Last Updated on 6th May 2020 by Caroline Haye
Perifollicular, diffuse and marginal repigmentation patterns
There is a fair amount of literature on the causes, treatments and possible cures of vitiligo. (See my post Vitiligo Science Is Progressing for a round-up.) The internet is awash with articles, research papers, forums, support groups and blogs exploring these topics. There is, I am glad to say, even a steadily growing number of sites containing examples of success stories. (Not just my own story). But I have found very few that feature vitiligo recovery from the point of view of repigmentation patterns… In other words the ways in which pigment actually returns to previously depigmented skin. So I want to share 3 examples of vitiligo recovery based on my own personal experience.
Researchers into pigmentary disorders – of which vitiligo is the most common – talk about the “melanocyte reservoir“. Melanocytes are the cells that produce the skin pigment melanin. And it is the loss of active melanocytes that explains why people with vitiligo develop white patches, or lesions, on their skin. (So, of course, they do not gain white patches at all. They simply lose the pigment in patches which means these areas look white by contrast with the surrounding normal skin colour.) The melanocyte reservoir is the term which describes the available sources of these pigment-producing cells in the body. It seems that there are (at least) three different sources of available melanocytes… A fact which might explain the three distinct effects I observed as my skin gradually regained its former colour.
I call these repigmentation patterns “The three “F”s
When my skin colour unexpectedly returned, after nearly 5 decades of steady depigmentation, I was ecstatic. And fascinated too to observe the process up close and personal on a day-to-day basis. I had always hoped and prayed that my vitiligo would disappear. But, at that time,I had never heard of anyone actually recovering their skin pigment and I had more or less come to terms with the idea that I would never respond to any kind of treatment, let alone achieve almost total recovery. So it seemed at first like a wonderful and mysterious miracle. And I really didn’t care how my normal skin colour returned, just so long as it kept coming back.
Then, as time went by I began to be more aware of, and intrigued by, the repigmentation process itself. (See my Pictures Of My Vitiligo page for examples.) What I noticed was that this process occurred differently in different places on my body. And it happened in three distinct ways. I have always thought of these three types of repigmentation as “my three Fs”, even though one is a “ph”!.
New pigment either Freckles, Fills or “Phases” in
I have never been in any doubt that my recovery happened as a direct result of nutritional supplementation and UV exposure. But I never understood much about the exact mechanism involved in pure white skin changing back to its original colour. And I was not aware until much later that the three types of repigmentation I experienced actually had medical names.
Freckles (Perifollicular Repigmentation)
Perifollicular repigmentation is one type. (The name refers to a process involving the region around the hair follicle and relates to the freckling phenomenon I shall describe below.) This occurs when melanocytes located in the outer root sheaths of pigmented hairs are stimulated into dividing and migrating to the surface of the skin. In particular, it is the melanocyte tissue stem cells located in the niche at the bulge region of the hair follicle that provide pigment for this process.
This was the first and most obvious kind of repigmentation that I experienced. (It started appearing approximately 6 weeks after starting a daily protocol of nutritional supplementation and sun exposure). The freckles first began emerging on the bony part of my chest. And, shortly after this, they also materialised on my shoulders, forearms, hands, shins and feet.
The entire area from my collar bone downwards had gradually lost all of its colour years before. And I often used a self tanning product to make it look less blindingly white. So, when the first freckles began to appear I actually tried washing them away. Because I thought they must be little flecks of self-tan that had not yet worn off. It wasn’t until I looked closely that I realised these marks were little flecks of skin pigment and that there were quite a lot of them starting to emerge all at once.
At first, there was what I would call a fairly good scattering of these light freckles across the whole expanse of otherwise white skin… A bit like a photographic negative of stars in the night sky. But, as the weeks went by, more and more freckles emerged and crowded in around the others. And this continued until there was more pigmented skin than white skin.
A gradual process
The whole process was gradual and went through several phases. Early on, the freckles were light and distinct from each other. After that, they became denser in colour as they started to overlap and merge with each other. And finally, the overall colour gradually began to match my normal skin. To put it very simply, this kind of repigmentation started out as freckles, then became mottled, before finally evening out into a normal skin colour.
The idea that freckled repigmentation starts in the hair follicle seems a little puzzling in the case of my chest. Because I definitely do not have a hairy chest! In fact I would go so far as to say that there is not one single, visible hair anywhere on this part of my body. But I am guessing there must still be follicles there somewhere for perifollicular repigmentation to have occurred. It is much easier to understand how melanocytes migrated from the follicles on my forearms. (These had previously lost all of their colour, except for one small island on my left arm) since there are plenty of fine hairs there, as the picture above clearly shows.
