Dear Members and Friends of VSI,

Have you ever unexpectedly burned your skin from sun exposure or a light treatment? Or - has your light treatment suddenly stopped working for no apparent reason? Surprisingly, several possible explanations might actually be found in the everyday products you are using. Many people don’t realize how many commonly used products can either make the skin more likely to burn or less responsive to the light. The wide use of so many of these products means that many vitiligo patients could unexpectedly end up with unwanted consequences such as adversely affecting their light treatments. We have heard from some of you who have had experienced these types of problems.      

Avoiding environmental substances that can negatively affect our light treatment is one factor within our control that can help to ensure better treatment results. Our main article in this issue looks at those products and substances in our everyday life that can affect how our skin reacts to light. We also consider the impact that common medications could have. Our goal is to arm you with the information you need to avoid these environmental landmines. 

Sincerely,

Jackie Gardner
Executive Director

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Ultraviolet light, whether from the sun or an artificial source, is an important treatment resource for many of us, who use light to repigment vitiligo-affected skin. If you use light as a treatment, you probably know the ideal dosing and exposure time you need to get the most benefit. But, despite this, have you ever unexpectedly burned yourself? Or alternately, have there been times when your treatments inexplicably became less effective?  These unexpected results could have been caused by an everyday product. Maybe the antibiotic you started using to treat an ear infection contains an ingredient that intensified the effects of the light, so your regular light treatment gave you a bad burn. Or perhaps you started using a new body lotion that had a built-in sun protection factor (SPF) or other sun-protective ingredient that reduced the amount of light penetrating your skin.

We are surrounded by a wide variety of products and substances containing chemicals that, when used orally, topically, or by injection in conjunction with sunlight or artificial ultraviolet light, can change how our skin reacts to the light. Those that sensitize our skin to ultraviolet light can cause a phototoxic or sunburn-like reaction on the skin. They can also cause other acute reactions including an eye burn, mild allergic reactions, hives, abnormal reddening of the skin, and eczema-like rashes with itching, swelling, blistering, oozing, and scaling of the skin.

These “photosensitizers” are often ingredients in common household products such as perfumes, soaps or saccharin-based artificial sweeteners. Medicinal plants and herbs like St. John’s wort can trigger a toxic reaction, as well as many common foods.

On the other hand, there are other everyday products that can “desensitize” or protect our skin from the effects of ultraviolet light. For vitiligo patients using ultraviolet light as a treatment, this can mean it may take longer to achieve the erythemal (pink) response, and ultimately, to repigment. Popular ingredients or products such as green tea and vitamins A and E are examples of “photoprotective” agents.

Though it is estimated that only 1 in 100 persons (though the number may well be higher because many cases go unreported) show varying signs of photosensitivity,  everyone with vitiligo, especially those with fair skin, needs to be aware of how everyday products can affect their skin’s reaction to ultraviolet light.  This knowledge will help you to protect your skin and effectively treat your vitiligo. We’ll begin with what to look out for in your personal environment that can make your skin photosensitive, including those photosensitizers used in treating vitiligo.

PHOTOSENSITIZERS

Plants and Foods

Psoralens, photosensitizing agents found in plants, are used in many common products and foods that we use and consume daily, which can potentially make us more sensitive to ultraviolet light. Many vitiligo patients are familiar with psoralens, as they are used in combination (topically and/or orally) with UVA light (P+UVA), under a physician’s direction, to repigment vitiligo-affected skin. In this case, the psoralen used is specially formulated to intensify the effects of the UVA light, making the light more effective in treating extensive skin disease. This is an example of where the photosensitive potential of an agent like a psoralen is carefully managed to achieve an optimal benefit for the individual.

PUVA, while still used to treat widespread vitiligo, is being replaced by Narrowband-Ultraviolet B Light (NB-UVB) in many doctors’ offices, as NB-UVB is reported to be as effective as PUVA, but has fewer side effects and does not require the addition of psoralen. Studies to date seem to indicate that NB-UVB does not pose the skin cancer risk following long-term use that PUVA does.

