Vitiligo is at present a disease very difficult to treat. It severely affects a person's appearance and causes inconvenience in life and work. Patients seek medical treatment in many hospitals only with discouraging results and this produced great psychological stress on them. Some are tormented all day by worries and agony. Therefore people are most concerned whether the disease is curable? How to treat it? What is a better therapy? How to choose the correct treatment? What are the medicines for the disease? How long dose it take for an effect to appear? How long dose it take for a cure?

1. Can vitiligo be cured
What is the current level of treatment for vitiligo? Can it be cured? There are currently different views on this question. We believe there are two misconceptions that affect the effects of treatment: one is exaggeration of effectiveness, i.e., all cases can be cured without distinction of the conditions. Such a misconception may often lead to over-use of the drugs, and no good results can be achieved. This over-use can even lead to disease progression and the loss of treatment opportunity. The second is the denial of any effects of treatment. Some medical workers have a negative attitude toward the treatment of vitiligo and believe that vitiligo is "a disease of no cure". Such a misconception can cause great psychological pressure on the patients, especially on the adolescent patients and their parents. For the treatment of some difficult cases all that modern medicine can offer is symptomatic treatment. Current western medicine has poor effects on the treatment of vitiligo, and some hospitals in Europe and America refuse to treat this disease. Medical workers in our country exploit the unique advantage of traditional medicine and use Chinese medicines or a combination of traditional and western medicines to treat the disease. After many years of research breakthrough has been made in the treatment of vitiligo. The cure rate for early cases of vitiligo has reached more than 95%, for intermediate cases more than 50 %, and for late cases 30%. This puts us in the leading position in the world for the treatment of the disease. No current treatment modalities can offer 100% cure. It is unscientific to say that all patients can be cured without a distinction of the patients' conditions. Therefore, there are still many difficulties in the treatment of the disease. The reason is for this is that traditional Chinese medicine therapy uses the method of diagnosis and treatment based on the overall analysis of symptoms and signs of the patients. In the course of the treatment the plan must be made based on the patient's condition, and for the best effects the treatment plans must be adjusted according to the changes in the patient's condition. Besides, the doctor's sense of responsibility and the close co-operation on the part of the patient are also important factors affecting the effects of treatment. Therefore, the process of treatment is a synthetic one, and no miracle drugs or secret preparations handed down in the family from generations can provide all the cure to the patients. The patients should realize the difficulties on the one hand, and on the other should have confidence in the treatment of the disease. After contracting the disease the patient should keep a stable mental status, overcome any blind impetuosity, and refrain from over-using drugs. The patients should select a proper therapy for his condition after consultations from many sources and repeated comparison. If a marked effects has been obtained in the initial therapy this will serve as a good basis for a complete cure. A complete cure may be achieved if early and appropriate treatment is selected, especially for early cases.
Many patients are worried if the disease will recur. According to our clinical observations and follow-up, the recurrence rate is only 0.5 % after a complete cure has been achieved.

2. An introduction to common therapies for vitiligo
At present there are many treatments for vitiligo. The following is our experience from clinical work.
