Vitiligo

Vitiligo.Leucoderma Kilasa.श्वित्र  सफेद दाग. सफेद कोढ़

It is an autoimmune disease in which depigmentation patches develop on the body. In this condition there may be complete  loss of melanocytes from affected patches. So in generalized vitiligo, white patches are seen on hands, wrists, knees, neck etc. The hair of scalp and beard may also be depigmented.

Vitiligo commonly known as Leukoderma. It leads to discoloration of normal skin and turns it into an abnormally white colour. It is neccessary to address this  problem at an early stage. If it progresses without check the results may be permanant and irreversible.

Worldwide prevalence of vitiligo is mentioned as 1% of the total population. The highest incidence  has been recorded in India and Mexico.. It is estimated between 3-4% in India. Although an incident rate as high as 8.8% has also been reported irrespective of race.. Many times common cause are observed as severe emotional stress.

Introduction

Vitiligo is a chronic (long lasting) disorder that causes patches of skin to lose pigment or color. This happens when melanocytes-skin cells, that make pigment are attacked and destroyed causing the skin to turn a milky white color.

Shwitra which covers all hypopigmented disorders of the skin. Shwitra is a chronic illness. The leision of shwitra being dry and also non-infectious thus differ from other types of kushta in general. though it has been described along with kushta in the classics. It is mainly caused by various dietetic and behavioral factors which aggravate the tridoshas. specifically kapha dosha which than in turn vitiates Medo Dhathu (Fat tissue).

Etiology

 According to Ayurveda:

1. Doshaja Atmaja (Due to vitiation of doshas).
2. Paraja (Due to contact with external factors) and 
3. Vranaja (caused by improperly healing of wounds) according to origin of disease.
4. "Atigoura" is one among these eight can be considered as congenital Shwitra.. Faulty dietetics of the mother.

2 Types

Sahaja (genetically transmitted) Jaatotara (acquired.

According to pathogenesis

A in consideration with vitiated Doshas

Vataja : Reddish , white in color, and causes horripilation of hair of the leisions

B Pittaja :Patches are  white, smooth and thick with itching.

B In consideration to  the affected Doshas with Dosha.

Dushya   Sammurchhana, Shiwitra because of affection of Dosha with Twak, Mamsa and Meda and Rakta seperately and in combination also. The shwitra is known as Kilasa when it affects Rakta and as Daruna when it affects Mansa.

According to clinical features: Discoloration of skin is known as Shwitra or Kilasa. in Ayurveda meaning thereby the normal color of the skin  is lost or white patches are seen on the skin surface. As we all know that  all types of Kushta in Ayurveda are Tridoshaja in nature. When the disease spots are mainly white in color and the seat of dosha-Dushya sammurchhana is Medo dhatu the type of kilasa is  known as Shwitram.

(a) Arun Varna : When the vata involve the Rakta dhatu.

(b) Tamra Varna : When the Pitta involved the Mamsa Dhatu.

(c) Sweta Varna :When kapha involves the Meda Dhatu.

According to distribution of patches

Ekadeshaja : Patches found at one part of the body

Sarvadeshaja : Patched found in different parts of the body.

Patches are isolated or not united which are stationary patches are isolated indication the  progressive nature of the disease.

According to prognosis

Sadhya (curable)

Asadhya (Incurable)

Ayurvedic Treatment

First line of treatment should always be Deepana and Pachana for better absorption of medicines and better outcomes. This can be achieved with Agnitundi vati or Gastin capsules. bd or tds.

Second line of treatment should be Snehpana and Virechana. Virechana is the most advised line of treatment in Twak rogas but Vaman and Vasti are also applicable according to the dosha avasta

Snehapana can be done with Mahatikthakam Ghrutham or guggulu thikthakam ghrutham.

Third line of treatment is Shamana Oushadha sevana. Once the panchkarmas are over and the vishrama kala (rest period) along with the dietetic regimen are all strictly observed., we can go with certain classical medicines like shiva gulika, Bakuchi churna or Gandhaka Rasayana. All these three medicines are spcifically mentioned for vitiligo.

There is also the usage of Shwithrahara Kashaya according to the bala of the patient. Proprietary medicines like Pigmenorm capsules and Asotec Forte are also  very useful in such conditions

If hair follicle pigments are not affected, there will be significant improvement in the coloration and size of the leision.