Some vitiligo patients manage their own “PUVA-like” treatment by using commonly found psoralens either topically or orally.  One such psoralen-containing product is bergamot oil, which can be purchased over-the-counter (OTC) and used in combination with sunlight to speed up repigmentation. Bergamot oil is derived from the skin of the bergamot orange, a type of citrus fruit that is a very potent photosensitizing agent. Care should always be taken when using a product as potent as bergamot oil so as not to incur dangerous burns. Psoralen extracted from this oil was used as a tanning accelerator in tanning oils and sunscreens until 1995, when the U.S. government discontinued its use in those products.

Bergamot oil or extract is widely used as a flavoring or scenting agent in medicines, perfumes, soaps, cosmetics, and in many foods (gelatins, puddings, ice cream, baked goods), confectionaries, smokeless tobacco products, liquors, and topical creams and lotions, as well as Earl Grey and Lady Grey teas. Additionally, it has been found to be a good anti-bacterial agent, which has prompted its use in food preservation, deodorant, and scented soaps.

There are a variety of oils that can cause photosensitivity. Some are marketed commercially as "Essential Oils," which are used in aromatherapy salons. These oils may not cause skin sensitivity, but when the skin is subsequently exposed to ultraviolet (UV) light, sun sensitivity may occur. Should phototoxic oil be used in aromatherapy massage, one should not sun tan, or spend extended unprotected time outside for at least 12 hours after the massage.

The main culprits are the oils from the citrus family when they are extracted by direct expression and without distillation. Oils like bergamot, lime and bitter orange are severely phototoxic when used undiluted, and some, like lemon, still remain phototoxic even after distillation. The agent causing the sun-sensitivity is the "bergaptene" contained in the oil. Because of their phototoxicity, the best advice is to read labels and avoid sun tanning lotions or creams containing any of these oils.

A variety of other plants contain psoralens, including figs, celery, carrots, parsnip, lime, and parsley. When consumed or applied topically to the skin, these products can be especially phototoxic. For that reason, some people with vitiligo experiment with these plants to accelerate their skin repigmentation. Celery juice and carrot juice are frequently used orally and topically in combination with sunlight. Whether drinking or applying topically, care must always be taken to avoid a phototoxic reaction.  We have heard from those who found this approach helpful, while others have experienced painful burning. Using psoralen-containing products like celery juice or bergamot oil topically poses a risk of severe burning. Some  in the VSI community forums report that they dilute the bergamot oil with other liquids such as jojoba oil to reduce the risk of burning.

Medications

We also can encounter photosensitizing agents among widely-used drugs and medications.

Prednisone, a systemic steroid, is frequently used by physicians expert in vitiligo treatment to stabilize fast, wide-spreading vitiligo. This steroid is administered orally for a short period to (1) halt the progression of vitiligo that is spreading rapidly, with large areas of depigmentation, and (2) induce repigmentation. It can also be used intermittently to treat extensive, slowly-progressive vitiligo episodes and relapses. It is a generally a weak photosensitizer, but some people have reported a reaction to it. For the majority of those who do, the reaction occurs within a few days to a week afterwards.

Some doctors prescribe coal tar medications, such as "V-tar," to treat vitiligo. V-tar is a prescription crude coal tar product that contains natural anti-inflammatory agents, skin conditioners, and antioxidants. It is water-soluble so it won’t stain the skin. It is applied once a week, left on for 5-6 hours (or overnight), then removed. Users must avoid direct sun exposure for 72 hours after treatment to avoid the photosensitizing effects of the tar. UV exposure is not required for treatment with V-tar, making it attractive to those who prefer to minimize the contrast between normal skin and vitiligo, as well as those who are unable to use light therapy due to other conditions. V-tar can be used by anyone, including children.

We have highlighted here just a few of the many products and substances that can photosensitize the skin.

PHOTOPROTECTORS

There are several substances/products used in a variety of common formulations and widely-used supplements that are photoprotective. Though they may not be equal in the level of photoprotection they provide, avoidance of these agents while using light as a treatment should be discussed with your physician. We have highlighted some of the more common agents here that hold particular interest for vitiligo patients.

Vitamins

Laboratory studies have shown that certain vitamins possess photoprotective capabilities. There is growing evidence that vitamins A, C, E, and B3 have photoprotective potential.

