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MagazineDecember 2010 (Vol. 21 Issue 9)Vitiligo

Vitiligo is a puzzling, often progressive, condition that causes de-pigmentation (whiten-ing) of the skin in patches

Vitiligo is a puzzling, often progressive, condition that causes de-pigmentation (whiten-ing) of the skin in patches. It arises when melanocytes, the cells responsible for the pigments that give colour to the skin, die or are unable to function normally. An estimated 100 million people are affected worldwide.

Although, medically speaking, vitiligo is usually not harmful and causes no physical pain, its emotional and psychological effects can be devastating. In fact, 16 to 35 per cent of sufferers experience significant psychiatric problems, such as chronic depression, sleep disturbances, suicidal thoughts and anxiety. Vitiligo can also lead to difficulties in forming relation-ships and avoidance of certain social situations (BMC Dermatol, 2008; 8: 2; doi: 10.1186/1471-5945-8-2).

Precisely what causes vitiligo is still a mystery, but the leading theory is that it's an autoimmune disease in which the immune system targets the body's own pigment cells and tissues (Autoimmun Rev, 2010; 9: 516-20). Gaining in popularity, however, is the idea that vitiligo is caused by the body's reduced ability to fight free radicals such as hydrogen peroxide, which can accumulate in the skin and damage melanocytes. Our cells are normally able to defend themselves against free-radical damage through the actions of antioxidant enzymes, such as super-oxide dismutase (SOD), glutathione peroxidase and catalase. But several studies have shown that this defence system is impaired in vitiligo sufferers, leading to a state of 'oxidative stress' (Indian J Dermatol Venereol Leprol, 2009; 75: 268-71). Oxidative stress is now thought to play an important role in vitiligo development.

The antioxidant connection

The good news about these findings is that they suggest that antioxidants-whether given orally or applied topically to the skin-may be an effective way to treat vitiligo. A number of researchers have already started investigating the use of antioxidants such as selenium, and vitamins C and E, for vitiligo-with promising results.

In one study-albeit an animal study, so the results do not necessarily apply to humans-autoimmune mice with visible signs of vitiligo were fed a commercial diet supplemented with a mix of antioxidants-including vitamins A, C and E, as well as selenium and zinc-and green tea to drink, for 22 weeks. By the end of the study, compared with the control group, which was given distilled water along with the usual commercial diet, the antioxidant-treated mice showed significant improvements in their vitiligo. Remarkably, 70 per cent demonstrated clear repigmentation in the affected skin (Indian J Dermatol, 2009; 54: 357-60).

Another study, this time in humans, investigated whether or not an anti-oxidant supplement could enhance the effects of narrow-band ultraviolet B phototherapy (NB-UVB), one of the most widely used treatments for vitiligo. For two months before and
six months during the NB-UVB photo-therapy treatment, 28 patients were given either a placebo or a supplement containing alpha-lipoic acid, vitamins C and E, and polyunsaturated fatty acids.

Not only did the supplement reduce levels of oxidative stress in the skin, but it also increased the therapeutic success of NB-UVB. Nearly half the treated patients saw more than 75-per-cent repigmentation vs only 18 per cent in the placebo group (Clin Exp Dermatol, 2007; 32: 631-6).

Yet another clinical study suggests that antioxidants applied topically might benefit vitiligo. VitilVenz, a Venezuelan product containing co-enzyme Q10, vitamins C and E, and other natural, "mitochondrial-stimu-lating" ingredients, was tested in 100 patients and controls-with good results. Those using the cream in conjunction with oral antioxidants and phenylalanine saw the greatest (statistically significant) return of skin repigmentation (Invest Clin, 2007; 48: 21-31).

Powerful pepper

The oxidative-stress hypothesis may also explain why piperine-the alkaloid compound that gives black pepper its spicy, pungent flavour-is also showing promise as a treatment for vitiligo. Piperine possesses direct antioxidant activity against various free radicals (Methods Find Exp Clin Pharmacol, 2000; 22: 271-4), and scientists have recently discovered that it can stimulate skin pigmentation in a mouse model of vitiligo.

