Can a flu vaccination make vitiligo worse?

As we approach flu season, the federal government is working with pharmaceutical companies to manufacture a novel vaccine to combat the new flu variant, H1N1 or Swine Flu. Candidate vaccines are now being tested. Latest media reports say the new vaccine is anticipated to be made broadly available this fall.

Members have asked us if a flu vaccination could worsen their vitiligo. As vitiligo is a disease involving the immune system, could a flu vaccine which targets the immune system have an adverse impact on vitiligo?

What do we know thus far? According to the Centers for Disease Control (CDC), the federal agency overseeing the development and administration of vaccines, we know that flu vaccines carry risks for certain categories of people whose health and age make them vulnerable to potential side effects from these drugs. Also, flu vaccine used by people with chronic medical conditions or who are immune-suppressed may not be as effective in preventing an infection as when used in healthy young adults and children.

According to the CDC, during a typical influenza outbreak, vaccination is recommended for people who are at high risk for developing serious complications as a result of flu. These high-risk groups include all people aged 65 years or older and people of any age with chronic diseases of the heart, lung or kidneys, diabetes, immunosuppression, or severe forms of anemia. Specifically, the CDC recommends a flu vaccine for any person over the age of 6 months who - because of age or underlying medical condition - is at increased risk for complications of influenza.

Medications such as (to list a few) prednisone, methotrexate, and biologics such as Humira, Enbrel and Remicade, can weaken the immune system, making a patient more susceptible to the H1N1 virus (swine flu) and the regular seasonal influenza. If a patient on an immunosuppressive drug does contract such a viral illness, there is a higher risk of developing more severe-and thus more life-threatening-disease.

As to whether vaccines can trigger or worsen autoimmune disease, the CDC states in its most recent Guide On Vaccines and Vaccine Safety that any connection between autoimmune disease and vaccines remains unclear and that there is thus far "few data implicating vaccines in the induction of autoimmune disease".

As vitiligo is an autoimmune disease, what should a person with vitiligo do? We posed the following frequently asked questions to leading vitiligo experts.

Q1. I understand carbolic acid is being used as a preservative in the flu vaccine. Since this is a phenol, could this cause a problem for my vitiligo?

• A1. Carbolic acid is indeed a phenol with the potential of triggering oxidative stress in the melanocyte. When topically applied in an individual genetically susceptible to developing vitiligo, it could trigger vitiligo. However, phenol is not likely to induce vitiligo when injected as a preservative in a flu vaccine. The carbolic acid will quickly be neutralized and will not reach the skin as a phenol. (Source: Ray Boissy, Ph.D., Professor of Dermatology & Cell Biology and Director of Basic Science Research at the University of Cincinnati College of Medicine (UCCOM)

Q2. Thimerosal, a mercury-based preservative, is often found in flu vaccines. Are there flu vaccines that are without thimerosal. I am concerned it will have an effect on my vitiligo.

• " A2. Because of increased awareness of the theoretical potential of even low levels of mercury having harmful effects on humans, concerns about the use of thimerosal in vaccines and other products have been raised. As a result, the Food and Drug Administration (FDA) has been, and is, working with vaccine manufacturers to reduce or eliminate thimerosal from vaccines. The Centers for Disease Control and Prevention estimates that about 15 percent of the total H1N1 (swine flu) vaccine available will be mercury-free. (Source: CDC)

Q3. I have read that those who have a weakened immune system should not get the Zoster vaccine for shingles. If you have an autoimmune disease like vitiligo, does that mean you/we have a weakened immune system?

• A3. No it does not mean you have a weakened immune system and I recommend the Zoster vaccine over the potential for shingles which could quite possibly cause vitiligo to spread. (Source: Nanette Silverberg, M.D., Attending physician, department of dermatology, St. Luke's-Roosevelt and Beth Israel, specializing in pediatric and adolescent dermatology, vitiligo)

Q4. I have read that vitiligo is one of the vaccine-related autoimmune disorders. Is this true?

• A4: Vitiligo can be a side effect of vaccinations given to promote an anti-tumor response in melanoma patients, because pigment cells share many properties with their malignant variant, the melanoma cell. This type of vaccine is the only one with a known link to vitiligo.(Source: Caroline Le Poole Ph.D. Associate Professor of Pathology Loyola University Medical Center)

Q5. Can the flu vaccine make my vitiligo worse? Should I as a person with vitiligo take a vaccine?

• A5. A skin prick per se can start a new lesion at the vaccination site in patients that have a tendency to respond to skin trauma (cut and burns etc) by depigmenting further. Apart from that, there is no evidence to link any other vaccine to vitiligo. The effect of the bulk of vaccinations on vitiligo development has not been tested. Unless there is a specific study to link vaccination with the development of vitiligo, such association has little chance of being found. (Source: Caroline Le Poole, Ph.D.)
  
