Vitiligo has no respect for race, socioeconomic status or age.
The following are celebrities who have or have had Vitiligo. Michael
Jackson, Lee Thomas Americo Garcia Holly Marie Combs, Winnie
Harlow, Rasheed Wallace, Tamar Braxton Joe Rogan Sisqo Richard
Hammond Thomas Lennon [1]. Vitiligo is a cutaneous pigmentary
disorder caused by selective destruction or ‘temporary sickness’
of melanocytes presenting with complete or partial loss of skin
color. Broader definitions are available from different authors and
medical scientists [2]. I have defined the entity in the first instance
in this way because it would explain many aspects and features
of Vitiligo. A definition from the researcher referred to above [2]
has the following key words: ‘Vitiligo, an autoimmune disorder
characterized by localized and / or generalized depigmentation of
the skin and / or mucous membranes’.
The downside of such definition is that it does not cover
what Vitiligo is all about. It focuses on ‘autoimmunity’ which is a
big issue in Europe and the Americas. Diseases considered to be
‘Autoimmune’ -pernicious anemia, Graves’s disease Hashimoto’s
thyroiditis are rare in Nigeria despite the high prevalence of Vitiligo
[3]. In a search for autoimmune diseases by Greenwood [4,5] at
the University College Hospital, Ibadan one of the largest hospitals
in the world he found pernicious anemia (PA) in 4 patients out
of over 90, 000 screened patients. Furthermore three of these
were Caucasians and one an Indian-out of a sea of ‘black’ skinned
Nigerian patients [6] documented only 10 cases of PA in a period
of 15 years (1973-1988) in Lagos University Teaching hospital
Nigeria’s second largest hospital.
The definition by Sehgal also in its emphasis on ‘autoimmunity’
fails to consider the possibility of chemicals in the causation
of Vitiligo which some like Stevenson have referred to as
‘Occupational Vitiligo’ [7], Other chemicals not ‘occupational’ with
chemical similarities abound in Nigeria [3] and are regularly used
as cosmetics. These include hydroquinone containing creams -with
over 50 brands, phenol solutions and bar soaps -‘Dettol’, ‘Septol’.Classification of Vitiligo may be clinical -focal, segmental, acrofacial,
universal as well as based on age of onset. Some experts
consider Vitiligo in children to be a subset or a different disease
from that of the adult [8,9].
From our observation we consider Vitiligo in the young adults
to be generally speaking ‘merely a cosmetic nuisance’ while we have
often rigorously look for serious etiological / underlying diseases
-endocrinopathies and neoplasm in the elderly or older than 50
year -age group [3,10]. A definition of Vitiligo adopted should
also explain the prognostic factors as documented [11,12]. He
documented that the face responded better (compared to the shin),
dark and brown-skinned people repigmented better, that natural
UVA gave better response, and that spontaneous repigmentation
was more common in children. The many and increasing modalities
of treatment-PUVA, PUVASOL (psoralens + artificial and natural
UVA), corticosteroids, Chinese Herbal, Australian natural and
Indian homeopathic remedies, Laser therapy etc [13,14] have
given different responses some as high as ‘a hundred percent’ cure
rate. The plausible explanation beyond sales gimmick is that the
underlying cause of the Vitiligo will determine the actual response
or non response.
From my observations over the years and from the huge amount
of documentation in literature I have come to the conclusion
that a definition that will embrace the present knowledge would
be:“Vitiligo is a pattern of skin reaction presenting with different
degree of skin color loss (hypo - or depigmentation) and without
textural changes”. It can thus be likened to the definition of anger
“an emotional reaction pattern” readily recognized by the facial
reaction and clenched fists. In the latter, a search should be made
for the underlying cause (s). Prognosis or the time of disappearance
of the cause of the anger will depend on how quickly solution
can be provided if at all. Similarly such a definition of Vitiligo
encourages a search for an underlying cause -autoimmune disease,
chemical usage (phenolic derivatives, hydroquinone) trauma (Road
traffic accidents, post surgery, Koebnerization), oxidative stress,neoplasm and the like. Vitiligo may thus be considered ‘primary” or
“secondary”). The former being the classification where extensive
investigation has not yielded a cause that should be treated i.e.
similar to Primary /essential and secondary systemic Hypertension.
Such an idea will aid etiological /aetiopathogenetic solutions
and explain prognosis and the variable responses to treatment
modalities. It would account for the contributions to the disease in
different countries. Most of the patients with Vitiligo in our study
from Nigeria are 30 years and below. Absence of autoimmune
diseases can thus be expected while the use of cosmetic products
like hydroquinone and phenolic derivatives are frequently used in
this age group.
Having searched for an underlying cause, the next stage in
Vitiligo management is to attempt to repigmentation of the skin by
the various modalities of treatments currently available consisting
of PUVA or PUVASOL- the use of photoactive chemicals-psoralens
and artificial or natural ultraviolet light, corticosteroids, needling,
grafting, melanocytes harvesting, artificial blister production
for grafting, melatonin, diets, lasers and a host of others. Medical
tattoo has been utilized as well as cosmetic masking with powders
(covermak). Spontaneous repigmentation does take place
occasionally especially in the pediatric age group. In conclusion
there is a need to take a fresh look at terminologies used in
dermatology which will remove overlaps, and reduce confusion
thus making management of skin diseases more rational if not
necessarily easier.
ISSN: 2574 -1241
