THIS ILLNESS WAS ALREADY KNOWN IN 1400 BC
1- What is vitiligo? What does the illness consist of?
It is an acquired dermatological complaint, consisting in the partial
or total loss of melanocytes, the cells responsible for the pigmentation
of the skin and other body organs and tissues. Therefore, clinically it
appears as a circumscribed loss of colour, in the form of milky-white
patches, which may appear in one or several areas of the skin. It is a
non-infectious process, with no pain or itching and, in most cases, the
other vital functions remain unaffected.
2- What disorders or pathologies appear in vitiligo patients? Are there different forms of marks?
In 15-20% of cases, this type of leucoderma appears together with other
disorders, such as diabetes mellitus, pernicious anaemia, alopecia
areata, thyroid problems (hyper- and hypothyroidism), psoriasis, etc.
Moreover, recent studies carried out on human melanocyte cultures appear
to indicate that it affects the pigmentary system in general, not just
the skin, affecting even cellular elements of the nervous system that
contain melanin.
The maculas come in extremely variable shapes and
sizes, from several millimetres to several centimetres. Sometimes they
change size irregularly and join with bordering lesions, forming more
complex patterns. Their shape is generally round or oval. The margins
are clearly visible and are often hyper-pigmented.
Since when has this disease been known and how is it known in other cultures?
In ancient times, this disorder was known by many different names:
SHWETAKUSHTA in the ATHARVA VEDA, the sacred book of India (1400 BC);
the words BOHAK and BARAS are used in Arabic. The word vitiligo is
probably derived from the Latin word VITIUM (stain) and the suffix IGO.
3- It would appear that in ancient time vitiligo was sometimes confused with leprosy. Why did this confusion arise?
The biblical references to this type of leucoderma go back to the
translation of the Hebrew word ZORAAK (Leviticus 13.2) by the Septuagint
scholars in the year 250 BC. Leprosy pandemics in the Middle Ages and
abundant myths and historical confusion have, even in recent times,
particularly in underdeveloped countries, led to vitiligo sufferers
being called lepers.
A DISORDER THAT AFFECTS MILLIONS OF PERSONS, MAINLY IN THE WARMER AREAS OF THE WORLD
4- What is the general frequency of vitiligo, statistically speaking?
The disorder is considered to be widely distributed and to affect
millions of persons. The frequency varies between 1-2% of the population
in the western world, and 5-8% in other regions, where the incidence is
higher, such as in the Middle East, Northern Africa and South-East
Asia. In these areas, we can observe that, in addition to the aesthetic
problem derived from the contrast between the pigmented and
non-pigmented areas of the skin, there is a marked psychosocial aspect,
leading to personal or even professional marginalisation of the
sufferers.
5- Is vitiligo more frequent in men, women or children? Does
it have any preferences as regards sex, age, race, countries,
professions, social class, climate or type of country?
This illness
has no definitive preferences as regards age, sex, race, profession or
social class. The only thing I can say, in my experience, is that most
patients are between 15-40 years of age. Likewise, there is a higher
incidence in the warmer parts of the planet.
6- Is the real cause of
the disease known? Occasionally, although it is not a contagious
disease, several members of the same family might have it. Could it be
considered a hereditary disease?
The etiology of human vitiligo is
unknown. After analysing recent research, we can affirm that the
syndrome probably responds to several, mutually tolerant, etiologies. I
would like to point out that, in studies carried out on animals,
de-pigmentation was observed to have a genetic component, related with
intrinsic defects in the melanocytes; these defects may also be
exacerbated by the immune system. In the case of humans, no hereditary
factor has been established. It is true that it often appears in several
members of the same family, allowing us to observe a family
predisposition; however, in at least 60% of cases, no direct family
members are affected, so we can reasonably conclude, as affirmed in a
recent work published by Professor J.J. Nordlund of the University of
Cincinnati, that there may be genetic factors involved, but the
transmission model is complex, compatible with a polygenic disorder.
