I was diagnosed with the skin disease vitiligo, which makes parts of my skin white. It started with the hands, and now I have noticed it is spreading to my face. The dermatologist who examined me gave me a cream named Dermovate to put on in the morning and another one for night time called Elidel. But he said that only 60 percent of the affected skin would return to normal. I'm ashamed of the white patches. Can you recommend a better solution to my problem?
- M.A., via e-mail from the Philippines.
Dr. Julian Schamroth, a veteran Jerusalem dermatologist, replies:
Vitiligo is a condition in which skin loses its normal color and consequently appears pale or white. It affects about 1 to 2 percent of the population and is due to a failure of the pigment-producing cells (melanocytes) to produce melanin, the pigment that gives skin its color. In the vast majority of patients, the cause is unknown, but it may occasionally be associated with other autoimmune diseases such as thyroid disease, alopecia areata (balding), type I diabetes and some forms of anemia. The skin disorder usually first appears before the age of 20.
The lesions can occur anywhere on the body, and are often bilateral - if one hand is affected, the other is also likely to be. If it occurs on the scalp, the hair growing from the area affected by vitiligo will be white. It can occur on mucous membranes and on the genitalia. Vitiligo can also develop around an existing pigmented nevus (mole) and is then called a "halo nevus."
The white patches are not dangerous, and they do not affect one's health. However, because vitiliginous skin has no melanin pigment to protect against the sun, sunburn occurs rapidly. If chronic, such repeated sunburn will eventually lead to the development of pre-cancerous and even cancerous skin lesions within the vitiliginous skin. Patients with vitiligo should thus take effective measures to avoid sun exposure on affected areas of skin.
The main problem of vitiligo is the cosmetic disfigurement it causes. There are many treatments available, including several new, novel therapies.
These are just a few examples:
1) Topical cortisone therapy using potent cortisone creams (such as Dermovate) is often tried in the early stages of the disease. In extensive, rapidly-developing cases, oral cortisone may even be prescribed.
2) Ultraviolet light in the "A" wavelength (UV-A) or "B" wavelength (UV-B) is used for extensive lesions, often in conjunction with a light-sensitizing drug called Psoralen. Such treatment is known as PUVA therapy.
3) Topical irritant creams such as dithranol (Dithrocream) are sometimes used for small patches of vitiligo.
4) Recently, immunomodulator creams such as pimecrolimus (Elidel) have been used, either alone or in conjunction with UV therapy.
5) Autologous skin grafts, minigrafts and epidermal grafting can also be used for patients with small lesions. Epidermal grafting involves creating a blister on the vitiliginous skin as well as on normal skin; removing the "roof" of the blisters; and grafting the "roof" from the normal skin blister onto the "deroofed" vitiliginous skin.
6) Laser therapy may also be tried for limited areas.
7) In severe cases, in which there is more depigmented skin than pigmented skin, attempts may be made to depigment (or bleach) the normal pigmented skin to create a better cosmetic appearance. Spontaneous repigmentation can occur, but is uncommon.
It is important that patients with vitiligo see a dermatologist to exclude possible underlying causes, to obtain advice about sun protection to discuss the range of treatment modalities. Many countries have support groups for such patients, and there is also an Internet support group at www.vitiligosupport.org.
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