A team from King's College London randomly allocated poorly pigmented mice to receive topical treatment with piperine or a placebo cream twice a
day for five days a week, with or without UV irradiation on three of those five days per week.

They reported that piperine alone led to significantly greater repigmentation than the placebo, while piperine combined with UV treatment resulted in darker, more even, pigmentation than achieved by UV alone (Br J Dermatol, 2008; 158: 941-50). We don't yet know whether these results apply to humans, but further research is currently underway.
Besides piperine, other spicy compounds might also be of benefit against vitiligo. Researchers from the University of Florence in Italy recently reported that curcumin (derived from turmeric) and capsaicin (the active ingredient in chili peppers) might represent an alternative approach to halting vitiligo progression. Like piperine, curcumin and capsaicin are natural antioxidants that have the potential to protect against oxidative stress in the skin of vitiligo sufferers. Using skin cells from 12 such patients, the Italian researchers discovered that the compounds were, indeed, able to increase antioxidant capacity and suppress the production of free radicals. They were also able to prevent cell death, suggesting that these compounds might even halt the progression of the disorder (Antioxid Redox Signal, 2010; 13: 1309-21).
However, as with piperine, the research is still in its early stages and it's still not known what effects, if any, these compounds will have in clinical trials. Furthermore, there's evidence to suggest that a high dietary intake of curcumin could have detrimental effects by contributing to oxidative stress and preventing repigmentation (Indian J Dermatol Venereol Leprol, 2006; 72: 57-9). It could be that these compounds need to be used topically to be effective.

A helpful herb

Another natural antioxidant that could potentially help vitiligo sufferers is Ginkgo biloba. This herb shows powerful scavenging activity for free radicals and, therefore, is considered useful for the treatment of diseases related to the production of free radicals, such as ischaemic heart disease and stroke, chronic inflammation, and memory loss and dementia (Antioxid Redox Signal, 1999; 1: 469-80).

Also, as of 2003, Ginkgo can now be considered a beneficial treatment for vitiligo, thanks to a high-quality trial conducted in India at the Postgraduate Institute of Medical Education and Research in Chandigarh.

In that double-blind placebo-controlled trial, 47 patients were given either Ginkgo biloba extract (40 mg three times daily, standardized to 24-per-cent ginkgoflavonglycosides), or a placebo in similar doses.

The results showed a "statistically significant cessation of active pro-gression of depigmentation" in the herb-taking group. What's more, markedly improved to complete repigmentation was seen in 10 patients in this group, whereas only two patients in the placebo group showed similar repigmentation. The researchers concluded that "G. biloba extract seems to be a simple, safe and fairly effective therapy for arresting the progression of the disease" (Clin Exp Dermatol, 2003; 28: 285-7).

However, considerably more trials are needed, using Gingko and other antioxidants, to establish their precise role in vitiligo, particularly with regard to effective dosages. Nevertheless, the evidence so far suggests that free-radical fighters may well be the key to halting-or even reversing-this distressing skin disorder.

Joanna Evans

Other natural approaches

o Get yourself checked for nutritional deficiencies. In a study of 15 patients with vitiligo, 11 had low folic acid levels, five had low vitamin B12 levels and four had low ascorbic acid (vitamin C) levels. Supplementation with high doses of folic acid (1-10 mg/day), along with vitamin C (1 g/day) and intramuscular vitamin B12 injections (1000 mcg every two weeks), resulted in marked repigmentation in eight cases. These improvements were seen after just three months, although complete repigmentation was not achieved until after one to two years of continuous supplementation (Cutis, 1992; 50: 39-42).

