Vitiligo: Signs and symptoms

Vitiligo causes loss of color. Your dermatologist may call this “loss of pigment” or “depigmentation.” We can lose pigment anywhere on our bodies, including our:

Skin.
Hair (scalp, eyebrow, eyelash, beard).
Inside the mouth.
Genitals.

Most people who get vitiligo lose color on their skin. The affected skin can lighten or turn completely white. Many people do not have any other signs or symptoms. They feel healthy.
A few people say that the skin affected by vitiligo itches or feels painful.

Vitiligo. It is common to have vitiligo on the hands.

Vitiligo can progress. With time, some people see their vitiligo cover a large area.

Vitiligo can affect hair. The white hair near this 22-year-old man's part is due to vitiligo.

Living with vitiligo can cause other symptoms such as low self-esteem and depression that is hard to beat. This can happen regardless of the amount of color loss or type of vitiligo.

Vitiligo has types and subtypes

If you are diagnosed with vitiligo, your dermatologist may tell you what type and subtype you have.
Types: Today, most doctors recognize two types:

Type	Traits
Segmental vitiligo Also called: Unilateral vitiligo	Appears on 1 segment of the body, such as a leg, face or arm. About half of people lose some hair color, such as on the head, an eyelash or an eyebrow. Often begins at an early age. Often progresses for a year or so then stops.
Non-segmental vitiligo Also called: Bilateral vitiligo Vitiligo vulgaris Generalized vitiligo	Most common type. Appears on both sides of the body, such as both hands or both knees. Often begins on hands, fingertips, wrists, around the eyes or mouth, or on the feet. Often begins with rapid loss of skin color, which then stops for a while. Color loss often starts up later. This start-and-stop cycle usually continues throughout a person's lifetime. Color loss tends to expand, growing more noticeable and covering a larger area.

Types of vitiligo. The child on the left has the most common type, non-segmental vitiligo. The child on the right has segmental vitiligo.

Images used with permission of Journal of the American Academy of Dermatology. (J Am Acad Dermatol 2010; 62:945-9)

Subtypes: The subtype tells you how much vitiligo appears on the body. The vitiligo subtypes are:

Localized: One or a few spots or patches appear, but these are limited to one or a few areas of the body.
Generalized: Most people develop this subtype, which causes scattered patches on the body.
Universal: Most pigment is gone. This is rare.

There is no way to predict how much color a person will lose. Color loss can remain unchanged for years. Some people see patches enlarge and new patches appear. On a rare occasion, the skin regains its lost color.

Learn more about vitiligo:

Images 1, 2, and 3 used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.

Image 4 used with permission of Journal of the American Academy of Dermatology. (J Am Acad Dermatol 2010; 62:945-9)

References:

Halder RM, Taliaferro SJ. “Vitiligo.” In: Wolff K, Goldsmith LA, Katz SI, et al. editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. United States of America, McGraw Hill Medical; 2008. p.616-21.

Mazereeuw-Hautier J, Bezio S, Mahe E et al. “Segmental and nonsegmental childhood vitiligo has distinct clinical characteristics: a prospective observational study.” J Am Acad Dermatol; 62: 945-9.

Ortonne JP, “Vitiligo and Other Disorders of Hypopigmentation.” In: Bolognia JL, Jorizzo JL, Rapini RP, et al. editors. Dermatology, 2nd ed. Spain, Mosby Elsevier; 2008. p. 913-20.

Vitiligo: Signs and symptoms AAD

Vitiligo: Diagnosis, treatment and outcome

How do dermatologists diagnose vitiligo?

If your dermatologist suspects that you have vitiligo, your dermatologist will:

Review your medical history, and may ask specific questions such as whether anyone in your family has vitiligo.
Perform a physical exam, looking carefully at the affected skin.

You also may need a blood test to check the health of your thyroid gland. People who have vitiligo often have an autoimmune thyroid disease. A blood test will tell whether your thyroid is healthy. If you have thyroid disease, treatment can successfully control it.

How do dermatologists treat vitiligo?

If you have vitiligo, you should discuss treatment options with your dermatologist. There are many treatment options. The goal of most treatments is to restore lost skin color.
Vitiligo cannot be cured, but many treatments help to restore lost skin color. Here are some key facts about treatment options to help you start a conversation with your dermatologist. The type of treatment that is best for you will depend on your preference, overall health, age and where the vitiligo appears on your body. Some people choose not to treat vitiligo.

1. No medical treatment (use cosmetics to add lost color):

Cosmetic options include makeup, a self-tanner and skin dye.
Offers safe way to make vitiligo less noticeable.
Often recommended for children because it avoids possible side effects from medicine.
Drawbacks: Must be repeatedly applied, can be time-consuming, takes practice to get natural-looking result.

2. Medicine applied to the skin:

Several different topical (applied to the skin) medicines can repigment the skin.
Prescribed for small areas.
The most commonly prescribed medicine is a potent or super-potent topical corticosteroid. About half, 45 percent, of patients regain at least some skin color after 4 to 6 months.
A topical corticosteroid may be combined with another medicine to improve results.
Topical medicine works best in people with darkly pigmented skin.
Topical medicines are most effective on certain areas of the body, such as the face. They are least effective on the hands and feet.
Not all topical medicines should be used on the face.
Drawbacks: These medicines have possible side effects, so patients must be carefully monitored. A possible serious side effect of using of a topical corticosteroid for a year or longer is skin atrophy. This means the skin becomes paper thin, very dry and fragile.

