Vitiligo

What Is Vitiligo?

[dropcap]V[/dropcap]itiligo is a pigmentation disorder of the skin characterized by permanent loss of melanocytes in defined areas and, in some patients, antibodies to melanin.

Vitiligo has significant psychological impact if occurring before adulthood.¹

Q: What are melanocytes?

A: Melanocytes are cells that produce melanin which is the pigment that colors skin. Regardless of a person’s natural skin color, the areas where melanocytes are unable to make melanin appears pink.

There is no cure yet for vitiligo, but there are treatments to make areas of lost pigment less noticeable.

Light treatment and laser treatment can be partially successful in restoring skin color. Treatment with steroid creams, if used, should be managed by a dermatologist because over time topical steroids can thin, dry, and weaken the affected skin.

Ginko biloba herbal supplements are also a treatment option.

What Is Vitiligo In Celiac Disease and/or Gluten Sensitivity?

• Relationship between vitiligo and celiac disease. Vitiligo is an associated autoimmune disorder in celiac disease. The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens. However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.²
• Relationship between vitiligo and autoimmunity. There is a well-established association of vitiligo with autoimmune conditions, and circulating autoantibodies to melanocytes have been demonstrated in the serum of patients with vitiligo.³

How Prevalent Is Vitiligo in Celiac Disease?

Vitiligo occurrence is 1.3% in dermatitis herpetiformis.⁴

In a study involving 64 patients with vitiligo and matched control participants, the serum of two vitiligo patients (3.1%) was positive for antibodies to celiac disease. There was no significant effect of sex and job on seropositivity.⁵

What Are The Symptoms Of Vitiligo?

• Vitiligo is marked in skin by unpigmented flat, white patches of varying size surrounded by normal pigmented skin.

How Does Vitiligo Develop In Celiac Disease and/or Gluten Sensitivity?

• Vitiligo results from an unclear etiology. An immune mechanism is postulated.

Does Vitiligo Respond To Gluten-Free Diet?

Studies are inadequate. Gluten free diet has been reported to restore depigmented areas in patients with celiac disease.⁶

6 Steps To Improve Vitiligo In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both vitiligo and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸
• Cocoa and Black Tea increase blood sugar.
• Rosemary. Increases blood sugar levels and should not be used by persons with insulin resistance or diabetes. [/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications used to treat vitiligo deplete nutrients. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

ANTI-INFLAMMATORIES

• Corticosteroid creams like triamcinolone acetonide cream deplete Magnesium. [/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Chelated magnesium as prescribed for low level, but do not take at same time as calcium because they compete for absorption.
• Ginko biloba 60 mg supplement twice a day for 12 weeks was shown to be effective in stopping the progression of vitiligo in all subjects and repigmenting in 15% of subjects.⁹

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion. However, because it increases blood sugar levels, it should not be used by persons with insulin resistance or diabete.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Vitiligo In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Vitiligo and autoantibodies of celiac disease.” This study investigating the frequency of celiac autoantibodies in a group of vitiligo patients compared with control found that there may be a relationship between celiac disease and vitiligo. This may indicate a common basic autoimmune mechanism that is an explanation for few case reports that gluten free diets were effective in the treatment of vitiligo patients. Both T test and exact fisher test showed no effect of age, sex and job on seropositivity of these patients (P = 0.56 and P = 0.74, respectively).

This was a cross sectional case control study that involved 128 individuals, 64 vitiligo patients and 64 individuals as control group. The means age of participants was 30.3 ± 14.4 years. IgA anti Endomysial antibody and IgA anti-glutaminase antibody were measured by ELISA method in the serum of all participants. Data were analyzed by SPSS software version 15. The serum of two vitiligo patients (3.1%) was positive for antibodies. All control groups were seronegative for these antibodies. There was no significant effect of sex and job on seropositivity.¹⁰

“Vitiligo and autoantibodies of celiac disease.” This study investigating the frequency of celiac autoantibodies in a group of vitiligo patients compared with control found that there may be a relationship between celiac disease and vitiligo. This may indicate a common basic autoimmune mechanism that is an explanation for few case reports that gluten free diets were effective in the treatment of vitiligo patients. Both T test and exact fisher test showed no effect of age, sex and job on seropositivity of these patients (P = 0.56 and P = 0.74, respectively).

