Overview

Vitiligo is a long-term skin condition that causes the loss of skin pigmentation, resulting in white patches or spots on the skin. It occurs when the cells that produce melanin (the pigment that gives colour to your skin, hair, and eyes) are destroyed, leading to the loss of colour in that area of the skin.  There is a similar similar condition called leukoderma (aka achromoderma), but this occurs only after a cut, a burn or a reaction to an irritant or allergen, whereas vitiligo can occur spontaneously.

Vitiligo affects 0.1%-2% of the world's population. This condition can occur in people of all ages, races, and genders. It is not contagious and does not cause any other health problems, but it can have significant social and emotional effects on individuals with the condition.

Vitiligo is an autoimmune disorder in which your body's immune system mistakenly attacks and destroys its own melanocytes. Genetic factors, environmental factors, and certain medical conditions may also contribute to the development of vitiligo.

Causes of vitiligo

The understanding of the causes of vitiligo has advanced significantly in recent years, and it is now recognized as an autoimmune disorder. This means that your body's immune system attacks and destroys its own melanocytes, which are the cells that produce melanin that gives colour to the skin, hair, and eyes.^4,7

Research has shown that vitiligo is associated with metabolic and oxidative stress, which can damage the melanocytes. Oxidative stress occurs when free radicals overwhelm the body and damage human body cells and their compartment like fats (lipids) and proteins. Metabolic and oxidative stress are also responsible for the immune cells that regulate melanocyte function.^4,6

In addition, several autoimmune disorders have been found to coexist with vitiligo, suggesting a shared pathogenesis. As a result, many people with vitiligo may also experience other autoimmune diseases, such as:^1,2,4

1. Thyroid issues: Hashimoto's thyroiditis and Graves' disease are two autoimmune diseases that affect the thyroid gland
2. Alopecia areata: another autoimmune disease that causes hair loss in patches
3. Rheumatoid arthritis: an autoimmune complaint that causes inflammation in the joints
4. Adult-onset type 1 diabetes: an autoimmune disease in which the immune system attacks and destroys the insulin-producing cells in the pancreas ¹
5. Addison's disease: an autoimmune disease that affects the adrenal glands, leading to a deficiency in cortisol and aldosterone hormones
6. Pernicious anaemia: an autoimmune disease that affects the body's ability to absorb vitamin B₁₂
7. Systemic lupus erythematosus (SLE): an autoimmune disease that can affect various parts of the body, including the skin, joints, and organs 
8. Psoriasis: an autoimmune disease that causes red, scaly patches on the skin.
9. Atopic dermatitis: A chronic inflammatory skin condition that can be caused by an overactive immune response

Hereditary factors also play a role in the development of vitiligo, as it is known to run in families. Several genes including CTLA4, PTPN22 and FOXD3 have been identified as contributing to the risk of developing vitiligo. These and other candidate genes are involved in immune regulation, melanin synthesis, and oxidative stress response.^3,6

Environmental factors, such as exposure to certain chemicals or toxins, as well as physical trauma or stress, have also been implicated in the development of vitiligo.

Signs and symptoms of vitiligo

According to the classification by the global consensus in 2011, vitiligo can be nonsegmental (NSV), segmental (SV), mixed (NSV +SV) and unclassified.⁸

NSV is the most common type, affecting both sides of the body symmetrically. It often begins on the hands, fingertips, and around body openings such as the eyes, mouth, and genital area.

SV is less common than NSV and typically presents as depigmented patches on only one side of the body. This type of vitiligo usually appears early in life and progresses for a short period of time before stabilising. Unlike nonsegmental vitiligo, the distribution of depigmentation in segmental vitiligo is often asymmetrical.

The Vitiligo European Task Committee has developed an appraisal process, useful for diagnosing vitiligo. This process involves asking patients about their family history of thyroid disease, other autoimmune disorders, premature hair greying, vitiligo, and other skin conditions. In addition, several other factors need to be considered during the evaluation, including:⁸

1. Skin phototype: the patient's skin type can affect their risk of developing vitiligo, as well as the severity of their symptoms
2. Disease duration: this can affect the prognosis and response to treatment
3. Extensiveness: the extent of depigmentation on the patient's skin can help determine the severity of the disease
4. Interaction: the presence of other skin conditions or diseases can complicate the treatment of vitiligo
5. Speed of progression or expansion of lesions: the rate at which vitiligo spreads can affect the prognosis and response to treatment
6. The presence of Koebner's phenomenon: the appearance of new lesions in areas of trauma or injury can indicate a more severe form of vitiligo
7. The presence of halo nevi: the appearance of depigmented areas surrounding a mole can indicate the presence of vitiligo
8. Previous therapies: information about prior treatments, including their duration and effectiveness, can help guide future treatment decisions
9. Previous incidents of repigmentation: the patient's history of spontaneous repigmentation can be a positive prognostic factor
10. Work-related history/exposure to toxins: exposure to certain toxins or chemicals in the workplace may be a risk factor for developing vitiligo

Management and treatment for vitiligo

The Vitiligo Subcommittee of the European Dermatology Forum recommends a stepwise approach to treating vitiligo, with first-line treatments being topical (locally applied) corticosteroids and calcineurin inhibitors.⁸ If these treatments are not effective or suitable, second-line therapies such as phototherapy (NB-UVB and PUVA) or systemic steroid management may be used. Surgical grafting methods and depigmenting therapies are reserved as third or fourth-line options, typically for more severe cases of vitiligo.⁸

It is important to note that treatment plans should be individualised based on the patient's unique characteristics and preferences. Regular follow-up with a dermatologist is recommended to monitor progress and adjust treatment as needed.