(1) Ultra-violet light (including sunlight) phototherapy
Ultraviolet light is just outside of the violet light on the spectrum. It is also called ultraviolet ray. There is large amount of ultraviolet light in the sunlight. Ultraviolet light will in theory stimulate melanocytes to make more melanin. It is a conventional therapy and is at present advocated by many people as well as by textbooks. But it is our observation that this form of therapy is not very beneficial to the vitiligo patients for two reasons: (1) Over-use of ultraviolet light will cause body damage; (2) Resistance to ultraviolet light is decreased in vitiligo. Therefore we believe that vitiligo patients should be exposed to less or avoid ultraviolet light. Although the body is exposed more or less to sunlight everyday it is not generally harmed to any significant extent because the protection mechanism is intact in normal subjects. The compensative ability of melanocytes to produce melanin to shield the body from injury by ultraviolet light irradiation is an important self-protection mechanism. As the UV light exposure prolongs or the intensity increases the melanocytes will turn on their compensative activity by producing more melanin accordingly, and thus the skin becomes darker to shield the body from ultraviolet light and to protect the cells and tissue (including the melanocytes themselves) from injuries. However, it is completely different in vitiligo in that the protective mechanism is damaged. Most melanocytes in the epidermis are in a state of injury to various extent with weakened or lost compensative capacity. The protective function is compromised. At this stage the increase in UV exposure will not only increase the workload of the melanocytes but also aggravate the destruction of melanocytes. At the same time other tissue will be damaged as evidenced by the appearance of erythematous and blistering lesions on the skin after strong UV light irradiation. This is a manifestation of severe tissue damage of the skin and the subcutaneous tissue. Sometimes we can see clinically that the skin surrounding the vitiligo patches will become hyperpigmented after sunlight exposure, or some pigmented islands will appear within the patches. This is a temporary compensation reaction because some of the melanocytes still have some residual functions. But as the UV exposure goes on or the intensity of UV increases the melanocytes will be further damaged and loose the ability to produce more melanin. The pigmented halos around and pigmented spots within the vitiliginous areas will disappear and the skin lesions enlarge in size, the color of the lesions whiter. In some cases there will even be rapid extension and dissemination. Some people call this "a good phenomenon because it will make the white patches more apparent and get rid of the diseased melanocytes". It is a view open to discussion. We believe that the disappearance of melanin and the increase of vitiliginous lesions are indications of the loss of more melanocytes after their destruction and decrease in melanin production. It is a manifestation of disease progression. Apart from this the treatment of vitiligo is a long process. Long-term UV irradiation will also cause mutagenesis and even cancer. We therefore hold that UV phototherapy is not suitable for the treatment of vitiligo.
(2) Immunological modulation
Through research and clinical observations it is clear that the occurrence and development of the disease is related to immune dysfunction. But the clinical use of immunologic modulators has not shown any significant therapeutic benefits. Immunological dysfunction is a very complicated pathophysiologic process, immune deficiency, decreased immune functions and hyper-immune status can all cause relevant diseases. Which immunologic factors are related to vitiligo is still unknown. The currently used immune modulating agents (e.g. transfer factor, thymosin) have significant therapeutic effects on infectious diseases due to immune compromise. Their effects on vitiligo is still in the stage of clinical observation. Clinically temporary relief of vitiligo can be observed in some patients receiving corticosteroids. But because of the severe side-effects, corticosteroids can not be used for long duration. There will be a rebound phenomenon rather than a cure after discontinuation of the agent. Therefore this agent can not be used as a routine therapy.
(3) Trace elements
Research showed that the deficiency and imbalance of trace elements are important factors in the pathogenesis of vitiligo. The normal physiologic activity of the body requires the participation of many trace elements, but the exact identity of the trace elements that is deficient or the imbalance among the various trace elements is largely unknown. Therefore there is no solid base for replacement therapy with trace elements. The clinical trial use of copper and zinc, etc. has not demonstrated any promising results. But we found clinically that the incidence of vitiligo is significantly higher in children with dietary bias, and they responded less well to therapy compared to other children. The correction of dietary bias in children with vitiligo during treatment can increase the therapeutic effects, indicating that the disease is related to nutritional deficiency (including trace elements).
(4) Anti-vitiligo (Zhibansu) injection and psoralea tincture
Anti-vitiligo injection is prepared from herbal medicine psoralea used as an intramuscular injection. It is effective for the early-stage vitiligo with a cure rate of about 1% ~ 2%, and an effective rate of 30%. Psoralea tincture is prepared from psoralea fruit by ethanol extraction. When used topically it manifested certain therapeutic efficacy but the cure rate is low when used alone.
(5) Meladinine
Meladinine was produced originally in France. It has two forms: oral tablet and topical tincture, and can be used either in combination or alone. Combined use has better results than use either agents alone. The cure rate is 1.5% and effective rate is 30%. The drug has strong side-effects. Oral administration can cause liver, kidney and digestive system side-effects. And "rebound phenomenon" is significant after discontinuation of the drug. Topical application may produce relatively strong local reaction, with most patients experiencing erythema, swelling and even blister formation at the site of application. In a small number of patients there will be repigmentation and cure after the healing of the blisters. However, in the majority of patients the vitiliginous skin lesions will enlarge after the formation of blisters, and disease progresses. If used incorrectly for more than half a month, the topical agent will produce injurious effects on the skin, and thickening and aging of the skin occur if used for more than 2 months. This makes the subsequent treatment by other methods more difficult. Thus, this drug should be used with caution and ultraviolet light should be avoided after the administration of the drug, otherwise there will be more severe damage to the skin.
