Vitiligo, the most common de-pigmentation skin disorder

1. Background

Vitiligo is an acquired and the most common depigmentation disorder of the skin, hair and mucosal surfaces. It manifests with white patches and macules as a consequence of the destruction and selective function loss of melanocytes. Melanocytes are very specific cells located at the bottom layer of the skin epidermis. Through a process called melanogenesis, they produce melanin. This is a dark pigment, responsible for our skin colour, which protects against UV light and free radical damage. Simply put, the darker your skin the more melanin you have.

The production of melanin within melanocytes is orchestrated by some organelles called melanosomes. These use specific enzymes and proteins, and involving interactions with the central nervous, endocrine and immune system.

Melanin synthesis, within melanocytes, can be related to three aspects: enzymes required for melanin synthesis; structural proteins of melanosomes; melanosomes transport and distribution.

Vitiligo can affect between 0.5% and 1% of the population and can be differentiated into two main categories. 1) Segmental vitiligo, confined to the dermatome, a section of the skin supplied by a single spine nerve. 2) Generalized vitiligo, appears on areas sensitive to friction, but also on the face, scalp, back of the hands. Vitiligo onset is more common around 24 years. It has no prevalence between men or women, or no difference in rate according to skin type.

2. Aetiology

First and foremost, it is very important that diagnosis of vitiligo is accurate, because its features may be confused with those of other types of hypopigmentation disorders.

The aetiology factors of this skin condition are still unclear, but they could be of different nature. Some hypotheses have suggested the involvement of genetic variations, neurohormonal, biochemical, oxidative stress, melanocytorrhagy. Endo and exotoxins exposure, low vitamin D, and a familial or personal auto-immune condition are also linked to vitiligo. Also, emotional and physical stress, especially if prolonged over time, could be a trigger for the development of the disease.

One recent study found presence of inflammation and other markers, like TNF-α, IL-17 and IFN-ƴ within the skin where white patches are present. These inflammatory markers impact on melanin production by suppressing the pigmentation related signalling.

There are different pathologies related to hypopigmentation like Alezzandrini syndrome, tuberous sclerosis, the Werner syndrome and others. Also, some infections like HIV, syphilis and Hansen’s disease may have a causative effect for depigmentation.  

The pathological pathway which is most understood and common is mediated by T-cell and has an auto-immune component. This hypothesis is strongly supported by the presence of antibodies against several antigens in the melanocytes. This means that the immune system of the person with vitiligo is destroying its own melanocytes, with consequent skin depigmentation. The reasons for this self-destruction are not completely clear, but they certainly involve genetic and environmental components.    

3. Treatments

Conventional treatments for vitiligo see the use of topical immune-modulating corticosteroids, like tacrolimus. This is the first line approach with a success rate of 75% of repigmentation mainly on neck and face. This corticosteroid has a very specific action by suppressing T-cell and TNF-α activity. The downside of this approach are the possible severe local and systemic side effects. These include steroid folliculitis, telangiectasia and epidermal atrophy, to mention just a few.     

Other orthodox approaches use plus UVA systemic radiation, so called phototherapy, for widespread vitiligo. Its efficacy is anyway equivocal and may increase the risks of different types of skin cancer.

Laser therapy may also be used, which is a more targeted form of phototherapy treatment with possible fewer side effects. A new device called “Bioskin” transmits UVB radiations which in a trial increased repigmentation up to 72% in combination with other forms of treatments.

Something else to consider in vitiligo patients is the impact on the person’s self-esteem. This may vary depending on the severity, skin type and cultural background. In extreme cases, when the person emotionally and physically withdraws from social interactions, counseling or psychotherapy, may help.

4. So, what else can be done?

Simply put, never self-diagnose or self-prescribe. Always consult a health care professional who can assess you correctly and guide your journey to possible recovery. This is true especially if you are pregnant, more vulnerable and on medications. Please bear in mind that there is no 100% success rate guaranteed in any therapeutic approaches for vitiligo.

