A Handbook for Schools

Vitiligo, a skin disorder, is characterized by the loss of melanin or skin pigment in various parts of the body. The skin in these areas appears spotted. The depigmented spots contrast markedly with the normally pigmented skin in the same area. The darker the normal skin tone, the more visible are the patches of pure white skin of vitiligo. While vitiligo is not a serious or life-threatening disorder, or a painful one, studies have shown that it has an impact on the social and psychological well-being of its victims. Many become embarrassed because of their impaired appearance, some experience a dramatic drop in their self-esteem, and depression is not an unusual response to the disease. It is estimated that between one and two percent of the world's population, regardless of race, is afflicted with vitiligo. Teachers should know about the condition, its impact upon victims, and ways of helping those who have the disorder.

As a teacher, you are dealing on a daily basis with children in their formative years. Self-esteem and a sense of personal efficacy can flourish or wither during this period. Because of the well documented relationship between impaired appearance and low self-esteem, it is very important that you help the pupil with vitiligo to cope with the social and psychological consequences of the impairment.

In this pamphlet, we will discuss the impact of vitiligo on three different age groups and point out some of the experiences of pupils in school settings. We will also suggest ways in which you can be of help to the child with vitiligo.

WHAT IS VITILIGO?
The pigment loss characterizing vitiligo comes from a destruction of melanocytes, or pigment cells. Part or all of a body surface may be involved, but pigment loss most often appears on exposed areas like the face and hands or around body openings like eyes, nostrils, or mouth. Once vitiligo starts, it often continues to spread. Vitiligo can begin at any age; but in half of all patients, it is noted before the age of twenty. The cause is unknown, but in more than half the victims, there is a family history of the disorder. Most individuals with vitiligo are in good health, suffer no symptoms other than depigmentation, and the disease is absolutely not contagious. The psychological effects of the impaired appearance associated with vitiligo are more detrimental to well being than the physical effects of the disease itself. Dermatologists can treat vitiligo by a combination of medication and sunlight, which usually creates at least some degree of repigmentation.

"THEY CALL ME NAMES."
The Elementary-School Age Child

Younger children in elementary school are very sensitive to teasing and unfriendliness. At the same time, many children of this age group can virtually forget their vitiligo in their enthusiasm for art, reading, and the development of new skills; for unlike adolescents, they have not yet become extremely preoccupied with appearance. As a teacher, you can best help children with vitiligo by creating a classroom environment which will not tolerate insults and abuse to the child and which, at the same time, presents the child with new challenges and interests.

It is important for you to take an active role in helping the child. Too often, teachers shrug off or ignore incidents of teasing and name-calling. The teacher should use such occasions to educate the culprit about vitiligo and comfort the victim. Children with the disorder need the assurance that the important adults in their lives will protect them and will care for them, regardless of their appearance. Otherwise, their self-esteem may suffer.

It is particularly important to give these children special attention when they find themselves in situations characterized by "newness"; i.e. in the first weeks of school, or the introduction of new classmates into the environment. Usually, as time passes, children with vitiligo relax their concerns and make friends, but they are very apprehensive about unknown people and places, feeling that they may not gain acceptance. Praise the child's strong points. Vitiligo can be forgotten in the flush of pride that accompanies achievement or the acquisition of a new skill.

If a child has highly visible vitiligo and/or seems to be having problems because of the disorder, contact the parents and determine whether or not the child is receiving treatment. Unfortunately, there are still many physicians who do not recognize vitiligo when they see it or who believe that nothing can be done for it. There are several vitiligo treatment centers in the United States, and you can put the parents in touch with one of these centers for further information.

You might also suggest some "cover-up" techniques to the family. Attractive pants or leotards can hide vitiligo on a child's legs; long sleeves may make vitiligo on the arm less of a concern. There are also several brands of special cosmetics made for people with skin disorders. They come in a full range of tones and do a good job of making the spots of vitiligo much less obvious. Sometimes parents have overly conservative notions about"make-up" believing that it's "not for children". While this may be so in the case of lipstick, rouge, and eye make-up, it should be stressed that any attempt to give the child's skin a normal appearance is a positive action if the child appears distressed.

