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Analysis of Online Diet Recommendations for Vitiligo
Internet platforms have become a common source of medical information for individuals with a broad range of skin conditions including vitiligo. The prevalence of vitiligo among US adults ranges from 0.76% to 1.11%, with approximately 40% of adult cases of vitiligo in the United States remaining undiagnosed.1 The vitiligo community has become more inquisitive of the relationship between diet and vitiligo, turning to online sources for suggestions on diet modifications that may be beneficial for their condition. Although there is an abundance of online information, few diets or foods have been medically recognized to definitively improve or worsen vitiligo symptoms. We reviewed the top online web pages accessible to the public regarding diet suggestions that affect vitiligo symptoms. We then compared these online results to published peer-reviewed scientific literature.
Methods
Two independent online searches were performed by Researcher 1 (Y.A.) and Researcher 2 (I.M.) using Google Advanced Search. The independent searches were performed by the reviewers in neighboring areas of Chicago, Illinois, using the same Internet browser (Google Chrome). The primary search terms were diet and vitiligo along with the optional additional terms dietary supplement(s), food(s), nutrition, herb(s), or vitamin(s). Our search included any web pages published or updated from January 1, 2010, to December 31, 2021, and originally scribed in the English language. The domains “.com,” “.org,” “.edu,” and “.cc” were included.
From this initial search, Researcher 1 identified 312 web pages and Researcher 2 identified 314 web pages. Each reviewer sorted their respective search results to identify the number of eligible records to be screened. Records were defined as unique web pages that met the search criteria. After removing duplicates, Researcher 1 screened 102 web pages and Researcher 2 screened 76 web pages. Of these records, web pages were excluded if they did not include any diet recommendations for vitiligo patients. Each reviewer independently created a list of eligible records, and the independent lists were then merged for a total of 58 web pages. Among these 58 web pages, there were 24 duplicate records and 3 records that were deemed ineligible for the study due to lack of subject matter relevance. A final total of 31 web pages were included in the data analysis (Figure). Of the 31 records selected, the reviewers jointly evaluated each web page and recorded the diet components that were recommended for individuals with vitiligo to either include or avoid (eTable).
For comparison and support from published scientific literature, a search of PubMed articles indexed for MEDLINE was conducted using the terms diet and vitiligo. Relevant human clinical studies published in the English-language literature were reviewed for content regarding the relationship between diet and vitiligo.
Results
Our online search revealed an abundance of information regarding various dietary modifications suggested to aid in the management of vitiligo symptoms. Most web pages (27/31 [87%]) were not authored by medical professionals or dermatologists. There were 27 diet components mentioned 8 or more times within the 31 total web pages. These diet components were selected for further review via PubMed. Each item was searched on PubMed using the term “[respective diet component] and vitiligo” among all published literature in the English language. Our study focused on summarizing the data on dietary components for which we were able to gather scientific support. These data have been organized into the following categories: vitamins, fruits, omega-3 fatty acids, grains, minerals, vegetables, and nuts.
Vitamins—The online literature recommended inclusion of vitamin supplements, in particular vitamins D and B12, which aligned with published scientific literature.2,3 Eleven of 31 (35%) web pages recommended vitamin D in vitiligo. A 2010 study analyzing patients with vitiligo vulgaris (N=45) found that 68.9% of the cohort had insufficient (<30 ng/mL) 25-hydroxyvitamin D levels.2 A prospective study of 30 individuals found that the use of tacrolimus ointment plus oral vitamin D supplementation was found to be more successful in repigmentation than topical tacrolimus alone.3 Vitamin D dosage ranged from 1500 IU/d if the patient’s serum 25-hydroxyvitamin D levels were less than 20 ng/mL to 3000 IU/d if the serum levels were less than 10 ng/mL for 6 months.