I believe that the body can self repair, as far as we eat the right nutrients and make perfect lifestyle choices. Symptoms are red lights, telling us that something we eat or do is causing or contributing to our dysfunctional bodies.

In my clinical practice I fully assess my clients’ present and past medical and health history. I also assess dietary and lifestyle choices, social interactions, emotional wellbeing, stress levels and sleep patterns. I may also use tests to allow for an in depth understanding of the pathophysiology of the symptoms and disease.

The vitiligo pathway that I mostly see in my practice involves an over activation of the immune system. If this is prolonged over a long period of time, our immune system may attack our own tissues. The reasons for this are many and may include stress, allergens, chronic inflammation, “leaky gut”, vitamin D deficiency and others.

5. Intervention

There are three different stages I follow in my clinical practice with clients with vitiligo:

Prevent further melanocytes stress and damage.

Decreasing inflammatory markers, toxins exposure, free radicals and allergens.

  • Avoid inflammatory foods like deep fried food; red and mainly processed and cured meat; all dairy products; industrialized cakes, biscuits, sodas and other sugary products; GMOs food; alcohol; processed meals; gluten containing products.
  • Introduce anti-inflammatory foods like oily fish (sardines, wild salmon, mackerel, trout); turmeric and ginger; seeds and nuts; green leafy vegetables; extra virgin olive oil.  
  • Reduce toxins exposure and engage in gentle detox, please read my article here on how to do that.
  • Reduce free radicals, because they can damage cell wall and DNA. Give up smoking if you are a smoker (the NHS can help you here); decrease emotional and physical stress, please read my article on how to decrease stress levels here. Introduce antioxidants from a variety of colourful fruits and vegetables.
  • This is an excellent antioxidants formula supplement. It already contains vitamin A, Copper and Cysteine, which are co-factors in melanin production. 

Manage the auto-immune self-harming mechanisms.

Decrease antibodies to melanocytes antigens.

  • Assess your digestive health, in order to find out if there are any agents creating gut lining inflammation. Inflammation may cause leaky gut, which may be a cause or contributing factor to auto-immune conditions. Gut inflammation may be a consequence of SIBO, intestinal parasites, candida, stress, medications, pro-inflammatory food, allergies and more.
  • To improve general digestive health, pre and probiotics may be very helpful, unless contraindicated due to SIBO.
  • Vitamin D regulates the immune system especially when there is an autoimmune condition present. I will supplement during the winter months and if you live in the Northern hemisphere anyway.
  • Vitamin A may increase your gut tolerance to allergens. Please also include oily fish, eggs, sweet potato, winter squash, kale, carrots, spinach, mango, cantaloupe, apricot in your diet.
  • Omega 3s can also regulate the immune response in relation to inflammatory markers.

Stimulate re-pigmentation.

Introducing cofactors needed by melanocytes to produce melanin.

  • L-Tyrosine is the amino acid from which the body synthesises melanin. This conversion needs cofactors like copper, cysteine, glutathione and vitamin C. You can find all this nutrients in the antioxidant formula named above.
  • For any repairing mechanism, your body needs energy, for which B vitamins are used. If you are over 30, very stressed and tired, I will also include CoQ10 in the very bioavailable form ubiquinol. This is also a potent antioxidant.
  • Your thyroid gland increases your metabolic functions, so you may want to include some iodine. This is true especially if you do not live by the sea, do not eat fish or sea vegetables.
  • Lastly, on top of the above, I will also look into laser therapy.

Please do not engage with everything at once, but follow each and every step. Once you have consolidated the first part, only then you will move to the second phase and then to the third.

As I mentioned earlier there is no guarantee in any healing approach for vitiligo. We only the believe that as the body gets ill, the body can also get better. This may happen by removing the possible causes of the problem and introducing the best healing agents.

Author, Cristiano Percoco, BSc (Hons) Nutritional Therapy.

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