vitiligo - Patients ask, Dr. Ringpfeil answers
Please feel free to use the blog below to share information about vitiligo or to ask Dr. Franziska Ringpfeil a question that might be of interest to others.
Philadelphia and Mainline Center of Dermatology and Cosmetic Surgery
Vitiligo
Vitiligo is a disease manifested by loss of pigment in the skin. It is an acquired disorder that often runs in families. It is characterized by depigmentation or total lack of melanin pigment. It can occur in small localized areas or be widespread. Fifty percent of individuals develop the disease before the age of 20 and 25% develop the disease before the age of 10. The cause is unknown but is believed to autoimmune in nature. It is more commonly seen in individuals with endocrine disorders such as thyroid disease.
DIAGNOSIS
The diagnosis can be made clinically in the presence of well demarcated areas of depigmentation found symmetrically over boney prominences such as the knees or around body orifices such as the mouth, eyes and perianal or periurethral area. When the diagnosis is unclear, a skin biopsy may need to be done.
MANAGEMENT
Patients with vitiligo must be advised to follow strict sun protection. The areas of skin affected by vitiligo cannot tan and will burn with sun exposure. Sunburns raise the risk of skin cancer. Also, when normal surrounding skin is tan the loss of pigment is more noticeable. Also, since vitiligo can be associated with endocrine disorders such as thyroid disease, blood tests to rule out an underlying disorder may need to be performed.
TREATMENT AND MEDICATION
Treatment options are influenced by the amount of skin involved and the location. Often a trial of treatment with a topical corticosteroid is the initial treatment choice. Topical immunomodulators such as Protopic Ointment or Elidel Cream have also been shown to be effective and are more appropriate for extended use on delicate areas. A series of narrowband ultraviolet light treatments (NB-UVB) have also been found to be very effective. The excimer laser delivers NB-UVB directly to specific skin areas without affecting normal surrounding skin. Ringpfeil Advanced Dermatology has an excimer laser and is proud to be able to offer excimer laser treatment to our patients. Excimer has come to be preferred over older light treatment modalities such as PUVA (psoralens plus ultraviolet A). The advantage of excimer over PUVA is shorter treatment times, decreased risk of phototoxic reactions, and the ability to use excimer in children, pregnant women and in individuals with kidney or liver disease since no oral medication is utilized. In cases where depigmentation due to vitiligo is very extensive, permanently removing all remaining pigment can be offered for cosmetic reasons.
COPING
For individuals who are self-conscious about vitiligo involving visible areas such as the face and hands, cosmetic products under the brand names of Covermark or Dermablend are available for camouflage. The National Vitiligo Foundation is an organization that can be a resource for educational materials and support groups.
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Do you use UVB therapy for vitiligo as well as the XTRAC laser? what other forms of treatment do you use?
Some forms of vitiligo respond to light treatment. Currently, narrowband UVB treatment appears to be the light treatment that is most efficacious and has the best safety profile. IF many areas of the skin are involved narrowband UVB is delivered in a UVB treatment box. If the area is small or the scalp is affected, an excimer laser is used instead to deliver the narrowband UVB ray. Other treatments include devices in the visible light range as well as topical medications. The type of treatment depends on the type of vitiligo, the body area affected as well as the extent of the body area affected.
We do excimer laser treatments.
I have diabetes and hypothyroidism, I am 46 and developed vitiligo back in 2003 in my genital area which didnt bother me but within the last 4 years, it showed up on my hands and has got worse. This year, it showed up on my face which in approximately 1/4 inch in diameter and 1 1/2 long. I tried Protopic and fluocinonide but neither worked. Even though my hands look bad, they aren’t as big of a deal as my face is but my funds are limited. I attempted to change diet, increase b vitamins and nothing has changed it with the fear of it getting worse. With being fairly young still, I would like to find the best possible way.
I know that every patient is different and being half Italian, my olive complexion gets darker in the summer making it much more noticeable, What are some of the best ways that you would try to correct this issue? Is the potential restoration of pigment at a higher level by newly seen spots as opposed to spots over a longer time frame? Which method have you’ve seen with the best results in restoring pigment?
Indeed, everyone is different and there are different ways vitiligo can present. The younger pigment deprived patches sometimes repigment easier.
Calcineurin inhibitors such as Protopic and narrowband UVB (including excimer laser) are the most successful treatments and are available here in the US. Surgical options may be considered but results are not always even and there is a chance of side effects such as unwanted hyperpigmentation or scarring. You may want to consider narrow band UVB treatments as your next step.