Personally, I think that there are still matters remaining to be solved.
AN AUTOIMMUNE DISORDER CREATED BY THE DEFENCES OF THE AFFECTED PERSON
7- Vitiligo is considered an autoimmune disorder. What does this mean?
The argument that the melanocytes are destroyed by lymphocytes, by
cytotoxic antibodies, or both, has been verified by many specialists in
the matter. Therefore, the immune system appears to play a fundamental
role in the pathogeny of vitiligo. We are dealing therefore with an
autoimmune disorder, created by the defences of the affected person.
This theory is based, among other reasons, on the observation of
circulating anti-melanin antibodies, detected in skin lesions, and in
the concomitancy of vitiligo with other autoimmune disorders that we
have mentioned earlier, including thyroid problems (hyper- and
hypothyroidism), liver problems, diabetes, alopecia aleata, etc. We
could also point out that, in some cases the antibodies could exacerbate
the intrinsic defects of the melanocytes and kill them, as ahs been
observed in animals, backing up the theories that vitiligo etiopathogeny
are not exclusive.
8- Many patients relate nervous or emotional
problems with the onset of the disorder. Is there any connection between
psychological traumatism and the illness itself?
The theory that
the nervous system intervenes in some way in the pathology of vitiligo
is actually backed by a lot of data. We could point out that the
melanocytes are embriologically related to nerve cells; they both
originate from the neural crest and are morphologically similar.
Moreover, some studies indicate that the concentration of certain neural
transmitters is abnormal when the skin is de-pigmented. Likewise,
although I have already stated that there are reasons to believe in an
immunogenic cause for the depigmentation of the skin, however, experts
frequently associate the main catalyst for this “exaggerated” response
of the immune system with some nervous disorder. Effectively, many
patients relate some emotional disorder with the onset of the illness.
This traumatic-psychological episode may have caused the release of
certain neuromediators toxic to melanocyte, which, on breaking up, frees
the antigens, which, under certain conditions, set off the autoimmune
process.
9- You have already commented that this complaint is not
exclusive to humans, that it may exist also in animals. Are there
different types of human vitiligo?
We treat different manifestations
of vitiligo in accordance with the location of the spots, which may
affect a small area, or spread over many parts of the skin. Localised
vitiligo may be focal, with one or several patches in a single area;
segmental, one or more macules in a semi-dermatomal pattern; or mucosal,
restricted to the mucous membranes alone. Generalised vitiligo may be
acrofacial, affecting the distal extremities and the face; or vulgaris,
consisting of scattered macules. This latter type may evolve into
universal vitiligo, where depigmentation is complete or almost complete.
POLYPODIUM LEUCOTOMOS (P.L). A FERN EXTRACT WITH IMMUNOREGULATORY EFFECTS CAPABLE OF STIMULATING MELANIN-PRODUCING CELLS.
10- Which treatment do you consider right for each typology? The treatment
you recommend here is endoexogenous. Why? What specific results have you
obtained with it?
I have seen that most cases of vitiligo respond
marvellously well to treatment with Polypodium Leucotomos (P.L.). This
fern is grown in tropical latitudes and is commercialised in Spain by
several laboratories, as tablets or capsules. In recent years, the
immunoregulatory effects of this fern and its capacity to stimulate
melanin-producing cells have been proven. Therefore, the aims of its
therapeutic use are, on the one hand, to stimulate the migration of
melanocytes towards the areas in which they have been destroyed or to
reactivate any that may remain in the area, in order to obtain
repigmentation of the amelanotic macules and, on the other hand, to
correct or suppress the autoimmune mechanisms or mechanisms harmful to
melanocytes that perpetuate the skin lesion. We are dealing with an
endoexogenous treatment, generally consisting of orally taking
Polypodium Leucotomos and topical application of the extract (P.L.E.)
daily, in the form of an emulsion (O/W… 5%). This P.L. therapy, together
with ultraviolet radiation, is useful in the repigmentation of vitiligo
macules, obtaining good (over 50% of the surface repigmented) or
excellent results in 60% of cases studied.
