by Thomas B. Fitzpatrick, MD , Ph.D
Myths About Vitiligo Treatment
Three myths about the treatment of vitiligo prevail in the medical profession.
The first myth is that treatment of vitiligo is "impossible." This is clearly not true and the majority of patients can achieve good results.
The second myth is that oral psoralens, which form the basis for some vitiligo treatments are "toxic to the liver." Oral psoralens are not toxic to the liver.
The third myth is that psoralen + UVA (PUVA) treatments for vitiligo "cause cancer of the skin." When used to treat vitiligo, PUVA therapy requires only a limited number of treatments-approximately 150 in number that has not been shown to cause skin cancer. By comparison, PUVA treatments for psoriasis can be as many as double the number for vitiligo. It has been shown that a small percentage of patients who receive more than 250 PUVA treatments can develop treatable squamous cell cancers of the skin.
Vitiligo Treatment Options
Four options are currently available for the treatment of vitiligo: sunscreens; cover-up; restoration of normal skin color; and bleaching of normal skin with topical creams to remove normal skin pigment to make an even color.
The two goals of sunscreen treatments are: to protect unpigmented involved skin from sunburn reaction and to limit the tanning of normal pigmented skin. The sun protection factor (SPF) of sunscreens should be no less than SPF 30, as this grade blocks not only erythema, but also the affects of sunlight on the DNA of the skin cells. Sunscreen treatment skin phototypes 1, 2, and sometimes 3 (those who burn, then tan to some degree).
The goal of cover-up with dyes or make-up is to hide the white macules so that the vitiligo is less visible. Self-tanning lotions and camouflage are quite helpful for some patients.
Restoring Normal Skin Color
Restoration of normal skin color can take the form of spot treatments or whole body treatment.
Spot Treatment: Topical Corticosteroid Creams
Initial treatment with certain topical corticosteroid creams is practical, simple, and safe. If there is no response in 2 months, it is unlikely to be effective. Physician monitoring every 2 months for signs of early steroid atrophy (thinning of the skin) is required.
Spot Treatment: Topical Oxsoralen
Much more complicated is the use of topical Oxsoralen (8-MOP). Oxsoralen is highly phototoxic (likely to cause a sunburn), and the phototoxicity lasts for 3 days or more. This should be performed only as an office procedure, only for small spots, and only by experienced physicians on well-informed patients. As with oral psoralens, 15 or more treatments may be required to initiate a response, and 100 or more to finish.
Spot Treatment: Mini Grafting
Mini grafting, which involves transplanting the patient's normal skin to vitiligo affected areas, may be a useful technique for refractory segmental vitiligo macules. PUVA may be required following the procedure to unify the color between the graft sites. The demonstrated occurrence of Koebnerization in donor sites in generalized vitiligo restricts this procedure to patients who have limited skin areas at risk for vitiligo. "Pebbling" of grafted site may occur.
Whole Body Treatment: PUVA Photochemotherapy (Oral Psoralens + UVA Irradiation)
For more widespread vitiligo, treatment with oral psoralen + UVA (PUVA) is practical. This may be done with sunlight and trimethylpsoralen (Trisoralen) or with artificial UVA (in the doctor's office or at an approved phototherapy facility) and Trisoralen or Oxsoralen-Ultra.
Ophthalmologic examination and ANA blood tests are required before starting PUVA therapy. Outdoor therapy may be initiated with 0.6 mg/kg Trisoralen followed 2 hours later by 5 minutes of New England sunlight (less in southern regions). Treatments should be twice weekly, not 2 days in a row, and sunlight exposure should increase by 3 to 5 minutes per treatment until there is a sign of response, and in a few this causes koebnerization. Individualization is required: treatment options are either 0.4 mg/kg of Oxsoralen-Ultra (well absorbed, efficient potentially very phototoxic, significant risk of nausea) or 0.6 mg/kg of Trisoralen (variably absorbed, not very phototoxic, little nausea).
Initial UVA exposure should be 1.0 J and increments (twice weekly, not two days in a row) 0.5 (Oxsoralen-Ultra) to 1.0 (Trisoralen) J per treatment until there is evidence of response of phototoxicity. The later is the sustaining UVA dose until reasonable repigmentation has been established.
