical lesions, which at times may exhibit mirror image symmetry which covers the extensive surface of the body

Acrofacial Vitiligo: Vitiligenous lesions of the acral or distal parts of limbs (i.e. Fingers, palms, toes and soles) and facial orifices, (mostly on lips) the latter in a circumferential pattern

Segmental/ Dermatomal Vitiligo: It affects the area supplied by a nerve, occurs in a unilateral, asymmetric distribution spreading over one or more dermatomes

Lip-tip Vitiligo: It refers to the type where lesions are restricted only to the lips and distal parts of fingers and toes

Focal Vitiligo: It is characteristic of one or two closely set depigmented lesions localized to a single area

Universal Vitiligo: In this case, there is loss of pigment over the entire body surface except a few small islands of pigmented skin

Combination Vitiligo: Very rarely vitiligo vulgaris and segmental vitiligo are seen in the same patient.

Mucosal Vitiligo: It affects only the areas with mucous membrane. Most common areas are lips, anogenital areas, etc.

Chemical contact vitiligo: This is the most fastest emerging type of vitiligo which results due to chemical contact (drugs/ chemicals: hydroquinone, phenolic compounds, detergents, antiseptics, adhesives, etc.), use of recycled plastic wear, poor-quality cosmetics (commonly bindis, lipstick), use of condoms are the few to mention.

Are there any symptoms before developing a patch?

Vitiligo mostly being an auto-immune disorder in which pigment cell destruction takes place, most of the patients experience itching before developing a white patch (vitiligo lesions are preceded with itching which is considered to be a bad sign)

How the patch does really appear?

The first symptom that initially appears is a scattered white patch or a de-pigmented area over the skin in response to a trauma, injury, burns, and scalds or over the pressure points or without any obvious reason. This is commonly found on exposed areas. For example: after getting traumatic injury due to fall which is more common among children, after healing of the wound it may lead to the development of white patch. This speaks the underlying susceptibility towards vitiligo known as active Koebenor’s phenomenon. Hairs over the vitiligo lesions may be altered which is known as leucotrichia.

What is oxidative stress?

The role of H2O2 accumulation is defined as oxidative stress. To date, there is ample evidence that vitiligo affects the entire epidermis. Convincing the data support, the participation of caratinocytes and langarhans cells besides the loss of functioning melanocytes, various degree of cellular vacuolation and debris in all epidermal cell have been documented. Recently, the vacuolation was attributed to H2O2 mediated lipid per oxidation which makes the lesion resistant.

Do genetics have a role in vitiligo causation?

There is undoubted genetic predisposition in causing vitiligo. Approximately, 13% patients have affected relatives but the mode of inheritance is not fully understood. However, it is considered to be a multi-factorial.

Which are the other diseases associated with vitiligo?

As vitiligo is an autoimmune disorder. The best evidence of auto immunity in vitiligo is its clinical association with other autoimmune disorders like diabetes mellitus, thyroid disorders (most commonly hypothyroidism), psoriasis, pernicious anemia, Halonevi, Addison’s disease, alopecia areata and atopic dermatitis, scleroderma and hyper parathyriodism, etc.

Is there any role of diet?

Certain food articles like sea food along with milk products, excess use of broiler chicken and egg, pickles, etc., are considered to be a cause of aggravation of disease. A balanced non-vegetarian/ vegetarian diet consisting of mutton, organic chicken, vegetables, chapatti, rice, sprouts, non citrus fruits is considered to be a good balanced diet.

What are the social implications of vitiligo?

Vitiligo is a complex metabolic disorder characterized by loss of pigmentation which is polygenic in nature and mostly regarded as social stigma. The course of vitiligo without treatment is unpredictable. The magnitude of the problem can be highlighted with the fact that the patients of vitiligo are condemned to spinsterhood, denied of first line jobs which needs public interaction leading to social isolation.

Does it affect the quality of life?

