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Vitiligo Content Supplied by NHS Choices
Introduction

Vitiligo is a long-term condition where pale white patches develop on the skin. It's caused by the lack of melanin, a pigment in the skin.

Vitiligo can affect any area of skin, but most commonly occurs on the face, neck and hands, and in skin creases.

The pale areas of skin are more vulnerable to sunburn, so it's important to take extra care when in the sun and use a sunscreen with a high sun protection factor (SPF).

This page covers:

Symptoms

Causes

Diagnosis

Treatment

Complications

Help and support

Symptoms of vitiligo

The areas most commonly affected by vitiligo include:

  • the skin around your mouth and eyes
  • fingers and wrists
  • armpits
  • groin
  • genitals
  • inside your mouth

It can also sometimes develop where there are hair roots, such as on your scalp. The lack of melanin in your skin can turn the hair in the affected area white or grey.

Vitiligo often starts as a pale patch of skin that gradually turns completely white. The centre of a patch may be white, with pale skin around it. If there are blood vessels under the skin, the patch may be slightly pink, rather than white.

The edges of the patch may be smooth or irregular. They're sometimes red and inflamed, or there's brownish discolouration (hyperpigmentation).

Vitiligo doesn't cause discomfort to your skin, such as dryness, but the patches may occasionally be itchy.

The condition varies from person to person. Some people only get a few small, white patches, but others get bigger white patches that join up across large areas of their skin.

There's no way of predicting how much skin will be affected. The white patches are usually permanent.

Types of vitiligo

There are two main types of vitiligo:

  • non-segmental vitiligo
  • segmental vitiligo

In rare cases, it's possible for vitiligo to affect your whole body. This is known as universal or complete vitiligo.

Non-segmental vitiligo

In non-segmental vitiligo (also called bilateral or generalised vitiligo), the symptoms often appear on both sides of your body as symmetrical white patches. Symmetrical patches can appear on the:

  • backs of your hands
  • arms
  • skin around body openings, such as the eyes
  • knees
  • elbows
  • feet

Non-segmental vitiligo is the most common type of vitiligo, affecting around nine out of 10 people with the condition.

Segmental vitiligo

In segmental vitiligo (also known as unilateral or localised vitiligo), the white patches only affect one area of your body.

Segmental vitiligo is less common than non-segmental vitiligo, although it's more common in children. It usually starts earlier and affects three in 10 children with vitiligo.

What causes vitiligo

Vitiligo is caused by the lack of a pigment called melanin in the skin. Melanin is produced by skin cells called melanocytes, and it gives your skin its colour.

In vitiligo, there aren't enough working melanocytes to produce enough melanin in your skin. This causes white patches to develop on your skin or hair. It's not clear exactly why the melanocytes disappear from the affected areas of skin.

Autoimmune conditions

Non-segmental vitiligo (the most common type) is thought to be an autoimmune condition.

In autoimmune conditions, the immune system doesn't work properly. Instead of attacking foreign cells, such as viruses, your immune system attacks your body's healthy cells and tissue.

If you have non-segmental vitiligo, your immune system destroys the melanocyte skin cells that make melanin.

Vitiligo is also associated with other autoimmune conditions, such as hyperthyroidism (an overactive thyroid gland), but not everyone with vitiligo will develop these conditions.

Risk factors

You may be at increased risk of developing non-segmental vitiligo if:

  • other members of your family have it
  • there's a family history of other autoimmune conditions - for example, if one of your parents has pernicious anaemia (an autoimmune condition that affects the stomach)
  • you have another autoimmune condition
  • you have melanoma (a type of skin cancer) or cutaneous T-cell lymphoma (cancer of the lymphatic system)
  • you have particular changes in your genes that are known to be linked to non-segmental vitiligo

Neurochemicals

Segmental vitiligo (the less common type) is thought to be caused by chemicals released from the nerve endings in your skin. These chemicals are poisonous to the melanocyte skin cells.

Triggers

It's possible that vitiligo may be triggered by particular events, such as:

  • stressful events, like childbirth
  • skin damage, such as severe sunburn or cuts (this is known as the Koebner response)
  • exposure to certain chemicals - for example, at work

Vitiligo isn't caused by an infection and you can't catch it from someone else who has it.

