What causes vitiligo? Diagnosis, prevention, and treatment

Overview: What is vitiligo?

Vitiligo is a chronic autoimmune skin condition in which areas of the skin lose their pigment. This is due to the body’s immune system attacking and destroying the skin cells that produce the skin’s dark pigment (melanocytes). White patches form on the skin. These patches can grow more prominent, or new ones can form elsewhere. The hair in those areas may turn silver or white. These patches can be highly localized, like on the neck or back of the hand. However, the most common type of vitiligo is generalized vitiligo, in which depigmented skin patches appear anywhere on the body. Often, vitiligo appears symmetrical on both sides of the body. Still, it could be a less common segmented subtype where depigmented skin only appears on one side of the body. The eyes and ears can be affected because both have pigment cells. Eye swelling, increased sensitivity to the sun, and even hearing loss are possible. Vitiligo can appear at any age, from child to adulthood but can be more common in teenagers and early adulthood.

Fortunately, vitiligo is not a health-threatening condition, but self-esteem and quality of life can suffer, especially if the affected skin is highly visible. 

What causes vitiligo?

Healthcare professionals don’t completely understand vitiligo causes. Vitiligo is believed to involve a complex interaction of genetic and environmental factors that trigger an immune system attack on melanocytes. These skin cells produce melanin, the substance that darkens the skin. Without melanocytes to produce melanin, the skin appears pale and white.

• Genetic causes of vitiligo: People with vitiligo are born with melanocytes vulnerable to oxidative stress. The release of free radicals, often caused by injury, damages these pigment-producing cells more readily than in other people. People with vitiligo also are born with more active immune system responses to damaged cells, so the immune system is more likely to attack and kill stressed melanocytes.

• Environmental causes of vitiligo: The process of vitiligo depigmentation is believed to be triggered by exposure to environmental shock or injuries like severe sunburn, cuts, scrapes, or toxic chemicals.

Though imperfectly understood, vitiligo depigmentation starts when a part of the skin is injured, damaging skin cells. This damage mainly affects melanocytes if they’re genetically vulnerable to free radicals. The stressed melanocytes give off chemicals that attract immune system killer cells. In people genetically susceptible to autoimmune disease, the body’s immune system attacks and destroys melanocytes as if they were foreign invaders. The death of these cells leaves no skin pigment-producing cells in that area. Without melanin, that area of skin and any hair on it may turn white. 

Risk factors for vitiligo

Since vitiligo involves a complex interplay between genetics and the environment, the major risk factors for vitiligo are:

• A family history of vitiligo

• Autoimmune conditions

• Exposure to toxic chemicals or skin injuries

Is vitiligo serious? When to see a doctor

Vitiligo is not a life-threatening medical condition but can profoundly affect self-image, self-esteem, mood, and social functioning. People may also develop complications such as eye swelling, increased sensitivity to the sun, and even hearing loss. Certain factors, like the age of vitiligo onset and the amount of body surface involvement, can impact the effectiveness of treatment. Treatment may be more effective if started as early as possible. Still, most people on treatment usually experience periodic cycles of pigment loss and disease stabilization, so visiting a healthcare provider when vitiligo patches first appear is helpful. 

How is vitiligo diagnosed?

Vitiligo is diagnosed by examining the skin. At some point, a dermatologist will make the final diagnosis. Dermatologists specialize in skin diseases. The healthcare provider will start by examining the white patches and will also look at those patches with a special ultraviolet lamp called a Wood’s lamp. It’s more popularly known as a black light. It can definitively rule out other causes. In some cases, the healthcare provider may take a skin sample and examine it under the microscope, a procedure called a biopsy. Because vitiligo can affect the eye, an eye doctor may also examine the eye for swelling.

When seeing a dermatologist, be prepared to answer questions like:

• When did the problem start? 

• How have the pigment changes progressed since then?

• Have the lesions changed?

• What happened before the skin lost pigment?

• Are there other symptoms?

• Are there any other medical conditions?

• What drugs are being taken?

Sometimes a blood test may be needed to discover other possible immune system problems like thyroid disease.

Is vitiligo hereditary?

Vitiligo has a genetic component, though the inheritance is very complex. There is a family history of vitiligo in 25% to 30% of people with vitiligo. People who have a sibling with vitiligo have a 6% chance of developing the same problem. Almost 1 in 4 people with an identical twin with vitiligo also develop the disease. Additionally, many people with vitiligo have other autoimmune diseases, including thyroid disease, Type 1 diabetes, pernicious anemia, rheumatoid arthritis, and psoriasis.

