Precipitating factors in vitiligo – Dr. Antonio Salafia (India)

A large number of patients claim that vitiligo appeared or spread from one tiny patch to a wide pattern, after severe physical and/or mental stress. These are called ‘precipitating factors’ because they are not the cause of the disease, but induce its development. Stress, in this case, cannot be considered to be the ‘cause’ of the disease, but rather a contributory factor or a ‘precipitating factor’.

The list of precipitating factors is long and can be divided into four sections:

1) Physiological

a) Menarche or first occurrence of menses. This could justify high incidence in young girls. b) Pregnancy, delivery and menopause. In all of these cases the female body undergoes stress and moreover, there are certain hormonal changes that occur. Oestrogens are known to increase skin color; decreased in the level of these hormones, as occurs during menopause, could explain the increased rate of vitiligo lesions in menopausal ladies.

 2) Pathological

a)Parasities, like Helmints, Amoeba and Giardia Lamblia. It is rather evident that intestinal parasites upset the normal functioning of the digestive system.

b) Bacteria and fungi. Many young girls with vaginal vitiligo have a history of a fungal infection called candidiasis. The same is true in case of penis glans vitiligo. Vitiligo is known to be a consequence of Tinea Versicolor (another fungal infection), which interferes with melanogenesis.

c) Viral disease. I do have a number of cases where vitiligo developed in patients previously affected by Herpes Zoster. There are a few patients who have developed a white patch on their lips after Herpes labialis.

d) Typhoid fever, malaria, jaundice. These diseases are stressful to such an extent that it is not surprising to have other diseases arising as consequences of these major body alterations.

e) Chronic gastritis and low-level of gastric acid have been found in some patients. Here we also can see impaired absorption of important and vital elements.

f) Hepatitis. The relation is not clear, though there are authors who believe that the evidence is compelling. A few years ago I met a general practitioner who achieved good results in vitiligo control (if not cure) by using Essentiale, a liver protector.

g) Thyropathies. This, in theory, can make vitiligo worse, as it has been explained earlier.

 3) Psychological factors

Death of one’s dearest, loss of job and/or family unhappiness are all stressful, often to the extreme. In this case Interleukins are involved and some clarifications will be given later.

The role of stress has been highlighted by various authors, however there is no consensus yet. Some of them say that stress may alter the immune system and, hence, plays an important role in precipitating autoimmune diseases in patients predisposed to them. Fisher reports a case of vitiligo as a consequence of persecution. Several authors have reported on poor quality of life in vitiligo patients. It is self-evident that vitiligo, or any other disfiguring disease, would have a certain impact on the patient’s life. This is more so in dark-skinned individuals, where any vitiligo patch shines like a star; in India there is one more problem: common people confuse vitiligo with leprosy and this adds a certain amount of fear as leprosy is considered to be a ‘curse from God’. I have seen young girls forced to divorce because of this disease, and I have seen young men contemplating suicide because they could not find a life-partner.

 4) Chemically-induced Vitiligo

A number of chemicals can be blamed for causing and/or precipitating a Vitiligo patch in a patient who has a disposition to the disease. Vitiligo due to para-tertiary butylphenol was reported in 1971 from St Johns Hospital of Dermatology in London and soon after that in Germany by Rodermund who reported vitiligo associated with hepato- and splenomegaly and goitre in three patients working in a factory producing para-tertiary butylphenol. Since then a number of authors have found a causal relationship between a form of chemical vitiligo indistinguishable from vitiligo vulgaris, and paratertiary butylphenol.

 Various dyes have been reported to cause vitiligo, such as:

1. Azo dye in Alta; Alta is a scarlet-red solution used by Indian women as a cosmetic colorant for their feet.

2.Hair dye.

3. Rubber, in various industries, tyre assemblers, in particular, as they often deal with a rubber antioxidant. Rubber footwear has been also blamed for chemical vitiligo. In these cases chemicals have been identified as typical allergenic accelerators in children’s rubber shoes, ladies’ rubber boots and ladies’ canvas shoes. Rubber and plastic chappals are a well-known cause of vitiligo in India. Therefore, a possibility of penis vitiligo development can be, in part, due to rubber condoms, at least in patients who are predisposed to vitiligo. The same can be said of contact with plastic purses and plastic glass-frames.

4. Cinnamic aldehyde in toothpaste and the adhesive used to stick on the Bindi worn bz women in india. Epoxy resin in dental acrylic materials. Nickel gives rise to contact dermatitis manifested as vitiligo.

