Vitiligo Treatments

by Thomas B. Fitzpatrick, MD , Ph.D

Myths About Vitiligo Treatment

Three myths about the treatment of vitiligo prevail in the medical profession.

The first myth is that treatment of vitiligo is "impossible." This is clearly not true and the majority of patients can achieve good results.

The second myth is that oral psoralens, which form the basis for some vitiligo treatments are "toxic to the liver." Oral psoralens are not toxic to the liver.

The third myth is that psoralen + UVA (PUVA) treatments for vitiligo "cause cancer of the skin." When used to treat vitiligo, PUVA therapy requires only a limited number of treatments-approximately 150 in number that has not been shown to cause skin cancer. By comparison, PUVA treatments for psoriasis can be as many as double the number for vitiligo. It has been shown that a small percentage of patients who receive more than 250 PUVA treatments can develop treatable squamous cell cancers of the skin.

Vitiligo Treatment Options

Four options are currently available for the treatment of vitiligo: sunscreens; cover-up; restoration of normal skin color; and bleaching of normal skin with topical creams to remove normal skin pigment to make an even color.

Sunscreens

The two goals of sunscreen treatments are: to protect unpigmented involved skin from sunburn reaction and to limit the tanning of normal pigmented skin. The sun protection factor (SPF) of sunscreens should be no less than SPF 30, as this grade blocks not only erythema, but also the affects of sunlight on the DNA of the skin cells. Sunscreen treatment skin phototypes 1, 2, and sometimes 3 (those who burn, then tan to some degree).

Cover-up

The goal of cover-up with dyes or make-up is to hide the white macules so that the vitiligo is less visible. Self-tanning lotions and camouflage are quite helpful for some patients.

Restoring Normal Skin Color

Restoration of normal skin color can take the form of spot treatments or whole body treatment.
Spot Treatment: Topical Corticosteroid Creams
Initial treatment with certain topical corticosteroid creams is practical, simple, and safe. If there is no response in 2 months, it is unlikely to be effective. Physician monitoring every 2 months for signs of early steroid atrophy (thinning of the skin) is required.

Spot Treatment: Topical Oxsoralen

Much more complicated is the use of topical Oxsoralen (8-MOP). Oxsoralen is highly phototoxic (likely to cause a sunburn), and the phototoxicity lasts for 3 days or more. This should be performed only as an office procedure, only for small spots, and only by experienced physicians on well-informed patients. As with oral psoralens, 15 or more treatments may be required to initiate a response, and 100 or more to finish.

Spot Treatment: Mini Grafting

Mini grafting, which involves transplanting the patient's normal skin to vitiligo affected areas, may be a useful technique for refractory segmental vitiligo macules. PUVA may be required following the procedure to unify the color between the graft sites. The demonstrated occurrence of Koebnerization in donor sites in generalized vitiligo restricts this procedure to patients who have limited skin areas at risk for vitiligo. "Pebbling" of grafted site may occur.

Whole Body Treatment: PUVA Photochemotherapy (Oral Psoralens + UVA Irradiation)

For more widespread vitiligo, treatment with oral psoralen + UVA (PUVA) is practical. This may be done with sunlight and trimethylpsoralen (Trisoralen) or with artificial UVA (in the doctor's office or at an approved phototherapy facility) and Trisoralen or Oxsoralen-Ultra. 

Ophthalmologic examination and ANA blood tests are required before starting PUVA therapy. Outdoor therapy may be initiated with 0.6 mg/kg Trisoralen followed 2 hours later by 5 minutes of New England sunlight (less in southern regions). Treatments should be twice weekly, not 2 days in a row, and sunlight exposure should increase by 3 to 5 minutes per treatment until there is a sign of response, and in a few this causes koebnerization. Individualization is required: treatment options are either 0.4 mg/kg of Oxsoralen-Ultra (well absorbed, efficient potentially very phototoxic, significant risk of nausea) or 0.6 mg/kg of Trisoralen (variably absorbed, not very phototoxic, little nausea). 

Initial UVA exposure should be 1.0 J and increments (twice weekly, not two days in a row) 0.5 (Oxsoralen-Ultra) to 1.0 (Trisoralen) J per treatment until there is evidence of response of phototoxicity. The later is the sustaining UVA dose until reasonable repigmentation has been established. 

PUVA is up to 85% effective in over 70% of patients with vitiligo of the head, neck, upper arms, legs, and trunk. Distal hands and feet are poorly responsive and alone are not usually worth treating. Genital areas should be shielded and not treated. Macules that have totally repigmented usually stay in the absence of injury/sunburn (85% likelihood up to 10 years), macules less than fully repigmented will slowly reverse once treatments have been discontinued. Maintenance treatments are required. 

Risks of treating vitiligo with PUVA include nausea, GI upset, sunburn, hyperpigmentation, and acute dryness. We advise against oral PUVA treatments for children under age 10. Treatment is most likely to be successful in highly motivated patients who clearly have reasonable objectives and understand the risks and benefits. While PUVA is not a cure, most patients who are responding well to treatment are not at the same time developing new vitiligo macules.

