|
●
Vitiligo
Introduction
back
to top
Vitiligo is a disease in which the cells that produce the pigment on the
skin (melanin) are destroyed. White spots can appear on any part, though
the most frequent are:
Face, neck, eyelids, nose, nipples, navel and genitalia.
Folds such as armpits and groins.
Areas that have suffered traumatisms, such as cuts, rubbing or burns.
Around pigmented moles.
Hair, appearing in the form of white hair on the scalp or beard.
Retina.
Psychological problems appear frequently because of the antiesthetic
lesions that make social relationships difficult.
●
Who suffer
Vitiligo?
back
to top
Vitiligo affects
about 1% of the population. Half of them have some lost of pigment
before they are 20 years old. A fifth part of them have a relative with
this same disease. Vitiligo is a benign disease and in most of the cases
is only an aesthetic problem. Nevertheless, a minority is at greater
risk of suffering the following diseases:
Thyroid gland diseases.
Pernicious anemia (lack of vitamin B12).
Addison disease (adrenal gland insufficiency).
Alopecia areata (patchy hair fall).
It is advisable a blood test that includes a haemogram, biochemistry and
a study of the thyroid hormones level (T3, T4, TSH), in order to discard
a possible association with alterations of the thyroid, pernicious
anemia and diabetes mellitus.
●
What determines the colour of the skin?
back
to top
The melanin is the substance that determines the colour of the skin,
hair and eyes. It is a pigment produced in the skin by some cells called
melanocytes. If melanocytes do not produce melanin or they are reduced,
the skin turns white.
Causes
The cause is unknown.
Sometimes, white spots appear after suffering emotional stress or a
physical trauma, such as sunburn. There are 3 theories about vitiligo.
According to the first one, an autocytotoxic process destroys the
melanocytes. The second mechanism is immunologic. The third one suggests
the implication of a neural factor.
1. Self-destruction. Intermediary metabolites are formed in the normal
biological process of melanogenesis, some of which are accumulated in
sufficient quantity and can be toxic for themelanocyte. This theory
suggests that melanocytes are destroyed because of the accumulation of
these toxic precursors of the melanin (improper elimination of the
metabolites or an excessive production of them).
2. Autoimmune Theory. Melanocytes are destroyed by an immune mechanism.
This is supported by the known clinic association of vitiligo with
various autoinmune processes, as well as in the detection of antibodies
against melanocytes and specific organ antibodies (antithyroid,
antiparietal cells, etc.). There are discrepancies in considering to
this autoinmune mechanism the first cause of the disease or as secondary
reaction to some aggression to the melanocytes, that implicates the
release of antigens with the subsequent antibodies development. Also
there is evidence implying the possibility of a cellular immune
mechanism in the pathogenesis.
3. Neural Theory. Neurochemical factors released in the peripheral
nervous ending would be responsible for the destruction of the
melanocytes.
●
What is the development of Vitiligo
?
back
to top
The beginning of vitiligo and its severity concerning the loss of
pigment depends on each person. White people note the loss in summer. A
contrast between the skin with vitiligo and the skin tanned is noted.
People with Mediterranean skin can observe the beginning of vitiligo at
any season. In serious cases, the pigment is lost on almost the whole
body. It's impossible to know how much pigment is going to be lost. Some
diseases and stress conditions produce a greater loss. Vitiligo begins
often with a rapid loss of pigment, which is followed by a slower period
in which the skin does not change. But later, the loss of pigment starts
again, normally when the patient suffers a physical or psychic trauma
(sunburn, anxiety). The loss of color can continue until, by unknown
reasons, the process stops. These cycles, followed by stability periods
can continue for years. It is uncommon that a patient with vitiligo is
repigmented spontaneously. Many patients who say that no longer have
vitiligo is because they have been depigmented thoroughly, that is to
say, they have been turned white. These patients seem cured, but they
are not. Vitiligo can also assume other clinical forms not often found
in the daily practice.
Complete or universal vitiligo: depigmentation affects to the whole body
surface, though normally small skin pigmented areas are left.
Segmental vitiligo: the depigmented area has a dermatomal incidence.
Eye vitiligo: in some cases pigmented changes may be detected on the
iris and/or retina tending to be symptom less.
