Vitiligo – Ala Disease
Vitiligo comes from the Latin word “vitelius”. Vitelius means calf in Turkish. The disease has been likened to spots on the back of this animal. There are melanocyte cells in our skin that produce pigment and therefore give our skin its color. As a result of damage to these melanocytes, pigment cannot be produced. As a result of pigment deficiency, scattered and patchy white spots and spots occur on the skin. The spots are a distinctive whiteness as milk. These spots can vary in size; It can be as large as a point to cover the entire face. Sometimes the loss of melanin pigment is partial and may not be a complete white patch. Not every white spot means vitiligo. Rarely, there may be color loss in the hairs. It is also known as mother-of-pearl ala, baras, ebreş among the people. In our society, vitiligo is confused with psoraisis disease, which is characterized by white dandruff-red sores on the skin. However, these two diseases are completely different from each other.
What is the course of vitiligo disease?
Vitiligo disease is a long-term, recurrent disease that can last a lifetime and sometimes with periods of exacerbation and remission. The disease shows a different and individualized course in each patient. In other words, each patient’s vitiligo is different. Some patients form a small number of plaques and never increase. In some people, the disease may be so widespread that there is almost no normal skin-colored area of the patient.
What are the incidence and characteristics of vitiligo?
Although vitiligo varies relatively in society, it is seen at a rate of 1-2%. There is no gender-related difference in the incidence. Approximately 30% of patients have vitiligo cases in their families. The disease itself is not inherited, but there is a genetic predisposition. It is common in blacks, Moroccan and Yemenite Jews. Although vitiligo can occur from birth to old age, the age of onset is most common between the ages of 10 and 30. It is very rare in older ages and infants. The increased interest in the appearance of the skin in women allows vitiligo to be noticed earlier than men.
What are the initial symptoms and features of complaints in vitiligo?
In early vitiligo, the white areas are not prominent and may be itchy. Initially, vitiligo progresses without symptoms. Vitiligo appears as sharply circumscribed and cosmetically disturbing white patches that become more evident especially when the skin is sunburned. Further prominence of the lesion can be prevented by sun protection.
Are there clinical types of vitiligo? What are these?
At first there are only a few small, sharply circumscribed areas often darker in color. There may be a red or dark ring at the borders. As the number of lesions increases, they may coalesce to form amorphous shapes. Vitiligo lesions can be in a single area or widespread, the widespread form is located symmetrically throughout the body. The most frequently affected areas are the face, neck and scalp. Skin folds are also frequently involved. The most common sites are bone protrusions exposed to repetitive trauma, forearm outer surface, wrist inner face, back of hand, fingertips. Vitiligo occurs quite often around areas such as lips, genital area, gums, areola and nipple. Moles called halo nevus with a white ring around it are common in vitiligo patients. Scalp vitiligo usually presents as regional patches of white or gray hair, but total whitening of the entire scalp can also be seen. Scalp involvement is observed. This is followed by eyebrow, inguinal region and armpit involvement, respectively. Hair whitening can be a bad sign for treatability. (With treatment or spontaneous coloration in vitiligo, it is caused by melacids found in the hair follicles.) If vitiligo is limited to a small area, it is called “local vitiligo”, if it is in a certain anatomical area, such as an entire arm, it is called “segmental vitiligo”, if it is widespread and symmetrical in the whole body, it is called “vitiligo”. vulgaris” and “universal vitiligo” definitions are used if it is widespread to cover the whole body.
What are the causes of vitiligo?
The cause of vitiligo is unknown. However, the following hypotheses have been developed. The immune system malfunction hypothesis; The causes of vitiligo are not completely understood, but medical research suggests that it is related to the immune system (our body’s defense system). T lymphocyte cells, one of the white blood cells found in our blood, attack their own color cells as a result of the deviation in the control of the defense system. Neural hypothesis: An intermediary substance released from the nerves destroys the color cell melanocytes or the production of the color substance melanin. Hypothesis of self destruction Color matter melanin synthesis can be destroyed by color cell melanocytes.
Genetic hypothesis; An inherited abnormality of melanocytes inhibits their growth and development.
Microchimerism Hypothesis: In some studies, it has been shown that there is cell transfer between individuals during pregnancy (between mother and baby), organ transplantation or blood transfusion. These cells or DNAs remain in the recipient for decades, creating a state of microchimerism. It is thought that vitiligo may have formed in such a way. Viral causes: Especially vitiligo and para-shaped hair loss due to CMV (citomegalovirus) have been suggested and antiviral treatments have been applied for this purpose.
B12 and Folic acid deficiency: It is thought that high homocysteine due to B12, B6 and folic acid deficiency may cause vitiligo. The high level of this amino acid is important because it also causes cardiovascular diseases and frequent bone fractures. Since none of these theories is satisfactory on its own, theories involving several of them are also supported by some experts.
