Vitiligo: The scourge and the stigma- how the battle can be won

Humans are enthralled by the concept of beauty. And in our pursuit of vanity, mankind has many a times, rebuked any contrary to the norm. Be it leprosy, syphilis or tuberculosis, diseases have been loathed and ostracized ruthlessly since primeval times. How could vitiligo escape this coercive subjugation. Since its first documentation in Egyptian medical papyrus in 1550 BC, vilitiginous white spots have been noted by Indians, Japanese and Latins alike. The journey of demystifying vitiligo traverses almost four thousand years in time. And the path to unfurl its scientific genesis is still in progress....  Vitiligo stood apart from other diseases due to its deceitful appearance, despite naive harmlessness. An innocuous disorder raised such harsh abhoration in communities in the eighteenth and ninteenth century! Hence baptized "historical curse of depigmentation"  Unlike our veteran vitiligans today, patients suffered despondent segregation from the society in the past. This stark stigma has aroused curiosity, resentment, distaste and sympathy across generations. Vitiligo patients are still divaricated from social throngs, as ugly ducklings. In our times, Michel Jackson catapulted the social standing of this disease to jolting acceptance. His unmatched contribution is etched in history. Vitiligans like Winnie Harlow, Lee Thomas further eased the battle by embracing their depigmented bodies, and shedding light on the disorder. Therefore, I believe that blemishes of vitiligo shall fade with time.
However, in developing countries like India and Nepal, the task of generating awareness about this disease is herculean. We lack vitiligo societies or foundations unlike in the West. It is still hurtful to disclose to a 10 year old that he/she has vitiligo, as it brings disgrace not just to the child, but the entire family. The prognosis maybe brighter in an adolescent, but the excruciating agony caused by the diagnosis, is hard to dampen, even with elaborate counseling. Hence, clarity about the disease and stupendous treatment efficacy will be the unwavering weapon against this discriminative illness.
The scientific task of delineating the etiopathogenesis has been arduous. Wide array of clinical causes have been postulated time after time, with newer theories emerging every now and then. As dermatologists, we are aware of the lists of various hypothesis. So lets take a brisk walk, down the lane of known etiopathogeneic factors. Autoimmunity, oxidative stress, cytorrhagia, traumatic, neural, genetic, biochemical factors are snippets of the dice we have yet to complete.  Oxidative stress and autoimmunity are the titans that have had paramount significance. Others fall out in the fringes. Recently genetic linkage and associations are surfacing as strong determinants of both the onset and severity of the illness. Various susceptibility genes have been identified. Unfolded protein response(UPR), melanocortin and Raper mason enzyme related genes, genome with linkage and association studies are rising as susceptibility indicators. More concrete impact of gene analysis on disease predictability and prognosis, is yet to be disclosed.
Coming back to autoimmunity, tremendous association of vitiligo with other autoimmune conditions such as thyroid disorders is unputdownable. Studies show thyroid association in quarter of the childhood cases, and more than half of adult vitiligo cases. A study conducted in our center, have also reaffirmed the coexistence of thyroid disorders with vitiligo. Newer studies reveal autoantibodies and T cells predomination in diffuse and localized vitiligo. CD8T cells were positive in lesional skin in localized vitiligo. Depending on whether the cellular or the humoral response is predominant, extent of the disease maybe predictable in future.
My concern for autoimmune association, is regarding thyroid autoantibodies. To me, thyroid disorders and their treatment guidelines, are biased against cutaneous disorders. Thyroid associations in the West, specifically advocate against treating mild thyroid alterations despite cutaneous manifestations. Their cut off for thyroxine supplementation is TSH>10. We frequently witness patients with vitiligo, who have moderately increased TSH and positive Thyroid peroxidase (TPO) antibodies. Will autoimmune vitiligo improve as long as TPO remains escalated? Does mild TSH alteration shift the balance of skin homeostasis? Do we wait for endocrine storm to abate or we intervene? These questions need to be addressed in order to find a solution for autoimmune skin conditions.
