I am ending this particular series of posts about conditions associated with vitiligo by focusing on Inflammatory Bowel Disease (IBD).
The two most common forms of IBD are #Crohn's Disease and #UlcerativeColitis. In both cases parts of the intestinal tract become sore and inflamed. Whereas Crohn's Disease can affect any part of the digestive system - from the mouth to the anus - Ulcerative Colitis affects the colon (large intestine) and the rectum. As with vitiligo, the causes of IBD are not fully understood. It is thought that some people are genetically predisposed to the condition and that others have an abnormal reaction to the bacteria in their intestine. One theory is that viral or bacterial infections, diet, stress, or environmental factors might act as a trigger to the onset of the disease. Sufferers tend to be susceptible to flare-ups alternating with periods of remission and symptoms include abdominal pain, bloating, diarrhoea, fatigue, mouth ulcers, loss of appetite and weight loss. Joints and eyes can also be affected. No definitive cure exists, although various treatments can lessen the symptoms.
In addition to the symptoms mentioned above, IBD sufferers often have other extraintestinal manifestations (diseases affecting parts of the body outside the intestinal tract) as well. These can be just as unpleasant and problematic as the IBD itself. Typically, these extraintestinal manifestations are autoimmune conditions affecting other organ systems, such as thyroid disease, diabetes, pancreatitis, psoriasis, vitiligo and others. This informative article on the subject, published in Frontiers in Physiology, states: "The skin is one of the most commonly affected organ systems in patients who suffer from IBD. The scientific literature suggests that a disturbance of the equilibrium between host defense and tolerance, and the subsequent over-activity of certain immune pathways are responsible for the cutaneous disorders seen so frequently in IBD patients."
The scientific papers that point to links between IBD and skin disorders make interesting reading and, from a layman’s point of view, the association does seem to make sense. It seems self-evident to me that a defective digestive tract will inevitably lead to nutritional deficiencies, which in turn, will cause all sorts of symptoms and, eventually, chronic conditions. It also seems logical to my mind – and forgive me for being simplistic - that if you suffer from inflammation of the skin on the inside (which is exactly what the surface of the digestive tract is) you are more likely to suffer from inflammation of the skin on the outside too.
In considering possible links between vitiligo and other diseases, I didn't want to leave out lupus, since the medical literature I've seen has sometimes pointed to an association between the two conditions - and also for the altogether less scientific reason that Michael Jackson, who famously suffered from vitiligo for a large portion of his life, was also rumoured to have lupus.
Before discussing whether or not there actually is any link between the two conditions it would, of course, be useful to know what lupus is.
Lupus is yet another autoimmune disease (one of around 80). Autoimmune diseases occur when the body's defence system produces antibodies that attack its own cells, resulting in inflammation and disease. There are two main types of lupus: discoid lupus erythematosus (DLE) – in which only the skin is involved - and systematic lupus erythematosus (SLE) – which can also affect the heart, lungs, kidneys, joints, and nervous system. Up to 10% of people with discoid lupus (lupus limited to the skin) eventually develop the systemic form of lupus.
SLE can cause various – often intermittent - symptoms in many different parts of the body: most commonly joint pains, skin rashes and extreme fatigue. Its severity can range from very mild to extremely serious, depending on which of the body’s organs are affected and it is 8 – 9 times more common in women than in men.
Higher instances of other autoimmune disorders among those with vitiligo, as compared to the general population, have been very widely reported - in particular, autoimmune thyroid disease, pernicious anaemia and Addison's disease and inflammatory bowel disease. But, whereas autoimmune thyroid disease is quite often associated with systemic lupus erythematosus, instances of SLE existing alongside vitiligo are not that common and cases of vitiligo coexisting with discoid lupus erythematosus (DLE) are even more rare.
So, it appears to be the case that, although vitiligo and lupus are both considered to be autoimmune diseases and although people with autoimmune diseases often suffer from more than one, the likelihood of having both lupus and vitiligo is relatively low.
For as long as I can remember I have had problems with my digestion. I routinely suffered from tummy aches and cramps as a child. I even had my totally healthy appendix removed for no good reason and was eventually diagnosed with the now seemingly ubiquitous Irritable Bowel Syndrome. Even though both ailments started in early childhood, it was a long time – and I mean decades – before I consciously connected the dots (no pun intended) between my white patches and my achy gut. But once I did make the connection it seemed as blindingly obvious as the areas of startlingly white skin that were spreading relentlessly across my face and body, leaving my self-esteem as fragmented as my complexion.
