Vitiligo: More than skin deep

Vitiligo (pronounced vit-uh-LIE-go) is a medical condition in which patches of skin lose their color. This occurs when melanocytes, the cells responsible for making skin pigment, are destroyed. Vitiligo can affect any part of the body, and it can occur in people of any age, ethnicity, or sex.

Affecting approximately 1% of the population, vitiligo can be an emotionally and socially devastating disease. Particularly frustrating to many is its unpredictable progression, which can be slow or rapid.

Thus far, there is no cure for vitiligo. But new hope is on the horizon, thanks to recent research that is improving our understanding of the pathways involved in this condition and potential new ways to treat it.

Body attacks cells responsible for producing skin’s pigment

Vitiligo is generally thought to be an autoimmune disease, in which a person’s immune system mistakenly attacks its own body (in this case, it attacks melanocytes). In addition, the melanocytes of people with vitiligo appear unable to deal with the imbalance of antioxidants and harmful free radicals in the body, which results in cell damage and death.

While most people with vitiligo are otherwise healthy, there is an association between vitiligo and thyroid disease (either over- or underactivity of the thyroid). Less frequently, it occurs together with other autoimmune conditions, such as lupus or type 1 diabetes.

Phototherapy and topical treatments can help

There are a number of treatments aimed at restoring color to depigmented skin. One of the oldest and most effective treatments is phototherapy (light therapy) with ultraviolet B (UVB) light. For this treatment, depigmented skin is exposed to UVB light several times a week, either in a clinic or at home.

Light therapy is often used in combination with topical medications that are applied to the skin. Topical treatments include topical steroids, topical calcineurin inhibitors (such as tacrolimus or pimecrolimus), or topical vitamin D analogues (such as calcipotriol and tacalcitol). Psoralen, a type of medication previously used in conjunction with phototherapy, has largely fallen out of favor. Topical medications may also be used on their own, without light therapy, although when the two treatments are used together, patients typically see better results.

If the depigmented areas are extensive, there is also the option of using topical medications to bleach unaffected skin, bringing it closer in color to the depigmented areas.

If medical treatments are ineffective, surgical treatment may be an option for certain people. Skin grafts can be taken from normally pigmented skin, usually from the buttocks or hips, and transferred to depigmented areas in more visible parts of the body.

New treatments for vitiligo may be on the horizon

Recently, several exciting studies have looked at a class of medications called JAK inhibitors as a possible new treatment option. JAK inhibitors target a type of immune communication pathway that has not been targeted before in vitiligo. These medications are thought to work by reducing levels of inflammatory chemicals that drive disease progression, and by stimulating melanocytes to regrow.

One study, published in JAMA, looked at the JAK inhibitor tofacitinib; another study, published in the Journal of the American Academy of Dermatology, looked at the JAK inhibitor ruxolitinib. Both reported promising results for repigmentation in people with vitiligo when the JAK inhibitor was used together with UVB phototherapy.

Though these initial studies analyzed small groups of patients, several larger-scale studies are underway to assess how both oral and topical JAK inhibitors may improve vitiligo. Preliminary data from these larger trials are showing promising results for repigmentation, especially on the face. The hope is that these results will eventually lead to FDA approval of JAK inhibitors for the treatment of vitiligo. For now, because they are still considered off-label by the FDA for use in vitiligo, these drugs are rarely covered by insurance for the treatment of vitiligo, and therefore can be quite expensive.

Psychosocial support is a key part of vitiligo treatment

A diagnosis of vitiligo can be life-altering. Patients may struggle with self-esteem or depression, and they often have to deal with social stigma, due to misunderstanding about the contagiousness of the condition. As a result, people with vitiligo typically benefit from psychosocial support in addition to medical treatment.

If you have vitiligo (or know someone who does) and would like to learn more about support groups and other available resources, please visit the Global Vitiligo Foundation or Vitiligo Support International.

Follow me on Twitter @KristinaLiuMD

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