Changing Skin Color

JCAS, the Journal of Cutaneous and Aesthetic Surgery has moulted. It has shed its skin and got a new one. We hope the new, vibrant color change is appreciated. Snakes and butterflies also shed their skins and acquire new colors. But unfortunately, not all color changes are appreciated.

A change in skin color in humans, especially if it is patchy, leads to severe stress. The prime example is vitiligo, a chronic disorder caused by the structural or functional loss of melanocytes, which leads to patchy, depigmented macules that appear very prominent on darker skin. Patients are treated as outcasts due to several misconceptions about the disease, and they find it difficult to live a normal life. It is a disease neglected by health planners and researchers as it is neither contagious nor life-threatening.

Vitiligo patches are often resistant to medical treatment. Surgery then becomes an option to restore the color of the skin. In vitiligo surgery, melanocytes from normal skin are transplanted onto depigmented skin by tissue or cellular grafts. Most articles in the literature discuss various procedures for obtaining donor melanocytes, but there are very few articles on the preparation of the recipient area. The review article in this issue by Al-Hadidi et al.[1] dwells on the preparation of the recipient site and subsequent dressings necessary to obtain optimum outcomes. Though mechanical dermabrasion to prepare the recipient area is the time-tested method, it can be a tedious technique for large areas. The increasing use of an ablative laser such as the Er:YAG laser or the CO₂ laser promises to make the procedure quicker, and as effective.

In spite of recent advances such as melanocyte suspensions and cultures, which have improved treatment outcomes, vitiligo surgery still has a lot of limitations.[2] Adverse results are mainly due to the unsatisfactory quality of repigmentation. The color obtained may not be uniform: It may be incomplete, with a halo marking the recipient site, or it may be patchy, with skipped areas. The texture of the skin may not be normal, and the danger of recurrence is always lurking round the corner. Acral vitiligo remains a challenge to treat both medically and surgically, with poor outcomes. The issue of stability of vitiligo is also controversial. Hence, there is still a long way to go for the optimal surgical treatment of vitiligo.

Further, dark skin itself and darkening skin color is also a source of stress. This has led to numerous skin-lightening creams, many of which have adverse effects: The steroids they contain cause skin atrophy, telangiectasia, severe acne, and hypertrichosis, to name a few. The incidence of side effects of the steroids that are used for skin lightening has reached alarming proportions in many parts of Asia, Africa, and elsewhere in the world among people with darker skins.[3] Exogenous ochronosis caused by hydroquinone, a skin lightener, is another problem, and it is resistant to treatment. Fairness is also a craze, and much of a esthetic practice involves procedures to even out the skin color and become lighter-skinned.

But skin color is just cells. It does not change what is within. To increase global awareness about vitiligo and alleviate the sufferings of vitiligo patients, World Vitiligo Day is observed on June 25, the death anniversary of Michael Jackson, the famous singer and dancer who suffered from vitiligo. We must utilize this opportunity to dispel the prejudices associated with it. Why should patients suffer because of a change in skin color?

Proving to be a role model for vitiligo patients is 19-year-old Chantelle Brown-Young, who was diagnosed with vitiligo at the age of 4. In spite of being teased and bullied for her patchy skin color, she regained her confidence and is now a top model in the US. She says, inspiringly, “I am the underdog and I want to prove that one can follow one's dreams despite all the flaws and setbacks.”[4]

We need many more people like her. “Black or White,” song number 4 in Michael Jackson's music video album Dangerous, expresses his feelings.[5] These are some verses from the song:

“I’ve seen the bright get duller
I’m not going to spend my life being a color
Don’t tell me you agree with me
When I saw you kicking dirt in my eye
But, if you’re thinkin’ about my baby
It don’t matter if you’re black or white
I said if you’re thinkin’ of being my baby
It don‘t matter if you’re black or white.”

Yes, as dermatologists, we must emphasize: It shouldn’t matter if you are black or white, or even black and white.