Vitiligo

What causes vitiligo

In vitiligo, immune cells (especially T cells) attack and destroy melanocytes. Interferon-gamma and the JAK-STAT signaling pathway drive this attack, which is why JAK inhibitors work. Contributing factors:

• genetics: about 1 in 5 people have an affected relative. Many genes involved in immunity are linked
• oxidative stress in melanocytes
• triggers: skin injury (Koebner phenomenon), sunburn, friction from clothing, chemical exposure (such as some hair dyes and rubber products), and emotional stress

Types of vitiligo

Early signs

• pale or white patches, often around the eyes, mouth, fingers, wrists, armpits or groin
• white or gray hair on the scalp, eyebrows, eyelashes or beard in an affected area
• loss of color inside the mouth or nose
• patches that are more visible after tanning, because the surrounding skin darkens

Signs of active, spreading vitiligo include:

• confetti-like small white spots
• trichrome areas with three shades (normal, lighter, white)
• Koebner phenomenon: new patches at sites of cuts or rubbing
• red, inflamed edges (rare)

Associated conditions

People with nonsegmental vitiligo have higher rates of other autoimmune diseases, especially:

• autoimmune thyroid disease (Hashimoto's thyroiditis and Graves' disease), the most common
• type 1 diabetes
• alopecia areata
• pernicious anemia
• Addison's disease
• rheumatoid arthritis and lupus

A thyroid blood test is often recommended at diagnosis and periodically.

Conditions that can look similar

• tinea versicolor: pale, finely scaly patches from yeast, on the chest and back
• pityriasis alba: pale, slightly scaly patches on the face in children, often with eczema
• post-inflammatory hypopigmentation after eczema, psoriasis or injury
• idiopathic guttate hypomelanosis: small white spots on sun-exposed legs and arms with age
• piebaldism: present from birth and stable
• rarely, hypopigmented mycosis fungoides or leprosy

Diagnosis

• examination, including Wood's lamp (ultraviolet light), which makes vitiligo patches glow bright blue-white
• thyroid function and antibody tests
• skin biopsy occasionally, if the diagnosis is uncertain

Treatment

Treatment can stop spreading and restore color. Response is best on the face and neck and slowest on the hands, feet and lips. It often takes 3 to 6 months or longer to see repigmentation.

Topical treatments

• ruxolitinib cream: a JAK inhibitor approved by the FDA in 2022 for nonsegmental vitiligo in people 12 and older. Around half of patients achieve substantial facial repigmentation after a year
• topical corticosteroids: for limited areas, used in cycles to reduce skin thinning
• calcineurin inhibitors (tacrolimus, pimecrolimus): especially for the face and folds

Light therapy

• narrowband UVB phototherapy two to three times a week, for widespread vitiligo
• excimer laser or lamp for small areas
• light therapy works better combined with topical treatment

Stopping spread

• short courses of oral steroid pulses for rapidly spreading disease, under specialist supervision
• oral JAK inhibitors are being studied in clinical trials

Surgery

For stable vitiligo that has not changed for at least 12 months, especially segmental vitiligo: skin grafts or melanocyte-keratinocyte cell transplantation.

Other options

• cosmetic camouflage: makeup, self-tanners, and skin dyes
• depigmentation: removing remaining pigment with monobenzone cream, for very extensive vitiligo
• sun protection: to prevent sunburn in white patches and reduce contrast

Living with vitiligo

Vitiligo does not cause physical illness, but it can affect self-esteem, mood and relationships, especially when visible. Support groups, counseling and connecting with others with vitiligo help many people.

Frequently asked questions

What causes vitiligo?

Vitiligo is caused by the immune system attacking melanocytes, the skin's pigment cells. Genetics play a role, and triggers such as skin injury, sunburn, chemical exposure and stress can start or worsen it. It is not caused by diet or infection.

Is vitiligo contagious?

No. Vitiligo cannot be passed from person to person by touch or any other contact. It is an autoimmune condition, not an infection.

What are the early signs of vitiligo?

Early signs are pale or milky-white patches of skin, often on the face, hands, feet or around the mouth and eyes, and premature white hair in a patch. Small confetti-like white spots can signal active spreading.

Can vitiligo be cured?

There is no permanent cure, but treatments can stop spreading and restore pigment, sometimes extensively. Ruxolitinib cream, topical steroids or calcineurin inhibitors and narrowband UVB light therapy work for many people, especially on the face.

Is vitiligo linked to other diseases?

Yes. People with vitiligo have higher rates of autoimmune thyroid disease, type 1 diabetes, alopecia areata, pernicious anemia and Addison's disease. A thyroid blood test is often recommended at diagnosis.