Vitiligo

What you need to know about Vitiligo during the Corona Virus pandemic:

Please read this blog by Dr John Harris from University of Massechusetts Medical School

What is Vitiligo?

The term Vitiligo refers to a skin condition presenting as white patches on the body.

The patches vary from a few millimetres to many centimetres in size. Significantly, there is no change in texture of the involved skin ie. the skin is not scaly, thickened or red.

Furthermore, there are no symptoms eg. itch, burning, stinging or pain. The only sign of its existence is a visible change in colour. Vitiligo cannot be felt.

How is Vitiligo caused?

In Vitiligo patches, there is a complete absence of melanocytes (pigment cells). The cause of Vitiligo is unknown. As in any condition where the cause is unknown, several theories exist. These theories are listed in the adjacent table.

Vitiligo is thought to be an inherited disease. Forty per cent of affected individuals have a family history. The condition affects 1% of the world's population.

If a person has vitiligo, the risk that a first-degree family member (parent, child, or sibling) is 5%, or 5 times higher than the general population ie. 1 in 20 first-degree relatives of vitiligo patients get vitiligo. (John Harris)

The identical twin of a person with vitiligo has a 23% risk of developing the disease as well, even though almost all of their DNA is identical. If genes were the whole story, that risk would be 100%

Vitiligo may start at any age although over 50% of individuals are below the age of 20 years. Any part of the body may be involved.

Types of Vitiligo

Koebner Phenomenon

The Koebner phenomenon may sometimes be seen in Vitiligo. In this situation, white patches develop at sites of injury eg. scratch marks. The picture below illustrates the common sites where koehler phenomenon may develop and the types of stimuli which produce this effect.

Koebner phenomenon resulting from scratch marks on the arms. The normal colour is lost at the sites of injury

Usually pigment cells in the upper part of the skin are involved (epidermis). Occasionally, however, pigment cells in the deeper part of the skin, around the hair follicles (roots of the hair), may be involved, in which case emerging hairs appear white.

Spontaneous repigmentation is seen in 20% of patients with Vitiligo. In the rest, the condition is gradually progressive. However, with treatment, up to 80% can expect some improvement in their condition. Treatment involves the stimulation of pigment cells around the hair follicles and their movement upwards into the epidermis. It can take up to three months before the effects of treatment is appreciated. The success of treatment is measured by the appearance of small pigmented spots around hair follicles within the white patch (see pic below). These spots gradually enlarge and join up until the patch becomes completely covered. It stands to reason that parts of the body not populated by hair follicles are difficult to treat eg. the lips, palms and soles, and the tips of the fingers.

Examples of follicular regimentation - pigmentation seen around hair follicles. These slowly join up to cover the patch,.

How is Vitiligo treated?

Topical Treatments:

2. Vitix Gel: This is an antioxidant cream which stabilises the melanocyte, preventing its destruction by oxidation. The active ingredients of Vitix are pseudocatalase and superoxide dismutase. It is applied twice a day and may be used with phototherapy or exposure to sunlight. Vitix gel is available from the practice, your pharmacy or online from SkinTECH.

2. Topical corticosteroids: These are applied followed by sun exposure for half an hour daily, ideally before 10am or after 3pm in order to avoid sunburn in the white patches.

3. Topical Tacrolimus (Protopic) ointment has been shown to be effective in the treatment of vitiligo. It may be combined with other topical modalities and/or surgical treatments.

Study with tacrolimus (J Am Acad Dermatol 2004;51:760-6)

57 paediatric patients treated with topical tacrolimus for 3 months
At least partial response seen in head and neck Vitiligo in 89% of the patients
and 63% in Vitiligo affecting the trunk and extremities
Tacrolimus was applied once or twice a day in 0,1 and 0,03%. No difference in response between different strengths but twice daily treatments did better than daily applications.

4. Cosmetic camouflage creams to cover the white areas: This is a painless form of treatment and results in instantaneous improvement. Camouflage creams could be used even while other forms of treatment are used. Viticolor is a unique dye which is applied on vitiligo skin, then reapplied after 8 hours to achieve a suitable colour match. The product is subsequently applied about two or three times a week.

Phototherapy:

1. Narrow band UVB: NBUVB is now considered the phototherapy of choice for extensive vitiligo. Treatment with NBUVB does not require the ingestion of Psoralen capsules prior to exposure. Although special goggles need to be worn whilst in the machine, no glasses have to be worn after treatment. Treatment time is much shorter than with PUVA. There is also no age limit with this machine and young children from the age of two months may be treated.

2. Excimer laser/light

The practice uses the 308nm Excimer Light (ExSys) which speeds up the repigmentation process compared to narrow band UVB. However, this treatment is suitable only for small areas of vitiligo. View results with Excimer Light.

4. PUVA (Psoralens and Ultra Violet A light): A treatment comprising the ingestion of psoralen tablets followed by exposure to Ultra Violet A light from a special UVA machine. Special spectacles have to be worn during treatment and for 24 hours thereafter in order to protect the eyes from Ultra Violet damage. With this treatment, it could take up to six months to a year for successful re-pigmentation to occur if treatment is administered once a week. Narrow band UVB has now overtaken PUVA as the preferred option for the treatment of vitiligo.

Surgical Treatments:

Surgical methods involve the removal of skin from the normally pigmented parts of the body and inserting it into areas of pigment loss. Several surgical methods are currently performed for the treatment of Vitiligo.

1. Suction blister grafting involves the creation of blisters on a donor site such as the thigh. The upper layer of skin (epidermis) is removed from the Vitiligo area being treated. The roof of the blister is then carefully removed and placed on the prepared Vitiligo area. Pigment cells from the graft begin moving into the Vitiligo area within a week. Re-pigmentation is usually complete within three months. The lips respond particularly well to suction blister grafting.

