Genital vitiligo: how to treat the intimate areas?

The vitiligo is a chronic autoimmune disease characterised by the progressive loss of melanocytes, the cells responsible for skin pigmentation. This loss leads to the appearance of depigmented white patches on various areas of the body, which can vary in size, shape and location. Among the possible forms, genital vitiligo of the intimate areas, or genital vitiligo, is relatively common but often underreported due to the embarrassment it causes. It affects the genital, perineal or pubic regions, sometimes in isolation, sometimes alongside other body areas. Although it is neither painful nor contagious, this form of vitiligo can have a significant psychological impact, particularly on self-esteem and intimate life, owing to the visibility and symbolism of these areas.

Vitiligo of the intimate areas demands specialised care, as the skin in this region, being very sensitive, does not always tolerate the same treatments as other forms of vitiligo.

Although only a few studies have been conducted on the topic, some techniques appear to be both effective and risk-free in the treatment of genital vitiligo.

• The transplantation of melanocytic and keratinocytic cells in conjunction with prednisolone.

  The transplantation of melanocytes and keratinocytes involves harvesting pigment cells (melanocytes) and epidermal cells (keratinocytes) from a healthy area of the patient’s skin, then culturing them in the laboratory before reimplanting them onto the depigmented areas. This procedure aims to restore melanin production and repigment the skin in a gradual and natural manner. It is a delicate technique generally reserved for stable forms of vitiligo and can be effective in cases of genital vitiligo.

  There is a study published in the Dermatologic Surgery indicating a treatment of the genital region in three patients with positive outcomes. Initially, a skin biopsy sample equivalent in size to the recipient site was harvested from the upper lateral epidermis of the thigh. A transplantation of melanocyte and keratinocyte cells was then performed, but no improvement was reported. The scientists then administered an oral prednisolone course for two weeks before performing a further transplantation. Prednisolone is part of the corticosteroid family, used for its anti-inflammatory properties. After the procedure, the patients achieved a near-complete repigmentation.

  Prednisolone in combination with melanocyte and keratinocyte cell transplantation appears to be effective in the treatment of genital vitiligo, although it remains unclear whether this efficacy is attributable to the transplantation procedure, to the drug itself or to their combination. The researchers nevertheless recommend exercising caution when using it concurrently with transplantation, pending confirmation of its usefulness in a controlled clinical trial involving a larger number of patients.

• Pimecrolimus.

  Immunomodulatory agents, such as pimecrolimus, can be used in the treatment of vitiligo, although topical corticosteroids often prove more effective. One study highlighted the efficacy of this approach in two children, one with vitiligo of the eyelids and eyebrows and the other with genital vitiligo. Since the second patient’s family did not consent to topical corticosteroid therapy, he applied a 1% pimecrolimus cream twice daily for three months. Following this, the patient showed a near-complete remission of all his symptoms. However, this remains an isolated case.

• Micrografting.

  Some researchers assert that micro-grafting is unsuitable for the non-keratinised mucosa of the glans penis and can lead to a highly noticeable mismatch in texture and colour. By contrast, transplantation involves applying melanocyte and keratinocyte cells isolated by biopsy from healthy skin onto depigmented areas, offering the advantage of a uniform result, whereas micro-grafting entails harvesting small fragments of pigmented skin and placing them directly onto the depigmented zones.

  However, a study published in the Journal of Cutaneous Medicine and Surgery reports significant repigmentation results on the intimate areas of four patients with genital vitiligo. Grafts were harvested from discreet body sites such as the buttocks, the gluteal fold, the post-auricular region and the lateral thigh. Within one week, the grafted area had healed normally, initially showing dark spots that faded within five days. A moisturising cream was applied to the healed skin in the weeks following surgery. The donor site, covered with an unaltered dressing, also healed in 10 to 14 days, aided by the use of a moisturiser.

  However, owing to the limited number of graft recipients and the small number of studies conducted on the topic, it is impossible to draw firm conclusions about the significant efficacy of micro-grafting in genital vitiligo.

  The results of the various studies should be interpreted with caution, as the number of treated patients remains limited. It is therefore essential to undertake further research and trials to enhance our understanding of the most suitable treatments for genital vitiligo.

• ASAAD M. & al. Genital vitiligo treated by autologous, noncultured melanocyte‐keratinocyte cell transplantation. Dermatologic Surgery (2005).

• KATSAMBAS A. & al. Imiquimod-induced vitiligo in a patient with genital warts. Journal of the European Academy of Dermatology and Venereology (2006).

• ARAGAO CRAVEIRO LEITE. & al. Two therapeutic challenges: Periocular and genital vitiligo in children successfully treated with pimecrolimus cream. Pharmacology and Therapeutics (2007).

• DEVENDRA S. Microskin grafting for stable vitiligo of the penis and vulva: Near total uniform pigmentation. Journal of Cutaneous Medicine and Surgery (2015).

• ALISSA A. & al. Vitiligo-like depigmentation following treatment with imiquimod 5% cream for condylomata acuminata. Case reports in Dermatology (2021)

• PASSERON T. & al. Male genital vitiligo. Annales de Dermatologie et de Vénéréologie (2022).