Written by Laurie Fargo, MD, assistant professor of dermatology, University of Nebraska Medical Center, Omaha, told by Susan Bernstein
Vitiligo is a largely chronic disease with an unpredictable course, so treatment can be difficult for many people. Everyone responds differently to different medications. First, I set their goals and expectations from treatment.
The mainstay of treatment for vitiligo includes various topical creams, light therapy and oral steroids. But the world of dermatology is constantly evolving, so now new treatments for vitiligo are emerging. If we need to, we can turn to a toolkit of new treatments. There is a lot of good research and evidence behind some of our age-old treatments for vitiligo, and most dermatologists will start with these treatments.
Vitiligo may be an autoimmune disease
The causes of vitiligo are still largely unknown. We think there is a component of autoimmunity. Vitiligo is usually associated with other autoimmune diseases. It is very important to know your history of treating vitiligo. Autoimmune thyroid disease is one of the most common conditions we see in people with vitiligo.
There are some newer treatments for vitiligo, and I usually use them when we haven’t seen any improvement with the older treatments. We have to weigh all the risks and benefits of any treatment. We must consider the potential side effects of any treatment, and cost is also a big issue for some patients.
There are many exciting new drugs in dermatology, but access to them can be a major barrier. Older treatments are better covered by insurance. I don’t want to offer someone a topical cream that they can’t afford when they go to pick it up at the pharmacy.
Start with topicals and light therapy
For vitiligo, we start with topical medications and light therapy. We create each treatment plan on an individual basis because Vitiligo can be a challenging and frustrating condition to treat. People usually have a lifelong illness and must continue their treatment. There is no guarantee that we will be able to recover [skin] pigmentation or your skin will return to normal.
One of the newer drugs for treating vitiligo is Janus kinase inhibitors, also known as JAK inhibitors. None of these medications are currently approved by the U.S. Food and Drug Administration for the treatment of vitiligo, but this is likely to change soon.
With this new class of oral and topical medications, we have to address the potential side effects that accompany treatment.
Excitingly, we have a topical version of one of these medications called ruxolitinib, which is currently used to treat eczema. There have been some encouraging studies for this in the treatment of vitiligo, including facial vitiligo.
Usually, when we use topical medications, we are not concerned about systemic side effects. However, with topical JAK inhibitors, including ruxolitinib, we are still not sure. [how much of the drug you absorb through your skin] And how it might relate to potential side effects. This question remains.
Protect eyes and skin
There are other health risks for people with vitiligo. Our pigment cells are the cells that give us our pigment and protect our skin from the sun. So when you’re lacking pigment-producing cells, you’re more at risk of getting a sunburn. I talk to all my patients with vitiligo about how important it is to keep the skin covered and protect your skin from burns. People with vitiligo do not have this barrier to protect their skin from the sun’s rays.
I recommend that people with Vitiligo or anyone else use a sunscreen with SPF 30 or higher, broad spectrum, and water-resistant. It is really important to put enough sunscreen on your skin and reapply it too. Most people don’t put enough sunscreen on their skin. You need to apply 1 ounce of sunscreen at a time. This is enough to fill a shot glass. It should be reapplied every two hours or after sweating or swimming.
I recommend a UV protection factor or UPF clothing. You can find these clothes in many stores these days. These clothing provide additional protection from the sun. It has become really popular with kids too. Children wear rash guards when they play outdoors. Because there are pigment-producing cells in our eyes as well, it is important for people with vitiligo to use sunglasses to protect their eyes when they are exposed to the sun as well.
It’s not just a ‘cosmetic’ condition.
Our skin is our largest and clearest organ. People with any skin condition are at increased risk of low self-esteem and a reduced quality of life due to the condition of their skin. People with vitiligo are often affected by this. I think it is important for me to educate my patients with Vitiligo, especially children, so that they can explain what Vitiligo is to others, such as on the playground or at school. I want them to be able to feel comfortable with the skin they are in. Adults with vitiligo too, and all of us, are prone to self-esteem issues when it comes to the appearance of our skin.
I’ve noticed that many people talk about vitiligo treatments as ‘cosmetic treatments’ or that vitiligo is a ‘cosmetic condition’. I feel the term “cosmetics” suggests that we take something natural and enhance it. But for Vitiligo, we treat your skin condition just as we treat any other health condition you have.
If you have symptoms of vitiligo, it is important to get a diagnosis from a dermatologist. That’s because other skin conditions can mimic or resemble vitiligo. There are some rare conditions that we want to rule out first. There are some allergic skin diseases that can resemble vitiligo.
Make-up and beauty
One thing I talk about with my patients is a makeup product called Dermablend for skin coverage. You can also use self-tanning products that contain DHA. Using a self-tanner is perfectly fine if you suffer from vitiligo. You can use it to cover up skin lesions if you want a more even look. If you go out and tan, you’ll only get the remaining tan from your skin.
I often recommend light therapy to people with vitiligo. This is one of my favorite treatments for this condition. It is also called photodynamic therapy. It is a treatment that uses directed ultraviolet light. Sometimes, when I recommend light therapy, my patients say, “Aren’t you a dermatologist? I thought the sun was bad for your skin!” But this type of light therapy should only be done as directed by a dermatologist.
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