Vitamin A

Some of the carotenoids, a group of micronutrients, and a form of vitamin A present mainly in fruits and vegetables, are believed to be somewhat photoprotective. Beta-carotene has been reported to offer some photoprotection based on small, uncontrolled studies of people with photosensitive diseases. However, one small controlled study found no benefit. (Interestingly, beta-carotene is in the skin of carrots, a vegetable that also contains the photosensitizer psoralen.) The carotenoid lutein has been shown to be an efficient photoprotector. Scientific data shows that another form of vitamin A, topical retinols and retinoids, can also be photoprotective.

Vitamins C and E

Virtually all plants and animals protect themselves from the sun using vitamins C and E. Multiple studies have found that the topical formulations of vitamin C and E seem to provide significant photoprotection. A derivate of vitamin C, L-ascorbic acid, has been found so far to be the only form of vitamin C to provide photoprotection. Though it is not clear that the oral form of vitamin E has photoprotective potential, the topical formulations of vitamin E (α-tocopherol) with concentrations ranging from 0.1% to 1% are reported to be effective in improving protection of the skin barrier. In addition, researchers found that the combination of 15% L-ascorbic acid and 1% α-tocopherol used topically provides even greater photoprotection and is superior to either of the products used alone.

While the oral forms of these vitamins may not provide strong photoprotection, the possibility of the effect on light therapy is something to be mindful of, as some physicians prescribe oral vitamin supplements C and E for their vitiligo patients due to their antioxidant benefits.

Vitamin B3

Because studies have shown that some people with vitiligo are deficient in certain vitamins like folic acid, B12, copper and zinc, many vitiligo patients take vitamin B supplements. Some studies have also shown that folic acid, B-12, and sun exposure can help to repigment the skin when used together. If you are taking B3 by itself or as part of a B complex vitamin, be aware that its possible photoprotective properties may affect your light treatment. Also keep in mind that you may be at risk of a burn from sunlight or UV light treatment if you have been taking one (or more) of these supplements and skip them for a few days or stop taking them. You should always consult with your doctor for proper dosages and combinations of any supplements.

Antioxidants

Because oxidative stress is associated with tissue or cellular damage and is believed to play a role in the development of vitiligo, many with vitiligo take oral antioxidants. Antioxidants are substances that may protect our cells from the effects of free radicals. Free radicals, the product of oxidative stress, are molecules produced when our body breaks down food, or by environmental exposures like tobacco smoke and radiation. Free radicals can damage cells and may play a role in heart disease, cancer and other diseases.

A 2007 Italian study of 28 vitiligo patients reported that an oral intake of several antioxidants including vitamins C and E enhanced the effectiveness of NV-UVB by reducing vitiligo-associated oxidative stress. Oral vitamin E alone in a 2009 Egyptian study was reported to markedly improve the rate of repigmentation in a group of patients using NB-UVB as compared to controls. Also, in 2009, Indian investigators reported that a diet supplemented by oral vitamin C and E along with the other oral antioxidants vitamin A, zinc and selenium but without NB-UVB, promoted repigmentation. Consistent with these findings, another 2009 study coming out of India also reported that vitiligo patients have lower levels of vitamins C and E and total antioxidant activity when compared with controls.

Because of the increased public interest in their potential health benefits, antioxidants such as vitamins C, E, A, selenium, silymarin, tea polyphenols and soy isoflavones are being incorporated into sunscreens and topical skin care products. They may have greater photoprotective potential than their oral versions (as discussed above), but due to their general instability and the challenge of delivering them into the skin, more research needs to be done to confirm the degree of photoprotection offered by this topical mix of antioxidants. Until more studies are done, you should discuss with your physician whether these combination vitamin formulations could affect your ultraviolet light treatments.

Polyphenols

Certain polyphenols, another type of antioxidant, are also reported to possess substantial skin photoprotective effects. Polyphenols are a large family of naturally-occurring plant products that are included in fruits, vegetables, nuts, seeds, flowers and bark. Polyphenols can absorb the entire UVB spectrum of wavelengths and some can absorb the UVC and UVA spectra as well. Polyphenols, as a result, could provide some level of sun protection.

Green tea, one of these products containing photoprotective polyphenols, is a popular antioxidant often enjoyed by vitiligo patients. Ironically, green tea is touted for its antioxidant qualities and has been reported to help promote repigmentation on its own or in combination with other vitamin antioxidants.