Topical Creams To Remove Normal Skin Pigment And Unify Skin Color

The goal of depigmentation is to unify skin color in patients with vitiligo virtually all over the body and those who have failed PUVA, who cannot use PUVA, or who reject the PUVA option. Bleaching with monobenzylether of hydroquinone 20% cream (Benoquin) is a permanent, irreversible process. Since application of Benoquin may be associated with distant depigmentation, Benoquin cannot be used to selectively to bleach certain areas of normal pigmentation, because there is a real likelihood that new and distant white macules will develop over the months of use. Bleaching with Benoquin normally requires twice-daily possible side effects. Uncommonly, contact dermatitis is observed. The success rate is about 93%. Periodically following sun exposure, an occasional patient will observe focal repigmentation, which will require a month or so of local use of Benoquin to reverse.

The end-stage color of skin bleached with Benoquin is the same chalk-white as the vitiligo macules. Most patients are quite satisfied with uniformity and the finality of the results. An occasional patient may wish to take 30 to 60 mg beta-carotene to impart on off-white color to the skin. The only side effect of beta-carotene is the uncommon risk of diarrhea.

Patients who undergo bleaching are at risk for sunburn. They should avoid midday sun exposure and should use a high-SPF sunscreen. To date no long-term untoward effects have been reported from the use of monobenzylether of hydroquinone for skin bleaching.

Why Is It Important To Treat Vitiligo?

Many physicians, and even some dermatologists, fail to recognize the profound social and psychological impact vitiligo may have on its victims. Vitiligo is painless and non-pruritic and, unlike psoriasis, it is not associated with shedding of skin scales. But the disfigurement of vitiligo, accentuated among persons with brown or black skin, can be devastating.

The recent media publicity about Michael Jackson's battle with vitiligo has helped raise public awareness of the disease. While vitiligo is worldwide and affects all races equally, it is a particularly troubling social problem for persons whose normal skin color is brown or black. The contrast between brown skin and white vitiligo spots can create a grotesque "harlequin" appearance. The same kind of disfigurement can become a problem for vitiligo victims with normally fair skin who tan deeply during the summer months or, among those who live in sunny climates, throughout the year.

In India, vitiligo, or "leukoderma" as it is called there, is regarded as "white leprosy." The late Prime Minister Jawaharlal Nehru ranked vitiligo as one of three major medical problems in India, alongside malaria and leprosy. A woman in India cannot marry if she has even one spot of vitiligo, and if a woman develops vitiligo after marriage it is considered grounds for divorce.

It is no wonder vitiligo patients can turn aggressive, feel a sense of shame, or become withdrawn and resentful. For many, vitiligo is not just a cosmetic problem-it is a major social dysfunction that seriously curtails their ability to lead a normal work, social or married life. Reversal of the white spots and restoration of normal skin color is therefore the primary hope for all these disfigured vitiligo patients.

Bibliography

Fitzpatriack TB, Eisen AZ, Wolff K, etal. "Disorders of Pigmentation" 

In: Dermatology In General Medicine, 4th ed., edited by TB Fitzpatrick et al. New York, McGraw-Hill, 1993.

Fitzpatrick TB, Johnson RA, Woff K etal. "Vitiligo" In: Color Atlas and Synopsis of Clinical Dermatology, 3rd ed. New York, McGraw-Hill, 1997. Ortonne JP. Mosher DB. Fitzpatrick TB. Vitiligo and Other Hypomelanoses of Hair and Skin. New York, Plenum Publishing Corporation, 1983.

Eat Chocolate for Sun Protection ?

Due to the heat wave being experienced here in South Africa, I have been exposed to sun a lot and I have a sunburn on my arms. I came across an interesting article on dark chocolate and its properties that have proved to have small protection from the sun. Nevertheless, we should keep on using our sunscreen with SPF 30 and above. Below is how dark chocolate can help protect from the sun.

Several studies, including a well known one 2006 German researchers have shown that dark chocolate beverages high in flavonols (plant-based antioxidants), may have protective properties against damaging UV rays. In the study, they compared two groups of women. One drank flavonol-rich chocolate beverages  while the other drank a less potent chocolate beverage. When both groups were exposed to UV-light, those who drank the richer chocolate beverage suffered the least sunburn.

A 2009 study published in The Journal of Cosmetic Dermatology similarly found that regular consumption of chocolate high in flavonols offered some protection against sun’s damaging rays.

What’s the sweet spot for protection? 3.5 ounces of dark chocolate was found to provide an SPF of 2 or 3. While that’s better than no protection, it certainly is not enough to adequately protect you from sun damage.

Since chocolate doesn’t list the amount of flavonoids it contains, look for brands with at least 70% cacoa. So, pack your broad-spectrum sunscreen with SPF of 30 for optimum sun protection and toss a few dark chocolate bars like Ghiradelli’s Intense Dark Twilight Delight 72%, in your carry-on.

Source:
http://thedermblog.com

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