Post-Inflammatory Hypopigmentation, White Patches, Vitiligo

Alright, so I've been doing an extensive research involving a multitude of references, articles, doctors' comments, and personal stories that I found on the internet. This research aims to seek the cure to what many experts and medical personnel believe to be a particular skin condition which has no cure, or at least, is very hard to be cured: "Hypopigmentation".

Before I move on, I am not a doctor. So, always consult your dermatologist before starting any treatment. This blog is intended for educational purpose only, it reflects my own personal opinion based on comparison of various literature, is not a substitute for a proper and competent medical advise, and is not an advertisement or promotion of any brand and/or trademark mentioned hereunder.

Hypopigmentation is the loss of skin color because the melanocyte, which is the cell that produces melanin, which gives the skin its color, is depleted, damaged, or unable to function. Hypopigmentation can also be due to the decrease in the amino acid tyrosine, which is used by melanocytes to make melanin. As a result, white or lightened patches may appear in some or all parts of the body, making it contrast to the remaining skin color, particularly in dark-skinned individuals. These white patches are neither painful, itchy, sore, nor contagious. This is why hypopigmentation is often called a "disorder" rather than "disease", and because of its nature, it requires an advanced dermatological treatment.

The cause of hypopigmentation can either be unknown, genetic, or autoimmune, such as in cases of albinism or vitiligo. Vitiligo is a skin disorder suffered by the late Michael Jackson. In many cases, hypopigmentation also results from trauma, burn, laser hair removal, or injury to the skin, or known as "Post-Inflammatory Hypopigmentation". When you have a superficial abrasion on your skin, the skin would develop a scab to protect the wound. In the few days the scab would fall. Once the scab shed away, the skin pigment would then be in response to sunlight, and finally, the color of the scar would match that of the rest of the skin.

On the other hand, if the wound was deep, most of the pigment producing layers of skin would be damaged while the deeper layers of skin would have to repair the damaged tissue. To start the repair process of the skin, then skin with elastin and collagen, blood vessels under the skin would protect the mesh. When the blood vessels damage occurs, a greater amount of inflammation may accompany the healing process. In these circumstances, a mild form of fibrosis or excessive scarring can occur due to skin damage and inflammation. With the development of scar tissue, melanocytes may not reach the surface of the skin, where they make melanin and give color to the skin. This leads to white, coarse scar tissue.

Hypopigmentation differs a lot from Hyperpigmentation, where instead of losing its color, the skin develops more color than it's supposed to. As a result, black/brown/dark patches appear on the spot where the trauma or injury previously existed. In general, hyperpigmentation is a lot easier to cure rather than hyopigmentation, such as by applying Hydroquinone cream.

Because of the difficulty to treat hypopigmentation, anyone that has it should be patient with the duration and intensity of the treatment. The existing types of treatment do not work the same way for everyone and the results are different in each individual. Sometimes, hypopigmentation goes away on its own after exposure to the sun, but others have to wait for 6-24 months to see the result. Treatments offered to post-inflammatory hypopigmentation patients are essentially the same as those done to vitiligo patients. They include:

1. Corticosteroid creams. One of the examples is Hydrocortisone. It is strongly suggested that you do not use highly potent corticosteroids, such as Dermovate or Betamethasone (Diprolene). These creams, although very effective in treating eczema, if used in a long term period, may actually worsen hypopigmentation and may add more white patches to the remaining normal skin. Mild corticosteroids such as Hydrocortisone 2.5% may be prescribed by dermatologists to treat hypopigmentation. It is also highly suggested that corticosteroids/cortisone are not given by way of injection, since there are cases reporting that injected corticosteroids treatment (such as acne or eczema treatment) actually caused hypopigmentation. In any event, corticosteroid creams must not be used for a prolonged period of time, since their side effects include: skin atrophy (skin thinning), allergic dermatitis, and osteoporosis.
2. Tacrolimus, such as Elidel Cream or Protopic Ointment. Protopic is available in 0.1% for adults and children above 15 years of age, and 0.03% for children aged 2 to 15. Tacrolimus is normally prescribed to treat eczema, but dermatologists may also prescribe it to treat hypopigmentation and vitiligo, because it functions as immunomodulators that suppress the immune system where applied, allowing the melanocytes to return. Side effects can include stinging, soreness, a burning feeling, or itching of the treated skin. These side effects are usually mild to moderate and are most common during the first few days of treatment.
3. Tar products, such as V-Tar. V-Tar is a crude coal tar product which contains a 30% concentration of tar that has been formulated to be water soluble, so it won't stain skin. It is applied once a week, left on for 5-6 hours (or overnight), then removed. Users must avoid sun exposure for 72 hours after treatment. V-tar can be used by anyone, including children.
4. Novitil. This product requires an exposure to the sun or infrared light once a day after the users apply it. The product should be applied twice daily. Its producer claims that it causes no allergy or skin irritation.
5. Phototherapy. This includes: PUVA ("Psoralen" + "UVA" light) and Narrowband UVB. Narrowband UVB is generally considered to be more effective than PUVA because it has way less side effects which typically come together with phototherapy, such as burns and hyperpigmentation (dark patches). Narrowband UVB may also be done on pregnant women. In PUVA treatment, psoralens are typically taken orally, but may also be given topically. It is recommended to avoid potent laser treatment, and those who wish to have it must first consult a dermatologist. The reason is because some laser treatments, such as laser hair removal, may cause or worsen hypopigmentation. In laser treatment for vitiligo patients, the laser is typically only used on stable vitiligo because when the vitiligo is active, there is a greater chance of pigment being lost afterwards. Hands and feet are often not treated with laser because it is less effective there. Potential side effects include burning and in a long term, it may cause skin cancer. Laser is one of the most expensive treatments.
   
