Everything about vitiligo: causes, symptoms, diagnosis and current treatments

Vitiligo is a chronic skin disease characterised by the appearance of white patches due to the loss of melanocytes, the cells responsible for producing melanin.

Although it does not produce pain nor represent a direct risk to health, it can have a profound emotional impact and affect self-esteem, social relationships and quality of life.

For many years it was believed that there were no effective treatments. Today we know that this is not true. Advances in the knowledge of the immune system and the development of new drugs have very importantly changed the management of vitiligo.

Vitiligo is an autoimmune disease in which the immune system selectively destroys the melanocytes.

When these cells disappear, the skin loses its pigment and completely white areas appear.

• It can affect any part of the body.
• It is not an infection.
• It is not contagious.
• It is not related to a lack of hygiene.

There is no single cause.

It is currently considered a multifactorial disease in which the following are involved:

• A genetic predisposition.
• Alterations of the immune system.
• Oxidative stress.
• Environmental factors.
• Repeated injuries to the skin in predisposed people.

All these mechanisms favour the destruction of the melanocytes.

There is a genetic predisposition.

However:

• Most children of patients with vitiligo will never develop the disease.
• Many people with vitiligo have no family history.

Genetics increases the risk, but it does not on its own determine its appearance.

It can appear at any age.

It is frequent for the first signs to appear before the age of 30, although it can also begin in childhood or in adulthood.

The onset is usually progressive.

The lesions appear as patches:

• White.
• Well defined.
• Without scaling.
• Without pain.
• Usually symmetrical.

In some people the evolution is slow and stable.

In others new lesions appear during periods of disease activity.

The most usual locations are:

• Face.
• Around the eyes.
• Around the mouth.
• Hands.
• Fingers.
• Elbows.
• Knees.
• Armpits.
• Groin.
• Genitals.

It can also affect:

• Scalp.
• Beard.
• Eyebrows.
• Eyelashes.

When the hair loses pigment it is called leukotrichia.

Non-segmental vitiligo. It is the most frequent form. It is usually bilateral and symmetrical.

Segmental vitiligo. It generally affects only one area of the body and tends to stabilise earlier.

Generalised vitiligo. It is the most usual presentation of non-segmental vitiligo.

Universal vitiligo. It is a rare form in which most of the body pigmentation is lost.

Yes.

As it is an autoimmune disease, some patients present other diseases of the same origin, especially:

• Autoimmune thyroid diseases.
• Type 1 diabetes.
• Alopecia areata.
• Pernicious anaemia.
• Other less frequent autoimmune diseases.

It does not mean that all people with vitiligo will develop them, but in some cases it may be advisable to carry out complementary studies.

Stress is not the cause of vitiligo.

However, it can act as a trigger or favour progression in some predisposed people.

In some patients new patches appear in areas where there has previously been:

• Chafing.
• Cuts.
• Burns.
• Trauma.

This phenomenon is known as the Koebner phenomenon.

The diagnosis is usually clinical.

The doctor may use:

• Physical examination.
• Dermoscopy.
• Wood's lamp.

The Wood's lamp makes it possible to better delimit the depigmented areas and to detect barely visible lesions.

In certain situations tests may be requested to rule out associated autoimmune diseases.

The treatment depends on:

• Extent.
• Location.
• Time of evolution.
• Disease activity.
• Age of the patient.

Each case requires an individualised plan.

In localised lesions the following may be used:

• Topical corticosteroids.
• Calcineurin inhibitors.
• Topical JAK inhibitors in selected patients and when indicated.

The objective is to slow the immune activity and to favour repigmentation.

Phototherapy with narrow-band UVB constitutes one of the most effective treatments for many forms of vitiligo.

It can achieve significant repigmentation, especially when it is started early.

In rapidly progressive phases immunomodulatory treatments may be used for limited periods and always under medical supervision.

One of the greatest recent advances has been the development of JAK inhibitors.

These drugs act by blocking specific pathways responsible for the immune attack against the melanocytes.

In selected patients they have demonstrated a very important capacity to favour repigmentation, especially when combined with phototherapy.

They represent one of the most relevant changes in the treatment of vitiligo in recent decades.

Yes.

Repigmentation usually begins around the hair follicles, since these preserve cells capable of producing melanin again.

The results depend on:

• Location.
• Time of evolution.
• Disease activity.
• Treatment used.

The face usually responds better than hands or feet.

Yes.

The depigmented areas lack melanin and are much more sensitive to ultraviolet radiation.

It is recommended to use:

• A broad-spectrum sunscreen.
• Protective clothing.
• Avoiding sunburn.

A controlled sun exposure within a prescribed treatment must not be confused with sunbathing indiscriminately.

The psychological impact of vitiligo can be very important.

Many people experience:

• A decrease in self-esteem.
• Anxiety.
• Shame.
• Social isolation.

These feelings are completely understandable.

Medical care must address both the disease and its emotional repercussion.

• Myth: Vitiligo is contagious. Fact: No. It cannot be transmitted by contact.
• Myth: The patches appear due to a lack of vitamins. Fact: Vitiligo is an autoimmune disease; vitamin deficiencies do not explain its appearance.
• Myth: There is no treatment. Fact: Today we have multiple therapeutic options capable of stabilising the disease and favouring repigmentation.
• Myth: Stress is the cause of vitiligo. Fact: It can act as a trigger in some people, but it is not the origin of the disease.
• Myth: All white patches are vitiligo. Fact: There are many other diseases that produce hypopigmentation and that must be differentiated through a medical assessment.

• Vitiligo is an autoimmune disease and not an isolated aesthetic alteration.
• It is not contagious nor related to poor hygiene.
• It can be associated with other autoimmune diseases, especially thyroid ones.
• Narrow-band UVB phototherapy and modern treatments have notably improved the prognosis.
• JAK inhibitors represent one of the most important therapeutic advances in recent years.
• An early diagnosis increases the chances of stabilising the disease and favouring repigmentation.