Management of Vitiligo with Combination of Treatment: A Case Study

Dr. Vandana Dave MD (Skin) & DVD

Consulting Dermatologist and Cosmetologist Surat, Gujarat

Introduction

Vitiligo is a chronic skin condition characterized by the loss of pigmentation in the skin, resulting in the development of white patches. It can affect anyone, but is more noticeable in people with darker skin tones. The cause of vitiligo is not fully understood, but it is believed to be related to a problem with the immune system. Vitiligo can affect people of any age, gender or ethnicity, but it is more noticeable in people with darker skin tones. The condition is diagnosed by the presence of white patches of skin on the body, which can be accompanied by other symptoms such as itching or burning.1 Symptoms of vitiligo include loss of colour in the skin and the development of white patches or spots on the skin, hair or mucous membranes. The loss of pigmentation can be symmetric or asymmetric and can be found in any part of the body, but it is common on the face, neck, underarms, hands, feet and genitalia. It can also affect scalp hair, beard hair and eyelashes. The affected areas can be small and restricted or disseminated throughout the body. These patches usually start out as small areas, but can become larger over time. Physically it appears as chalkywhite macules with clear edges dispersed throughout the body parts.2

It is classified into several types, based on the pattern of the depigmented areas, such as: 3

• Acrofacial (affecting fingers and face)

• Mucosal (affecting mucous membrane)

• Universal (affecting more than 80% of the body)

• Segmental (affecting one segment of the body)

The exact cause of vitiligo is not known, but several theories have been proposed. Some experts believe that it is an autoimmune disorder, in which the immune system mistakenly attacks the melanocytes (cells that produce pigment) in the skin are destroyed. Some associated autoimmune diseases such as Hashimoto's Thyroiditis, Addison's disease and pernicious anaemia may also contribute in causing vitiligo.1

Others believe that it is caused by a combination of genetic (as it tends to run in families) and environmental factors. Certain triggers like sunburn, stress or exposure to certain chemicals can worsen the condition. The condition is not contagious, painful or life-threatening, but it may lead to significant psychological distress and social isolation.1

The diagnosis is made primarily on the clinical examination by a dermatologist and there is no laboratory test to confirm it. There is no cure for vitiligo, so treatment focuses on restoring colour to the affected skin, improving the appearance of the skin and minimizing the spread of depigmentation.2 The best approach will vary depending on the severity of the condition and individual patient circumstances. The absence of melanocytes in an area is usually done using confocal microscopy.1

While there is no cure for vitiligo, treatment can help to manage the symptoms and improve the appearance of affected skin. Treatment options include topical medications, light therapy, surgery and depigmentation. Other treatment options include topical corticosteroids, topical immunomodulators, phototherapy, depigmenting agents and surgical options.3

Lifestyle modifications such as protecting the skin from sunburn and avoiding certain triggers can also be helpful in managing the symptoms. Vitiligo can be a difficult condition to manage and treatment options vary depending on the size, location and progression of the condition.1 It is important to work with a healthcare provider to develop an appropriate treatment plan as the best approach will vary depending on the severity of the condition and individual patient circumstances. Additionally, psychological support is also important for many people living with vitiligo, as it can have a significant impact on one's selfesteem and self-confidence.

Case Presentation

A 65 years old female patient was presented to the Dermatology clinic for having whitish patches over forearm, legs, fingers etc. She was suffering this condition since last 5 years. She is diabetic patient, obese and having sedentary life style. She asked me to give her some treatment. On physical examination, she had large areas of unpigmented skin with well-demarcated white macules which are encircled with normal pigmented skin. Further I investigated the case by performing some pathology reports. Looking at her reports and her present condition I started her on some medications. I had started her oral tofacitinib 5mg 2 times a day for 1 year and then gradually to 5mg at night for 8 months and still continuing her medications. No side effects were seen. Tofacitinib, was found to be a janus kinase (JAK) inhibitor, recent advances have resulted in significant regimentation. Along with oral medication, she was also applying bakuchi oil at morning and tacrolimus at night for long term base. After the application the patient was advised to expose it to morning sunlight daily for growth of melanocyte migration and its proliferation. Topical tacrolimus also cause repigmentation of the skin. She was my regular follow up patient and I am very happy to see her results.

