More Than Just Skin Deep: The Management Of Vitiligo

Affecting between 0.5%- 1% of the global population, vitiligo is an acquired depigmentation disorder of the skin characterised by the loss of melanocytes (pigment cells) from the epidermis.

Elusive Pathogenesis

Why and how melanocytes fail to produce melanin or decrease in number to induce achromic lesions is not fully understood. There are, however, several major hypotheses for the pathogenesis of this skin disease, with three of which being autoimmune, neural and autocytotoxic/metabolic dysfunctional.

The association of vitiligo with other autoimmune disorders has been widely reported, showing a familial trait in about 18% of cases. Autoimmune thyroid diseases, particularly Graves’ disease and Hashimoto’s thyroiditis, are commonly associated with vitiligo; as with other endocrinopathies, such as diabetes mellitus and Addison’s disease. Pernicious anaemia, systemic lupus erythematosus and inflammatory bowel disease are often associated, but these associations’ significance is often debated.

The neural hypothesis suggests that an accumulation of neurochemical mediators causes a decrease in melanin production. This theory suggests that the nerve endings release a toxin that gradually damages melanocytes.

The biochemical hypothesis implicates that the destruction of melanocytes is primarily due to the accumulation of toxic free radicals. Compared to controlled subjects, the red cells enzymes of patients with vitiligo are observed to have lower levels of glutathione, an antioxidant that helps prevent free radical mediated injury and oxidative stress.

Whilst these hypotheses are based on convincing evidence, none of them can truly pinpoint and explain the cause of the disease. Most experts have agreed that vitiligo may be born from the convergence of several pathologic pathways rather than a single entity.

Classification of Vitiligo

Whilst it’s characterised by a general disappearance of epidermal and/or follicular melanocytes, vitiligo is classified into generalised, segmental, focal, universal and acrofacial.

Generalised vitiligo: Also known as vitiligo vulgaris, generalised vitiligo is the most common pattern out of all the classifications. The symptoms often appear on both sides of the patient’s body as symmetrical lesions.

Segmental vitiligo: Characterised by one or more lesions in a quasidermatomal pattern, segmented vitiligo tends to have an early onset. Though this type has little to no association to autoimmune diseases, more than half of segmental vitiligo patients have poliosis.

Focal vitiligo: Focal vitiligo is defined as either a small acquired solitary depigmented lesion, or 2 to 3 small acquired lesions with a maximum size of 5cm.

Universal vitiligo: This type of vitiligo is presented as macules (depigmented lesions 1cm wide) and depigmented patches all over the body. It is also often associated with multiple endocrinopathy syndrome.

Acrofacial vitiligo: This clinical form of vitiligo is characterised by macules in distal digits (tips of fingers or toes) and periorificial areas, including the areas around the eyes, nostrils, mouth and occasionally, the genitals.

Psychosocial Effects of Vitiligo

Vitiligo may have associations with autoimmune diseases, but vitiligo itself isn’t medically dangerous. However, patients with vitiligo suffer from severe psychological and social problems due to their depigmented patches of skin. Many global cultures and societies place a profound significance on appearance, aesthetics and pigmentation. Any condition that affects one’s appearance may be fraught with discrimination, and the loss of privilege, opportunities and upward social mobility. In India, for instance, vitiligo patients suffer from severe social problems, especially for young unmarried women whose social mobility and financial security are primarily dependent on marriages.

Whether innate or a byproduct of the societal prejudices or a combination of both, vitiligo patients develop psychological disorders, including depression and social anxiety. Due to their skin appearance, they attract undue attention from the general public, which can easily develop into self-consciousness, internalised stigmatisation, low self-esteem, and social isolation. This, coupled with the social barriers, greatly influenced the quality of life of these patients.

Treatments to Manage Vitiligo

Salzer and Schallreuter reported that about 75% of those that suffer from vitiligo found their disfigurement moderately or severely intolerable. Since its pathogenesis is non-conclusive, treatments to prevent or cure vitiligo have yet to be discovered. Even so, there are available treatments that help with the management of this condition, and which also improves the appearance of the depigmentation. Below are a few common examples.

Sunscreen: Sunscreens will protect the skin from UVB rays, the main culprit behind dark spots, pigmentation and sunburns. This helps to decrease tanning of the uninvolved skin, thus reducing the contrast with the lesions.

Cosmetics: Arguably one of the more accessible and cheaper options, cosmetic coverups offer not only an affordable alternative, but also minimal side effects and ease of application.

Corticosteroid Creams: Often the first line of therapy in pediatric patients, corticosteroid creams are used to treat limited areas of vitiligo. Lesions on the face, in particular, have a better response rate; followed by lesions on the neck and extremities with the exception of the fingers and toes.

Topical Immunomodulators: Topical immunomodulators 0.03%-0.1% is effective in the repigmentation of lesions when applied twice daily, especially on the face and neck. Its effectiveness improves if the treatment is combined with an excimer laser or UVB therapy. Considered as an alternative to the use of a potent topical steroid, topical immunomodulators offer a better side effect profile and are considered safe for both children and adults.

Ultraviolet Light Therapy: UVA irradiation works best with 8-methoxy psoralen in treating vitiligo by decreasing expression of vitiligo-associated melanocyte antigens. However, it is worth noting that unwanted side effects are common. Such side effects include hyperpigmentation of the skin surrounding the lesions, severe itch and severe phototoxicity. Whilst 70%-80% of patients have experienced some repigmentation with this therapy, careful patient selection is still important.

Final Thoughts

Whilst medically safe, vitiligo can develop into a very psychologically devastating skin disorder. Especially true in patients with darker skin colour, vitiligo carries numerous psychological implications. Treating this skin disorder may potentially require a multidisciplinary approach where medical treatments need to be supported by psychology or psychiatry consultation in patients with significant psychological impact.

At Angeline Yong Dermatology, we hold onto the belief that absolute beauty begins with absolute health in both mind and body. We combine exceptional and genuine service in a bespoke approach and offer a wide range of treatments to manage varying skin conditions across the ages. On top of topical and oral medications, our dermatology clinic also utilises up-to-date laser technology such as the PicoWay, Pico Sure and Gentlemax Pro lasers, to treat epidermal and dermal pigmented lesions.

Armed with over 15 years of medical practice, Dr Yong is an esteemed dermatologist who carries a significant influence on matters regarding aesthetic dermatology products and laser devices.

Take the first step towards feeling comfortable in your own skin and give us a call today!

References

Gawkrodger, D. J., Ormerod, A. D., Shaw, L., Mauri‐Sole, I., Whitton, M. E., Watts, M. J., … & Young, K. (2008). Guideline for the diagnosis and management of vitiligo. British Journal of Dermatology, 159(5), 1051-1076.

Parsad, D., Dogra, S., & Kanwar, A. J. (2003). Quality of life in patients with vitiligo. Health and quality of life outcomes, 1(1), 1-3.

Halder, R. M., & Chappell, J. L. (2009, June). Vitiligo update. In Seminars in cutaneous medicine and surgery (Vol. 28, No. 2, pp. 86-92). WB Saunders.

Passeron, T., & Ortonne, J. P. (2005). Physiopathology and genetics of vitiligo. Journal of autoimmunity, 25, 63-68.

Ongenae, K., Van Geel, N., & Naeyaert, J. M. (2003). Evidence for an autoimmune pathogenesis of vitiligo. Pigment Cell Research, 16(2), 90-100.

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More Than Just Skin Deep: The Management Of Vitiligo