In regards to management, counselling has a tremendous role. It is encouraged to make intelligible leaflets in patient’s language. For me, it is heart-crunching to see patients willing for painful surgeries for this asymptomatic condition. Hence, generating awareness in our community should be our prime priority.
Treatment modalities in vitiligo have metamorphosed over centuries, as we unravel this enigmatic condition. Treatment guidelines have been simplified, and rendered more precise in recent times. Dichotomy of segmental and nonsegmental vitiligo, treatment modalities according to body surface areas and stability of lesions are primary considerations for choosing treatment modalities.
Conventional treatment modalities such as steroids, are the veteran warhorse that still reign supreme in vitiligo. Oral steroids are the most potent tool to halt disease progression. Immunomodulators such as azathioprine, tacrolimus and phototherapy are prevailing steroid sparing alternatives. Phototherapy is an irrefutable asset. NB-UVB is superior to PUVA, with excellent color matching and minimal adverse effect profile. However, we have found rewards in Bath PUVA, turban PUVA and bathing suite PUVA in our vitiligo patients.
Newer molecule Tofacitinib has grabbed limelight of late. Tofacitinib inhibits the IFN-Y signalling via Jak pathway, hence halting progression and maintenance of vitiligo. Multiple clinical trials hint towards excellent potential role of Janus kinase inhibitors in near future.
Adjunctive or alternative therapies are topical gingko biloba, levamisole, latanoprost, vitamin D analogues, topical ruxolitinib and antioxidants.
Selenium in the form of selenomethionine or sodium selenite, has shown promise in cutting off the TPO levels. Selenium improves TPO profile, and also directly quenches the oxidative surge. Hence, it might emerge as a robust tool in autoimmune vitiligo. Some studies have shown the linkage between vitamin D deficiency and vitiligo. Vitamin D accentuates photo-induced melanogenesis and hinders cytokines linked to vitiligo via immune-modulating properties. Vitamin D deficiency related vitiligo might be more important in our skin types, as some reports have shown significant role of Vitamin D induced repigmentation with NB-UVB. Role of micronutrients such as selenium, zinc and copper should be further extrapolated.
Interventional strategies have gained momentum for some time now. Experts are fanatic about surgical grafting in patients with stable lesions. However, surgery maybe double edged sword, because of debacle of stability. Scoring these lesions, serial photographs and performing test grafts may aid in warranting stability. In test grafts, unequivocal repigmentation beyond 1mm from the border of the test graft is said to indicate stability. Individual lesional stability is cardinal before holding a scalpel. Evidence based practice will further uplift the surgical results in vitiligo patients. However, the despairing fact of failure of surgical grafts should be counselled even in the most promising patient.
Punch grafts were the harbinger of surgical interventions in vitiligo, and mini punch grafting still remains one of the most common surgeries. However, threats of cobblestone, lopsided repigmentation and anatomic restraints limits its utility.
Epidermal suction blister grafts, split skin grafts and tissue grafts are met by their rewards and hindrances. At present, non cultured epidermal cell suspension and cultured melanocyte suspensions are at the heart of vitiligo surgeries, as they address large recipient areas, provide excellent response and admirable color matching.
Hair transplantation, excision of small lesions have all been done with variable results. Nonsurgical interventions such as lasers and home-based phototherapy may prove to have snowball effect, as they gain momentum among patients with localized disease. Neon lasers, fractional lasers, microfocused bioskin phototherapy are glimmering in the horizon as promising innovations. In recent past, Mosenson et al. showed that vitiligo can be reversed through immune targeting with mutant  Heat shock proteins(HSP70), given the evidence of association of Heat shock proteins (HSP) in depigmentation.
In conclusion, patient specific and lesion specific individualized approach in vitiligo management can defeat this colossal stigma. Unambiguous patient counselling at first patient visit should follow individual targeted therapy at achieving disease control and repigmentation. We stand at this glorious era in the history of vitiligo, where we have defined many uncharted spheres in etiogenesis and management. Future gleams in delight, as we discover newer prospects in battling this ancient disease.