This cross sectional case control study involved 128 individuals, 64 vitiligo patients and 64 individuals as control group. The mean age of participants was 30.3 ± 14.4 years. IgA anti Endomysial antibody and IgA anti-glutaminase antibody were measured by ELISA method in the serum of all participants.

The serum of two vitiligo patients (3.1%) was positive for celiac antibodies. All control groups were seronegative for these antibodies.¹¹

“Ginkgo biloba for the treatment of vitilgo vulgaris: an open label pilot clinical trial.” This pilot study investigating the feasibility and effectiveness of gingko biloba as a treatment for vitiligo found that ingestion of 60 mg of ginkgo biloba twice a day was associated with a significant improvement in total Vitiligo Area Scoring Index (VASI) vitiligo measures and Vitiligo European Task Force (VETF) spread, and a trend towards improvement on VETF measures of vitiligo lesion area and staging.

Twelve participants 12 to 35 years old were recruited to a prospective open-label pilot trial and treated with 60 mg of standardized G. biloba two times per day for 12 weeks. The criteria for feasibility included successful recruitment, 75% or greater retention, effectiveness and lack of serious adverse reactions. Effectiveness was assessed using the Vitiligo Area Scoring Index (VASI) and the Vitiligo European Task Force (VETF), which are validated outcome measures evaluating the area and intensity of depigmentation of vitiligo lesions. Other outcomes included photographs and adverse reactions. Safety was assessed by serum coagulation factors (platelets, partial prothrombin time (PTT), and INR) at baseline and week 12.

Eleven participants completed the trial with 85% or greater adherence to the protocol. The total VASI score improved by 0.5 (P = 0.021) from 5.0 to 4.5, range of scale 0 (no depigmentation) to 100 (completely depigmented). The progression of vitiligo stopped in all participants; the total VASI indicated an average repigmentation of vitiligo lesions of 15%. VETF total vitiligo lesion area decreased 0.4% from 5.9 to 5.6 from baseline to week 12. VETF staging score improved by 0.7 from 6.6 to 5.8, and the VETF spreading score improved by 3.9 from 2.7 to -1.2. There were no statistically significant changes in platelet count, PTT, or INR. Larger, randomized double-blind clinical studies are warranted and appear feasible.¹

CASE REPORT SUMMARIES

“Multiple Disease Associations in Autoimmune Polyglandular Syndrome Type II. “ This case report describes the course of a 25 year old female with a history of ulcerative colitis, celiac disease and type 1 diabetes who presented with mental status changes. She was diagnosed with Hashimoto’s encephalopathy and treated with high dose steroids and intravenous immunoglobulin. She recovered well from her encephalopathy but her post-hospitalization course was complicated due to the development of Addison’s disease, vitiligo, sero-negative arthritis, and hypothyroidism.

This patient had a dramatic development of eight autoimmune diseases over the course of ten years. She developed Addison’s disease, hypothyroidism, type 1 diabetes, Hashimoto’s encephalopathy, vitiligo, celiac disease, sero-negative arthritis, and ulcerative colitis. This represents a particularly aggressive course of APS II and this combination of autoimmune diseases has not been previously reported. It highlights the potential complexity and severity of the clinical course of APS II.¹²

“Dermatitis herpetiformis co-localised with vitiligo in a patient with autoimmune polyglandular syndrome.” This case report describes the unusual presentation of dermatitis herpetiformis co-localised with segmental vitiligo in a 37-year-old woman with a background history of autoimmune polyglandular syndrome type 2. The patient presented with a 3-day history of a severe, pruritic, bullous eruption on the trunk and limbs associated with malaise. Her past medical history included Addison’s disease, autoimmune hypothyroidism, type 1 diabetes mellitus, coeliac disease and vitiligo. Coeliac disease was diagnosed following distal duodenal biopsy which demonstrated subtotal villous atrophy. The patient reported strict adherence to a gluten-free diet. Vitiligo on the limbs, trunk, and neck was treated with moderate potency topical corticosteroids fourteen years prior to this acute presentation. Her non-identical twin sister also suffered from autoimmune hypothyroidism and vitiligo.