Dairy products are a source of vitamin D.2,3 Of the web pages that mentioned dairy, a subtle majority (4/7 [57%]) recommended the inclusion of dairy products. Although many web pages did not specify whether oral vitamin D supplementation vs dietary food consumption is preferred, a 2013 controlled study of 16 vitiligo patients who received high doses of vitamin D supplementation with a low-calcium diet found that 4 patients showed 1% to 25% repigmentation, 5 patients showed 26% to 50% repigmentation, and 5 patients showed 51% to 75% repigmentation of the affected areas.4
Eleven of 31 (35%) web pages recommended inclusion of vitamin B12 supplementation in vitiligo. A 2-year study with 100 participants showed that supplementation with folic acid and vitamin B12 along with sun exposure yielded more effective repigmentation than either vitamins or sun exposure alone.5 An additional hypothesis suggested vitamin B12 may aid in repigmentation through its role in the homocysteine pathway. Although the theory is unproven, it is proposed that inhibition of homocysteine via vitamin B12 or folic acid supplementation may play a role in reducing melanocyte destruction and restoring melanin synthesis.6
There were mixed recommendations regarding vitamin C via supplementation and/or eating citrus fruits such as oranges. Although there are limited clinical studies on the use of vitamin C and the treatment of vitiligo, a 6-year prospective study from Madagascar consisting of approximately 300 participants with vitiligo who were treated with a combination of topical corticosteroids, oral vitamin C, and oral vitamin B12 supplementation showed excellent repigmentation (defined by repigmentation of more than 76% of the originally affected area) in 50 participants.7
Fruits—Most web pages had mixed recommendations on whether to include or avoid certain fruits. Interestingly, inclusion of mangoes and apricots in the diet were highly recommended (9/31 [29%] and 8/31 [26%], respectively) while fruits such as oranges, lemons, papayas, and grapes were discouraged (10/31 [32%], 8/31 [26%], 6/31 [19%], and 7/31 [23%], respectively). Although some web pages suggested that vitamin C–rich produce including citrus and berries may help to increase melanin formation, others strongly suggested avoiding these fruits. There is limited information on the effects of citrus on vitiligo, but a 2022 study indicated that 5-demethylnobiletin, a flavonoid found in sweet citrus fruits, may stimulate melanin synthesis, which can possibly be beneficial for vitiligo.8
Omega-3 Fatty Acids—Seven of 31 (23%) web pages recommended the inclusion of omega-3 fatty acids for their role as antioxidants to improve vitiligo symptoms. Research has indicated a strong association between vitiligo and oxidative stress.9 A 2007 controlled clinical trial that included 28 vitiligo patients demonstrated that oral antioxidant supplementation in combination with narrowband UVB phototherapy can significantly decrease vitiligo-associated oxidative stress (P<.05); 8 of 17 (47%) patients in the treatment group saw greater than 75% repigmentation after antioxidant treatment.10
Grains—Five of 31 (16%) web pages suggested avoiding gluten—a protein naturally found in some grains including wheat, barley, and rye—to improve vitiligo symptoms. A 2021 review suggested that a gluten-free diet may be effective in managing celiac disease, and it is hypothesized that vitiligo may be managed with similar dietary adjustments.11 Studies have shown that celiac disease and vitiligo—both autoimmune conditions—involve IL-2, IL-6, IL-7, and IL-21 in their disease pathways.12,13 Their shared immunogenic mechanism may account for similar management options.
Upon review, 2 case reports were identified that discussed a relationship between a gluten-free diet and vitiligo symptom improvement. In one report, a 9-year-old child diagnosed with both celiac disease and vitiligo saw intense repigmentation of the skin after adhering to a gluten-free diet for 1 year.14 Another case study reported a 22-year-old woman with vitiligo whose symptoms improved after 1 month of a gluten-free diet following 2 years of failed treatment with a topical steroid and phototherapy.15
Seven of 31 (23%) web pages suggested that individuals with vitiligo should include wheat in their diet. There is no published literature discussing the relationship between vitiligo and wheat. Of the 31 web pages reviewed, 10 (32%) suggested including whole grain. There is no relevant scientific evidence or hypotheses describing how whole grains may be beneficial in vitiligo.
Minerals—Eight of 31 (26%) web pages suggested including zinc in the diet to improve vitiligo symptoms. A 2020 study evaluated how different serum levels of zinc in vitiligo patients might be affiliated with interleukin activity. Fifty patients diagnosed with active vitiligo were tested for serum levels of zinc, IL-4, IL-6, and IL-17.16 The results showed that mean serum levels of zinc were lower in vitiligo patients compared with patients without vitiligo. The study concluded that zinc could possibly be used as a supplement to improve vitiligo, though the dosage needs to be further studied and confirmed.16
Vegetables—Eleven of 31 (35%) web pages recommended leafy green vegetables and 13 of 31 (42%) recommended spinach for patients with vitiligo. Spinach and other leafy green vegetables are known to be rich in antioxidants, which may have protective effects against reactive oxygen species that are thought to contribute to vitiligo progression.17,18
Nuts—Walnuts were recommended in 11 of 31 (35%) web pages. Nuts may be beneficial in reducing inflammation and providing protection against oxidative stress.9 However, there is no specific scientific literature that supports the inclusion of nuts in the diet to manage vitiligo symptoms.
Comment
With a growing amount of research suggesting that diet modifications may contribute to management of certain skin conditions, vitiligo patients often inquire about foods or supplements that may help improve their condition.19 Our review highlighted what information was available to the public regarding diet and vitiligo, with preliminary support of the following primary diet components: vitamin D, vitamin B12, zinc, and omega-3 fatty acids. Our review showed no support in the literature for the items that were recommended to avoid. It is important to note that 27 of 31 (87%) web pages from our online search were not authored by medical professionals or dermatologists. Additionally, many web pages suggested conflicting information, making it difficult to draw concrete conclusions about what diet modifications will be beneficial to the vitiligo community. Further controlled clinical trials are warranted due to the lack of formal studies that assess the relationship between diet and vitiligo.
- Gandhi K, Ezzedine K, Anastassopoulos KP, et al. Prevalence of vitiligo among adults in the United States. JAMA Dermatol. 2022;158:43-50. doi:10.1001/jamadermatol.2021.4724
- Silverberg JI, Silverberg AI, Malka E, et al. A pilot study assessing the role of 25 hydroxy vitamin D levels in patients with vitiligo vulgaris. J Am Acad Dermatol. 2010;62:937-941. doi:10.1016/j.jaad.2009.11.024
- Karagüzel G, Sakarya NP, Bahadır S, et al. Vitamin D status and the effects of oral vitamin D treatment in children with vitiligo: a prospective study. Clin Nutr ESPEN. 2016;15:28-31. doi:10.1016/j.clnesp.2016.05.006.
