Leucoderma – No longer a curse

    A black spot on a white skin is a blessing; but a white spot on a black skin is a curse

    Thus spoke Omar Quayyam, about leucoderma, centuries ago. Perhaps he had in his mind, the severe suffering, social stigma and the emotional stress that leucoderma patients had to undergo.

    It is indeed unfortunate that even after centuries after his statement; patients of leucoderma still undergo so much stress and stigma. Even today, in the age of modern medicine, when many new effective treatments are available, these patients suffer social embarrassment, find it difficult to get married, have difficulty to get proper jobs and undergo untold misery. Depressed and frustrated, they tend to seek isolation. All this for a disease which causes no bodily harm except change of color and which can be treated effectively if help is sought at early stage!

    What is leucoderma?

    The medical name for leucoderma (leucos means white; derma means skin) is vitiligo. It is a disease caused by destruction of cells called melanocyte in skin, which produce the pigment melanin responsible for our skin colour. Loss of this pigment leads to white patches in different parts of the body- there are no other symptoms associated with it. It can occur at any age.

    the impression that leucoderma can not be treated is totally incorrect

    Why the stigma?

    The social stigma seen about the disease is seen mostly in the Indian subcontinent, but not so much in other countries. The reasons for this are:

    1. The white patches are more obvious and prominent on the brown-black Indian skin; in western white skin, the disease is not taken seriously as it is not very obvious and apparent.
    2. Erroneous belief that it is infectious , that it will spread to others
    3. Erroneous belief that it is always hereditary and that all the members of the family would also get the disease ( and hence the fear of marrying such a  person)
    4. Erroneous belief that it always spreads to all over the body
    5. Erroneous belief that there is no treatment for the disease

    Myth 1: Leucoderma is infectious

    Leucoderma is not an infection; It is not contagious and does not spread from person to person.

    In ancient Ayurveda, the disease was referred to as “Shwetha kushta” because of the white patches. This unfortunate and erroneous terminology is responsible for much of the suffering of vitiligo patients.

    Leucoderma and Leprosy are two different and unrelated diseases. Leucoderma is not related or associated with leprosy in any way.

    Leucoderma is believed to be the result of antibodies produced by the body against pigment -producing melanocytes causing their destruction.  Environmental toxic substances such as phenolic chemicals in rubber, plastic industry may also be responsible for the death of these cells.

    Myth 2: Vitiligo is ALWAYS hereditary

    This is another misconception in the common public, that vitiligo is always hereditary, which needs to be corrected. Only 30% of vitiligo cases show hereditary background. In the majority of patients, there is no family history .Even if one person in a family is affected, in most patients, other members of the family do not get the disease. For this reason, there is no bar for these patients to get married and lead a normal life like any other person.

    Myth 3: Vitiligo causes harm to patients

    Vitiligo does not affect any other organ in the body. These patients are otherwise healthy.

    Myth 4: Leucoderma spreads all over the body

    No, in most cases, leucoderma does not spread all over the body. It is important to note that there are different types of vitiligo which behave differently.

    1. Localized vitiligo vulgaris: These patients have patches in any one area such as knee, elbow, face, neck etc. The lesions remain localized and do not spread, they also respond very well to treatment
    2. Segmental vitiligo: These patients show patches in one particular area only, on one side of body along a nerve segment such as face or abdomen. There is no spread from this site and the lesions respond very well to treatment, particularly surgical treatment
    3. Generalized vitiligo vulgaris: These patients show widespread lesions on face, neck, forearms, legs, abdomen, and chest. Most of these areas are hairy areas and respond well to treatment
    4. Acrofacial vitiligo: these patients have lesions on acral

    (Peripheral)  parts of the body, such as tips of fingers, toes, genitals, lips, palms and soles etc. All these are non hairy and bony areas and respond only partially to treatment.

    A large percentage of patients do not have wide spread leucoderma and have localized disease limited to only a part of the body.

