Considerations for Evaluating Patients With Vitiligo

Heather Woolery-Lloyd, MD: Now I want to talk Dr Lain. How do you approach your patients with vitiligo? When a patient is referred to you for vitiligo, how do you evaluate them? Do you do certain tests? Tell me what you do with your patients.

Ted Lain, MD: Thanks, Heather. First, can we please acknowledge how brave Tarasha is. I mean, for her to come on this. Tarasha and I know each other, and she was so gracious and offered to volunteer for this. Thank you, Tarasha, you are helping so many people, both patients and caregivers, such as Dr Woolery-Lloyd and myself. Thank you.

Tarasha: Thank you. Thank you very much.

Ted Lain, MD: In terms of how we evaluate vitiligo, it is a striking presentation. Especially Tarasha having such a quick onset and drastic reduction of pigment is a striking presentation for her. In some people it is much less, where it is a single area or a very small area, and they catch it early and they’re coming in. In patients with more richly pigmented skin, using just your naked eyes is enough usually because there is such a contrast. In those patients who are more fair, however, with less pigment in their skin, it may require the use of what we call Wood’s lamp, which uses such black light to highlight where the pigment is and where it isn’t. Usually, we perform a full body skin examination, not only to look for the vitiligo, but to look for any other combinate skin disease and perhaps skin cancer as well if the patient has had vitiligo for long and has not been protecting themselves, just like Tarasha was saying. But then in terms of diagnostic tests, we do check when a patient has 1 other immune disease. We have to check for others because they tend to partner. On top of that, we also find thyroid disease that partners with the vitiligo, and that is done via lab tests.

Heather Woolery-Lloyd, MD: I do the same thing in my practice. We always are looking for thyroid disease because those two tend to go hand in hand, right?

Ted Lain, MD: And hopefully we catch it before their symptoms. So, it is important.

Heather Woolery-Lloyd, MD:So then when you have a patient with vitiligo, how do you explain that diagnosis to the patient? Many people know what vitiligo is. How do you explain this to the patient?

Ted Lain, MD: My explanation has evolved as science has because 10-15 years ago, we did not really understand why vitiligo happened. The immune system responds to your melanocytes or the cells in your skin that produce the pigment. What we know now is that there is some kind of alteration on the cell surface whether it is genetically based or otherwise. The melanocytes present either an antigen or some kind of complex on the cells that elicit an immune response. So, the melanocytes in people with vitiligo are altered compared to those people without vitiligo. That then generates an immune system response. This recruits T cells, or inflammatory cells. They release interferon that causes all recruitment of T cells, and this is positive feedback within the immune system and the melanocytes that unfortunately leads to melanocyte destruction. And when you lose melanocytes, you lose the ability to produce the pigment and hence the skin turns lighter.

Heather Woolery-Lloyd, MD: When a patient gets that diagnosis of vitiligo, what type of reaction do you typically see in your practice?

Ted Lain, MD: Quite frankly, many of them already know just because of their Googling and their social media aspect of vitiligo. They come in with a suspicion that they have this condition. I then go through the education part. They are not surprised for the most part. Every once in a while, especially with someone with more fair skin where they notice some kind of difference, they may not have really thought about that possibility. In those cases, it’s quite a surprise. But for the most part people come prepared for the diagnosis, honestly.

Heather Woolery-Lloyd, MD: People often come in saying, “This isn’t vitiligo, is it?” That’s a common question I’ll get. Sometimes it isn’t, but sometimes it is.

Transcript edited for clarity