Vitiligo: why white patches appear and what treatments exist

Why does vitiligo appear?

The most widely accepted explanation is that there is an autoimmune response against the melanocytes.

The immune system, which normally protects us, incorrectly identifies these cells as a target and ends up interfering with their survival or function.

There is also a genetic predisposition.

But that does not mean vitiligo is inherited in a straightforward way.

It can appear in a person with no obvious family history. And a predisposition can exist without the disease ever developing.

So does stress cause it?

We cannot reduce vitiligo to: 'It's because of stress.'

Stress may be linked to flares or worsening in some people, just as it is in many inflammatory or autoimmune diseases.

But vitiligo is a multifactorial disease. It is not simply an emotional reaction.

What do the patches look like?

The lesions typically appear as well-defined white patches on the skin.

They can appear on virtually any area of the body.

They are common on the face, hands, fingers, elbows, knees, armpits, genital region, and around openings such as the eyes and mouth.

Hair located within a lesion may also be affected and can lose its pigment.

Are all white patches vitiligo?

No. And this is fundamental.

A pitiriasis versicolor. A pitiriasis alba. Post-inflammatory hypopigmentation. A hipomelanosis guttata idiopática. All of them can produce lighter areas.

That is why we have our dedicated article 'White spots on the skin: the most common causes'.

A diagnosis of vitiligo should not be made simply because an area looks white.

How is it diagnosed?

In many cases the clinical appearance is very informative.

But we can use additional tools.

One of them is the lámpara de Wood, which emits long-wave ultraviolet radiation and helps make the depigmentation more evident.

We can also use dermoscopy.

In certain cases, the clinical history may justify complementary investigations to assess associated conditions.

But there is no blood test that on its own 'diagnoses vitiligo'.

Are there different types of vitiligo?

Yes. An important distinction is between non-segmental vitiligo and segmental vitiligo.

Non-segmental vitiligo

It is the most common form.

The lesions tend to appear on both sides of the body with a degree of symmetry, and can progressively affect different areas over time.

Segmental vitiligo

It tends to affect a specific region and often appears following a unilateral distribution.

Its behaviour and course can be different.

This distinction is important because it can influence the therapeutic strategy.

Can it progress?

Yes.

In some people, vitiligo remains stable for years. In others, new lesions appear or existing ones increase in size.

There can even be phases of activity and phases of stability.

That is why, when we assess a patient, we are not only interested in how much vitiligo they have. We also want to know: is it active?

What does it mean for it to be active?

We are referring to a disease that is progressing. New lesions appear. Existing patches enlarge. Or certain clinical signs are observed that suggest activity.

Under certain circumstances, trauma to the skin can trigger a new lesion in that area. This is known as the Koebner phenomenon.

Can it be associated with other autoimmune diseases?

Yes.

There is an association with certain autoimmune diseases, particularly thyroid disorders.

But this does not mean that every person with vitiligo necessarily has another disease.

The decision to carry out additional tests depends on the clinical history, background and symptoms.

Is vitiligo dangerous?

It is not a cancer. It is not an infection. And it is not contagious.

But it can have a significant psychological impact, especially when it affects visible areas.

Depigmented skin also has less melanin, so it needs good sun protection.

Can it be treated?

Yes. And there is an important message here: vitiligo does not mean there is nothing we can do.

The goals of vitiligo treatment can be: stopping progression, encouraging repigmentation, maintaining the results achieved and improving quality of life.

There is no single treatment that is right for everyone. The strategy depends on age, extent, location, activity and type of vitiligo.

Topical corticosteroids

Corticosteroids can be used for certain localised lesions.

Their aim is to modulate immunological inflammation.

But they must be used correctly, because prolonged or inappropriate use can cause adverse effects such as skin atrophy.

That is why it is not simply a matter of applying 'a cortisone cream' indefinitely.

Tacrolimus and pimecrolimus

Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, can be used especially in certain locations where we want to avoid the effects of prolonged corticosteroids.

They are particularly useful in areas such as the face and skin folds in selected patients.

Ruxolitinib cream: an important new development

In recent years, a new therapeutic option has emerged: ruxolitinib cream, a JAK inhibitor.