Here is another question that I have on Vitiligo:
If white patches are evident on a vitiligo patients skin but the hair that grows in that same region are still dark and obviously still has pigment in the follicle core, then how can you get the pigment from those hair follicles to reproduce new pigment in that skin region? It seems odd that if the melanin is destroyed in the skin, then why wouldn’t the melanin in the follicles also be destroyed?
It is possible that in the early stages of vitiligo, the immense density of melanin in the hair follicle is incompletely destroyed by the immune response of our body. In fact, the residual and much more dense melanin in hair follicles is believed to be the source for repigmentation as repigmentation occurs first around the opening of hair follicles. When vitiligo is longer standing, even the pigment in the hair follicles gets destroyed, which is most noticeable in scalp, beard or other terminal hair.
Is it possible for hair that has turned white fom vitiligo to turn back to black?
Also, I am currently undergoing eximer laser treatments, and the skin looks pink but isn’t freckling. Does this mean the treatment isn’t working?
Hair that has turned white from vitiligo can repigment when vitiligo resolves. Excimer treatments first cause pinkishness in treated areas before repigmentation occurs. If nothing is visible after 20 treatments, it may mean that this treatment does not work for you.
If the home treatment that I am trying doesn’t get the fingers, hands or toes pink with 5 minute sessions, but the other areas are turning pink with less time, does that mean to increase the exposure time or just that the area will not respond?
Also, what is your opinion on Scenesse and have you kept abreast of those studies? It looks promising and exciting for us vitiligo patients.
It is unclear if you are exposing your vitiligo spots to UV rays or to a sensitizing medication. Regardless, you can play with exposure times by covering the areas that react adequately after 5 minutes and increasing exposure by very little at a time to the areas that are not yet pink.
Scenesse, the implantable melanocortin receptor agonist, has great theoretic potential and time will tell how it can be used.
I’ve had Vitiligo for many years now, but it’s only recently started spreading. I’ve been to my dermatologist and he recently suggested UVB treatment as well as the cream Fluocinonide. I go to UVB treatment when I can afford it, but it can get expensive after a while.
My two questions are: 1. Can the Fluocinonide cream make my Vitiligo worse? I’m not sure if its just my Vitiligo spreading fast, but it seems like its gotten gradually worse in a fairly short amount of time (right around when I started the cream). And 2. If the UVB treatment doesn’t work, are there any other options? I’ve heard about the Excimer laser, but that’s even more expensive than the UVB box.
Any insight to my questions would be greatly appreciated!
Fluocinonide is a topical steroid and is not known to worsen vitiligo. As you had suspected, it is the rapidly spreading vitiligo that may not yet have responded to treatment and causes additional depigmented areas. Next to topical steroid and calcineurin inhibitors (Protopic or Elidel) narrrowband UVB treatments are the current standard of care in vitiligo. This can be administered in a UVB light box with narrowband UVB lamps or through an excimer laser. Normal skin can be spared with excimer laser treatments, allowing higher levels of energy to be administered to vitiligo spots. This can in some people make the treatment much more efficient. Excimer laser treatments are useful for localized vitiligo.
Thank you for the quick reply Dr. Ringpfeil. Would you suggest I ask my dermatologist if I should be put on either Protopic or Elidel in addition to Fluocinonide? Currently, the Vitiligo is only only my hands (started with the fingertips, quickly spreading) and elbows. I’d like to do everything I can to stop it, especially before it starts crawling up my arms and onto my face.
Excimer laser treatments are very expensive, which is why I’m only doing the UVB light box. My dermatologist said that the UV light treatment is fairly effective for patients, but didn’t elaborate when I asked him what ‘fairly effective’ means. If my body does NOT respond to UVB light treatment, do I have any other options?
Thank you again for your input, it is greatly appreciated.
I agree that narrowband UVB light from a light box is effective, and excimer laser treatments may not be necessary. Your medical management depends on a number of different factors and I believe, the details of the management (steroids by mouth to try to abort the flare, Protopic or Elidel or topical
steroid) are best discussed with your dermatologist.
I am a 38 year old mother and have had vitiligo since i was young. i have tried many creams and stuff to regain my pigment loss and nothing has worked. i spoke to many Dr.s and have been told there is nothing to help this disorder. I have several auto immune disorders as per graves desease, R.A and vitiligo. Is this a possible way to go for me PUVA and is this covered by health insurance. I would like to speka to someone in this feild is there some way for someone to call me
PUVA or narrow band UVB treatments are not contra-indicated when you have Graves disease or rheumatoid arthritis. However, if you take certain medications for rheumatoid arthritis, oral psoralen (P in PUVA) may not be tolerated. Typically, health insurance covers these treatments but there could be a copayment or coinsurance even after you meet your deductible for procedures. Precertification is needed for both procedures and your insurance will inform you of your responsibilities with these procedures. It can take many treatments (20 or more) to see the effect. Unfortunately, we do not provide over the phone consultations at this time but I encourage you to speak to your dermatologist about these treatments If he/she does not offer it, your could be referred to a center that does.
