Experts Excited by Advancements in Vitiligo Treatment

"I think [awareness] has been sparked by celebrities who have revealed that they have vitiligo. My older patients, particularly older Black patients, will refer to it as that ‘disease that Michael Jackson had.’ And younger patients will refer to Winnie Harlow, who is a famous model,” said Susan C. Taylor, MD, FAAD. She kicked the conversation about vitiligo during “Informed Perspectives: Expert Insights on Treatment Strategies for Patients With Vitiligo,” a custom Dermatology Times DermView video series.

Taylor is the Bernett Johnson Endowed Professor of Dermatology at the University of Pennsylvania Perelman School of Medicine in Philadelphia. Taylor joined George Han, MD, PhD, an associate professor in the Department of Dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra University in Hempstead, New York, to share insights on vitiligo awareness, demographics, treatment approaches, and the impact of the condition on patients’ quality of life.

Awareness and Demographics

Although prevalence estimates range from 0.5% to 2% worldwide, the onset typically occurs before the age of 30 years, making it a condition that affects people from all walks of life. There are deep-rooted beliefs about vitiligo in certain cultures that can affect a patient’s mental health.¹

“There was a whole talk about the kind of psychosocial impact of vitiligo and the historical basis of vitiligo in Southeast Asia in Southern Asian populations,” Han explained. “In some Indian populations, it was [once] closely aligned with leprosy. These people were shunned by society… and they were kind of outcasts. So it’s important to realize that, even though we might approach it in our way of thinking that this is obviously a cosmetic problem, it might carry different beliefs with them.”

Autoimmunity and Vitiligo

Taylor explained that vitiligo is not contagious, debunking a common misconception. She highlighted the role of autoimmunity, environmental triggers, and oxidative stress in its etiology. Interferon gamma, along with certain chemokines such as CXCL9 and CXCL10, plays a crucial role in driving depigmentation through CD8 T cells and the destruction of melanocytes.²

Autoimmune Comorbidities

Taylor stressed the importance of assessing autoimmune comorbidities in patients with vitiligo, particularly thyroid disease, diabetes, rheumatoid arthritis, and lupus. Regular screenings, including thyrotropin, thyroid antibodies, hemoglobin A_1C, rheumatoid factor, and antinuclear antibody, are recommended to ensure comprehensive care.

Quality of Life Considerations

Recognizing the profound impact of vitiligo on patients’ quality of life, Taylor advised clinicians to approach discussions with humility and respect. Understanding how vitiligo affects a patient’s daily life and identifying troubling areas, such as hands or face, can guide treatment decisions. Additionally, providing resources on support groups and foundations can offer valuable emotional and psychological support.

Types of Vitiligo

Taylor categorized vitiligo into nonsegmental and segmental types. Segmental vitiligo affects 1 side or a specific dermatome, whereas nonsegmental vitiligo encompasses various subtypes, including generalized, universal, mucosal, and focal disease. Distinguishing vitiligo from other pigmentation disorders is crucial for accurate diagnosis, she said.

Treatment Approaches

Han emphasized the importance of setting realistic treatment expectations for patients, especially with the time it takes to see results. He highlighted the genetic risk factor for vitiligo, which differs significantly from that of melanoma, offering a potential positive perspective. Taylor explained the various treatment options, including topical agents, phototherapy, laser therapy, and the promising topical JAK inhibitor ruxolitinib (Opzelura, Incyte).

Ruxolitinib: A Game-Changer

The conversation delved into the mechanism of action of ruxolitinib, a JAK inhibitor that regulates IFNβ - mediated JAK-STAT signaling, which is thought to reduce CD8+ T cell–mediated destruction of melanocytes. Its topical formulation offers a safer alternative to systemic JAK inhibitors, with impressive results in clinical trials for patients 12 years and older with nonsegmental vitiligo.¹

“It’s a wonderful tool to have in the toolbox. Studies have shown a significant improvement after 6 months,” Taylor said. “In a large percentage of the patients, ruxolitinib was used as a monotherapy.... If you continue the treatment beyond 6 months, you get even better results. Now there have been [data published in] some publications where they’ve combined ruxolitinib with ultraviolet B phototherapy, and the results have been even more robust.”

Follow-Up and Future Prospects

Taylor recommended follow-up appointments every 3 months, acknowledging that patience is crucial in vitiligo treatment. They expressed optimism about the future of vitiligo care, with ongoing research exploring new targets and therapies. Han concluded by highlighting the need for increased access to vitiligo treatments and the importance of advocating for insurance coverage.

“I think there are a lot of vitiligo patients out there who have just given up because they’ve been told no, ‘we can’t help you’, or they tried these various things that are not really targeted for them,” Han said, reflecting on his experiences in treating patients and facilitating clinical trials.

Han and Taylor agreed that advancements in vitiligo treatments, such as ruxolitinib, pave the way for more effective solutions in the future and a brighter outlook for those with vitiligo.

References

1. Bibeau K, Pandya AG, Ezzedine K, et al. Vitiligo prevalence and quality of life among adults in Europe, Japan and the USA. J Eur Acad Dermatol Venereol. 2022;36(10):1831-1844. doi:10.1111/jdv.18257

2. Riding RL, Harris JE. The role of memory CD8+ t cells in vitiligo. J Immunol. 2019;203(1):11-19. doi:10.4049/jimmunol.1900027

3. Sheikh A, Rafi que W, Owais R, Malik F, Ali E. FDA approves ruxolitinib (Opzelura) for vitiligo therapy: a breakthrough in the field of dermatology. Ann Med Surg (Lond). 2022;81:104499. doi:10.1016/j.amsu.2022.104499