The poem Pied Beauty by Gerard Manley Hopkins celebrates all things that are dappled, stippled and freckled. He marvels at the distinct contrasts and patterns in nature, finding beauty in all that is unconventional. Yet the skin condition known as vitiligo – a loss of pigment in areas of the skin, resulting in the piebald effect the poet so admired – is more often than not misjudged and misunderstood. In its most dominant form, it is (ironically) perfectly symmetrical, appearing equally on both sides of the body. A perfect imperfection, one might say…
The changing face of vitiligo Once stigmatised and deemed unslightly, the mindset and visibility of this skin condition has seen positive changes over recent years. This is due, in part, to remarkable women such as Canadian fashion model Winnie Harlow, American CoverGirl cosmetics ambassador and model Amy Deanna, and of course our very own Boitumelo Rametsi – founder of Spotted Beauty and vitiligo spokesperson. They have all inspired those with vitiligo by accepting their unique beauty and raising awareness. Moreover, they urge people to do away with the stereotypical ideals of beauty. In fact, Mattel has recently launched four new Barbie dolls – including one with vitiligo – in an attempt to be more inclusive and encourage body positivity.
Be that as it may, vitiligo still causes deep distress for some, as well as provoking a risk of trauma and loss of confidence. A famous case in point is the late celebrity King of Pop, Michael Jackson, who claimed to suffer from vitiligo (he ‘came out’ on Oprah’s talk show in 1993), and went to extreme lengths to hide it. Unfortunately, he changed his appearance so drastically in the process, it ended up exposing him to serious negative attention. According to American dermatologist John E Harris, MD, Phd, it was unlikely that vitiligo alone could have caused such a radical transformation from African American to very pale skin. Indeed, his autopsy report revealed that he used a form of hydroquinone to lighten his skin.
Whatever the case, in order to better understand this condition and gain some insight on treatment options, we spoke to:
Dr Judey Pretorius
Biomedical scientist
Dr Pholile Mpofu
Dermatologist
Dr Debbie Norval
GP with special interest in aesthetics
What is vitiligo?
Dr Pretorius
“Vitiligo is a condition that causes patchy loss of skin pigmentation, and is considered progressive. Generalised vitiligo is deemed to be the most prevalent form and can be characterised as large areas of depigmentation occurring all over the body (it is not confined to a specific area or section). Segmental vitiligo, on the other hand, is considered less common (occurring in approximately 10% of affected individuals). It is characterised as smaller areas of depigmentation, appearing on one side of the body, in a limited area.”
Dr Mpofu
“In my practice, generalised vitiligo is common. Segmental vitiligo does occur, yet it’s quite unusual, appearing only in one area – i.e. Blaschko’s lines. This tends to be stable and more resistant to treatment. Common among my patients is vitiligo in areas of trauma – e.g. rubbing and scratching around the eyes, lips, elbows, neck, knees.”
How does it usually develop and what causes it?
Dr Pretorius
“While any part of the body may be affected by vitiligo, depigmentation usually first develops on sunexposed areas of the skin, such as the hands, feet, arms, face and lips. Most experts believe that it is an autoimmune condition, in which the body’s immune system mistakenly attacks and destroys certain cells. Vitiligo is also sometimes associated with other medical conditions, such as thyroid dysfunction.”
Dr Mpofu
“Autoimmunity is the main cause of vitiligo. This is due to the melanocytes being affected, which ultimately leads skin to lose pigmentation.”
In your practice, what treatment is the gold the standard for vitiligo?
Dr Pretorius
“We have developed a treatment protocol that uses melanocyte growth factors with microneedling techniques to stimulate repigmentation.”
Dr Mpofu
“The most successful type of treatment in my practice:
- avoidance of trauma (rubbing, scratching)
- calcineurin inhibitors
- topical steroids
- microneedling
- excimer light
- in rapidly spreading diseases, a course of systemic immune suppressors are used.
Very effective is a combination of topical treatment and excimer light.”
