Vitiligo

What is Vitiligo?

Vitiligo is a chronic, acquired autoimmune disorder in which the immune system destroys melanocytes, the cells in the skin that make pigment. It affects about 0.5% to 2% of people worldwide.^{[1, 2]}

Common symptoms

The main sign is well-demarcated, chalky-white patches that can appear on any part of the skin. The patches are usually symptom-free, though some people notice itching before a new patch appears.^{[1, 3]}

Vitiligo is not contagious or dangerous. It can still take a real toll: a review of 168 studies found higher rates of depression, anxiety, stigma and sleep problems in people with vitiligo.^[4]

Causes and risk factors

Vitiligo is classed as an autoimmune disease, and interferon-gamma signaling and the JAK pathway play a central role in the immune attack on melanocytes.^{[1, 2]} Segmental vitiligo, which affects one area of the body, is classified separately from the more common nonsegmental form.^[2]

Vitiligo is linked with other autoimmune conditions, including thyroid disease, alopecia areata, lupus and rheumatoid arthritis.^[5] Family history, skin injury, sunburn and stress are commonly named triggers, although the exact cause is not fully understood.^[1]

How it is diagnosed and treated conventionally

Vitiligo is diagnosed by a clinician from the look of the patches and your history. Blood tests may be done to look for associated conditions such as thyroid disease.^{[1, 5]}

Treatment aims to stop spread and restore color. Some treatments can bring pigment back, but none removes the underlying disease.^[3] An international expert statement covers topical corticosteroids, calcineurin inhibitors and JAK inhibitors, systemic therapies, light therapy, and procedures for selected patients.^[6] Narrowband UVB light therapy works better the longer it continues, and it works best on the face and neck.^[7]

Why Vitiligo calls for a whole-person approach

Vitiligo is first of all a disease of the immune system and the skin, so dermatology care is the foundation. Other factors, such as emotional health, sleep and other autoimmune conditions, shape how people live with it.

Care that supports these areas is a reasonable addition to treatment, as long as the medical side is in place.

Immune activity and oxidative stress

Autoimmune activity is the core of vitiligo.^[1] Some complementary agents, such as ginkgo, Polypodium leucotomos and certain vitamins, have been studied for vitiligo on the basis of proposed mechanisms.^[8]

Emotional health and stress

A meta-analysis of 25 studies found that about one in four people with vitiligo had depression, and that vitiligo was linked to a higher odds of depression compared with controls.^[9] Visible or genital lesions, female sex and age under 30 were linked to a higher burden.^[4]

Sleep and daily life

Sleep disturbance, stigma, avoidance and relationship difficulties are reported more often by people with vitiligo.^[4] The review authors concluded that multidisciplinary support for these problems is warranted.^[4]

Other autoimmune conditions

Because thyroid disease and other autoimmune conditions are more common in people with vitiligo, they should be checked by your physician.^[5]

Acupuncture for Vitiligo

What the research shows

Acupuncture-related therapies may add to light therapy or laser for some people, but the research is limited and mostly done in China. An overview of 10 systematic reviews found acupuncture and related therapies more effective than control treatment for vitiligo. It rated the methods of every one of those reviews as critically deficient, and rated the underlying evidence from high to very low quality.^[10]

Much of the evidence involves fire needling, a heated-needle technique used in China, which is different from standard acupuncture. A meta-analysis of 10 trials with 1,333 people found fire needle plus 308 nm excimer laser worked better than laser alone, but the authors said study quality was suboptimal.^[11] A small trial of 35 people found repigmentation was greatest when fire needle was combined with a topical tacrolimus, and the authors called it preliminary.^[12]

In a Taiwanese trial of 8 completers, needling around the patches combined with narrowband UVB improved scores more than UVB alone, but the sample was very small and the trial was open-label.^[13] We found no large, well-controlled trial of ordinary acupuncture for vitiligo.

