Depigmentation: To Pursue or Not to Pursue

There has been some misunderstanding in our communities in regards to depigmentation. We have to admit they are people out there who use certain products to lighten their skin complexion at the same time there is depigmentation for vitiligo patients. This article intends to enlighten how skin depigmentation works. Enjoy!!

If you have vitiligo, you most likely have heard of depigmentation, the process by which the remaining pigment is permanently removed from the skin and wondered where it fits into vitiligo treatment. Is it something you should consider?

People who consider depigmentation have reached a point where medical therapy no longer offers hope for controlling their disease. Generally, the vitiligo has become so severe that one has come to the place where you either continue to live with the diseases progression or depigment. Some who have extensive vitiligo find it preferable, and easier, to depigment the remaining unaffected skin rather than try to repigment the vitiligo-affected skin.

The first step in the decision

Even though one reaches the point of considering depigmentation, making the actual decision to go forward is not an easy one. Depigmentation is permanent, irreversible. There are many concerns and even fears that naturally arise. For example, will the pigment come back? Are there skin reactions?

Do people regret having started the treatment? Are there side effects?

People of non-white ethnicity face additional concerns about loss of racial identity, as well as cultural and social concerns that also must be addressed prior to starting treatment. How will family and friends respond? Will people still accept me if I am a different color?

What is involved in depigmenting the skin?

Depigmentation therapy is designed to remove the remaining pigment in the skin to match the areas that are already white. For people who have vitiligo on more than 50% of their bodies, depigmentation may be the best treatment option.

A dermatologist must decide whether this treatment is appropriate. A recent survey showed that dermatologists vary in their opinion as to who should be eligible for this therapy. The survey showed that 42% of dermatologists are in favor of depigmentation when vitiligo affects more than 50% of the body, while 32% feel that patients must wait until it affects more than 75% of the body.

In general, depigmentation is limited to the patient for whom repigmentation therapies have failed and/or has more than 50% pigment loss in their skin or when the depigmentation is extensive in the cosmetically sensitive areas of the hands and face. Depigmentation is not generally recommended for children.

The main method used to depigment vitiligo-affected skin is the topical application of monobenzyl ether of hydroquinone (MBEH) (also referred to as monobenzone). MBEH is a topical prescription product applied to the pigmented areas. This is the only drug approved by the FDA for depigmentation therapy of advanced vitiligo. For many years, MBEH was available under the brand name Benoquin, but it has now been discontinued by the manufacturer. MBEH is now only available as a compounded product (monobenzone powder added to a base cream) made by specialized pharmacies

How is it used?

A cream with a 20% concentration of MBEH is applied twice a day for 3-12 months. It is important to understand that this is a systemic treatment, meaning that regardless of where the cream is applied, it will affect the entire system or body and areas away from the treated area will still lighten. This is not a treatment used to selectively lighten or depigment a specific or confined area. Treatment will generally begin with a concentration of 20% MBEH. Depigmentation should begin after 3 to 4 months of application. The concentration is frequently increased to 30% or 40% during the process, but MBEH concentration greater than 40% is not recommended. If the vitiligo has been stable for years, a longer duration of therapy and higher concentration of MBEH may be required. Direct skin-to-skin contact with other people must be avoided for at least two hours after applying the drug, as transfer of the drug may cause depigmentation of the other person’s skin

How well does it work?

 According to a study on the effectiveness of MBEH in the depigmentation of vitiligo patients. It is a retrospective study where researchers at Massachusetts General Hospital in Boston looked back at the experience of 18 vitiligo patients who underwent MBEH therapy. The patients ranged in age from 26 to 68 years of age and had had vitiligo from 6 months to 51 years. Fifteen were women and three were men. Two of the patients were African American and sixteen were Caucasians. The patients had 40 to 90% depigmentation prior to beginning treatment with MBEH. In only one patient was the vitiligo rapidly progressive at the time. The remainder of the patients had stable or slowly progressing vitiligo. The treatment protocol involved the twice-daily application of 20% MBEH.

