Brief Answer: Kindly provide details and pictures Detailed Answer: Hello XXXXXXX Welcome and thanks for posting your query to the forum. I can understand your concern for your mother’s problem of white spots. Before I can guide you best regarding all of your queries I would like to know certain important points regarding your mother’s problem. Kindly elaborate certain important points: -Since how long the problem of white spots is present in your mother. Do anybody else in your family have white spots. -Was the treatment you have written, provided by a dermatologist. - What was the diagnosis given by the dermatologist or the treating doctor. Was it - vitiligo only or as guttate hypomelanosis or as Post inflammatory hyperpigmentation(PIH). In view to help you best I suggest you to upload few good resolution pictures of affected area. For that you have a feature to upload images by yourself at the right side of the query page. Or else, you can send as an attachment to YYYY@YYYY with the subject as "Attn: Dr. Sanjay Kumar Kanodia. Hope to hear soon from your side. Wish you good health. Regards. Dr Sanjay Kumar Kanodia MD (Dermatology & STD)

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Brief Answer: Use the medication for at least minimum of 3 month Detailed Answer: Hello XXXXXXX Thanks a lot for sending the important details. The pictures will help us in deciding the exact nature and extent of problem and therefore the part of treatment. You please take time to send these pictures. Now before I directly provide suggestions to your queries, let me elaborate some of the points regarding your mothers’ problem and therefore in your queries- Our skin is a multi-layered structure divided into epidermis and dermis. This epidermis is again a superficial multilayered structure. The deepest of the layer of epidermis contains specific cells which are known as melanocytes. These melanocytes are actually the color producing cells which have the tendency to produce color according to its own genetical tendency. Our skin daily produces pigment form the special cells called as melanocytes. In vitiligo these cells stops secreting melanin. Vitiligo occurs when the cells that produce melanin die or no longer produce melanin. This causes slowly enlarging white patches on our skin. There is no exact cause identified and defined but it is considered to be an auto-immune disorder where there is formation of antibodies which works against the melanocytes. The diagnosis of the vitiligo requires no any important instruments or tests and can be diagnosed by simple naked eye examination only. But in some cases where there is confusion then wood's lamp examination reveals the exact nature of hypo-pigmentation due to vitiligo or any other cause. The causes of white hypo-pigmentation in sixties of life can be due to vitiligo or as guttate hypomelanosis or as Post inflammatory hyperpigmentation(PIH). In guttate hypomelanosis – there is hypopimented areas of pin head to slightly larger size and these never increase in size larger than few millimeters. Post inflammatory hyperpigmentation – Thre hypopimented area at the previously inflamed or affected skin. In any of these conditions our goal of treatment is to return the normal color by stopping or slowing the progression of pigment loss. There are multiple ways of treatment such as Steroid creams, Psoralen photochemotherapy, topical psoralens and immunomodulator agents such as tacrolimus cream or pimecrolimus cream locally. If the lesion is spreading one needs oral steroids for few months. IN your query, I can get that they are not increasing and not anywhere on the body. In these cases Topical psoralens (Melanocyl or Octomop) with steroids are the choice of treatment and we do not want to give any oral treatment. All these therapies either halt the progression of activity and helps in production of color by melanocytes from the surrounding areas. The only part is that it should be applied under dermatological supervision only as topical psoralens (Melanocyl or Octomop) can cause lot of irritation and redness. An important fact is that both Melanocyl and Octomop contain the same content of Methoxasalen1% and 0.75% respectively. In my patients I generally start with one of the lotions rather than using both. As both of these lotions have strong irritation potential therefore it is to be diluted with distilled water. IN my patients I generally start with a proportion of 1:8 (1 part of lotion and 8 part of distilled water). It is to be applied at night time initially for few days to check for the irritation potential. If there is no irritation or redness then it is started in day time. The response is noted in 2 weeks interval and accordingly the proportion is reduced to 1:6 then 4 and 2 before applying the pure Melanocyl or Octomop. But it is a general rule that both the lotions are never combined on account of similar nature of contents as well as increase in irritation potential. It takes minimum of 3 months of period to get good pigmentation. It also depends on the age of patient and the activity of the lesions (increasing or decreasing). Now coming on your queries in the previous mail: 1) Current medication is using for the last 2 weeks and is she suppose to continue with it if yes then for how long @ You can get from the above guiding points that she has to use the medications for at least minimum of 3 months to get good pigmentation. A good sign is that the white spots have not increased since its appearance. As your mother is in her sixties, so it may take bit longer due to less production of color by melanocytes from the surrounding areas. 2) How much time will it take to cure and skin color match @ As above 3)Is it due to allergy to mehandi that she applies on hair every week as of now she is using herbal mehandi-Shehnaaz/Ramdev @ Mehandi if causing irritation then can cause both redness as well as later on white spots. So it is better to shift towards non-irritating products for hair color. 4) What all food/fruits she can take or avoid @ Previously there was a dictum that people having vitiligo should avoid all sour things in the diet. But according to latest of studies as well as in my own personal experience I have not seen any increase in vitiligo despite consuming sour things. So in my view she can take all types of fruits, vegetable and eatables. I hope these information will help you. I will be glad to answer any further queries. "Wish you good health" Regards, Dr Sanjay Kumar Kanodia MD (Dermatology)