In the European Union, Opzelura (ruxolitinib) is authorised for the treatment of non-segmental vitiligo with facial involvement, in adults and adolescents from 12 years of age.

This is important because it is a therapy directed at specific immunological mechanisms involved in the disease.

How does it work?

Ruxolitinib inhibits the enzymes JAK1 and JAK2, which are involved in inflammatory signalling pathways relevant to vitiligo.

The goal is to reduce the immunological signal that interferes with melanocitos and to promote repigmentation.

Does it work quickly?

No. And this is something we must explain clearly.

Repigmentation takes time.

According to the EMA, more than six months may be needed to achieve satisfactory repigmentation with ruxolitinib cream.

This reflects something that applies broadly to vitiligo treatment: results are not measured in days.

NB-UVB phototherapy

Another fundamental tool is narrowband ultraviolet B phototherapy, known as NB-UVB.

It is used especially when multiple lesions are present or when the extent of involvement is greater.

Exposure is carried out in a controlled manner, using specific doses of radiation.

This has nothing to do with 'getting more sun to get your colour back'. Phototherapy is a dosed medical treatment.

Which areas respond best?

Not all locations respond in the same way.

The face and neck tend to have better chances of repigmentation.

The hands, fingers and feet are usually more difficult to treat.

This is related, among other factors, to the distribution of hair follicles capable of acting as a reservoir of melanocytes.

That is why vitiligo on the face can behave differently from a lesion located on the fingers.

Can it be definitively cured?

We currently do not have a cure that guarantees the disease will never return.

We can achieve repigmentation and control disease activity, but the possibility of relapse exists.

Some patients require maintenance strategies.

That is why I prefer to speak of controlling + repigmenting + maintaining, rather than promising a 'definitive cure'.

Does sun help?

I do not recommend using uncontrolled sun exposure as a treatment.

Depigmented skin is especially vulnerable to ultraviolet radiation.

Moreover, tanning of normal skin can further increase the contrast between pigmented and depigmented skin.

When we use light to treat vitiligo, we do so through controlled medical phototherapy.

What about supplements?

There is no universal supplement capable of repigmenting vitiligo.

If a specific deficiency exists, correcting it may obviously make sense.

But taking vitamins indiscriminately is no substitute for treating an autoimmune disease.

Can laser be used?

In localised lesions, certain forms of targeted phototherapy may be used, including láser excímer in selected patients.

The advantage is treating specific areas without unnecessarily exposing large areas of skin.

But again, the indication depends on location, extent and activity.

What about when vitiligo is stable?

In certain highly selected and stable cases, surgical procedures involving cellular or tissue grafting may be considered.

These are not first-line treatments and require appropriate patient selection.

Disease stability is especially important before considering these techniques.

Is photoprotection important?

Yes. For two reasons.

First, skin lacking melanin has less natural protection against ultraviolet radiation.

Second, avoiding excessive tanning of normal skin can reduce the visual contrast with depigmented areas.

That is why photoprotection is part of routine management.

What about the psychological impact?

We must not minimise it.

A visible condition can affect self-esteem, social relationships and quality of life.

And simply saying 'It's not dangerous, it's nothing to worry about' can be medically incomplete.

It is not life-threatening. But it can affect a person in a very real way. Treatment must also take this aspect into account.

When should we seek medical advice?

When a new white area appears and we do not know what it is. When it grows. When new lesions appear. When it affects the face, hands or sensitive areas. When we notice loss of pigmentation in the hair. Or when a diagnosis of vitiligo already exists and we notice it is progressing.

The goal is not solely to confirm the name. It is to assess: type + extent + activity + treatment options.

What I want you to remember

Vitiligo is not simply 'a white patch'. It is a condition in which the immune system attacks the melanocitos.

It is not contagious. It is not an infection. And it does not mean that no treatment exists.

Today we have topical treatments, phototherapy, calcineurin inhibitors, corticosteroids in certain situations, and new targeted therapies such as ruxolitinib cream for certain patients with non-segmental vitiligo.

But there is a rule that remains valid for everything we have discussed in this cluster: diagnosis first. Then we assess activity and extent. And finally we choose the treatment that is right for that individual.

Because two white patches can look very similar. But only when we know it is truly vitiligo can we talk about how to repigment them.