Approaching the Treatment of Vitiligo

Amit G. Pandya, MD, FAAD: When I talk to patients about treatment, I tell them that there are 3 pillars of treatment. One is to reduce the stress on the skin. There are reactive oxygen species being made all the time in the skin because of the inherent defect of melanocytes in patients with vitiligo, as well as life in general, UV [ultraviolet] damage and chemicals, a trauma that can cause the stress. I ask my patients to take oral antioxidants, vitamin C and vitamin E. I know gingko biloba has been published about, alpha-lipoic acid, these are easy to find antioxidants at the store. I also ask them to increase antioxidants in their diet, for example, 5 servings of fruit and vegetables every day and a handful of nuts. That’s the first pillar of therapy. For the second pillar of therapy I talk to them about removing those cytotoxic T cells from their skin. We want to clear those CD8-positive T cells from their skin, and we can do that with topical corticosteroids, topical immunomodulators, and now topical JAK inhibitors. They cause those T cells to be cleared from their skin so that the damage to the melanocytes by the immune system can diminish.

I also tell them about the third pillar of therapy, and that is to stimulate monocytes to repigment their skin. The primary way that we do that is with phototherapy. Phototherapy stimulates those melanocytes to repigment the areas, and causes them to migrate up the sides of the hairs and fill in the skin. After 3 or 4 months, when the phototherapy has reached certain doses, it will cause immunosuppression of the skin to help clear out the T cells. It has a dual function when you get to the higher doses after the patient’s been on the treatment for a few months. With these three pillars of therapy, patients can understand that they should combine these to have the most effective treatment of their vitiligo.

When you’re treating a patient with vitiligo, the most important aspect is to ensure that you are making treatment decisions on a shared basis with the patient. Patients can have different expectations when it comes to vitiligo. Some patients simply want it to be stable, so that it doesn’t spread to more visible areas. Some want the lesions to be repigmented 100%, or they don’t want to have treatment at all; some want to see the maximum repigmentation they can achieve. Some want the hands treated most of all, and they’re not as concerned about other areas, and others want other specific areas to be treated. There are many different desires that patients have for their vitiligo. That’s one of the first things I ask, “What do you want to achieve with the treatment of your vitiligo, and what bothers you the most about your vitiligo?” Once I hear that, I can then guide the treatment decisions. For example, if a patient says that they want an area of vitiligo treated that has completely white hairs, and it has not responded to treatment in the past, then I might suggest surgical modalities, in which we must do either a skin transplant or a melanocyte transplant of their skin. If patients want to have as much of their body repigmented as possible, then I might treat them with full body phototherapy as opposed to more localized treatment. The most important factor is to talk with the patient and determine what their goals are, and then customize your treatment plan based on their desires.

Another important factor in the treatment decision is the patient’s time and ability to afford the treatments. Patients may not be able to come into my office 3 times a week for treatment, and they may not be able to afford the various treatments, or they may not have insurance coverage. This is an important part of the conversation that I have with patients.

Transcript Edited for Clarity