3. Light treatment:

Uses light to repigment the skin.
Patient may sit in a light box or receive excimer laser treatments.
Light box used to treat widespread vitiligo; laser used to treat small area.
Works best on the face; least effective on hands and feet.
Effective for many patients; about 70 percent see results with excimer laser.
Results can disappear. About half, 44 percent, see results disappear within 1 year of stopping treatment. After 4 years, about 86 percent lose some color restored by treatment.
May cause patients with darkly pigmented skin to see areas of darker skin after treatment, but treated skin usually matches untreated skin within a few months.
Requires a time commitment. Patients need 2 to 3 treatments per week for several weeks.
May be combined with another treatment such as topical corticosteroid.

4. PUVA light therapy:

Uses UVA light and a medicine called psoralen to restore skin color.
Psoralen may be applied to the skin or taken as a pill.
Can treat widespread vitiligo.
About 50 percent to 75 percent effective in restoring pigment to the face, trunk, upper arms and upper legs.
Not very effective for the hands or feet.
Time-consuming, requiring treatment at a hospital or PUVA center twice a week for about 1 year.
Psoralen can affect the eyes, so this treatment requires eye exams before starting treatment and after finishing treatment.
To help prevent serious side effects, patients need to be carefully monitored.

5. Surgery:

May be an option when light therapy and medicines applied to the skin do not work.
For adults whose vitiligo has been stable (not changed) for at least 6 months.
Not for children.
Not for people who scar easily or develop keloids (scars that rise above the skin).
Different surgical procedures available. Most involve removing unaffected skin or skin cells and placing where need pigment.
Can be effective for 90 percent to 95 percent of patients.
Possible side effects include failure to work, cobblestone-like skin and infection.

6. Unconventional treatment:

Some vitamins, minerals, amino acids and enzymes have been reported to restore skin color in people who have vitiligo.
Most have not been studied, so there is no evidence to support these treatments and no knowledge of possible side effects.
Ginkgo biloba, an herb, has been studied in a clinical trial. Results from this trial indicate that the herb may restore skin color and stop vitiligo from worsening.
In the ginkgo biloba trial, 10 patients given ginkgo biloba had noticeable or complete return of skin color. Two patients taking the placebo (contains no active ingredient) also had noticeable or complete return of skin color.
Because some patients taking the placebo regained their skin color, more study is needed.

If you have treatment to restore lost skin color, it’s possible that the color will return slowly or incompletely. Sometimes, a treatment does not work.

7. Depigmentation:

This treatment removes the remaining pigment from the skin.
Very few patients opt for this treatment.
Removing the rest of the pigment leaves a person with completely white skin.
It may be an option for an adult who has little pigment left and other treatment has not worked. Removing the remaining pigment can be an effective way to get one skin color.
To remove the remaining color requires you to apply a cream once or twice day. This cream gradually removes color from the skin.
Depigmentation can take 1 to 4 years.
Once treatment is finished, some people see spots of pigment on their skin from being out in the sun. To get rid of these spots, you can use the cream that removed your remaining skin color.

Outcome

It is not possible to predict how a patient will respond to treatment. It is important to keep in mind that no one treatment works for everyone. Results can vary from one part of the body to another. Combining two or more treatments often gives the best results.

Treatment Q&A

Q: Can a child with vitiligo be treated?

A: Yes, but some treatments are not appropriate for children. The following may be an option for a child:

Medicine applied to the skin.
PUVA that uses psoralen applied to the skin. PUVA therapy that uses the psoralen pill is usually not recommended until after 12 years of age. Even then, the risk and benefits of this treatment must be carefully weighed.
For children with extensive vitiligo, a dermatologist may recommend narrowband UVB light treatments.

Q: Are researchers looking for more effective treatment?

Yes. They are studying the genes involved in vitiligo. Researchers believe that by identifying all of the genes involved in vitiligo, they will learn what destroys the cells that give skin its color. With this knowledge, it should be possible to develop better treatments. One of the key goals of this research is to develop a treatment that will permanently stop the skin from losing color.

Learn more about vitiligo:

References

Gawkrodger DJ, Ormerod AD, Shaw L et al. “Guideline for the diagnosis and management of vitiligo.” Br J Dermatol 2008; 159: 1051-76.
Grimes PE, “Vitiligo.” In: Kelly AP and Taylor SC, editors. Dermatology for Skin of Color, China, McGraw-Hill; 2009. p. 317-23.
Halder RM, Taliaferro SJ. “Vitiligo.” In: Wolff K, Goldsmith LA, Katz SI, et al. editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. United States of America, McGraw Hill Medical; 2008. p.616-21.
Linthorst Homan MW, Spuls PI, de Korte J et al. “The burden of vitiligo: patient characteristics associated with quality of life.” J Am Acad Dermatol 2009; 61: 411-20.
Nicolaidou E, Antoniou C, Stratigos A et al. “Narrowband ultraviolet B phototherapy and 308-nm excimer laser in the treatment of vitiligo: a review.” J Am Acad Dermatol 2009; 60: 470-7.
Ortonne JP, “Vitiligo and Other Disorders of Hypopigmentation.” In: Bolognia JL, Jorizzo JL, Rapini RP, et al. editors. Dermatology, 2nd ed. Spain, Mosby Elsevier; 2008. p. 913-20.
Whitton ME, Ashcroft DM, Gonzalez U. “Therapeutic interventions for vitiligo.” J Am Acad Dermatol 2008; 59: 713-7.