- Finamor DC, Sinigaglia-Coimbra R, Neves LC, et al. A pilot study assessing the effect of prolonged administration of high daily doses of vitamin D on the clinical course of vitiligo and psoriasis. Dermatoendocrinol. 2013;5:222-234. doi:10.4161/derm.24808
- Juhlin L, Olsson MJ. Improvement of vitiligo after oral treatment with vitamin B12 and folic acid and the importance of sun exposure. Acta Derm Venereol. 1997;77:460-462. doi:10.2340/000155555577460462
- Chen J, Zhuang T, Chen J, et al. Homocysteine induces melanocytes apoptosis via PERK-eIF2α-CHOP pathway in vitiligo. Clin Sci (Lond). 2020;134:1127-1141. doi:10.1042/CS20200218
- Sendrasoa FA, Ranaivo IM, Sata M, et al. Treatment responses in patients with vitiligo to very potent topical corticosteroids combined with vitamin therapy in Madagascar. Int J Dermatol. 2019;58:908-911. doi:10.1111/ijd.14510
- Wang HM, Qu LQ, Ng JPL, et al. Natural citrus flavanone 5-demethylnobiletin stimulates melanogenesis through the activation of cAMP/CREB pathway in B16F10 cells. Phytomedicine. 2022;98:153941. doi:10.1016/j.phymed.2022.153941
- Ros E. Health benefits of nut consumption. Nutrients. 2010;2:652-682.
- Dell’Anna ML, Mastrofrancesco A, Sala R, et al. Antioxidants and narrow band-UVB in the treatment of vitiligo: a double-blind placebo controlled trial. Clin Exp Dermatol. 2007;32:631-636.
- Gastrointestinal microbiome and gluten in celiac disease. Ann Med. 2021;53:1797-1805. doi:10.1080/07853890.2021.1990392
- Forabosco P, Neuhausen SL, Greco L, et al. Meta-analysis of genome-wide linkage studies in celiac disease. Hum Hered. 2009;68:223-230. doi:10.1159/000228920
- Akbulut UE, Çebi AH, Sag˘ E, et al. Interleukin-6 and interleukin-17 gene polymorphism association with celiac disease in children. Turk J Gastroenterol. 2017;28:471-475. doi:10.5152/tjg.2017.17092
- Rodríguez-García C, González-Hernández S, Pérez-Robayna N, et al. Repigmentation of vitiligo lesions in a child with celiac disease after a gluten-free diet. Pediatr Dermatol. 2011;28:209-210. doi:10.1111/j.1525-1470.2011.01388.x
- Khandalavala BN, Nirmalraj MC. Rapid partial repigmentation ofvitiligo in a young female adult with a gluten-free diet. Case Rep Dermatol. 2014;6:283-287.
- Sanad EM, El-Fallah AA, Al-Doori AR, et al. Serum zinc and inflammatory cytokines in vitiligo. J Clin Aesthet Dermatol. 2020;13:(12 suppl 1):S29-S33.
- Ames BN, Shigenaga MK, Hagen TM. Oxidants, antioxidants, and the degenerative diseases of aging. Proc Natl Acad Sci U S A. 1993;90:7915-7922. doi:10.1073/pnas.90.17.7915
- Xian D, Guo M, Xu J, et al. Current evidence to support the therapeutic potential of flavonoids in oxidative stress-related dermatoses. Redox Rep. 2021;26:134-146. doi:10.1080 /13510002.2021.1962094
- Katta R, Kramer MJ. Skin and diet: an update on the role of dietary change as a treatment strategy for skin disease. Skin Therapy Lett. 2018;23:1-5.
Internet platforms have become a common source of medical information for individuals with a broad range of skin conditions including vitiligo. The prevalence of vitiligo among US adults ranges from 0.76% to 1.11%, with approximately 40% of adult cases of vitiligo in the United States remaining undiagnosed.1 The vitiligo community has become more inquisitive of the relationship between diet and vitiligo, turning to online sources for suggestions on diet modifications that may be beneficial for their condition. Although there is an abundance of online information, few diets or foods have been medically recognized to definitively improve or worsen vitiligo symptoms. We reviewed the top online web pages accessible to the public regarding diet suggestions that affect vitiligo symptoms. We then compared these online results to published peer-reviewed scientific literature.
Methods
Two independent online searches were performed by Researcher 1 (Y.A.) and Researcher 2 (I.M.) using Google Advanced Search. The independent searches were performed by the reviewers in neighboring areas of Chicago, Illinois, using the same Internet browser (Google Chrome). The primary search terms were diet and vitiligo along with the optional additional terms dietary supplement(s), food(s), nutrition, herb(s), or vitamin(s). Our search included any web pages published or updated from January 1, 2010, to December 31, 2021, and originally scribed in the English language. The domains “.com,” “.org,” “.edu,” and “.cc” were included.
From this initial search, Researcher 1 identified 312 web pages and Researcher 2 identified 314 web pages. Each reviewer sorted their respective search results to identify the number of eligible records to be screened. Records were defined as unique web pages that met the search criteria. After removing duplicates, Researcher 1 screened 102 web pages and Researcher 2 screened 76 web pages. Of these records, web pages were excluded if they did not include any diet recommendations for vitiligo patients. Each reviewer independently created a list of eligible records, and the independent lists were then merged for a total of 58 web pages. Among these 58 web pages, there were 24 duplicate records and 3 records that were deemed ineligible for the study due to lack of subject matter relevance. A final total of 31 web pages were included in the data analysis (Figure). Of the 31 records selected, the reviewers jointly evaluated each web page and recorded the diet components that were recommended for individuals with vitiligo to either include or avoid (eTable).