  There has, however, been a vitiligo response to a very specific vaccine in the Smyth line chickens (SL) which are an animal model that very closely mimic human autoimmune vitiligo. Dr. Gisela Erf reports that all USA poultry is required to be vaccinated for Marek's disease. If the Smyth line chickens are vaccinated with the Marek's live vaccine, the incidence of vitiligo is significantly higher than normal. However, when vaccinated for Marek's disease with an inactivated or "dead" vaccine, there was no abnormal reaction, nor have there been any such reactions to any other live vaccines. (Source: Gisela Erf Ph.D., immunology: Professor Department of Poultry Science Specializing in Avian immunology with emphasis on cell-mediated immunity, autoimmunity, tumor regression and immunology of the skin)

Talk with your medical care provider who can help you address any concerns and help you weigh the potential benefits and risks.

See the accompanying article prepared by the University of Missouri Arthritis Rehabilitation Research and Training Center. People with Autoimmune Diseases Should Consult a Doctor Before Flu Shot

To stay up to date on what is happening with the H1N1 vaccine, you may find these additional sources helpful
http://www.cdc.gov/FLU/protect/keyfacts.html
http://www.nlm.nih.gov/medlineplus/print/h1n1fluswineflu.html
Nasal Mist (Live Vaccine) Facts     H1N1 Vaccine Package Insert

What are they? Are they a safe option for people with vitiligo?

Have you ever covered up your vitiligo for a special occasion? If so, you most likely used, or considered using, a sunless tanning product or preparation. This sunless tanning approach differs from a cosmetic cover-up in that it chemically changes the color of one's skin as opposed to just providing a covering. People with vitiligo have a couple of options: they can use a commercial preparation to chemically change the color of their vitiligo-involved skin, or they can use a homemade alcohol based stain that does not involve a chemical change, but does not stay on as long as the sunless tanning products.

The homemade stain is often preferred out of fear of skin damage and a worsening of the vitiligo following the use of commercial self tanners. However, homemade stain preparations, while effective, lack some of the application and wear time advantages of the commercial options. For that reason, we went to the scientific community to find out more on the safety of the commercial sunless tanners.

Commercial Sunless tanners - What are they?

Everyone was introduced to commercial sunless tanners when Coppertone came on the scene in the 1960's. The product offered the ability to turn your skin brown without the sun. Today, the many commercial sunless tanners on the market fall into three main types: two of the three are unapproved by the U. S. Food and Drug Administration (FDA) and, therefore, not deemed safe for your use:

• Tanning accelerators - unapproved by the FDA;
• Tanning pills - unapproved by the FDA; and
• DHA (dihydroxyacetone) sprays and lotions - approved by the FDA if used correctly.

For the purposes of this article, we are focused on those sunless tanners that contain DHA. DHA is a sugar which interacts with the dead surface cells in the outermost layer of the skin to temporarily darken skin color. The coloring doesn't wash off, but it gradually fades as the dead skin cells slough off. In most cases, the color is completely gone after five to seven days.

The DHA-containing sunless tanners come in many different formulations, including lotions, gels, creams, tinted moisturizers and brush-on powders. Some companies offer a sunless option that involves spraying customers in a tanning booth with the DHA. "Glow" lotions, which are moisturizers that gradually darken the skin with each use, are also a growing trend. Some products use Erythrulose combined with the DHA. Erythrulose works identically to DHA on the skin surface, but develops more slowly. The two chemicals used together may produce a longer-lasting sunless tan.

While these products have much improved over the years, there can be problems in achieving the right color and application. Their chief benefit is providing a tan that does not wash off or smear. For that reason, these products have great appeal to people in the vitiligo community who want to camouflage their skin or make it less obvious.

What do we know about the safety of these DHA-containing sunless tanners?

While the generally-held medical opinion is that these commercial sunless tanners are safe, there have been questions in the public and in the vitiligo community as to their safety. Also, many in the vitiligo community have expressed concern about the ability of these DHA-containing products to cause vitiligo to spread or worsen.

Can the DHA damage my skin or worsen my vitiligo over time?

The bottom line: medical professionals generally consider this unlikely. Though DHA has been shown to cause cell damage at relatively high doses in laboratory studies which theoretically could lead to skin thinning or skin cancer, the much lower doses of DHA that are actually used by the individual, and the weak penetration of DHA into the skin, make these risks remote.

DHA is a weak penetrator. It does not penetrate the skin much beyond the stratum granulosum, meaning that the cytotoxic and DNA damaging effects of DHA would not reach the cells vulnerable to these effects i.e., proliferating keratinocytes or stem keratinocytes in the stratum basalum, respectively. DHA predominantly penetrates only about 20 microns into the skin (i.e., not quite through the stratum corneum). For reference, the epidermis of thick skin of palms is 1500 microns. The epidermal thickness of the legs, feet or tops of hands is about 1,000 microns, and thin skin of eyelids is 50 microns.

