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by Thomas B. Fitzpatrick, MD , Ph.D
(continued)

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.

Bibliography

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.