For comparison and support from published scientific literature, a search of PubMed articles indexed for MEDLINE was conducted using the terms diet and vitiligo. Relevant human clinical studies published in the English-language literature were reviewed for content regarding the relationship between diet and vitiligo.
Results
Our online search revealed an abundance of information regarding various dietary modifications suggested to aid in the management of vitiligo symptoms. Most web pages (27/31 [87%]) were not authored by medical professionals or dermatologists. There were 27 diet components mentioned 8 or more times within the 31 total web pages. These diet components were selected for further review via PubMed. Each item was searched on PubMed using the term “[respective diet component] and vitiligo” among all published literature in the English language. Our study focused on summarizing the data on dietary components for which we were able to gather scientific support. These data have been organized into the following categories: vitamins, fruits, omega-3 fatty acids, grains, minerals, vegetables, and nuts.
Vitamins—The online literature recommended inclusion of vitamin supplements, in particular vitamins D and B12, which aligned with published scientific literature.2,3 Eleven of 31 (35%) web pages recommended vitamin D in vitiligo. A 2010 study analyzing patients with vitiligo vulgaris (N=45) found that 68.9% of the cohort had insufficient (<30 ng/mL) 25-hydroxyvitamin D levels.2 A prospective study of 30 individuals found that the use of tacrolimus ointment plus oral vitamin D supplementation was found to be more successful in repigmentation than topical tacrolimus alone.3 Vitamin D dosage ranged from 1500 IU/d if the patient’s serum 25-hydroxyvitamin D levels were less than 20 ng/mL to 3000 IU/d if the serum levels were less than 10 ng/mL for 6 months.
Dairy products are a source of vitamin D.2,3 Of the web pages that mentioned dairy, a subtle majority (4/7 [57%]) recommended the inclusion of dairy products. Although many web pages did not specify whether oral vitamin D supplementation vs dietary food consumption is preferred, a 2013 controlled study of 16 vitiligo patients who received high doses of vitamin D supplementation with a low-calcium diet found that 4 patients showed 1% to 25% repigmentation, 5 patients showed 26% to 50% repigmentation, and 5 patients showed 51% to 75% repigmentation of the affected areas.4
Eleven of 31 (35%) web pages recommended inclusion of vitamin B12 supplementation in vitiligo. A 2-year study with 100 participants showed that supplementation with folic acid and vitamin B12 along with sun exposure yielded more effective repigmentation than either vitamins or sun exposure alone.5 An additional hypothesis suggested vitamin B12 may aid in repigmentation through its role in the homocysteine pathway. Although the theory is unproven, it is proposed that inhibition of homocysteine via vitamin B12 or folic acid supplementation may play a role in reducing melanocyte destruction and restoring melanin synthesis.6
There were mixed recommendations regarding vitamin C via supplementation and/or eating citrus fruits such as oranges. Although there are limited clinical studies on the use of vitamin C and the treatment of vitiligo, a 6-year prospective study from Madagascar consisting of approximately 300 participants with vitiligo who were treated with a combination of topical corticosteroids, oral vitamin C, and oral vitamin B12 supplementation showed excellent repigmentation (defined by repigmentation of more than 76% of the originally affected area) in 50 participants.7
Fruits—Most web pages had mixed recommendations on whether to include or avoid certain fruits. Interestingly, inclusion of mangoes and apricots in the diet were highly recommended (9/31 [29%] and 8/31 [26%], respectively) while fruits such as oranges, lemons, papayas, and grapes were discouraged (10/31 [32%], 8/31 [26%], 6/31 [19%], and 7/31 [23%], respectively). Although some web pages suggested that vitamin C–rich produce including citrus and berries may help to increase melanin formation, others strongly suggested avoiding these fruits. There is limited information on the effects of citrus on vitiligo, but a 2022 study indicated that 5-demethylnobiletin, a flavonoid found in sweet citrus fruits, may stimulate melanin synthesis, which can possibly be beneficial for vitiligo.8
Omega-3 Fatty Acids—Seven of 31 (23%) web pages recommended the inclusion of omega-3 fatty acids for their role as antioxidants to improve vitiligo symptoms. Research has indicated a strong association between vitiligo and oxidative stress.9 A 2007 controlled clinical trial that included 28 vitiligo patients demonstrated that oral antioxidant supplementation in combination with narrowband UVB phototherapy can significantly decrease vitiligo-associated oxidative stress (P<.05); 8 of 17 (47%) patients in the treatment group saw greater than 75% repigmentation after antioxidant treatment.10
Grains—Five of 31 (16%) web pages suggested avoiding gluten—a protein naturally found in some grains including wheat, barley, and rye—to improve vitiligo symptoms. A 2021 review suggested that a gluten-free diet may be effective in managing celiac disease, and it is hypothesized that vitiligo may be managed with similar dietary adjustments.11 Studies have shown that celiac disease and vitiligo—both autoimmune conditions—involve IL-2, IL-6, IL-7, and IL-21 in their disease pathways.12,13 Their shared immunogenic mechanism may account for similar management options.