(六) Other imported drugs
In the recent couple of years, some clinics have used drugs imported from America and Japan, such as Bailingsu injection. According to our foreign patients from US, Japan and France, there is no effective treatment for vitiligo in foreign countries and most hospitals refuse to treat these patients. Some patients therefor come to China for treatment. For some time certain advertisements proclaimed that Bailingsu injection "effective after 3 injections", "cure after 7 injections". And some clinics used Bailingsu injection (produced in America) together with topical Baidianjing produced in China. Some patients experienced good response when used topical Baidianjing alone. It is impossible to tell which drug is working in the situation. According to many users of Bailingsu no cure was seen in patients using Bailingsu alone. If it is really a miracle drug, why the US does not use it but sells it to China, and the patients from US have to come to China for treatment? Therefore repeated inquiries should be made to these imported drugs and use them only after careful observations and comparison.
(七) Acupuncture
Theoretically acupuncture can regulate the endocrine functions of the body and enhance immune response. But clinically observed effectiveness does not match the theory. On the contrary some patients experienced exacerbation of the disease after acupuncture. On close examination acupuncture may produce fear and psychological stress in the patients. Therefore therapy with acupuncture is not suitable to all patients but should be selective according to the patients' condition. For patients who are afraid of the needles, especially for children with vitiligo acupuncture is not appropriate. Besides, therapies that directly injure the skin must not be used, e.g., plum-blossom needle, pyro-puncture and other similar therapies are traumatic to the skin. "Isomorphic reactions" will occur with progression of the disease. For severe cases there will be scar formation in the local tissue, leaving permanent damage.
(八) Epidermal autografting
This therapeutic modality is directed towards the decrease or absence of melanocytes in the lesional areas of vitiligo. It entails the removal of autologous epidermal sheets by a blistering device from a normal area of the body and grafting the sheets onto the vitiliginous areas to increase the quantity of melanocytes in the diseased areas to promote recovery. This therapy was first reported in 1964 in U.S. by Kiistala who grafted the epidermal sheets taken from the roof of blisters generated by vacuum suction. This modality was first used for clinical trial treatment in the 1980's in our country by Shanghai Medical University and China Medical University. However, the simple vacuum suction is not suitable for large-scale clinical use because it took a long time to generate the blisters and the sizes of the blisters are small. In 1995 the Vitiligo Institute of Shandong University and Shandong Engineering University jointly developed model PSJ-1A epidermal autografting apparatus. Later on Shandong Engineering University developed such modified models as PSJ-1 and DLY-2. This machine has the feature of dual effects on the separation the skin by exerting vacuum suction and elevated temperature. It has a precise regulation of the vacuum suction pressure and a stable control of temperature. It can separate the epidermis from the underlying dermis rapidly (40-90 minutes) and exactly at the dermo-epidermal junction. The blisters thus formed are of uniform size. The procedure by this apparatus will not cause any scar and can simultaneously separate large areas of epidermis, the largest area maybe up to 15.7 cm2. It is easy to operate and has wide applications. This has greatly promoted the epidermal autografting as a therapy to vitiligo in our country, and the epidermal autografting as a therapeutic modality in our country has reached international level. On the basis of our previous experience, treating vitiligo with traditional Chinese medicinal herbs combined with epidermal grafting technique has achieved a total cure rate of 57% over the previous cure rate of 35.8%. The cured patients with the smallest lesions were only grafted once with 5 grafts from the blister roof (0.5cm2); those with the largest lesions were grafted 22 times with 602 grafts, amounting to 1/10 of the total body surface area. The largest area grafted each time was 64 blister grafts. It is our experience that those with better results when treated with traditional medicine would have better results with epidermal grafting, while for those unresponsive to traditional medicine the treatment with epidermal grafting would also be ineffective. For those patients with generalized, universal and acrofacial vitiligo epidermal grafting can only be carried out when there are improvements and shrinkage of the lesions after treatment with traditional medicinal herbs otherwise grafting is ineffective and there will be "isomorphic reactions". The best results can be achieved if epidermal autografting is performed between 3-6 months after the initiation of an effective therapy with herbal medicine. Early operation will have lower survival rate for the grafts, and late operation will unduly prolong the course of treatment. The long-term, inappropriate use of topical agents can cause thickening and ageing of the skin, and therapy for such skin lesions is generally unfavorable. Care must be taken when grafting for areas involving the sternum, fingers, periobital areas and in those with cicatricial diathesis. The depth must be carefully monitored to avoid damage, scar and impairment of function.