Of the 18 patients:

Eight (44%) severely-affected vitiligo patients achieved complete depigmentation. Their first signs of depigmentation occurred within one to six months (average under three months) of the start of therapy and full depigmentation was achieved in 4 - 12 months. Furthermore, after six months of MBEH use, one of these eight patients, who had experienced partial depigmentation, continued on to completely depigment after discontinuing MBEH.

• Three (17%) had dramatic, though incomplete depigmentation.
• Three (17%) experienced partial depigmentation.
• Three (17%) elected not to complete the trial.
• One (5%) could not use MBEH because of contact dermatitis.

The researchers observed that the average patient in the trial did not begin to depigment until after two-three months or more of application of the MBEH, and also found that the time of the first appearance of depigmentation was not predictive of the final degree of depigmentation. They concluded that consistent use of MBEH correlated with the eventual success of depigmentation. They reported that all those who depigmented fully said they were very pleased with their results. Two of these patients were African American.

In terms of side effects, seven of the 18 patients reported no complications. In two cases, the sensation of burning lasted only the first month of therapy. In two other patients it did limit therapy; however, mixing the MBEH with an emollient helped relieve the burning in these patients. Severe contact dermatitis did cause one patient as described above to drop out of the trial. Other side effects observed were redness or rash, dryness, and swelling.

The study's authors concluded that MBEH was effective, produced generally satisfactory results, and involved limited side effects. They concluded that treatment should lead to an onset of depigmentation within three-six months of therapy being started and full depigmentation within a year. They cautioned that occasional use thereafter may be required.

They also pointed out that during and upon completion of the depigmentation therapy patients are unusually sensitive to sunlight and permanently at risk for acquiring sunburn. Midday sun exposure should be minimized and a sunscreen used to avoid recurrence of pigment that can occur on sun-exposed sites.

Depigmentation and Melanoma

One of the concerns frequently expressed by those interested in depigmentation is whether the process increases their risk of serious skin cancers like melanoma. A study coming out in April 2011 concludes that using MBEH may actually be helpful to prevent the occurrence of melanoma in those with a family history of the disease. Since melanoma is cancer of the melanocytes, and the melanocytes are destroyed by using MBEH, it has long been reported that the risk of melanoma is low to non-existent in those who have completely depigmented.

 (Source: Dr. James J. Nordlund, Professor of Dermatology, Group Health Associates, Cincinnati, OH and Wright State School of Medicine)

Hope for Women with Vitiligo

By Dr. Dara Spearman

Dermatologist
 

Peggy - Beyond Vitiligo Project Director

Vitiligo is a disease whereby the melanocytes, the cells that give our skin pigmentation, are destroyed. This results in depigmented (or white) patches of skin. This can be localized to certain areas of the body or generalized, involving most of the body surface area. These patches may also be found on both the mucous membranes (tissues that line the inside of the mouth and nose), and in the retina (inner layer of the eyeball). The hair that grows on areas affected by vitiligo may also become depigmented. Vitiligo is a condition that is limited to the skin, hair and mucous membranes and does not cause internal problems. However, it has been shown to be highly associated with a number of other autoimmune diseases, mostly thyroid disease, but also pernicious anemia, rheumatoid arthritis, lupus, and adult-onset autoimmune diabetes.

Vitiligo can have a significant effect on an individual's psychological well being. For women of color, this is especially true due to the sharp contrast of the depigmented skin with their natural, darkly pigmented skin. In fact, in some cultures there is a social stigmata associated with the condition. People affected by the disease may be viewed as evil and/or are shunned by the community.

