Vitiligo

Vitiligo is a skin condition that causes patches of skin to lose their color, creating smooth white or light areas on the body. Affecting about 1% of people worldwide, this chronic condition is not harmful to physical health but can significantly impact how people feel about their appearance.

What is vitiligo?
Who gets vitiligo?
Types of vitiligo
Symptoms and where they appear
What causes vitiligo?
How is vitiligo diagnosed?
Treatment options
Living with vitiligo

What is vitiligo?

Vitiligo is a chronic skin condition that causes skin to lose its color or pigment, which is the substance that gives skin its natural tone^[1]. When this happens, smooth white or light patches appear on the skin. These light areas are called macules if they are less than 1 centimeter wide, or patches if they are larger than 1 centimeter^[1].

The condition occurs when your body’s immune system destroys melanocytes, which are skin cells that produce melanin. Melanin is the chemical that gives skin its color^[1]. If you have vitiligo on a part of your body that has hair, the hair in that area may turn white or silver^[1].

Vitiligo is not contagious, meaning you cannot catch it from someone else who has it^[4]. While it can change the way your skin and hair look, it is not harmful to your overall physical health^[8].

Who gets vitiligo?

Vitiligo affects all races and sexes equally, appearing in over 1% of the population throughout the world^[1]. The condition is more visible in people with darker skin tones because of the greater contrast with the white patches^[1]. Although vitiligo can develop in anyone at any age, the white patches usually become apparent before age 30^[1]. About half of people with vitiligo develop it before age 20^[3].

You might be at a higher risk of developing vitiligo if you have certain autoimmune conditions, which are disorders where the immune system attacks the body’s own healthy tissues. These conditions include^[1]:

Addison’s disease
Anemia
Diabetes (Type 1)
Lupus
Psoriasis
Rheumatoid arthritis
Thyroid disease

About 30% of people with vitiligo have a family history of the condition, suggesting that it can run in families^[19]. The inheritance involves both genetic and environmental factors, and scientists believe that multiple genes may influence whether someone develops vitiligo^[5].

Types of vitiligo

There are several types of vitiligo, classified based on how the white patches appear and spread on the body^[1]:

Generalized vitiligo is the most common type, also called non-segmental or bilateral vitiligo. It causes white patches to appear in various places on your body, often on both sides in a symmetrical pattern^[1]^[4]. This type affects around 9 in 10 people with vitiligo^[4].

Segmental vitiligo, also known as unilateral or localized vitiligo, only affects one side of your body or one specific area, such as your hands or face^[1]. This type is less common but appears more frequently in children, affecting around 3 in 10 children with vitiligo^[4]. It usually starts earlier and tends to progress for a year or two before stabilizing^[2].

Mucosal vitiligo affects the mucous membranes, which are the moist linings of your mouth and genitals^[1].

Focal vitiligo is a rare type where the white patches develop in a small, limited area and don’t spread in a certain pattern within one to two years^[1].

Trichome vitiligo creates a bullseye pattern with a white or colorless center, then an area of lighter pigmentation, and finally an area of your natural skin tone^[1].

Universal vitiligo is a rare type that causes more than 80% of your skin to lose pigment^[1].

Symptoms and where they appear

The main signs and symptoms of vitiligo include^[1]:

Patches of skin or mucous membranes that lose color, appearing white or lighter than your natural skin tone
Patches of hair on your body that turn silver, gray, or white

The patches are usually characterized by well-defined borders and a smooth appearance. The center of a patch may be white, with paler skin around it. If there are blood vessels under the skin, the patch may appear slightly pink rather than white^[4]. The edges may be smooth or irregular, and sometimes appear red or have brownish discoloration^[4].

Symptoms can be mild, affecting only a small area of your body, or severe, affecting a large area of your skin. Some people with vitiligo experience itchy skin before the loss of color starts^[1]^[2].