Upon review, 2 case reports were identified that discussed a relationship between a gluten-free diet and vitiligo symptom improvement. In one report, a 9-year-old child diagnosed with both celiac disease and vitiligo saw intense repigmentation of the skin after adhering to a gluten-free diet for 1 year.14 Another case study reported a 22-year-old woman with vitiligo whose symptoms improved after 1 month of a gluten-free diet following 2 years of failed treatment with a topical steroid and phototherapy.15
Seven of 31 (23%) web pages suggested that individuals with vitiligo should include wheat in their diet. There is no published literature discussing the relationship between vitiligo and wheat. Of the 31 web pages reviewed, 10 (32%) suggested including whole grain. There is no relevant scientific evidence or hypotheses describing how whole grains may be beneficial in vitiligo.
Minerals—Eight of 31 (26%) web pages suggested including zinc in the diet to improve vitiligo symptoms. A 2020 study evaluated how different serum levels of zinc in vitiligo patients might be affiliated with interleukin activity. Fifty patients diagnosed with active vitiligo were tested for serum levels of zinc, IL-4, IL-6, and IL-17.16 The results showed that mean serum levels of zinc were lower in vitiligo patients compared with patients without vitiligo. The study concluded that zinc could possibly be used as a supplement to improve vitiligo, though the dosage needs to be further studied and confirmed.16
Vegetables—Eleven of 31 (35%) web pages recommended leafy green vegetables and 13 of 31 (42%) recommended spinach for patients with vitiligo. Spinach and other leafy green vegetables are known to be rich in antioxidants, which may have protective effects against reactive oxygen species that are thought to contribute to vitiligo progression.17,18
Nuts—Walnuts were recommended in 11 of 31 (35%) web pages. Nuts may be beneficial in reducing inflammation and providing protection against oxidative stress.9 However, there is no specific scientific literature that supports the inclusion of nuts in the diet to manage vitiligo symptoms.
Comment
With a growing amount of research suggesting that diet modifications may contribute to management of certain skin conditions, vitiligo patients often inquire about foods or supplements that may help improve their condition.19 Our review highlighted what information was available to the public regarding diet and vitiligo, with preliminary support of the following primary diet components: vitamin D, vitamin B12, zinc, and omega-3 fatty acids. Our review showed no support in the literature for the items that were recommended to avoid. It is important to note that 27 of 31 (87%) web pages from our online search were not authored by medical professionals or dermatologists. Additionally, many web pages suggested conflicting information, making it difficult to draw concrete conclusions about what diet modifications will be beneficial to the vitiligo community. Further controlled clinical trials are warranted due to the lack of formal studies that assess the relationship between diet and vitiligo.
Internet platforms have become a common source of medical information for individuals with a broad range of skin conditions including vitiligo. The prevalence of vitiligo among US adults ranges from 0.76% to 1.11%, with approximately 40% of adult cases of vitiligo in the United States remaining undiagnosed.1 The vitiligo community has become more inquisitive of the relationship between diet and vitiligo, turning to online sources for suggestions on diet modifications that may be beneficial for their condition. Although there is an abundance of online information, few diets or foods have been medically recognized to definitively improve or worsen vitiligo symptoms. We reviewed the top online web pages accessible to the public regarding diet suggestions that affect vitiligo symptoms. We then compared these online results to published peer-reviewed scientific literature.
Methods
Two independent online searches were performed by Researcher 1 (Y.A.) and Researcher 2 (I.M.) using Google Advanced Search. The independent searches were performed by the reviewers in neighboring areas of Chicago, Illinois, using the same Internet browser (Google Chrome). The primary search terms were diet and vitiligo along with the optional additional terms dietary supplement(s), food(s), nutrition, herb(s), or vitamin(s). Our search included any web pages published or updated from January 1, 2010, to December 31, 2021, and originally scribed in the English language. The domains “.com,” “.org,” “.edu,” and “.cc” were included.
From this initial search, Researcher 1 identified 312 web pages and Researcher 2 identified 314 web pages. Each reviewer sorted their respective search results to identify the number of eligible records to be screened. Records were defined as unique web pages that met the search criteria. After removing duplicates, Researcher 1 screened 102 web pages and Researcher 2 screened 76 web pages. Of these records, web pages were excluded if they did not include any diet recommendations for vitiligo patients. Each reviewer independently created a list of eligible records, and the independent lists were then merged for a total of 58 web pages. Among these 58 web pages, there were 24 duplicate records and 3 records that were deemed ineligible for the study due to lack of subject matter relevance. A final total of 31 web pages were included in the data analysis (Figure). Of the 31 records selected, the reviewers jointly evaluated each web page and recorded the diet components that were recommended for individuals with vitiligo to either include or avoid (eTable).
For comparison and support from published scientific literature, a search of PubMed articles indexed for MEDLINE was conducted using the terms diet and vitiligo. Relevant human clinical studies published in the English-language literature were reviewed for content regarding the relationship between diet and vitiligo.
Results
Our online search revealed an abundance of information regarding various dietary modifications suggested to aid in the management of vitiligo symptoms. Most web pages (27/31 [87%]) were not authored by medical professionals or dermatologists. There were 27 diet components mentioned 8 or more times within the 31 total web pages. These diet components were selected for further review via PubMed. Each item was searched on PubMed using the term “[respective diet component] and vitiligo” among all published literature in the English language. Our study focused on summarizing the data on dietary components for which we were able to gather scientific support. These data have been organized into the following categories: vitamins, fruits, omega-3 fatty acids, grains, minerals, vegetables, and nuts.