3. How to select the therapeutic regime
(1) More inquiries
1) Ask patients under treatment
As the saying goes "Fellow-sufferers have mutual sympathy". The communications between patients is most genuine and can reveal true conditions. After the onset of the disease the patient should not rush to a clinic in haste, but should make inquiries to the patients under treatment. The patients being treated should truthfully tell the inquirers about their experience to help them in the selection of a good treatment.
2) Ask the cured patients
After the onset of the disease it is vitally important to select an appropriate treatment regimen to obtain the best therapeutic effects at the first treatment. If there are too many failed treatments the disease may become resistant to further treatment. The patients must face the reality and keep a stable mind. The patient should actively seek and visit the cured patients to gather information about treatment from many sources. The patient can then select a treatment regimen based on his own condition after careful comparison. The patient should avoid selecting blindly a treatment without making inquiries because of shyness. In our clinical work we saw 2 strange phenomena: one is that parents seek secret treatment for their children for fear that other people might know about their kids' illness. The second is that when a patient visit a cured patient and inquired about their experience of the treatment, the cured denied that he had ever suffered from the disease and refused to provide any information about the treatment. As a consequence many patients selected inappropriate treatment that made their conditions worse. It is the patient's own responsibility for his early recovery to make many inquiries and visits to obtain early and appropriate treatment. For the cured patients after suffering from the torments of the illness they should have sympathies for the new patients and should enthusiastically help them. The reason why these patients are unwilling to communicate with other people is that they think by admitting they have the disease they may ruin their reputation. Some people have prejudice against this disease and regard vitiligo as infectious or inheritary. Such worries should be dismissed as it is not infectious and the rate of inheritance is low. Do not let vanity spoil the chance of treatment as it may make the disease incurable, and you will regret for the rest of your life.
3) Inquiries to the hospitals for the treatment modalities
Currently common drugs used for vitiligo are western and traditional Chinese medicines, e.g., vitiligo bolus, Baishi bolus, Vitiligo capsules. The therapeutic effectiveness is insignificant if only one drug is used alone. Most drugs in the special clinics and hospitals are self-made proven recipes, and approved as "non-standardized preparations". Such preparations were originally approved by drug administrative authorities from the city government, but now from the provincial as well as city governments. The officials from the provincial and city authorities are close to and are familiar with the real situations of the clinical practice, and the approval needs less time and money. Using these proven recipes with flexibility various hospitals have treated many difficult diseases. The current short-comings of this approach is that synthetic treatment measures must be taken according to the different conditions. The doctors can design a treatment plan based on the overall conditions of the patient and should constantly adjust the plan during the course of the treatment according to the change of the patients' conditions. Therefore the effectiveness of treatment in various hospitals is quite different. Before deciding on a treatment the patient should visit a number of hospitals to make inquiries, mainly about the effectiveness of treatment, such as the rate of effectiveness, the rate of cure. The patient should ask the hospital for data on the treated cases. The before- and after-treatment photos should also be inspected. But the photos should be inspected closely to determine the authenticity. The genuine photos will have clearly-focused images and the fine structure of the skin surface can be clearly visualized, such as the skin fields, villous hair and follicular orifices. The margins of the vitiliginous lesions are generally sharply defined yet irregular in shape. But for those photos that have been tainted or manipulated technically, the color, the margin and the shape of the lesion are usually unnatural and the image unclear. Sometimes the traces of manipulation can be discerned. Therefore the manipulated photos can be identified upon close examination however modified. In the medical records the patients' personal details such as name, sex, age, time of onset, diagnosis and details of treatment, address and contact phone number should also be documented.
After inquiries from many sources, an analysis and comparison can be made based on these information. This will make it possible to select an appropriate treatment regimen suitable to the patients condition.
(2) Observation of the effects
1) Initial effectiveness: The clinical manifestations of the 1st signs of effectiveness are the shrinking of the white patches from the periphery to the center. The margin of the white patches is becoming clear (blurred margin is a sign of disease progression). The color of the skin around the white patches is slightly darker than the normal skin. Black dot (pigmented island) within the white patches may also appear. If the treatment is effective, 65% of the patients will show effects within 1 month, 85% within 2 ~ 3 months. It is very rare that patients do not show any sign of improvement for more than 3 months.
