Vitiligo

Vitiligo is an acquired skin disorder caused by the disappearance of pigment cells from the epidermis that gives rise to well defined white patches which are often symmetrically distributed. The lack of melanin pigment makes the lesional skin more sensitive to sunburn. Vitiligo can be cosmetically disfiguring and it is a stigmatizing condition, leading to serious psychologic problems in daily life. It occurs worldwide in about 0.5% of the population and it occurs as frequently in males as it does in females. The cause is unknown, but might involve genetic factors, autoimmunity, neurologic factors, toxic metabolites, and lack of melanocyte growth factors. Since a causative (gene) treatment is not (yet) available, current modalities are directed towards stopping progression and to achieving repigmentation in order to repair the morphology and functional deficiencies of the depigmented skin areas. Many treatments have been used for some time; however; there are some new developments: narrowband ultraviolet (UV) B (311nm) therapy, the combination of corticosteroid cream + UVA therapy, and the transplantation of autologous pigment cells in various modalities. In widespread vitiligo, residual pigment can be removed by depigmentation agents. Sunscreens, camouflage products, and good guidance may help the patient cope better with the disease.     

Cosmetic camouflage in vitiligo

Vitiligo is not a life-threatening nor a contagious disease. But the disfigurement of vitiligo can be devastating to its sufferers, especially dark-skinned individuals. Available treatment options are disappointing and sufferers often use various forms of camouflage. Remedial cosmetic cover creams help conceal the blemish of vitiligo at least temporarily. A high concentration of pigment is incorporated into water-free or anhydrous foundations to give a color that matches the patient's skin, thereby concealing vitiligo patches. The article highlights the content and technique of application of these creams.     

Vitiligo: a review of the published work

Vitiligo is a common depigmenting skin disorder, characterized by acquired, idiopathic, progressive, circumscribed hypomelanosis of the skin and hair, with total absence of melanocytes microscopically. It occurs worldwide, with an incidence rate of between 0.1% and 2%. Vitiligo is an important skin disease having a major impact on the quality of life of the patient suffering from it. The causes of this condition are uncertain but seem to be dependent on the interaction of genetic, immunological and neurological factors. Vitiligo coexists with other autoimmune disorders, Sutton or halo nevus, and malignant melanoma. The substantial disfigurement associated with vitiligo can cause serious emotional stress for the patient, which necessitates treatment. Because its pathogenesis is still not understood, there is a plethora of different treatments. Among them, topical steroids and narrowband ultraviolet B monotherapy were the most common as current treatments for localized and generalized vitiligo, respectively. Cosmetic improvement can be achieved by camouflage products and self-tanning dyes. The course of vitiligo is unpredictable, but often progressive. Spontaneous repigmentation may occur in a few people (10–20%), mainly in children, but this tends to be only partial and on sun-exposed areas. In this article, we review vitiligo as a whole, including epidemiology, pathogenesis and etiology, histopathology, clinical manifestations, classification, clinical variants, diagnosis and differential diagnoses, specific investigation, treatment, prognosis, psychosocial view and its association with other disorders.     

Depigmentation therapy in vitiligo universalis with cryotherapy and 4‐hydroxyanisole

Vitiligo is a disease characterized by the loss of melanocytes, resulting in progressive depigmentation of skin, and areas of normally pigmented skin can be of cosmetic concern. Several options have been tried to remove the pigment and make the skin a more even colour. We present an easy and effective therapeutic procedure based on single‐session cryotherapy followed by topical 4‐hydroxyanisole (4‐HA).     

Bases inmunológicas de la hipopigmentación vitiligoide asociada a melanoma

Vitiligo is a skin condition characterized by white, hypopigmented macules. Melanocyte loss is a feature of the disease, and it has been hypothesized that an autoimmune mechanism could be responsible for the depigmentation. Melanoma is a malignancy that develops in melanocytes; if not detected and treated early, it is often deadly. Leukoderma, a condition characterized by depigmentation of the skin, is sometimes associated with malignant melanoma. An immune response against melanocyte antigens leading to destruction of either melanoma cells or melanocytes has been observed in both vitiligo and melanoma. Studies in animal models and humans have shown that humoral and cell-mediated immune responses are involved in modulating cytotoxic activity against tumor cells and normal melanocytes. The study of factors associated with anti-tumor immunopathogenic mechanisms —autoimmunity for example— may provide us with tools for the diagnosis and treatment of diseases such as vitiligo and malignant melanoma.     

