Types of Vitiligo - How They Are Different?

What Is Vitiligo

Vitiligo is an autoimmune condition which attacks the melanin-producing cells that create the pigment of our skin. Vitiligo results in skin pigment loss that can affect any part of the body, including the mouth, hair, and eyes. Common symptoms of vitiligo include white or “bleached” areas on the surface of the skin.

This disease affects approximately 1% of the world’s population, presenting equally in both sexes and in individuals of all ethnicities.^[1] Over the years, vitiligo has become very well studied because of its complex genetic component, and a high association with other diseases.

Vitiligo can be disfiguring, oftentimes affecting patients psychologically. The loss of skin pigmentation can be difficult to cope with and may cause major emotional distress in an individual’s life. There are different types of vitiligo that appear on the skin in several various ways, making vitiligo a unique skin condition.

The difference between non-segmental and segmental types of vitiligo:

• Non-segmental/Generalized vitiligo is vitiligo that appears in more than one area of the body and can be symmetrical. In severe cases, most of the body’s pigmentation can be lost.
• Segmental/Localized vitiligo is vitiligo that only affects one area or spot of the body.

Generalized or Non-Segmental Type Vitiligo

Non-segmental vitiligo originates from an autoimmune abnormality.^[2] Studies have found that patients with non-segmental vitiligo contain antibodies that attack pigment-producing cells. Patients with non-segmental vitiligo are prone to having another autoimmune disease that affects the endocrine system, such as Grave’s disease which affects the thyroid gland. Therefore, vitiligo treatment options include therapies that suppress the immune system.^[3]

Non-Segmental Vitiligo Subcategories

Non-segmental is the broadest term to describe the different types of vitiligo. It is further subdivided into several types depending on its distribution area. Non-segmental vitiligo most commonly affects the hands, feet, eyes, and mouth, eventually resulting in a symmetrical spread to other areas.^[2,4,5] It is also progressive in nature and has periods of activity and/or halting. 

Vitiligo vulgaris

• Characterized by scattered small, flat, white-colored spots with a wide distribution on both sides of the body.
• Typically affects the face, armpits, elbows, hands, knees, and feet.

Acrofacial vitiligo

• Specifically affects the hands, feet, and face.

Vitiligo universalis

• Typically affects large areas of the body
• Most of the body’s pigmentation is usually lost.

Localized or Segmental Vitiligo

Segmental vitiligo is characterized as depigmentation of the skin in an asymmetrical pattern and affects only one specific area or side of the body.^[6] Segmental vitiligo is more common than non-segmental vitiligo and occurs at an early age, typically before the age of 30.[1,8]

One of the factors that differentiate segmental vitiligo from non-segmental is that stops progressing after the initial presentation.^[1,6] Although further research needs to be conducted, the origin of segmental vitiligo is thought to have an underlining autoimmune cause or neural dysfunction of the sympathetic system.^[6,7]

Types of Vitiligo That Are Neither Segmental nor Non-Segmental

Focal

Focal vitiligo is a variant of vitiligo characterized by loss of skin pigmentation of a few spots in a single area. Focal vitiligo can develop into segmental or non-segmental types of vitiligo and its progression is often unpredictable.^[9] Little information is known about how focal vitiligo progresses into other types of vitiligo, which can make treatment challenging.

Definitive diagnosis for focal vitiligo remains controversial, however, it is typically defined when areas of pigment loss have stopped evolving into a segmental or non-segmental vitiligo distribution after 1 to 2 years. It is possible for focal vitiligo to progress into other types of vitiligo after a period of 5 years, complicating the diagnosis.^[9]

Mixed

Mixed vitiligo typically begins as segmental vitiligo and may progress to non-segmental vitiligo.^[8] Some studies have observed a reversal phenomenon in which segmental vitiligo developed from non-segmental vitiligo.^[5] 

Treatment Considerations

The main therapies targeting different types of vitiligo are phototherapy, laser therapy, topical therapy, and less frequently, surgery. Segmental vitiligo is known to be more resistant to treatment, especially if the vitiligo started at the age of 14 or younger.

• Surgical treatment has been used for segmental vitiligo if the treatment area is small and not actively growing in size.

• Phototherapy has shown promising results in non-segmental vitiligo and is a preferred treatment because it is cost-effective, safe, and well-tolerated.^[10-12]

• Laser therapy has also shown promising results, however, the cost of this treatment is often expensive and unattainable to some patients.^[10,12]

• Topical medications are often combined with phototherapy and laser therapy for improved results.

Conclusion

Dealing with vitiligo and loss of skin pigmentation can be extremely difficult for patients. It can decrease a patient’s self-esteem and cause emotional stress that affects their quality of life. It is important to understand the different types of vitiligo and the possible treatment options available.