SUN AS A VITAL ELEMENT IN VITILIGO TREATMENT
11- Does sunlight play an important role in both the onset and treatment of the disorder?
It is quite normal to observe that vitiligo lesions increase with
excessive exposure to sunlight; as a matter of fact, many patients
relate sunburn with onset of vitiligo. In addition, sunburn may cause a
Koebner phenomenon, i.e., the amelanotic macule may develop over the sun
damage. However, controlled exposition of the body surface to an
ultraviolet radiation unit, or to sun in the summer, is a fundamental
element in the treatment of vitiligo sufferers, because of its capacity
to stimulate existing melanocytes. The treatment pattern consists of
subjecting the affected part to an initial dose of 0.5 J/cm2, increasing
said dose successively up to 10 J/ cm2 on average, after topical
application of P.L.E. In this way, the optimum results that we mentioned
earlier are achieved.
12- From what parts of the skin is it most difficult to eradicate vitiligo lesions?
In my personal experience, which coincides with studies published by
other specialists, the parts most resistant to the repigmentation
process are the distal extremities (hands and feet), or the so-called
acral location. In cases where the treatment indicated above is not
successful, we may advise the combined use of P. Leucotomos extract with
puva therapy (psoralenes and UVA). In this regard, Professor Thomas
Fitzpatrick, of Harvard Medical School in Boston, pioneer and expert in
the use of puva therapy in dermatology, recommends the use of P.
Leucotomos extract together with puva therapy to avoid some of the
secondary effects of the latter. Recent studies have shown that P.
Leucotomos prevents the damage caused by the phototoxic reactions
induced by puva therapy, acting as a photoprotective agent. Therefore,
combined treatment may be of great importance in the repigmentation of
certain vitiligo patients.
13- Does treatment with Polypodium Leucotomos, which is achieving such good results, have any type of contraindications?
PLE, both oral and topical, has been well tolerated by all patients and
has not been observed to be in any way toxic. The results of the blood
biochemistry tests, thyroid profiling and analysis of liver and kidney
functions confirm this.
14- When do patients begin to notice an improvement with P.L.E. treatment?
The reply depends largely on the particular case and whether the
patient suffers any associated pathology that could hinder the
development of the repigmentation. In general, perifollicular
repigmentation (repigmentation around the hair follicles) is normally
observed between the first and second months. This perifollicular
repigmentation increases and joins other macules, until the amelanotic
patch disappears. This observation suggests that the follicles act as a
reserve of melanocytes, which are stimulated by the therapy to begin the
repigmentation. On occasions, I have observed non-gradual
repigmentation, when repigmentation occurs in certain areas and the
patches are repigmented homogenously, in a rapid process. This
phenomenon confirms the opinion of some researchers who believe that the
melanocytes or their precursors are present in the amelanotic areas,
all though at present most available data indicates that these cells
have been destroyed.
INFORMATION, SELF-ACCEPTANCE BY PATIENTS
THEMSELVES AND MEDICAL FOLLOW-UP OF THEIR PRIOR MEDICAL HISTORY ARE VERY
IMPORTANT IN THE THERAPY OF THIS COMPLAINT.
15- Do you believe that patients may become obsessed by vitiligo?
I believe that most patients are under almost permanent pressure
because of their physical appearance and the constant preoccupation
nowadays with improving our image. We often observe how difficult it is
for affected children and even adults to adapt, especially in certain
cultures where, through lack of knowledge, it is believed to be a
contagious illness and those who suffer it are not allowed to life a
normal life. Fortunately in our normal environment, the process is
becoming better known. In this regard, we must inform vitiligo patients
of the medical concepts of most interest to them and of the most recent
research regarding their pathology, bearing in mind, above all, their
concern with feeling more in accordance with their external aspect and,
therefore, more accepted in their social surroundings. This point
constitutes a very important aspect of the therapy of this complaint. I
consider that it is just as important to draw up a complete clinical
file of the patient, contemplating their worries about their complaint,
in addition to keeping a periodical photographic control of the lesions
in order to carry out a follow-up of the repigmentation process, which
contributes to encourage patients, allowing them to observe the positive
evolution of their complaint compared to their initial state.
