Key takeaways

  • Vitiligo patches lack melanin and its natural sun protection. They burn easily and need high-SPF sunscreen. NHS
  • The pigment loss is not a growth or infection, and it is not contagious. Patches do not cause dryness or discomfort, although they may itch occasionally. NHS
  • Non-segmental vitiligo is the common form, affecting about 9 in 10 people with the condition. It is thought to involve immune destruction of pigment-producing melanocytes. NHS
  • Other autoimmune conditions, including an overactive thyroid, are associated with vitiligo. They do not develop in everyone who has it. NHS
  • Cuts and severe sunburn can trigger new patches, called the Koebner response. NHS
  • The white patches are usually permanent; their spread cannot be predicted. Some remain small, while others merge into larger areas. NHS
  • Face, neck, hands and skin creases are common sites. The NHS also lists the mouth, eyes, fingers, wrists, armpits, groin and genitals. NHS

What does vitiligo look like, and where does it appear?

Pale white patches, most often on the face, neck and hands, and in skin creases.

A pale patch may gradually turn completely white. In the NHS description, a white centre can have paler skin around it, and blood vessels underneath can give a pink tint. Borders vary: smooth, irregular, reddened and inflamed, or brownish. Occasional itching is possible, but dryness and discomfort are not features of vitiligo.

Check the hair as well as the skin. Where vitiligo involves hair roots, including on the scalp, hair can turn white or grey. The mouth lining can also be affected. NHS

There are two main types:

  • Non-segmental vitiligo, also called bilateral or generalised, is the more common. Symptoms often appear on both sides of the body as symmetrical white patches, including the backs of hands, arms, and skin around body openings such as the eyes.
  • Segmental vitiligo, the less common type, is thought to be caused by chemicals released from nerve endings in the skin that are poisonous to the melanocytes. It affects one area, is also called unilateral or localised vitiligo, and often starts earlier. The NHS gives a figure of around 3 in 10 children with vitiligo. NHS

How far it spreads varies greatly. Some people get only a few small white patches, others get larger patches that join up across large areas, and the NHS is explicit that there is no way of predicting how much skin will be affected. The white patches are usually permanent.

What causes it?

In the more common type, the immune system attacking the cells that make pigment.

In non-segmental vitiligo, the immune system is thought to destroy melanocytes, the skin cells that make melanin. It attacks healthy tissue instead of targets such as viruses. The NHS gives pernicious anaemia, an autoimmune condition affecting the stomach, as an example to mention in the family history. NHS

Family history matters: vitiligo in a relative, or other autoimmune conditions in the family, increases the risk of non-segmental vitiligo. The NHS also lists another autoimmune condition in the person themselves, particular genetic changes, melanoma (skin cancer) and non-Hodgkin lymphoma (cancer of the lymphatic system). NHS

Triggers can include stressful events, such as childbirth, and skin damage. DermNet illustrates the Koebner response with vitiligo over the knuckles. Its injury examples include cuts, sunburn, abrasions and scratches; also eye rubbing, lip licking, watch pressure and tight clothing. DermNet

Should I have my thyroid checked?

It is worth raising, because vitiligo is associated with other autoimmune conditions including an overactive thyroid.

DermNet describes thyroid disease as the strongest autoimmune association, affecting up to 15% of adults and 5 to 10% of children with vitiligo. The NHS stresses that not everyone with vitiligo develops associated autoimmune conditions. DermNet

Mention vitiligo when discussing symptoms at another appointment, including fatigue, so the skin and general health history are considered together. The NHS says a thyroid blood test may be needed. Do not dismiss possible thyroid symptoms. Thyroid symptoms and testing are covered in thyroid problems.

What can treatment achieve?

It can improve appearance for some people, and expectations should be set honestly.

Treatment options depend on the type, how much skin is affected and where, and they include topical treatments such as steroid creams and calcineurin inhibitors like tacrolimus, which is often used on the face where prolonged steroid use is undesirable. Light therapy is used for more extensive disease, under supervision. Camouflage cosmetics are a legitimate choice, and for some people the whole answer. DermNet lists waterproof products, dyes and stains, and dihydroxyacetone products that colour skin without sun exposure. DermNet

Depigmentation therapy is a very different approach, removing the remaining pigment to even the skin tone rather than restoring it. DermNet describes it as using 20% monobenzyl ether of hydroquinone (MBEH), and states it may be considered in severely affected, dark-skinned individuals with vitiligo that has failed to re-pigment spontaneously or with therapy. This is a specialist decision for that narrow group. Discuss the consequences of removing remaining pigment carefully.

DermNet describes returning pigment as small brown spots around hair follicles, or perifollicular repigmentation. The follicle is the main source of restored pigment; the border of a white patch is another possible source. Response is better on the face and trunk, poorer on hands, feet and areas of white hair. Newer patches tend to respond better. Photographing them records what is usually gradual, partial progress, with substantial variation between people. DermNet

The NHS describes the patches as usually permanent. Treatment aims for improvement, without promising a cure.

What about the part that is not medical?

The visible nature of vitiligo affects people out of proportion to its physical symptoms, and that is worth naming.

Vitiligo causes no pain and no illness in itself. It can still have a significant effect on confidence, particularly when it affects the face and hands, and particularly on darker skin where the contrast is greater. That is a legitimate reason to seek treatment, not a vanity, and it is a legitimate thing to raise with a doctor.

Do and don’t

Do:

  • Use high-factor broad-spectrum sunscreen and reapply it properly. After swimming, remember that water both removes sunscreen and reflects light; hats, long sleeves and midday shade are part of protection too.
  • Treat cuts, grazes and burns promptly to avoid triggering new patches; use loose protective clothing. Sun protection also helps avoid sunburn as a trigger. DermNet
  • Tell the clinician about vitiligo when discussing other symptoms. Discuss camouflage as well as medicines; the waterproof products and dihydroxyacetone options described above may be useful.

Don’t:

  • Don’t tan to even out the difference. DermNet says depigmented skin can only burn, while surrounding skin can tan and increase the contrast. The patches lack melanin and its natural UV protection, a year-round concern in the Gulf. DermNet
  • Don’t expect a cure, and be sceptical of anything promising one.
  • Don’t use potent steroid creams on the face without supervision.
  • Don’t dismiss the psychological effect as unimportant.

How does a clinician distinguish vitiligo from other pale patches?

Examination usually establishes the diagnosis; a Wood’s lamp may help. The NHS describes holding this ultraviolet lamp 10 to 13cm from the skin in a dark room. It makes vitiligo easier to see and helps distinguish it from pityriasis versicolor, where a fungal infection causes pigment loss. NHS

The clinician may ask about previous sunburn or a rash in the same area, family autoimmune conditions, treatment already tried and whether any patches have improved by themselves. They should also ask about confidence, self-esteem and work. NHS

Where can I read about skin care and other pigment changes?

The skin care and vitiligo pages organise the catalogue; the melasma article covers excess pigment.

The skin care category lists what is stocked here, and vitiligo approaches it from the diagnosis. Since sun exposure is central, and since another pigmentary condition is driven by the same light, melasma covers the opposite problem of too much pigment rather than too little.

MedicForce option: our skin listings show active ingredient and strength, which matters for topical treatments where potency and site of use go together.

  • Vitiligo, NHS symptoms, the two types, the autoimmune explanation, risk factors and triggers, and the sun protection advice.
  • Vitiligo, DermNet a fuller clinical reference, including why depigmented skin can only burn rather than tan, and the depigmentation therapy option and who it is considered for.