- Best Results9-24 months
- Treatment Recovery8-14 days
- Procedure TimeVariable
- Skin SpecialistDermatologist
- Duration of ResultsLong-term
- Back to WorkVariable
For extensive areas of vitiligo, depigmenting normal skin can give a uniform colour. Careful consideration is required as this is frequently irreversible. This form of vitiligo treatment is best conducted in a public hospital as side effects to chemicals & lasers are universally seen.
FactsFacts On Vitiligo Depigmentation
- This is a last resort treatment for vitiligo
- It is considered if vitiligo affects more than 60-80% of body surface area
- MBEH topical creams are first line
- Skin lightening with MEBH is always associated with skin irritation
- Treatment can take up to 18 months to complete
- Focal areas of pigment can be treated with lasers
- Skin lightening & depigmentation is best conducted in a dermatology department
What is the aim of depigmentation?
This procedure aims to give the vitiligo patient a more uniform skin colour. In a nutshell it takes away pigment. This gives skin a white appearance. Think Michael Jackson white. The long-term implications must be considered as it is irreversible.
When to consider depigmentation as a treatment for vitiligo?
Careful patient selection is required. As a guide, dermatologists consider depigmentation if the total BSA or body surface area of vitiligo exceeds 60-80%. Patient factors including skin type, location, age & psychological impact are taken into consideration.
What is the most frequent ingredient for skin whitening?
MBEH or mono-benzyl ether of hydroquinone is the drug of choice in most countries. It destroys cells that produce pigment, in addition to blocking melanin synthesis. Concentrations range from 5% to 40%. It is performed under the guidance of an experienced dermatologist.
How is skin lightening performed?
Most specialists will start on a small area first, such as your forearm. This is called a test patch. If you do not have allergic contact dermatitis, they will then instruct you to apply MBEH on other areas. Different concentrations are used according to areas treated & your skin reaction. Examples- MBEH 15% face & neck, MBE 40% legs & torso.
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What are the side effects?
Lots- hence why this should be managed in a public hospital. The most common side effect is irritant contact dermatitis. It presents as intense redness, itch, & swelling in areas of both normal skin (more common) & vitiligo. Allergic reactions are less common. The risk of cancer is another factor you should consider, hence why MBEH is banned in Europe.
How long will it take to depigment skin?
It ranges from 6 to 24 months, depending on the body surface area involved, location of vitiligo, side effects, technique & your motivation.
Disclaimer: I do not provide this service in private clinics. The PA Hospital department of dermatology may provide depigmentation. Failing that, I can refer you to Dr R. Whittal in Sydney for an option.
Can IPL be used on darker skin types?Is depigmentation permanent?
In most cases, yes. In some cases, there may be pockets of melanocytes holding the last glimmer of hope. They typically produce pigment around the hair follicle (perifollicular pigmentation). These melanocytes are deep in the skin’s layer, having had protection from immune attack.
If there are pigmented hairs, you may get more pigment production over the next few months. A simple solution is to kill off the remaining hair follicles with long pulse hair removal lasers. 3-6 sessions will do the trick.
Can skin whitening be performed in focal areas?
Most depigmenting agents will induce unpredictable skin whitening in other areas. This is due to your immune system. Hence it is not possible to only remove pigment from your face.
Can lasers depigment skin in vitiligo patients?
Yes, but only in small patches. I use pigment lasers such as Q Switch & Pico lasers in super high settings to destroy melanocytes. Given the power levels used, scarring secondary to blistering is not uncommon. Patients require 8-15 sessions over one year. Lasers are not used as primary methods to de-pigment. You cannot laser a regional area such as the face or arm!
What lasers are used to depigment skin?
Really short pulse duration lasers are employed to destroy melanocytes. The first reported laser is the ruby 694 nm.
My team also uses long pulsed lasers including 755 Alex, 810 diode & LP 1064 Nd Yag lasers to destroy remaining hair follicles that are a source of residual melanocytes.
