Written by Basil Mahmoud, MD, as told by Susan Bernstein
Vitiligo is essentially an autoimmune disease of the skin that targets pigment-producing cells called melanocytes. This results in patches of pigmentation in the form of chalky white areas on the skin that can range from very small to very large, even covering most of the skin’s surface.
Vitiligo affects 0.5% to 2% of the population, both adults and children, and affects people of all ethnic groups and all skin types. Although Vitiligo is most often considered a cosmetic problem, it can have a devastating psychological impact on patients and can affect their quality of life.
Treatments for vitiligo include topical and systemic immunosuppressive medications. The best option for you depends on the extent and activity of your disease. There is also phototherapy that uses ultraviolet light and lasers. Other options include surgical treatment.
Immune T cells attack melanocytes
Recent research studies have looked at the pathogenesis of vitiligo, which simply means the chain of events that lead to this disease. These studies demonstrated that vitiligo is a disease driven by interferon-gamma that leads to the recruitment of CD8-positive T cells. These are cytotoxic T cells that deal with and kill the melanocytes, or pigment-producing cells in the skin. Now that we have a better idea of how vitiligo occurs, we can develop better treatments to address this process. These new treatments target and prevent these chains of events.
The newly developed medicines for Vitiligo that have shown promising results are Janus Medicines
Kinase inhibitors (JAC). Examples include ruxolitinib and tofacitinib. Both are immunosuppressive drugs that disrupt cytokine signaling in the interferon-gamma pathway. Some of these newer medications can be used in topical creams or taken by mouth. It takes a few months to start seeing re-pigmentation of the vitiligo skin.
Many conventional treatments are still in use and can be effective for vitiligo, such as oral and topical corticosteroids, which can have side effects if taken for a longer period of time, even topical corticosteroids. The main side effect of topical corticosteroids is skin atrophy and thinning of the skin. Calcineurin inhibitors, such as tacrolimus, are non-steroidal alternative topical treatments, and do not pose a risk of skin thinning.
Light and laser therapy
Light therapy is also a popular traditional treatment for vitiligo. The most commonly used is narrowband UVB light. It is effective and relatively safe when used under the supervision of a certified dermatologist. There is another type of light therapy called PUVA, which is still used in some countries, but studies show that if used for too long, it can cause skin cancer.
Previously, light treatments were only performed in a dermatologist’s office two to three times a week. While it only takes a few seconds to a few minutes to get treated, you should still leave work or school to come to your doctor’s office. Now, light therapy devices are available at home, including many that are covered by dermatologist’s insurance.
There is also a laser treatment for vitiligo called the excimer laser. You must go to your doctor’s office for this treatment. A machine used to target vitiligo areas of the skin with an excimer laser. This treatment falls within the UV spectrum, but it is a laser, not a light. It is stronger and can have a good effect on areas that do not respond to UV treatment. You need to have the treatment two to three times a week.
New cell and tissue transplant surgery
Cell transplant surgery is an option to treat recalcitrant vitiligo, which means when patches of vitiligo fail to respond to other conventional medications or mild treatments. There are very few places in the United States that offer this surgery; One of them is in the Department of Dermatology at the University of Massachusetts. In vitiligo, there is a loss of melanocytes in your skin, but hair follicles in this area may be present and act as a reservoir for melanocytes. But if the hair also becomes white, the melanocyte reservoir will be lost, and the vitiligo area will not respond to conventional treatment, and this is the time when the cell transplantation achieves the best results.
One type of surgical treatment is tissue culture, such as punching grafting from normal skin and applying it to the vitiligo area. But the surface area to be treated with this type of implant is very limited. Also, the result is not ideal because it can cause a “cobbled” appearance, which may be cosmetically unacceptable.
The other type of surgical option, the one that I make, is the cell transplant technique. We take a small amount of normal skin from a donor area, usually a hidden area of the body such as the groin or buttocks. Then we extract the melanocytes and attach them to a solution. While doing this step, we use a laser to re-appear the areas of vitiligo. Then, when the cells are ready, we put them on the vitiligo spots and cover them with a bandage. This technique only requires taking a small area of skin from the donor area to cover a much larger area of vitiligo, which is a huge advantage. The result leads to homogeneous re-pigmentation without the cobbled effect. All this procedure is done under local anesthesia as an outpatient procedure. Complications are minimal with excellent results.
Talk about your options
When a patient with Vitiligo comes to our office, he is counseled regarding the nature of his condition, different treatment options, techniques, and complications in detail. Then we come up with the best treatment plan for you. There are also many resources to help you understand vitiligo and treatment options that can be found on the American Academy of Dermatology website, so please visit www.aad.org Learn more about skin, hair and nail health www.umassmed.edu/vitiligo/ For the Vitiligo Clinic and Research Center at UMass.
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