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Vitiligo

The vitiligo is a skin condition characterized by the appearance of white spots on the feet, hands, face, lips, or any other body part. These spots are caused by a “depigmentation”, that is to say, the disappearance of melanocytes, the cells responsible for the color of the skin (pigmentation).

The depigmentation may be more or less important, and the white spots, of varying sizes. In some cases, the hairs or hair that grows inside the depigmented areas are also white. Vitiligo is neither contagious nor painful, but it can lead to significant psychological distress.

The Vitiligo is a disease whose symptoms are particularly bothersome aesthetically, the spots are not painful either directly hazardous to health. As a result, vitiligo is often “minimized” and is still inadequately cared for by doctors. However, this is a disease that has a very negative impact on the quality of life of those affected, as confirmed by a study conducted in 2009. People with dark skin suffer particularly.

Prevalence

The Vitiligo affects approximately 1% to 2% of the population. It usually appears around the age of 10 to 30 years (half of the people with it are before the age of 20). Vitiligo is therefore quite rare in children. It affects men as well as women, and occurs anywhere in the world, on all skin types.

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Types of vitiligo

There are several types of vitiligo:

  • The segmental vitiligo, located on one side of the body, for example on a part of the face, upper body, a leg or arm. This form of vitiligo appears more often in children or adolescents. The depigmented zone corresponds to a “territory of innervation”, that is to say, an area of skin innervated by a particular nerve. This form appears quickly in a few months, and then usually stops evolving;
  • The widespread vitiligo which is in the form of often more or less symmetrical spots, touching both sides of the body, particularly the loopers of friction or pressure. The term “generalized” does not necessarily mean that the spots are extensive. The evolution is unpredictable, the spots can remain small and localized or spread quickly;
  • The vitiligo Universalis, rarer, which spreads rapidly and can, affect almost the whole body.

Causes of vitiligo

The causes of vitiligo are not well known. However, it is known that the appearance of white spots is due to the destruction of melanocytes, the skin cells that produce melanin. Once the melanocytes are destroyed, the skin becomes totally white. Several hypotheses are now advanced to explain the destruction of melanocytes. Vitiligo is probably a disease that has genetic, environmental and autoimmune origins.

  • Autoimmune hypothesis

Vitiligo is a disease with a strong autoimmune component. In fact, people with vitiligo produce abnormal antibodies that attack melanocytes directly and help destroy them. In addition, vitiligo is often associated with other autoimmune diseases, such as thyroid disorders, suggesting that there are common mechanisms.

  • Genetic hypothesis

Vitiligo is also linked to genetic factors, which have not all been clearly identified. It is common for many people to have vitiligo in the same family. At least 10 genes are involved, as one study showed in 2010. These genes play a role in the immune response.

  • Accumulation of free radicals

According to several studies, the melanocytes of people with vitiligo accumulate many free radicals, which are forms of waste produced naturally by the body. This abnormal accumulation would result in “self-destruction” of melanocytes.

  • Nerve hypothesis

Segmental vitiligo results in a depigmentation of a delimited area, corresponding to the area innervated by a given nerve. For this reason, researchers thought that depigmentation may be related to the release of chemical compounds through the nerve ends, which would decrease the production of melanin.

  • Environmental factors

Although they are not the cause of vitiligo, strictly speaking, several triggering factors can contribute to the appearance of the spots.

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Melanocytes and melanin
Melanin (from Greek means black) is a dark pigment (of the skin) produced by melanocytes; she is responsible for the color of the skin. It is mainly genetics (but also exposure to the sun) that dictates the amount of melanin contained in the skin. Albinism is also a pigmentation disorder. Unlike vitiligo, it is present from birth and causes a generalized absence of melanin in the skin, hair, hair, and eyes.

 

Evolution and complications

Most often, the disease evolves at an unpredictable rate and can stop or spread without knowing why. The vitiligo can evolve in phases, the aggravations occurring sometimes after a psychological or physical triggering event. In rare cases, the plates disappear on their own.
Apart from aesthetic damage, vitiligo is not a serious disease. People with vitiligo, however, have an increased risk of having skin cancer because depigmented areas no longer block the sun’s rays. These people also have a higher probability of suffering from other autoimmune diseases. However, this is not the case for people with segmental vitiligo.

Symptoms of vitiligo

The vitiligo is characterized by white spots as chalk to the contours defined by a darker skin band.
The first spots appear most often on the hands, arms, feet, and face, but can occur anywhere on the body, including mucous membranes.

Their size can vary from a few millimeters to several centimeters. The spots are usually painless but may be itchy or burning when they appear.

People at risk for vitiligo

  • People with another autoimmune disease. Thus, many people with vitiligo have another concomitant autoimmune disease, such as alopecia areata, Addison’s disease, pernicious anemia, lupus or type 1 diabetes. In 30% of cases, vitiligo is associated with an autoimmune disorder of the thyroid gland, namely hypothyroidism or hyperthyroidism;
  • People who have a   family history of vitiligo (observed in about 30% of cases).

Risk factors

In people at risk, certain factors can trigger vitiligo:

  • Injuries, cuts, repeated rubbing, severe sunburn or contact with chemicals (phenols used in photography or in hair dye) may cause vitiligo stains at the affected area;
  • A great emotional shock or intense stress may be involved 22.