Is vitiligo curable?

Vitiligo is not curable, but it can be treated. The condition’s progress can be slowed down, and repigmentation of blanched areas of skin is possible with drugs, phototherapy, or surgery. Unfortunately, treatment is slow and uncertain. Some people can achieve a complete remission with treatment, but the recurrence rate is high. Treatments are most successful when combination therapy is used. 

An effective treatment is UVB light therapy. It works well on early or localized vitiligo. The affected area is bathed in UVB light, which can stimulate the restoration of color to the whitened skin. This treatment option is usually given two to three times a week for six months to one year. UVA light therapy can be used with a drug called psoralen, which makes skin more sensitive to UV light, but this is less common.

Other treatment options include applying topical immunosuppressants to the affected skin, typically corticosteroid or calcineurin inhibitor creams. Topical vitamin D (calcipotriene) or prostaglandin analogues might also be prescribed to restore pigmentation. Some doctors may advise dietary supplements that contain antioxidants to prevent skin cell damage or vitamins and minerals that can help restore pigment. Again, combination treatment is often most effective as it can lead to faster results and greater repigmentation.

For more advanced cases, medications such as oral corticosteroids, systemic immunosuppressants, or the melanocyte-stimulating drug Scenesse (afamelanotide) may be prescribed. Surgical skin grafts or cell transplants can also be used to restore pigment. Skin grafts sound serious, but only small amounts of skin need to be grafted. This healthy skin will provide enough melanin to restore pigment to the entire affected area. 

Some people who have lost most of their skin pigmentation may choose to have all the remaining skin pigment removed with a topical medication, such as monobenzone.

How to prevent vitiligo

Although vitiligo is an autoimmune disorder with a genetic component, avoiding environmental triggers can prevent damage to skin pigment cells. The American Academy of Dermatology (AAD) recommends the following measures to prevent vitiligo from spreading:

• Avoid sun damage

• Always use broad-spectrum, water-resistant SPF 30 or higher sunscreen when exposed to the sun

• Apply sunscreen 15 minutes before being exposed to the sun

• Wear protective clothing in the sun

• Stay in the shade

• Do not use tanning beds

• Avoid skin injuries like burns, cuts, and scrapes

• Protect the areas of the body most vulnerable to scrapes and cuts, such as hands, elbows, and knees

FAQs about vitiligo causes

What causes vitiligo to spread?

Vitiligo can be triggered by skin injuries such as sunburns or scrapes, so dermatologists advise people with vitiligo to protect their skin from injuries and the sun. Emotional and physical stress might also contribute to the spread of vitiligo. Stress increases immune system activity and is associated with the worsening of other autoimmune diseases, such as inflammatory bowel disease (IBD) and rheumatoid arthritis.

What causes vitiligo to get worse?

Anything that causes skin damage or triggers the immune system can worsen vitiligo. This includes cuts, scrapes, burns, emotional stress, and physical stress. 

Is vitiligo related to liver disease?

Vitiligo is an autoimmune disease, but the genetics are complicated. Nonetheless, people with vitiligo have an increased risk of developing other autoimmune diseases, particularly thyroid disease, Addison’s disease (an autoimmune disease of the adrenal glands), and Type 1 diabetes (an autoimmune disease of the pancreas). There is also an association between vitiligo and autoimmune disorders of the liver, such as autoimmune hepatitis.

What’s next? Additional resources for people with vitiligo

Test and diagnostics

• Vitiligo, StatPearls

Treatments

• Recent advances in understanding vitiligo, F1000Research

• Surgical interventions for patients with vitiligo: a systematic review and meta-analysis, JAMA

• Vitiligo: a narrative review, Cureus

• Vitiligo: diagnosis and treatment, American Academy of Dermatology (AAD)

• Vitiligo: diagnosis, treatments, and steps to take, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Scientific studies and clinical trials

• The relationship between stress and vitiligo: evaluating perceived stress and electronic medical record data, PLOS ONE

• Skin manifestations associated with autoimmune liver diseases: a systematic review, Clinical Reviews in Allergies & Immunology

• Vitiligo pathogenesis and emerging treatments, Dermatologic Clinics

More information on related health conditions

• Hyperthyroidism vs. hypothyroidism: compare causes, symptoms, treatments, & more, SingleCare

• Tinea versicolor treatments and medications, SingleCare