Vitiligo can appear anywhere on the skin, but the most common places to have symptoms include^[1]^[2]:

Hands and fingers
Feet and ankles
Arms, particularly forearms
Face, especially around the mouth and eyes
Mucous membranes (inside of your mouth, lips, and nose)
Genitals
Armpits and groin
Elbows, wrists, and knees

Vitiligo usually starts with a few small white patches that may gradually spread over your body. Larger patches may continue to widen and spread, but they usually stay in the same place for years. The location of smaller white areas can shift and change over time, as certain areas of skin lose and regain their pigment^[1]. The amount of affected skin varies greatly from person to person^[1].

There is no way to predict how much skin will be affected or how the condition will progress^[4]. In rare cases, in one out of every five to 10 people with vitiligo, some or all the pigment eventually returns on its own, causing the white patches to disappear^[19].

What causes vitiligo?

The exact cause of vitiligo is unknown, but experts believe it is an autoimmune disorder, which means the immune system does not work properly and attacks healthy cells in the body^[4]. In vitiligo, the immune system destroys melanocytes, the skin cells that produce melanin pigment^[1].

There are different theories about why this happens. Scientists think that vitiligo may be related to immune system changes, genetic factors, stress, or sun exposure^[7]. Research shows that the condition has incomplete inheritance patterns, meaning it involves both environmental and genetic factors^[5].

For segmental vitiligo, which is the less common type, scientists believe it may be caused by chemicals released from nerve endings in the skin. These chemicals may be harmful to melanocytes^[4].

It’s possible that vitiligo may be triggered by particular events, such as^[4]:

Stressful events, such as childbirth
Skin damage, such as severe sunburn or cuts (this is known as the Koebner phenomenon)
Hormonal changes to the body, such as puberty
Problems with the liver or kidneys
Exposure to certain chemicals

Additionally, researchers suggest that melanocytes in people with vitiligo may be less capable of managing an imbalance between substances called antioxidants and harmful particles known as free radicals in the body^[19].

How is vitiligo diagnosed?

A doctor will be able to diagnose vitiligo by asking about your medical history and examining your skin^[4]^[10]. In some cases, the doctor may use a special ultraviolet light called a Wood’s lamp to examine the skin more closely. Under this lamp, areas without pigment appear chalky and bright, making them easier to see^[19].

Sometimes a skin biopsy is necessary to confirm the diagnosis. During a biopsy, a small sample of skin is removed and examined under a microscope to check for the absence of melanocytes in the affected areas^[3]^[5].

Your doctor may also recommend blood tests to check for other autoimmune conditions that are sometimes associated with vitiligo, particularly thyroid disorders^[10].

Treatment options

Treatment for vitiligo is not necessary for everyone. If you have lighter skin or only small patches, you may choose not to pursue treatment^[1]. However, various treatment options are available if you wish to restore color to your skin or even out your skin tone.

The choice of treatment depends on your age, how much skin is involved and where, how quickly the condition is progressing, and how it affects your life^[10]. It’s important to understand that treatment may take many months to judge its effectiveness, and you may need to try more than one approach or a combination of treatments^[10]. Even if treatment is successful, results may not be permanent, and new patches may appear^[10].

Medicines applied to the skin

Topical corticosteroids are creams or ointments containing steroids that can be applied to affected skin. This treatment may help restore color and is most effective when vitiligo is still in its early stages^[10]^[11]. You might not see changes in your skin’s color for several months. Possible side effects include skin thinning or the appearance of streaks or lines on your skin^[10]^[11]. Treatment typically involves applying the cream once a day and having regular follow-up appointments to monitor progress and side effects^[11].

Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, are creams that help decrease inflammation and may be effective for treating vitiligo, especially on the face and neck^[3].

In 2022, a new treatment called ruxolitinib cream was approved. This is a topical JAK inhibitor that blocks the overactive immune response. Studies have shown significant improvement of white patches, especially on the face, with this treatment^[12]^[13].