Is blood analysis necessary in vitiligo and what are the diagnostic methods?
Although the diagnosis of vitiligo is usually made clinically, biopsy can rarely help in distinguishing it from other diseases. Vitiligo may be associated with other autoimmune diseases, especially thyroid diseases and diabetes mellitus. 30% have thyroid disease. Other coexisting autoimmune diseases include: Perniosis anemia, Addison’s disease, Alopecia areata, insulin dependent Diabetes, Uveitis, Chronic mucocutaneous Candidiasis, Polyglandular autoimmune syndromes. Patients should be alert to the initial signs and symptoms of hypothyroidism, Graves’ (thyroid disease), diabetes, and other autoimmune diseases.
Diagnosis can be made by examination under Wood’s light. This light makes the color loss even more pronounced. Especially underarm, anus, and genital areas are not very clear without Wood’s light.
Is Vitiligo Disease Contagious?
Vitiligo is definitely not a contagious and microbial disease. There is no transmission from one part of the body to another.
Does vitiligo spread?
This is a controversial topic. Its onset is usually slow and sometimes it can stay that way. However, since there may be a rapid increase in the spots after months, the patient must be under close follow-up.
Does vitiligo go away on its own?
Usually single lesions can regress spontaneously by showing freckles on them.
Is There a Recommended Diet for Vitiligo Disease?
Vitiligo is not an allergic disease and is not caused by a particular food. The use of antioxidants, namely vitamins A, E and B, protects the patient with vitiligo against the harmful effects of the sun.
Is vitiligo related to a disease in the internal organs?
It is not a disease related to internal organs. However, some diseases can be seen together with vitiligo: thyroid gland diseases, hair loss, diabetes, adrenal gland diseases. However, absolute examination should be made in terms of all these diseases.
Does Vitiligo Disease Turn into Skin Cancer?
No ! However, since melanocytes, which are the natural protection system of the skin, are not present in vitiligo disease, sun-borne skin cancers are observed more frequently. In addition, some uncontrolled treatment methods may increase the risk of skin cancer. Therefore, it is important to continue the treatment under the supervision of a specialist.
Does vitiligo have a relationship with stress and distress?
Although it has not been proven, spots may increase as heavy stress affects the body’s defense system. For this reason, psychological evaluation should be done when necessary.
What is the treatment for vitiligo?
Although there are many treatment methods in the treatment of vitiligo, there is no single treatment method that gives good results in all patients. Therefore, treatment should be individualized according to the patient. Patients should also be warned about the duration and risks of treatment. The response to the treatment is the formation of small freckling islets of color within the white spots and then they merge and close the area.
A. Medical treatments consisting of topical and systemic drugs
B. Surgical applications
C. Additional treatment approaches can be evaluated under the headings.
A. Topical Treatments
1. Corticosteroids (drugs with cortisone); They are the most commonly used vitiligo drugs. It is not preferred in common patients because it has systemic and side effects where it is used. More in children, localized areas and new-onset vitiligo
it is effective. It gives the fastest and best response, especially in facial lesions, but care should be taken in terms of side effects such as cataracts in the eye and increasing eye pressure. Dark-skinned people have a better response. The advantages of being inexpensive and easy to administer are the disadvantages of side effects and recurrences after treatment.
PUVA therapy is a treatment that can be summarized as the administration of photosensitizing substances such as 8-methoxypsoralen, 5-methoxypsoralen, trimethylpsoralen and then the application of UVA. It is especially preferred in patients with extensive skin type IV-VI. However, it is not used much anymore because it can be used over 12 years of age, the disease recurs within 1-2 years after the treatment, it cannot be used in fair-skinned people, and it is at risk of developing cataracts and skin cancer in the eye in long follow-ups.
Ultraviolet B Treatment: UVB treatment was applied as an alternative to PUVA. There was no statistically significant difference compared to PUVA, except for the ease of application and the need for a chemical substance. However, although the narrow band results seem satisfactory, since UVB or PUVA is applied to the normal skin during the treatment, the contrast between the lesion and normal skin increases, the risk of skin aging, telangiectasias and skin cancers increases in normal skin. There is no chance of applying different doses to different areas.
Excimer Laser: In order to overcome the problems in PUVA and UVB treatments, special devices called Excimer laser have been developed under the name of microphototherapy. These devices detect the white skin and direct the UV rays here. We get a chance to give different doses to different areas. The total dose given is reduced. Higher doses can be applied to the problem areas compared to the minimal erythema dose.