Kutaki : Vitiligo

Due to the phytotoxic property . Vitiligo is a disease that leads to formation of white patches on the skin. Regular use of Kutki helps to reduce vitiligo. Vitiligo is a disease in which melanocyte of the skin are destroyed and lead to the formation of white patches on the skin. It is also known as shwitra. It occurs due to the imbalance of pitta dosha that leads to the formation of AMA in the body . This Ama impairs other body tissues and eventually leads to depigmentation of skin. Due to the presence of appetizer and purgative properties it can help manage vitiligo, remove ama from the body and balance pitta.

Classification

There are two types of vitiligo : 

1. Non-Segmental Vitiligo (most common)
2. Segmental Vitiligo (Less common)

Non-Segmental Vitiligo (most common)

Non segmental vitiligo happens when the white patches appear symmetrical on both sides of the body. This can have rapid loss of color or pigment and tend to cover a large area. Nonsegmental vitiligo is an acquired leukoderma characterized by the destruction of melanocytes. Autoimmunity is the most widely accepted hypothesis to explain the pathogenesis of nonsegmental vitiligo. Increased oxidative stress and decreased expression of E-cadherin may facilitate the loss of melanocytes.

Non Segmental Vitiligo

Non Segmental Vitiligo

Nonsegmental Vitiligo (NSV) is a chronic skin disorder that is the more common of the two types of vitiligo. It is characterized by progressive, depigmented lesions of the skin, mucosa, and hair. Just like Segmental Vitiligo (SV), NSV can appear at any age. However, many studies suggest that it is more likely to appear around the age of 20.
The total area of affected skin varies between individuals. However, it is always hard to predict whether the patches will spread, and by how much. The spread might take weeks, or remain stable for months or years. They can also affect the eyes, the inside of the mouth, and the hair. In most cases, the skin affected by Nonsegmental vitiligo remains depigmented for the rest of the person’s life. Since the condition is photosensitive, affected areas are more sensitive to sunlight than those that are not.

It is believed that Nonsegmental vitiligo is caused by an immunologically complex mechanism. It is often difficult to distinguish the onset of new NSV lesions from segmental vitiligo lesions developed on the skin.

Possible Causes

The NSV induced patches appear when melanocytes (the cells responsible for producing the skin pigment) within the skin die off. Why ongoing loss of melanocytes takes place is still unknown and the subject of various ongoing studies.

According to many experts, the leading role in the damage of melanocytes in vitiligo is played by autoimmune mechanisms. Hence, autoimmunity is the most widely accepted hypothesis to explain the pathogenesis of NSV. Oxidative stress is also currently considered to be one of the causes.

Researchers have been frequently associating NSV with other autoimmune diseases, (Hashimoto’s Thyroiditis and Graves’ disease, Rheumatoid Arthritis, Type 1 diabetes, Psoriasis, Pernicious Anemia, Systemic Lupus Erythematosus, Addison’s disease, and Alopecia Areata). In many research studies, family history, detection of associated disorders and side effects of previous therapy were reported in the non- segmental vitiligo group only. While the exact causes of NSV are unclear, a number of factors may contribute, including:

• A stressful event
• Harm to the skin due to a critical sunburn or cut
• Exposure to some chemicals
• A neural cause
• A virus

Treatment options

Since the exact cause of the vitiligo is not known, there is no effective treatment to cure Nonsegmental Vitiligo. New drugs targeting the immune response in combination with antioxidant agents may help some patients, while some may get benefitted by stress management practices. Some of the available treatment options include:

Phototherapy with UVB light: Exposure to ultraviolet B (UVB) lamps is emerging as common treatment option. While home treatment requires a small lamp for daily use, full-body treatment is done at a healthcare facility. Combined with other treatments, UVB phototherapy can have a positive effect on vitiligo. However, the result is not totally predictable.

Phototherapy with UVA light: UVA Phototherapy is usually conducted once the patient takes a drug that increases the skin’s sensitivity to UV light. Then, in a series of treatments, the affected skin is exposed to high doses of UVA light.

Steroid creams: At times, applying topical corticosteroids can stop the spread. Many people using them have even reported total restoration of the original skin color. A form of vitamin D, Calcipotriene can also be used as a topical ointment.

Medication: As per a 2013 research, Pseudocatalase may provide a cure for the loss of skin color in Nonsegmental Vitiligo. Some people might be low melanin levels due to lower levels of the α-melanocyte-stimulating hormone (alpha-MSH). Hence, usage of Afamelanotide can be effective. An arthritis drug – tofacitinib citrate – has also shown some promise

Skin grafts: In this method, a surgeon removes healthy patches of the person’s pigmented skin and uses them to cover affected areas. This procedure is not very common.