Diagnosing vitiligo

Your GP will be able to diagnose vitiligo after examining the affected areas of skin.

They may ask whether:

  • there's a history of vitiligo in your family
  • there's a history of other autoimmune conditions in your family
  • you've injured the affected areas of skin - for example, whether you've had sunburn or a severe rash there
  • you tan easily in the sun, or whether you burn
  • any areas of skin have got better without treatment, or whether they're getting worse
  • you've tried any treatments already

Your GP may also ask you about the impact vitiligo has on your life. For example, how much it affects your confidence and self-esteem, and whether it affects your job.

Wood's lamp

If available, your GP may use an ultraviolet (UV) lamp called a Wood's lamp to look at your skin in more detail. You'll need to be in a dark room and the lamp will be held 10-13cm (4-5in) away from your skin.

The patches of vitiligo will be easier to see under the UV light, which will help your GP distinguish vitiligo from other skin conditions, such as pityriasis versicolor (where there's a loss of pigment due to a fungal infection).

Other autoimmune conditions

As non-segmental vitiligo is closely associated with other autoimmune conditions, you may be assessed to see whether you have any symptoms that could suggest an autoimmune condition, such as:

  • being tired and lacking energy (signs of Addison's disease)
  • being thirsty and needing to urinate frequently (signs of diabetes)

A blood test may also be needed to check how well your thyroid gland is functioning.

Treating vitiligo

The white patches caused by vitiligo are usually permanent, although treatment options are available to improve the appearance of your skin.

If the patches are relatively small, skin camouflage cream can be used to cover them up.

In general, combination treatments, such as phototherapy (treatment with light) and medication, give the best results.

Although treatment may help restore colour to your skin, the effect doesn't usually last. Treatment can't stop the condition spreading.

Read more about treating vitiligo.

Complications of vitiligo

Vitiligo can sometimes cause other problems.

Because of a lack of melanin, your skin will be more vulnerable to the effects of the sun. Make sure you use a strong sunscreen to avoid sunburn.

Vitiligo may also be associated with problems with your eyes, such as inflammation of the iris (iritis), and a partial loss of hearing (hypoacusis).

Problems with confidence and self-esteem are common in people with vitiligo, particularly if it affects areas of skin that are frequently exposed.

Help and support

Support groups can provide help and advice, and may be able to put you in contact with other people with vitiligo.

Your GP may suggest a group in your local area, and charities such as The Vitiligo Society may also be able to help.

Treatment

Treatment for vitiligo is based on improving the appearance of the skin by restoring its colour.

However, the effects of treatment aren't usually permanent, and it can't always control the spread of the condition.

Your GP may recommend:

Further treatment may not be necessary if, for example, you only have a small patch of vitiligo or you have very fair skin anyway.

You may be referred to a dermatologist (a specialist in treating skin conditions) if further treatment is needed.

The various treatments for vitiligo are outlined below. You can also read a summary of the pros and cons of the treatments for vitiligo, allowing you to compare your treatment options.

Protection from the sun

Sunburn is a real risk if you have vitiligo. You must protect your skin from the sun and avoid using sunbeds.

When skin is exposed to sunlight, it produces a pigment called melanin to help protect it from ultraviolet light. However, if you have vitiligo there isn't enough melanin in your skin, so it isn't protected.

Always apply a high-factor sunscreen, ideally with a sun protection factor (SPF) of 30 or above, to protect your skin from sunburn and long-term damage. This is particularly important if you have fair skin.

Protecting your skin from the sun will also mean you don't tan as much, which will make your vitiligo less noticeable.

Vitamin D

If your skin isn't exposed to the sun, there's an increased risk of vitamin D deficiency. Vitamin D is essential for keeping bones and teeth healthy.

Sunlight is the main source of vitamin D, although it's also found in some foods, such as oily fish.

It might be difficult to get enough vitamin D from food and sunlight alone. You should therefore consider taking a daily supplement containing 10 micrograms (mcg) of vitamin D.

Read more about who should take vitamin D supplements and how much vitamin D adults and children need.