Treatment

Treatment for vitiligo can be challenging and depends on the extent, location and progression of the condition. The goal of treatment is to restore the colour to the affected skin and to prevent the spread of white patches. There is no single treatment that is effective for everyone and treatment plans may involve a combination of different therapies. Some of the treatment options for vitiligo include:

Topical Corticosteroids: These include corticosteroids, calcineurin inhibitors, and vitamin D analogs. These are first line treatment being very cost effective and having patient compliance. These medications are applied directly to the skin and can help to reduce inflammation and slow down the progression of the vitiligo. These are a type of cream or ointment that can help to restore colour to the affected skin. They are typically used for small areas of vitiligo and are most effective when used in the early stages of the condition. These drugs inhibit collagen synthesis and can cause skin atrophy on chronic use.3,4

Topical Immunomodulators: These are a type of cream or ointment that can help to reduce inflammation and restore colour to the affected skin. They are typically used for small areas of vitiligo and are most effective when used in the early stages of the condition. These drugs can be used to target the immune system and slow down or stop the progression of the vitiligo, but these are usually prescribed for more severe cases. Calcineurin inhibitors like tacrolimus and pimecrolimus are immunosuppressant’s having good absorption when applied topically. These inhibit calcineurin function by hampering activation and maturation of T cell.

Cyclosporine having poor skin penetration is used systemically.5

Janus kinase (JAK) inhibitors: Tofacitinib, ruxolitinib are commonly used. These are known to cause down regulation of the JAK-STAT pathway which reduces the IFN-y count, which is responsible for cell mediated immunity in vitiligo. These are associated with side effects like arthralgia, increased lipid level, upper respiratory infections.6

Phototherapy: This treatment involves exposing the skin to controlled amounts of natural or artificial light, especially narrowband UVB, is a common treatment option. It is the oldest forms of treatment for vitiligo. Phototherapy can be done in a clinic or at home using a special UV lamp. Phototherapy can help to restore colour to the affected skin and can be used alone or in combination with other treatments. Topical psoralen photo chemotherapy (PUVA) is treatment of choice in patients having being affected to less than 20% of the body. Sunburn and blister formation are some of its side effect. In current times, narrow-band UVB are more preferred for vitiligo.4 Monochromatic excimer light which is a combination of excimer light with xenon chloride gas producing wavelength of 308nm can also be used.3

Surgical options: These options are used in more advanced or stable cases, such as skin grafting, blister grafting and melanocyte transplantation, these options usually have a good result but are not commonly used because of its invasive nature and potential risks. Such therapies are used in patients who failed to react to classical therapies.3 Skin grafting involves transplanting healthy skin from one part of the body onto the affected area and micro pigmentation, where a tattooing technique is used to restore the colour to the affected area. This treatment often provides cobblestone appearance.3 Suction Blister Epidermal Grafting (SBEG) is achieved dermoepidermal separation by prolonged vacuum suction in the donor area.3

Depigmenting agents: These agents are topical creams or pills that are used to reduce the colour of normal skin surrounding the white patches. By making the surrounding skin colour lighter, the contrast between the white patches and the surrounding skin is reduced, making the vitiligo less noticeable. This option is more commonly used in larger vitiligo patches. Melanocytotoxic agents are commonly used agents like monobenzyl ether, 4-methoxyphenol etc.4 Depigmentation is usually observed after 3-6 months of application to the affected areas.6

New Drug Delivery Systems: The failure of topical medications due to poor penetration and inability of drug to reach the site of action and sometimes failure of systemic absorption, hence a tailored system is needed to for carrying the drug to desired targets which has lead to development of new drug delivery systems like drug- carrier systems which uses phospholipid-structured carriers for its topical drug delivery. This system has provided enhanced drug penetration, prolonged action and dose reduction.

Vesicular approaches by using Transferosomes, Ethosomes, Liposome’s and Non-vesicular approaches like lipid emulsion, solid lipid nanoparticles, and lecithin organogels. These approaches have improved the pharmacokinetic and pharmacodynamic properties of drug molecules.4

Cosmetics: Used for camouflage the affected area.4

It is important to work with a healthcare provider to develop an appropriate treatment plan, as the best approach will vary depending on the severity of the condition, location, progression and individual patient circumstances. It's also worth noting that, even with treatment, repigmentation may not be complete, and sometimes the therapy can't guarantee that white patches won't come back.

