Medical Edge Newspaper Column

Restoring Skin-Color Loss

April 9, 2007
Dear Mayo Clinic:
A few months ago I noticed that I've lost some of the pigmentation of my skin at the neck area, and I'm concerned it might be vitiligo. Could this have been caused by something I wore on my neck? Is this serious? Do I need to see a doctor, or are there any over-the-counter treatments? -- Brampton, Ontario

Answer:
We need to distinguish between "hypopigmentation" (less pigment in particular places on the skin) and "depigmentation" (no pigment at all). In the former, skin cells called melanocytes are still producing some melanin, which gives your skin its characteristic color and helps protect it from the sun's ultraviolet rays. In the latter, the melanocytes have been completely destroyed, no melanin is produced, and the affected section has turned a porcelain white color.

While hypopigmentation has many possible causes -- natural aging, dermatitis, past sunburns, and allergic reactions, among others -- depigmentation usually has only one cause: vitiligo. Either way, your condition is likely not serious, but you should still see a doctor as soon as possible. The earlier treatment starts, the better your chance of reducing the extent of the skin discoloration.

Experienced dermatologists can usually diagnose vitiligo through taking the patient's history and performing an examination. While hypopigmentation can be accompanied by a variety of other symptoms, whitened and asymptomatic skin is vitiligo's only presenting sign. Other characteristics, such as texture and sensation, are unaffected. Other factors include heredity -- vitiligo often runs in families -- and the presence of certain autoimmune diseases, with which vitiligo is correlated. Reliable technologies, involving a Wood's lamp exam or skin biopsy, can confirm the diagnosis.

Scientists do not yet know whether an autoimmune disease, when it coincides with vitiligo, is the cause or the effect. The two conditions may not even be related. But while what triggers the sequence of events in vitiligo remains debatable, doctors generally agree that the immune system does the attacking; it gets activated to selectively destroy melanocytes in certain places. Affected locations may have been rendered particularly vulnerable by a prior event, such as serious sunburn, or by the cumulative effects of irritation from, say, a tight-fitting necklace. Though incurable, vitiligo is potentially manageable -- we can attempt to suppress the immune system's action as it affects the skin's pigment cells.

Treatment alternatives are all by prescription, and topical corticosteroid therapy is often the treatment of choice. Regular corticosteroid application to the affected areas permits melanocytes to regrow and restore some or all of the skin's normal color. Alternatively, steroid-like immunomodulator creams, such as tacrolimus (Protopic) or pimecrolimus (Elidel), may be applied for similar effect.

Another route to immunosuppression in the skin, paradoxically, is ultraviolet radiation. Under controlled conditions at specific wavelengths and intensities, this light is immunosuppressive and non-damaging to the skin. A similar technique is used with excimer laser light as well. And an alternative approach is not to suppress the immune system but to distract it from targeting melanocytes by using topical irritants, which essentially create decoys.

An altogether different option is to graft normal skin from elsewhere in the body to the depigmented site. Melanocytes in the transplanted patch may then grow, unaffected by the immune system's action. This alternative has yielded good results for many people but it is time-consuming, expensive, and offered at only a few centers in the United States.

Note that none of these options are over-the-counter, and I would caution you to beware of any proffered treatments that are.

Remember, though, that one good option is no therapy at all. If the affected patches are modest in number and extent, small in size, or out of sight when normally clothed, you may just periodically apply coverup cosmetics and always stay "photo-protected," as the depigmented sites are highly vulnerable to sunburn and its sometimes-serious consequences. And some patients are fortunate enough to experience a complete reversal of their vitiligo, spontaneously and for unknown reasons.

-- Dawn Marie Davis, M.D., Dermatology, Mayo Clinic, Rochester, Minn.