Vitiligo is a common pigmentary dermatosis characterized by localized or generalized white depigmented skin macules or patches. The disease has a world-wide occurrence. India has the highest incidence of vitiligo. In our country 12 million people suffering from the disease. The disease spares no races or ethnic groups, with equal incidence in both sexes. In recent years the incidence of vitiligo is gradually increasing, causing generalized concerns among the public. What are the reasons for the gradual increase in the incidence of vitiligo? How to prevent it? Can it be cured or can it relapse after recovery? Does heredity play a role in the disease? These are questions that cause great concern. Here we introduce our understanding of the disease based on our clinical work for the reference of our readers.

1. Causes of the disease
Currently the etiology of vitiligo is still unknown and the pathogenesis is quite complicated. Diverse theories that have been proposed are under investigation. There are two types of factor that are important as possible causes:
(1) Food and environmental contamination
In the recent years there is a tendency of increase in the incidence of many diseases such as leukemia, malignant tumors, urticaria and asthma, etc. These are related to environmental pollution. According to reports, because of the rapid increase in the world population, human production and living activities have caused increasingly serious pollution to the environment. The use of chemicals in agricultural production and the release of industrial pollutants, automobile exhaust fumes(tail gas), house internal decoration, all these cause pollution, not only to the immediate surroundings of human inhabitat but to the entire globe. Researchers have found benzene hexachloride, DDT and such poisonous substances as arsenic and mercury inside the bodies of polar bears and dolphins of the Antarctic. These findings indicated that environmental pollution threatens the survival of human and other animals. Environmental pollution is a global problem, and the solution lies in the institution of measures and regulations for environmental protection and improvement by various governments and international organizations. It is a long-term project requiring joint efforts. Personal protection measures are to strengthen vigilance to avoid or decrease the harmful effects of the poisonous substances when possible.
Environmental pollution will inevitably cause various degrees of food contamination. According to our statistics in 1995 childhood vitiligo was 21%, but the ratio increased to 36% by the year 2000. Children in the developmental stage are more susceptible to the harmful effects of poisonous substances than adults. Their tissue and organs are more readily damaged and are the first victims of food contamination. Therefore much attention should be paid to the dietary hygiene and nutrition of the children. Some parents dote on their children, and without strict requirement and correct guidance, the children are unable to form good dietary habits. Our statistics from July to December, 2000, showed that 63% of the pediatric vitiligo patients indulge in snack foods and have dietary bias. Snack foods and drinks not up the health standards may contain harmful chemicals and heavy metal salts, and their intake may cause direct damage to the child's body, interfere with a series of physiological functions and compromise the child's health as well as growth and development. Besides, snack foods and drinks are sweet, and according to Chinese medicine, long-term intake of sweet foods can harm the spleen and the stomach, which is one of the causes of dietary bias and anorexia in children. Therefore the parents' duty is not only to take care of the children but also to foster healthy dietary habit in their children with strict requirements. Stick to 3 meals a day (more meals as necessary according to the child's age), and allow less snack foods. Observe formal meals. The parents should educate the children to foster healthy living habits, and work out a balanced diet for their children. Some children like to eat sweet foods, meat, but less or no vegetables. This is a behavior of dietary bias, and this in the long run can cause nutritional imbalance within the body. Such imbalance will affect with growth and development of the children, or even lead to disease. It should be corrected.
(2) Neurological and psychological factors
The fast pace of modern life is too heavy a psychological burden for some people. The business men are anxious when business is not doing well; workers are worrying about possible unemployment; office workers worry too much about inter-personal relations and about promotion. Some, although broad-minded and psychologically stable, will be deep in distress when struck by the severe blow of a sudden event which exceed the psychological limits of the sufferer. Long-term psychological pressure and tension will cause disease by endocrine imbalance and immune dysfunction. Furthermore, long-term work overload, irregular night-life, and unhealthy hobbies, causing over-fatigue of the body, are also responsible for the disease.
2. Prevention
(1) Fruits and vegetables should be thoroughly washed before consumption, and if time allows, they should be soaked in water for 15 to 30 minutes before rinse and use. Fruits should be peeled if possible.
(2) Morning or other exercises should be carried out in places with fresh air.
(3) Good occupational protection, avoid direct contact with hazardous substances such as chemical materials, paints, and heavy metal salts.
(4) Be aware of the hazards of house internal decoration. The decorating materials may contain series of poisonous substances such as formaldehyde, ammonia, benzene. Marble used for flooring can release radiation. These can cause injury to many organ-systems of the human body. A newly decorated house should be ventilated for 3 months before moving in. The house should also be ventilated often after residing. If possible the house should be contamination-monitored.
(5) Strengthen self-cultivation, keep optimistic spirit, relieve psychological pressure, maintain mental health.

