Today we know that vitiligo is an autoimmune disease. The body's own immune system attacks the melanocytes - the pigment cells, causing them to lose their function.

At the same time, there is almost always increased oxidative stress in the skin: an accumulation of free radicals, such as hydrogen peroxide, which damage the cells. The melanocytes lose their “arms”, the projections that otherwise spread the pigment evenly to the skin’s keratinocytes.

Previously, it was believed that the white spots were completely devoid of melanocytes, but more recent research has shown that the melanocytes are still there - they have just lost their ability to produce pigment.

Patients with vitiligo, especially vitiligo vulgaris, often have antibodies against melanocyte proteins and at the same time elevated levels of hydrogen peroxide. The question is which comes first – the autoimmune attack or the oxidative stress. It is probably a combination of both.

Diagnosing vitiligo is often easy. In fair-skinned patients, a so-called Wood's lamp may be needed to confirm the diagnosis. Under the lamp, the affected areas fluoresce white.

In the 1990s, Professor Karin Schallreuter and her colleagues discovered that the skin of people with vitiligo contains biopterins – substances that produce a characteristic fluorescence when illuminated with UV light. The same substances are actually responsible for the fluorescent color of some butterflies. The discovery was published in Science in 1994 and became one of the milestones that changed the understanding of vitiligo.

Many patients can identify periods when the disease flares up - a separation, a stressful period at work or the death of a family member. Stress hormones such as cortisol affect both the immune system and the balance between oxidative stress and antioxidants. Sex hormones can also trigger vitiligo, such as pregnancy, breastfeeding or the pill.

Vitiligo can also be triggered by damage to the skin - a phenomenon called the Köbner phenomenon. Tear marks, pressure from tight clothing, tattoos or a cut can cause new spots to appear in that area.

When I met Professor Schallreuter, I got to follow her work. She and her husband showed that vitiligo is linked to elevated levels of hydrogen peroxide in the skin and developed a treatment with pseudocatalase (PCKUS) – a cream that imitates the body's own catalase enzyme – in combination with controlled UVB light therapy.

I worked with her, both as a researcher and a patient. For several years, I worked on clinical and experimental studies, sometimes conducted at the Dead Sea – a place with unique UV radiation where the relationship between UVA and UVB favors pigment formation. The days began with swimming in the mineral-rich water and continued with blood cell analyses in the laboratory.

The results were sometimes almost miraculous. For me, over 90 percent of the pigment came back on my face. It was slower on my hands and feet, and those areas are still the most difficult to treat.

Research has not stopped. Since 2022 in the US and 2023 in the EU, there has been the first approved treatment for vitiligo: ruxolitinib cream (Opzelura®), a JAK inhibitor that suppresses the immune system locally in the skin and can restore pigment. Unfortunately, it is not covered by high-cost coverage in Sweden and is therefore very expensive if you still want to choose this path.

Other treatments used are:

• Pseudocatalase (PCKUS) - especially effective on the face.
• Tacrolimus (Protopic®) - used off-label on sensitive areas.
• UVB light therapy - can stimulate pigment formation.

For the first time, we can talk about standardized treatment options, although hands and feet remain challenging.

Since the first edition of Hudbibeln, I have had contact with many people with vitiligo and also parents of children with vitiligo. They have often been told by healthcare professionals that “there is nothing that can be done”. I usually invite them to talk, both to tell them about the treatments that actually exist and to highlight the positive aspects.

Today, there are even Barbie dolls and Lego figures with vitiligo – small but important steps towards normalization. And at home, our dog Maja, an Aussie, runs around with symmetrical patches on her paws, neck and stomach that resemble vitiligo. In animals, we see patches as something natural – why should it be different in humans?

• Avoid swimming in chlorinated pools.
• Avoid skin care products with active ingredients that can affect pigmentation: vitamin C, retinol, retinal and other retinoids, azelaic acid, acids, kojic acid, arbutin, epigallocatechin gallate (EGCG from green tea) and other ingredients that even out skin tone. Therefore, avoid large amounts of green tea – EGCG has been shown to trigger vitiligo.
• Avoid smoking – smoking is linked to slower repigmentation, especially around the mouth.

The Dead Sea is sandwiched between Israel, the West Bank and Jordan and is an interesting place for several types of skin research – not least on psoriasis and vitiligo. Here we are four hundred meters below sea level, which affects how solar radiation falls into the area.

At the Dead Sea, the biggest difference is the relationship between UVA and UVB light: Here, more UVB than UVA falls in, and also in a special wavelength, which positively triggers the melanocytes and keratinocytes in both vitiligo and psoriasis.

When Professor Karin Schallreuter and her husband Professor John Wood decided to find out the causes of the white spots on the skin in the 1980s, they soon discovered that they were due to unusually high levels of oxidative stress. Under a microscope, they could see that the melanocytes had lost their arms. As you probably remember, it is the melanocytes that produce pigment in the skin and the even distribution is due to the cells' arms.

Inspired by the environment around the Dead Sea, they developed a treatment and annually invited several hundred people from all over the world. For several years, I participated both as a researcher and as a patient, which turned out to be incredibly interesting. It was a fantastic time. The days began and ended with swimming in the Dead Sea, and in between, I isolated blood cells, measured pH, and analyzed the oxidative stress in the skin of several hundred people.

The treatment consisted of 15 minutes of bathing (or rather floating) twice daily and a cream with properties from the mineral-rich Dead Sea water that imitates the skin's own antioxidant catalase enzyme, as well as light therapy with UVB radiation that stimulates the melanocyte to form pigment.

The cream was named pseudocatalase and Karin Schallreuter now treats patients from all over the world with the cream pseudocatalase (pc-kus) at her clinic in Greifswald, Germany. For the face, the treatment was amazing, while the results for the hands and feet were a little slower and they are still difficult to treat today.

But despite uneven results, Schallreuter's treatment is the only one that currently actively affects oxidative stress in the skin. I personally got back ninety percent of the lost pigment on my face - and on my legs.

Since I wrote Hudbibeln in 2019, many patients with vitiligo from both Sweden and Norway have contacted me. The last time I went to Jordan together with Schallreuter, her team and about 200 patients with vitiligo was in the summer of 2019. When the pandemic ended yesterday, Karin unfortunately had to close the clinic, because it was so difficult for people to travel. But since 2025, her work lives on.

One of her former students and also a close friend of mine, Dr. Katharina Rübsam , has taken over and is now running a clinic in Munich focusing on vitiligo. She has continued to work with the treatment developed by Schallreuter - the combination of pseudocatalase (PCKUS) and controlled UVB therapy - and receives patients from all over the world.

One of her former students and also a close friend of mine, Dr. Katharina Rübsam , has taken over and now runs a clinic in Munich focusing on vitiligo. She has continued to work with the treatment developed by Schallreuter – the combination of pseudocatalase (PCKUS) and controlled UVB therapy – and receives patients from all over the world.

For those who want to get in touch with Dr. Rübsam, she can be found at:

Dr. Katharina Rübsam, Dermatology in der Burgstrasse, Burgstrasse 7, 80331 Munich.