Depigmenting: If the affected area covers 50 percent (or more) of the body, depigmentation therapy can be considered as an option. The method reduces the skin color (by applying strong topical lotions or ointments) in unaffected parts to match the depigmented areas. Though treatment is permanent, it can make the skin more fragile. Hence, long exposure to the sun is avoided.

Tattooing: Surgery is used to implant pigment into the skin. The procedure works best on the lips. Drawbacks can include difficulty matching the color of skin and the fact that Tattoos ultimately fade out. 

Skin camouflage: if the person has mild vitiligo, he/she can camouflage some of the patches with cosmetic creams and makeup. Most of such topical applications are waterproof.

Segmental Vitiligo (Less common)

Segmental vitiligo happens when the white patches are only on one side of the body, or arm. This often begins at an early age and progresses for about 1-2 years and than usually stops.

Usually, when you paint a picture in your head about any human being, you see them with uniform skin color. However, sometimes you will come across some people that have experienced a loss of natural skin color. They have patches of white in some parts or all over their bodies. These white patches essentially denote loss of pigment. Segmental vitiligo gets recognition as a separate entity. It has varied differences from generalized or non-segmental vitiligo. Due to its early onset and progressive development of patches or macules, segmental vitiligo gets characterized by segmented patterns on the skin over 6-24 months, followed by rapid stabilization. The main distinguishing factor lies in its unilateral distribution (where lesions do not cross the midline). The underlying cause of segmental vitiligo remains debatable. But it usually occurs due to an autoimmune response to melanocytes. The majority of segmental vitiligo cases occur from infancy to adulthood, usually before 30 years of age. While the affected skin remains asymptomatic, it could get affected due to sunburns. Moreover, it remains highly uncommon and can affect up to 5% of adults and up to 20% of children. When you get vitiligo – whether segmental or generalized – it affects the significant parts of the body. It can affect your skin, hair (scalp, eyebrows, beard, eyelashes), eyes, inside of the mouth, or even genitals. Flat white patches or spots on the skin can get characterized as the only symptom of segmental vitiligo. The first time you might notice spots or patches is when your skin gets exposed to the sun. Other signs include:

• Slightly pale spots or patches that eventually turn white
• Irregularly shaped patches or a spot
• Inflamed edges with a slight red tone, sometimes resulting in itchiness Most times, segmental vitiligo does cause any discomfort, irritation, or soreness in the skin. However, it affects only a handful of people and does not spread as quickly as generalized vitiligo (which impacts larger areas of your skin).While the exact cause of segmental vitiligo remains unknown, you could find a few factors that may be behind its occurrence. Although it affects only 0.5-2% of the world’s population, if you have vitiligo or know someone who does, the causes may help you to reason and understand its treatment.

Causes:

• • Melanocytes within the skin reduce or die-off
  • Reduction in the production of skin pigment – melanin
  • Autoimmune disorder or virus
  • If your body’s nervous system goes awry (especially in the case of segmental vitiligo) Although these causes could cause segmental vitiligo, studies do not yet show why it happens. However, it can affect people across the world of all skin colors and races.

Segmental Vitiligo Treatment 

Since segmental vitiligo remains confined to one section of your body, determining the treatment guidelines gets easier. However, response to any treatment depends on how well your body gets accustomed to it. Most often, the treatment for segmental vitiligo includes both medical and surgical therapies. But, surgical treatment remains limited to the response you get via medical treatment. If it fails, your dermatologist may suggest surgical methods to improve the appearance of your skin.

The treatment for segmental vitiligo gets administered in two stages – the first line of treatment and the second line of treatment. The first line of treatment includes:

Topical corticosteroids: You can gain some skin color back with the help of topical corticosteroid creams. Depending on the diagnosis, they alone may work for you very well, or the doctor might prescribe combination therapy.

Topical immunomodulators: Calcineurin inhibitors have gained quite the reputation when it comes to their efficacy. Even the use of topical vitamin D analogs along with immunomodulators may work to reduce the appearance of white patches on your skin.

Narrowband UVB therapy: It works very well in segmental vitiligo treatment as the UV light emitted focuses on small, targeted areas of your body. You may require two to three sessions of NB-UVB therapy per week for a few months for it to work. Again, this depends on the diagnosis.