Journey with Fibromyalgia

I was just tender 22. One sunny summer noon, frens at med school planned an outing by the river-side of Dolalghat. We swam all day under the dazzling sun. And when I woke up next morning, i couldnt move. It was as if I was trapped in a casket. My hands and body crunched in pain. Oblivious to the source of pain, my friends tried giving me painkillers, massage and hotbags. None of that worked however. I was bedridden. 
That was my first attack of fibromyalgia. ...

But it was only a harbinger of the upheaval.. that was about to turn my life upside down!

My hands and back felt foreign to me. I sat stiff, days after days, writhing, hurting, crying and devastated. Disabling pain pinged into my bones. I still sorely remember sitting by my hostel window, wearing jacket in summer heat, and trying to read my course books. I almost flunked my third year final exam. My friends were lost in their own stress of med-school. But i was at war, war i lost everyday. My dreams were thwarted, I sank in my wretchedness. I woke up every morning just to find the demons stronger and fiercer than the day before. I couldn't eat, dinner table sobs became a mundane routine. I was entangled in a vicious web of vexation. Thoughts of ending my sufferings constantly plagued me, and wished for euthanasia back then. My then boyfriend, and now spouse, was the only person who encouraged me to move on.

It took me more than a year to demystify the source of pain. I was temperature sensitive. I had allodynia and hyperalgesia. Temperature changes and wind triggered my attacks. But I didnt know how to avoid or abate it. Desperate for answers, I knocked all doors... specialists, traditional healers, fortune tellers and who not. Renouned orthopedician misdiagnosed me with arthritis and prescribed Methotrexate for a year, with no improvement. Rheumatologist at AIIMS Delhi, brushed off my condition as not arthritis, but wonder what...

Years passed, harrowing pain became a bitter constant. However, I didn't let it forestall my life goals. It wasnt one particular day or event, but when I looked back after 6-7 years of affliction, I realised I had won the battle. I wasn't cured, it still followed me like dark shadow. The disability still tainted my brightest days. During MBBS finals, MD finals or pregnancy, pain would shoot up, forcing me to immobility. But I worked. I worked when I was fine, I worked when it hurt. I worked when I was unable to hold a pen, I paddled through choppy waters. Now I am a proud  Derm graduate. Despite days of bedlock right before MD finals, I am Kathmandu University's first distinction holder in Dermatology. Even today, my hands hurt during every hair transplant, while holding laser probes, in household chores and as I carry my daughter on my hips. But I do all of that, and the triumph is priceless.

I am sharing my journey because I know, there are so many others who live this chronicity, shunned and dejected. Life is a battle, one way or the other.  Fibromyalgia is a havoc, it engulfs you if you succumb. You have to fight, you cant give up, just cant give up.

A fish trying to climb up the shore.. a woman in Nepal

Sometimes I feel like a fish trying to climb up the shore... with my powerful feeling of womanhood, strong views on freedom and deeply opinionated persona!

A woman rather be a femme-fatale, than an aficionado here. Her strength of thoughts, are vilified than respected. How many women do we actually know, to have made a mark in Nepal politics?? Is it my feeble memory or we actually have none!

We had Pasang Lamhu, who combated and conquerred the Everest. We had Parijit, who enriched our literature with her imagination. Of late, CNN heroes who shone brighter in international arena. Ladies like Bidhya Bhandari, to whom politics was gifted in lineage. I cant think of many.

A country with polemic and gibberish politicians, Nepal stands at crossroads today. It may either veer off a sharp cliff into despondency or rise like a phoenix, like South Korea, Japan and Singapore. Illuminated hopes come with this budget and other amendments. But with ropes of power scattered in many hands, so many mushrooming heads of prominence, its hard to fathom which way we progress.

And in this mix-bag of ethnic, dogmatic and ethical dichotomy, where exactly do women stand? In this league of patriarchial politics, legislation have been rectified. Property inheritence, citizenship claims to name a few. But will people embrace them without prejudice? Our social framework is structured in a way where women have a weaker hand. More so after marriage. She cannot pursue her goals and aspirations passionately, when she has to live in subordination.

Women from different ethnic and cultural backgounds are living in completely different era. Rural women still live in primitivity.  Their dreams are thwarted, shelved, because of their male siblings, husbands and children.

And women like me, seemingly liberal and independent, we live in a mirage. We are customed to believe we are equals. We got similar education, similar job opportunities, even similar pay. But there are obligations that pulls us down. Little routines like cooking, bathing the children, making the shelves, closet, homeworks, linens, and cleaning consumes our leisure time. There is immense gratification in home-biding. But it overshadows our career and blurs our social stand in the long run.

This gap will probably end, only when gender based roles end, right from early childhood. A seismic shift cannot be anticipated!

A Ride To Revel... one such happily everafters.... :)

Last month, we made a quick trip to Bandipur and Pokhara. It was sort of a getaway, with bits of government paperworks too.

Up the winding roads of lush green Bandipur, sun had climbed its tallest. Mint green freshly blooming crops of leaves capped the mountains. Breezing skittish winds bantered with flowery trees. Spring gleamed in pious delight.

But the government paperwork snarled at our vacation spirit. Asim had to xerox the documents so many times. He was annoyed at the tenuous redundancy. To further excruciate our disappointment, we were told we had to go to Damauli to complete the procedure. We hissed... Its stifling that a snippet of government work requires so much travel.... :(

We drove back hurriedly coz we ran short of time. Aaliyah was however excited despite the rush. She savoured every bit of the sunshine and ride. Outdoor trips are revelous for kids. It inculcates love for nature in them!

But we were still gripped, coz more work waited us. As we expected, Damauli was another damp squib. We went through tedious form-filling again! And our job was finally done by late afternoon.