However, with time (like when being applied routinely as a self tanning), and with the simultaneous addition of moisturizers, in the eyelids, DHA could penetrate a little further, reaching the melanocytes. Now, if DHA reaches the melanocyte it could theoretically react in the cell to produce tyrosine, the substrate for melanin and could theoretically increase melanin synthesis, increase oxidative stress, and trigger more vitiligo to appear. However, this is a theory which has not been scientifically demonstrated.

In Summary

Scientific data reported thus far would indicate that long-term use of sunless tanners containing DHA is safe and that the risk of skin damage or worsening or spread of vitiligo associated with long-term use is small, if not remote.

VSI would like to acknowledge and thank Ray Boissy Ph.D., Professor of Dermatology & Cell Biology and Director of Basic Science Research at the University of Cincinnati College of Medicine (UCCOM) for his contribution and review of the above article.

Click Here for Tips on using Sunless or Self Tanners

Click here to learn more about Alpha Hydroxy

Vitiligo is not contagious! You cannot "catch" vitiligo by eating, drinking or otherwise associating with a person who has vitiligo.

Vitiligo is apparently caused by inheritance of multiple causal genes simultaneously, possibly in different combinations in different people, plus exposure to environmental risk factors or triggers that are not yet known. Phenols, and stress whether emotional or physical, are suspected to be environmental triggers, but research continues into these and other possibilities.

Approximately 20% of vitiligo patients have a family member with the same condition. However, only 5% to 7% of children will get vitiligo even if a parent has it.

"Most investigators do not believe that segmental vitiligo results from an autoimmune process. Probably the most convincing data come from epidemiologic studies of co-occurrence of autoimmune diseases. Numerous studies comparing the occurrence of various autoimmune diseases in patients with segmental versus non-segmental vitiligo. In general, the prevalence of autoimmune diseases (especially autoimmune thyroid disease) is significantly elevated in patients with generalized vitiligo, but not in patients with segmental vitiligo." (Source: Richard A. Spritz, M.D. Professor and Director Human Medical Genetics Program University of Colorado Health Sciences Center)

Research has shown that at least 12% of those with vitiligo experience itching of vitiligo affected areas at the onset of depigmentation.

Our members have reported trying many things to relieve this insatiable itch,
These are a few:
Class 1 prescription topical steroid
Coconut oil.
Gold Bond Medicated Lotion, Extra Strength (in the green bottle)
Shea Butter
Jojoba oil (pronounced "ho-HO-bah)

Did you know VSI has a "Doctor Search"?

This valuable resource is unique in that all entries are patient referred. If you've seen a supportive dermatologist knowledgeable in vitiligo treatments, please take a minute or two to gather the information and submit it in the Doctor Search section found on the website.

If you are looking for a physician to treat your vitiligo or have a physician you'd like to include, we hope you'll check it out!

Coming up in our Winter Newsletter, we will feature another new column, titled
"What Works for Me."
This column will offer readers the chance to share personal tips and ideas relating to vitiligo that they've found useful. If you have an idea or tip to share, you may contact us at [email protected]. Please be sure to put "What Works for Me" in the subject line so your email is not overlooked.

As of October 15, only Supporting Members will be able to post messages in the forums. This requirement is necessary in order for us to expand our capacity to respond to a wider range of needs within the vitiligo community. We hope those of you who use the forums extensively will want to continue using the forums and join VSI if you are not already a member. Please be assured that an abundance of free information will continue to be readily available, and whether you donate or not, you will be able to read the forum messages.

If you would like information on a specific topic or treatment, the "Search" function is available to everyone once they are logged on to the website. The VSI database is rich and should be able to address most questions. For more information on the best way to use "Search" and return the most results, select "Website Tips" from the menu on the left after logging on. We encourage you to read over the comprehensive information provided on the Home Page on topics such as "Treatments & Research" and Genetics & Incidence as well as our "Frequently Asked Questions" (FAQ) page.

The following Clinical Trials are currently enrolling*

• Dr Spritz's Vitiligo Genetic Study
• Vitiligo Skin Pigment Cell Transplantation Study
• Vogt-Koyanagi-Harada Disease (VKH)
• Detroit-Area Vitiligo Genetics Study

Click here and scroll to each study to see if you qualify

VITILIGO SURVEY

The "Vitiligo Quality of Life Study" is accepting participants for a paid study in New York City*
http://www.vitiligosupport.org/treatments_and_research/surveys.cfm

*Note
The above Research and Study are all active as of the sending of this newsletter.
If they are not located on the page when you check, that means they have since filled.

As we enter the holiday season, please keep VSI in mind!

VSI participates in two free programs that make it easy for online shoppers to support VSI! Amazon.com has all kinds of items in addition to books and iGive.com has over 700 stores in its shopping mall. Both options are EASY and FREE. As long as you use these provided links or the Amazon or iGive boxes on our Community Home Page these two companies will return a portion of the sale to VSI. You do have to register to use iGive and if you refer a friend, VSI receives a bonus! Our Vitiligo Library and Store is also powered by Amazon, so when you are ready to shop VSI has you covered!