There are a number of treatments available for vitiligo, although at this time there is no cure. For some individuals, treatment may actually involve only sun protection to prevent tanning of the unprotected areas. For lighter-skinned individuals, the difference may be hardly perceptible. For darker individuals, sun protection is necessary to prevent sunburn of the affected areas but does not improve the appearance. In people with limited involvement, makeup or cosmetic camouflage solutions can be used to hide the vitiligo patches. I often recommend Dermablend or Leg Magic cosmetic camouflage to my patients. Micropigmentation tattooing of small areas may also improve appearance.

If the patches are so widespread that coverup is not an option, other treatments are available from your dermatologist. Treatment is usually aimed at repigmentation, or returning normal pigment. Initially, topical steroid creams are often prescribed, although this treatment only results in repigmentation in 25 percent of individuals. PUVA is a therapy that improves appearance in 50-70 percent of patients. This therapy involves a medication, psoralen, and a special type of ultraviolet light, UVA. The psoralen may be applied topically to the affected areas, but is often taken in pill form. This therapy can be time consuming with two to three treatments per week for months and may also increase the risk of skin cancer.

Newer therapies include transplantation of melanocytes to affected areas to repigment the region. This is performed by taking skin grafts from inconspicuous sites, such as the gluteal region, separating out the melanocyts and then grafting them to the affected areas. The area is then exposed to UV light for two months with 70-85 percent of people experiencing almost complete repigmentation. It was discovered in early 2008 that piperine, a compound in black pepper, can stimulate pigmentation in the skin, particularly when combined with ultraviolet radiation. This repigmentation is often darker and more evenly distributed than with ultraviolet light alone. Finally, complete depigmentation with a chemical called monobenzylether of hydroquinone is an option for patients with extensive involvement. Vigilant sun protection is especially important to prevent sunburn and skin cancer.

If you are affected by this condition, it is important to discuss your treatment options with a dermatologist and to realize that new, effective therapies are available

Deeper than Skin: Inside the World of Vitiligo Patients

This is an article by Naomi Ogaldez

Queens, New York-Isabel Goncalves was diagnosed when she was four years old. “I was overwhelmed, shocked, and cried when I heard the news of her diagnosis of vitiligo,” said Goncalve’ mother, Maria Gonzalez.

Now that Goncalves is 12-years-old, eight years later, her skin depigmentation has spread throughout her whole body, except her face.

“She is really confident. She doesn’t like to cover up her vitiligo, ” said Gonzalez.

Even though, she is confident in her own skin, Goncalves said, people still look at her differently and, at times, make her the outcast. “On a daily basis, people are constantly making fun of me and they say I look like a cow. They are constantly saying I look weird. I am bullied,” she said.

Gocalves has vitiligo.

WHAT IS VITILIGO

The Indian Journal of Dermatology stated that about one to two percent of the world’s population suffers from this diseas

e. This skin depigmentation affects all ethnic groups and racial groups equally. Although it may seem that Latinos and African Americans are more affected because of their darker skin color, but in reality, they are not.

According to Vitiligo Support International, half of people with vitiligo have had it developed before the age 20 and about 95 percent get it before the age of 40.

“I thought I was the only one that had it, but, in reality, there are a lot of people that have it,” said Alejandra Riera, from San Juan, Puerto Rico, who has had vitiligo for 15 years. “People have a lot of misconceptions of vitiligo such as it being contagious, hereditary, and painful, but all of that is not true.”

The cause of vitiligo is still unknown, however, there are various scientific theories to the cause of vitiligo.

Clinuvel Pharmaceuticals, a global biopharmaceutical company focused on developing drugs for the treatment of skin disorders, stated that vitiligo is characterized by the destruction of melanocytes pigment cells that stop functioning, which causes the skin that is affected to become white in color.

“In order for this to happen something has to precipitate this dysfunction in the immune system, something coming [from] within, such as a sunburnt, pregnancy, physiological and psychological stress, bug bites, certain chemicals, and the environment,” said Dr. Raymond Boissy, President of the National Vitiligo Foundation and Director of Basic Science Research at the University of Cincinnati College of Medicine, who has studied vitiligo for more than 30 years.

