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    New thoughts, therapies for vitiligo

    Cutting-edge therapies combined with old-fashioned TLC

    New knowledge of the pathogenesis of vitiligo (ICD-10-CM L80) has given rise to new treatments and new hope for sufferers of this condition, says Pearl E. Grimes, M.D. She is director of the Vitiligo and Pigmentation Institute of Southern California and clinical professor of dermatology at The University of California Los Angeles David Geffen School of Medicine.

    65-year-old African-American female treated for six months with NBUVB phototherapy and four afamelanotide implants. Photo:  Pearl Grimes, M.D.65-year-old African-American female treated for six months with NBUVB phototherapy and four afamelanotide implants. Photo: Pearl Grimes, M.D.Dr. Grimes spoke about vitiligo at MauiDerm 2016. Thanks to genetic research over the past decade, she says that "We now know that probably 90% of the genes that have been identified in vitiligo are immune-susceptibility genes; 10% are pigment-related genes." Such a genetic predisposition can lead to "sick melanocytes," she says. "Melanocytes from people with vitiligo do not grow as well in culture.1 There are probably some inherent defects in these melanocytes that may tie back to the genetics of the disease."

    Oxidative stress might be the primary event that initiates the immune dysfunction that leads to vitiligo, says Dr. Grimes. "In vitiligo, we know that hydrogen peroxide is up, [while] catalase—a major oxidative stress fighting molecule—is down. Alterations in the body's innate ability to protect against oxidative damage may play a role in releasing autoantigens and neo-antigens, she says. This leads to a major influx of CD8 lymphocytes—the major players in mediating the destruction of melanocytes in vitiligo. Studies suggest that these cytotoxic lymphocytes are increased in the blood and infiltrating into the epidermis in the areas of damaged melanocytes, she says: "Interferon (IFN)γ is key in mediating the destruction of melanocytes. This cytokine stimulates CXCL10, a chemokine that serves as a homing molecule that helps to attract CD8 cytotoxic lymphocytes into the skin."

    White patches, bruised souls

    Far from just a skin ailment, the white patches of vitiligo can devastate patients' self-image. For example, a beautiful 40-year-old patient recently told Dr. Grimes that the final straw of her self-esteem snapped when the mere sight of her face caused a stranger's toddler to point at her and cry. "In response to that incident, the patient said, ‘I don't go out. I don't date anymore, I have isolated myself, and I feel ugly.' That's a common story on the spectrum of patients' experiences."

    When a patient presents with vitiligo, "It's probably the longest and most detailed consultation I do. We take a very detailed history—looking at family history, time of disease onset, disease progression, associated symptoms, associated autoimmune illnesses and medications—to tease out any other causative factors that may be contributing to pigment loss."

    While getting the patient's medical history, Dr. Grimes also subtly explores the disease's psychological impact. Rather than asking direct, probing questions, "I go about it in a subdued, roundabout way—trying to let them talk about it first. I want them to be comfortable." Instead of asking what impact vitiligo has had on their quality of life, she may ask about changes in patients' daily routines, activities or hobbies. "Some will say, 'I wear makeup all the time, even on my hands.'" Many patients limit social and recreational activities that require going out in public.

    Dr. Grimes also performs a detailed physical exam, complete with photos, and a thorough laboratory assessment. "By the time I finish that consultation, I'm able to put together a treatment regimen based on that patient's symptoms." She also assembles a healthcare team for each patient that, if needed, includes an immunologist or rheumatologist and a mental-health professional.

    If a patient has limited disease, "I can treat them with a topical regimen involving topical corticosteroids and topical calcineurin inhibitors."

    Next: How to stabilize and repigment

    Read: Expert insights for vitiligo and melasma

    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.

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