Vitiligo

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis | Management and Treatment | When to Refer | References

Introduction

Vitiligo is a chronic skin condition characterised by the loss of pigment-producing cells (melanocytes), leading to the development of well-demarcated, depigmented patches on the skin. These patches can occur anywhere on the body and may gradually increase in size over time. Vitiligo can affect individuals of all ages, genders, and ethnicities, though it is more noticeable in those with darker skin. The condition is not life-threatening but can cause significant psychological distress due to its impact on appearance.

Aetiology and Risk Factors

The exact cause of vitiligo is not fully understood, but it is believed to be a multifactorial condition involving genetic, autoimmune, and environmental factors:

• Autoimmune Component: Vitiligo is often associated with autoimmune diseases such as thyroiditis, alopecia areata, and type 1 diabetes. The body’s immune system mistakenly attacks and destroys melanocytes, leading to depigmentation.
• Genetic Predisposition: A family history of vitiligo or other autoimmune conditions increases the risk, suggesting a genetic component.
• Environmental Triggers: Factors such as skin trauma (Koebner phenomenon), sunburn, or exposure to certain chemicals may trigger or exacerbate vitiligo in genetically predisposed individuals.
• Oxidative Stress: An imbalance between the production of free radicals and the body’s ability to counteract their harmful effects may contribute to the destruction of melanocytes.
• Neurogenic Factors: The release of certain neuropeptides from nerve endings in the skin may play a role in the development of vitiligo.

Clinical Presentation

Vitiligo presents with the following characteristic features:

• Depigmented Patches: The primary feature of vitiligo is the appearance of well-demarcated, depigmented (white) patches on the skin. These patches are often symmetrical and can occur on any part of the body.
• Common Sites: Vitiligo frequently affects areas exposed to the sun, such as the face, hands, and arms, as well as areas around body orifices (e.g., eyes, mouth, nose) and sites of previous injury.
• Segmental vs. Non-Segmental Vitiligo: Vitiligo is classified into two main types:
  • Non-Segmental Vitiligo: The more common type, characterised by bilateral and symmetrical patches. It often progresses slowly over time.
  • Segmental Vitiligo: A less common type, characterised by unilateral, segmental patches that typically have a more stable course.
• Koebner Phenomenon: New depigmented patches may develop at sites of skin trauma, such as cuts, burns, or friction.
• Hair Depigmentation: The hair within vitiligo patches may also lose pigment, resulting in white or grey hair (leukotrichia).
• Psychological Impact: Due to its visible nature, vitiligo can cause significant psychological distress, anxiety, and depression, particularly in individuals with darker skin tones.

Diagnosis

The diagnosis of vitiligo is primarily clinical, based on the characteristic appearance of the lesions and patient history:

• History: Take a detailed history, including the onset and progression of depigmentation, family history of vitiligo or autoimmune diseases, and any potential triggers such as trauma or sunburn.
• Physical Examination: Examine the skin for well-demarcated, depigmented patches. Use a Wood’s lamp (UV light) to enhance the contrast between normal and depigmented skin, which may help in assessing the extent of vitiligo.
• Differential Diagnosis: Consider other conditions that may cause depigmentation, such as post-inflammatory hypopigmentation, tinea versicolor, and albinism. The absence of scaling and the presence of symmetrical patches can help distinguish vitiligo from these conditions.
• Laboratory Tests: Routine blood tests are not required for diagnosing vitiligo, but screening for associated autoimmune conditions (e.g., thyroid function tests) may be considered, especially in cases with other autoimmune symptoms.
• Biopsy: A skin biopsy is rarely needed but may be performed if the diagnosis is unclear. Histology typically shows a lack of melanocytes in the affected skin.

Management and Treatment

Management of vitiligo focuses on halting disease progression, promoting repigmentation, and addressing the psychological impact:

1. Topical Treatments

• Topical Corticosteroids: Potent or very potent topical corticosteroids (e.g., clobetasol propionate) are first-line treatments for localised vitiligo, particularly in non-segmental cases. They help reduce inflammation and may promote repigmentation. Treatment should be monitored to avoid side effects such as skin thinning.
• Topical Calcineurin Inhibitors: Tacrolimus or pimecrolimus are alternative options, particularly for sensitive areas such as the face and genitals. They are steroid-sparing and can be used long-term with a lower risk of side effects.

2. Phototherapy

• Narrowband UVB (NB-UVB) Therapy: NB-UVB phototherapy is the most effective treatment for widespread vitiligo. It involves regular exposure to UVB light, which can stimulate repigmentation. Treatment typically requires multiple sessions over several months.
• PUVA Therapy: Psoralen plus UVA (PUVA) therapy is another option, but it is less commonly used due to the risk of side effects, including an increased risk of skin cancer.

3. Systemic Treatments

• Oral Corticosteroids: Short courses of oral corticosteroids may be used to halt rapidly progressing vitiligo, but long-term use is generally avoided due to the risk of side effects.
• Immunosuppressants: In severe or refractory cases, systemic immunosuppressants such as methotrexate or ciclosporin may be considered under specialist supervision.

4. Cosmetic and Supportive Treatments

• Camouflage Makeup: Specialised cosmetic products can help conceal depigmented patches, improving the patient’s confidence and quality of life.
• Depigmentation Therapy: For extensive vitiligo, particularly in patients with fair skin, depigmentation of the remaining pigmented skin using agents like monobenzyl ether of hydroquinone may be considered to create a more uniform skin tone.
• Psychological Support: Referral to counselling or support groups may be beneficial for patients struggling with the psychological impact of vitiligo.

5. Surgical Treatments

• Skin Grafting: In selected cases, surgical options such as autologous skin grafting or cellular grafting (e.g., melanocyte transplantation) may be used to repigment stable vitiligo patches.

When to Refer

Referral to a dermatologist or other specialists may be necessary in the following situations:

• Extensive or Rapidly Progressing Vitiligo: Patients with widespread or rapidly progressing vitiligo should be referred for specialist evaluation and treatment, including consideration of phototherapy or systemic therapies.
• Refractory Cases: If vitiligo does not respond to standard treatments, referral to a dermatologist for advanced therapies or surgical options is advised.
• Psychological Impact: Patients experiencing significant psychological distress due to vitiligo should be referred for psychological support or counselling.
• Diagnostic Uncertainty: If the diagnosis is unclear or if there is concern for other conditions, a referral for further evaluation is warranted.

References

1. British Association of Dermatologists (2024) Guidelines for the Management of Vitiligo. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Vitiligo: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng101 (Accessed: 26 August 2024).
3. British National Formulary (2024) Topical and Systemic Treatments for Dermatological Conditions. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).