Vitiligo

Overview

Vitiligo is a long-term condition where pale white patches develop on the skin. It's caused by the lack of melanin, which is the pigment in skin.

Vitiligo can affect any area of skin, but it commonly happens on the face, neck and hands, and in skin creases.

The pale areas of skin are more vulnerable to sunburn, so it's important to take extra care when in the sun and use a sunscreen with a high sun protection factor (SPF).

Symptoms of vitiligo

The areas most commonly affected by vitiligo include:

mouth and eyes
fingers and wrists
armpits
groin
genitals
inside your mouth

It can also sometimes develop where there are hair roots, such as on your scalp. The lack of melanin in your skin can turn the hair in the affected area white or grey.

Vitiligo often starts as a pale patch of skin that gradually turns completely white. The centre of a patch may be white, with paler skin around it. If there are blood vessels under the skin, the patch may be slightly pink, rather than white.

The edges of the patch may be smooth or irregular. They're sometimes red and inflamed, or there's brownish discolouration (hyperpigmentation).

Vitiligo does not cause discomfort to your skin, such as dryness, but the patches may occasionally be itchy.

The condition varies from person to person. Some people only get a few small, white patches, but others get bigger white patches that join up across large areas of their skin.

There's no way of predicting how much skin will be affected. The white patches are usually permanent.

Types of vitiligo

There are 2 main types of vitiligo:

non-segmental vitiligo
segmental vitiligo

In rare cases, it's possible for vitiligo to affect your whole body. This is known as universal or complete vitiligo.

Non-segmental vitiligo

In non-segmental vitiligo (also called bilateral or generalised vitiligo), the symptoms often appear on both sides of your body as symmetrical white patches.

Symmetrical patches can appear on the:

backs of your hands
arms
skin around body openings, such as the eyes
knees
elbows
feet

Non-segmental vitiligo is the most common type of vitiligo, affecting around 9 out of 10 people with the condition.

Segmental vitiligo

In segmental vitiligo (also known as unilateral or localised vitiligo), the white patches only affect one area of your body.

Segmental vitiligo is less common than non-segmental vitiligo, although it's more common in children. It usually starts earlier and affects 3 in 10 children with vitiligo.

What causes vitiligo?

Vitiligo is caused by the lack of a pigment called melanin in the skin. Melanin is produced by skin cells called melanocytes, and it gives your skin its colour.

In vitiligo, there aren't enough working melanocytes to produce enough melanin in your skin. This causes white patches to develop on your skin or hair. It's not clear exactly why the melanocytes disappear from the affected areas of skin.

Autoimmune conditions

Non-segmental vitiligo (the most common type) is thought to be an autoimmune condition.

In autoimmune conditions, the immune system doesn't work properly. Instead of attacking foreign cells, such as viruses, your immune system attacks your body's healthy cells and tissue.

If you have non-segmental vitiligo, your immune system destroys the melanocyte skin cells that make melanin.

Vitiligo is also associated with other autoimmune conditions, such as hyperthyroidism (an overactive thyroid gland), but not everyone with vitiligo will develop these conditions.

Risk factors

You may be at increased risk of developing non-segmental vitiligo if:

other members of your family have it
there's a family history of other autoimmune conditions – for example, if one of your parents has pernicious anaemia (an autoimmune condition that affects the stomach)
you have another autoimmune condition
you have melanoma (a type of skin cancer) or non-Hodgkin lymphoma (cancer of the lymphatic system)
you have particular changes in your genes that are known to be linked to non-segmental vitiligo

Neurochemicals

Segmental vitiligo (the less common type) is thought to be caused by chemicals released from the nerve endings in your skin. These chemicals are poisonous to the melanocyte skin cells.

Triggers

It's possible that vitiligo may be triggered by particular events, such as:

stressful events, such as childbirth
skin damage, such as severe sunburn or cuts (this is known as the Koebner response)
exposure to certain chemicals – for example, at work

Vitiligo isn't caused by an infection and you can't catch it from someone else who has it.