Discussion

Vitiligo is a depigmenting skin disorder, commonly acquired pigmentary skin disorder that causes demolition of melanocytes. The etiology is unknown but recent progress explain its pathogenesis as autoimmune disease, oxidative stress, genetic (as it tends to run in families) and environmental factors.7,8 In some cases, there may be a family history of vitiligo and certain triggers such as sunburn, stress or injury to the skin may lead to the development of white patches. Some researchers think that vitiligo occurs when the immune system mistakenly attacks and damages certain cells in the skin called melanocytes, which are responsible for producing the pigment that gives colour to the skin.1

Many mechanisms are involved in subsequent loss of melanocyte most of them are explained either by immune attack or cell degeneration and detachment. Some authors have suggests neural system playing some role in its pathogenesis.1 The colour and size of white patches may change over time and new patches may appear. Diagnosis of vitiligo is usually made by visual examination; a physician will also perform some tests such as wood's lamp examination, skin biopsy and blood tests to rule out other pigmentation disorders.8

Treatment for vitiligo can be challenging and it depends on the size, location and progression of the condition. It can include topical corticosteroids, topical immunomodulators, phototherapy (such as narrowband ultraviolet B) and depigmenting agents, newer drug delivery. Sometimes, a combination of these methods is used and sometimes surgical options can be considered.3 The best approach will vary depending on the severity of the condition and individual patient circumstances.

Moreover, while some people experience little to no psychological impact, others may experience a significant impact on their self-esteem and quality of life. Support and counselling can be helpful to many people dealing with vitiligo.

Conclusion

Vitiligo is an acquired cutaneous disorder of depigmentation with no underline cause and with no definitive cure having complex pathogenesis. Constant efforts have been put to reconstruct its treatment and are still under studies and observation. The diagnosis of vitiligo is usually made by a dermatologist based on the appearance of the white patches on the skin and a physical examination. Treatment for vitiligo can be challenging as it is a chronic condition with no definite cure. The treatment options available are aimed at restoring the skin colour and slowing down or stopping the progression of the condition.

Treatment plans should be tailored to each individual patient and may involve a combination of different treatments. The best approach will depend on the individual case, taking into account the severity, location, progression of the condition, subtype of the disease, as well as the preferences of the patient. Advice on cosmetic camouflage should be offered by specialized nurse or practitioner on the affected areas. These may include foundation based sunscreens which are self tanning products containing dihydroxyacetone are used.

Topical therapy is preferred for mild-to-moderate vitiligo conditions. This therapy mainly targets the immune system and arrest the spread of white patches. Topical corticosteroids having anti-inflammatory and immunomodulating capacity are primarily used. On chronic use of this corticosteroid is known to cause skin atrophy hence care must be taken for application on skin, genitals or for that matter on children. Treatment response of topical corticosteroid with phototherapy is providing promising synergistic effect. Surgical methods can be offered for patients who failed to respond to above mentioned therapies. Living with vitiligo can be challenging, as the condition can have a significant impact on a person's self-esteem and quality of life. Many people with vitiligo find it helpful to connect with support groups and talk to a counsellor or therapist who can help them cope with the emotional aspects of the condition. Regular follow-ups, monitoring and adjusting the treatment plan as per the need will help to achieve better control of symptoms and improve the quality of life.

References

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2. Joge R R, Kathane P U, Joshi S H (September 18, 2022) Vitiligo: A Narrative Review. Cureus 14(9): e29307. doi:10.7759/cureus.29307

3. Faria AR, Tarlé RG, Dellatorre G, Mira MT, Castro CC. Vitiligo--Part 2--classification, histopathology and treatment. An Bras Dermatol. 2014 Sep-Oct;89(5):784-90. doi: 10.1590/ abd1806-4841.20142717. PMID: 25184918; PMCID: PMC4155957.

4. Garg BJ, Saraswat A, Bhatia A, Katare OP. Topical treatment in vitiligo and the potential uses of new drug delivery systems. Indian J Dermatol Venereol Leprol 2010;76:231-238

5. Dr Kresimir Kostovic, Aida Pasic (2005). New Treatment Modalities for Vitiligo. , 65(4), 447–459. doi:10.2165/00003495-20056504000002

6. Kubelis-López DE, Zapata-Salazar NA, Said-Fernández SL, SánchezDomínguez CN, Salinas-Santander MA, Martínez- Rodríguez HG, VázquezMartínez OT, Wollina U, Lotti T, Ocampo - Candiani J. Updates and new medical treatments for vitiligo (Review). Exp Ther Med. 2021 Aug;22(2):797. doi: 10.3892/etm.2021.10229. Epub 2021 May 25. PMID: 34093753; PMCID: PMC8170669.

7. Nordlund JJ. Vitiligo: a review of some facts lesser known about depigmentation. Indian J Dermatol. 2011 Mar;56(2):180-9. doi: 10.4103/00195154.80413. PMID: 21716544; PMCID: PMC3108518.

8. Ahmed jan N, Masood S. Vitiligo. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm. nih.gov/books/NBK559149/