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It is a rare event that a patient with vitiligo inquires about the
option of depigmentation. The usual course of action I take when I
see a patient for the first time who has extensive vitiligo — more
than 50 percent loss of pigment of the exposed areas including the
hands, arms, and face — is repigmentation. But if repigmentation
techniques fail, we should consider depigmentation. Even after we
have been unsuccessful in repigmenting their skin with PUVA and
topical steroids, patients are sometimes still reluctant to undergo
depigmentation. They want to be of one color again, but they fear
that they will be too light, that they will burn when they go out in
the sun, and that they will not be able to repigment if a cure for
vitiligo becomes available in the near future. Additionally, other
concerns such as obtaining the medication, allergic reactions due to
the depigmenting cream, pigment spots reappearing on the face,
extensive repigmentation and even hyperpigmentation occur in a few
cases. In spite of all these real difficulties, when one becomes one
color, that is totally white, the patient, the families, and the
physician have a feeling of great accomplishment. I have never had a
patient who was unhappy after being depigmented. Some patients state
that they are now cured. More than 50 percent of the patients who
begin depigmentation therapy are able to go on to total vitiligo —
that is, complete depigmentation. The key to depigmentation is the
topical application of a cream containing monobenzyl ether of
hydroquinone, an antioxidant, that has the generic name monobenzone.
The most widely used commercial product is called Benoquin that
contains 20 percent monobenzone. Other compounds such as
hydroquinone simply do not work. It is a shame that moneys from
industry and government have not been available to find other
com-pounds and other ways to bring about total vitiligo. The major
source of Benoquin in the United States has been ICN Pharmaceuticals
in Costa Mesa, California. They a lways find some excuse not to make
it. I believe that there is not enough money to be made from a cream
that serves only a single purpose — to depigment completely only
those people with extensive vitiligo who will accept being totally
white. But for those who need it, that cream is essential. Benoquin
should never be used as a general lightening agent for people with
normal dark skin because most will end up with disfiguring white
streaks that can be worse than vitiligo. Patients with an unstable
pigmentary system, such as those with vitiligo, depigment easily and
usually completely.
Because complete depigmentation will take one to four years, there
is no hurry in applying Benoquin all over the body. I always want
first to demonstrate to the patient that the process works.
Photographs are taken of both arms, but Benoquin with 20 percent
monobenzone is applied only to one arm for two to three months. For
the first 3 to 4 days, the patient applies Benoquin to only a small
patch to one arm as a test to find out whether or not one is
sensitive to the drug. A stinging feeling may occur immediately
after the cream is put on the skin because of fine particles in the
preparation. It is difficult for the pharmacist to grind the
crystals of monobenzone fine enough. This stinging is due to
physical irritation — not an allergic reaction — and should last
only a few minutes. If one is allergic to Benoquin, a rash will
appear one to two days after the cream has been applied. If there is
no allergic reaction, the patient can apply the cream once or twice
a day for the duration of the demonstration period. Benoquin is
usually not applied at bedtime because the patient may inadvertently
rub the treated arm onto the face and get cream into the eyes. Also,
a spouse, if allergic to Benoquin, will get a dermatitis. When the
patient returns in two to three months, photographs are taken again.
The treated arm should be significantly lighter than the untreated
arm. If it is not, the patient should continue treating the arm for
another one to three months. When it is obvious that the treated arm
has become noticeably lighter than the controlled one, the patient
applies the cream to the hands, arms, and the face. While all these
areas are depigmenting, other parts of the body where no cream was
applied usually lighten as well. Most patients have a wonderful
response and are happy to once again be of one color. In public no
one comments or stares at them. The hair may or may not become more
gray. Eye color will not change. If the patient does not depigment
with the 20 percent Benoquin prep aration, we have a pharmacist make
up a 40 percent cream. Most pharmacists cannot get the pure
monobenzone chemical, and they don't have the facilities to make a
40 percent product. At the end of this report I give the names and
addresses of four pharmacies in different parts of the country that
can fill prescriptions for monobenzone cream.
The most common and important problem that comes up is a contact
dermatitis type of allergic reaction. Approximately 15 percent of
the patients develop a rash similar to that seen in people allergic
to poison ivy. The dermatitis, even when severe, responds well to
treatment in several days. It is striking to see that most of the
rash occurs in the normal pigmented skin, and not in the white
patches. To counter this allergic problem we usually have the
patient stay away from treatment for a couple of months. We then
have a pharmacist dilute the concentration of monobenzone in the
cream from 20 to one percent. If the patient does not have an
allergic reaction to the one percent preparation, we use it for a
month and then go on to a 5 percent preparation for another month.
If all is well, we repeat the step-up with 10 percent and finally
back to 20 percent.
Once satisfactory depigmentation is achieved, most patients have no
further problems. However, a few people may get some pigmented spots
on the face during the summer months. These spots should be treated
with 20 percent Benoquin or, if available, the 40 percent
preparation. Sometimes freezing the spots with liquid nitrogen
helps. On rare occasions a patient will initially respond well to
Benoquin but then may stop or later repigment or even hyperpigment.
In these patients Benoquin in 40 percent concentration will not
work. They may even go on to repigment enough so that they no longer
need to consider depigmentation. |