Filling in (Marginal Repigmentation)
Marginal (or border spreading) is a second type of repigmentation. The term that describes the kind of repigmentation that fills in from the outer margins of vitiligo lesions. It uses the active melanocytes at these outer edges to repopulate the depigmented areas. And this results in a gradual shrinking of the white patch.
I noticed a lot fewer examples of this kind of repigmentation during my recovery, as compared to the perifollicular type. But, then again, I had lost approximately 80% of my pigment. So most of my vitiligo consisted of entire portions of my skin that were virtually totally white, rather than isolated patches with clear borders. However, I did observe some marginal repigmentation in a spot about the size of a pound coin on my neck and on both shins, once they reached the stage where they had repigmented about 90%, leaving just a narrow strip of vitiligo which then gradually closed in on itself until it was almost completely normal again.
Phasing (Diffuse Repigmentation)
Diffuse is a third type of repigmentation. This term describes a process that stimulates active melanocytes still present in depigmented areas of skin. Rather than producing freckles or causing lesions to shrink from the outer edges inwards, diffuse repigmentation looks more like either a mottled scattering or else a fairly even “phasing in” of colour.
In my case, this effect was so gradual and so evenly pigmented as it returned that I almost didn’t realise it was happening. I can clearly remember two occasions in particular when it really hit me that my normal skin colour had actually returned to parts of my body that had previously been completely white. The first was when I looked in the mirror one day and realised my ears were a normal, tan, flesh colour. (Instead of snowy white, as they had been for years.)
And the other occasion was the first time I noticed that the insides of my arms were back to their normal, smooth light tan colour. The pigment had returned in such an smooth way, without any freckles, that it was as if a painter had applied a wash of colour with a brush. Only a very faint marble effect was visible which reminded me of a baby’s skin. This occurred all over my legs. (Except for the aforementioned shins and some freckling on the knees.) It also occurred on the undersides of both arms and armpits, my spine, waist and abdomen.
Can all three types of vitiligo recovery happen at once? (Combined Repigmentation)
Yes – clinical research confirms that any combination of these three types of repigmentation can occur together. And, when it does, it is known (not surprisingly) as combined repigmentation. (Some people see it as a fourth category in its own right. So if I wanted to continue with my “F”s I would have to call it Fusion Repigmentation!)
From my own point of view, this probably best describes the kind of new pigment that developed on my hands and feet. This is where I had a combination of freckles in those areas with more hair follicles and diffuse repigmentation in the hairless parts.
Reading up on this subject, it appears that there is even a fifth type of repigmentation called Medium Spotted Repigmentation. I did not experience this myself and I gather it is quite rare. All of which goes to show that the world of skin colour really is a weird and wonderful one.
I never believed that the odd variety of repigmentation effects I experienced could possibly be unique to me. But, having said that, I had never heard anyone else talk about them before. And it is only recently that I have come across a handful of authority websites that deal with the subject. In trawling through these, I have realised that not only do my three (or four?) “F”s have other, more scientific names but that they are the subject of ongoing research.
Repigmentation therapies
What is not clear from the research I have read is whether or not there is any obvious correlation between the different repigmentation patterns and the various vitiligo treatment methods used. This question occurred to me recently when I checked the application instructions for Vitix Repigmentation Gel. These advise applying the product to the vitiligo lesion and surrounding border. (This is in order to stimulate marginal repigmentation.) And my impression of having used it is that it does produce this kind of vitiligo-shrinking effect, rather than freckling or diffuse repigmentation. Sunlight, on the other hand, resulted in freckles and gradual, diffuse results in my case. And narrowband UVB phototherapy produced the most, and darkest freckling of all.
However, most researchers seem to agree that the key factor in any successful repigmentation of vitiligo is not the method of treatment so much as the availability of sufficient viable melanocytes. So the fact that an individual like myself, using one particular type of therapy, can regain their pigment in differing patterns on different parts of their skin suggests that the location and number of active melanocytes available varies from one part of the body to another.
The whole subject is certainly a fascinating one. So I hope you have enjoyed reading about it as much as I enjoyed delving into it. But, more importantly, let’s hope that a greater understanding of the various types of repigmentation will prove to be a crucial key to developing more effective and widely accessible vitiligo treatments in the near future.