Diagnosing vitiligo

A GP will be able to diagnose vitiligo after examining the affected areas of skin.

They may ask whether:

there's a history of vitiligo in your family
there's a history of other autoimmune conditions in your family
you've injured the affected areas of skin – for example, whether you've had sunburn or a severe rash there
you tan easily in the sun, or whether you burn
any areas of skin have got better without treatment, or whether they're getting worse
you've tried any treatments already

A GP may also ask you about the impact vitiligo has on your life. For example, how much it affects your confidence and self-esteem, and whether it affects your job.

Wood's lamp

If available, your GP may use an ultraviolet (UV) lamp called a Wood's lamp to look at your skin in more detail. You'll need to be in a dark room and the lamp will be held 10 to 13cm away from your skin.

The patches of vitiligo will be easier to see under the UV light, which will help the GP distinguish vitiligo from other skin conditions, such as pityriasis versicolor (where there's a loss of pigment due to a fungal infection).

Other autoimmune conditions

As non-segmental vitiligo is closely associated with other autoimmune conditions, you may be assessed to see whether you have any symptoms that could suggest an autoimmune condition, such as:

being tired and lacking energy, which may be a sign of Addison's disease
being thirsty and needing to urinate often, which may be a sign of diabetes

A blood test may also be needed to check how well your thyroid gland is functioning.

Treating vitiligo

If vitiligo is severe or making you unhappy, you may want to consider treatment.

The white patches caused by vitiligo are usually permanent, although treatment options are available to reduce their appearance.

If the patches are relatively small, skin camouflage cream can be used to cover them up.

Steroid creams can also be used on the skin to restore some pigment, however long-term use can cause stretch marks and thinning of the skin

If steroid creams do not work, phototherapy (treatment with light) may be used.

Although treatment may help restore colour to your skin, the effect does not usually last. Treatment cannot stop the condition spreading.

Complications of vitiligo

Vitiligo can sometimes cause other problems.

Because of a lack of melanin, your skin will be more vulnerable to the effects of the sun. Make sure you use a strong sunscreen to avoid sunburn.

Vitiligo may also be associated with problems with your eyes, such as inflammation of the iris (iritis), inflammation of the middle layer of the eye (uveitis), and a partial loss of hearing (hypoacusis).

Problems with confidence and self-esteem are common in people with vitiligo, particularly if it affects areas of skin that are frequently exposed.

Help and support

Support groups can provide help and advice, and may be able to put you in contact with other people with vitiligo. A GP may suggest a group in your local area.

The charity The Vitiligo Society also offers advice and support.

Treatment

Treatment for vitiligo is based on changing the appearance of the skin by restoring its colour.

However, the effects of treatment aren't usually permanent, and it cannnot always control the spread of the condition.

A GP may recommend:

sun safety advice
a referral for camouflage creams
topical corticosteroids (a cream or oitment that contains a steroid)

Further treatment may not be necessary if, for example, you only have a small patch of vitiligo or your natural skin colour is very light.

You may be referred to a doctor who specialises in treating skin conditions (dermatologist) if further treatment is needed.

Protection from the sun

Sunburn is a severe risk if you have vitiligo. You must protect your skin from the sun and do not use sunbeds.

When skin is exposed to sunlight, it produces a pigment called melanin to help protect it from ultraviolet (UV) light. However, if you have vitiligo there is not enough melanin in your skin, so it's not protected.

Always apply a sunscreen, ideally with a sun protection factor (SPF) of 50 or above, to protect your skin from sunburn and long-term damage. This is particularly important if you have fair skin.

Vitamin D

If your skin is not exposed to the sun, there's an increased risk of vitamin D deficiency. Vitamin D is essential for keeping bones and teeth healthy.

Sunlight is the main source of vitamin D, although a form of vitamin D is also found in some foods, such as oily fish.