In another long-term vitiligo study, oral supple-mentation of folic acid (10 mg/day) and vitamin B12 (2000 mcg/day) combined with sun exposure resulted in clear repigmentation in about half the patients after three to six months. Moreover, six patients eventually saw their vitiligo resolve completely. The combination treatment was more effective than either vitamin supplementation or sun exposure alone (Acta Derm Venereol, 1997; 77: 460-2).

Consider low stomach acid, which has been linked to vitiligo in early reports (J Invest Dermatol, 1959; 32: 285-310). In one small study, four patients with achlorhydria (no stomach acid) all saw their vitiligo resolve within two years of starting a regime of 15 cc of dilute hydrochloric acid with each meal (Nebraska Med J, 1931; 16: 25-6). However, bear in mind that hydrochloric acid and its more modern counterpart, betaine hydrochloride, should be taken only under medical supervision.

Rule out heavy-metal toxicity. Chronic skin contact with nickel has been implicated in vitiligo-like skin depigmentation. In two reported cases, the cause was the metal frames of their eyeglasses, which were made of nickel. Both patients turned out to have nickel hypersensitivity that, in turn, caused low production of melanin (Yonsei Med J, 1991; 32: 79-81).

Chronic arsenic poisoning is also associated with vitiligo-like skin changes (N J Med, 1989, 86: 377-80). Arsenic is found in lawn and garden products, but is also present in cigarettes, so if you're a smoker, it's yet another reason to quit.

Try l-phenylalanine, an amino acid that's effective for vitiligo when combined with UV phototherapy. One study showed that oral l-phenylalanine at a daily dose of less than 50 mg/kg body weight/day (for example, 2750 mg/day if you weigh 55 kg) increased the extent of repigmentation induced by UVA phototherapy (Dermatology, 1994; 188: 215-8). Another trial suggested that 10-per-cent l-phenylalanine cream applied to the skin twice a day may also be beneficial (Dermatol Ther, 2008; 21 Suppl 1: S20-6).

Check out khella (Ammi visnaga). Khellin, the active constituent of this North African herb, appears to stimulate repigmentation of the skin in vitiligo patients when exposed to sunlight. A double-blind trial of 30 patients given oral khellin and subsequently exposed to natural sunlight showed that most enjoyed some degree of repigmentation after four months (Dermatologica, 1982; 165: 136-40). In general, studies have used a daily dose of 120-160 mg of khellin.

Look into hypnosis, which has been successfully used as an alternative or complementary therapy for a variety of dermatological disorders, including vitiligo (Arch Dermatol, 2000; 136: 393-9).

o Consider Dead Sea climatotherapy (DSC), which involves daily bathing in the Dead Sea, in Jordan, for several weeks. Although mainly used for psoriasis, one study has suggested that it may be a beneficial complementary therapy for vitiligo. The results showed that short-term DSC (21 days), combined with the use of a prescription cream called 'pseudo-catalase', led to significantly faster repigmentation in vitiligo patients compared with either DSC alone or a placebo cream in combination with DSC (Int J Dermatol, 2002; 41: 482-7). (For more information, see www.

Conventional treatments

In those with only mild cases of vitiligo, the conventional treatment is topical corticosteroids, which appear to be effective, but at a cost, especially in younger patients who have to use them over the long term. Topical steroids can have the same side-effects as their oral cousins, including thinning of the skin, growth problems and hormone disorders (Am Fam Physician, 2009; 79: 135-40).

For more extreme cases of vitiligo, the most accepted standard treatment is to attract more pigmented cells to the surface of the skin through phototherapy (UVA or UVB)-such as seen naturally when you lie in the sun to get a tan-used either on its own or combined with other treatments such as psoralen drugs.
However, concerns have been raised over side-effects such as phototoxic reactions and blistering, and the lack of data for skin-cancer risks associated with long-term UV irradiation (BMC Dermatol, 2008; 8: 2; doi: 10.1186/1471-5945-8-2).
Increasingly, however, phototherapy is being combined with natural treatments such as l-phenylalanine and antioxidants, which can enhance or speed up the effects. The result is that the total amount of UV doses is reduced.


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