Vitamins—The online literature recommended inclusion of vitamin supplements, in particular vitamins D and B12, which aligned with published scientific literature.2,3 Eleven of 31 (35%) web pages recommended vitamin D in vitiligo. A 2010 study analyzing patients with vitiligo vulgaris (N=45) found that 68.9% of the cohort had insufficient (<30 ng/mL) 25-hydroxyvitamin D levels.2 A prospective study of 30 individuals found that the use of tacrolimus ointment plus oral vitamin D supplementation was found to be more successful in repigmentation than topical tacrolimus alone.3 Vitamin D dosage ranged from 1500 IU/d if the patient’s serum 25-hydroxyvitamin D levels were less than 20 ng/mL to 3000 IU/d if the serum levels were less than 10 ng/mL for 6 months.
Dairy products are a source of vitamin D.2,3 Of the web pages that mentioned dairy, a subtle majority (4/7 [57%]) recommended the inclusion of dairy products. Although many web pages did not specify whether oral vitamin D supplementation vs dietary food consumption is preferred, a 2013 controlled study of 16 vitiligo patients who received high doses of vitamin D supplementation with a low-calcium diet found that 4 patients showed 1% to 25% repigmentation, 5 patients showed 26% to 50% repigmentation, and 5 patients showed 51% to 75% repigmentation of the affected areas.4
Eleven of 31 (35%) web pages recommended inclusion of vitamin B12 supplementation in vitiligo. A 2-year study with 100 participants showed that supplementation with folic acid and vitamin B12 along with sun exposure yielded more effective repigmentation than either vitamins or sun exposure alone.5 An additional hypothesis suggested vitamin B12 may aid in repigmentation through its role in the homocysteine pathway. Although the theory is unproven, it is proposed that inhibition of homocysteine via vitamin B12 or folic acid supplementation may play a role in reducing melanocyte destruction and restoring melanin synthesis.6
There were mixed recommendations regarding vitamin C via supplementation and/or eating citrus fruits such as oranges. Although there are limited clinical studies on the use of vitamin C and the treatment of vitiligo, a 6-year prospective study from Madagascar consisting of approximately 300 participants with vitiligo who were treated with a combination of topical corticosteroids, oral vitamin C, and oral vitamin B12 supplementation showed excellent repigmentation (defined by repigmentation of more than 76% of the originally affected area) in 50 participants.7
Fruits—Most web pages had mixed recommendations on whether to include or avoid certain fruits. Interestingly, inclusion of mangoes and apricots in the diet were highly recommended (9/31 [29%] and 8/31 [26%], respectively) while fruits such as oranges, lemons, papayas, and grapes were discouraged (10/31 [32%], 8/31 [26%], 6/31 [19%], and 7/31 [23%], respectively). Although some web pages suggested that vitamin C–rich produce including citrus and berries may help to increase melanin formation, others strongly suggested avoiding these fruits. There is limited information on the effects of citrus on vitiligo, but a 2022 study indicated that 5-demethylnobiletin, a flavonoid found in sweet citrus fruits, may stimulate melanin synthesis, which can possibly be beneficial for vitiligo.8
Omega-3 Fatty Acids—Seven of 31 (23%) web pages recommended the inclusion of omega-3 fatty acids for their role as antioxidants to improve vitiligo symptoms. Research has indicated a strong association between vitiligo and oxidative stress.9 A 2007 controlled clinical trial that included 28 vitiligo patients demonstrated that oral antioxidant supplementation in combination with narrowband UVB phototherapy can significantly decrease vitiligo-associated oxidative stress (P<.05); 8 of 17 (47%) patients in the treatment group saw greater than 75% repigmentation after antioxidant treatment.10
Grains—Five of 31 (16%) web pages suggested avoiding gluten—a protein naturally found in some grains including wheat, barley, and rye—to improve vitiligo symptoms. A 2021 review suggested that a gluten-free diet may be effective in managing celiac disease, and it is hypothesized that vitiligo may be managed with similar dietary adjustments.11 Studies have shown that celiac disease and vitiligo—both autoimmune conditions—involve IL-2, IL-6, IL-7, and IL-21 in their disease pathways.12,13 Their shared immunogenic mechanism may account for similar management options.
Upon review, 2 case reports were identified that discussed a relationship between a gluten-free diet and vitiligo symptom improvement. In one report, a 9-year-old child diagnosed with both celiac disease and vitiligo saw intense repigmentation of the skin after adhering to a gluten-free diet for 1 year.14 Another case study reported a 22-year-old woman with vitiligo whose symptoms improved after 1 month of a gluten-free diet following 2 years of failed treatment with a topical steroid and phototherapy.15
Seven of 31 (23%) web pages suggested that individuals with vitiligo should include wheat in their diet. There is no published literature discussing the relationship between vitiligo and wheat. Of the 31 web pages reviewed, 10 (32%) suggested including whole grain. There is no relevant scientific evidence or hypotheses describing how whole grains may be beneficial in vitiligo.