Frequently, we hear from people who tell us they can’t seem to get their vitiligo pink from their light treatment. As many people drink green tea these days, we have wondered if they are inadvertently making their skin less sensitive to the ultraviolet light. Alternately, if one suddenly stops drinking the tea and continues with the light treatments, could they run the risk of burning?

Common Everyday Products

Many of the most common products we use daily, such as deodorant, scented soaps, perfumes, and colognes can contain bergamot oil or other photosensitizing ingredients such sandalwood, rosemary or lavender oil. While these products may not cause you a problem, they do have a potential for photosensitivity in some people. Many hotels in sunny destinations, in fact, no longer offer deodorant soaps, but instead provide mild soaps. If you are using medicated cosmetics to treat wrinkles, acne, or other cosmetic problems, be sure to check their ingredients as well, as many contain a sunscreen or other photoprotective ingredient. Both photosensitizing and photoprotective products can potentially have an impact on the success of therapeutic light treatments, so it is important to be aware of them in the products you use and the foods you eat.

WAYS TO MANAGE AND PREVENT
A PHOTOSENSITIZING REACTION

Managing the Reaction

If you have a skin reaction, a sudden burn or some other phototoxic reaction while using ultraviolet light as a treatment, you will want to consult with your physician. In the absence of an underlying condition, the physician will then want to identify the photosensitizing drug or substance. These types of phototoxic reactions generally peak within 12-24 hours after the initial exposure. He or she will make the diagnosis through a thorough history, examination, and review of the medications/products and the duration of the exposure to the UV rays.

A photo-patch test may also be performed if an allergic response is suspected. An allergic reaction can be delayed up to 24-72 hours (even up to several months) after the initial exposure and may spread to areas that were not UV-exposed. Generally, the allergic reaction resolves after stopping the offending drug/substance.

If you are using ultraviolet light to repigment your skin and stopping an offending drug is not possible, discuss with your physician the possibility of delaying your light treatment until you are no longer on the drug. Or, if you must continue your light treatments or be on the photosensitive drug indefinitely, discuss with your physician whether there are other options such as changing your dosing schedule and the timing of your light treatment.

Once the substance causing the phototoxic reaction has been identified and stopped, the reaction should resolve within a few days, though in some rare instances, the reaction can persist. It is a good idea to avoid direct sunlight for a couple of weeks after stopping the responsible substance. Using UVA/UVB blocking sunscreens can also be helpful. Meanwhile, you can generally calm the reaction by keeping the area of skin eruption moist and applying wet dressings and soothing lotions to help relieve the symptoms. Topical OTC hydrocortisone products, which are mild corticosteroids, may help reduce swelling, itching and redness. OTC oral antihistamines such as Benadryl can also be helpful in minimizing the itching. Keep in mind, though, that antihistamines can increase light sensitivity. This is also important to remember if you are using any antihistamines or anti-inflammatories to treat itching that may be occurring as a result of a vitiligo flare. Itching has been found to occur in about 20% of patients with non-segmental vitiligo as part of the depigmentation process.

In the case of a severe phototoxic reaction, a physician should be consulted. A physician may prescribe a short course of oral steroids if the reaction is severe and persistent.

PREVENTION

The best method of preventing these substances from potentially impacting vitiligo treatment is to become educated on the foods and products which can either photosensitize or photoprotect your skin before going out in the sun or stepping into the ultraviolet light box.. If you suspect a problem, you should check with your doctor to see if an adjustment can, or should be made to improve the situation.

Also, study the way your skin reacts after being exposed to ultraviolet light. If you see spots or signs of irritation, redness or an uneven tan, then check to see if you may be using a personal product or eating a food or supplement that could be affecting your skin. If your skin is sensitive and you are trying to protect it from ultraviolet light by using a sunscreen, titanium dioxide is the least likely sunscreen ingredient to cause photosensitivity disorders.

SUMMARY

We hope that this article has alerted you to the importance of staying informed of the potential products, foods or medications, that when combined with UV light, could be phototoxic and cause a burn, or photoprotective, thereby reducing your treatment response. If you feel that your light treatment is not working very well, or you have unexpectedly burned, it's time to carefully read labels and review ingredients to see what might have caused the change in your skin's reaction to light. Being informed will help you better manage your skin's response and reap the most benefit from light therapy.

