What is vitiligo?
It is a non-infectious condition of the skin which shows up as white patches. It can have different presentations: localised or generalised. For example, like just on the lips, just on the fingertips or one side of your body, like one side of shoulder or hip, or it could be quite widespread and generalised.
Can vitiligo affect one internally? Or does having vitiligo mean one has a problem with their internal organs?
It is just a cosmetic disfigurement. It really does not have an internal effect of your body. The darker the skin is, the more obvious it will look. On a light skin it does not show very much so even the management also depends on that.
What causes vitiligo?
The exact cause of vitiligo is not known, but there are many theories on the process that brings it about. The most popular one is that it is an autoimmune condition; meaning the body itself creates antibodies directing them to attack the colour producing cells (melanocytes). What triggers this autoimmune process is the big question and so far there is no known cause.
Is there a specific autoimmune condition that has a link to vitiligo?
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The only close association of vitiligo is with the thyroid autoimmune condition and that is in patients with widespread vitiligo. So for these patients we usually check for the thyroid function because it is associated.
Does this mean if this autoimmune condition is treated vitiligo will go away?
It (thyroid autoimmune condition) is not really the cause, but an association. As we have said, the cause of vitiligo is not known.
What of risk factors? Are there any that can predispose someone to vitiligo?
One of them is if you have a family history then it is likely that you may or somebody in the next generation might get vitiligo. However, there is no specific risk factor. But if you have a scar, like if you get injured if you have a tendency of vitiligo then you are likely to get it. This is called the Koebner phenomenon, which predisposes one to vitiligo due to trauma or injury where one develops light patches.
How does this happen?
Even normally when you have an insect bite, some people heal with lightening of the skin but it goes back to normal; but people who have tendency for vitiligo tend to have a permanent white patch in that area.
Considering family history plays a role in vitiligo, is there a link between vitiligo and albinism, which also has genetic relation?
For vitiligo we talk of susceptibility which is just an association. In albinism, unlike vitiligo, there is a specific gene linked to the condition.
What is the difference between the two conditions?
Albinism results from deficiency of an enzyme which is in the pathway of producing melanin in the melanocytes. The melanocytes are totally intact but they lack that enzyme which converts melanin into the visible colour so persons with albinism are known to genetically have deficiency of this enzyme. As a result, unlike vitiligo, albinism means total lack of pigment so in those patients you cannot stimulate them to produce colour. In vitiligo there is hope of getting colour but for albinism, you just manage using sun blocks.
How is vitiligo managed?
First you have to counsel the patient. You have to tell them what the condition is and what you know about it. Let them know it is just a cosmetic disfigurement. If the patient has dark skin, management may be aggressive but if the patient has a fair skin, then they can get away with it and you can use sunscreen on the rest of the skin so that it does not get tanned.
Why is counselling important?
There are lots of misconceptions around the condition. Some think that now that they have one patch it will spread all over their body very fast and they will be totally white. You must tell them it is not a rule that it will spread. There are many patients who have recovered completely from one patch of vitiligo.
The other misconception is that having vitiligo means that it will have some internal effect. There are patients who have vitiligo in their private parts but it does not mean they will have problems with fertility.
Another myth is that having high protein diet has a link to vitiligo, but these have been disapproved in studies.
What kind of treatment are used?
There are multiple treatment modes: like topical applications (applied on the body surface) mainly these are calcineurin inhibitors which tend to stimulate melanocytes to start producing colour. We use those in very limited areas, for example if the patient has just light patches on the eye brows. We can also use topical steroids. Steroids can also be applied either in cream form or injections with very good response.
There is also psoralen, which is used as lotion for localised vitiligo and tablets for widespread conditions. There is light treatment as well which is used in combination with the other modes where the patient is exposed to narrow band UV-B light.
Some patients can also have skin graft surgery. But this is done only on patients who have had a white patch which has not spread for a long time.
What is the sign that the treatment is working?
Little brown dots on the white patch and the edges of the patch start becoming darker and later the pigment at the edges merges with the dots and that is how improvement occurs.
Can these treatment modes work if let’s say almost 95 per cent of the body is white?
For these patients, the sensible thing to do in order to make the body look uniform, we depigment the dark areas. I have one or two patients who insist that ‘yes doctor I want the rest of my dark pigment removed’. On those patients we use a completely different type of cream, which takes away the dark colour so that the whole skin is uniform. The patients become used to their white appearance that they do not want any other treatment to treat the vitiligo.
Is the management or treatment the same for both children and adults?
Yes, because they are all safe treatments. But for newborns, we usually just tell the parents that we will follow up because we do not want any side effects from the application like skin irritation, and treatment will start when they are slightly older.
How is the progress for treating vitiligo?
The progress is usually slow. I find that younger patients with vitiligo tend to respond better than older people. It is a condition I have seen in newborns to people in their 60s and 70s. When children get it they tend to respond better to treatment.
Why will some people have just small white patches while others have their bodies covered with vitiligo?
This is just the spectrum of the disease that we may have people with very few occasional white patches of the condition, which can sometimes spontaneously go away whereas others have widespread. It is not known. There is a lot which is not known about the condition. There is no way of determining which patient will have widespread vitiligo and which will have limited.
Can vitiligo lead to skin cancer?
Many studies have been done on this issue and most support the view that vitiligo does not make you susceptible to skin cancer. But there are many more studies required across large populations find if this is true.