Try to be flexible with regard to your own rules We have seen some unfortunate cases in which the teacher's rigidity has increased the embarrassment of the patient. For example, one child had a streak of white hair,which caused him much embarrassment at school. To disguise this, he wore a small ski-hat to class. His teacher, who had a rule that no hats could be worn indoors,forced him to remove the hat every day. This, of course, brought even more attention to the vitiligo from his classmates, who ridiculed him. He became afraid to go to school. Realize that these children have few defenses; they need the ones they have. Most teachers are willing to relax rules if they realize the child's self-esteem is at stake.

"I LOOK AWFUL".
The Early Adolescent (10-14)

During the junior high school years, young people are particularly concerned with the way they look. Even the most attractive children become self-conscious and complain about their height, weight, shoe size, complexion, and facial features. This normal prepubescent concern with being attractive is intensified for the child who really does have an impaired appearance. This is the most difficult stage for the child with vitiligo. Appearance is not valued in the abstract, but is linked to the discovery of the opposite sex, the importance of peers in establishing one's own sense of self, and the many transitions that occur at this time of life.

Many vitiligo patients have mentioned the switch from elementary school to junior high school as a particularly bad experience. Over the elementary school years, the child has become accustomed to peers, teachers, and the physical setting. The vitiligo has become "invisible" in the sense that it is no longer salient or novel and the child has been accepted by the group. The change to a new school and new classmates often triggers a great deal of anxiety in the child.

As this is also the point in our educational system at which group showering after gym is introduced, the child with a case of vitiligo not visible in street clothes becomes fearful of losing friends if the vitiligo is detected while showering after gym.

The enthusiasm for school and the skills acquired there which we see in the younger child begin to wane and are replaced by consuming social concerns and the desire to be part of the group. This makes it more difficult to distract the child from a concern with vitiligo. The best thing for the teacher to do is to tackle the matter of appearance with a vitiligo patient of this age who seems anxious and depressed. You can offer advice on cosmetics and clothing, and inform the patient that treatment is available. Teasing of the child should not be allowed, and you should make an effort to integrate the child into group activities. The communication with parents mentioned above is still important. Students who manifest evident social and emotional disturbance should be referred for counseling.

HIGH SCHOOL
Many young people with vitiligo who are of high school age have come to terms with the disorder. Their minds are on other matters: getting into college, finding a vocation, and forming close relationships with members of the opposite sex. For example, one patient who had been extremely anxious about vitiligo at age 13 was found at sixteen to be quite unconcerned about it, although the vitiligo itself was relatively unchanged. An interview with this young man revealed that three events had occurred which minimized his concern with vitiligo: he had entered a vocational track in school and was deriving great satisfaction from mastering the craft of carpentry; he had matured physically; and he had a steady girlfriend who "doesn't even notice the vitiligo". All of these events gave verification to his ability to be an adequate person. The self-confidence he gained compensated for any worries he had about vitiligo.

When we see a young person in this age group who has had vitiligo for some time and is still very concerned about it, we are seeing a person in need of help. A teacher may be the first one to observe the young person's concern and can refer him or her to a counselor.

If a young person has just experienced the onset of vitiligo during the late teens, we may see quite a different picture. The late adolescent onset of vitiligo may impair an appearance in which one has taken pride, and thus erode self-confidence. Coping strategies will have to be acquired. It is very important for teachers to give support to this group of vitiligo patients, suggesting cosmetic cover-ups, giving the patient emotional support, and informing him or her of the possibility of help. Counseling should be suggested for students who seem depressed.

GUIDELINES FOR TEACHERS
In all cases and for all age groups, there are certain general guidelines for the teacher:

Give support to the patient by your example and your teaching. If you pull back from the touch of a vitiligo victim, you should not be surprised to see your pupils follow suit.
Intervene in situations which are painful to the child with vitiligo. Do not ignore teasing or torments from other pupils, and try to integrate the child into group activities.
Act as partner with the parents. If the parents do not know about concealment strategies or the possibility of treatment by a dermatologist, inform them about these possibilities.
Refer the genuinely troubled student to counseling. Impaired appearance can lead to impaired self-esteem.

RESOURCES
Further information about vitiligo may be obtained from the Vitiligo Treatment Centers at either Howard University Hospital, Department of Dermatology, Washington, D.C. 20060; Yale University School of Medicine, Department of Dermatology, New Haven, Connecticut, 06510; or the University of Cincinnati School of Medicine, Department of Dermatology, Cincinnati, Ohio, 75467-0592 and the National Vitiligo Foundation 611 South Fleishel, Tyler, Texas 75701.