Minerals—Eight of 31 (26%) web pages suggested including zinc in the diet to improve vitiligo symptoms. A 2020 study evaluated how different serum levels of zinc in vitiligo patients might be affiliated with interleukin activity. Fifty patients diagnosed with active vitiligo were tested for serum levels of zinc, IL-4, IL-6, and IL-17.16 The results showed that mean serum levels of zinc were lower in vitiligo patients compared with patients without vitiligo. The study concluded that zinc could possibly be used as a supplement to improve vitiligo, though the dosage needs to be further studied and confirmed.16
Vegetables—Eleven of 31 (35%) web pages recommended leafy green vegetables and 13 of 31 (42%) recommended spinach for patients with vitiligo. Spinach and other leafy green vegetables are known to be rich in antioxidants, which may have protective effects against reactive oxygen species that are thought to contribute to vitiligo progression.17,18
Nuts—Walnuts were recommended in 11 of 31 (35%) web pages. Nuts may be beneficial in reducing inflammation and providing protection against oxidative stress.9 However, there is no specific scientific literature that supports the inclusion of nuts in the diet to manage vitiligo symptoms.
Comment
With a growing amount of research suggesting that diet modifications may contribute to management of certain skin conditions, vitiligo patients often inquire about foods or supplements that may help improve their condition.19 Our review highlighted what information was available to the public regarding diet and vitiligo, with preliminary support of the following primary diet components: vitamin D, vitamin B12, zinc, and omega-3 fatty acids. Our review showed no support in the literature for the items that were recommended to avoid. It is important to note that 27 of 31 (87%) web pages from our online search were not authored by medical professionals or dermatologists. Additionally, many web pages suggested conflicting information, making it difficult to draw concrete conclusions about what diet modifications will be beneficial to the vitiligo community. Further controlled clinical trials are warranted due to the lack of formal studies that assess the relationship between diet and vitiligo.
- Gandhi K, Ezzedine K, Anastassopoulos KP, et al. Prevalence of vitiligo among adults in the United States. JAMA Dermatol. 2022;158:43-50. doi:10.1001/jamadermatol.2021.4724
- Silverberg JI, Silverberg AI, Malka E, et al. A pilot study assessing the role of 25 hydroxy vitamin D levels in patients with vitiligo vulgaris. J Am Acad Dermatol. 2010;62:937-941. doi:10.1016/j.jaad.2009.11.024
- Karagüzel G, Sakarya NP, Bahadır S, et al. Vitamin D status and the effects of oral vitamin D treatment in children with vitiligo: a prospective study. Clin Nutr ESPEN. 2016;15:28-31. doi:10.1016/j.clnesp.2016.05.006.
- Finamor DC, Sinigaglia-Coimbra R, Neves LC, et al. A pilot study assessing the effect of prolonged administration of high daily doses of vitamin D on the clinical course of vitiligo and psoriasis. Dermatoendocrinol. 2013;5:222-234. doi:10.4161/derm.24808
- Juhlin L, Olsson MJ. Improvement of vitiligo after oral treatment with vitamin B12 and folic acid and the importance of sun exposure. Acta Derm Venereol. 1997;77:460-462. doi:10.2340/000155555577460462
- Chen J, Zhuang T, Chen J, et al. Homocysteine induces melanocytes apoptosis via PERK-eIF2α-CHOP pathway in vitiligo. Clin Sci (Lond). 2020;134:1127-1141. doi:10.1042/CS20200218
- Sendrasoa FA, Ranaivo IM, Sata M, et al. Treatment responses in patients with vitiligo to very potent topical corticosteroids combined with vitamin therapy in Madagascar. Int J Dermatol. 2019;58:908-911. doi:10.1111/ijd.14510
- Wang HM, Qu LQ, Ng JPL, et al. Natural citrus flavanone 5-demethylnobiletin stimulates melanogenesis through the activation of cAMP/CREB pathway in B16F10 cells. Phytomedicine. 2022;98:153941. doi:10.1016/j.phymed.2022.153941
- Ros E. Health benefits of nut consumption. Nutrients. 2010;2:652-682.
- Dell’Anna ML, Mastrofrancesco A, Sala R, et al. Antioxidants and narrow band-UVB in the treatment of vitiligo: a double-blind placebo controlled trial. Clin Exp Dermatol. 2007;32:631-636.
- Gastrointestinal microbiome and gluten in celiac disease. Ann Med. 2021;53:1797-1805. doi:10.1080/07853890.2021.1990392
- Forabosco P, Neuhausen SL, Greco L, et al. Meta-analysis of genome-wide linkage studies in celiac disease. Hum Hered. 2009;68:223-230. doi:10.1159/000228920
- Akbulut UE, Çebi AH, Sag˘ E, et al. Interleukin-6 and interleukin-17 gene polymorphism association with celiac disease in children. Turk J Gastroenterol. 2017;28:471-475. doi:10.5152/tjg.2017.17092
- Rodríguez-García C, González-Hernández S, Pérez-Robayna N, et al. Repigmentation of vitiligo lesions in a child with celiac disease after a gluten-free diet. Pediatr Dermatol. 2011;28:209-210. doi:10.1111/j.1525-1470.2011.01388.x
- Khandalavala BN, Nirmalraj MC. Rapid partial repigmentation ofvitiligo in a young female adult with a gluten-free diet. Case Rep Dermatol. 2014;6:283-287.
- Sanad EM, El-Fallah AA, Al-Doori AR, et al. Serum zinc and inflammatory cytokines in vitiligo. J Clin Aesthet Dermatol. 2020;13:(12 suppl 1):S29-S33.