Halo nevus: many patients with vitiligo have or have had a mole with a
white halo. Sometimes a physical examination can verified it, there is a
depigmented peripheral ring within a pigmented mole, and normally this
is followed by the mole disappearance.
●
What are the treatments for Vitiligo ?
back
to top
Vitiligo has had, until very recently, a reputation of being incurable.
In the last years the treatment has improved considerably, fundamentally
because UVA cabins have been developed, and also because new substances
to promote pigmentation have been identified. In spite of all, the
treatment continues being difficult and long. It must be understood
clearly that results are not seen in the short term, but in the long
one. There are 3 types of treatments:
- Restoring pigment or repigmentation with ultraviolet radiation A.
- Treatment with medicines promoting repigmentation.
- Depigmentation.
Repigmentation with UVA (PUVA)
The patient takes a medicine called
psoralen and 3 hours later the skin is exposed to ultraviolet radiation
A. This treatment is called PUVA (Psoralen + UVA). The treatment may be
performed with natural light in spring and summer. Anyway, it's better
using artificial UVA cabins because they have a constant intensity and
more energy than the sunlight, and also because they permit the
treatment throughout all year. In both cases, psoralens are activated by
the ultraviolet light and increase the availability of pigment to
produce cells, stimulating thus repigmentation.
Psoralens used for the treatment
include trimetilpsoralen and oxsoralen. The dosage is prescribed
according to weigh, and the patient has to take the capsules 2 hours
before the skin is exposed to a computerized source of high-intensity
UVA rays or to the sunlight. From 12 to 4 p.m. are the hours advised for
exposure to natural sunlight. Treatments should be followed 3-4 times a
week. The ordinary solar lamps, as well as the UVA cosmetic used by
aesthetician salons, do not work for this treatment because they do not
have the ideal wavelength or the sufficient intensity for the
interaction between the medicine and the radiation. People receiving
treatment with PUVA should use eyewear during sun or UVAR exposure, and
also during the rest of that day.
●
Who are good
candidates for repigmentation?
back
to top
All the patients are not good candidates. The ideal person for this
treatment must have the following requirements:
- Loss of pigment less than 5 years. It is possible to treat a vitiligo
appeared more than 5 years ago, but results are not so good.
- Patients should be at least 10 years old. Younger children can follow
this treatment, but it is long and better results are achieved when the
child is interested in the treatment. The process is long and requires
much patience. Furthermore, younger children still have not completed
the development of the crystalline, and therefore there is an increased
cataracts risk for oral psoralens. In these cases, treatment will have
to be topical or with drugs that do not produce phototoxic eye damage.
- Normally, children and young adults have better response than older
persons do. Patients should be healthy. Pregnant woman should not be
treated because treatment is dangerous for the fetus.
- The patient must have time to follow the treatment 3 times a week from
2 to 5 years. 85% of patients treated with PUVA will respond the
treatment in greater or minor degree, and just in a few cases total
repigmentation will be achieved. We have to indicate that, after the
first 3 treatment weeks, patients can present a worse aesthetic
appearance. This is due to the contrast produced between the tanned
normal skin and the white areas with vitiligo. Soon after, small round
brownish spots begin to appear and tend to confluent, covering the white
areas. In some cases psoralen lotions may be applied on the spots, and 2
hours later the skin is exposed to the sunlight. This treatment turns
the skin very sensitive to the sun, and also very susceptible to develop
sunburns if sun exposure is excessive.
- It is accepted, as a rule, that for a vitiligo affecting less than 20%
of the skin surface, the treatment must be topical. In cases affecting
50% of the surface or more, only the visible zones must be treated.
Depigmenting the skin or therapeutic abstention are other choices.
- Segmental and acrofacial vitiligo respond poorly to the treatment, as
well as vitiligo on areas such as palms and soles, folds, wrists,
ankles, feet and eyelids.
- It is possible that associating several of the oral treatment
modalities and/or topical agents, the response could be better in
percentage and/ or rapidity of repigmentation.
