Advances in the understanding and treatment of vitiligo

Vitiligo is a skin disease of variable course characterized by the appearance of whitish lesions produced by a dysfunction or loss of melanocytes (melanin-producing cells in the skin).

Clinically, two types of vitiligo are distinguished:

  • Non-segmental vitiligo (the most common).
  • Segmental vitiligo, in a localized area.

The onset and course of the disease is variable according to the clinical form of vitiligo, in addition to producing various psychosocial disturbances in sufferers, including low self-esteem and depression.

Causes of vitiligo

The causes of vitiligo include genetic factors, alterations in biochemical pathways, melanocyte adhesion dysfunction, autoimmune disorders and nervous system disorders. Greater knowledge of these alterations is allowing the development of new and very promising treatments.

The best prognosis for this pathology is when we find vitiligo:

  • Vitiligo in young people
  • Less than 5 years of vitiligo evolution.
  • Segmental vs. non-segmental forms
  • High phototypes (darker skins)
  • Facial and body locations versus distal areas and fingers.

Treatment for vitiligo

Traditional treatments for vitiligo include topical and systemic immunomodulators and phototherapy. Depigmenting treatments of unaffected areas are rarely used; they are only indicated when repigmenting treatments fail and more than half of the body surface is affected.

Topical treatments for vitiligo

Medium-high potency topical corticosteroids have been shown to be effective as have calcineurin inhibitors (tacrolimus and pimecrolimus), although they require months of application to achieve results. Topical corticosteroids should be applied according to the specialist’s indications to avoid possible adverse effects.

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Systemic treatments for vitiligo

They are used to stabilize the progression of rapidly progressive vitiligo, and have been used with variable results: oral corticosteroid pulses, oral minocycline (100 mg/day over 1 month) and methotrexate. High-dose sinvastatin has been shown to repigment isolated cases of vitiligo.

New biologic treatments for vitiligo

JAKinase inhibitors such as tofacitinib and ruxolitinib have been shown to be effective in cases with vitiligo and other autoimmune diseases. Specific clinical trials are ongoing. Abatacep , a fusion protein that prevents co-stimulation of T lymphocytes by dendritic cells,

Ultraviolet phototherapy for vitiligo

PUVA, broadband UVB and narrowband UVB (311 nm) have been shown to be effective. The latter are the form of phototherapy of choice because they are the most effective and have the least adverse effects (they can also be used on children and pregnant women). In European and American guidelines it is considered one of the most effective standard treatments. DermoMedic’s phototherapy unit is equipped with this type of device.

Laser and excimer light for vitiligo

These are lamps that emit high-intensity, focused 308 nm light. They are applied only on the affected areas of vitiligo, and have proven to be effective in repigmenting many vitiligo plaques without adverse effects. They are applied 1-3 sessions per week for several months. At DermoMedic clinic we have years of experience with the use of excimer laser with very good results.

Combination treatments for vitiligo

In general, the combination of phototherapy and topical immunomodulators produces higher response rates than separate therapies.

  • Afamelanotide for vitiligo; this is a synthetic MSH analog that binds to the melanocortin receptor stimulating melanocyte production and function. Afamelanotide implants have been shown to pigment vitiligo lesions especially in combination with phototherapy. They also increase the pigmentation of unaffected skin so that the color difference may be accentuated especially in fair skin, a fact that limits their use.
  • Latanoprost and bimatoprot for vitiligo; it is a prostaglandin F2alpha analog that induces skin pigmentation by stimulating melanocytes and tyrosinase. Its topical effect on vitiligo is being investigated with encouraging results.
  • Physical procedures for vitiligo
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Dermabrasions with eribium laser and fractional CO2 laser together with phototherapy are being used to repigment patients with vitiligo with satisfactory preliminary results. At DermoMedic we have these therapeutic procedures available. Other treatments for vitiligo Surgical treatments of melanocyte transplantation from non-vitiligo skin areas to affected areas have been tried with different techniques. The results are variable and the indication is for localized and stable forms of vitiligo.

Conclusions:

In recent years, progress has been made in the knowledge of the alterations that cause vitiligo, which is allowing the implementation of new drugs and very hopeful therapeutic measures. Although we still do not have a cure for vitiligo, the future is very promising.

For more information, consult your dermatology specialist.