How acupuncture may work

How acupuncture might act in vitiligo is not known. Fire needle trials measured changes in CD4+ T-cell levels, which suggests an effect on immune activity, but this has not been shown to explain repigmentation.^[11] Sleep and mood problems commonly accompany vitiligo,^[4] but we found no vitiligo trials testing whether acupuncture helps with them.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the body, usually left in place for about 20 to 40 minutes. A course of several visits is followed by a reassessment of whether it is helping.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000.^[14] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Vitiligo

The Ayurvedic view

Ayurveda describes pigment loss as Shvitra or Kilasa, a condition said to arise when the tridoshas, especially Kapha, are disturbed along with the tissue called Meda dhatu.^[15] These are traditional categories used to plan care, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine, such as regular meals and sleep, and stress reduction
• Herbs used traditionally for pigment disorders, including bakuchi (Psoralea corylifolia), taken by mouth or applied to the skin^{[15, 16]}
• Oil and herbal paste applications to the skin
• Panchakarma purification in selected patients

Panchakarma is not appropriate during pregnancy, acute illness or frailty. Bakuchi contains psoralen compounds, so it should only be used under practitioner guidance and with attention to sun exposure. The clinic can discuss herbal preparations applied to the skin (transdermal therapy), but no research supports a benefit of this for vitiligo.

What the research shows

The research on Ayurveda for vitiligo is very limited. A PubMed search found no systematic reviews or placebo-controlled trials. One uncontrolled study of 50 people reported that most of those given a bakuchi-containing decoction and paste improved over 6 months. It had no placebo group and very few people in the comparison group, which used a Western psoralen treatment.^[15] A review of bakuchi described a long traditional use for pigment loss and called for standard clinical trials.^[16]

Herbal medicine for Vitiligo

Herbs and formulas that have been studied

Herbs and supplements that have been studied include Chinese herbal formulas given with light therapy, ginkgo (Ginkgo biloba), Polypodium leucotomos and a few vitamins and minerals.^{[8, 17]} Psoralea (called bu gu zhi in Chinese medicine, bakuchi in Ayurveda) is widely used in Asia for leukoderma.^{[16, 18]}

What the research shows

The evidence is limited. A meta-analysis of 5 trials with 513 people found that oral Chinese herbal medicine plus narrowband UVB gave a higher repigmentation rate than UVB alone. The authors rated overall quality as low and noted the lack of long-term follow-up.^[17]

For ginkgo, the Cochrane review of vitiligo treatments found one small study in which it was better than placebo, but one study cannot settle the question.^[3] A review of complementary agents described their proposed mechanisms and possible adverse effects.^[8]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Ginkgo has been reported to cause bleeding when combined with warfarin or aspirin.^[19] Psoralea constituents affect enzymes that break down drugs, so interactions with prescribed medicines are possible.^[18] In a small study, oral psoralen with UVA produced sunburn, severe itching and stomach upset, which is why herbs containing psoralens should not be combined with light therapy without your dermatologist's knowledge.^[15]

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes vitiligo as a pattern involving qi and blood disharmony or blood stasis, and Ayurveda describes Shvitra as a disorder of Kapha and the tissues.^[15] Researchers studying vitiligo measure different things: autoimmune T-cell activity, interferon-gamma signaling, oxidative stress and melanocyte loss.^{[1, 11]}

Treatments that calm stress and improve sleep may map onto the psychosocial burden that research has documented in vitiligo.^[4] No study has shown that a traditional pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for vitiligo is complementary. Keep your dermatologist, and do not stop or change topical steroids, calcineurin inhibitors, JAK inhibitors or light therapy without your prescriber. We do not diagnose vitiligo or manage the disease itself.

Please bring your diagnosis, any thyroid or autoimmune test results, a full list of medicines and supplements, and details of any light therapy or surgery. Continue to protect your skin from sunburn, since depigmented skin is more vulnerable.

When to seek urgent medical care

Vitiligo itself is not an emergency, but some changes need prompt medical review.

• Patches that spread quickly or appear in large numbers
• Signs of thyroid problems, such as unexplained weight change, palpitations, or heat or cold intolerance
• Sudden changes in vision or hearing
• A new or changing mole, or a sore on a pale patch that does not heal
• Feeling hopeless or thinking about harming yourself; call or text 988 (Suicide and Crisis Lifeline)

If you have severe sunburn with blistering, fever or trouble breathing, call 911 or go to the nearest emergency department.