While hydroquinine is controversial in SA, it can be prescribed (below 2% strength) – is this a recommended topical treatment?
Dr Pretorius
“It can be used in persons affected by widespread treatment-resistant vitiligo to bring about a smoother, more uniform appearance. However, the active ingredient used can be limited in certain cases due to side-effects experienced by the individual. Hydroquinone is a very unstable molecule, and can basically only be prepared as a compounded item (and not a commercial product), which means that there isn’t much clinical data on its biological effects on the skin.”
Dr Mpofu
Certain drugs can also affect the pigmentation of the skin, as in the case of Bev Segal, Johannesburg wife, mother and volunteer for an NGO for underprivileged children, Magical Moments. Diagnosed with ocular melanoma in 2010, Bev underwent various treatments that included radiation, chemotherapy and five surgeries – as the cancer had metastasised to the liver. After an enucleation (removal of the right eye) and a course of metastatic melanoma treatments*, she was finally in remission. When the cancer returned two and a half years ago, it presented in the liver and bones. It was at this point that an immunotherapy drug* was prescribed.
Bev explains further:
“The medicine* I received was Biologic – a targeted therapy that works exclusively on one’s immune system, thereby limiting the side effects on healthy cells (unlike chemotherapy that targets all rapidly dividing cells). This medication* is used alone, or as combination therapy for various types of cancers. One of its side effects is vitiligo, which appeared in my ninth month of treatment. My oncologist was thrilled, as this meant that it was working. But I was devastated. It affected my mood and overall well-being. I generally never applied make up, yet started covering up most of my visible skin that was affected by vitiligo. A dermatologist discussed using UV lights as a possible option, then dismissed this due to my diagnosis of melanoma.”
Dr Mpofu concurs:
“Vitiligo suggests that the immunity of the patient is responding positively to the melanoma treatment (which is true for 70% to 80% of those who develop this skin condtion). Interestingly, while the vitiligo present actually protects those with melanoma, they cannot undergo treatment while on melanoma therapy (except to cover the lesions with camouflage to avoid activating the melanocytes and melanoma cells). During remission, some manage the discolouration by transplanting the patient’s own melanocytes from pigmented areas (e.g. skin grafts), but this is not common.” As for Bev, she manages her vitiligo by applying camouflage make-up every morning – this has restored her confidence in her appearance and has enabled her to see her vitiligo in a more positive light: “I know my treatment is working, as I am stable now,” she says.
Dr Debbie Norval, a GP with a special interest in aesthetic medicine, sums it up:
“Although vitiligo is a chronic and lifelong condition, it can be reduced and managed. There are some exciting new techniques to reverse the hypo-pigmentation typical of vitiligo. For instance, microneedling helps to regulate and regenerate skin through the release of growth factors into the affected areas. Microneedling also stimulates melanocyte migration from the healthy pigmented areas into the hypopigmented pale areas. The application of a fluorouracil topical cream immediately after microneedling further stimulates the melanocytes. However, it must be noted that using this agent does not help for vitiligo that has already affected more than 50% of the body, or for segmental vitiligo, where only one side of the body is affected – yet it does show promise for early and smaller patches. Patients require two to six sessions, at two-to-four-week intervals. “Meanwhile, topical products that induce pigmentation through stimulation of the melanocortin 1 receptor (MC1R) on melanocytes show promise in inducing the production of melanin pigment. MC1R agonists are used as skin pigmentation enhancers, modulating skin pigmentation and reducing oxidative stress. Extracts of black pepper fruit and Piper Nigrum L contain high concentrations of piperine, which ultimately stimulates melanocyte replication and skin repigmentation. These products are available in creams and from certain compounding pharmacies.”
Dr Debbie Norval, a GP with a special interest in aesthetic medicine, sums it up:
The crux of the matter is that the onus of understanding vitiligo, its source, accepting and even reconsidering beauty by viewing it in a different light should not solely rest on the shoulders of those who have this condition – but rather on all of us. After all, beauty is, without a doubt, not only skin deep.