Suction blister grafting is performed routinely at the practice in Westville Hospital.

2. Punch grafting is another popular surgical technique. Tiny bits (1,5mm diameter) of full thickness skin are removed from a donor area such as the thighs, using a device called a biopsy punch. At the same time, equal sizes of holes are made in the recipient area, about 0,5cm apart. The puched out pieces of skin from the donor area are then transplanted into the recipient area. About 30 grafts can be easily inserted at one sitting. The process may be repeated to treat larger areas.

Punch grafting is offered at the practice at Westville Hospital.

3. Needling

A novel surgical method of repigmentation of vitiligo skin takes the form of needling. With this technique, the edges of the vitiligo patch are repeatedly needled using a 30 G needle. The area is first prepared with EMLA - a local anaesthetic which is applied on the skin. The treatment is perfomed weekly and combined with ultraviolet light either in the form of narrow band UVB or excimer laser/ excimer light. There may be pin point bleeding which stops in a few minutes.

To see a poster presented at the 23rd World Congress of Dermatology about how needling works in vitiligo, please click here.

4. Ultra-thin epidermal sheet grafts can be removed using an instrument called a dermatome. These sheets are transferred onto denuded Vitiligo areas.

5. Autologous cultured epidermal cell grafting is a technique where epidermis grown in the laboratory is grafted onto areas of pigment loss, after surgically removing the epidermis from the involved area. With this technique, pigment cells are grown from skin obtained from a punch biopsy specimen usually behind the ear. Although the technology is available is South Africa and the procedure has been performed in the country, cultured melanocyte grafting is not offered at the practice because of the cost.

6. Non-cultured melanocyte rich epidermal cell suspensions may be made up from epidermis removed from a donor area. These cells are grafted directly onto denuded epidermis in a Vitiligo area. The following steps are involved:

The above procedure is carried out at Westville Hospital by Dr N Raboobee and Dr M Raboobee. In commemoration of World Vitiligo Day, this procedure will be provided free of charge to two patients in July 2018.

Patients for this procedure must be clinically evaluated (physically examined). Suitability for this procedure cannot be determined by telephone or email. If you would like to be considered, please contact the secretary at 031 265 1505 or email skinspec@iafrica.com.

7. A novel method of non-cutured melanocyte transfer involves separation of pigment cells (melanocytes) from hair follicles. The hair follicles are extracted from the scalp using a 1mm punch and placed in trypsin to separate the melanocytes from the from the follicles. The suspension of melanocytes is applied to denuded areas of vitiligo. It takes a few months for repigmentation to be complete.

8. A recently described surgical treatment involved the creation of blisters on the thigh. Trypsin is injected into the blisters and left to incubate for 1 hour. The fluid is then removed and used as a cellular suspension for grafting onto vitiligo areas which is prepared by means of dermabrasion. The first surgical procedure of this nature in South Africa was performed by Dr N Raboobee and Dr M Raboobee at Westville Hospital.

9. Described at the Vitiligo International Symposium in Rome in December 2016, a cellular graft is prepared by taking a tissue sample and soaking it overnight in trypsin, to separate the pigment cells from the sample. The suspension so obtained is applied onto vitiligo skin which is then subjected to rolling with a derma roller - a device with multiple needles.

10. Jodhpur technique: An innovative modification to surgical treatment was described in Bangkok during the 2nd International Aesthetic and clinical Dermatology Conference. In this technique, the recipient area is prepared with a dermabrader as demonstrated above. The difference is at the donor area. Instead of taking a thin skin graft, a manual dermabrader is used to abrade the skin and collect all skin cells abraded in the process. The skin cells are prevented from flying off or being blown off by using an ointment fist of the donor site. The abraded skin cells mix with the ointment to form the donor cells. This mixture is then applied to the recipient site. No trypsin required. No incubator and centrifugation required. The technique is known as the Jodhpur technique and offers an additional method on non-cultured melanocyte grafting. This method has already been introduced in the practice.

Other treatments:

1. Bleaching: If Vitiligo is very extensive, it is not unreasonable to depigment (remove pigment) from remaining pigmented areas using 20% Monobenzyl ether of Hydroquinone, making the entire skin surface white in colour. One has to consider this form of therapy very carefully, as pigment removal is permanent.

2. Tattooing: Ferrous oxide tattooing is offered in some centres to cover up areas of Vitiligo. Colour mismatch is a potential problem with this method. If melanocyte grafting is to be considered in areas where tattooing has been performed, it is necessary to first remove the tattoo by means of a Q switched NdYAG laser.

New Advances in the treatment of vitiligo

The Janus Kinase inhibitors (JKIs) are a new class of medicines used in the treatment of some cancers. They have been found to block the pathway responsible for the development of vitiligo and may prove useful as a treatment modality. There are two members in this class - Tofocitanib (Xeljanz) and Ruxolitinib (Jakafi) - which are currently undergoing clinical trials to assess their efficacy. These drugs are not registered yet in any country for use in vitiligo.

For further information on JKIs, please click here

Further resources

The Vitiligo Society of South Africa

The Vitiligo Society of South Africa has been in existence since 2008 and functions under the umbrella of the Dermatological Society of South Africa. The aim of this society is to offer support to Vitiligo sufferers and increase understanding of the condition. Membership is free and is essential if you wish to receive notices of meetings and newsletters. The web address of the Vitiligo Society is www.vitiligosocietysa.com

The Vitiligo Society of South African hosts an active Facebook page which you are invited to LIKE and participate in .