What's On Your Mind?

Q. In recent months I've noticed my hearing is not as sharp as it used to be. I first saw my ear, nose and throat doctor and he didn't find any problems. I have an appointment with an ear specialist in a couple of weeks, and I was just wondering if vitiligo could affect your hearing? 

A. As it turns out, the answer is yes. Several of the studies consulted were comprehensive in nature, meaning that the hearing test was conducted as just one part of multiple routine testing of vitiligo patients. Interestingly, the results found that around 20% of the vitiligo patients had some level of hearing loss, but most had not previously noticed or mentioned it. Also of interest, the hearing loss did not seem to be influenced by age, gender, occupation, treatment or duration of vitiligo, and it was different between the right ear and the left ear, and between those with active vitiligo and those with stable vitiligo.

Q.  I began taking Cymbalta for a nerve condition, and within 2 months time my vitiligo spread enough that I lost about 2 years of treatment progress. Do you know what could have caused this reaction?

A. While we were not able to locate research specific to Cymbalta and vitiligo, we did uncover some interesting facts that might help explain your experience.

Scientists from Georgetown University Medical Center and a Canadian research institute report that SSRI (selective serotonin reuptake inhibitors) drugs such as Cymbalta manipulate the neurotransmitter serotonin in the brain, which may also affect the user's immune system. The investigators found that serotonin is passed between key cells in the immune system, and that the chemical is specifically used to activate an immune response.

Gerard Ahern, Ph.D., assistant professor of Pharmacology at Georgetown and lead researcher on the study said, "The wider health implication is that commonly used SSRI antidepressants, which target the uptake of serotonin into neurons, may also impact the uptake in immune cells."

He said that while it may be possible that SSRI drugs may restore a healthy immune function in people who are depressed and prone to infections, it is possible that they might also bolster immunity to the point that they trigger autoimmune disease. "At this point we just don't know how these drugs might affect immunity, so we really need to clarify the normal role of serotonin in immune cell functioning."

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Medical News Updates

Highlights of recently-published medical
articles on vitiligo and its treatments

Growing research has focused on incorporating AOxs into sunscreens and skin care products to replenish the depleted reservoirs in the skin. Researchers at Memorial Sloan-Kettering Cancer Center evaluated the potential benefit of several topical antioxidants in these products, including vitamins C, E, and A; selenium; silymarin and tea polyphenols; and soy isoflavones. 

The investigators concluded that, while these antioxidants showed promise in the lab, more research is needed to effectively translate this antioxidant benefit to the consumer. Getting the AOxs into the skin in sufficiently high concentrations is challenging because, in general, AOxs are inherently unstable. For example, delivery of topical L-ascorbic acid, a form of vitamin C with photoprotective effects, has been challenging, so some companies use lesser substitutes that are more stable, but are not as effective. In order to be effective, AOxs used also need to have a high antioxidative capacity. Unfermented tea extract has very high antioxidative activity, but tea polyphenols are also inherently unstable, so their level of activity may vary according to how they are processed, meaning that not all products containing green tea have the same effects in reducing oxidative stress. Green tea holds high interest for manufacturers looking to incorporate AOxs into their products, as various tea polyphenols are more effective combating free radicals than vitamins A or C, and also have anti-inflammatory and anti-cancer properties. In summary, while delivery of topical AOXs has the potential to provide additional benefits, challenges remain in effectively incorporating them into skin care and sunscreen formulations.  

Long-Term Use of Blood Pressure Meds Found To Promote
Sun Sensitivity and Lip Cancer Risk in Non-Hispanic Whites

They recommended that people at high risk of lip cancer because of their fair skin and long-term UV exposure consider lip protection, such as wearing a hat with a brim sufficiently wide enough to shade the lips and using lip sunscreens. The researchers further commented that lip cancer remains rare and an increased risk of developing it is generally outweighed by the benefits of these blood pressure drugs and other photosensitizing medications.

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Research & Clinical Trials

New Clinical Trial in Massachusetts!

Major Expansion of Vitiligo Genetics Project

Patients and Controls Invited to
Participate in Online Vitiligo Survey

Earn Funding for VSI 3 Ways When You Shop!