Vitiligo

Vitiligo is a long-term condition in which patches of skin lose their colour and turn pale or milky white. Skin colour comes from a pigment called melanin, made by cells called melanocytes. In vitiligo those cells are destroyed or stop working, so the skin in that area has no colour.

It can begin at any age, and often starts before the age of twenty. It causes no pain and does no harm to the body. What it does affect, in India especially, is how people are treated, because white patches are still widely and wrongly linked with leprosy or with something the person did. None of that is true, and no one brings vitiligo on themselves.

The first sign is usually a pale patch of skin that slowly loses all its colour. Patches have a clear border, are often more obvious on brown and black skin, and may enlarge, stay the same for years, or occasionally regain some colour.

• Common sites: hands, fingers, wrists, feet, face, and around the mouth and eyes
• Skin folds such as the armpits and groin, and areas that have been injured or sunburnt
• Hair in a patch, or on the scalp, eyebrows or eyelashes, turning white or grey early
• Loss of colour inside the mouth or nose
• Patches that itch occasionally, but are usually not sore

In the commoner form, patches appear on both sides of the body in a roughly matching pattern. In a less common form, seen more often in children, patches affect one area or one side only and then usually stop spreading.

See a doctor in the next few days for new or spreading patches, for a pale patch where the skin feels numb, for patches that are scaly or raised, for red or painful eyes, or if the patches are affecting your mood, your work or your confidence.

In most cases vitiligo is an autoimmune condition: the immune system, which normally attacks germs, turns against the body's own pigment cells and destroys them. It often occurs alongside other autoimmune conditions, particularly thyroid disease, type 1 diabetes, pernicious anaemia and Addison's disease.

An inherited tendency plays a part, and vitiligo is commoner in people who have a relative with it or with another autoimmune condition. Something may then set it off, such as bad sunburn or another skin injury, contact with certain industrial chemicals, or a period of severe stress. In the one-sided form, chemicals released from nerve endings are thought to damage the pigment cells.

• A parent, brother or sister with vitiligo
• A family or personal history of autoimmune disease
• Thyroid disease, type 1 diabetes, pernicious anaemia or Addison's disease
• Severe sunburn, cuts or other injury to the skin
• Regular contact with certain industrial chemicals
• A period of intense emotional stress

Skin without pigment has no protection from the sun, so it burns quickly and needs covering or sunscreen. Vitiligo is also linked with inflammation inside the eye and with hearing changes, and thyroid disease is common enough that doctors often check for it.

The heaviest burden is usually social. Many people with vitiligo face staring, questions, difficulty at work and hurtful assumptions about marriage, and lose confidence as a result. That distress is real and it is common. It is worth telling a doctor about, and counselling and support groups help a great deal.

Vitiligo cannot be prevented, and nothing anyone eats or does brings it on. These steps protect the skin and may reduce new patches:

• Use a high-factor sunscreen on pale patches, and reapply it through the day
• Cover up with clothing and a hat in strong sun, and stay in the shade at midday
• Avoid sunburn, and treat cuts, burns and grazes carefully
• Do not use skin-bleaching or unprescribed fairness creams
• Wear gloves if work involves strong chemicals
• Keep up with thyroid and other checks the doctor suggests

A doctor examines the skin and asks about when the patches started, whether they are spreading, sunburn or injury at those sites, other illnesses and family history. Sensation in the patch is checked, because a numb patch points to a different diagnosis.

An ultraviolet lamp, called a Wood's lamp, may be shone on the skin in a darkened room, which makes vitiligo patches look chalky and bright and separates them from other causes of pale skin. Blood tests are often done to look for thyroid and other autoimmune disease, an eye check may be advised, and a small skin sample is occasionally taken.

There is no cure, and treatment cannot be promised to work. The aims are to slow the loss of colour, bring pigment back where possible, and protect and cover the skin. Results differ a great deal between people and between sites, and the face and neck usually respond better than the hands and feet.

Creams and ointments that damp down the immune reaction, including steroid preparations and non-steroid alternatives for delicate areas such as the eyelids, are the usual first step. Measured doses of ultraviolet light, given in a clinic over several months, are used for widespread patches, and a laser can be used for small ones.

For patches that have not changed for a long time, small grafts of pigmented skin or pigment cells can be moved from another area. Where very little normal colour is left, removing the remaining pigment to make the skin an even shade is occasionally offered. Skin camouflage, cosmetic cover and self-tanning products help many people, and sun protection is part of every plan. Support for mood and confidence is as much a part of treatment as anything applied to the skin.