By Nancy W. Burkhart, BSDH, EdD
Your patient today is Edward, a 52-year-old African American male who shows you his hand and asks for your opinion on what has caused his loss of skin color. He tells you that he has noticed the color change during the past year, and it seems to be progressing. Edward has made an appointment with a dermatologist and will see the doctor in a few days.
As you view his hand, vitiligo comes to mind. What could have caused this to occur? What can you tell this patient about the loss of pigmentation (see Figures 1, 2)?
Etiology: Vitiligo is an acquired, autoimmune disease that is associated with cytotoxicity-possibly a chemical exposure that may be toxic to the melanocytes. Genetics, or alterations from metabolic or oxidative stress resulting in destruction of melanocytes, produces the loss of pigmentation in the body. Although the pathogenesis is unknown, a vitiligo gene may be responsible for allowing some susceptibility to developing vitiligo and other autoimmune type diseases. Generally, a multifactorial etiology is accepted, and "trigger" mechanisms in susceptible individuals are recognized.
Pathogenesis: Poliosis (the absence of, or lessening of, pigmentation or melanin production) in the hair, scalp, brows, or lashes is due to a lack of pigment production. The pigment-producing cells in the body are termed melanocytes. The melanocytes migrate to the basal cell layer of the tissues and, through dendritic processes of the melanocytes, allow granules to be transferred by melanosomes that extend close to the keratinocytes in the cell layers. The actual pigmentation process is determined by the process of the melanocytes and not by the increase in the number of the melanocytes.
In vitiligo, the melanocyte is destroyed or absent, and the pigmentation process does not occur. Illness and stress may result in loss of pigmentation and also may occur in individuals being treated for disease states such as melanoma when certain drugs used to combat cancer may cause damage to the melanocytes.
Figure 1
Hands depicting vitiligo of an African American male. Courtesy of Nancy W. Burkhart.
Figure 2
Facial view of same patient. Courtesy of Nancy W. Burkhart.
Epidemiology: According to the National Vitiligo Foundation, more than 5 million people in the United States live with vitiligo. About half of these individuals develop vitiligo before age 20. Approximately one third of all these individuals report another family member with vitiligo. People with vitiligo also have more reported cases of Addison's disease, pernicious anemia, hyperthyroidism, hypothyroidism, and alopecia areata. Inflammation of the eyes has been reported as well. There is no race or ethnic propensity, and males and females are equally susceptible.
Method of transmission: There is no transmission associated with vitiligo, and it is an acquired disorder.
General characteristics: In Figure 1, an African American male has lost pigmentation in his hands and his arms. Figure 2 is that of an African American male with vitiligo on facial areas, depicting the loss of pigmentation. Vitiligo can be unnoticeable in very light skinned individuals, and the pigmentation loss may be widespread in isolated areas. Vitiligo may be classified into three categories: nonsegmental, segmental, and unclassified/undetermined vitiligo.
Oral characteristics: Generally, we do not see hypopigmentation intraorally, since there is already a sparsely populated amount of melanocytes and lighter color in the oral cavity. Variation in pigmentation is usually not an issue, but may appear noticeable in dark skinned individuals. The lips and inner perioral tissue may be affected. Sometimes lip grafting is performed since there may be little improvement in the esthetic quality when compared with those found in techniques in other areas of the skin that exhibit vitiligo.
Treatment: The goal in treatment is to develop repigmentation. Ultraviolet light narrow band UVB, psoralen, and ultraviolet laser treatments are often used for the small areas. PUVA and psoralen drugs are given and followed by exposure to UVA-light. Bleaching, topical corticosteroids, hydrocortisone, and calcineurin inhibitors produce some success in treatment.
In many cases, tattooing is an option, as well as cosmetic products that conceal the areas of vitiligo. However, tattooing not associated with a treatment modality is not suggested as purely a social statement/cosmetic enhancement. This procedure may accentuate and accelerate vitiligo in that area or even cause new areas of vitiligo to occur. The second line of treatment would be "increasing depigmentation" so that the skin appears uniform.
No one treatment works for all patients, and sometimes combinations of these treatments may be needed. At this point, vitiligo is not curable, but there are some options for patients to consider to limit cosmetic concerns. Melanocyte transplantation is being researched, topical products continue to improve, and skin grafting techniques are being perfected. Some new treatments are on the horizon and the research continues.
Cutaneous vitiligo is advanced by sun exposure, so the use of a high SPF sunscreen of 30 is suggested and prescribed. Limiting the amount of sun exposure is highly suggested. Since vitiligo may be progressive, monitoring the patient is necessary.
Oral medicine perspective: Self-esteem issues in patients is often an issue, and this is especially true with children (Pinto, 2005). Cosmetic procedures and/or cosmetic products that blend the color variation may assist in promoting comfort for the patient. Since other autoimmune diseases may occur, the patient is monitored closely with long-term, health follow-ups at visits. The knowledge displayed by a dental professional during dental visits strengthens the confidence that the patient develops in the dental professional/patient relationship.
As always, ask good questions and continue to listen to your patients. RDH
References
1. American Academy of Dermatology. https://www.aad.org/public/diseases/color-problems/vitiligo
2. Glick M. Burket's Oral Medicine. 12th edition, People's Medical Publishing House, Shelton Connecticut. 2015.
3. Mayo Clinic: Vitiligo http://www.mayoclinic.org/diseases-conditions/vitiligo/basics/lifestyle-home-remedies/con-20032007 4. National Vitiligo Foundation http://www.mynvfi.org/about_vitiligo#What_Is_Vitiligo 5. Pinto A. Pediatric soft tissue lesions. Dent Clin North Am. 2005 Jan: 49(1):241-58.
NANCY W. BURKHART, BSDH, EdD, is an adjunct associate professor in the department of periodontics/stomatology, Baylor College of Dentistry and the Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (http://bcdwp.web.tamhsc.edu/iolpdallas/) and coauthor of General and Oral Pathology for the Dental Hygienist. She was awarded a 2016 American Academy of Oral Medicine Affiliate Fellowship (AAOMAF). She was a 2006 Crest/ADHA award winner. She is a 2012 Mentor of Distinction through Philips Oral Healthcare and PennWell Corp. She can be contacted at [email protected]