3. Treatment
Many patients have inquired whether there are curative therapies or medicines for vitiligo, and what the cure rate is.
Currently a cure has not been found, and there is no single specific drug that is a cure. According to patients who visited me from the United States, Japan, France, Korea, and Russia, there is no effective treatment in these countries. On the contrary in China some patients can be cured by traditional Chinese medicine or by therapies combining Chinese and western medicines. Many vitiligo clinics and hospitals have achieved relatively good therapeutic effects after years of clinical trials, each with its own features.
We believe that the cure rate for vitiligo is low if only one single agent is used. Better results can be achieved by a combination of different modalities and agents after diagnosis and treatment based on the overall analysis of symptoms and signs. It is very important that prompt and appropriate treatment be given to patients with early vitiligo since the cure rate can be as high as 95%, whereas a rate of less than 30% can be expected for late cases. Therefore the timely treatment is crucial for a cure, a missing opportunity may lead to life-long disease.
The doctor's sense of responsibility is also an important factor influencing the effectiveness of therapy. The doctor should adopt a careful and rigorous work attitude, conscientious in his care of the patients. The doctor should also be hard working, grasping every aspect of the patient's condition, from dietary habit and psychological status to family and working environment. The patients' disease conditions should also be carefully observed. Satisfactory treatment results can only be achieved by the regimens based on the analysis of these observations and subsequently adjusted according the change of the patient's conditions.
One final point is that the doctor should not overstate the effectiveness of his therapy solely for the purpose of getting more fees, thus increasing the patients' financial burdens. Just like one patient said in his letter to me: "every time I was cheated I felt like a handful of salt dropping on my bleeding heart". This letter is a warning to me and for the reference of other doctors.

4. Avoidance of certain foods and sun exposure during treatment?
During treatment children should avoid snack foods and drinks, and adults should avoid drinking and smoking. It is not necessary to avoid fish, shrimp, beef, mutton, or fruits and vegetables rich in vitamin C. Fish, shrimp, beef, mutton, or fruits and vegetables are good sources of nutrients for the growth and development of children. Vitiligo runs a long course and long-term avoidance of these food will lead to nutritional deficiency which is not beneficial to patients' recovery. We have compared 200 patients and the results showed that patients without food avoidance faired better than those with food avoidance. For the avoidance of sun exposure and drinking and smoking, please see appendix 2 for detail.

5. Genetic probability, influence on the next generation, relapse after recovery
Our statistics from July to December, 2000 showed that 95 of our patients have positive family history. Furthermore, for patients with positive history it does not mean that the disease in them is inheritable. Patients with family history may have to genetic factors, but many other factors may be operative for the disease. The therapeutic effects for patients with or without genetic factors are the same. After prompt and correct treatment these patients can be cured without recurrence as well. The cured vitiligo patients will not unduly influence their next generation.
Many patients and their families are worried about recurrence after recovery. According to our observation the recurrence rate is about 0.5% after cure, and cure can be achieved even after recurrence.

Summary

1. Main causes of the disease
(1) Environmental and food pollution and contamination and nutritional deficiency are the main causes for childhood vitiligo.
(2) Apart from environmental and food pollution and contamination, long-term mental stress and psychological tension are also important in the pathogenesis of vitiligo in adults.
2. Prevention and treatment
(1) It is important to avoid intake of contaminated food, correct dietary bias, maintain proper meals, formulate a balanced diet, supply complete nutrition needs for children.
(2) Decrease the aspiration of poisonous gases, do exercises in places with fresh air, be aware of occupational protection.
(3) Be aware of contamination of the recently decorated houses
(4) The most important factor in adult prevention of vitiligo is to relieve worries and anxiety, and to maintain an optimistic spirit.
① Be optimistic and increase the capability of psychological adaptation
② Do not think about things that are unrealistic, do not do things that are impossible
(5) The most important factor in the treatment of vitiligo is early treatment
① The best time for the treatment is early after the onset of the disease
② After the onset of the disease steroids should be avoided in the treatment as they may cause "rebound phenomenon" (see appendix 2)
③ ultraviolet light and sun exposure should not be used in the treatment. Normal diet without avoidance to certain foods.