THE FERN USED BY NATIVE AMERICANS UNDER THE NAME OF KALAWALLA
16- Dr Azmi, how did you decide to test the efficacy of P.L.E. and from where does the fern from which the extract is taken come?
The main reasons I decided to test the activity of P.L. as a
therapeutic alternative for vitiligo treatment were, on the one hand,
the lack of efficient pharmacological therapy with no side effects and,
on the other, a personal experience, published in the International
Journal of Dermatology in 1989, based on the improvement of vitiligo
symptoms in patients who had been recommended P.L. therapy to treat
another associated dermatological process (psoriasis). Later, I have
been continuously motivated by the good results obtained in clinical
studies carried out in recent years. Regarding the fern, I can tell you
that it is originally from Central America, and specifically that it is
grown on the banks of lake Yojoa, in Honduras.
17- P. Leucotomos was
already used by American natives in the past, is there any evidence that
it could be used to cure other illnesses?
P.L., commonly known as
Kalawalla, has been used for centuries to relieve inflammatory
complaints and some skin disorders. However, its use in modern medicine
is very recent. At present, it is used empirically as therapy for other
complaints such as atopical dermatitis and some cases of psoriasis.
DR AZMI MOHAMMAD HAS PIONEERED THE APPLICATION OF POLYPODIUM LEUCOTOMOS
TO INCREASE THE RESPONSE RATIO IN THE REPIGMENTATION OF THE AFFECTED
SKIN.
18- Dr. Azmi, in the 1995 “Yearbook of Dermatology”, the
prestigious American dermatologist, professor Thomas B. Fitzpatrick,
recognised you as the first dermatologist to apply Polypodium Leucotomos
to increase the response rate of vitiligo repigmentation. How do you
feel when you see how the good results of your treatment give physical
and mental help to patients some of whom were already disappointed with
the results obtained with other therapies?
I think that recognition
of my work is always gratifying. In medicine, progress depends not only
on the discovery of what was formerly unknown, but also on projecting
facts that were known but not properly interpreted, and the rational
ordering of known but disperse truths into the general scheme of
knowledge. In this regard, I cannot deny the merit of Professor
Fitzpatrick, who has brought together prestigious dermatologists, such
as Professor Lerner (Yale University) and Professor J.J. Nordlund
(Cincinnati University), and other Spaniards, such as Professor Robledo
Aguilar, Professor Moragas and Professor Alomar, all very interested in
vitiligo treatment research. I would like to take this opportunity to
thank the support that I have always received from Professor Eduardo
Fonseco, my former colleague and now Head of the Dermatology Department
of the Juan Canalejo Hospital in La Corunna; and the effort invested by
my collaborator, the pharmacist Ana Calderón, whose contributions,
together with the results we are obtaining from our patients in
different parts of the world, are sufficient repayment for me and
encouragement to continue my work and research, in spite of the
difficulties that we still meet on our road, not having the same
possibilities as our American colleagues.
19- What is your main advice for vitiligo patients?
I think that they should maintain the confidence that their illness can
be relieved. We know that the pigmentary disorder suffered by vitiligo
patients has an important social and psychological impact, especially
for dark-skinned people. To all sufferers, I have to say to them that it
is fundamental that there be collaboration and confidence between
patient and specialist. In this regard, I consider that they should set
out their worries and that they should be informed of all therapies
within their reach, for the patients to take the decision that they
believe right, bearing in mind always that treatment is laborious and
must be carried out.
We would like to thank doctor Azmi for allowing us to publish this interview on our blog.
Dra Lehdia M. Dafa