5. A large number of drugs have been associated with vitiligo:

a) Chloroquine.

b) Hydroquinone, present inphotographic developer, and monobenzone.

c) Alpha-Interferon, used in treatment of active hepatitis C.

d) Even corticosteroids have been blamed and it is common experience – I have 19 such cases of

chemical vitiligo developed after extensive and long-term use of Betnovate cream.

e) Levodopa used in treatment of Parkinson’s disease.

f) Beta blocking drugs (such as Atenolol) may exacerbate vitiligo

h) Proton Pump inhibitors, such as Lansopran used to treat gastric problems.

Chlorine-induced Vitiligo is not a rarity. Chlorine is found in excess in swimming pools which are not scientifically purified and maintained; I have three young girls and two boys without family histories of vitiligo, who clearly ascribe the development of vitiligo to the swimming pool used on daily basis for 2-3 months. A patient of mine attributed his lip vitiligo to Alum, used to clean teeth!

Alum was used as a base in skin whiteners during the late 16th century. Ghosh et.al. have recently done an interesting and detailed study of some of the chemicals known to cause leukoderma, and individuals at risk. They list among others: hair dyes, deodorants / perfumes, adhesives (bindi), rubber sandals, black socks / shoes, eyeliners, lipliners, rubber condoms, lipsticks, cuddly toys, toothpaste, and insecticides.

Most common and generally used items include:

Rubber gloves 12%

Lubricants and motor oils 6.8%

Detergents 5.3%

Printing ink 3.6%

Chemical laboratory agents 1.5%

Every dermatologist in India has come across a vitiligo patch localized on the left breast in some

women: often ladies hide their purses in their brassiere. Vitiligo due to Bindis (the beauty spot Indian ladies like to wear in the middle of the forehead) is common experience, and when patients are told to avoid it, not all of them agree because of pressure from relatives and in-laws:

young married girls in Maharashtra have to wear a Bindi. Patients often ask: “When do I stop getting white patches?” Well, it is difficult to predict the course of this disease; in a good number of patients – as I have noted – the disease goes on for 3-4 years and then it settles down, with one or two stubborn patches and the clearance of the others, but there are patients in whom the disease has certain periods of stability and then suddenly starts increasing. And there are patients, although very few in fac, who gradually and inevitably turn completely white, some of them porcelain-white, others white similar to Caucasian skin color. The natural course of vitiligo is unpredictable.

Vitiligo cures do not yet exist. Fake “quick cures” and treatments that could potentially damage your health.

At the moment there are huge numbers of web sites promoting natural cures, quick cures, guaranteed cures and treatments with vitamins, diet, lifestyle change, as well as oils, lotions and creams sold without FDA approval or even any kind of solid scientific research behind them. The most aggressive at the moment seems to be the Michael Dawson ‘”vitiligo cure” which is promoted using poorly written articles and fake testimonials written by paid bloggers, fake web links that redirect users to the site promoting this method and even fake scam reporting sites and articles that “prove” his method is genuine. Many of these sites are even possible sources of spyware that can potentially harm your computer and even result in personal information theft.
Now, it is entirely possible that this and other so called “cures” can work for some people and I can even explain why. Antioxidants make up a large proportion of these treatments and have recently been shown by researchers to help arrest the spread of vitiligo lesions ad even promote conditions for repigmentation.  At the World Health Academny vitiligo roundtable in Kitzbühel, Austria Professor Robert Schwartz gave a presentation on the possible benefits of anti-oxidants, in particular ginko biloba, but also made it clear that there has not yet been enough conclusive research defining safe dosage amounts and effecacy.  Dr. Antonio Salafia also ave a presentation of his treatment combining dermabrasion and vitamin B lotions which have also had positive results and made the same point, that more research is needed.

Antioxidants are thought to reduce the amount of of stress causing free radicals in the skin affecting the melanocytes. Vitiligo is now known to be the combined result of Autoimmune disorder, melanocyte malfunction and stress factors affecting the poorly functioning melanocytes and all three of these factors need to be present for vitiligo to occur. Antioxidants may be able to reduce the stress factor on the melanocytes thereby stopping the symptomatic white lesions of vitiligo appearing.

