Vitiligo
Vitiligo is a condition in which patches of skin lose their colour completely. The cells that make the pigment melanin stop working, or disappear, in those…
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On this page
- What it looks like and how it behaves
- Why it happens
- What it means for the person
- The sun: what to deal with from day one
- Camouflage make-up is a legitimate choice
- What treatment can realistically give
- How long it takes and what to count on
- What is checked besides the skin, and when not to wait
- Online consultation
Medicines commonly prescribed for Vitiligo
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: OINTMENT, 0.3 mg/gActive substance: tacrolimusManufacturer: Leo Pharma A/SPrescription requiredDosage form: TOPICAL SOLUTION, 1 mg/gActive substance: mometasoneManufacturer: Korhispana S.L.Prescription requiredDosage form: TOPICAL SOLUTION, 1 mg/gActive substance: mometasoneManufacturer: Laboratorio Reig Jofre, S.A.Prescription required
Vitiligo is a condition in which patches of skin lose their colour completely. The cells that make the pigment melanin stop working, or disappear, in those places, and the skin turns milk-white. Vitiligo is not catching, it does not hurt and it is not a threat to life: everything that can be done without it can be done with it. Its whole weight lies elsewhere — in how a person feels among other people, and in the fact that skin without pigment burns in the sun almost at once. Those are the two things worth talking about first, rather than hunting for "a cause that needs removing".
What it looks like and how it behaves
It usually starts with a single small patch, slightly paler than the skin around it. Gradually it whitens completely, the edges become sharp, and sometimes a darker rim is left around them. The skin inside the patch stays normal to the touch: it does not scale, does not thicken, does not hurt, and only occasionally itches a little. Hair growing on a white patch can lose its colour too, in time.
Patches appear most often on the face — around the eyes and mouth — on the hands and wrists, elbows and knees, feet, armpits and groin, the genitals, and wherever skin rubs against clothing or is frequently injured. This is no coincidence: in many people new patches turn up exactly where there has been a cut, a burn, a bad graze or sunburn. That reaction is called the Koebner phenomenon, and it explains why skin with vitiligo needs care and protection.
Two main forms are distinguished. Non-segmental vitiligo is what the great majority have: patches appear on both sides of the body in roughly mirror image, and the course comes in waves, with quiet spells alternating with new areas appearing. Segmental vitiligo takes one area on one side of the body, usually starts in childhood or adolescence, stops spreading fairly soon — normally within a year or eighteen months — and then stays stable. The distinction is a practical one: both the outlook and the choice of treatment depend on which form it is.
How much skin will end up affected cannot be predicted in advance. In some people it stays at a couple of patches for many years; in others the areas merge into large fields. Sometimes colour comes back partly on its own, most often on sun-exposed areas and in children.
Why it happens
Underlying non-segmental vitiligo is an autoimmune process: the person's own immune system destroys the melanocytes, the cells that make pigment, by mistake. Why it starts in this particular person and at this particular moment cannot be said precisely. An inherited predisposition is known to matter: vitiligo or other autoimmune conditions are often found in relatives. The onset is also known to coincide frequently with something — severe stress, an illness, pregnancy and childbirth, bad sunburn, an injury to the skin, contact with certain chemicals, including some found in rubber and hair dyes. In the segmental form the mechanism appears to be different and to involve the nerve endings in the skin.
And it is worth saying straight away what vitiligo is not caused by. It does not come from poor eating, "accumulated toxins", a fungus, nerves in the everyday sense of the word, an immune system ruined by tablets, or a shortage of the vitamins sold "for white patches". Most importantly: vitiligo is not contagious under any circumstances — not by shaking hands, not in a swimming pool, not in a shared bed, not through cutlery. This has to be said plainly, because it is precisely that fear in other people that hurts those with vitiligo most.
What it means for the person
Medically vitiligo is benign, and doctors sometimes say so as though that closed the conversation. In practice it changes life appreciably for a great many people. Patches on the face and hands cannot be hidden, they appear without warning, people look at them and ask about them, and children get teased. Hence the avoidance of the beach, the gym, short sleeves, photographs, meeting new people. Anxiety and low mood are common in vitiligo, and they are a normal response to a visible change in appearance rather than a weakness of character or "dwelling on it".
This side of things is worth raising with a doctor exactly as the patches are: it is a legitimate reason for help. Psychological support, and where anxiety or low mood are marked, work with a psychotherapist, help noticeably and rule out no other treatment. For many people it matters to find a community with the same experience. And a separate word about children: what helps a child is less the treatment than the calm attitude of the adults, plain words about what is happening to them, and a conversation with the school if teasing has started.
The sun: what to deal with from day one
This is the most practical part of the whole text, and it is not about looks. Melanin is the skin's natural defence against ultraviolet light, and in the white patches there is none at all. That skin burns within minutes, and sunburn is not merely painful: it raises the risk of long-term skin damage and, on top of that, can set off new patches through the Koebner phenomenon. So sun protection in vitiligo is treatment rather than cosmetics, and it is needed all year round, not only on holiday.
- A high-factor, broad-spectrum product on all exposed areas, reapplied every two or three hours and after swimming or sweating.
- Long sleeves, a wide-brimmed hat and shade in the middle of the day protect better than any cream.
