Genital vitiligo: how should intimate areas be treated?

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

Vitiligo of the intimate areas requires specialized care, because the skin in this highly sensitive region does not always tolerate the same treatments as other forms of vitiligo.

Although few studies have investigated this topic, some techniques appear to be effective and risk-free for treating genital vitiligo.

• Transplantation of melanocytic and keratinocytic cells in conjunction with prednisolone.

  The transplantation of melanocytic and keratinocytic cells 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 to gradually and naturally repigment the skin. 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 genital treatment in three patients and showing positive results. First, a skin biopsy sample the size of the recipient area 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 treatment for two weeks before proceeding with a new transplantation. Prednisolone belongs to the corticosteroid family and is used for its anti-inflammatory properties. After the operation, the patients achieved a nearly complete repigmentation.

  Prednisolone combined with melanocyte and keratinocyte cell transplantation appears to be effective in the treatment of genital vitiligo, although it is not possible to determine whether this efficacy is attributable to the transplantation, the drug itself, or their combination. The researchers nevertheless recommend exercising caution when using it in conjunction with transplantation until a controlled clinical trial with a larger patient cohort confirms its utility.

• Pimecrolimus.

  Immunomodulatory drugs, such as pimecrolimus, can be used in the treatment of vitiligo, although topical corticosteroids often prove more effective. A study demonstrated the efficacy of this approach in two pediatric patients, one with eyelid and eyebrow vitiligo and the other with genital vitiligo. Since the second patient’s family did not accept topical corticosteroid therapy, the patient applied a 1% pimecrolimus cream twice daily for three months. Following this, the patient exhibited a near-complete remission of all symptoms. However, this remains an isolated case.

• Micrografting.

  Some researchers claim that micrografting is not suitable for the non-keratinized mucosa of the penile glans and may result in a highly noticeable discrepancy in texture and color. In contrast to transplantation—which involves applying melanocytic and keratinocytic cells isolated by biopsy from healthy skin onto the depigmented area and has the advantage of producing a uniform outcome—micrografting consists of harvesting small fragments of pigmented skin and applying them directly to the depigmented regions.

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

  However, due to the limited number of grafted patients and the small number of studies conducted on the subject, it is impossible to conclude that micrografting is significantly effective in cases of 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 conduct further research and clinical trials to deepen our understanding of the most appropriate 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).