More Than a Cosmetic Concern – Increasing Understanding of and Addressing Challenges and Care in Vitiligo, an Autoimmune Condition

Sponsored by Incyte

Vitiligo is a chronic autoimmune condition resulting in depigmented lesions of skin that can appear on any part of the body. The condition, which has been diagnosed in approximately 1.5 million people in the United States¹, occurs with similar frequency in all ethnic groups and can occur at any age, although initial symptoms often appear before the age of 30^2,3.

Given the visual nature of the disease, vitiligo is sometimes viewed as a cosmetic issue rather than as an autoimmune condition⁴. Because of this misconception, the severity and impact of vitiligo – both physical and emotional – can often be downplayed or overlooked. In addition, the limited treatment options currently available for vitiligo can lead people living with this condition to believe they have little to no choices⁴.

More than cosmetic: The role of the immune system in vitiligo

Research suggests vitiligo develops in genetically-susceptible individuals when environmental triggers – e.g., sun exposure, chemical exposure, physical skin trauma or psychological strain – induce stress responses in the skin⁵.This causes a localized autoimmune response in which melanocytes are targeted and destroyed by CD8+ T-cells^5,6.

• Trigger event: An environmental trigger combined with genetic factors leads to melanocyte stress, causing an inflammatory response⁷.
• Immune activation: Innate immune cells activate CD8+ T-cells that target melanocytes and release IFN-γ⁷.
• JAK-STAT activation and inflammatory cycle triggering: IFN-γ activates the JAK-STAT pathway (by binding to JAK 1 and 2) to induce production of immune mediators (CXCL9/10) by keratinocytes. More autoreactive T-cells are attracted to the site, where they continue the inflammatory cycle by producing more IFN-γ in a positive feedback loop^{3, 7-9}.
• Melanocyte death and depigmentation: The T-cell attack creates a hostile environment resulting in melanocyte death, which leads to depigmentation^7,9.

People living with vitiligo would benefit from additional options to consider with their health care team.

Vitiligo has a significant burden of disease

The social stigma around vitiligo, and the idea that it is a cosmetic issue rather than an autoimmune condition, can significantly impact people with vitiligo. Findings from the global Vitiligo And Life Impact Among INTernational Communities (VALIANT) study underscore the profound impact vitiligo has on people’s lives. This was an observational, cross-sectional evaluation of the burden of vitiligo from the perspective of patients aged 18 years and older with vitiligo and health care professionals who treat patients with vitiligo¹⁰.

• Of the more than 3,500 adults with vitiligo surveyed, nearly 60% said they had been diagnosed with mental health conditions, including anxiety (28.8%) and depression (24.5% )¹⁰.
• 49% said having vitiligo made them feel less confident and more self-conscious¹⁰.
• Some of those surveyed also said they experience sleep disturbance and approximately half said the progression of their disease worries them¹⁰.

Additionally, a patient-focused meeting held by the U.S. Food and Drug Administration (FDA) in March 2021 explored the health effects and daily impact of vitiligo as well as management goals⁴. Among the key findings was that vitiligo can lead to feelings of loss of identity, particularly among African Americans⁴. Some participants expressed that others are unable to see past their condition, making it hard to establish successful friendships or secure employment⁴.

As such, it is critical for health care providers to approach discussions about vitiligo with their patients as an autoimmune condition and to consider the full impact that vitiligo can have on a person’s daily life. By educating people with vitiligo about the science behind their condition and forming a doctor-patient relationship based on trust, an individualized management plan tailored to a patient’s specific needs and goals can be established.

Supporting patients and managing vitiligo

As a result of their disease, people with vitiligo may feel frustrated, misunderstood and unheard, and their health care teams may have a challenging time supporting their needs. It is essential that dermatologists and other health care providers who diagnose and manage vitiligo discuss the science behind the condition and the impact it may have with their patients. Approaches to engage in these conversations can include:

• Explain the autoimmune nature of vitiligo
• Create individualized management goals
• Inquire about the mental health impact
• Establish a regular cadence of appointments to ensure appropriate follow up

It is important that dermatologists take the time to understand how the condition impacts their patients’ quality of life and emotional well-being. Management of vitiligo is a process, and expectations need to be set based on each patients’ individualized management plan. We need to form open lines of communication with patients early on and provide easily understood information about the science behind the condition. We can thereby help people living with vitiligo see it as an autoimmune rather than cosmetic issue and support informed decisions about their health and the overall management of their disease.

For more information, visit vitiligodeeper.com.

Note: Dr. Batra has been compensated for her time.

References

1. Bowcock AM, Fernandez-Vina M. Targeting skin: vitiligo and autoimmunity. J Invest Dermatol. 2012;132:13-15. Dermatol. https://www.sciencedirect.com/science/article/pii/S0022202X1535452X. Accessed June 23, 2022.
2. National Library of Medicine. Medline Plus. Vitiligo. https://medlineplus.gov/genetics/condition/vitiligo/. Accessed April 11, 2022.
3. Frisoli M, Essien K, Harris JE, et al. Vitiligo: mechanisms of pathogenesis and treatment. Annu Rev Immunol. 2020;38(1):621-648.
4. U.S. Food and Drug Administration. The voice of the patient: A series of reports from the U.S. Food and Drug Administration’s (FDA’s) patient-focused drug development initiative. https://www.fda.gov/media/155068/download. Accessed May 4, 2022.
5. Manga P, Elbuluk N, Orlow SJ. Recent advances in understanding vitiligo. F1000Res. 2016;5LF1000 Faculty Rev-2234.
6. Rodrigues M, Ezzedine K, Hamzavi I, Pandya AG, Harris JE; Vitiligo Working Group. New discoveries in the pathogenesis and classification of vitiligo. J Am Acad Dermatol. 2017;77(1):1-13.
7. Strassner JP, Harris JE. Understanding mechanisms of autoimmunity through translational research in vitiligo. Curr Opin Immunol. 2016;43:81-88.
8. Damsky W, King BA. JAK inhibitors in dermatology: the promise of a new drug class. J Am Acad Dermatol. 2017;76(4):736-744.
9. Howell MD, Kuo FI, Smith PA. Targeting the Janus kinase family in autoimmune skin diseases. Front Immunol. 2019;10:2342.
10. Bibeau K, Hamzavi IH, Ezzedine K, et al. Mental health and psychosocial burden among patients living with vitiligo: findings from the global VALIANT survey. Presented at Maui Derm for Dermatologists, January 2022.
    

MAT-DRM-00447 07/22