Adapted from Aaron B. Lerner, M.D. – Department of Dermatology, Yale University School of Medicine
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, which contains 20 percent monobenzone. Other compounds such as hydroquinone simply do not work. It is a shame that funding from industry and government have not been available to find other compounds 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 always 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 preparation, 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.
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 1 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.