Light therapy

Phototherapy, also called light therapy, involves exposing the affected areas of skin to special wavelengths of light. This treatment induces satisfactory return of color in a majority of patients with early or localized disease^[16]. Treatment two to three times weekly for up to a year may be necessary, and pigment returns gradually^[3].

Narrowband UV-B (NB-UVB) is the most widely used type of phototherapy and has become the first choice for adults and children with widespread vitiligo. Wavelengths of 311-312 nanometers are typically used^[16]. This treatment can be safely used in children, pregnant women, and nursing women^[16]. Short-term side effects may include burning, itching, and dry skin^[16].

The excimer laser produces single-wavelength rays at 308 nanometers to treat limited, stable patches of vitiligo. This treatment is effective, safe, and well-tolerated^[16].

Surgical treatments

Surgical options may be considered for localized and stable vitiligo, as well as for segmental vitiligo^[13]. These procedures typically involve taking skin from an area with normal pigment and moving it to an area without pigment. Surgery is usually performed on an outpatient basis, meaning you go home the same day, and complications are extremely rare^[8].

Other approaches

Skin camouflage creams can be applied to white patches to help them blend with the rest of your skin. These creams are made to match a range of skin tones and can be waterproof^[11]. They last for up to 4 days on the body and 12 to 18 hours on the face^[11].

Depigmentation treatments may be considered when treatment to restore pigmentation is unsuccessful and vitiligo is very extensive^[3]. This approach involves removing the remaining pigment from unaffected skin to create a more uniform appearance.

Living with vitiligo

Sun protection

Sunburn is a serious risk if you have vitiligo because white skin patches have no natural protection against the sun’s rays^[17]. When skin is exposed to sunlight, it produces melanin to help protect it from ultraviolet light. However, if you have vitiligo, there is not enough melanin in the affected skin, so it is not protected^[11].

It is essential to always apply sunscreen with a sun protection factor of at least 30 or higher, ideally 50 or above, to protect your skin from sunburn and long-term damage^[1]^[17]. Areas without pigment are particularly vulnerable to sunburn, which not only is painful but might also stimulate the vitiligo to spread^[17]. Sunburn also increases the risk of skin cancer^[17].

You should also protect your skin by wearing loose cotton clothes, a hat, and sunglasses. Stay in the shade, especially during the hottest time of day from 11 am to 3 pm^[17]. Avoid tanning beds or sun lamps, as tanning increases the contrast between your natural skin tones and the white patches, making them more obvious^[22].

Vitamin D

If your skin is not exposed to the sun because you are protecting it, there is an increased risk of vitamin D deficiency. Vitamin D is essential for keeping bones and teeth healthy^[11]. While sunlight is the main source of vitamin D, you should consider taking a daily supplement containing vitamin D to ensure you get enough^[11].

Emotional and psychological support

Because vitiligo affects physical appearance, living with the condition can be challenging and may impact emotional well-being^[8]. Many people with vitiligo feel self-conscious, and feelings can range from embarrassment to clinical depression^[3]. Research confirms an impact on self-esteem and quality of life, including side effects such as anxiety and depression^[21].

Supporting your mental health is an important part of managing vitiligo. Consider these approaches^[21]:

Learn as much as you can about vitiligo to feel more in control of the situation
Practice stress reduction techniques such as meditation or relaxing hobbies
Try regular exercise, which promotes physical well-being and may help reduce stress
Practice mindfulness, which is being fully present and self-aware
Seek counseling or therapy if you feel distressed about your condition
Join support groups to connect with others who have vitiligo

Your doctor may refer you to a specialist if you need additional support for the psychological and social impact of vitiligo^[16].

General skin care

Treat your skin gently to prevent triggering new patches. Vitiligo can develop at sites of trauma or friction, a response known as the Koebner phenomenon^[22]. Vitiligo does not cause discomfort to your skin, such as dryness, but the white patches may occasionally be itchy^[4].