I now realise that I am not alone in suffering from both IBS symptoms and vitiligo. In fact, the link between so-called Leaky Gut Syndrome / Low Stomach Acid / Malabsorption and pigment loss is well documented and it seems that most vitiligo sufferers I speak to report some sort of digestive problem. However, not everyone with vitiligo has gastric symptoms. This could mean that they are not suffering from any digestive abnormalities or it could simply mean that they are unaware of such abnormalities.
I came across an example of this earlier this week when I received an interesting email from Jonathan C. who has followed my blog. He sent me the following information and kindly gave me permission to share it.
“A few months back, I was introduced to a new biomedical start-up in California that specializes in sequencing the human microbiome. I found this to be of particular interest since the few success stories I have read with regard to treating vitiligo centered around changes in diet; I too have benefited from the addition of a b-vitamin and folic acid supplement. With this in mind, I was curious to learn more about my gut flora and potential factors that may be playing a role with respect to malabsorption and vitamin intake. I received the results yesterday and it was interesting to note the discrepancies compared with normative levels. I have attached a snapshot of the results below.
Since providing the gut sample (3 months ago), I have started a new prebiotic + probiotic routine. I am also taking steps to ensure a more balanced diet. Moving forward, it will be interesting to see whether these changes positively influence my microbiota as it relates to vitiligo. The microbiome data is still in its infancy, but could prove useful moving forward. Thanks for your help and feel free to share the results. It would be interesting to see if fellow vitiligo patients share a gut profile similar to my own.”
Thanks for sharing this, Jonathan. It is fascinating. I hope you will let me know what effect the pre- and probiotics have :)
Moving on with this series about diseases that are sometimes associated with vitiligo, I’d like to turn the spotlight on diabetes. Both diabetes and vitiligo share a common theory of autoimmunity and, whilst the two conditions certainly don't always occur together, diabetes can bring about the onset of vitiligo.
For some reason, diabetes is probably one of the most widely publicised diseases around and yet most of us have only a sketchy knowledge (unless we have first-hand experience of course) of what it is, what causes it and how it is treated.
For starters, what is it?
Diabetes is a condition in which your body cannot make proper use of glucose. Glucose comes from digesting carbohydrate and it is also produced by the liver. If you have diabetes, the glucose builds up in the blood instead of being used as fuel. This happens either because the pancreas does not produce enough insulin – the hormone that unlocks the cells of the body allowing glucose to be used for energy - or because the insulin produced does not work properly (known as insulin resistance).
Next up, who gets it?
According to Diabetes UK, there are 3.2 million people diagnosed with diabetes in the UK and an estimated 630,000 people who have the condition, but don’t know it.
Most people are aware that there are two sorts of diabetes, Type 1 and Type 2, but may not be clear about the difference. Type 1 is when no insulin at all is produced and Type 2 is when too little is produced or it is not working properly. Type 1 usually develops during childhood (and is sometimes referred to as juvenile diabetes) whereas Type 2 (adult-onset diabetes) is generally related to obesity. As a person becomes more and more overweight they generally become increasingly resistant to insulin and consequently their blood sugar levels rise. Eventually, they can become so resistant to insulin that their sugars remain at high enough levels for them to develop diabetes. If this situation is not addressed the pancreas can stop making insulin altogether, resulting in a very similar condition to type 1 diabetes. This then becomes a life-long condition and is one that is becoming increasingly common in the developed world as the number of obese people is consistently on the rise.
So, how is diabetes treated? Type 1 - and also Type 2, if it goes untreated for long enough – requires life-long management, usually by means of insulin injections. But Type 2, if it is diagnosed soon enough, can be reversed by making the appropriate changes to diet and lifestyle, above all by losing excess weight. Alcohol consumption is one lifestyle issue that can impact diabetics: ADT Healthcare's article “The Ultimate Guide to Alcohol and Diabetes", written by Paul Clarke is a very useful source of guidance on the subject.
It appears, from the information that I have read on the subject, that vitiligo is more often associated with Type 1 diabetes. Evidently, patients with type 2 diabetes more often develop skin infections, whereas those with type 1 more often have autoimmune-related lesions, vitiligo being one example of this. Between 1% and 7% of all diabetic patients have vitiligo vs 0.2% to 1% of the general population. The mechanism behind this association is not at all clear but it has been suggested that it might be due to Polyglandular Autoimmune Syndrome (PAS), a rare immune condition in which at least two endocrine gland insufficiencies based on autoimmune mechanisms exist side by side. This syndrome develops mainly in the patient’s 30’s or 40’s and is characterised by adrenal failure, autoimmune thyroid disease, or type 1 diabetes. If, like me, you suffer from digestive problems, it is worth noting that Immunogastritis (or Autoimmune Metaplastic Atrophic Gastritis) is another of the conditions that sometimes features in this syndrome.
