Introduction

Vitiligo

Vitiligo is a long-term condition where pale white patches develop on the skin. It is 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).

See a slideshow of other rashes and skin conditions.

How is vitiligo treated?

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

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

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

In some cases, treatment may restore pigment (colour) to your patches but the effect does not usually last. Treatment cannot stop the condition from spreading.

Read more about treating vitiligo.

Complications

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 sun cream 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 the condition affects areas of frequently exposed skin.

Help and support

Support groups can provide help and advice and may be able to put you in contact with other people who have vitiligo. Your GP may suggest a group in your area. Charities such as The Vitiligo Society may be able to help.

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Symptoms

The areas most commonly affected by vitiligo include:

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

Sometimes vitiligo can 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.

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 is 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 of vitiligo often appear on both sides of your body as symmetrical white patches. Symmetrical patches can appear on areas such as 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 up to 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 is more common in children. Segmental vitiligo usually starts earlier and affects three in 10 children who have vitiligo.

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Causes

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 is not clear exactly why the melanocytes disappear from the affected areas of skin.

Autoimmune conditions

Non-segmental vitiligo, the most common type of vitiligo, is thought to be an autoimmune condition. In autoimmune conditions, the immune system does not 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 destroys the melanocyte skin cells that make melanin.

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

Neurochemicals

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

Increased risk

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

  • members of your family have it
  • there's a family history of other autoimmune conditions – for example, 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 (a type of cancer of the lymphatic system)
  • you have particular changes in your genes that are known to be linked to non-segmental vitiligo

Triggers

It is possible that the vitiligo may be triggered by particular events, for example:

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

Vitiligo is not caused by an infection and you cannot catch it from someone else who has the condition.

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Diagnosis

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

Your GP may ask whether:

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

Your GP may also ask about the impact that vitiligo has on your life. For example:

  • how much it affects your confidence and self-esteem
  • whether it affects your job

Wood’s lamp

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

Under the ultraviolet light, the patches of vitiligo will be easier to see. This can help your GP tell the difference between vitiligo and 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 if you have any symptoms that could suggest an autoimmune condition, such as:

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

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Treatment

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

However, the effects of treatment are not usually permanent, and it cannot 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 have very fair skin anyway. You may be referred to a dermatologist (a specialist in treating skin conditions) if further treatment is needed.

Protection from the sun

Sunburn is a real risk if you have vitiligo. 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. If you have vitiligo, there is not enough melanin in your skin, so it is not protected.

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

Read more about sunburn.

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 is not exposed to the sun, there is 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 is 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.

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 up to four days on the body and 12-18 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 you need to reapply them. 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 are not 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 (see below). 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.

You can use the Patient UK guide, Fingertip Units for Topical Steroids, to find out how many FTUs to use to treat different areas of the body.

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 much your vitiligo has improved. If there is no improvement, you may be referred to a dermatologist (see below).

If your vitiligo has 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

You GP may refer you to a dermatologist if:

  • they are unsure about your diagnosis
  • you are pregnant and need treatment
  • more than 10% of your body is affected by vitiligo
  • you are distressed about your condition
  • your face is affected and you want further treatment
  • you cannot use topical corticosteroids because of the risk of side effects
  • you have segmental vitiligo and want further treatment
  • treatment with topical corticosteroids has not 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 are 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 that 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:

  • burning or painful sensations 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 have not worked
  • the vitiligo is widespread
  • the vitiligo is having a significant impact on their 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. You can take psoralen by mouth (orally), or you can add it to your bath water.

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

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

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

Skin grafts

A skin graft is a surgical procedure that involves removing healthy skin from an unaffected area of the body and using it 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 have not gotten worse in the last 12 months
  • your vitiligo was not triggered by damage to your skin, 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, for example, 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, that has also been used with phototherapy, it can cause side effects

Complementary therapies

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

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

If you decide to use herbal remedies, check with your GP first, as 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. This 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 how you think and act.

Unlicensed medicines

Many treatments used for vitiligo are unlicensed. 'Unlicensed' means the medicine's manufacturer hasn't applied for a licence for it to be used to treat your condition. The medicine hasn't undergone clinical trials to see whether it's effective and safe in treating your condition.

Doctors may recommend using an unlicensed medicine if they think it will be effective, and the benefits of treatment outweigh any associated risk. Before prescribing an unlicensed medicine, they should inform you it's unlicensed, and discuss the possible risks and benefits with you.

Read more about unlicensed medicines.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 21/02/2017 08:29:23