2) Marked effectiveness: the increase in size of the dark spots and subsequent coalescence to form large pigmented patches. The smaller vitiliginous patches will disappear and the larger ones will decrease in size significantly.
3) Cure: the complete disappearance of patches. The repigmented areas may be hyperpigmented and thus appear darker than the surrounding normal skin. The complete recovery of skin color may take more than 3 months.
4) No effects: If no effects are observed after 3 months of therapy, then a change of therapy should be contemplated.
During the course of treatment, the patient should be examined by the doctor once a month. Only by careful evaluation of the patients' condition can a doctor adjust the medicine to the patients' symptoms. If a monthly visit to the doctor is not possible, photos of the skin lesions should be sent for examination every 1 ~ 2 months. A regular telephone interview (once a month at least) or correspondence to the doctor is necessary to inform the doctor the condition of the disease and reactions to therapy. If the patients can co-operate with the doctors during treatment relatively good results can often be anticipated even for some severe patients.
(3) The time of cure: the time required for a cure is influenced by the following 6 factors:

1) The duration of illness: In early stage of illness (within 3 months) a cure may be achieved between 3-10 months of therapy, on average within 7 months. For intermediate stage (4 months to 3 years) 6 months - 2 years may be required for a cure, on average within 1 year. For late stage (>4 years) one to 4 years may be needed for a cure, 2 years on average. According to the statistics of 2597 patients in our hospital on the cure rates of different stages of vitiligo, the cure rate for early stage vitiligo is 95%, intermediate stage 57% and late stage 33%.
2) The size of the lesions: for localized, small patches of grain to finger-nail sized lesions 3-10 months may be needed for a cure. For a single palm-sized lesion 8-14 months may be required for a cure; and lesions of 2 ~ 3 palm-sized patches 10 ~ 16 months may be required. For large, disseminated lesions 2-4 years may be required.
3) Location of the lesion: The lesions on face are quick to respond to therapy. The lesions with descending order of response to therapy are: face, head, neck, back, chest, hips, waist, abdomen, hand-foot and mucous membrane. Lesions around joints of the limbs, hands and feet, and mucosal surfaces require long therapy and cure rate is low. Color of chequered black and white hair is easy to turn black, but complete white hair is difficult to treat. White eye-brow is easy to cure but white eyelash is difficult to recover.
4) Age: The effects are superior in children and adolescent patients to middle and old aged patients, but for early lesions no difference in effectiveness can be observed. The effects are significantly different in different ages for intermediate and late stages of the disease.
5) Individual differences: There are individual differences in response to therapy, such as living habit, mental status, general health. Slow response and long therapy are observed in patients with dietary bias, smoking and drinking, and in children with partial to snack foods and drinks. Patients with ease and stability of mind have better effects than those with psycho-neurological dysfunction such as mental stress, melancholy and insomnia. It is also difficult to treat overweight children and those with fair skin color.
6) Types of vitiligo: For localized patients the cure rate may be as high as 96 %. The cure rate for the segmental type may be 96% but the course of treatment is long and slow, sometimes can be as long as 9 months. For severe patients 2 ~ 3 years may be required for a cure. Because of the complete depletion of melanocytes in this type of vitiligo, autologous epidermal grafting must be used for complete cure. For generalized patients and for patients with involvement of joints, limbs, hands and feet skin as well as those with unstable conditions a cure is difficult to achieve. The most difficult type is the universal type with a cure rate of less than 5%.
(4) The doctor's sense of responsibility
Because vitiligo is a complicated disease with many pathogenic factors the effects of treatment is also influenced by many factors. One drug or one type of treatment can not cure all the patients. Therefore the doctors sense of responsibility is very important in achieving the best effects and in accelerating complete recovery in the patients. The medical staff should follow the good example of Dr. Bethune and have good medical ethics and quality, and treat the patients as if they were their family members. The conditions of every patient should be carefully observed and documented, only then can appropriate treatment plan be made based on the differences in the individuals and conditions. Thereby a doctor can fully discharge his duty to relieve the patients their sufferings and worries as early as possible.

《Lesson Six：Brief introduction of the therapeutic regimes of our hospital 》　　　>Lesson Four <　>Back<