The diets, supplements exercise and lifestyle regimes promoted by many of the “quick cures” for vitiligo are basic dietary common sense mixed with a little pseudo science speak and dietary supplement sales pitches. As I have said, they can have positive effects for some patients but will not for all as the are not a cure. The same goes for most of the creams, oils and lotions that are on the market. They can have positive results based on the same  logic but again, they are unproven and in some cases could even be detrimental and so their use should supervised by an experienced and qualified dermatologist.

The fact is that while vitiligo remains an ignored condition at an official level, companies and individuals selling quack remedies and fake treatments will continue to glut the market and fleece patients. The millions of patients without the financial ability to invest in treatments, no matter how effective or non-effective, will remain without hope. There is of course hope with an ever increasing number of eminent  dermatology, genetics, immunology, pharma, and biochemical researchers joining forces to find a real cure or treatment. There are also treatments available that can really help in a large number of cases. In our vitiligo Q and A the latest and most effective treatments are described. Support, education and awareness though are always the first step in really addressing the immediate problems that millions face each day with vitiligo. These three tools can help rid the world of the discrimination, social stigma and misunderstanding that plagues those with vitiligo, help them keep their jobs, keep their families and  keep their self respect.

Start by signing the World Vitiligo Day petition and encouraging your friends and family to do the same. It is free, takes only a couple of minutes and could really help to save lives and livelihoods. 25june.org

Vitiligo Q & A 21: Psychotherapy: when and how?

Vitiligo is a distressing disease because of its perceived stigma, cosmetic disfiguration and tendency to
chronic relapse. The social stigma and often open discrimination that is experienced by vitiligo sufferers can have devastating psychological effects. In certain cases treatment of these psychological factors may both improve both self-esteem and clinical results which can in turn lead to a dramatic increase in the quality of life of the patient. Cognitive behavior therapy may be appropriate in certain cases.
Vitiligo is often considered by both the affected subjects and doctors to be emotionally triggered. An incubation period of 2-3 weeks between the stress event and the clinical manifestation of vitiligo patches is reported by over 70% of patients.
Even the localization of white patches has been anecdotally but significantly reported as related to specific affective relationships. As an example, according to some reports, men who had been betrayed developed vitiligo on the genital areas and women who had an unsuccessful pregnancy, have developed vitiligo on their abdomens. The case of a woman who developed vitiligo on hands in a few hours after cleaning the sheets
where her son’s girlfriend had had a miscarriage, although anecdotal, is also illuminating.
These are obviously anecdotal reports in medical literature, which are of very limited “per se” value, but are clearly disclosing possible general psycho-somatic trends, which could direct researchers toward possible causes and to the cure of vitiligo, in as yet unexplored psycho-neuro-immuno endocrine territories.
Nobody can ignore the burden of the psychosomatic rebound effects of vitiligo on the psyche
of the affected subject.
Vitiligo subjects may adopt (more or less consciously) different behaviors to cope with vitiligo. Some will adopt the “mastery active” psychological mechanism consisting of reading, studying and researching actively the causes of the disease.
Others will behave as “natural acceptors” showing good self-esteem and not hiding their skin lesions.
Others instead will make heroic attempts to hide their white spots, will be always embarrassed and often depressed. These subjects can tend to limit their social interaction and could lose their jobs because of vitiligo.
While examining any vitiligo subject and discussing therapeutic options, the skilled dermatologist will try to understand both the possible psycho-somatic mechanisms inducing the appearance of vitiligo patches (if any) and the psychological  rebound effect of the disease on self-esteem and thequality of life of each individual subject.

Should the dermatology always refer each and every vitiligo patient to a psychologist or the psychiatrist?
this can be a difficult chioce. If the vitiligo patient has chosen the dermatologist for “Physical and psychological” assistance regarding understanding his/her condition and the psychological effects, the dermatologist must always respond to the needs of the patient by giving complete care, including supplying proper counseling.
“Forcing” the patient to visit another (non-skin) specialist is, in fact, dangerous.
Immediate insensitive referral of skin patients to a psychiatrist can even lead to suicidal thoughts in over sensitive subjects, as has already been reported in literature.
Thus, when psychological intervention is considered “necessary”, the dermatology should
use the “liaison consultation” practice of encouraging the patient into close collaboration with the
psychiatrist-psychologist. It is a direct connection of two to one: the vitiligo subject, the dermatologist
and the psychiatrist working as a team.
Only later, can the two experts have the full right to treat the same patient separately, with expectation of positive results.
In this context, it seems that cognitive behavior therapy could give fair results in contrast to other psychiatric or psychological approaches.