The prevention of vitiligo

Currently, there is no way to prevent vitiligo, the causes of which are unknown. However, it is important for people with the disease to protect themselves from the sun.

Preventing Skin Cancer
The bleached skin of people with vitiligo lost his protection against the sun, making it more conducive to burning by the sun and in the long term, to skin cancer. In addition, burns sometimes enlarge the areas of depigmentation. Therefore, it is essential for these people to protect themselves from the sun with a minimum SPF 30 sunscreen applied 30 minutes before exposure to the sun (check that the screen protects UVA and UVB rays). It is important to stay in the shade from noon to 4 pm, the sun being at its zenith.

Medical treatments of vitiligo

There is no cure for vitiligo. Current treatments, however, limit the size and number of depigmentation spots. In children, doctors rarely resort to vigorous treatment and most often favor protection from the sun and camouflage by clothing.

 

Camouflage by cosmetics.  The application of cosmetics on depigmented areas, such as specialized foundations (Dermacolor, ColorTration, and Kamaflage in Canada, Couvrance Unifiance, and Covermark in France) or self-tanning creams, makes the discoloration less visible. Skin, but without treating the disease. Similarly, self-tanning creams may be useful because they act even in the absence of melanocytes. Cosmetics are especially useful for people who have vitiligo spots around the eyes, where topical corticosteroids and UV rays are contraindicated.

Repigmentation treatments

The goal of these treatments is to stimulate the multiplication of melanocytes still present in the skin. Dermatologists would be able to get repigmentation in many cases, especially if they are treated early. Repigmentation can be done by two methods: phototherapy or topical (local) treatments.

Topical treatments may be prescribed to repigment small spots of vitiligo. These creams reduce the activity of the immune system (including the autoimmune reaction), which has the effect of curbing the destruction of melanocytes. They must be applied once a day for several months. They are unfortunately not effective in all cases.
Creams containing corticosteroids are often prescribed to be applied to newer spots. Be careful not to exceed the number of applications prescribed, as this may lead to thinning (atrophy) of the skin. These creams are sometimes prescribed to children, with increased supervision.
Of topical immunomodulatorsPimecrolimus (Elidel in Canada) and tacrolimus (Prograf in Canada, Protopic in France) cream can also be applied to stains. They do not seem effective on stains located on the neck and face.

Photochemotherapy using the PUVA method (combination of psoralen and UVA rays) involves combining the exposure of the skin with UVA rays to the intake (orally, topically or in the form of a bath) of a substance called psoralen. Psoralen, ingested 2 to 3 hours before phototherapy, makes the skin more sensitive to ultraviolet light. Oral psoralen is usually reserved for extended forms of vitiligo (more than 20% of the body surface affected). The treatment requires great attendance since it takes place in several sessions (from 100 to 300) at a rate of 1 to 3 times a week. It takes about 2 or 3 months (or 200 sessions) to get a visible effect. PUVA therapy is quite effective. It can cause itching, pain and a burn like a sunburn. In the long term, this treatment slightly increases the risk of skin cancer.
Contraindication. Photochemotherapy is contraindicated for children under 12 and pregnant or breastfeeding women.

Phototherapy with narrow-spectrum UVB radiation. It is a recent phototherapy method that does not require the taking or application of psoralen and is, therefore, simpler than PUVA photochemotherapy. It is based on exposure to ultraviolet B radiation that stimulates repigmentation of spots. It is mainly used for extended vitiligo and is especially effective on facial lesions. Up to 3 sessions a week can be given and there are fewer immediate side effects than with the PUVA method (less burning or pain). Doctors still lack the perspective to compare UVB phototherapy with PUVA therapy, but early clinical trials have been very encouraging. This technique can even be offered to some children with very troublesome forms of vitiligo.

Laser. The use of the laser (excimer type 308 nm) seems promising, but there are still few clinical trials.

Depigmentation treatments

The objective here is to permanently depigment the entire skin to obtain a uniform appearance. This therapeutic option is quite radical and is only considered when vitiligo covers most of the body (vitiligo universalis). “Bleaching” chemical solutions (eg Benoquin) are applied daily for over a year. However, half of the people treated would suffer from side effects (redness and dryness of the skin, burns, etc.), and once treatment is over, exposure to the sun should be avoided as much as possible since the skin becomes strong. Sensitive.

Surgical treatments

In some cases, especially when the hair and the hair themselves are depigmented, skin transplants may be proposed. These transplants are specially adapted to people with segmental vitiligo, that is to say, touching only part of the body and no longer evolving. It is autologous grafts that are to say that the grafts are taken from the patient himself, in areas of the body that are not reached by vitiligo. This makes it possible to avoid rejection of the transplant and the use of immunosuppressive drugs.
A new technique, melanocyte transplantation (or “melanocyte grafting”) is used to recover melanocytes from areas of healthy skin and inject them into depigmented spots. Still experimental, this treatment is not available everywhere.

 

Support group. Because it changes the appearance and often affects visible areas of the body, such as hands, face, and arms, vitiligo can cause discomfort and embarrassment to others. The aesthetic impairment can sometimes be the source of real psychological distress, which must not be minimized and must absolutely be taken care of. For those who feel the need to exchange about this, support groups can provide significant emotional support. A psychotherapy can also provide relief for some patients. Consult the Resources section.

 

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Updated: November 10, 2018 — 3:10 pm

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