- Sunbeds are no use: they do not "even out" the colour, they only do harm.
- Do not try to tan so that the patches show less — the surrounding skin darkens, the white areas stay as they were, and the contrast only becomes sharper.
There is a flip side to this: somebody who consistently avoids the sun risks running short of vitamin D. That is manageable — the level can be checked and, if need be, a supplement taken at the dose a doctor advises. Giving up sun protection over vitamin D is not the answer.
Camouflage make-up is a legitimate choice
Cosmetic camouflage is sometimes seen as surrender, or as something unserious. It is neither. Being able to leave the house without thinking about where people are looking affects wellbeing more than many medicines do, and using it is a sensible decision, not a weakness. It is equally fine to camouflage nothing: that is a personal choice, and there is no right answer here.
Several options work. Purpose-made camouflage products cover more heavily than ordinary foundation, are matched to skin tone, last a long time and are not troubled by water. Self-tanning products containing dihydroxyacetone colour the top layer of skin and last several days; the colour comes out more even if it is applied thinly and repeated regularly. For small areas, ordinary high-coverage foundations and long-wear powders do the job. Getting the shade right first time is rare — allow for several attempts, and advice on matching can be asked of a dermatologist. Camouflage goes on top of sunscreen, not instead of it.
What treatment can realistically give
Honesty is needed here, because inflated expectations lead to disappointment and to people abandoning treatment before it could have worked. The aim is to bring pigment back to areas that have already whitened and to stop new ones appearing. It helps some people rather than everybody, and the result is almost never quick.
- Topical treatments. Steroid ointments and creams are used in limited courses and under supervision, because used for long they thin the skin. For the face, the eyelids and the skin folds, calcineurin inhibitors — tacrolimus and pimecrolimus — are usually chosen: they do not thin the skin and so suit delicate areas. A cream containing a Janus kinase inhibitor is also authorised in Europe for non-segmental vitiligo, including in adolescents; it is prescribed by a dermatologist.
- Phototherapy. Narrowband ultraviolet B given in a clinic is the mainstay for widespread disease, frequently combined with topical treatment. Sessions run several times a week over many months. Home lamps and sunbeds are not a substitute and can do harm.
- Surgical methods. Grafting a person's own melanocytes or thin sheets of skin is considered in stable vitiligo that has not spread for about a year, and mostly in the segmental form.
How long it takes and what to count on
The first signs of colour returning — small pigmented dots around the hairs inside a patch — do not appear before two or three months, and the effect is only worth judging at around six. The face, neck and trunk respond appreciably better than the hands, feet, fingertips and lips: where there are few hair follicles the pigment has nowhere to return from, and complete recovery of colour there is rarely achieved. Even a good result is often partial, and patches sometimes come back once treatment stops, so a maintenance phase is often needed. One warning as well: supplements "for vitiligo" and herbal remedies bought online have no proven benefit, and skin-lightening creams containing hydroquinone used on one's own initiative can permanently ruin healthy skin.
What is checked besides the skin, and when not to wait
The diagnosis is made by a doctor on examination, if necessary with a Wood's lamp: under its light areas without pigment stand out more clearly, which helps separate vitiligo from other causes of pale patches such as pityriasis versicolor, marks left by previous inflammation, or pityriasis alba in children. A biopsy is rarely needed.
There is a separate and important part: the work-up beyond the skin. Vitiligo frequently goes together with thyroid disease, so thyroid function is checked with a blood test and repeated over time if there are symptoms. Depending on the case, other things are looked at as well: blood sugar, a blood count and vitamin B12 where deficiency is suspected, and signs of other autoimmune conditions. This is not done "just in case" but because these conditions often travel together and several of them stay silent for a long while.
See a doctor without delay if:
- the patches are spreading fast — new ones appearing within weeks and old ones visibly growing;
- eye symptoms appear: pain, redness, discomfort in the light, worsening or blurred vision;
- hearing changes — it has dulled, or there is noise or ringing in the ears;
- something else has arrived along with the patches: severe tiredness, weight loss, thirst and passing water often, dizziness on standing, darkening of the skin in the creases and over scars, tremor, palpitations or feeling the cold;
- a white patch scales, itches, is inflamed, changes shape or crusts over — that may be something quite different;
- the patches have appeared in a child: children are examined by a doctor, and treatment is chosen differently from adults.
Online consultation
A remote conversation works better here than in many other subjects, because the skin can be shown. Good photographs in daylight, without flash or filters and taken from several angles, give the doctor almost everything needed for a first judgement. It is worth photographing the patches and repeating the photographs a few months later under the same conditions: that shows whether they are growing or standing still, and it is the only reliable way to judge both the course and the response to treatment.
A consultation covers whether this looks like vitiligo or like another cause of pale patches, which form it is, which tests are worth doing, whether a referral to a dermatologist and for phototherapy is needed, how to use the prescribed products properly and what to expect from them and by when. It is also the place to discuss choosing sun protection and camouflage, a child's questions and school, and anxiety or low mood if they are there. The limits are obvious: examination with a Wood's lamp, blood tests and procedures are only possible in person, and the decision about prescription treatment is made by a dermatologist after examining the skin. And with a painful red eye or a sudden drop in vision there is no consultation to wait for — that needs attention straight away.
This material is for information only and does not replace medical advice.
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