Which subtype of vitiligo is more responsive to laser treatment?
The ideal patient is the opposite to what I look for when re-pigmenting vitiligo. Patients with a history of trauma do best (Koebner). A simple test to see if you are a candidate is to do a test spot.
In some cases, we get patients to tan in areas to be treated. This gives us a clearer target to hit. We do not treat more than 100 cm2 with each visit as the treatment is very painful. It can take up to 2 weeks before the skin recovers.
Why is sunscreen use essential?
Sunscreen use is essential for two reasons. Firstly, to prevent re-pigmentation of viable pigment cells & secondly to stop your skin from burning. Apply a high factor SPF 50+ to all exposed skin 15 minutes before sun exposure.
At what age can you undergo depigmentation in vitiligo?
This depends on your treating dermatologist. Most will consider depigmentation in the teenage years or older. Careful consideration is placed as removing normal pigmentation is largely irreversible.
What natural ways are there to depigment skin?
There are no safe oral (systemic) ways to reduce pigment in normal skin in patients with vitiligo. Ingestion of high concentrations of phenol-based drugs, liquorice root & other medicinal herbs & potions can be toxic to the liver & other organs.
Topical creams that can aid in reducing melanin output include arbutin, bearberry, liquorice extract, & kojic acid.
How does Glutathione + Vitamin C IV therapy work?
Glutathione in combination with ascorbic acid or vitamin C are powerful antioxidants that are used for skin bleaching & skin whitening. These compounds assist the body in getting rid of the harmful effects caused by toxic hydrogen peroxide & free radicals. Both chemicals decrease the production of melanin.
In combination, they are one of the most effective skin whitening products. They are best used as adjunctive therapy for MBE or for patients with small areas of normal skin. Glutathione does not work as monotherapy.
What is cryotherapy?
This treatment uses cold liquid nitrogen to destroy skin cells, including melanocytes. It is used in countries like India & Pakistan. Nitrogen therapy is performed on small patches, spaced 3 -5 weeks apart. Blistering is universally seen. I do not perform this procedure.
What are experimental drugs used to lighten skin in patients with vitiligo?
These methods are only used in research studies. I do not prescribe these medications due to the safety profile & costs.
Imiquimod is an immune stimulator used to treat skin cancer. It can cause skin whitening. Imatinib is a tyrosine kinase inhibitor used for cancer. Other chemicals include hydroquinone (H), 4-ethoxyphenol (4-EP), 4-methylcatechol (4- MC), 4-tert-butylcatechol (4-t-BC), monobenzone (M), hydroquinone bis (2-hydroxyethyl)-ether (HHEE), and catechol (C). These compounds were injected into animal skin as 10% and 20% solutions dissolved in 95% ethanol.
Who to see for depigmentation?
The most experienced dermatologists in Australia in the context of depigmentation are Dr Richard Wittal & Dr Michelle Rodriguez in Sydney & Melbourne respectively. We used to perform depigmentation at the PA Hospital Brisbane when I was a registrar there in the early 2000s.
Disclaimer: My skill sets are polar opposite to depigmentation, I repigment vitiligo. I can assist with depigmentation towards the end with pigment lasers.
Davin’s Viewpoint on Vitiligo Depigmentation
This is one area of vitiligo treatment that I have no experience with in private practice. The last patient I treated for skin lightening in the context of vitiligo was in 2005. The agent of choice is still an ester of hydroquinone.
Complete removal of pigmentation is an enormous step to take. It changes the social acceptance of some cultures, namely darker skin patients. Complete removal of pigment also increases the susceptibility to skin cancer, photoaging & sun burn.
The process of skin lightening can take several years. Your dermatologist will guide you accordingly. The first few months is learning how to modulate your inflammatory response (skin irritation) due to MBEH. Residual pigmentation can be effectively treated with lasers. This is where my team & I come in.
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