Emerging Treatments for Vitiligo Leave Patients with Limited Options and Uncertain Outcomes
The one thing patients tend to know about vitiligo is that it’s incurable. Beyond that, they encounter a bewildering range of information and attitudes. They’ll hear everything from “vitiligo is treatable” to depressing accounts of vitiligo that keeps spreading or constantly relapses after treatment. The disease is really that variable—treatment results are unpredictable and never 100 percent effective—which makes it essential to keep up with emerging treatments. Pharmacists who can offer expert guidance make a world of difference for patients with vitiligo.
Emerging Treatments and Information about Vitiligo
Every time they listen to the news, patients are bombarded with the latest research; what they might not realize that it takes years for a genetic breakthrough to actually result in a new treatment. Pharmacists should keep this in mind right now, in light of another round of recently released news about vitiligo. Staying abreast of such developments can help pharmacists educate patients who are seeking more effective options.
Pearl E. Grimes, MD, director of the Vitiligo and Pigmentation Institute of Southern California and clinical professor of dermatology at the University of California Los Angeles, announced in the August 2016 issue of Dermatology Times that “new knowledge about the pathogenesis of vitiligo has given rise to new treatments and new hope for sufferers of this condition.”1 Here’s the gist of the information presented in the article:
- Genetic research has produced enough data to show that about 90 percent of the genes identified in vitiligo are immune-susceptibility genes, and 10 percent are pigment-related genes. In other words, melanocytes from patients with vitiligo don’t grow well due to genetic defects.
- Oxidative stress may be the primary pathology that triggers immune dysfunction and causes vitiligo. Oxidative damage leads to the influx of cytotoxic T cells, CD8 lymphocytes, that mediate the destruction of melanocytes.
- Afamelanotide, a potent form of alpha-melanocyte-stimulating hormone, is currently in clinical trials. It upregulates melanoblasts in the hair follicle, stimulates melanoblast differentiation, and increases melanin production. A phase 3 study should begin during 2017, but so far, results show that vitiligo patients have faster and better repigmentation, regardless of whether afamelanotide is used alone or with narrowband UVB treatment.
- Prostaglandin F2-alpha analogues such as latanoprost and bimatoprost have increased melanocyte proliferation in patients with vitiligo, results that hold true both for monotherapy and in combination with narrowband UVB.
- Janus kinase (JAK) inhibitors such as tofacitinib and ruxolitinib are promising treatments for vitiligo, but more research is needed to prove their efficacy.
Current Treatment Recommendations for Vitiligo
The optimism expressed in the Dermatology Times article must be tempered with the current state of treatments for vitiligo. As recently as May 2016, a systematic review concluded that evidence for the efficacy of existing treatment options is limited and further studies are needed.2 Vitiligo remains incurable—and even when treatments are effective, relapse is common. Physicians must try individualized regimens and wait to see how each patient responds. Common options include:
- Phototherapy – Narrowband UVB radiation is the treatment of choice for most doctors, although combining psoralen with UVA radiation is another option.3 Even though repigmentation is successful in up to 70 percent of patients with early or localized cases of the disease, the relapse rates are 21 percent within one year and 55 percent within two years.
- Excimer laser therapy – This treatment is used on limited and stable patches of vitiligo. It’s well tolerated, but therapy is expensive, as the regimen is usually twice weekly for 24 to 48 sessions.4
- Topical and systemic steroids – Oral steroid mini-pulse therapy may stop disease progression, with nearly 90 percent of patients stabilized within a few months. About 80 percent of patients experience some repigmentation; 70 percent have side effects such as weight gain, insomnia, and acne. About one-third of patients using topical corticosteroids will see 75 percent repigmentation.
- Topical immunomodulators – A review of the literature found topical immunomodulators are effective and well tolerated, but up to 14 percent of patients were nonresponsive, and further standardized studies are required.5
- Combination therapy – Combining phototherapy or lasers with steroids or immunomodulators—and sometimes with vitamin D analogs or khellin ointment—produces better results than monotherapy.
- Depigmentation – When vitiligo is widespread, some patients may qualify for chemical or physical depigmentation. However, depigmentation is irreversible, and patients must be psychologically prepared for the change in skin color.
- Surgery – Physicians can replace melanocytes with cells from a normally pigmented autologous donor site. A limited number of patients are suitable candidates for surgery: their vitiligo must be stabilized for six months to two years, and their pathophysiology must meet specific requirements.
Counseling Your Patients with Vitiligo
Vitiligo affects about 1 percent of the population, including all ethnicities and skin types. For this diverse group of patients, pharmacists primarily need to do what they do best—explain the benefits and potential adverse effects of the different pharmaceuticals and teach how to properly apply topical treatments. However, there are other aspects to treating the disease that you should be prepared to manage:
- Mental health needs: Patients are devastated by vitiligo. They report low self-esteem and poor quality of life and many limit their social activities. Psychiatric comorbidities occur in 25 to 30 percent of fair-skinned patients and in 56 to 75 percent of dark-skinned patients. Dr. Grimes often assembles a health care team that includes a mental health professional. Have a list of local therapists to hand out to patients if necessary.
- Comorbid autoimmune diseases: Patients diagnosed with vitiligo are more likely to have thyroid disease, alopecia areata, psoriasis, systemic lupus erythematosus, inflammatory bowel disease, pernicious anemia, discoid lupus, myasthenia gravis, and Sjogren’s syndrome.6
- Cosmetic agents: Stock quality cosmetic makeup to help patients camouflage white patches. Dermablend Professional is one brand that sells vitiligo makeup if regular cosmetics don’t provide enough cover.
- Home phototherapy: Dr. Grimes says that home phototherapy with narrowband UVB is an effective and safe option. Pharmacists can help patients source the best units and work out insurance coverage.
Pharmacists Help Patients Make Sense of Conflicting Information
When patients are faced with a life-long disease that impacts their social and psychological health, they need consistent and empathetic support. It’s important to understand that they’re depressed over their appearance and frustrated with relapses that require repeated therapies. On top of this, they may then need to be told that treatments aren’t covered by insurance providers. Pharmacists who understand the complex dynamics at play and reach out with appropriate information can significantly improve patients’ quality of life.
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- “New Thoughts, Therapies for Vitiligo,” August 2016, http://dermatologytimes.modernmedicine.com/dermatology-times/news/new-thoughts-therapies-vitiligo ↩
- “Evidence-Based Management of Vitiligo: Summary of a Cochrane Systematic Review,” May 2016, http://www.ncbi.nlm.nih.gov/pubmed/26686510 ↩
- “Guidelines for the Management of Vitiligo,” 2013, http://www.medscape.com/viewarticle/777000_4 ↩
- “Vitiligo,” August 2016, http://emedicine.medscape.com/article/1068962-overview ↩
- “Effectiveness and Safety of Topical Tacrolimus Monotherapy for Repigmentation in Vitiligo: A Comprehensive Literature Review,” March 2016, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861566/ ↩
- “Comorbid Autoimmune Diseases in Patients with Vitiligo: A Cross-Sectional Study,” February 2016, http://www.jaad.org/article/S0190-9622(15)02134-9/abstract ↩