3. Immunomodulators; For this purpose, successful results have been obtained with tacrolimus and pimecrolimus in recent years. It has fewer side effects than topical steroids, may have irritant effects, and is safer than topical steroids in children. For this reason, it is preferred especially in children with limited involvement in the face and neck. Combination with excimer laser/light systems and UVB gave better results. It is not used in combination with UVA treatments due to the increased risk of cancer.
4. Calcipotriol; Calcium reuptake is impaired in vitiligo skin. Calcipotriol regulates calcium hemostasis by stimulating D vit 3 receptors in melanocytes. It is mostly used in combination with narrowband UVB.
5. PGE2(prostaglandin E 2); It has been found successful especially in vitiligo with UV.
6. Pseudocatalase; Catalase is an antioxidant enzyme normally found in the skin that reduces the damage of free oxygen radicals. Good results are obtained with the use of UV in patients with vitiligo.
7. Phenyl alanine; It is used alone and in combination with UV treatments.
8. Placenta; placenta extract. It stimulates the production of melanin in the skin. There is a gel form.
9. Depigmentation; It can be considered in patients with more than 50% involvement and especially in patients who do not respond to repigmentation attempts on the face and neck. After depigmentation, a complete color integrity is achieved regardless of skin type. Patients should be given sufficient information about the application and its results, and patients should accept that they will never sunbathe. The monobenzyl ether of hydroquinone (monobenzene) is the only agent available in the USA and Europe. It permanently destroys epidermal melanocytes by increasing the release of free oxygen radicals.
10. Camouflage applications; Micropigmentation Iron oxide pigments were used for the first time in 1989. Today, a similar technique is used for permanent eyeliner. Tatuaj can only be used in people with dark skin, for the purpose of repigmentation of the depigmented area. Color matching is difficult, and color tends to fade.
Although leather can be dyed with dihydroxyacetone preparations (sunburn), color matching is often not successful.
B. Systemic treatments;
1. Steroids; In active progressive lesions, cytotoxic effects against melanocyte antibodies provide rapid healing. However, their use is limited due to their side effects and treatment should be started by considering the benefit-harm balance.
2. Treatment with Levamisole: It has been found to be safe and effective in the treatment of vitiligo.
3. Vitamins: B 12, Ascorbic acid, Folic acid has been suggested in the treatment.
4. Suplatast tosilate: It is recommended to be used together with other drugs. Tcell is an anti-allergic agent that inhibits IL-4 mRNA transcription.
* Surgical Approach: Patients with small areas and stable (no progression for 4-6 months) vitiligo are candidates for surgical transplantations. The application is time consuming, limited only to patients with segmental or localized vitiligo. Other treatments are difficult to achieve on the dorsal sides of the fingers, wrists, forehead and hairline. Surgical applications can be performed here.
The surgical techniques applied are as follows;
1-Epidermal and melanocyte suspensions: Melanocyte and skin suspensions prepared from the patient’s normal skin are placed on the vitiligo area removed by dermabrasion or laser. If the taken melanocytes are cultured and multiplied, they can be used in larger areas. However, it is a long, laborious and more expensive application.
2-Thin dermoepidermal grafts: normal skin taken with a dermatome is placed on the vitiligo skin area taken with a dermatome.
3- Suction bulla grafts: Grafts are obtained from normal pigmented skin with vacuum and certain pressure. The roof of the bulla removed from the vitiligo area by freezing or suction is removed and this normal donor is placed in its place.
4- Punch minigraft: Normally pigmented skin is taken with special tools called punches with a diameter of 0.7 or 1 mm, and these are placed on the skin with vitiligo to the places taken with punches of the same diameter.
C. Adjunctive Therapies;
1. Psychological Support: Scientific studies have shown that providing psychological support to vitiligo patients increases the quality of life and contributes to the recovery of the disease. For this reason, various psychotherapy methods can be used when necessary, with or without appropriate drugs.
2. Herbal Medicines: Similarly, herbal treatments and natural medicines cannot provide long-term well-being. Herbal and natural medicines taken orally can have severe visceral (eg liver) toxicities, significant side effects and drug interactions. For this reason, the treatment of vitiligo, a skin disease, should be carried out by a dermatologist with approved drugs that have proven safety as well as efficacy. Your physician is the source where you can reach the most reliable and accurate information about newly developed drugs or other treatment methods.
What should a person with vitiligo pay attention to?
The substance that gives color to the skin also protects the skin from sun rays. Since this substance is destroyed in vitiligo spots, these spots have become unprotected against the sun. Sunburn can easily occur. For the same reason, since the susceptibility to some skin cancers increases in these spots, sunscreen cream should be used at the recommendation of a dermatologist, and if possible, white spots should be protected from sunlight. New stains may appear in places of impact, scratch and friction. Therefore, it is necessary to protect the skin from harmful effects.