In vitiligo, a faulty immune reaction kills off pigment cells called melanocytes and leaves patches of white skin. Considered an autoimmune disorder, vitiligo often emerges in adolescence or later, occurring in an estimated 1 to 2 percent of the world’s population and affecting all ethnic groups equally — although the depigmentation is more obvious on darker skin and carries greater social stigma in certain cultures. More than 50 separate gene changes have been linked to a greater risk of developing vitiligo, but what actually triggers it is unclear. Some areas of the body, such as the face, are more likely to be affected, as are areas of the skin that have had trauma.
In some small percentage of people, the patches clear up spontaneously, but most linger for life. That can take a psychological and emotional toll. Surveys show that the majority of people with vitiligo experience shame and insecurity; for some such feelings can bloom into clinical depression. And as with other kinds of immune activity gone awry, it can be hard on other parts of the body as well. It’s impossible to predict how widespread a person’s vitiligo will be and when it will stop spreading (if ever).
Existing treatment are non-targeted, time consuming and offer moderate efficacy.
Currently, the only FDA-approved drug for vitiligo — called monobenzone or Benoquin — actually worsens it, stripping the body of all remaining pigment cells to give the skin a more uniform tone. So, management is primarily through the use of off-label therapies.
The mainstay of treatment in vitiligo is immunosuppressives and phototherapy. Multiple factors, including disease extent activity, and distribution, should be considered when developing a management strategy in each patient. The treatment may be less effective in patients with the segmental variant of vitiligo, which is characterised by rapid progression of depigmentation in a unilateral distribution, which then stabilizes and remain confined to this focal area.
Vitiligo is not a life threatening condition; therefore patient may decline treatment. However, early and aggressive treatment is associated with better outcomes, which should be addressed with each patient. Regardless, education about the disease and psychological support should be offered to all patients. For treatment purposes, vitiligo patient are generally classified into two groups: patient with limited body surface area (BSA) involvement and patient with more widespread disease.
Segmental Vitiligo and Limited Vitiligo
First-line treatment in patient in this group is treated with potent topical steroids (clobetasol propionate 0.05%) and /or calcineurin inhibitors (tacrolimus 0.03-0.1% or pimecrolimus 1%).weaker steroids have not demonstrated efficacy, thus potent steroids are preferred. One common strategy to reduce the potential side effects of potent steroids is to use both steroids and topical calcineurin inhibitors in an alternating schedule. This can be achieved by application of steroids twice daily for 1 week, followed by calcineurin inhibitors twice daily for the next week, and continued in this way through an alternating weekly schedule. For sensitive areas like the face, genitals, axillae, and breasts, use of calcineurin inhibitors without steroids is preferred.
Targeted phototherapy devices, which deliver light in the UVB range, can be considered a second line option in patients who do not respond to topical treatments. Due to certain limitations like the unavailability of the devices and the poor compliance of patients to this particular mode of treatment I have limited experience.
Surgical procedures are offered in a minority of carefully selected patients with highly stable disease and have the best outcome in segmental variants. There are multiple different techniques to achieve this, including punch grafting, epidermal blister grafting, and cellular grafts, each with advantages and disadvantages. Regardless of the technique used, surgical procedures are contraindicated in patients with unstable disease or evidence of the Koebner phenomenon.
Widespread Disease (>3% BSA)
Phototherapy is considered the first-line treatment in patients with widespread disease but due to the reasons mentioned above I have limited experience here.
Systemic steroids may be indicated to arrest disease activity in patient with highly progressive disease, before other therapies have demonstrated efficacy. This is delivered as pulse therapy (5 mg betamethasone / 4 mg dexamethasone on 2 consecutive days each week or alternate-day doses of 20 mg prednisolone) to reduce the side effects. Corticosteroid pulse therapy is tapered gradually over 6 months depending on the patient’s response. This can be followed by maintenance with other steroid-sparing immunosuppressant.
Low dose Methotrexate (oral 10 mg weekly) for 6 months is equally effective in patients with widespread vitiligo. Other immunosuppressant like Azathioprine has been tried in numerous patients with variable response.
Placentrax extracts are not effective. Minocycline has been reported to be effective for vitiligo when given for long duration, but I have resisted any attempt to try in any of the patient. I don’t think it is rational to prescribe antibiotics for prolonged periods, keeping in mind the rising menace of bacterial resistance. Oral vitamins and supplements are given to most of the patient owing to their antioxidant properties.
Relapse of disease is common after discontinuation of treatment. Tacrolimus 0.1% or pimecrolimus 1% applied twice weekly are given to prevent relapse in patients and thus a reasonable approach to maintenance therapy.
Irrespective of the systemic and the topical treatments given, one needs light exposure, either natural sunlight or UV phototherapy, to produce a noticeable response to the drug.
What’s new: Healing in the light
Known as JAK inhibitors, these agents block a different family of immune molecules, called the Janus kinase or JAK proteins, which also rev up the body’s T cell attacks on itself. These drugs arrived on the vitiligo scene after Brett King, a dermatologist at Yale University, published a case report in 2015 describing his off-label use of tofacitinib, a JAK-blocking agent from Pfizer. Although the drug was proven then to work only for patients with rheumatoid arthritis, King showed that it also helped to repigment the face, hands and arms of a middle-aged woman with widespread vitiligo.
A nationwide phase II clinical trial, coordinated out of Tufts Medical Center in Boston, has found that a topical cream was extremely effective in reversing the effects of vitiligo, a relatively common autoimmune disease that causes loss of skin pigmentation. Topical application of the medicated cream, ruxolitinib, which is currently used as an oral treatment for certain blood disorders, resulted in substantial improvement of facial vitiligo symptoms in nearly half of the trial’s participants. Results of the clinical trial were presented by David Rosmarin, MD, Dermatologist at Tufts Medical Center and Primary Investigator for the study, on Saturday, June 15, at the World Congress of Dermatology in Milan, Italy.
Conclusion
Even as scientists celebrate progress in the lab, a stigma-busting movement asserts that those with the autoimmune skin condition are more in need of acceptance than medicine.
The treatment of vitiligo needs to be individualized and thus a tentative plan of management should be decided at the very outset and a realistic goal should be set. Finally, the management of vitiligo would not be complete without good counselling, motivation and psychological support to the patient.
Yet because the changes brought by vitiligo are mostly cosmetic, some in the vitiligo community have been working, with some success, to push back against defining it as a disease. In news reports, the face of vitiligo is Winnie Harlow, a supermodel who thrives with dappled skin. The online conversation is now dominated by social media influencers who promote messages of inclusivity and diversity on Instagram, Facebook and elsewhere. There, vitiligo is portrayed as beautiful, a skin-deep condition worth embracing, not fixing.
Dr. Dilimpou Pamei
Dermatologist
District Hospital, Tamenglong
Govt. of Manipur
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