Skin camouflage

Skin camouflage creams can be applied to the white patches of skin. The creams are specially made to match your natural skin colour. The cream blends in the white patches with the rest of your skin, making them less noticeable.

For advice about skin camouflage, your GP may refer you to the Changing Faces skin camouflage service.

You need to be trained in using the camouflage creams, but the service is free (although donations are welcome) and some creams can be prescribed on the NHS.

Camouflage creams are waterproof and can be applied anywhere on the body. They last for up to four days on the body and 12 to 18 hours on the face.

You can also get skin camouflage cream that contains sun block or has an SPF rating.

Self-tanning lotion (fake tan) may also help cover vitiligo. Some types can last several days before they need to be reapplied. Self-tanning lotion is available from most pharmacies.

Topical corticosteroids

Topical corticosteroids are a type of medication that contain steroids. You apply them to your skin as a cream or ointment.

They can sometimes stop the spread of the white patches and may restore some of your original skin colour.

A topical corticosteroid may be prescribed to adults if:

  • you have non-segmental vitiligo on less than 10% of your body
  • you want further treatment (sun protection advice and camouflage creams are enough for some people)
  • you aren't pregnant
  • you understand and accept the risk of side effects

Topical corticosteroids can be used on the face, but care should be taken in selecting and using this type of medication on your face.

Read more about topical corticosteroids.

Using topical corticosteroids

Your GP may prescribe a cream or an ointment, depending on what you prefer and where it will be used. Ointments tend to be greasier. Creams are better in your joints - for example, inside your elbows.

Possible corticosteroids that may be prescribed include:

  • fluticasone propionate
  • betamethasone valerate
  • hydrocortisone butyrate

Your GP will tell you how to apply the cream or ointment to the patches and how much you should use. You normally need to apply the treatment once a day.

Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU). One FTU is the amount of topical steroid squeezed along an adult's fingertip. One FTU is enough to treat an area of skin twice the size of an adult's hand.

Read more about fingertip units.

Follow-up

After one month, you'll have a follow-up appointment so your GP can check how well the treatment is working and whether you have any side effects. If the treatment is causing side effects, you may need to stop using corticosteroids.

After another month or two, your GP will check how much your vitiligo has improved. If there's no improvement, you may be referred to a dermatologist (see below).

If it's improved slightly, you may continue treatment, but have a break from treatment every few weeks. You may also be referred to a dermatologist.

Treatment will be stopped if your vitiligo has improved significantly.

Your GP may take photos of your vitiligo throughout your treatment to monitor any signs of improvement. You may also want to take photos yourself.

Side effects

Side effects of topical corticosteroids include:

  • streaks or lines in your skin (striae)
  • thinning of your skin (atrophy)
  • visible blood vessels appearing (telangiectasia)
  • excess hair growth (hypertrichosis)
  • contact dermatitis (inflammation of your skin)
  • acne

Referral

Your GP may refer you to a dermatologist if:

  • they're unsure about your diagnosis
  • you're pregnant and need treatment
  • more than 10% of your body is affected by vitiligo
  • you're distressed about your condition
  • your face is affected and you want further treatment
  • you can't use topical corticosteroids because of the risk of side effects
  • you have segmental vitiligo and want further treatment
  • treatment with topical corticosteroids hasn't worked

Children with vitiligo who need treatment will also be referred to a dermatologist.

In some cases, you may be prescribed strong topical corticosteroids while you're waiting to be seen by a dermatologist.

Some treatments your dermatologist may recommend are described below.

Topical pimecrolimus or tacrolimus

Pimecrolimus and tacrolimus are a type of medicine called calcineurin inhibitors, which are normally used to treat eczema.

Pimecrolimus and tacrolimus are unlicensed for treating vitiligo, but they can be used to help restore skin pigment in adults and children with vitiligo.

They can cause side effects, such as:

  • a burning or painful sensation when applied to the skin
  • making the skin more sensitive to sunlight
  • facial flushing (redness) and skin irritation if you drink alcohol

However, unlike corticosteroids, pimecrolimus and tacrolimus don't cause thinning of the skin.