The prevalence of psychological comorbidity in people with vitiligo: a systematic review and meta‐analysis

Vitiligo is a long‐term condition where pale white patches develop on the skin. It's caused by a lack of melanin, a pigment (colour) in the skin. People of any age, skin type and gender can develop vitiligo and it can affect any area of skin. It is estimated that about 1 in 100 people around the world has vitiligo. The researchers who conducted this study are based in Nigeria and the UK. Our study aimed to find out how commonly psychological symptoms such as depression and anxiety occur in people in vitiligo, by looking at all relevant published studies from around the world. After extracting data from 29 studies published in this area we found that people living with vitiligo experience a range of psychological symptoms or disorders. Approximately one in four people with vitiligo appear to have depression and at least one in seven have anxiety. However, they were significantly less likely to show symptoms of depression than people with psoriasis. We also found that there were many tools to measure psychological outcomes (the emotional impact) in skin diseases, and more work needs to be done to develop tools which can be used in people with vitiligo. Our conclusion is that assessment of psychological state during clinical evaluation of vitiligo patients, as suggested by the British Association of Dermatologists’ guidelines, is essential. The same can be said for clinical evaluation of people with other skin conditions.     

Childhood vitiligo

Vitiligo is a common skin disorder in which pigment is lost from the skin and adnexae. Half of all cases begin before the age of 20 years. Until recently, there was a paucity of published data regarding effective therapy of vitiligo. Current therapy is quite effective, and while many patients may not experience complete repigmentation, 50% to 75% repigmentation of vitiligo with recent onset routinely can be expected with available therapeutics.     

Vitiligo and pernicious anemia presenting as congestive heart failure

The skin often provides diagnostic clues to systemic disorders. Vitiligo is an acquired disease characterized by depigmentation of the skin due to destruction of melanocytes. Vitiligo may be an autoimmune disease and is associated with other disorders that may also arise due to autoimmune mechanisms. We present the unusual case of vitiligo associated with pernicious anemia in a patient who presented to the hospital because of hyperdynamic congestive heart failure.     

Autoimmunity as an aetiological factor in vitiligo

Vitiligo is a common dermatological disorder characterized by the presence on the skin of depigmented macules resulting from the destruction of cutaneous melanocytes. Autoimmunity is an important hypothesis with regard to vitiligo aetiology and the evidence for autoimmune responses being involved in the pathogenesis of this disorder will be discussed in the present review. All immune system compartments, including innate and adaptive immunity have been implicated in vitiligo development. Particularly relevant are autoantibodies and autoreactive T cells in vitiligo patients that have cytotoxic effects upon pigment cells. Furthermore, predisposition to vitiligo appears to be associated with certain alleles of the major histocompatibility complex class II antigens as well as with other autoimmune-susceptibility genes. Moreover, the association of vitiligo with autoimmune disorders, the animal models of the disease, and the positive response to immunosuppressive therapeutic agents emphasize the role of autoimmunity in the development of this disorder.     

Vitiligo and the Vogt-Koyanagi-Harada syndrome

Vitiligo is a common acquired systemic disease that can be associated with several different autoimmune disorders. Besides the psychologically upsetting depigmentation of the skin that it causes, it can be associated with ocular abnormalities. There are three different theories regarding the etiology of vitiligo, none of which is entirely satisfactory. There are some valuable animal models for studying the disease, but they obviously have limitations in their application to the human disease. The melanocyte is present in other areas besides the skin, including the leptomeninges, the retinal pigment epithelium, the uveal tract, and the inner ear. Therefore, it is not surprising that whatever process destroys the melanocyte in the skin can also affect diverse tissues such as the eye, the ear, and the central nervous system. It is postulated that the Vogt-Koyanagi-Harada syndrome may be part of the systemic disease, vitiligo.     

Factors affecting quality of life in patients with vitiligo: a nationwide study

In vitiligo, areas of skin lose their colour and become completely white. These white areas, which are often irregular like islands on a map, usually stand out against the normal skin around them, and are very obvious in individuals with a naturally pigmented (brown or black) skin, or in white‐skinned people with a tan. People with vitiligo can become very embarrassed and withdrawn, not wanting to go out or to meet people; as a result, the quality of their day‐to‐day life can suffer. Vitiligo affects between 0.5% and 2% of the population and treatment does not work very well. This study from South Korea looked at what factors to do with vitiligo most affected patients’ quality of life. It was a large study involving more than 1,100 adults from 21 different hospitals. Patients filled in a detailed questionnaire called the Skindex‐29 questionnaire and members of the study team examined the patients’ skin. From the questionnaire results, what concerned patients most were whether the vitiligo was going to get worse and whether it was a serious condition. They were also concerned about how loved ones felt about it, and over half the patients felt depressed about their condition. Involvement of large areas of the body, or areas of the body that other people could easily see, particularly affected quality of life. Vitiligo is far from just a cosmetic problem: over a third of patients were affected emotionally even if the areas of vitiligo were normally covered up.     

