Between Myth(s) and Fact(s): What you should know about Vitiligo

Between Myth(s) and Fact(s): What you should know about Vitiligo
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By Dr. Devraj Dogra & Dr.Mubashar Mir

Vitiligo is a disease characterised mainly by the destruction of melanin producing cells called melanocytes in the skin which impart the skin its natural colour. This loss of melanocytes presents as sharply demarcated bright white or chalky white patches which may appear on any part of our skin including the mucosal surface. It affects around one percent of the Indian population; around half of the patients develop vitiligo before the age of 20.
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 it, 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.
IADVL which is the largest association of dermatologists in India celebrates Vitiligo Week every year 25th June onwards to create awareness among public regarding the disease. It plays instrumental an role in dispelling myths regarding Vitiligo among masses besides organising academic events to update doctors regarding the disease.
Vitiligo is a disease surrounded by stigma and myths from centuries and people often land up in unqualified hands which expose the patient to the risk of unscientific treatment and high doses of chemicals and drugs which may have long term implications on a given patient’s health. By approaching a quack, the patient often wastes the crucial time which has a direct bearing on the prognosis of the disease. It is highly advised that whenever any abnormal patch is observed by a patient, a dermatologist should be approached at the earliest since dermatologists are specialists who can correctly diagnose the disease and advise regarding appropriate management of the disease well in time.

CELEBRATING WORLD VITILIGO WEEK
Misconceptions associated with Vitiligo
1. It must be emphasized that Vitiligo is neither infectious nor communicable. It does not spread from one person to the other. It is a disease chiefly limited to depigmentation of human skin and hair. It is absolutely safe to play, share food and items with your friend or relative having vitiligo;
2. Vitiligo does not occur by intake of any food products like fish and milk. It has no relation with intake either;
3. Vitiligo has no causative relation with leprosy; however both may often be confused with each other due to similar appearance of skin patches and poor understanding of disease causation in the past. Many old books refer to vitiligo as sweta kushta or white leprosy confusing the picture further. However, it is now very clear leprosy is an infectious disease caused by an acid-fast bacillus known as mycobacterium leprae whereas vitiligo is purely a disease of non-infectious etiology;
4. It is wrongly believed that individuals suffering from vitiligo are mentally or physically subnormal. It must be known that vitiligo is purely a condition that affects the skin alone. It has no bearing on the intelligence or health of the people who are affected by it.
5. All white patches are not vitiligo. There are many other conditions when the white patches appear on skin. Thus, considering the nature of the disease it is highly recommended that any white patch should be examined by a dermatologist;
6. It must be understood that vitiligo is a disease limited to skin without any direct internal organ involvement. It is not a dangerous or life-threatening problem even though, most patients have a psychological impact, excessive anxiety and depression too. The patients need adequate counselling and reassurance about the nature of disease and that the disease is essentially a cosmetic problem without serious life-threatening complications.
7. About 15-20% of vitiligo patients have one or more affected first-degree relative. This leaves 80-85% of cases which occur without any family history. You don’t need to panic even if someone from your family has vitiligo. There are high chances that you will not have the disease throughout your life.
8. Vitiligo is not related to albinism or skin cancers. Albinism is a genetic disorder, that is, patients born with this have no melanin. These patients have white skin all over, including hair, iris and eyebrows, since birth. On the other hand, vitiligo patients have normal skin at birth. Later in life they develop abnormal immune response towards melanocytes causing their destruction. Similarly, vitiligo has no association with skin malignancies.
9. It would be unfair to believe that vitiligo lacks satisfactory treatment. Vitiligo is a subject of active research and evolving treatment modalities. In fact, around 70 percent of the patients can be satisfactorily managed by the currently available options and the success of treatment is dependent on early detection and treatment.

Causes
Destruction of melanocytes is central to the pathogenesis of vitiligo. While the 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 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 hands, feet, arms, face elbows, knees and so on. 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, referred to as 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 the 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.

Treatment
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 and concern of patients towards disease.
The treatment approach needs to be individualised. A 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. Photo chemotherapy 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 also 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, its sufferers and the superstitions and stigmas associated with it needs to be shunned.

—The authors are President IADVL(J&K), Professor & Head of Department and M.D Resident Department of Dermatology, Government Medical College, Jammu, respectively. They can be reached at the composite email: mubashar.mir@gmail.com