Understanding Vitiligo

​Dr. Jeffrey Byers, Associated Professor of Clinical Dermatology at VUMC, discusses risk factors, signs and symptoms, treatment approaches, and prognosis of vitiligo.

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Shaina Farfel:  Welcome to this edition of the Vanderbilt Health and Wellness Wellcast.  I'm Shaina Farfel with Occupational Health.  Today, we are speaking with Dr. Jeffrey Byers, Associate Professor at Clinical Dermatology in the Department of Dermatology here at Vanderbilt Medical Center.  Hi, Dr. Byers.  Thank you for joining us today.

Dr. Jeffrey Byers:  Hi, Shaina.  My pleasure.

Shaina Farfel:  This Wellcast is the first part of a two-part series about a skin condition known as vitiligo.  Dr. Byers, can you tell us what vitiligo is and how prevalent it is in the population?

Dr. Jeffrey Byers:  Vitiligo is defined as depigmented patches of skin and depigmented is to be contrasted from hypopigmented.  Depigmented means that the skin has actually lost all of its pigment, so it's kind of a milky white, and this is due to the loss of functional pigment cells in the skin.  It is an acquired disorder, which means that it is not present at birth and it has its onset sometimes after birth in childhood or sometimes as late as late middle age or even old age.  As far as prevalence goes, worldwide, the estimate is somewhere between 0.5% to 2%, so, in America, it's pretty close to 1 in 100.  The average age of onset is around 20 years of age.

Shaina Farfel:  Are there any known causes or risk factors for vitiligo?

Dr. Jeffrey Byers:  There are probably both genetic and nongenetic factors involved in the onset of disease.  There are absolutely no proven outside causes or environmental triggers.  Interestingly, family studies have shown a 7% rate of vitiligo in first-degree relatives of vitiligo patients, which is higher than expected in the general population.  So, there are probably genetic factors.  But, on the other hand, there is only a 23% concordance rate in identical twins.  In other words, if one twin has it, there is only a 23% chance that the other twin has it.  So, there are probably also environmental triggers that are bringing on the disease in people who are susceptible.  There are several chromosomal susceptibility spots identified and many of these genes are associated with other pigmentary disorders and also other autoimmune or inflammatory disorders.  

Shaina Farfel:  And we touched on this already a little bit, but any additional signs and symptoms that people may need to know about for vitiligo?

Dr. Jeffrey Byers:  Well, again, with vitiligo, one sees the onset of these milky white patches of skin that can expand either slowly or rapidly in different people.  It is generally more noticeable the darker your skin is.  In other words, it is often very subtle in fair-skinned Caucasians.  It is much more obvious with skin of color.  If it is subtle, the use of a Wood's lamp or a special ultraviolet lamp may be useful in diagnosis.  Early on, the lesions may be partial or less noticeable, and typically, there are no symptoms associated with it, although occasionally there is slight itching.  The most common areas are on the face, around the eyes or mouth, the nipples, the underarms, the belly button, the genital and anal areas, the inguinal folds, elbows, knees, and shin and hands, but vitiligo can occur anywhere on the body.  There are other diseases that can cause skin lightening patches, certain fungal infections, certain fungal overgrowth situations.  Even eczema can cause pretty significant lightening of skin, but these patches are not usually the fully-depigmented, striking white of vitiligo.

Shaina Farfel:  How is this condition typically managed and treated in clinical practice?

Dr. Jeffrey Byers:  In our clinic, we often start with topical therapy.  Topical steroids and topical calcineurin inhibitors, which are other immune-modifying medications, are usually the first-line treatment of choice.  With these topicals, about half of patients achieve over 75% repigmentation of their depigmented skin; however, there is a relapse rate of about 40%.  Overall, about 10% to 20% of people are able to fully regain their skin color, and people who are young and people who have facial and neck involvement tend to do better.  It seems that the closer you get to the far areas, such as the hands and feet, the more difficult it becomes to treat, and the lips are also particularly refractory to treatment.  There are other treatments that have been used for vitiligo.  The most common for generalized vitiligo, where it involves a large body surface area, would be phototherapy with narrowband UVB.  Certain lasers can also help treat focal patches of vitiligo.  And, finally, occasionally, surgical minigrafting is done where normal skin is grafted into the areas of vitiligo.  That normal skin can sometimes then grow with the pigment cells and can repigment that area.

Shaina Farfel:  Just looking more kind-of long term, what is disease prognosis?  Can we prevent progression?

Dr. Jeffrey Byers:  Again, I wish I could say we could prevent progression.  Right now, we do not have that assurance.  The disease can be very, very progressive in some people and we don't have sure-fire prevention.  It's important to point out that we definitely have hope and we definitely have treatments, and in some people, again, I said 10% to 20%, can achieve basically what we would call a cure, which means complete repigmentation of their skin.  It's important to note that, again, there are a lot of cures available, but also the availability of psychological support is very important and also the availability of cosmetic camouflage products, Dermablend, Covermark, is very important.  I've seen people who were refractory to treatment with vitiligo but were able to do an excellent job of camouflaging the vitiligo using these cosmetic camouflage creams and they have been particularly happy about how that has turned out.

Shaina Farfel:  Well, thank you so much for sharing this valuable information with our listeners and I hope it brings some increased awareness to this chronic skin condition.  I appreciate your time.

Dr. Jeffrey Byers:  Thank you very much, Shaina.

Shaina Farfel:  Thanks for listening.  If you have a story suggestion, please email it to us at health.wellness@vanderbilt.edu or you can use the "Contact Us" page on our website at www.vumc.org/health-wellness.