To assess the effectiveness of vitiligo treatment, the Vitiligo Noticeability Scale (VNS) measures the impact of vitiligo on a person's quality of life and evaluates the effectiveness of treatment.⁵ The scale ranges from 0 (no noticeable difference) to 4 (significant difference), and measures the size, location, and colour of the depigmented areas.

The VNS has been shown to be a valid and reliable measure of treatment success and is recommended for use in clinical trials and record keeping. However, it's important to note that the VNS may not be appropriate for all individuals with vitiligo, and it's important for healthcare providers to consider the individual's unique circumstances when evaluating treatment success.⁵

Individuals with vitiligo may experience psychological and social difficulties due to the noticeable changes in their skin pigmentation. The condition may harm self-esteem, body image, and overall quality of life.⁹ This is particularly true for those with visible patches on exposed areas such as the face, hands, and feet. 

Therefore it is important to seek professional help if you or someone you know is experiencing psychological distress related to vitiligo. A dermatologist or a mental health professional can provide support and guidance on coping strategies and treatment options to manage the physical and emotional aspects of the condition.⁹

Additionally, it may be advisable to allow time for residual hyperpigmentation to clear up post-treatment before assessing the VNS score. This is because hyperpigmentation may initially occur as the depigmented areas start to pigment again, and it may take some time for the hyperpigmentation to resolve and for the final results of the treatment to become apparent.

FAQs

How is vitiligo diagnosed?

Vitiligo is usually diagnosed based on the appearance of the depigmented patches on the skin. A dermatologist or other healthcare professional will typically perform a physical examination of the skin and take a thorough medical history to rule out other possible causes of depigmentation. In some cases, a small sample of skin (a biopsy) may be taken and examined under a microscope to confirm the diagnosis and rule out other skin conditions that may look similar to vitiligo. 

Additional laboratory tests, such as blood tests or thyroid function tests, may be recommended to assess for underlying autoimmune conditions associated with vitiligo.

Can I prevent vitiligo?

Unfortunately, it is not currently possible to prevent vitiligo, as the exact cause of the condition is not yet fully understood. While some factors may increase the risk of developing vitiligo, such as a family history of the condition or other autoimmune disorders, there is no way to completely prevent it from occurring.

However, some people with vitiligo may find that avoiding excessive sun exposure and using sunscreen can help to protect the skin and prevent sunburn, which can sometimes trigger the development of new patches. Additionally, some experts recommend following a healthy diet and lifestyle, as there is evidence to suggest that oxidative stress may play a role in the development of vitiligo.⁶

Who is at risk of vitiligo?

Anyone can develop vitiligo, regardless of age, sex, or ethnicity. However, some factors may increase the risk of developing vitiligo, including:

1. Family history: having a family member with vitiligo increases the likelihood of developing the condition
2. Autoimmune diseases: having an autoimmune disorder, such as Hashimoto's thyroiditis, psoriasis, or alopecia areata, increases the risk of developing vitiligo
3. Stress: emotional stress or physical illness can trigger or exacerbate vitiligo
4. Exposure to chemicals: some chemicals, such as phenols and catechols, have been linked to the development of vitiligo
5. Sunburn: severe sunburn may increase the risk of developing vitiligo
6. Genetic factors: some genes have been associated with an increased risk of vitiligo

How common is vitiligo?

Vitiligo is a relatively common skin condition. According to estimates from the World Health Organization (WHO), it affects 0.1% to 2% of the world's population. It can occur in people of any race or ethnicity, but it is more noticeable in people with darker skin. Vitiligo can occur at any age, but it often first appears in people between the ages of 10 and 30 years old. It affects both men and women equally.

What are the types of vitiligo?

There are several types and subtypes of vitiligo, including:

1. Non-segmental vitiligo: the most common type, affecting both sides of the body symmetrically. It often begins on the hands, fingertips, and around body openings such as the eyes, mouth, and genital area
2. Segmental vitiligo: affects only one side or segment of the body, usually in a localized area such as the face or trunk. It tends to occur at a younger age and progress more rapidly than generalised vitiligo

Vitiligo can also be mixed type, combining segmental and nonsegmental skin conditions. 

There is also a very rare universal vitiligo type that involves almost the entire body, with extensive depigmentation.

When should I see a doctor?

You should see a doctor if you notice any depigmented patches or changes in your skin colour. Additionally, you should see a doctor if you experience any other symptoms such as itchiness or pain in the affected area. It's also a good idea to see a doctor if you have a family history of vitiligo or autoimmune disorders. Your doctor can perform a physical examination and may order further tests to diagnose the condition and recommend appropriate treatment.

Summary

Vitiligo is a chronic skin condition characterised by patches of depigmentation, which means loss of skin colour, due to the destruction of melanocytes, the cells that produce skin pigment. Vitiligo may arise from an autoimmune disorder in which the body's immune system attacks and destroys melanocytes. Vitiligo is diagnosed through a combination of physical examination, medical history, and sometimes a skin biopsy to confirm the absence of melanocytes in the affected area.

There is currently no known cure for vitiligo, but there are several treatment options that can help to restore skin colour or even out skin tone. Treatment options for vitiligo include topical medications, phototherapy and surgery. It is important to consult a dermatologist or other qualified healthcare professional for proper diagnosis and treatment of vitiligo.