Many patients with vitiligo may feel depressed and start lacking confidence especially when the lesions are on exposed areas and always eager to re-gain their lost pigmentation.

Does vitiligo spread?

The course of the disease is unpredictable. Usually has periods of stability followed by rapid progression. As every person has a different body condition like for some vitiligo can spread very slowly whereas for others it spreads very rapidly. This disease is a progressive in nature and over the time, it usually spreads to other parts of the body. Few patients report the onset of the disease followed by periods of physical and emotional stress. However, the non-dermatomal vitiligo tends to spread.

Is vitiligo contagious?

No. Neither its contagious nor infectious.

Is total care of vitiligo available?

The comprehensive treatment for vitiligo must consist of good amount of psychological counseling, drugs to control the further spreading and to induce re-pigmentation. It can be achieved sometime only with the medical treatment and some patients needs an integrated approach where a surgical intervention can be made.

What are the treatment options?

Following are the various treatment options for Vitiligo

A.      Immune modulators to overcome the auto-immune phase

B.      Drugs to overcome the resistance created by previous treatments as vitiligo being a stubborn pigmentary metabolic disorder which needs prolong treatment

C.      Melonogenetic drugs and UV therapy to induce and to accelerate the rate and percent of re-pigmentation

D.      Surgical interventions like melanocytes transplantation and micro-grafting. These techniques can be employed once disease becomes stable

E.       Camouflage (masking)

 

Are there any other factors which have influence on treatment outcome?

Age, duration of disease, type of vitiligo, site of the lesion, extension of the lesion, distribution of the lesion, leucotrichia and the mental stress are the few factors which has influence on the treatment outcome.

Whether an integrated approach is required?

Yes, there is a great need for an integrated approach for complete cure of vitiligo but not always.

An integrated approach can be taken:

A.      Once the disease becomes stable

B.      When there are unyielding macules

Surgical interventions are considered for auto skin graft, micro graft/ punch graft and melanocyte transplantation.

What are the chances of re-pigmentation?

The chances of repigmentation are excellent in non-dermatomal vitiligo, vitiligo vulgaris, followed by focal vitiligo, segmental vitiligo, acro-facial vitiligo and mucosal vitiligo, respectively.

Can you specify the time for re-pigmentation? Is the color gain permanent?

Usually, initial 3 months of treatment is a very good time to see the visible improvement. If disease becomes stable, the regained pigmentation will remain permanently.

What are the good sites of the body to regain pigmentation?

Except acral areas and lips, every site of the body has an excellent re-pigmentation chance.

Have we reached a stage now that we can call this disease ‘completely curable’?

Every patient of vitiligo is a new challenge to the doctor as a complex disease phenomenon exists. However, based on new knowledge and new modalities both medical and surgical, not all but most of the patients may definitely expect a complete cure (to the extent of over 70% of vitiligo patients).

How far and how satisfactorily are we able to treat this disorder now?

For the last two decades Unani compound formulations both for systemic and topical use are catering the needs of vitiligo patients in treating and inducing the cosmetically acceptable re-pigmentation. There are different treatment modalities available under the banner of Central Research Institute of Unani Medicine (CRIUM), like formulations to overcome the resistance created because of prolong treatments, to control the further spreading of the disease, to induce the re-pigmentation. The above measures are the excellent tools not only to control the disease process and to induce the re-pigmentation but also to minimize the chances of relapse.

What are we doing?

CRIUM, Hyderabad has taken initiatives in creating awareness about Vitiligo in order to eradicate the misconceptions of the disease by writing articles in health magazines, newspapers, etc. By organizing radio talks and television interviews and conducting group counseling and individual counseling.

How sage is Unani System of Medicine in treating Vitiligo?

Drugs are safe, as no ocular, hepatic and renal toxicity is reported. The drugs are well tolerated and are suitable even in prolong use.

 

Compiled by

Dr.M.A.Waheed,

Deputy Directory, CRIUM, Hyderabad.

Tel: +91 93462 87487

E-mail: maw023@yahoo.com