●
Pigmentation
Treatments
back to top
Steroid creams (clobetasol). They have been shown very helpful as a base
treatment on certain locations. The cream will have to be applied in
alternating days twice a day on the white spots. On the following day an
alphahydroxyacid body milk is applied on the areas where the steroid
cream was applied the previous day. This body milk will prevent the
steroid-induced damage in the long term. L-Phenylalanine (Fenalderm
Capsules). It's an essential amino acid, precursor of melanin, the
pigment of the skin. It favors tanning, stimulates skin repigmentation
and stops the production of antibodies against the melanocyte, the cell
producing the pigment. It can be taken with or without sun exposure.
Often it is advised to take it 30 minutes before sun or UVA exposure (Pauva).
Treatment must be followed for years and there are no contraindications
(natural product for the body).
Vitamins.
Vitamins A, C, B12 and others favor
the skin repigmentation, therefore they should be taken intermittently
in capsules or injections.
Melagenine. It is a lipoprotein extracted from the human placenta and it
is marketed in Cuba. It has acquired a great diffusion for the vitiligo
treatment in the last years. The high incidence of cases of
repigmentation that was communicated initially in that country has not
been demonstrated thereinafter. There are serious doubts on the quality
and atoxicity in its manufacturing process. We recommend staying out of
this treatment.
Skin Grafts. They can be employed on areas that do not repigment after
previous treatments, or initially on areas known to be difficult for
repigmentation, as well as in cases of segmental vitiligo. However, it's
important to think previously about the risk of Koebner phenomenon on
the donor zones, and the possibility of non-aesthetic defects on the
receptor areas.
●
What are the new treatments
for vitiligo ?
back
to top
Pseudocatalase, calcium cohloride and exposure to UVB light. It is a new
treatment that requires confirmation. In vitiligo there is an alteration
in the biosynthesis of catecholamines. The investigation related to the
regulation mechanism of such biosynthesis, has led to discover the role
of a cofactor, which intervenes in the regulation of the tyrosine
synthesis and in the principal products of its double metabolic route,
the melanin and the catecholamines. The treatment refunds the activity
of the catalase in order to provide to all the epidermis the necessary
enzyme to demote the excess of H202, and, on the other hand, in the
calcium contribution to restore the altered calcium homeostasis.
The treatment consists of the application, twice a day on the whole body
surface, of a product containing pseudocatalase and CaCI2. The
pseudocatalase is a complex of low molecular weight capable of producing
more 02 and H202 than the own catalase, and it possesses an excellent
breakthrough capacity in the cornea layer due to its anionic properties.
The treatment is completed with the exposure to UVB radiation (at
suberythemal doses) one-hour after the application of the cream, twice a
week. The beginning of repigmentation after 21 months was observed in
most cases, with excellent response on face, back of the hands and areas
with focal vitiligo in more than 90% of the patients.
Repigmentation was not observed on fingers neither on feet. The response
to the treatment was from good to moderate in vulgar vitiligo, being
stopped the activity of the disease in all the patients.
It is possible also to increase the activity of tyrosinase with the
depletion intracelular of glutathion or other endogenous compounds with
the thiol group, which stimulates the eumelanogenesis. Furthermore, the
melanogenesis can also be stimulated by the topical application of
dypirimidinic products (dypirimidin dytimidilic acid), which are
originated from the ultraviolet irradiation exposure and from the
consequent damage in the DNA.
The functional stimulus of melanocytes by these and other possible
mechanisms (hormones, eicosanoids or cytokines), probably could be
combined with standard immunomodulation treatments, such as the steroid
minipulses or a potent topical steroid therapy. In the future we will
see the optimization of combined and cyclical treatments for vitiligo,
hoping to obtain better results than nowadays.
See vitises program
Depigmenting Treatment
If vitiligo has affected 50%
of the exposed areas, it is not advisable to repigment the patient. It
is easier to whiten (depigment) the areas that are still colored. This
is made with creams containing Hydroquinone Monobenzyl Ether. Most of
the patients following this bleaching treatment are very satisfied with
the result. However, these patients will always have to protect their
skin from the sun radiation using adequate clothes and sunscreens with
protection factor superior to 15.
Cosmetics
Some patients with vitiligo
spots require to conceal or to camouflage certain white areas while they
are following the treatment. This can be made with special cosmetics to
achieve such effect. There is also a micropigmentation technique
(permanent makeup) that can be useful in some cases. |
medi-spa
treatment
available to go with this home care ask your local spa about 
SeSDERMA