Vitiligo is a chronic disease characterised by the appearance of white patches on the skin, caused by the loss of melanin, the pigment responsible for skin colouration. It affects about 1-2% of the world’s population and, in Italy alone, it is estimated that over 330,000 people live with this disorder. Its visibility makes it not only an aesthetic problem, but also a major challenge from a social and psychological point of view.
Causes of vitiligo
Vitiligo is considered an autoimmune disease, in which the immune system mistakenly attacks melanocytes, the cells that produce melanin. The exact causes are not yet fully known, but some predisposing factors have been identified:
- Genetic predisposition. Vitiligo is believed to be a polygenic and multifactorial condition. Approximately 20-30% of people with vitiligo have a relative suffering from the same disorder. Some 50 genetic loci, i.e. specific points on chromosomes where genes are found, have been identified that may increase the risk of developing vitiligo and other autoimmune diseases.
- Environmental factors, such as exposure to chemicals. Chemicals such as phenols, catechols and other substances found in some disinfectants, hair dyes and industrial products can damage melanocytes.
- Skin trauma, such as sunburn. Excessive exposure to UV rays damages melanocytes.
- Psychological stress. Psychological stress is considered one of the factors that can trigger or worsen vitiligo, as it affects the immune system. Moreover, stress can increase the production of free radicals, contributing to oxidative stress. At the same time, vitiligo itself can cause psychological stress, due to the social and emotional impact of white patches on the skin. This creates a vicious circle: stress can worsen vitiligo and vitiligo can in turn cause further stress.
- Oxidative stress, a condition in which free radicals, unstable molecules that can damage cells, override the body’s ability to neutralise them via antioxidants. It is believed that the melanocytes of people with vitiligo are particularly vulnerable to free radical damage, which can trigger an autoimmune response when they damage them.
- Presence of type 1 diabetes. Vitiligo and type 1 diabetes are both autoimmune diseases and often coexist in the same person. In the former case, the immune system attacks the melanocytes, while in the latter it attacks the pancreas cells responsible for insulin production.
- Thyroid dysfunction. Vitiligo is often associated with other autoimmune diseases such as Hashimoto’s thyroiditis, a chronic thyroid disease that can cause hypothyroidism.
- Nutritional factors. Deficiencies in essential vitamins and minerals, such as vitamin D, copper and vitamin B12, have sometimes been associated with vitiligo. Lack of these nutrients can affect the health of melanocytes and the functioning of the immune system.
Manifestations
The manifestations of vitiligo are diverse and may include:
- Depigmentation (or whitening) of the skin. The main symptoms of vitiligo include the appearance of clearly defined white patches, mainly on the face, hands, elbows, knees and in the genital area. In some cases, vitiligo can affect the mucous membranes, such as the mouth and nose, causing the typical white patches. Vitiligo discolours the skin because the immune system attacks the melanocytes, the cells that produce melanin, causing pigment loss in the affected areas.
- Hair and hair depigmentation. Vitiligo can cause loss of colour in the hair, eyebrows, eyelashes and beard due to the loss of melanin in the hair follicles. The underlying mechanism is similar to what occurs in the skin: the immune system mistakenly attacks the melanocytes, the cells responsible for melanin production, not only in the skin but also in the hair follicles. When the melanocytes in the hair follicles are destroyed or damaged, they stop producing melanin, leading to the growth of white or grey hairs in the affected areas.
- Change in eye colour. In some cases, vitiligo can alter the pigmentation of the retina and iris, but without affecting vision.
There is a special type of vitiligo, called segmental vitiligo: this is a form of vitiligo that presents differently from the more common form, called non-segmental vitiligo. In segmental vitiligo, the depigmented patches do not develop bilaterally but on one side of the body and tend to follow a linear pattern, often along the path of a specific nerve.
The progression of vitiligo can vary greatly from person to person. In some cases, the disease can progress rapidly, with new white patches developing in different areas of the body over a short period of time. In other cases, the progression is very slow, with patches only gradually increasing or only occurring in certain areas. There are also people in whom vitiligo remains stable for years, with no noticeable changes, and in some rare cases, the patches may even partially or completely repigment, although this usually occurs spontaneously and unpredictably.
Physical and psychological impact
Vitiligo, while not painful, can have significant implications for sufferers:
- Risk of sunburn. Depigmented areas are more vulnerable to UV damage, so it is essential to protect these areas with sunscreen and protective clothing.
- Mental health. The visibility of white patches can generate psychological distress, particularly in people with darker skin because the spots are more noticeable. Many patients suffer from anxiety, insomnia, depression and self-esteem problems, especially when the spots are present in visible areas such as the face and hands.
- Social impact. The disease can limit social and professional life, creating difficulties in interpersonal relationships and leading to incidents of discrimination or stigma due to lack of knowledge about the condition, which is neither contagious nor dangerous.
Vitiligo is a disease that can occur as early as childhood and is also quite common in paediatric age, as it affects around 1% of children globally. In younger children, the disease can have a significant psychological impact, as visible white patches can affect their self-esteem and cause difficulties in relationships with peers.
Available treatments
There is currently no definitive cure for vitiligo, but medical treatments and dietary supplements are available that can help improve the appearance of affected areas and slow down the progression of the disease:
- Supplements containing copper, nicotinamide, L-phenylalanine, L-tyrosine and other useful nutrients to promote skin pigmentation and combat oxidative stress. These supplements are often used in conjunction with other treatments to improve the appearance of the skin.
- Creams containing folic acid, resveratrol and other substances indicated for balancing skin processes.
- Topical corticosteroids, to reduce inflammation and stimulate repigmentation, especially in the early stages of the disease.
- Calcineurin inhibitors: tacrolimus and pimecrolimus, indicated for sensitive areas such as the face, are a good alternative to corticosteroids.
- Narrowband UVB phototherapy, one of the most effective therapies that artificially reproduces sunlight and stimulates residual melanocytes to produce melanin. It requires regular sessions in a hospital setting and can take several months to produce visible improvements.
- PUVA (psoralen + UVA): combination therapy with photosensitising drugs and UVA rays, although it has a higher risk of side effects such as sunburn and possible long-term risks. It is used for vitiligo in cases where depigmented patches are particularly extensive or resistant to other topical treatments.
- Melanocyte transplantation and skin grafts. Used for areas resistant to other treatments, these surgeries can help repigment depigmented areas in a localised manner.
Tips for the daily management of vitiligo
In addition to the above-mentioned treatments, vitiligo sufferers can take certain steps to better manage the condition and improve their quality of life:
- Sun protection. Use sunscreen with a high sun protection factor (SPF) regularly to protect depigmented areas.
- Use of cosmetics. Foundation and self-tanners can help cover white patches and reduce the contrast with normal skin.
- Psychological support. Psychological counselling, cognitive-behavioural therapy or support groups can help manage the emotional impact of the disease.
- Healthy lifestyle. Following a balanced diet rich in fruit, vegetables and antioxidants can help maintain the overall health of the skin and manage stress.
- Regular monitoring. It is important to have a regular dermatological examination with a specialist to monitor the evolution of the disease and adapt the therapy according to changes.
Future perspectives
As we have observed, vitiligo still has no definitive cure, yet scientific research continues to progress and promises new treatment possibilities. Currently, numerous studies are focusing on the efficacy of specific Janus kinase (JAK) inhibitors and monoclonal antibodies. These treatments aim to modulate the body’s immune response by reducing the aggression of melanocytes, the cells responsible for skin pigmentation. These advances could lead to significant developments in the treatment of vitiligo, offering new hope for those living with the condition.
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