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Opinion ArticleOpen Access

Vitiligo Definition Classification Treatment and Prognosis A Personal Opinion Volume 1 - Issue 3

Adekunle George*

  • Department of Medicine, College of Medicine, University of Ibadan Nigeria, Ibadan, Nigeria

Received: July 26, 2017;   Published: August 03, 2017

Corresponding author: Adekunle George, Department of Medicine, College of Medicine, University of Ibadan Nigeria, Ibadan, Nigeria

DOI: 10.26717/BJSTR.2017.01.000253

Opinion

Vitiligo has no respect for race, socioeconomic status or age. The following are celebrities who have or have had Vitiligo. Michael Jackson, Lee Thomas Americo Garcia Holly Marie Combs, Winnie Harlow, Rasheed Wallace, Tamar Braxton Joe Rogan Sisqo Richard Hammond Thomas Lennon [1]. Vitiligo is a cutaneous pigmentary disorder caused by selective destruction or ‘temporary sickness’ of melanocytes presenting with complete or partial loss of skin color. Broader definitions are available from different authors and medical scientists [2]. I have defined the entity in the first instance in this way because it would explain many aspects and features of Vitiligo. A definition from the researcher referred to above [2] has the following key words: ‘Vitiligo, an autoimmune disorder characterized by localized and / or generalized depigmentation of the skin and / or mucous membranes’.

The downside of such definition is that it does not cover what Vitiligo is all about. It focuses on ‘autoimmunity’ which is a big issue in Europe and the Americas. Diseases considered to be ‘Autoimmune’ -pernicious anemia, Graves’s disease Hashimoto’s thyroiditis are rare in Nigeria despite the high prevalence of Vitiligo [3]. In a search for autoimmune diseases by Greenwood [4,5] at the University College Hospital, Ibadan one of the largest hospitals in the world he found pernicious anemia (PA) in 4 patients out of over 90, 000 screened patients. Furthermore three of these were Caucasians and one an Indian-out of a sea of ‘black’ skinned Nigerian patients [6] documented only 10 cases of PA in a period of 15 years (1973-1988) in Lagos University Teaching hospital Nigeria’s second largest hospital.

The definition by Sehgal also in its emphasis on ‘autoimmunity’ fails to consider the possibility of chemicals in the causation of Vitiligo which some like Stevenson have referred to as ‘Occupational Vitiligo’ [7], Other chemicals not ‘occupational’ with chemical similarities abound in Nigeria [3] and are regularly used as cosmetics. These include hydroquinone containing creams -with over 50 brands, phenol solutions and bar soaps -‘Dettol’, ‘Septol’.Classification of Vitiligo may be clinical -focal, segmental, acrofacial, universal as well as based on age of onset. Some experts consider Vitiligo in children to be a subset or a different disease from that of the adult [8,9].

From our observation we consider Vitiligo in the young adults to be generally speaking ‘merely a cosmetic nuisance’ while we have often rigorously look for serious etiological / underlying diseases -endocrinopathies and neoplasm in the elderly or older than 50 year -age group [3,10]. A definition of Vitiligo adopted should also explain the prognostic factors as documented [11,12]. He documented that the face responded better (compared to the shin), dark and brown-skinned people repigmented better, that natural UVA gave better response, and that spontaneous repigmentation was more common in children. The many and increasing modalities of treatment-PUVA, PUVASOL (psoralens + artificial and natural UVA), corticosteroids, Chinese Herbal, Australian natural and Indian homeopathic remedies, Laser therapy etc [13,14] have given different responses some as high as ‘a hundred percent’ cure rate. The plausible explanation beyond sales gimmick is that the underlying cause of the Vitiligo will determine the actual response or non response.