Emerging role of dermal compartment in skin pigmentation: comprehensive review

The variations in human skin colour mainly occur due to differences in the distribution of melanin pigment throughout the body, synthesized by epidermal melanocytes which are further taken up by keratinocytes present in epidermis. Recently, it has been discovered that besides these cells, dermis derived fibroblast factors also play a prominent role in regulating skin pigmentation. There exists a signal crosstalk between epidermal melanocytes, keratinocytes and dermal fibroblasts and any impairment in these signalling pathways may give rise to pigmentary disorders. Vitiligo is a hypopigmentary disorder and alteration in the expression level of several fibroblast-specific factors has been reported in the lesional skin of vitiligo patients. In such patients, there is decrease in the expression levels of factors such as basic fibroblast growth factor, stem cell factor (SCF) and keratinocyte growth factor (KGF) along with a steep increase in the expression levels of Dickkopf 1. Patients affected with hyperpigmentary disorder like melasma exhibit a marked increase in SCF and KGF expression levels leading to increase in melanin production and those affected with solar lentigo experience upregulation in the expression levels of SCF, KGF and HGF (hepatocyte growth factor). Hence, we conclude that new therapeutic strategies can be adopted to cure these pigmentary disorders by targeting factors involved in crosstalk signalling between epidermal melanocytes, keratinocytes and dermal fibroblasts.     

Vitiligo is more than skin deep: a survey of members of the Vitiligo Society

Background. Vitiligo is a common, largely acquired skin disease of unknown aetiology, which causes a variable amount of skin and hair depigmentation in affected people. It affects over half a million people in the UK alone, and a massive 50 million people worldwide. Aim. To quantify the psychosocial burden of vitiligo in the UK, by estimating its effect on daily life. Methods. All members (n = 1790) of the Vitiligo Society, a UK national patient support group, were sent a questionnaire. Survey questions included demographics, disease‐related characteristics, effect of vitiligo on daily life, and psychosocial support measures for patients with vitiligo. Results. In total, 520 (29% of members) responded, of which 354 (68%) were women. Vitiligo affected the hands in 414 (80%) and the face in 394 (76%) of the respondents. Over half (56.6%) of respondents indicated that vitiligo moderately or severely affects their quality of life (QOL). Finding a cure or effective lasting treatment was the main priority for most affected respondents. Most respondents obtain information about their disease from nonmedical sources: 431 (83%) from the Vitiligo Society and 129 (25%) from the internet, compared with 61 (12.5%) from dermatologists. Conclusion. Vitiligo is a skin condition that moderately or severely affects the QOL of most patients. Although most patients look for a cure or long‐lasting treatment, only 12.5% of respondents to our survey had obtained information from a dermatologist. Vitiligo is a common condition that affects more than the skin, and has profound psychosocial implications for affected patients.     

What are those white patches on my patient's skin?

Vitiligo is a skin disease that affects 1% of the population. Vitiliginous skin does not contain pigment-producing cells called melanocytes. This leaves the appearance of white patches on the skin, which can either be generalized or localized. It is important for dermatology nurses to understand the basic pathophysiology of vitiligo, the various treatment methods, how to protect vitiliginous skin, and the psychological impact of the disease.     

Vitiligo as a systemic disease

Vitiligo is an acquired depigmentary skin disorder of unknown etiology. Vitiligo is not only a disease of melanocytes of the skin. Human melanocytes are derived from the neural crest and are located on various parts of the body. The involvement of skin melanocytes is the most visible one, but a systemic involvement of melanocytes can be observed. Some types of vitiligo (nonsegmental vitiligo) may also be associated with various diseases, mainly with autoimmune pathogenesis. Vitiligo represents a spectrum of many different disorders with different etiologies and pathogeneses, causing a common phenotype: the loss of melanocytes and/or their products. This phenotype is always consistent with a systemic involvement.     

On the pathophysiology of vitiligo: Possible treatment options

Vitiligo is an acquired depigmenting disorder usually classified as non-segmental and segmental types with a higher incidence of the non-segmental ones. The cause of non-segmental vitiligo is still unknown. Currently, it is a dogma that there are several genes affecting the immune system and the pigment system that predisposes someone to develop vitiligo. A precipitating factor must then ellicit an interaction between the immune system and the melanocyte, resulting in destruction of the melanocyte population in discrete areas of the skin. Starting from the overlapping but distinct pathomechanisms, treatment should be finalized to the cellular targets and possibly related to the disease phase.     