It might be difficult to get enough vitamin D from food and sunlight alone. You should therefore consider taking a daily supplement containing 10 micrograms (mcg) of vitamin D.

Skin camouflage

Skin camouflage creams can be applied to the white patches of skin. The creams are specially made to match your natural skin colour. The cream blends in the white patches with the rest of your skin, so they are less noticeable.

For advice about skin camouflage, a GP may refer you to the Changing Faces Skin Camouflage Service.

You need to be trained in using the camouflage creams, but the service is free (although donations are welcome) and some creams can be prescribed on the NHS.

Camouflage creams are waterproof and can be applied anywhere on the body. They last for up to 4 days on the body and 12 to 18 hours on the face.

Topical corticosteroids

Topical corticosteroids come as a cream or ointment you apply to your skin.

They can sometimes stop the spread of the white patches and may restore some of your original skin colour.

A topical corticosteroid may be prescribed to adults if:

you have non-segmental vitiligo on less than 10% of your body
you want further treatment (sun protection advice and camouflage creams are enough for some people)
you are not pregnant
you understand and accept the risk of side effects

Speak to a GP if you want to use a topical steroid on your face.

Using topical steroids

A GP may prescribe a cream or an ointment, depending on what you prefer and where it will be used. Ointments are greasier.

Possible corticosteroids that may be prescribed include:

fluticasone propionate
betamethasone valerate

A GP will tell you how to apply the cream or ointment to the patches and how much you should use. You usually need to apply the treatment once a day.

Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU). One FTU is the amount of topical steroid squeezed along an adult's fingertip. One FTU is enough to treat an area of skin twice the size of an adult's hand.

Follow-up

After one month, you'll have a follow-up appointment so the GP can check how well the treatment is working and whether you have any side effects. If the treatment is causing side effects, you may need to stop using a topical steroid.

After another month or 2, the GP will check how much your vitiligo has improved. If there's no improvement, you may be referred to a dermatologist.

If it's improved slightly, you may continue treatment, but have a break from treatment every few weeks. You may also be referred to a dermatologist.

Treatment will be stopped if your vitiligo has improved significantly.

The GP may take photos of your vitiligo throughout your treatment to monitor any signs of improvement. You may also want to take photos yourself.

Side effects

Side effects of topical steroids include:

streaks or lines in your skin (striae)
thinning of your skin (atrophy)
visible blood vessels appearing (telangiectasia)
excess hair growth (hypertrichosis)
inflammation of your skin (contact dermatitis)
acne

Referral

A GP may refer you to a dermatologist if:

they're unsure about your diagnosis
you're pregnant and need treatment
more than 10% of your body is affected by vitiligo
you're distressed about your condition
your face is affected and you want further treatment
you can't use topical steroids because of the risk of side effects
you have segmental vitiligo and want further treatment
treatment with topical steroids has not worked

Children with vitiligo who need treatment will also be referred to a dermatologist.

Some treatments your dermatologist may recommend are:.

Topical pimecrolimus or tacrolimus

Pimecrolimus and tacrolimus are a type of medicine called calcineurin inhibitors, which are normally used to treat eczema.

Pimecrolimus and tacrolimus are unlicensed for treating vitiligo, but they can be used to help restore skin pigment in adults and children with vitiligo.

They can cause side effects, such as:

a burning or painful sensation when applied to the skin
making the skin more sensitive to sunlight
facial flushing (redness) and skin irritation if you drink alcohol

However, unlike steroids, pimecrolimus and tacrolimus do not cause thinning of the skin.

Phototherapy

Phototherapy (treatment with light) may be used for children or adults if:

topical treatments haven't worked
the vitiligo is widespread
the vitiligo is having a significant impact on quality of life

Evidence suggests that phototherapy, particularly when combined with other treatments, has a positive effect on vitiligo.