From my observations over the years and from the huge amount of documentation in literature I have come to the conclusion that a definition that will embrace the present knowledge would be:“Vitiligo is a pattern of skin reaction presenting with different degree of skin color loss (hypo - or depigmentation) and without textural changes”. It can thus be likened to the definition of anger “an emotional reaction pattern” readily recognized by the facial reaction and clenched fists. In the latter, a search should be made for the underlying cause (s). Prognosis or the time of disappearance of the cause of the anger will depend on how quickly solution can be provided if at all. Similarly such a definition of Vitiligo encourages a search for an underlying cause -autoimmune disease, chemical usage (phenolic derivatives, hydroquinone) trauma (Road traffic accidents, post surgery, Koebnerization), oxidative stress,neoplasm and the like. Vitiligo may thus be considered ‘primary” or “secondary”). The former being the classification where extensive investigation has not yielded a cause that should be treated i.e. similar to Primary /essential and secondary systemic Hypertension. Such an idea will aid etiological /aetiopathogenetic solutions and explain prognosis and the variable responses to treatment modalities. It would account for the contributions to the disease in different countries. Most of the patients with Vitiligo in our study from Nigeria are 30 years and below. Absence of autoimmune diseases can thus be expected while the use of cosmetic products like hydroquinone and phenolic derivatives are frequently used in this age group.

Having searched for an underlying cause, the next stage in Vitiligo management is to attempt to repigmentation of the skin by the various modalities of treatments currently available consisting of PUVA or PUVASOL- the use of photoactive chemicals-psoralens and artificial or natural ultraviolet light, corticosteroids, needling, grafting, melanocytes harvesting, artificial blister production for grafting, melatonin, diets, lasers and a host of others. Medical tattoo has been utilized as well as cosmetic masking with powders (covermak). Spontaneous repigmentation does take place occasionally especially in the pediatric age group. In conclusion there is a need to take a fresh look at terminologies used in dermatology which will remove overlaps, and reduce confusion thus making management of skin diseases more rational if not necessarily easier.

References

  1. Sehgal VN, Srivastava G (2007) Vitiligo: Compendium of clinicoepidemiological features. Indian J Dermatol Venereol Leprol 73(3): 149- 156.
  2. George AO (1989) The incidence of vitiligo at the University College Hospital, Ibadan, Nigeria, was 6% for the period from 1980-1983. Int J Dermatol 28(6): 385-387.
  3. George AO (1989) The incidence of vitiligo at the University College Hospital, Ibadan, Nigeria, was 6% for the period from 1980-1983. Int J Dermatol 28(6): 385-387.
  4. Greenwood BM, Herrick EM, Voller A (1970) Can parasitic infection suppress autoimmune disease? Proc R Soc Med 63(1): 19-20.
  5. Greenwood BM (1968) Autoimmune diseases and parasitic infections in Nigerians. Lancet 2(7567): 380-382.
  6. OO Akinyanju, C.C Okany (1992) Pernicious anaemia in Africans. Clin Lab Haematol 14(1): 33-40.
  7. O Sullivan JJ, Stevenson CJ (1981) Screening for occupational vitiligo in workers exposed to hydroquinone monomethyl ether and to paratertiary-amyl-phenol. Br J Ind Med 38(4): 381-383.
  8. G O Alabi Z F Falope U G Lekwauwa (1991) Coexisting malignant melanoma and vitiligo in a Nigerian. West Afr J med 10(1): 443-446.
  9. AJ Kanwar (2012) Childhood Vitiligo: Treatment Paradigms. Indian J Dematol 57(6): 466-474.
  10. Shah (2014) Vitiligo in Children: Causes, Diagnosis and Treatment.
  11. A Jarrett, G Szabo (1956) The pathological varieties of vitiligo and their response to treatment with meladinine. Br J Dermatol 68(10): 313-326.
  12. Szabo G (2000) Vitiligo: A Monograph on the Basic and Clinical Science, (ed) James Nordlund copyright by Blackwell science limited.
  13. Remove Vitiligo Naturally - Australian Made Organic Remedy .
  14. Suite M, Quamina DB (1991) Treatment of vitiligo with topical melagenine--a human placental extract. J Am Acad Dermatol 24(6 Pt 1): 1018-1019.
  15. Matin M, Latifi S, Zoufan N, Koushki D, Rahdari F, et al. (2014) The effectiveness of excimer laser on Vitiligo treatment in comparison with a combination therapy of Excimer laser and tacrolimus in an Iranian population. J Cosmet Laser Ther 16(5): 241-245.