    Myth 5: Leucoderma can not be treated. Treatments are not effective

    There are a number of excellent treatments available and Vitiligo can be treated effectively in most cases. For long there has been a belief that Leucoderma can not be treated effectively. The reasons for this  is that Vitiligo is a visible disease which is difficult to hide from people; most  cured  patients Vitiligo tend not to reveal or publicize  the success of the treatment because of the social stigma associated with the disease. Hence, only those patients with longstanding, extensive, visible disease who have not responded well to treatment in the past when effective treatments were not available, get noticed. The outlook for the disease has significantly changed in recent years with a number of new effective treatments being available. Most varieties of leucoderma can now be treated effectively.

    Myth 6: Diet is important in Leucoderma

    No; Diet is not important in Leucoderma. Many patients mistakenly believe that they should avoid sour substances (such as lemon and tamarind), fish, curds etc. The author has seen patients who have not tasted tamarind and lemon for years! There is no proof that diet affects leucoderma-eating fish with milk, eating sour products do not affect the course of the disease. A well balanced diet to avoid nutritional deficiencies is adequate.

    What are the different treatments for vitiligo?

    The treatment objectives are:

    1. To control disease and prevent further spread by drugs,
    2. To produce pigmentation in the lesions by phototherapy and
    3. Provide melanocyte cell reservoir in resistant cases by melanocyte transplantation

    Prevention of fresh lesions: This is achieved by using immunomodulatory drugs (drugs that alter the patient’s response to disease) such as steroids, new nonsteroidal drugs such as tacrolimus. In addition, improving the nourishment of the patient and correcting deficiency of vitamins such as folic acid, iron, and copper are also important. Antioxidants (drugs which absorb harmful substances called free radicals which damage melanocytes) are also used. Recently drugs which affect the growth of melanocytes (called growth factors) have become available.  Finally, in selected cases, avoidance of harmful chemicals in the environment, such as rubber, resins, and phenolic compounds is important in selected patients. Avoidance of injury to skin is important as damage to skin can produce fresh lesions.

    Production of pigmentation: Ultraviolet light therapy or phototherapy has long been the main treatment for this distressing condition, since the ancient days of Ayurveda. Using drugs called psoralens which are obtained from various plants, and exposing the affected part to natural sun light or artificial ultraviolet a (wavelength 320-400 nanometers) -called photo chemotherapy or PUVA – has been the mainstay of treatment.  This is an effective and cheap treatment. However the disadvantages of this treatment are that, exposing to sun is not feasible for most patients, particularly for those with patches on abdomen, thighs, and chest, and in women. Also, sunlight is no uniformly present and hence the response to this treatment is variable.

    Now, artificial ultraviolet chambers are available, wherein patient is exposed to ultraviolet light tubes in chambers. The latest machines use a type of ultraviolet light called narrow Band ultraviolet B (wavelength 311 nanometers). This machine emits a specific radiation of wavelength 311 nanometers, which is required for producing pigmentation and is therefore extremely safe, and effective. It can also be used for children, and even pregnant women. The treatment lasts for several months. These phototherapy machines are of different types;

    1. Whole body cabinet for patients with extensive lesions
    2. Hand and foot machines for lesions on palms and soles
    3. Scalp machine for hairy areas
    4. Home photo-therapy panels which consist of small panels of 4-6 tubes for use at home by patients.

    Targeted photo-therapy: In a significant recent advance, machines which deliver ultraviolet light therapy specifically targeted at the affected area, avoiding unnecessary exposure of the uninvolved skin have become available. High doses of Ultraviolet light are delivered through a fiber optic cable, very quickly in seconds. The treatment is quick, response is faster (pigmentation often seen in few weeks) and difficult areas such as nose, ears, underneath chin, genitals can all be treated easily.The treatment is also very suitable for children.

    Lasers for vitiligo: A laser called exhimer laser has been shown to be effective in producing pigmentation even in resistant lesions. However, this treatment is presently expensive.

    Is Ultraviolet light safe? Does it not cause skin cancer?

    Skin cancer caused by ultraviolet light is a risk only western white skin and is not an important risk in Indian skin. Further, the specific wavelength Ultraviolet light as used in leucoderma (311 nanometers) is very safe.