6. Depigmentation. For patients whose therapies have failed or hypopigmentation has covered more than 50% of the body, depigmentation may become an option. This treatment essentially kills all the remaining pigment so that the color of the skin becomes even. Monobenzyl, such as Hydroquinone, which is also used to treat hyperpigmentation, may depigment the skin, leaving the entire body fair. The process requires patience and consistency, as it can take up to 2 years to complete, though some are done sooner depending on the initial amount of remaining pigmentation and the strength of the medication used. This medication is only available in compounding pharmacies, and can be ordered in a 20%, 30% or 40% strength. The late Michael Jackson used to undergo this treatment.
7. Alternative treatments. A 1997 report suggests that combining Vitamin B12 and folic acid supplements with sun exposure caused repigmentation in 52% of cases. An open label pilot clinical trial using the herb Gingko Biloba found that the progression of vitiligo stopped in all participants. Furthermore, camouflage cosmetics such as Dermablend and Covermark are also available for hypopigmented patients.
   

Hypopigmentation remains a delicate issue in the dermatological science. Not only because it is difficult to heal, but also because many times its cause is unknown and its treatments show different results from one person to another. Some dermatologists suggest that hypopigmented individuals do not even need to worry about their skin condition and they may just leave it that way, since it is not a disease and it is not contagious. In some cases, it may even go away on its own.

Specifically for post-inflammatory hypopigmented patients, make sure that the wound has completely healed before starting any treatment. The treatments described above may worsen fresh or open wounds. If the healed wound also leaves a keloid (overgrowth of skin tissue), you can apply Dermatix, Mederma, or Hiruscar. This would help reduce the additional tissue, but hypopigmentation may persist and may be treated using the options mentioned above.

REFERENCES & CREDITS:

1. http://www.vitiligosupport.org/treatments_and_research/depigmentation.cfm
2. http://info.med.yale.edu/dermatology/resources/vitiligo.pdf
3. http://www.brownskin.net/vitiligo.html
4. http://www.medscape.org/viewarticle/739758_7
5. http://www.medhelp.org/forums/Dermatology/show/65
6. http://www.skinsight.com/adult/post-InflammatoryHypopigmentation.htm
7. http://www.skinandallergynews.com/views/skin-of-color-by-naissan-wesley-lily-talakoub/blog/skin-of-color-postinflammatory-hypopigmentation-and-hypopigmented-scars/0c9d39d5ba.html
8. http://en.wikipedia.org/wiki/Vitiligo
9. http://en.wikipedia.org/wiki/Corticosteroid
10. http://en.wikipedia.org/wiki/Topical_steroid
11. http://www.lasertreatmentforacnescars.goodarticlesite.com/white-scars-hypopigmentation-their-causes-and-cures/
12. http://rscm.co.id/facilities.php?id=89
13. http://www.lasertreatmentforacnescars.goodarticlesite.com/white-scars-hypopigmentation-their-causes-and-cures/
14. http://www.dermabest.com/products.aspx?type=1&pID=1
15. http://findarticles.com/p/articles/mi_hb4393/is_3_33/ai_n28907224/?tag=content;col1
16. http://en.wikipedia.org/wiki/Hyperpigmentation
17. http://en.wikipedia.org/wiki/Tacrolimus
    
18. http://www.protopic.com/what-is-protopic/