Phototherapy

Phototherapy (treatment with light) may be used for children or adults if:

  • topical treatments haven't worked
  • the vitiligo is widespread
  • the vitiligo is having a significant impact on quality of life

Evidence suggests that phototherapy, particularly when combined with other treatments, has a positive effect on vitiligo.

During phototherapy, your skin is exposed to ultraviolet A (UVA) or ultraviolet B (UVB) light from a special lamp. You may first take a medicine called psoralen, which makes your skin more sensitive to the light. Psoralen can be taken by mouth (orally), or it can be added to your bath water.

This type of treatment is sometimes called PUVA (psoralen and UVA light).

Phototherapy may increase the risk of skin cancer because of the extra exposure to UVA rays. The risk of skin cancer is lower with UVB light. Your dermatologist should discuss the risk with you before you decide to have phototherapy.

Sunlamps that you can buy to use at home for light therapy aren't recommended. They're not as effective as the phototherapy you'll receive in hospital. The lamps are also not regulated, so may not be safe.

Skin grafts

A skin graft is a surgical procedure where healthy skin is removed from an unaffected area of the body and used to cover an area where the skin has been damaged or lost. To treat vitiligo, a skin graft can be used to cover the white patch.

Skin grafts may be considered for adults in areas that are affecting your appearance if:

  • no new white patches have appeared in the last 12 months
  • the white patches haven't got worse in the last 12 months
  • your vitiligo wasn't triggered by skin damage, such as severe sunburn (known as the Koebner response)

An alternative to skin grafting involves taking a sample of normal skin, removing the melanocytes from it and then transplanting them onto the areas of vitiligo.

These types of treatments are time-consuming, carry a risk of scarring and aren't suitable for children. They're also not widely available in the UK and aren't funded by the NHS.

Depigmentation

Depigmentation may be recommended for adults who have vitiligo on more than 50% of their bodies, although it may not be widely available.

During depigmentation, a lotion is painted on to the normal skin to bleach away the remaining pigment and make it the same colour as the depigmented (white) skin. A hydroquinone-based medication is used, which has to be applied continuously to prevent the skin from re-pigmenting.

Hydroquinone can cause side effects, such as:

  • redness
  • itching
  • stinging

Depigmentation is usually permanent and leaves the skin with no protection from the sun. Re-pigmentation (when the colour returns) can occur, and may differ from your original skin colour. Applying depigmenting treatments in one area of skin can sometimes cause loss of pigmentation of skin on other parts of the body.

Other treatments

Your dermatologist may recommend trying more than one treatment, such as phototherapy combined with a topical treatment. Other possible treatments include:

  • excimer lasers - high-energy beams of light that are used in laser eye treatment, but may also be used in phototherapy (not available on the NHS)
  • vitamin D analogues - such as calcipotriol, which may also be used with phototherapy
  • azathioprine - a medicine that suppresses your immune system (the body's natural defence system)
  • oral prednisolone - a type of corticosteroid, which has also been used with phototherapy; it can cause side effects

Complementary therapies

Some complementary therapies claim to relieve or prevent vitiligo. However, there's no evidence to support their effectiveness, so more research is needed before they can be recommended.

There's very limited evidence that ginkgo biloba, a herbal remedy, may benefit people with non-segmental vitiligo. There's currently not enough evidence to recommend it.

Check with your GP if you decide to use herbal remedies. Some remedies can react unpredictably with other medication or make them less effective.

Counselling and support groups

If you have vitiligo, you may find it helpful to join a vitiligo support group. It can help you understand more about your condition and come to terms with your skin's appearance.

Charities, such as The Vitiligo Society, may be able to put you in touch with local support groups (you may need to become a member first). Your GP may also be able to suggest a local group.

If you have psychosocial symptoms - for example, your condition is causing you distress - your GP may refer you to a psychologist or a counsellor for treatment such as cognitive behavioural therapy (CBT).

CBT is a type of therapy that aims to help you manage your problems by changing the way you think and behave.

"My vitiligo has never stopped me from pursuing anything in my life"

Living with vitiligo has been the most challenging and rewarding part of Elena's life. She tells her story.

"As a child aged four, I was blissfully unaware of any difference between myself and other children. I never experienced any animosity, cruelty or name-calling. For that, I must be grateful, as not everyone is so fortunate.