On examination, multiple, well-demarcated, segmental areas of depigmentation were present on the forearms, neck, groin, and upper thighs. There were vesicles and bullae of up to 20 mm in diameter with adjacent crusted, erythematous papules exclusively within the depigmented areas but not within the pigmented patches. She was managed with a gluten-free diet and hydroxyzine 25 mg when required. The patient declined dapsone therapy due to her concerns regarding potential adverse effects. Her skin remained relatively well-controlled however she died 17 months later from a myocardial infarction.

“We propose genetic mosaicism as a possible mechanism. There has only been one previous case report in which dermatitis hepetiformis co-localised in close proximity but not exclusively within vilitigo in a patient with autoimmune thyroiditis.”¹³

“Repigmentation of vitiligo lesions in a child with celiac disease after a gluten-free diet.” This report presents a case of repigmentation of vitiligo lesions in a girl with celiac disease after initiating a gluten-free diet, which to our knowledge has not been reported.⁶

Sources:

1. Szczurko O, Shear N, Taddio A, Boon H. Ginkgo biloba for the treatment of vitilgo vulgaris: an open label pilot clinical trial. BMC Complement Altern Med. 2011 Mar 15;11:21. doi: 10.1186/1472-6882-11-21. [↩] [↩]
2. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380. [↩]
3. Rodríguez-García C, González-Hernández S, Pérez-Robayna N, Guimerá F, Fagundo E, Sánchez R. Repigmentation of vitiligo lesions in a child with celiac disease after a gluten-free diet. Pediatr Dermatol. 2011 Mar-Apr;28(2):209-10. [↩]
4. Reunala T, Collin P. Diseases associated with dermatitis herpetiformis. British Journal of Dermatology. Mar 1997;136(3):315-8. [↩]
5. Shahmoradi Z, Najafian J, Naeini FF, Fahimipour F. Vitiligo and autoantibodies of celiac disease. Int J Prev Med. 2013 Feb;4(2):200-3. [↩]
6. Rodríguez-García C, González-Hernández S, Pérez-Robayna N, Guimerá F, Fagundo E, Sánchez R. Repigmentation of vitiligo lesions in a child with celiac disease after a gluten-free diet. Pediatr Dermatol. 2011 Mar-Apr;28(2):209-10. [↩] [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Szczurko O, Shear N, Taddio A, Boon H. Ginkgo biloba for the treatment of vitilgo vulgaris: an open label pilot clinical trial. BMC Complement Altern Med. 2011 Mar 15;11:21. doi: 10.1186/1472-6882-11-21. [↩]
10. Shahmoradi Z, Najafian J, Naeini FF, Fahimipour F. Vitiligo and autoantibodies of celiac disease. Int J Prev Med. 2013 Feb;4(2):200-3. [↩]
11. Shahmoradi Z, Najafian J, Naeini FF, Fahimipour F. Vitiligo and autoantibodies of celiac disease. Int J Prev Med. 2013 Feb;4(2):200-3. [↩]
12. Maturu A, Michels A, Draznin B. Multiple Disease Associations in Autoimmune Polyglandular Syndrome Type II. with autoimmune polyglandular syndrome type II (APS II). Endocr Pract. 2014 Aug 22:1-13. [↩]
13. Macbeth AE, Lee KY, Levell NJ, Igali L, Millington GW. Photoletter to the editor: Dermatitis herpetiformis co-localised with vitiligo in a patient with autoimmune polyglandular syndrome. J Dermatol Case Rep. 2013 Sep 30;7(3):101-2. doi: 10.3315/jdcr.2013.1153. [↩]