Optimal Management of Recalcitrant Disorders of Hyperpigmentation in Dark-Skinned Patients

Alterations in skin pigmentation may often have a dramatic expression in individuals with a dark skin complexion and can be a source of significant emotional distress in these individuals. Hyperpigmented disorders such as melanosis (melasma), post-inflammatory hyperpigmentation, drug-induced hyperpigmentation, and erythema dyschromicum perstans tend to have a prolonged course and, in many cases, are refractory to treatment, further contributing to the psychological impairment of the affected patients. Melanosis, is a common form of facial pigmentation attributable to sunlight and hormonal factors. A range of treatment modalities, such as depigmenting agents, topical retinoids, and chemical peels in conjunction with rigorous sun protection, can improve the melanosis but the condition usually recurs. Combination regimens, including frequent applications of superficial- and medium-depth chemical peels, appear to be particularly effective and well tolerated in dark-skinned patients with melanosis. Post-inflammatory hyperpigmentation is the result of excess pigment deposition following an inflammatory skin disorder. Topical tretinoin, hydroquinone, azelaic acid, kojic acid, and glycolic acid peels have been employed with variable degrees of success. Drug-induced pigmentation is a frequent cause of acquired hypermelanosis, its clinical expression depending on the triggering molecule and the underlying pathogenetic mechanism. Identifying and discontinuing the offending agent is the main approach in this condition, although, recent reports have demonstrated the efficacy of Q-switched lasers in accelerating the pigment removal. Erythema dischromicum perstans is a characteristic dermal pigmentation occurring mainly in dark-skinned individuals. Immunomodulating agents, such as clofazimine and dapsone have been shown to lighten this disorder, although, the exact mode of action is not clear.     

Do we have to pay more attention to vitiligo patients? Peculiar histopathological features of primary cutaneous melanoma preceded by vitiligo

Vitiligo is an acquired depigmenting skin disease characterized by the loss of functioning epidermal melanocytes. Vitiligo can be associated with an autoimmune disorder. An unusual and important aspect of vitiligo is its relationship to melanoma. We present herein a 34-year-old man who developed regional lymph node metastases of malignant melanoma 2 years after the diagnosis of vitiligo.     

A mouse model for vitiligo

As the result of a long search for a depigmenting mouse that could serve as a model for the study of vitiligo, we have located a strain that arose from the C57BL/6J. Its provisional genetic designation is C57BL/6J Ler-vit/vit. This vitiligo mouse has congenital dorsal and ventral white spots (piebaldism) as well as progressive replacement of pigmented hairs by white hairs with each spontaneous molt or after plucking. The lack of pigment is due to the absence of melanocytes from the amelanotic hair follicles and epidermis. As in human beings and the Smyth chicken model, there is also diminution of ocular pigment. Reciprocal skin transplants between C57BL/6J and vitiligo mice, and transplants into nude mice, suggest a programmed pigment cell death in the vitiligo mice. Like human beings with vitiligo, maximally depigmented vitiligo mice have a decreased contact sensitivity response in comparison to age-matched C57BL/6J controls. The resistance to injected B16 melanomas is lowered. Vitiligo mice show no signs of premature aging. Already at this early stage in the study of this new animal model, there are findings that open a range of new approaches to the study and treatment of patients with vitiligo and melanomas.     

Management of vitiligo patients and attitude of dermatologists towards vitiligo

As vitiligo does not cause any physical impairment, it is often considered unimportant by physicians. Vitiligo patients repeatedly experience disinterest from the medical world regarding their skin problem. A questionnaire survey was used to assess the management of vitiligo patients and the attitude of dermatologists towards vitiligo in Belgium. Vitiligo patients (n = 244) visiting an academic affiliated dermatology department were included and 454 out of 558 Belgian dermatologists returned a mailed questionnaire. Vitiligo patients do not often visit a doctor concerning their disease and do not often treat their disease. Disease severity as reported by the patient is correlated with the number of doctor visits (p = 0.001) but not to treatment of the disease. Information about the treatment and physician's encouragement to treat seem important in motivating patients to treat their vitiligo, but 50% of the patients were not adequately informed about their disease and its treatment during their first doctor visit. Today, nearly all the dermatologists report widely informing their patients, but only 36% of them encourage their patients to treat their disease, being pessimistic concerning expected treatment results. Interestingly, two thirds of the patients who ever treated their disease find it worthwhile.