"It wasn't until I approached school age that I saw the true effect. I noticed that my family felt a need to hide the fact that I was different. My parents spoke to the local GP, who referred us to a hospital outpatient's clinic that could supply me with a camouflage cream.

"I never had a problem with the trips to the doctors or hospitals, but when we arrived at the camouflage unit and my vitiligo was covered up, I knew I was different.

"School began, and everyone would have been none the wiser, except that the make-up was too dark for my skin, so there was a noticeable difference. At times I felt alone and unhappy with the way I looked.

"My mother was my rock. She helped me through every step, applying the cover cream in the mornings and telling me how beautiful I was when I took my make-up off at night.

"Eventually, my dad and I were introduced to Dermablend (camouflage make-up), and we managed to obtain it on prescription. It was perfect timing as I was now a teenager and appearance was very important at that age.

"For the next 10 years, I forgot that I had vitiligo as the Dermablend gave me so many opportunities. I could go swimming and not worry about reapplying throughout the day. The colour match was so perfect that I didn't have to tell anybody unless I wanted to.

"After contacting The Vitiligo Society, I've been referred to Guy's & St Thomas' hospital, where they're treating my vitiligo with a steroid cream.

"So far it's going really well. I'm hopeful that this will mean not spending five minutes a day applying make-up. If not, then I'm happy to continue, as my vitiligo has made me who I am today and has never stopped me from pursuing anything in my life."

"My experience of narrowband UVB has been incredible"

Paul Johnson has had vitiligo for most of his life. He tells his story.

"I started noticing the white patches in my early teens. They progessed relatively slowly to my elbows, knees, hands and feet by the age of 18.

"After that, they spread rather rapidly. By 21, I had plenty of smaller patches across my face, trunk and legs. By 30, I had lost the tanned colour across about 80% of my body, which is quite interesting when you have a Maltese ancestry. That's the way things stayed for years, until recently.

"Last summer, I noticed a small amount of randomly scattered repigmentation on my arms. Nothing to get excited about really, as I often get small patches of colour during the peak summer months. But by November, when the sun and heat of summer had gone, the little repigmented spots were still there.

"I was intrigued and happy about this new development. Like many people, I have managed to live with vitiligo for years now. But I can't deny that it remains in the back of my mind almost continuously. It has affected my confidence. Physically, I haven't been totally at ease with myself.

"I thought that if I could have some additional treatment it may help the body to repigment.

"I heard about many treatments, but the one that caught my eye was narrowband UVB. The Vitiligo Society has a list of all the UK hospitals that offer this treatment. The nearest was two miles from home. I saw my GP and requested a referral to a consultant dermatologist.

"The consultant was positive. After a discussion and examination, she put me forward for a three-month trial.

"As I drove to the hospital for the first appointment, I was worried about what the treatment was like. But my experience has been no problem.

"Typically, each visit takes about 20 minutes from arriving at the hospital to leaving. The machine is a large rectangular 'box' where you stand for treatment. Each of the walls and door are covered in light tubes that switch on for the time period set by the hospital staff.

"I was started on a very low dose of around 20 seconds, two or three times a week. This was increased slowly as the treatment progressed, making sure that I didn't burn in between treatments. Generally, I go slightly pink, which is about the right amount of light exposure to get the skin working.

"It took six weeks before I achieved any repigmentation. It happened first on my face, which I believe is the most susceptible part of the body. Small dots of brown appeared on my forehead. Slowly other parts of the body showed similar signs of repigmentation.

"After a follow-up visit to the consultant in April, it was agreed that I should continue with the treatment as it was having an impact.

"In May, all areas of my trunk and legs showed repigmentation from almost all the hair follicles. It looks like somebody has covered my white patches with dots of brown felt pen.

"My hands and feet haven't really shown much repigmentation yet. They're the hardest part of the body to repigment. The dots of brown on my face are starting to join up, and my face has gone from 80% white to 90% brown.

"I knew the treatment was working when the window cleaner asked me if I'd had a nice holiday. I can't tell you how uplifting it is when people comment on how brown I look.

"Although no results can be guaranteed, my own experience with narrowband UVB has been incredible so far."

 
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