Vitiligo

An Autoimmune Disease

Vitiligo is the loss of skin colour, resulting in almost pure white patches. The sensation on the skin is normal.

If in doubt, consult a doctor, he will rule out the diagnosis of leprosy and may prescribe some local application combined with  exposure to sunlight or ultraviolet light.

Parents must meet school authorities with a certificate from a doctor that the disease is not infectious.

The change in appearance caused by vitiligo can affect a person's emotional and psychological well-being and may create difficulty in becoming or remaining employed, particularly if vitiligo develops on visible areas of the body, such as the face, hands or arms. Participating in a vitiligo support group may improve social coping skills and emotional resilience.

Introduction

Vitiligo is a chronic (long-lasting) autoimmune disorder that causes patches of skin to lose pigment or color. This happens when melanocytes – skin cells that make pigment – are attacked and destroyed, causing the skin to turn a milky-white color.

Myth about Vitiligo 

People say milk and fish taken together cause vitiligo, but there is no scientific basis for this.

Some believe vitiligo is incurable. The truth is  when treatment is started early enough, near complete recoloration is possible. But long term medicines may be needed to maintain the cure.

The Challenges 

Although vitiligo is mainly a cosmetic condition, people with it may experience a variety of problems.

People with vitiligo are more likely to get other autoimmune diseases such as  hypothyroidism, diabetes, pernicious anemia and more.

They feel embarrassed or anxious. An acceptance by society may help the person to deal with fewer challenges.

This is a skin condition which face discrimination. The main cause of vitiligo is a genetic disposition with 20% chance of getting it if  a family member has it. The lack of melanin pigment, that give color to our skin , 

a few stress related issues and traumas  can also trigger vitiligo.. It causes distress those dealing with it It is not contagious. Its  not an infection. People might be born with it. but if you can't identify the patches on a baby as it develops later on in the life. One has to accept oneself with it. Its important to educate your self. 

Causes

• Unknown
• Melanin : It is the pigment that gives skin its color; it is produced by skin cells called melanocyte.
• Variations in genes that are part of the immune system or part of melanocytes have both been associated with vitiligo. It is also thought to be caused by the immune system attacking and destroying the melanocytes of the skin.
• Autoimmune disorder :  that occurs due to lack of a pigment called melanin. " Melanin is produced by skin cells called melanocytes. It is responsible for the skin colour. In vitiligo, the lack of melanin in the skin leads to white patches to develop in skin and hair.Vitiligo is sometimes associated with autoimmune  and inflammatory diseases such as Hashimoto's thyroiditis, scleroderma, rheumatoid arthritis, type 1 diabetes mellitus, psoriasis, Addison's disease, pernicious anemia, alopecia areata, systemic lupus erythematosus and celiac disease.

• Among the inflammatory products of NLRP1 are caspase 1,7  and which activate the inflammatory cytokine interleukin-1 Beta.  Interleukin-1β and interleukin -18 are expressed at high levels in people with vitiligo. In one of the mutations, the acid leucine in the NALP1 protein was replaced by histidine (Leu155 → His). The original protein and sequence is highly conserved in evolution, and is found in humans, chimpanzee rhesus monkey, and the bush baby. Addison's disease  (typically an autoimmune destruction of the adrenal glands ) may also be seen in individuals with vitiligo.

• Genetic predisposition : is a skin condition which face discrimination. The main cause of vitiligo is a genetic disposition with 20% chance of getting it if  a family member has it. The lack of melanin pigment, that give color to our skin , 
• Stress :  is an added factor that derives the condition. It acts as a catalyst.
• Sun exposure :
• Environmental Factor :  Can cause or exacerbate the condition, but that this idea is not well-supported by good evidence.
  

Signs & Symptoms

• Depigmented Skin : The only sign of vitiligo is the presence of pale patchy areas of depigmented skin which tend to occur on the extremities

Skin Depigmentation

Leucoderma

• Itching Some people may experience itching before a new patch occurs.The patches are initially small, but often grow and change shape. When skin lesions occur, they are most prominent on the face, hands and wrists.

• The loss of skin pigmentation is particularly noticeable around body orifices, such as the mouth, eyes, nostrils, genetalis.

and Umbilicus.  Some lesions have increased skin pigmentation  around the edges.Those affected by vitiligo who are stigmatized  for their condition may experience depression and similar mood disorders. 

Diagnosis

An Ultraviolet light  can be used in the early phase of this disease for identification and to determine the effectiveness of treatment. Using a Wools' light, skin will change colour (Fluoresce) when it is affected by certain bacteria, fungi, and changes to pigmentation of the skin.

Classification

Classification attempts to quantify vitiligo have been analyzed as being somewhat inconsistent, while recent consensus have agreed to a system of segmental vitiligo (SV) and non-segmental vitiligo (NSV). NSV is the most common type of vitiligo.