PUVA is up to 85% effective in over 70% of patients with vitiligo of the head, neck, upper arms, legs, and trunk. Distal hands and feet are poorly responsive and alone are not usually worth treating. Genital areas should be shielded and not treated. Macules that have totally repigmented usually stay in the absence of injury/sunburn (85% likelihood up to 10 years), macules less than fully repigmented will slowly reverse once treatments have been discontinued. Maintenance treatments are required.
Risks of treating vitiligo with PUVA include nausea, GI upset, sunburn, hyperpigmentation, and acute dryness. We advise against oral PUVA treatments for children under age 10. Treatment is most likely to be successful in highly motivated patients who clearly have reasonable objectives and understand the risks and benefits. While PUVA is not a cure, most patients who are responding well to treatment are not at the same time developing new vitiligo macules.
Topical Creams To Remove Normal Skin Pigment And Unify Skin Color
The goal of depigmentation is to unify skin color in patients with vitiligo virtually all over the body and those who have failed PUVA, who cannot use PUVA, or who reject the PUVA option. Bleaching with monobenzylether of hydroquinone 20% cream (Benoquin) is a permanent, irreversible process. Since application of Benoquin may be associated with distant depigmentation, Benoquin cannot be used to selectively to bleach certain areas of normal pigmentation, because there is a real likelihood that new and distant white macules will develop over the months of use. Bleaching with Benoquin normally requires twice-daily possible side effects. Uncommonly, contact dermatitis is observed. The success rate is about 93%. Periodically following sun exposure, an occasional patient will observe focal repigmentation, which will require a month or so of local use of Benoquin to reverse.
The end-stage color of skin bleached with Benoquin is the same chalk-white as the vitiligo macules. Most patients are quite satisfied with uniformity and the finality of the results. An occasional patient may wish to take 30 to 60 mg beta-carotene to impart on off-white color to the skin. The only side effect of beta-carotene is the uncommon risk of diarrhea.
Patients who undergo bleaching are at risk for sunburn. They should avoid midday sun exposure and should use a high-SPF sunscreen. To date no long-term untoward effects have been reported from the use of monobenzylether of hydroquinone for skin bleaching.
Why Is It Important To Treat Vitiligo?
Many physicians, and even some dermatologists, fail to recognize the profound social and psychological impact vitiligo may have on its victims. Vitiligo is painless and non-pruritic and, unlike psoriasis, it is not associated with shedding of skin scales. But the disfigurement of vitiligo, accentuated among persons with brown or black skin, can be devastating.
The recent media publicity about Michael Jackson's battle with vitiligo has helped raise public awareness of the disease. While vitiligo is worldwide and affects all races equally, it is a particularly troubling social problem for persons whose normal skin color is brown or black. The contrast between brown skin and white vitiligo spots can create a grotesque "harlequin" appearance. The same kind of disfigurement can become a problem for vitiligo victims with normally fair skin who tan deeply during the summer months or, among those who live in sunny climates, throughout the year.
In India, vitiligo, or "leukoderma" as it is called there, is regarded as "white leprosy." The late Prime Minister Jawaharlal Nehru ranked vitiligo as one of three major medical problems in India, alongside malaria and leprosy. A woman in India cannot marry if she has even one spot of vitiligo, and if a woman develops vitiligo after marriage it is considered grounds for divorce.
It is no wonder vitiligo patients can turn aggressive, feel a sense of shame, or become withdrawn and resentful. For many, vitiligo is not just a cosmetic problem-it is a major social dysfunction that seriously curtails their ability to lead a normal work, social or married life. Reversal of the white spots and restoration of normal skin color is therefore the primary hope for all these disfigured vitiligo patients.
Fitzpatriack TB, Eisen AZ, Wolff K, etal. "Disorders of Pigmentation"
In: Dermatology In General Medicine, 4th ed., edited by TB Fitzpatrick et al. New York, McGraw-Hill, 1993.
Fitzpatrick TB, Johnson RA, Woff K etal. "Vitiligo" In: Color Atlas and Synopsis of Clinical Dermatology, 3rd ed. New York, McGraw-Hill, 1997. Ortonne JP. Mosher DB. Fitzpatrick TB. Vitiligo and Other Hypomelanoses of Hair and Skin. New York, Plenum Publishing Corporation, 1983.