INTRODUCTION
Vitiligo is an autoimmune, acquired condition resulting in patchy depigmentation, affecting approximately 1% of the general population.1 Due to its unpredictable clinical course and predilection for the hands and face, it can have an enormous psychological burden on patients, especially those with darker skin types. First line treatment includes topical corticosteroids, calcineurin inhibitors, and narrowband ultraviolet-B phototherapy. Rates of repigmentation approximate 50% to 60% after months of treatment,2 with a considerable population of patients still continuing to suffer the psycho-social burden of their disease both during and after treatment. For patients with recalcitrant vitiligo, or for patients with vitiligo in particularly difficult to treat areas such as the fingers, attempts to find a way to cover the depigmented patches are an essential (but often overlooked) step in minimizing the psychological burden of vitiligo.
Visible skin disease has consistently been shown to have a profoundly negative impact on quality of life with an increase in adverse effects on mental health. Studies have shown an increase in depression, anxiety, and suicidal ideation in patients suffering from a cosmetically disfiguring visible skin disease, such as acne or psoriasis.3 Vitiligo can result in social ostracization, with female vitiligo patients in certain parts of India considered to be ineligible for marriage.1 A study performed by Kent et al found that 47% of the patients with vitiligo whom they examined made a conscious and consistent effort to conceal the discoloration, including 87% of female patients.4
While quality of life scores significantly improve after consistent camouflage of vitiligo lesions, options for adequate coverage
continues to be limited.5 Camouflage is too often overlooked as a “cosmetic†issue, which neglects the psychological impact of visible disease. Dermatologists should be experts on the options available and be ready to present them as early as the patient’s initial visit. Here we review the camouflaging options for vitiligo patients, with the advantages and disadvantages of each summarized in Table 1.
DISCUSSION
Permanent Camouflage
Cosmetic tattoos are primarily comprised of inert chemical substances available in over 15 shades.6 Tattoo pigments include white (titanium dioxide), red (cinnabar, mercuric sulfate), black (iron oxide), yellow (cadmium sulfide), camel yellow (iron oxide), light brown (iron oxide), and dark brown (iron oxide);6 and color is injected into the dermis. The procedure entails minimal side effects; however, there are reports of occasional adverse events, including hypertrophic scar formation. Allergic reactions to pigment injection are rare.7 The most common complications are related to improper technique and pigment migration. Ideal locations include small areas of the face (particularly periorally) and the dorsal hands. This technique is preferred in patients with dark skin.
Unfortunately, positive cosmetic results are dependent on the physician or technician’s degree of experience and skill, and unsatisfactory application may be difficult to hide. Very few tattoo technicians and permanent makeup artists are specialized in the type of skin pigment tattooing that a vitiligo patient would require.8 Moreover, the pigmentation, while technically classified as permanent, does fade over time and reapplications are