Then....we headed for Pokhara for a real vacation. It was a lavish treat! Unhindered straight highways promised a jolly staycation. It was a beautiful sight... barren soil, pretty girls on the sidewalk, twin toddlers, rain trickling down the arid roads... Twilight embraced us along the way, the fervent dipping sunrays threw patronizing glare at the rising pale moonlight!

And we arrived! The roitous conundrum of city life seemed like a carousal. The nimbus of light at lakeside was invigorating. It felt so special..."you and me, in this paradise" :) :)

Contrary to banal rush of urgency in kathmandu, Pokhara was laid back, inviting, tempting and soothing. Lofty soft winds greeted us in summer. Air wasn't thick with smoke, and sky wasnt clouded. Stars had already woken up, flashing their silvery grin. Music enlivened our tired bodies.

We explored the bright lanes on flipflops. There were crowds... couples, teens and salmon-skinned travellers, perhaps bloggers, singers and dreamers too. We were elated. Watching people is always captivating. They remind of simple joys of life... a new mother proudly carrying her cheruby cub on her love handles, her smile priceless... a gorgeous teenager on windowseat with plugged earphones, lost in the world of musical fantasy... a young couple awkwardly holding hands, still trying to figure each other out... that moment seemed to ooze happiness..

Restaurants offered foods to drool for. After enriching our tastebuds, we took to a friend's hotel for the stay.

Next morning, breakfast at Himalayan coffee beans was delightful. It reminded so much of Starbucks. Really! We then paddled the concrete roads in bicycles. It had been a long long time, since I actually got to take on the roads. I was pleased. And after an hour of sweaty cycle-ride, we strolled along lakeside, went food hunting. We found some awesome korean food to satiate our growling tummies.

In the afternoon, we decided to find "Paame" as it sounded like a tourist destination. We drove along lakeside on our four wheeler. But it was a little disappointing coarse ride. Tracks were muddy and bumpy. We gave up midway and instead, landed at a paragliding site. The airglider lands at that small piece of land leftover by the huge lake. Both of us were fascinated at the actual gliders and their flight. While we couldnt decide whether to give it a try, time had ran out for the day. They wouldnt embark the glide after 3pm. Interestingly, we met the last two people who came down that flight. They were couples and they flew in two parallel crafts. The fascinating part was that they were almost 50 years old. Wow. That was quite a sport to choose at 50! With promise of doing it ourself next time, we headed back HOME. :) :)

Thoughts... they cant be random, however bizzare!

One gloomy day, I slip into retreat. I feel sore. I hunker down my scrawny bones on crusted-creaky floor. Usually, I slid into warm memories when I'm blue. But tonight, my thoughts traverse elsewhere. I am confused. I wonder about human behaviours... how we constantly exude, potray and flaunt "positivity". These days, social media has become a perfect "hide-out". We quote the redundant tropes... about life, love, etc. We hardly admit our fervent inadequacies in those scrolls. But, all of us acquiesce to our demons sometimes, dont we? Sun doesnt always shine. It rains, it hails, it snows. So, I juggle my mental volleys.... I wouldnt be me, without my negativity.... my fusillades, trailblazing anger, my woes, aches, some lies, insecurities, etc. :) :) So why shouldnt I heartily embrace my flipsides?
Of course, I keep straddling to cultivate healthier thoughts. We always should. But I also know, old habbits die hard, wonder if they really do!

Tips for good skin... cosmeceutical facts!

Smriti Shrestha

Cosmeceuticals is one of the most rapidly expanding $280 billion global industry, growing steadily at the rate of 10% per year. Cosmeceuticals include all cosmetics, foods and chemicals that enhance beauty. Signs of ageing - dull, tight, rough skin, pores, spots, yellowness, wrinkles and sagging. Smoking, mental stress, excessive dieting, wrong food habits, excessive sun exposure, lack of exercise and pollution lead to premature ageing and skin disorders. People using excessive heavy make-up all day suffer from pigmentation, pimples, contact allergy and sensitive/reactive skin. Reactive skin is sensitive to heat, cold, wind, topical creams leading to itching, burning, tingling, redness and dryness. Both reactive or aged skin can be prevented and controlled by disciplined dietary habits and proper skin care.

Here, I discuss how to eat your way to fabulous skin and how to choose your skin care products wisely. Don’t miss out on my recommended food journal.

