Time to Re-pigmentation in Vitiligo

Brett King, MD: Wrapping up this section, a couple of important points everybody has said at one point or another, this takes time. We've talked about counseling patients, this is going to take time. How much time, and here Heather, what do you tell patients to create reasonable expectations? We know if we tell a patient, go home, and use this and we don't tell them this is going to take months, it makes sense. They're going to stop in 6 weeks and go find another dermatologist. And so how do we need to have this conversation with patients? What do we need to tell them to expect over time?

Heather Woolery-Lloyd, MD: This is such a good point because we really need to set realistic expectations when it comes to vitiligo improvement. I am very honest with my patients. I feel like the face as we've discussed is the easiest to repigment. I tell my patients, you should see significant improvement at around 4 months. You should definitely start to repigment and a lot of patients do quite well. I do think that I am lucky as to where I practice where we just get a tremendous amount of ultraviolet light. But, in addition to the patients who are doing UV treatments in the office, but I say months and months and months. For the face, I say at least 4 months for you to see results that you will feel like this is really working. Now for the other parts of the body so we've talked about the more challenging areas, the hands particularly the tips of the fingers that can take much longer, a year. And we must be honest with our patients. I think that's very, very, very important to say, this can take 6, 8, 12 months to treat these areas. And you may not see improvement in the most challenging areas, like the tips of the fingers. I set the expectations early and I tell them for the face I'm confident. It's important to give vitiligo patients hope. I do emphasize on the positive. Most patients that I see present with some facial involvement. And I say with a lot of confidence, your face is going to do really great. And in around 4 months you should see some significant improvement. And then I temper that with the realistic expectations for the body, which we all know covered areas, genitals, chest underarms are hard to treat. I set those expectations to be months and some areas are very, very challenging to repigment and we may not see pigmentation in those areas.

Brett King, MD: Hearing you say that reminded me of what Amit said earlier about photography and the value of photography in the vitiligo patient encounter. Because the worst is when somebody comes back and they're living in their skin. And they're not necessarily seeing the dramatic change because it's happening day after day. And they get used to it and they fail to remember what they look like 4 months ago or 6 months ago. And a photograph is critically important in helping them understand, whoa, whoa, whoa, look how far we've come or look that we've made even a little bit of progress. But again, if you establish, early in the relationship with patients that this is going to take a lot of time, even seeing a little bit of improvement, it helps to reinforce, look, I said that this is going to take time, but look, you're making progress. And let's keep going if that's what you want to do.

Heather Woolery-Lloyd, MD: Yes. And the other thing I want to bring up is that we also should never make assumptions on what a patient thinks improvement is. Sometimes a patient might follow up and they might just be when you look at the photographs a little bit better, but they get excited because they do see some change and some improvement. Other patients can totally repigment except for a few little areas and be very disappointed because those few little areas didn't repigment. It requires a lot of discussion setting expectations and also discussing with the patient realistically, what results would you be happy with. Once you set those expectations at the beginning, it's a much easier management– once you set those expectations with the patient, it's much easier to manage vitiligo as a team. The dermatologist and the vitiligo patient together are on the same team. We know what our expectations are and what we're both actively working to achieve.

Amit Pandya, MD: I'd like to answer their question of why it takes so long to see repigmentation. I'm amazed that when I see a patient with guttate psoriasis, I can give them 12 phototherapy treatments. And when they come back after just 12 treatments, they are substantially better or clear. Why is that? In psoriasis the phototherapy is getting rid of a band of T cells in the dermis and the neutrophils in the epidermis. And once those are gone, everything just comes back to normal. But in vitiligo, the phototherapy, and the creams and such, you're applying first it has to get the epidermal keratinocytes and dendritic cells to make less CXCL9 and CXCL10. And then the T cells that are attacking the melanocytes have to disappear from the epidermis. And then the helper T cells have to disappear from the dermis. And then the melanocytes that are at the edges, who are in a state of shock must recover from the killing. And then the melanocytes at the base of the hair, which is one centimeter or half a centimeter way below the epidermis must be stimulated to start replicating and migrating. And you're asking cells to migrate up the outer roots sheath and then fill in the skin and the ones from the side to move in. This helps explain why psoriasis and vitiligo are so different in terms of response. And the studies have shown that in the average improvement with everything we've talked about is 25% improvement in 3 months, 50% improvement in 6 months, and 75% improvement in nine months. And then it plateaus. Now, like Heather said, the face will do more than 25%. The hands will do less than 25%, but on the mean improvement is 25, 50, and 75. I explain that to every single patient. They know that they're going to be my friend for at least 9 months, and I'm going to be walking this path with them, and we're going to be seeing that percentage improvement.

Brett King, MD: Again, the conversation with patients and helping them understand the process, and love that. For the patient who wants more information, helping them understand that is critical, but, I also think Amit, it's really important that all of us, that providers understand that process. Because again we have this idea from psoriasis biologics, why can't we make everything go away, and get improvement in three months? It's because we're talking about melanocyte destruction and melanocyte revival. And that fundamentally is not like making red skin go away, as is often true in other inflammatory diseases that we're accustomed to treating. And it's helpful for us as providers to understand that process and to understand why it's so slow, but also to communicate that with patients, so that they get early buy-in to the amount of time this is going to take.

Transcript Edited for Clarity