Sharni Kaur, right, and her mother, Roop Singh. Sharni has suffered from vitiligo, which causes her skin to lighten, since she was nine years old.

Singer/songwriter Michael Jackson suffers from vitiligo (see upper-arm)

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Vitiligo

Vitiligo (IPA /ˌvɪtəˈlaɪgo/) or leukoderma is the patchy loss of skin pigmentation due to an auto-immune attack by the body's own immune system on skin melanocytes. It frequently begins in late adulthood, with patches of unpigmented skin appearing on extremities. The patches may grow or remain constant in size. Occasional small areas may repigment as they are recolonised by melanocytes. The population incidence is between 1% and 2%. more...

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Vitiligo is not contagious.

In some cases, mild trauma to an area of skin seems to cause new patches - for example around the ankles (caused by friction with shoes or sneakers). Vitiligo may also be caused by stress that affects the immune system, leading the body to react and start eliminating skin pigment.

The disease is not medically a problem, but it is mentally and socially to some people, other than the problem that the affected skin areas have no protection against sunlight - they burn but never tan. However, if the skin is naturally dark, the visual effect of the white patches may be considered disfiguring by some. (If the affected person is pale-skinned, the patches can be at least be made less visible by avoiding sunlight and the tanning of unaffected skin.) The location of vitiligo affected skin changes over time, with some patches re-pigmenting and others becoming affected. (Exposure to sunlight is always better; it helps the melanocytes regenerate to allow the pigmentation to come back to its original color.)

Vitiligo on the scalp may affect the colour of the hair (though not always), leaving white patches or streaks. It will similarly affect whiskers and body hair.

In some cultures there is a stigma attached to having vitiligo. Those affected with the condition are sometimes thought to be evil or diseased and are sometimes shunned by others in the community. People with vitiligo may feel depressed because of this stigma or because the way their skin looks is a dramatic change.

Treatment

Steroids have been used to remove the white patches, but they are not very effective. Other more dramatic treatments include chemically treating the patient to remove all pigment from the skin to present a uniform skin tone. Current experimental treatments include exposure to narrow-band UV light, which seems to blur the edges of patches, and lightly freckling the affected areas. Immunomodulator creams are believed to cause repigmentation in some cases, but there is no scientific study yet to back this claim. All these treatments alter the appearance but do not address the underlying cause of vitiligo.

In late October of 2004, doctors successfully transplanted melanocytes to vitiligo affected areas, effectively repigmenting the region. The procedure involved taking a thin layer of normally pigmented skin from the patient's "gluteal region". Melanocytes were then separated out and used to make a cellular suspension. The area to be treated was then ablated with a laser, and the melanocyte graft applied. Three weeks later, the area was exposed to UV light repeatedly for two months. Between 73 and 84 percent of patients experienced nearly complete repigmentation of their skin. The longevity of the repigmentation differed from patient to patient.

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A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo
From Journal of Drugs in Dermatology, 11/1/05

A Randomized Placebo-Controlled Double-Blind Study of Levamisole in the Treatment of Limited and Slowly Spreading Vitiligo

Agarwal S, et al. Br J Dermatol. 2005;153:163-166.

Summary

The authors present a randomized, double-blind, placebo-controlled study to evaluate the efficacy of levamisole in halting the progression of limited and slowly spreading vitiligo. Sixty patients were enrolled in the study. All patients had to have vitiligo affecting less than 2% of their body surface area. To fulfill criteria for "slowly spreading," patients were required to have 1 to 5 new lesions in the month prior to enrollment, or 6 to 15 new lesions within 3 months prior to enrollment. This was based on history provided by the patient. Patients were then randomized to receive 150 mg of oral levamisole daily for 2 consecutive days a week, or placebo. Patients who were of ages 6 through 12 received a dose of 100 mg instead of 150 mg. In addition, all patients applied mometasone furoate 0.1% cream daily to lesions of vitiligo. Patients were evaluated monthly for a total of 6 months. As the primary outcome was the occurrence of new lesions, assessment at each visit consisted of counting any new lesions of vitiligo that had developed since the last visit. Patients were withdrawn from the study if they had more than 10 new lesions within 1 month or more than 20 new lesions in 3 months. Patients were excluded from analysis if they were lost to follow-up, if they discontinued intervention, or if they did not complete 6 months of treatment. Results showed a statistically significant difference between the levamisole-treated and the placebo-treated groups in the cessation of new lesions in only the fourth month of treatment. In all other months, differences were not statistically significant, though trended toward the levamisole-treated group.

Comment

The authors present a randomized, double-blind, placebo-controlled study to evaluate the efficacy of the antihelminthic drug levamisole in halting the progression of limited and slowly spreading vitiligo. This study was based on a prior open-label study in which levamisole was effective in stopping the development of new lesions in 34 of 36 patients. (1) Results from this study do not support those seen in the earlier study. In this study, 83% of patients in the levamisole-treated group stopped developing new lesions, while 60% of placebo-treatment patients did so as well. The authors rightly point out several confounders within this study, most notably the effect of recall bias in the enrollment of patients. Criteria defining patients as "slowly spreading" was based solely on the recollections of patients, making it difficult to assess whether or not the patients had truly active disease. In addition, the authors also state the study was inadequately powered to ascertain whether or not levamisole accounted for the difference between the 2 groups, as enrollment number was determined with an expected rate of only 20% for cessation of new lesions in the placebo-treated group, not 60%. This study does not support the efficacy of levamisole seen in an earlier trial and underlines the importance of following up open-label trials with blinded, randomized ones. Because of the striking efficacy noted in the open-label trial, it may be worth repeating a randomized study with levamisole after ensuring that patients have clinically active disease.

Reference

1. Pasricha JS, et al. Effect of prolonged treatment with levamisole on vitiligo with limited and slowly-spreading disease. Int J Dermatol. 1994;33:584-7.

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