- Ames BN, Shigenaga MK, Hagen TM. Oxidants, antioxidants, and the degenerative diseases of aging. Proc Natl Acad Sci U S A. 1993;90:7915-7922. doi:10.1073/pnas.90.17.7915
- Xian D, Guo M, Xu J, et al. Current evidence to support the therapeutic potential of flavonoids in oxidative stress-related dermatoses. Redox Rep. 2021;26:134-146. doi:10.1080 /13510002.2021.1962094
- Katta R, Kramer MJ. Skin and diet: an update on the role of dietary change as a treatment strategy for skin disease. Skin Therapy Lett. 2018;23:1-5.
- Gandhi K, Ezzedine K, Anastassopoulos KP, et al. Prevalence of vitiligo among adults in the United States. JAMA Dermatol. 2022;158:43-50. doi:10.1001/jamadermatol.2021.4724
- Silverberg JI, Silverberg AI, Malka E, et al. A pilot study assessing the role of 25 hydroxy vitamin D levels in patients with vitiligo vulgaris. J Am Acad Dermatol. 2010;62:937-941. doi:10.1016/j.jaad.2009.11.024
- Karagüzel G, Sakarya NP, Bahadır S, et al. Vitamin D status and the effects of oral vitamin D treatment in children with vitiligo: a prospective study. Clin Nutr ESPEN. 2016;15:28-31. doi:10.1016/j.clnesp.2016.05.006.
- Finamor DC, Sinigaglia-Coimbra R, Neves LC, et al. A pilot study assessing the effect of prolonged administration of high daily doses of vitamin D on the clinical course of vitiligo and psoriasis. Dermatoendocrinol. 2013;5:222-234. doi:10.4161/derm.24808
- Juhlin L, Olsson MJ. Improvement of vitiligo after oral treatment with vitamin B12 and folic acid and the importance of sun exposure. Acta Derm Venereol. 1997;77:460-462. doi:10.2340/000155555577460462
- Chen J, Zhuang T, Chen J, et al. Homocysteine induces melanocytes apoptosis via PERK-eIF2α-CHOP pathway in vitiligo. Clin Sci (Lond). 2020;134:1127-1141. doi:10.1042/CS20200218
- Sendrasoa FA, Ranaivo IM, Sata M, et al. Treatment responses in patients with vitiligo to very potent topical corticosteroids combined with vitamin therapy in Madagascar. Int J Dermatol. 2019;58:908-911. doi:10.1111/ijd.14510
- Wang HM, Qu LQ, Ng JPL, et al. Natural citrus flavanone 5-demethylnobiletin stimulates melanogenesis through the activation of cAMP/CREB pathway in B16F10 cells. Phytomedicine. 2022;98:153941. doi:10.1016/j.phymed.2022.153941
- Ros E. Health benefits of nut consumption. Nutrients. 2010;2:652-682.
- Dell’Anna ML, Mastrofrancesco A, Sala R, et al. Antioxidants and narrow band-UVB in the treatment of vitiligo: a double-blind placebo controlled trial. Clin Exp Dermatol. 2007;32:631-636.
- Gastrointestinal microbiome and gluten in celiac disease. Ann Med. 2021;53:1797-1805. doi:10.1080/07853890.2021.1990392
- Forabosco P, Neuhausen SL, Greco L, et al. Meta-analysis of genome-wide linkage studies in celiac disease. Hum Hered. 2009;68:223-230. doi:10.1159/000228920
- Akbulut UE, Çebi AH, Sag˘ E, et al. Interleukin-6 and interleukin-17 gene polymorphism association with celiac disease in children. Turk J Gastroenterol. 2017;28:471-475. doi:10.5152/tjg.2017.17092
- Rodríguez-García C, González-Hernández S, Pérez-Robayna N, et al. Repigmentation of vitiligo lesions in a child with celiac disease after a gluten-free diet. Pediatr Dermatol. 2011;28:209-210. doi:10.1111/j.1525-1470.2011.01388.x
- Khandalavala BN, Nirmalraj MC. Rapid partial repigmentation ofvitiligo in a young female adult with a gluten-free diet. Case Rep Dermatol. 2014;6:283-287.
- Sanad EM, El-Fallah AA, Al-Doori AR, et al. Serum zinc and inflammatory cytokines in vitiligo. J Clin Aesthet Dermatol. 2020;13:(12 suppl 1):S29-S33.
- Ames BN, Shigenaga MK, Hagen TM. Oxidants, antioxidants, and the degenerative diseases of aging. Proc Natl Acad Sci U S A. 1993;90:7915-7922. doi:10.1073/pnas.90.17.7915
- Xian D, Guo M, Xu J, et al. Current evidence to support the therapeutic potential of flavonoids in oxidative stress-related dermatoses. Redox Rep. 2021;26:134-146. doi:10.1080 /13510002.2021.1962094
- Katta R, Kramer MJ. Skin and diet: an update on the role of dietary change as a treatment strategy for skin disease. Skin Therapy Lett. 2018;23:1-5.
Practice Points
- There are numerous online dietary and supplement recommendations that claim to impact vitiligo but most are not authored by medical professionals or dermatologists.
- Scientific evidence supporting specific dietary and supplement recommendations for vitiligo is limited.
- Current preliminary data support the potential recommendation for dietary supplementation with vitamin D, vitamin B12, zinc, and omega-3 fatty acids.
