Dr. Devraj Dogra , Dr.Mubashar Mir
Vitiligo although being a benign disease which is not life threatening or communicable has a huge psychosocial impact. It is said that a patch of vitiligo etches bigger on mind than it appears on the skin implying the potential effect on body image, confidence and self-esteem of the patient. Another problem with vitiligo is that it is often confused with other contagious diseases like leprosy which adds to the social stigma associated with vitiligo, which however is nothing more than a myth. In India, vitiligo holds even more relevance due to the relatively darker skin tone of Indian population as compared to the white race which makes the white lesions of vitiligo even more apparent against a darker background.
* Destruction of melanocytes is central to the pathogenesis of vitiligo. Exact cause remains unknown, however various hypothesis have been put forth to explain this mechanism which include autoimmune destruction of melanocytes. Auto-immune hypothesis is the most widely accepted theory.
* Others theories include the neuro-humoral, auto-cytotoxic, oxidative stress and intrinsic defects in the melanocytes.
* Convergence theory: According to this theory all these factors may together contribute to the pathogenesis of Vitiligo.
* Clinical features:
Vitiligo typically presents as bright or milky-white, sharply demarcated patches of complete loss of skin colour which can be few in number or numerous mainly distributed over on sun-exposed sites and trauma prone sites, such as the hands, feet, arms, face elbows, knees etc. Also, over the face these patches are localized more so around the mouth, eyes and nose. Sometime the hair overlying these patches may be depigmented too, a phenomenon known as leukotrichia. Occasionally, lesions of vitiligo may have a raised red border known as inflammatory Vitiligo or may present as multichrome Vitiligo where zones of hypopigmentation surround the depigmented macule.
It may also present as white patches in the mucosal tissue that line the inside of your mouth and nose. It affects both the sexes equally but girls usually develop the disease early. Depending on the type of vitiligo the patches may be seen in different arrangements and configurations.
* Patches may be diffusely present and bilaterally symmetrical. This is the most common type, called generalized vitiligo.
* In segmental vitiligo, patches involve particular segment of body area unilaterally. This type tends to occur at a younger age, usually progresses for a year or two and then stops.
* In focal vitiligo, the white patches cover only a few areas focally.
* In Universal Vitiligo, the whole body or almost whole body is left depigmented with only occasional areas of normally pigmented skin left.
It’s difficult to predict how your disease will progress. The forms of vitiligo other than segmental type usually follow a protracted and an unpredictable course. Segmental vitiligo however commonly shows an early onset and rapid progression for some time followed by cessation of further progression of the patches.
Vitiligo can sometimes be associated with autoimmune diseases like thyroid disorders, pernicious anemia, type one diabetes and alopecia areata.
Because of the stigma associated with this less talked about disease there are a number of misconceptions associated and questions which need to be answered and understood clearly.
Current treatment modalities are directed towards stopping progression of the disease, and achieving regimentation and to improve the quality of life of patients
Treatment in vitiligo depends on type of vitiligo, distribution, extent of involvement, disease activity (stability / progression), psychosocial, economic status & concern of patients towards disease.
Treatment approach needs to be individualised. Combination of more than one modality is commonly used to hasten response and prevent side-effects
Medical management forms the front-line treatment with the use of drugs to control the activity of the disease and induce repigmentation. Photochemotherapy forms the backbone of medical management. Surgical and laser assisted techniques aim at re-pigmentation by grafting methods in cases of stable vitiligo and to remove the residual pigment in cases of extensive vitiligo.
Interesting work is being done in the field of targeted gene and stem cell therapy which holds promise in the future management of vitiligo. The concept of inducing resident and perilesional melanocytes and preventing using growth factors holds promise.
For the patients who still fail to achieve satisfactory results with the available options, they must not lose hope and not let the skin patch scar their mind. With this there is need of change in the public perception regarding vitiligo and its sufferers and the superstitions and stigmas associated with it needs to be shunned.
(The authors are Professor & Head Department of Dermatology, GMC Jammu and MD resident Dermatology GMC Jammu)
Dr. Devraj Dogra , Dr.Mubashar Mir