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Brief Answer: apply only Flutivate cream and melgain lotion Detailed Answer: Hi XXXXXXX Thanks a lot for sending the pictures so that I can now guide you best regarding your mother's condition. After analyzing the pictures I can make out that the condition appears to be vitiligo. Most of the part of treatment given by the treating dermatologist is very good except for the combination and direct application of Melanocyl + Octomop -Morning 1:10 ratio. I can make out one more important point that the application is also not done in correct manner. This is on the basis of the fact that I can see redness all over her neck and way beyond on her back too. This occurs when the application is done deliberately all over in over and excess manner. Adding to this is the fact that a pure application of Melanocyl + Octomop is doen in your mother's case. As I guided you in previous mail- If I were your mother's treating doctor then would have preferred to start either of lotion with a proportion of 1:8 (1 part of lotion and 8 part of distilled water). This can be made by a dropper and once made is sufficient for almost two weeks as very little of amount is to be applied. The application should be done by a ear bud dipped in the lotion and is to be applied very lightly over affected areas only and not all over the skin so that it should not spill over the normal skin (as can cause irritation and redness). As I can see in your mother's case the application is done all over the neck and back. So you should improvise the application as guided above.It is to be applied at night time initially for few days to check for the irritation potential. If there is no irritation or redness then it is started in day time. The response is noted in 2 weeks interval and accordingly the proportion is reduced to 1:6 then 4 and 2 before applying the pure Melanocyl or Octomop. The rest of the application of MELGAIN lotion can be done in day time till we shift Melanocyl or Octomop from night time to day time. Flutivate cream is fine in day time. A rule of thumb for the application of Flutivate cream is that a pea size amount is sufficient for palm size of area. So in your mother's case as per the extent of area you should not take amount more thatn a pea size (just on finger tip). Apply in small dots over the affected areas and then massage it gently so that it should get blended with affected skin and not get spread to normal skin. A daily proper application will help you mother a lot in improving the condition at its best. The only one issue id the age factor because in old age there is less formation of melanin pigment so it can take bit longer of time. At present as there is redness and irritation is present therefore you should apply only Flutivate cream and melgain lotion. Once the redness and irritation subsides (in about 5-7 days) you can start the lotion as guided above or can take similar guidance form the treating dermatologist also. My all best wishes for early recovery in your mother. I hope these information will help you. I will be glad to answer any further queries. "Wish you good health" Regards, Dr Sanjay Kumar Kanodia MD (Dermatology)

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Brief Answer: Start Melanocyl once the redness subsides Detailed Answer: Hi XXXXXXX The current treatment with flutivate cream and melgain lotion is perfectly alright and is best suited according to the redness and irritation. The only one difference is that I would have preferred to apply flutivate cream all over the red areas for two times. This can be applied for next 5-7 days or till the time you see angry looking redness subsides. For the part of Melanocyl and Octomop lotion: As I guided you in previous mails- If I were your mother's treating doctor then would have preferred to start either of lotions and not both the lotions together. I would have used either Melanocyl OR Octomop with a proportion of 1:8 (1 part of lotion and 8 part of distilled water). You can be make it by a dropper in which one drop of lotion with 8 drops of distilled water. Once made is sufficient for almost two weeks as very little of amount is to be applied. The application should be done by a ear bud dipped in the lotion and is to be applied very lightly after proper draping the ear bud. This should be done over affected areas only and not all over the skin so that it should not spill over the normal skin (as can cause irritation and redness). You can start the lotion at night time as above after the redness subsides almost completely. If there is no irritation or redness then it is started in day time. The response is noted in 2 weeks interval and accordingly the proportion is reduced to 1:6 then 4 and 2 before applying the pure Melanocyl or Octomop. I hope these information will help you. I will be glad to answer any further queries. "Wish you good health" Regards, Dr Sanjay Kumar Kanodia MD (Dermatology)

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