During phototherapy, your skin is exposed to ultraviolet A (UVA) or ultraviolet B (UVB) light from a special lamp. You may first take a medicine called psoralen. This can be taken orally, added to your bath water, by soaking individual body parts or in gel form.

This type of treatment is sometimes called PUVA (psoralen and UVA light).

Phototherapy may increase the risk of skin cancer because of the extra exposure to UVA rays. The risk of skin cancer is lower with UVB light. Your dermatologist should discuss the risk with you before you decide to have phototherapy.

Sunlamps that you can buy to use at home for light therapy are not recommended. They're not as effective as the phototherapy you'll receive in hospital. The lamps are also not regulated, so they may not be safe.

Skin grafts

A skin graft is a surgical procedure where healthy skin is removed from an unaffected area of the body and used to cover an area where the skin has been damaged or lost. To treat vitiligo, a skin graft can be used to cover a white patch.

Skin grafts may be considered for adults in areas that are affecting your appearance if:

no new white patches have appeared in the past 12 months
the white patches have not become worse in the past 12 months
the vitiligo was not triggered by skin damage, such as severe sunburn (Koebner response)

An alternative to skin grafting involves taking a sample of skin, removing the melanocytes from it and transplanting them onto the areas of vitiligo.

These types of treatments are time-consuming, carry a risk of scarring and aren't suitable for children. They're also not widely available in the UK and are not funded by the NHS.

Depigmentation

Depigmentation may be recommended for adults who have vitiligo on more than 50% of their bodies, although it may not be widely available.

During depigmentation, a lotion is painted on to the normal skin to bleach away the remaining pigment and make it the same colour as the depigmented (white) skin. A hydroquinone-based medication is used, which has to be applied continuously to prevent the skin from re-pigmenting.

Hydroquinone can cause side effects, such as:

redness
itching
stinging

Depigmentation is usually permanent and leaves the skin with no protection from the sun. Re-pigmentation (when the colour returns) can occur, and may differ from your original skin colour.

Other treatments

A dermatologist may recommend trying more than 1 treatment, such as phototherapy combined with a topical treatment. Other possible treatments include:

excimer lasers – high-energy beams of light that are used in laser eye treatment, but may also be used in phototherapy (not available on the NHS)
vitamin D analogues – such as calcipotriol, which may also be used with phototherapy
prednisolone tablets – a steroid, which has also been used with phototherapy; it can cause side effects

Complementary therapies

Some complementary therapies claim to relieve or prevent vitiligo. However, there's no evidence to support their effectiveness, so more research is needed before they can be recommended.

There's very limited evidence that the herbal remedy ginkgo biloba may benefit people with non-segmental vitiligo. There's currently no evidence to recommend it.

Check with a GP if you decide to use herbal remedies. Some remedies can react unpredictably with other medication or make them less effective.

Counselling and support groups

If you have vitiligo, you may find it helpful to join a vitiligo support group. It can help you understand more about your condition and come to terms with your skin's appearance.

Charities such as The Vitiligo Society, may be able to put you in touch with local support groups (you may need to become a member first). A GP may also be able to suggest a support group.

If you have psychosocial symptoms – for example, your condition is causing you distress – your GP may refer you to a psychologist or a counsellor for treatment such as cognitive behavioural therapy (CBT).

CBT is a type of therapy that aims to help you manage your problems by changing the way you think and behave.

Unlicensed medicines

Many treatments used for vitiligo are unlicensed. 'Unlicensed' means the medicine's manufacturer has not applied for a licence for it to be used to treat your condition. The medicine has not undergone clinical trials to see whether it's effective and safe in treating your condition.

Doctors may recommend using an unlicensed medicine if they think it will be effective, and the benefits of treatment outweigh any associated risk. Before prescribing an unlicensed medicine, they should inform you it's unlicensed, and discuss the possible risks and benefits with you.

The information on this page has been adapted by NHS Wales from original content supplied by

NHS website nhs.uk