What is vitiligo?
Vitiligo is an acquired skin disorder affecting skin color due to a loss of pigment-producing cells called melanocytes. This skin condition is relatively rare and affects approximately 0.5% to 1% of the entire population. Patients who are diagnosed with vitiligo present with well-demarcated milky white patches affecting the skin on any area of the body. These white patches can either be isolated to a specific location or may coalesce into a large depigmented area. Although the incidence is not very high, some well-known celebrities like pop singer Michael Jackson and actor Steve Martin have this condition.
What causes vitiligo?
Research has uncovered various pathways associated with the lack of melanocyte production, but the exact etiology is less understood. Factors that are believed to have an association with vitiligo are emotional stress, previous sites of physical injury or illness, sunburn, and pregnancy. There has also been an association in patients receiving hematopoietic stem cell transplants.
What are my options?
Oral and Topical Steroids. Several studies have shown that both high potency topical steroids and low dose oral steroids have great efficacy in reducing the progression of vitiligo and inducing repigmentation. Steroids suppress the immune system activity to reduce the inflammation that is associated with depigmentation in vitiligo. Oral steroids are typically reserved for use in rapidly progressive cases of vitiligo and can be prescribed in conjunction with a topical medication.
Topical Calcineurin Inhibitors. Topical calcineurin inhibitors are an alternative to topical steroids and have been found to have similar efficacy in numerous studies. A study conducted by Kose et al. found 42% repigmentation with calcineurin inhibitors compared to 65% repigmentation achieved with topical steroids. Although topical steroids have shown greater results, topical calcineurin inhibitors are preferred to steroids when treating facial vitiligo due to fewer adverse effects. Chronic use of high potency topical steroids is associated with skin atrophy, striae, and telangiectasias (visible blood vessels), whereas calcineurin inhibitors have a great safety profile.
Oral and Topical JAK inhibitors. JAK inhibitors are a drug class commonly used to treat immune-mediated conditions such as atopic dermatitis, alopecia areata, psoriasis and rheumatoid arthritis. JAK inhibitors have emerged as an excellent treatment option for vitiligo. They function by blocking a specific receptor of one or more of the Janus kinase family of enzymes (JAK1, JAK2, JAK3, TYK2), thereby interfering with the JAK-STAT signaling pathway that causes inflammation and associated pigment loss.
Latanoprost. In cases of recalcitrant vitiligo, meaning vitiligo that will not resolve despite various attempts at treatment, latanoprost is an option to consider. Research shows that a prostaglandin analogue like latanoprost can induce skin pigmentation by up-regulating an enzyme called tyrosinase and promote the production of melanocytes. A case study conducted in India by Dr. Narang found that the use of a prostaglandin analogue twice daily resulted in improvement of repigmentation between 50% and 100% after 4 months.
UV light. UV light therapy is another option that can be considered as monotherapy or in combination with other treatments. UVA and UVB rays are natural energy released by the sun at different wavelengths. UVA has a longer wavelength while UVB is shorter. A study by Majid discovered that both wavelengths have been found to significantly repigment skin in about 60.5% of patients and increased to 71% of patients when combined with topical tacrolimus.
As medicine continues to advance, more treatment options will become available. With an immune mediated condition like vitiligo, it is recommended to regularly see a board-certified dermatologist to ensure that the condition is stable and treated properly to achieve optimal results.
Joshua Attias, PA-C
Brandon Kirsch, MD, FAAD