    Do all patients respond well? How many sessions of treatment are needed?

    Treatment response is variable and depends on a number of factors. Response to treatment is best in hairy areas – hair follicles are the reservoir of pigmentation. Early lesions, lesions in young people and children, lesions on face also respond very well to treatment. In such patients, treatment for few weeks or few months are enough. In contrast, lesions in old people. Old and longstanding lesions, lesions on acral (tips of fingers and toes, palms, soles) and bony areas respond slowly and moderately and may need surgical treatment as below. Hence it is important for the patients should seek help early, be well motivated, and be regular and persistent with treatment. They should not delay treatment, should not do self medication, and   should try only trying established medications and not fall prey to hyped advertisements

    Surgical treatment for vitiligo: What is Melanocyte transplantation ?

    As mentioned previously, response to treatment with phototherapy in non-hairy areas may not be satisfactory, because of lack of melanocyte cells. In such areas, new cells can be introduced by surgical treatments or grafting (also called melanocyte transplantation). However surgical treatment can be done only in those patients in whom disease is stable and has stopped spreading in the previous one year.  In melanocyte grafting, a thin layer of donor skin is taken form a normal area and is spread on the affected area after removing the white skin. In 2-3 months proper natural looking coverage is achieved.

    Cellular melanocyte transplantation: New methods have emerged in which cells are separated or cultured in the laboratory and then transplanted to affected area.

    Epidermal cell suspensions: In this method, the donor skin is processed to produce a suspension of cells which are then applied on the affected area. This is simple method and can be done with in 30 minutes and has the advantages that a large area can be covered, and is relatively easy.

    Melanocyte culture: In this new method, the result of recent developments in biotechnology, a small patch of donor skin is sent to a cell culture laboratory. The melanocytes are grown in the laboratory over 6 weeks and then area applied to the affected area, where they take root and grow to produce pigmentation. The advantages of this new method are that:

    1. Only a small area of donor skin in required and his can be increased by cultured by four folds.
    2. Results are natural and pigmentation is uniform
    3. It is possible to enhance the activity of cultured melanocytes by feeding them with growth factors.

    This treatment represents an important development in the treatment of vitiligo, though it is relatively expensive and available at only few centers.

    Micro pigmentation: This is a method of camouflaging the lesion by introducing synthetic black pigments in to skin. This is suitable for localized lesions such as lips and has the advantage that it yields results very quickly-with in a week.

    Chemical camouflages: the patches can be hidden or camouflaged by applying creams which match the surrounding skin in colour. This is important for people who are shy of facing society because of their patches.

    Psychological management: Patients need full support, understanding , sympathy and cooperation of the family. Often the patients suffer from an inferiority complex about their diseases and face uncomfortable questions, which leaves them depressed and even socially isolated.

    The author has known a lady who did not come out of her room four years because of her leucoderma lesions! Another lady was afraid to give bath to her baby because she was afraid of passing the disease to the baby! A waiter lost his job in a hotel because the owner thought that his customers would not want to be served by such a person!

    The misery such patients undergo is often equal to or even more than what even patients with serious disease such as HIV-AIDS or cancer undergo. The author has known patients who attempted suicide because they could not get married and were blamed by their family for the misfortune they brought to the family! This situation can be avoided if society at large understands facts about this disease and sheds old myths and misconceptions. Patients should be encouraged to engage in their day-today activities without any inhibition. Leucoderma should not be a factor for deciding a life partner as it is not a serious disease.

    The outlook for patients of vitiligo has significantly improved over the last decade. Several new treatments such as calcipotriol, catalase etc have become available and the impression that the disease can not be treated is totally incorrect – in fact most patients with extensive disease that we see are patients who developed disease 2-3 decades back when many of the above treatments were not available. Now with the latest modalities in drugs, phototherapy and melanocyte transplantation, effective treatment is possible. The patients should not therefore hide the disease, and should seek the help from a qualified dermatologist early. Also, the families of patients in particular and the society in general needs to be sympathetic, understanding, and supportive of these patients.