All this information is very interesting but what does it mean for someone with vitiligo? Well, hopefully, if you have diabetes and manage it properly, you may be able to lessen the chances of developing vitiligo (there is no guarantee of this but it does seem to make sense that if you can keep your diabetes well under control, all related conditions will also improve). But, more crucially, for anyone who develops vitiligo later in life (as opposed to people like myself who have it from childhood) the advice is to get tested for diabetes without delay. Before you get too anxious, the chances are that you do not have it, but if it turns out that you do, you will at least be able to start getting the diabetes treatment you need so you can minimise, or completely avoid, some of the other health problems that are the inevitable result of ignoring the condition long-term.
Vitiligo has been associated with numerous endocrine disorders (that is, disorders relating to the hormones and the glands that make and secrete them into the bloodstream.) One of the main associations is with thyroid abnormalities. This association is quite well established. But the exact reason for it is still not clear and the whole subject can be confusing, especially to those of us with no medical training. Hopefully, this blog post will help to put the subject into context.
First of all, what exactly is the thyroid? It is a small gland at the base of your neck, just below your Adam's apple. This gland produces two main hormones known as T3 and T4. These hormones are carried in your blood to every part of your body and are responsible for controlling the rate of many of your body’s internal functions. Examples of these are how fast you burn calories and how fast your heart beats. All of these activities are known collectively as your metabolism. If your thyroid is working correctly it will produce the right amounts of hormones needed to keep your body’s metabolism working at a rate that is neither too fast nor too slow.
So, what can go wrong with your thyroid, and why? Autoimmunity is a feature of most, though not all, thyroid disease and it is these autoimmune thyroid conditions that are often associated with vitiligo.
At one end of the scale, the thyroid can become overactive – a condition known as hyperthyroidism. This is when the thyroid makes more thyroid hormones than the body needs. The most common cause of hyperthyroidism is Graves' disease, an autoimmune disorder in which the body's own defence system overstimulates the thyroid, causing the thyroid gland to swell and leading to symptoms like increased heartbeat, muscle weakness, disturbed sleep, weight loss, loose stools and irritability. Other symptoms can include bulging of the eyes and problems affecting the circulation, nervous system and the skin. Genetics account for about 80% of the risk of developing Graves’ disease. It is 7 to 8 times more common in women than men, sometimes developing after childbirth, and affects up to 2% of the female population.
At the other end of the scale the thyroid can become underactive – known as hypothyroidism. This is when your thyroid does not make enough thyroid hormones. The most common cause of hypothyroidism is Hashimoto's disease, yet another autoimmune disease, in which the immune system mistakenly attacks the thyroid gland causing it to produce insufficient thyroid hormones to keep your metabolism working properly. Symptoms of an underactive thyroid can include fatigue and sluggishness, muscle weakness, depression, weight gain, constipation, elevated cholesterol, a hoarse voice and a puffy face. The main risk factor for developing this thyroid disorder is having a pre-existing autoimmune condition.
One of the questions this poses in my mind is “which comes first – the chicken or the egg?” Does having an autoimmune thyroid disease make you more likely to develop vitiligo, or does having vitiligo make you more likely to have thyroid disease? Personally, I don't think it is necessarily the case that either condition causes the other. I wonder if both thyroid disease and vitiligo (and, for that matter, all the other autoimmune conditions that seem to be so prevalent nowadays) might be symptomatic of other, more fundamental health issues. Maybe the reason that autoimmune disorders often occur together is because the body is not getting the quality or quantity of fuel it requires to stay healthy and so it quite simply starts to break down.
I realise that it may be simplistic to lay the blame for all mankind's diseases at the door of poor nutrition. But, having experienced first-hand how compensating for my digestive malabsorption with nutritional supplements has reversed my vitiligo (also considered by most doctors to be an autoimmune disease) it now seems self-evident to me that the first, and most important, line of defence we have against illness is our gut. When the digestive system is working as it should all the other processes of the human body tend to follow suit because they are receiving the right fuel for the job. But if a person's diet is lacking, or their digestive tract is malfunctioning in some way (as mine was), the rest of the body either becomes starved - because essential nutrients are not being properly absorbed - and/or poisoned by substances that are making their way into the bloodstream instead of being eliminated. It would be hardly surprising in these circumstances for the natural consequence of this to be a body that gradually stops functioning as it should and even starts attacks its own cells.
My name is Caroline.