I am 38 and have just been diagnosed with vitiligo and melasma. I have had the vitiligo around my eyes for the last nine years (I asked several dermatologists during that time if I had Vitiligo and I was told I did not but no one used a Wood’s lamp to check) and around my nose and spreading out to my cheek a bit for the last year. I have had the melasma for the last two and a half years. I have now gone off the bcp. Everything is limited to my face (as far as I know, there are a few speckles on my leg and chest but the doctor did not look at them).
I was prescribed Desonide for a week and then Protopic for three weeks and then the Desonide for a week and the Protopic for three. I was told I cannot do light therapy as it will exacerbate the melasma and my skin darkens very quickly (I am half Indian). Is this the right course of treatment? I am getting married this year and very anxious to re-pigment and clear up the melasma. I have read about vitamins and Bimatoprost and homeopathy and gluten free diet and the dangers of phenols in hair coloring online. Do these things affect Vitiligo? My doctor did not mention any of them. Thank you for your help!
Treatment of vitiligo is difficult and thus far we do not yet know of any that assures 100% repigmentation. Should you not respond to Protopic, your vitiligo on the eyelids may be treatable with excimer laser, which delivers narrowband UVB light and can be precisely delivered to the vitiligo spots.
UVB is not typically the ray that is implicated in firing up melasma, however, caution should be exercised to avoid the melasma spots. Bimatoprost also helps in vitiligo.
Your melasma is very difficult to treat due to the fact that you have vitiligo. Any trauma of the skin could trigger vitiligo in somebody who has vitiligo. Therefore, I would stay away from Melanage peel (otherwise the best treatment for melasma). The key is very slow treatment of your melasma with various topicals, such as hydroquinone or plant based non-hydroquinone fading creams, glycolic acid, vitamin C over many months. Microdermabrasion may be used to speed up the process.
The role of vitamins, gluten, phenol and other chemicals in vitiligo is still debated.
Hello,
I am 27 and have vitiligo around my mouth, and have melasma above my upper lip as well…. I use topicals for both: Protopic and Hydroquinone in the respective spots.
My question is: does Protopic worsen my melasma when messing up with the dark spot? (I know hydroquinone could worsen vitiligo, of course, but I want to know if something bad happens the other way too)…
Thank you very much in advance!
Protopic is not known to worsen melasma.
Hi, I have had vitiligo since I was 11 years old. I’m 52 now, on gluten free diet for 3 years. I started repigmenting a year ago. I repigmented quickly on my arms, which were the areas I lost pigmentation recently, but for my total surprise my legs, which have been depigmented since I was a kid, are starting to repigment.
I have done lots of treatments with no results, including UVB lamps, to see this results when I was nor expecting anything is like a miracle to me. I must say that gluten makes me feel awful, so I’m 100% gluten free, except accidental cross contamination in restaurants, my house is 100% gluten free, my whole family feels better.
I look and feel younger, no more migraines, depression, fibromyalgia, fatigue, restless legs, and vitiligo repigmenting, I owe my life to the doctor who told me “I think you are gluten intolerant” and tested me for those antibodies. I keep pictures of the process.
This is really a great success story. Thank you for sharing it!
Can excimer lazer be given on Lips (Vitiligo) ?
Excimer laser treatments can be performed on the lip with proper dose adjustment.
About a year ago my wife, 50 rears old, developed vitiligo spots on forehead just below hairline. For last five months she is having full body uv narrow band treatment, in the beginning twice a week and for past two months once a week. Every time she asks the doctor about the length of treatment he say its a trade off. This leaves a question of safety level.
We are thinking of reducing the treatment to once a month with longer exposure.
Can someone please advise what should be our next course?
Vitiligo is not easy to treat and narrowband UVB is the correct and most reliable treatment. Narrow band UVB can be delivered focally to only the affected area via a laser called excimer laser. Please find a dermatologists in you vicinity who offers this treatment.
i ve alwayz had this dry and flaky lips all round the year like some pple have during harmmatan[am a nigerian]which i constantly peel off….naw d affected dry part now depigmented….my dermatologist says its vitiligo….and am so worried..i wanna knw wat is the best option for treatment of lip vitiligo is pls
Confirmation of the diagnosis through skin biopsy is appropriate. In my experience, Protopic works best for repigmentation of the lips. It must be used with care near moist mucous membranes (the moist portion of your lip)