Non-segmental

In non-segmental vitiligo (NSV), there is usually some form of symmetry  in the location of the patches of depigmentation. New patches also appear over time and can be generalized over large portions of the body or localized to a particular area. Extreme cases of vitiligo, to the extent that little pigmented skin remains, are referred to as vitiligo universalis. NSV can come about at any age (unlike segmental vitiligo, which is far more prevalent in teenage years).

Classes of non-segmental vitiligo include the following:

• Generalized vitiligo: the most common pattern, wide and randomly distributed areas of depigmentation
• Universal vitiligo: depigmentation encompasses most of the body
• Focal vitiligo: one or a few scattered macules in one area, most common in children.
• Acrofacial vitiligo: fingers and periorificial areas.
• Mucosal vitiligo: depigmentation of only the mucous membranes.

Segmental

Segmental vitiligo (SV) differs in appearance, cause, and frequency of associated illnesses. Its treatment is different from that of NSV. It tends to affect areas of skin that are associated with dorsal roots  from the spinal cord  and is most often unilateral. It is much more stable/static in course and its association with autoimmune diseases appears to be weaker than that of generalized vitiligo. SV does not improve with topical therapies or UV light, however surgical treatments such as cellular grafting can be effective.

Treatment

Treatment options include topical medications, light therapy, surgery and cosmetics. 

There is no cure for vitiligo but several treatment options are available. The best evidence is for applied steroids  and the combination of ultraviolet light  in combination with creams. Due to the higher risks of skin cancer, phototherapy be used only if primary treatments are ineffective. Lesions located on the hands, feet, and joints are the most difficult to repigment; those on the face are easiest to return to the natural skin color as the skin is thinner in nature.

Immune mediators

Topical preparations of immune suppressing medications including  glucocorticoids (such as 0.05% clobetasol or 0.10% betamethasone) and calcineurin inhibitors (such as tacrolimus or pimecrolimus ) are considered to be first-line vitiligo treatments.

In July 2022, ruxolitinib  cream (sold under the brand name Opzelura) was approved, for medical use in the United States for the treatment of vitiligo.

Photo Therapy

Phototherapy is considered a second-line treatment for vitiligo. Exposing the skin to light from UVB lamps is the most common treatment for vitiligo. The treatments can be done at home with an UVB lamp or in a clinic. The exposure time is managed so that the skin does not suffer overexposure. Treatment can take a few weeks if the spots are on the neck and face and if they existed not more than 3 years. If the spots are on the hands and legs and have been there for more than 3 years, it can take a few months. Phototherapy sessions are done 2–3 times a week. Spots on a large area of the body may require full body treatment in a clinic or hospital. UVB broadband and narrowband lamps can be used, but narrowband ultraviolet peaked around 311 nm is the choice. It has been constitutively reported that a combination of UVB phototherapy with other topical treatments improves re-pigmentation. However, some people with vitiligo may not see any changes to skin or re-pigmentation occurring. A serious potential side effect involves the risk of developing skin cancer, the same risk as an overexposure to natural sunlight.

Ultraviolet light (UVA) treatments are normally carried out in a hospital clinic. Psoralen  and ultraviolet A light (PUVA) treatment involves taking a drug that increases the skin's sensitivity to ultraviolet light, then exposing the skin to high doses of UVA light. Treatment is required twice a week for 6–12 months or longer. Because of the high doses of UVA and psoralen, PUVA may cause side effects such as sunburn-type reactions or skin freckling.

Narrowband ultraviolet B (NBUVB) phototherapy lacks the side-effects caused by psoralens and is as effective as PUVA. As with PUVA, treatment is carried out twice weekly in a clinic or every day at home, and there is no need to use psoralen. Longer treatment is often recommended, and at least 6 months may be required for effects to phototherapy. NBUVB phototherapy appears better than PUVA therapy with the most effective response on the face and neck.

With respect to improved repigmentation: topical calcineurin inhibitors plus phototherapy are better than phototherapy alone,  hydrocortisone plus laser light is better than laser light alone, gingko biloba  is better than placebo, and oral mini-pulse of prednisolone (OMP) plus NB-UVB is better than OMP alone.

Skin camouflage

In mild cases, vitiligo patches can be hidden with makeup or other cosmetic camouflage  solutions. If the affected person is pale-skinned, the patches can be made less visible by avoiding tanning  of unaffected skin.

Depigmenting

In cases of extensive vitiligo the option to de-pigment the unaffected skin with topical drugs like monobenzone, mequinol, or hydroquinone may be considered to render the skin an even color. The removal of all the skin pigment with monobenzone is permanent and vigorous. Sun-safety must be adhered to for life to avoid severe sunburn  and melanomas . Depigmentation takes about a year to complete.

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