Phototherapy: It requires the use of both psoralen and UVA light to restore your skin color. It can treat both generalized and segmental vitiligo effectively. However, opt for this therapy only if advised by your doctor. If the first line of treatment fails to garner the desired results, your doctor might suggest surgical therapy – the second line of treatment. It includes:

• • Epidermal grafting
  • Mini-grafting
  • Transplantation of epidermal cell suspensions

While you may not always find the entire affected area of your skin to get re-pigmented, reducing the appearance of white spots or patches remains the ultimate goal. Any treatment requires an understanding of the skin condition, the extent of its spread, and a proper diagnosis and examination, which will lead to the most suitable form of treatment. Therefore, the responsibility of identifying and diagnosing segmental vitiligo lies with the skincare practitioner, who can share the right treatment method for you. Mostly, if you get affected with vitiligo, the cells that produce melanin die-off, thus regaining the loss may not always yield the needed results. However, if you detect segmental vitiligo early on, you can curb its spread and get the necessary treatment at the earliest.

Segmental Vitiligo Vs Non-Segmental Vitiligo

The primary difference between segmental and non-segmental vitiligo is that the former does not usually occur in response to autoimmune disorders (opposed to the latter). You will find a few more differences listed between the two below:

Segmental Vitiligo	Non-segmental Vitiligo
Early age of onset	Variable age of onset
Unilateral in nature	Bilateral in nature
Spreads rapidly and stabilizes in a few years	Takes a chronic and progressive course
Predictable spread of white patches	Unpredictable spread of white patches
High percentage of white hair in the early stages of the disease	Variable percentage of white hair of lesional skin
Satisfactory response to autologous grafting	Unpredictable response after autologous grafting
Not associated with autoimmune disease	Often associated with personal or family history of autoimmune disease

According to Ayurveda, all types of skin diseases are corelated to kushta or Kshudra kushta. The main feature of kushtam are "Kushnati Angam" that which causes disfigurement of the doshas, dhatus anga's of our body is called Kushta.. Main nidana / cause for this are virudhahara (Incompatible foods) i.e. Taking seeta (cold) or usna (hot) food together, Curd with fish, honey and ghee in equal quantity etc. All these lead to visha (poison) in our body. Taking excess oily, spicy food and improper lifestyle also are  the causative factors.

Due to above causes, the prakupita vata dosha takes shelter in our tvak (skin), mamsa, lasika etc. dhatus and does vikritha in the causing small rashes on the body. Main features include excess dryness or oily ness, itching, discolouration, burning sensation, numbness, loss of sensation etc.

Kilas / Switra may be compared with vitiligo/ leucoderma. In this shareera (body) becomes white in color  Swetha varna.

How does Naturopathy or Natural therapy for vitiligo work? 

Natural therapies assist in the management of vitiligo by finding out what is driving or triggering the skin condition in the first place. For some, it may be an imbalance in the digestive system, for others, it could be stress. Some of the treatment methods covered under Naturopathy for vitiligo after finding the trigger include: 

Elimination of food allergens

Elimination of common allergenic foods such as dairy, soy, corn, fish, citrus, eggs, wheat, and peanuts are encouraged to be eliminated by naturopaths. As a common method, naturopaths first remove the allergens listed above for two weeks then introduce one at a time every three days to note any changes. To check allergies, intolerance testing is performed to check for IgG immune-mediated reactions in allergies or other subtler immune reactions in people with sensitivities to food.

Healthy diet

People undergoing Naturopathy for vitiligo are encouraged to reduce foods in the diet that promote inflammation and cause an imbalance in the immune system. These red-coded foods usually include high saturated fats such as dairy, meat, and poultry and foods cooked in oils high in omega 6 such as sunflower oil, grapeseed oil, soybean oil, and margarine. A diet rich in essential fatty acids to reduce inflammation such as cold-water fish, walnuts, nuts, seeds, chia seeds, and flaxseed oil is prescribed.

Stress management

If stress has been found to be a trigger, Yoga or meditation exercises are suggested to help people with vitiligo release tension. Based on the prognosis, the use of herbal teas of passionflower, chamomile, or lemon balm is advised throughout the day for calm and clarity. Foods that are rich in Vitamin B and magnesium are also suggested to support a healthy nervous system.

Exposure to Sunlight

Exposure to sunlight in moderation is also tried under naturopathy to help the melanocytes to regenerate given that many studies point out the Vitamin Deficiency in people with vitiligo. One study even found significant improvement in people with vitiligo with high-dose supplementation. However, it is of utmost importance to consult a GP before considering supplementing with high doses of vitamin D.

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