Several genes have to dysfunction in order for someone to be susceptible to this complex, multi-genetic disease.

“I would describe vitiligo as the cancer or the AIDS of the 2000 because people are afraid to come out,” said Dr. Boissy. “Like cancer and HIV, therapies have developed, people with those diseases have come out and advocate for themselves, which has helped bring awareness and a better life for them. I see the same happening for vitiligo. I see the renaissance in the horizon.”

Although, there is hope in the development of a cure and awareness about vitiligo, there are still issues concerning this disease. First off, there are some health insurance companies that don’t cover vitiligo patients.

Health insurance plans sometimes consider treatments for vitiligo to be cosmetic. Most health insurance plans will not cover medical care for cosmetic purposes. For that reason, “most treatments are not to cure vitiligo, they are to conceal or lessen the appearance of white patches. This strongly suggests that the treatments are for cosmetic reasons rather than medical reasons,” said Lisa Dahl, health insurance agent at Hoffman Brown Company. This has also given a reason to Mayo Clinic to state in their website that “medical treatment for vitiligo isn’t always necessary.” According to Boissy, about 60 percent of insurance companies cover vilitigo patients, the other 40 percent does not.

“It’s not a cosmetic issue, it’s a disease, we know that there are genes that cause it,” he said.

For that reason, he went on to say that without pigmentation in the skin, people are more susceptible to skin cancer and skin aging. In addition to affecting the skin, it can also have a dramatic auto immune response, which can affect other parameters such as the thyroid, amino glands, and the joints can develop arthritis or diabetes.

LIVING WITH THE DISEASE

Danny Arcanjo, 20-year-old, from Newark, New Jersey, who is the first in his family to have vitiligo, has had it for four years now. His insurance company doesn’t cover the cost for his treatments, so he has to pay out of his pocket for them. He has paid $2,500 to get started on his skin graphing and laser treatment. Arcanjo is required to visit the dermatologist on a weekly basis– each session costs $200.

Beyond the external physical changes and battles for insurance coverage that vitiligo patients undergo, many vitiligo patients have also been affected psychologically.

“I have seen a lot of people that have vitiligo get really depressed, angry, sad, paranoid, pessimistic, and negative because you are stuck with it for life. They still haven’t found a cure for it,” said Arcanjo.

Arcanjo went on to say that people should be aware about vitiligo because it could help prevent and solve many problems for the vitiligo community such as the psychological affects that may occur from having this skin depigmentation. When people discriminate people with vitiligo, they don’t realize that they are harming them psychologically to the point of giving them a reason to commit suicide.

Also, with awareness, many people in this community would be able to achieve their dreams, instead, of having to change them.

Before he had vitligo, he was on his way to becoming a professional soccer player. His vitiligo doesn’t let him be out in the sun too much, so he had to give up that dream. He said he is only one of many who have had to alter their hopes and dreams.

The psychological ramifications of vitiligo can be seen in various patients that have it.


Isabel Goncalves from Queens, New York was diagnosed with vitiligo when she was four years old/ By: Maria Gonzalez
“It’s not only a depigmentation, a cosmetical problem, it’s physical, psychological, and it deals with your health. You will never know how it feels until you have it,” said 35-year-old mother, Johana Galindez from Long Island, New York, who is the first in her family to get vitiligo.

She experiences psychological affects from having vitiligo daily. “I hate when people stare at me, I try to hide my hands. On a daily basis, I experience a lot of negativity, it feels like a roller coaster. I know beauty comes from within, but it is very hard thing to accept, especially, if you are a person like me who was very active and had a big open social life,” said Galindez

At the age of 26, she was diagnosed with vitiligo. This caused her to end her dancing career in New York. “People don’t tell you up front, the producers, the teachers, and the cast members, but you know inside that people don’t see you the same way. They don’t care the same way,” said Galindez

source : http://www.elnuevosol.net