Vitiligo is an acquired skin disorder characterized by white spots on the skin (depigmentation), caused by the loss of functioning of the melanocytes. The hair and rarely the eyes can also lose color. Vitiligo spots can appear on any part of the skin, but usually they are around the holes, genitals or areas exposed to the sun such as the face and hands. The disease is classified according to its scope and distribution, and can be subdivided into generalized or localized. (Table I)
It’s difficult to predict how your disease will progress. Sometimes the patches stop forming without treatment. In most cases, pigment loss spreads and eventually involves most of your skin. Rarely, the skin gets its color back.
Table I. Vitiligo topographic classification
|Located||Affects a corporal segment of the body|
|Disseminated||It affects two or more segments, but less than 75% of the body surface|
|Generalized||It affects more than 75% of the body surface|
The age of onset of vitiligo is variable, usually begins in childhood and adulthood, approximately 50% of patients acquire the disease at the age of 20 years, and its incidence decreases with increasing age. The prevalence of the disease in the United States has been
estimated at 1%, although in other countries it has been found in: 0.38% for Denmark, 1.13% in Surat, India, and 0.46% in Calcutta, India. In studies conducted in Latin America such as Gay Prieto, it is reported that it corresponds to 2 to 4% of all dermatological patients. In Mexico, vitiligo occupies between the 3rd and 5th place among all dermatoses, with 3 to 5% of the total. It predominates in women, it is rare that it is congenital, that it occurs in the infant, as well as that it starts after 50 years.
Symptoms of vitiligo disease
The main sign of vitiligo is patchy loss of skin color. Usually, the discoloration first shows on sun-exposed areas, such as the hands, feet, arms, face and lips.
Vitiligo signs include:
- Patchy loss of skin color
- Premature whitening or graying of the hair on your scalp, eyelashes, eyebrows or beard
- Loss of color in the tissues that line the inside of your mouth and nose (mucous membranes)
- Loss of or change in color of the inner layer of the eyeball (retina)
In patients with recently started vitiligo, treatment with a potent or very potent topical steroid should be considered for a trial period of no more than 2 months. (Table II) Although the benefits have been observed, skin atrophy has been a common side effect. Patients should be evaluated during treatment very four weeks to assess side effects. In the presence of signs of cutaneous atrophy it is recommended to stop treatment with topical steroids.In adults with symmetrical vitiligo, topical pimecrolimus should be considered as an alternative to the use of topical steroids especially in lesions located in the head, neck and genitals. The side effect profile of pimecrolimus topical is better than that of a very potent topical steroid. The use of topical calcipotriol as monotherapy is not recommended. In combination with phototherapy or topical steroid it can produce initial repigmentation and the degree of long-term repigmentation is not clear.Oral systemic treatment.
The use of oral dexamethasone stops the progression of vitiligo; but due to common adverse effects is not recommended as the first line for the treatment or of vitiligo. The extract of Ginkgo biloba can stop the active vitiligo of the acrofacial type, however, it is advisable to carry out more studies for confirmation of the beneficial effects.
The use of Nb-UVB is recommended in the treatment of moderate to severe generalized vitiligo due to its efficacy compared to PUVA. By consensus among specialists the use of PUVA is recommended in the treatment of vitiligo. When UVA light devices are not available, sunlight can be used as a source of radiation (PUVAsol). It has been recommended
the administration of PUVA combined with vitamin D analogues because they are well tolerated and allow the dose of UVA to be decreased; however, it is necessary to carry out more studies to avoid the bias that the pigmentation has been spontaneous.
Surgical treatment is recommended in patients with scores on the LIFE scale of -1 or 0 (patients without activity of the lesions) and without the Koebner phenomenon (Table III). The choice of the procedure area depends on the affected site, the experience of the dermatologist surgeon, the infrastructure, the cost and the patient’s preference.
Depigmentation with monobenzyl ether hydroquinone (MBEH) or 4-methoxyphenol (4MP) should be reserved for adults with severe disease.
vitiligo (for example, more than 90% of depigmentation surface or those who have extensive depigmentation on the face or hands) or who do not
can offer repigmentation therapy. It’s not recommended its use in children. Treatment for vitiligo may restore color to the affected skin. But it does not prevent continued loss of skin color or a recurrence. When to see a doctorSee your doctor if areas of your skin, hair or eyes lose coloring. Vitiligo has no cure. But treatment may help to stop or slow the discoloring process and return some color to your skin.
|Table II. Classification of the potency of topical corticosteroids|
|Power / Group||Corticosteroid||Type Of vehicle / form||Conc.|
|Group 1 Very high power||Betamethasone dipropionate||Ointment||0.05%|
|Cream based emollients||0.05%|
|Spray foam (for scalp)||0.05%|
|Solution (for scalp)||0.05%|
|Flurandrenolida||Tape (roll)||4 mgc /Cm2|
|Diflorasona Diacetate||Ointment (petrolatum)||0.05%|
|Group 2 High power||Amcinonide||Ointment||0.10%|
|Acetonido de Triamcinolone||Ointment||0.50%|
|Group 3 Medium power||Amcinonide||Cream||0.10%|
|Betamethasone dipropionate||Emollient hydrophilic cream||0.05%|
|Fluocinonide||Emollient watery cream||0.05%|
|Fomerate of Mometasona||Ointment||0.10%|
|Group 4 Low power||Triamcinolone acetonide||Cream||0.10%|
|Spray||0.2 mg for 2 seconds|
|Group 5 Low average power||Triamcinolone acetonide||lotion||0.1|
|Group 6 Low power||Alclometasone dipropionate||Ointment||0.05%|
|Group 7 Minimum power||Hydrocortisone (base)||Ointment||2.50%|
|Combination of hydrocortisone acetate with 1% pramoxine||Ointment||1- 2.5%|
|Cream||1 – 2.5%|
|Lotion||1 – 2.5%|
|Adapted from: Lacy, CF et al (Eds) Lexi-Comp’s Drug Information Handbook, 18th ed. Lexi-Comp Inc, Hudson OH. Copyright © 2010 and Tadich|