VRF Vitiligo Masterclass Shenyang – report

The 2012 International Vitiligo Symposium was held in the historic former Manchu capital of Shenyang in northeastern China on November 16-18. The symposium is a globally important meeting on vitiligo which brought together dermatology experts from around the world to share the latest research and techniques for treating vitiligo. It was generously hosted by China Medical University and sponsored by the Vitiligo Research Foundation (VRF), China Medical University (CMU), and the Shenyang Institute of Science and Technology.

Congress President Xing-Hua Gao was ably assisted by Honorary Presidents Hong-Duo Chen, Torello M. Lotti (Italy), and CMU President Zhao Qun together with an enthusiastic and energetic group of participating faculty members and young physicians in bringing together a highly successful symposium.

 

The congress was opened by a welcoming address from Hong-Duo Chen and an introduction by the VRF Chief Executive Officer Yan Valle (Canada), describing the VRF as a charitable organization dedicated to promoting awareness and finding a cure for vitiligo. A huge amount of information was exchanged with presentations given by experts from around the world.

Jian-Zhong Zhang (Beijing), President of the Chinese Society of Dermatology gave a lecture on vitiligo epidemiology in specific regions of China. Andy Goran from the United States gave a presentation on next generation phototherapy. Jana Hercogová (Czech Republic) gave a detailed presentation on the medical treatment of melasma and other hypermelanoses. Tian-Wen Gao (Xi’an) talked about phototherapy for vitiligo patients and Torello M. Lotti (Italy) discussed combination therapy for vitiligo.

Hong guang Lu (Guiyang) provided an overview of melanin pigmentation in different races as well as in in vitiligo. Yuan-Hong Li (Shenyang) was able to provide information about promising results when treating melasma using fractional ruby laser and Rina Wu (Hohhot), Chairman of the Chinese Society of Inner Mongolia Institute of Dermatology also provided valuable insights into vitiligo. Robert A. Schwartz (USA) gave an address that was mainly focused anti-oxidant therapy for vitiligo and especially observing that the gingko is China’s national tree and a rich source of anti-oxidants. Prof. Schwartz was also awarded the title of Honorary Professor of China Medical University by University President Zhang Cun.

 At the conclusion of the symposium the announcement of a VR foundation special grant of up to 50,000 USD for vitiligo research based in China was also made by the professor Xing-Hua Gao. The focus of the grant is on making new breakthroughs in research into vitiligo causes and into finding new treatment modes.

The difference between piebaldism and vitiligo

A few days ago a very observant reader pointed out that the two lovely models on our facebook page have piebaldsim and not vitiligo. Yan, our CEO mentioned also that one of the girls was originally misdiagnosed as having vitiligo. But I though I would take the opportunity to describe some differences, and also perhaps some similarities.

Vitiligo and piebaldism both have characteristic white patches that are a result of total lack of melanin in areas where the melanin producing cells or melanocytes are missing. In vitiligo the melanocytes are destroyed whereas in piebaldism they are missing from birth.

The key difference is that vitiligous white patches can change, repigment and form in different areas over time where as the patches resulting from piebaldism are static and remain sofo the entire lifespan of the affected individual. Piebaldism is a rare genetic disease that is autosomal dominant which means that only one of the affected genes needs to be passed from the parent for the child to be affected (For the more genetically minded amongst you, it is caused by mutations in the KIT proto-oncogene). The chance of vitiligo being inherited is currently estimated at around 20%.
Piebaldism is one of the signs of Waardenburg syndrome and can also be accompanied by deafness.
Piebaldism is particularly characterized by a white forelock in 80-90% of cases and a white in the middle of the forehead. Differentiating can sometimes be difficult because vitiligo lesions can also appear in these places and so a skin biopsy is recommended.

Treatment of piebaldism is a little more limited than in vitiligo in that topical creams are not used but melanocyte transplant accompanied by UVB therapy has been affective, as in vitiligo cases. In both conditions cosmetic camouflage is often used.

Where vitiligo and piebaldism are also similar is in the social stigma attached, lack of understanding, discrimination and and the resulting psychological trauma. Both require the education of the general public, awareness and understanding. Research that applies to one condition very often also has benefits for patients with the other.

If you haven’t already, please take the time to sign the 25 June petition, share it with as many people as you can and help make World Vitiligo Day official. Help us raise awareness and thank you.