- Multifactorial disorder related to genetic and non-genetic factors.
- Familial predisposition & susceptbility genes that include SLEVI and NALPI.
- Theories to Aetiology: Autoimmune destruction, intrinsic defect of melanocytes, defective free radical(s), reduced melanocyte survival, viral infection, membrane lipid alteration in melanocytes and deficiency of unidentified melanocyte growth factor(s).
I. The widely used classification of vitiligo as localized, generalized, and universal types is based on the distribution, as follows:
- Focal: One or more macules in one area but clearly in a segmental or zosteriform distribution
- Segmental: One or more macules in a quasi dermatomal pattern
- Mucosal: Mucous membrane alone
- Acrofacial: Distal extremities and face
- Vulgaris: Scattered macules
- Mixed: Acrofacial and vulgaris involvement, or segmental and acrofacial and/or vulgaris involvement
C. Universal - Complete or nearly complete depigmentation
II. When progression prognosis and treatment are considered, vitiligo can be classified into two major clinical types: segmental and non-segmental:
- Segmental vitiligo: Usually segmental vitiligo has an early onset and spreads rapidly. In this case, depigmented patches can remain unchanged for the rest of the life of the patient.
- Non-segmental vitiligo: It includes all types of vitiligo except segmental vitiligo. In this common distribution is seen around the eyes, mouth, genitals, and hands
III. Trichrome vitiligo: Lesions show a tan zone between the normal skin and completely depigmented skin.
IV. Quadrichrome vitiligo: Lesions show tan and dark brown zone between normal skin and depigmented skin
V. Isomorphic koebner phenomenon: Vitiligo develops in sites of specific trauma.
VI. Association with other Diseases: Vitiligo may be associated with halo nevi, other autoimmune diseases especially thyroid (Graves' disease, Hashimoto's thyroiditis), and diabetes mellitus. Other instances of associated autoimmune diseases include pernicious anemia, addison disease, and alopecia areata.
If you wish to opt for a vitiligo treatment in one of the best vitiligo clinic in Chandigarh, then you can start with the following lab investigations before wasting any time:
- Fasting glucose or glycosylated haemoglobin
- Rheumatoid factor
The best vitiligo treatments are as follows:
1. PUVA (PO or topical)
2 or 3 treatments per week for months are required before repigmentation from perifollicular openings merges to produce confluent repigmentation. Optimum results can be obtained on the face and on the proximal parts of extremities.
3 times a week
3. Excimer Laser
It produces monochromatic rays at 308 nm. 2 to 3 times a week to treat limited, stable patches of vitiligo.
4. Topical creams
Topical creams and ointments like corticosteroids, calcineurin inhibitors, novel drug combinations etc. have been tried with variable results.
5. Punch Grafts
Punch biopsy specimens from pigmented donor site are transplanted into depigmented sites. Repigmentation and spread of colour begin about 4-6 weeks after the grafting is done. A major problem here is the formation of a residual, pebbled, pigment-like pattern.
6. Mini Grafts
Small donor grafts are inserted into the incision of the recipient sites and held in place by pressure dressing. The grafts heal readily and begin to show repigmentation within 4-6 weeks. Some pebbling persists but it is minimal, and the cosmetic result is excellent.
7. Suction Blister
Epidermal grafts can be obtained by vacuum suction usually with 150 mm Hg. The recipient site can be prepared by suction, freezing, or dermabrasion of the sites, 24 hours before grafting. The depigmented blister roof is discarded, and the epidermal donor graft is placed on the vitiliginous area.
Tattooing can be used to regiment depigmented skin in dark-skinned individuals. Colour matching is difficult, and the colour tends to fade.
If the patient does not respond to repigmentation therapies, the doctor could consider depigmenting all the areas of the body to make the skin colour uniform. It is used only for a selected few patients because it can have long-term social and emotional implications. Complete psychological evaluation is done prior to this. 20% cream of monobenzylether of hydroquinone is applied BID for 3-12 month. Burning or itching may occur. Allergic contact dermatitis may be seen.
Pearls and Pitfalls
Uveitis is the most significant ocular abnormality seen in vitiligo, but rare. Ophthalmology consultation with a vitiligo specialist in Chandigarh is a must if eye symptoms are present. Vitamins may be helpful.