SKIN CARE: Basic skin care products are sunscreens, moisturizers, use of umbrella and appropriate day and night creams. Moisturizer: Moisturizers are key ingredient in beauty care. Effective moisturizer must decrease water loss from the skin surface, known as transepidermal water loss (TEWL). Their job is to create an environment for healing. Our skin is constantly undergoing minor unnoticed trauma due to external factors. Therefore, healing is essential for healthy skin. Petrolatum(vaseline jelly) is an ideal moisturizer that decreases TEWL by 99%, creating effective occlusion, thus promotes healing. Other moisturizers are mineral oil and vegetable oil. Glycerine holds water like a sponge, and prevents TEWL by 50%. Sorbitol, uear, lactic acid, NMF (natural moisturizing factor), gelatin, hyaluronate are other constituents of moisturizers to look for. However, any rehydration caused by moisturizer is temporary and works for around half an hour. Therefore, it should be reapplied frequently in copious amount. Sunscreen: Rays from the sun such as UVA, UVB and infrared radiation amounts to upto 70% of external ageing. Application of liberal amount of sunscreens every 3 to 4 hourly is essential to prevent sun-induced damage. Meticulous care is needed while swimming, at beaches, deserts and snow as they reflect more sunlight onto our skin. Gel based solutions work well on oily skin and lotions/creams are preferable for dry skin. Sunscreens containing titanium dioxide or zinc oxide provide better protection as they are physical blockers. For our skin, spf 15 is recommended for daily use and spf 30 preferred during outdoor activity. Kathmandu has one of the highest UV index (intensity of UV rays) in the world, hence, we are highly susceptible to damage.

Retinol: It is a synthetic form of vitamin A, most widely used by all A-listed cosmetic brands worldwide. Pro-activ is one such example. Retinol works by binding to skin and repairing virtually all age related changes in skin. It enhances layers of skin and its components. But it needs to be applied for a long time to appreciate visible change. Expected side effects are discomfort, burning, stinging, sun-sensitivity when applied inappropriately. Strict sunprotection is advised during its use.

Others: Vitamin C, Vitamin E are antioxidants that fight free radicals responsible for skin damage. But very few products actually contain adequate amount of these chemicals. Rice ceramide, rice germ, bran, litche extract, grape extract, flavonoids, zinc, selenium are natural components of beauty products that have scientifically proven benefits.

DIETARY CHOICES Eating right is a lifestyle and you are what you eat. Eating smart is an intelligent way to attain healthy lifestyle. Gastrointestinal maintenance positively influences skin health directly and indirectly. Lately, the concept of “functional food” is on the rise. Functional food are ingredients (natural or added) that provide health benefits beyond their traditional value. Example, fortified food containing vitamins and minerals.

Here is the list of beneficial food:

SOY: Soy is available in the form of soy milk, soy beans. It acts on skin, hairs and nails when consumed or applied to skin for 3 to 6 months. Variety of soy milk with added nutritives are available in stores these days. It contains carbs, fat, protein and essential nutrients such as calcium, zinc, iron, vitamins, etc. Dietary soy improves obesity, bone health, alleviates menopausal symptoms and decreases risk of breast and skin cancer. It protects the skin against solar damage, allergy, skin swelling, DNA damage.

PROBIOTICS: Probiotics are fermented food products that contain bacteria beneficial for human body. Probiotics are found in yogurt, enriched milk and various formulated functional food. They were initially used for diarrhea. Now, their use has extended to various skin allergies and sensitive skin. They also enhance absorption of dietary nutrients.

OLIVES: Consumed as olive oil or olives, these are one of the most trending health food. They protect against heart disease, various cancers and skin ageing.

OTHERS: Green Tea, carotenoids (carrot), broccoli, lemon, nuts, pumpkin seed, fish oil are other antioxidants that fight skin ageing. Red wine contain resveratrol, which acts as a defense against skin damage. Tropical fruits such as berries(strawberry, blueberry, cranberry), pineapple and papaya are low calorie antioxidants.

YOUR DAILY FOOD JOURNAL: Breakfast: Soy milk/Green Tea. Cornflakes/oats(fortified) Lunch: Use olive oil instead of mustard or vegetable oil. Eating carrots/ cucumber before big meal reduces calorie intake and supplements antioxidant requirement. A fist/palmful of rice with green vegetables, soybeans and pulses. Finish your meal with yogurt. Afternoon snack – replace your afternoon junk food with fresh fruits, berries, fruit juices and mixed fruit salad. Dinner – Whole grain pasta/ brown bread. Peanut butter. A glass of red wine. “Breakfast like a king, lunch like a common-man, dinner like a beggar” “Cleanse your skin and remove the last bit of make-up. Apply generous amount of moisturizer to let your skin heal while your body rejuvenates through the night”