Vitiligo, the dermatologist: 'Mitigated with innovative therapeutic approaches'

By Cristiano Antonino On Feb 10, 2022

Vitiligo is a skin pigmentation disorder characterised by the appearance of white patches on various parts of the body, but can also affect mucous membranes such as the eyes, mouth and nose

To reassure those unfamiliar with the disease, it should be noted that it is not transmissible and that there is no specific age of onset.

While the age of onset used to coincide more often with adolescence, it is now not uncommon for the disorder to affect young children.

Andrea Paro Vidolin, Head of the Centre for Photodermatology and Vitiligo Treatment at the Ospedale Israelitico in Rome and Scientific Advisor of the Centre for Dermatological Phototherapy in Rome, spoke to provide a better understanding of what the disease is, what the most innovative treatments are, and how to expose oneself to the sun correctly and which creams are specific for the condition.

How many types of vitiligo are there and which body areas are most affected?

“Vitiligo is a disease that affects about 3-4% of the population and there are three known types: one is called ‘vulgar’, i.e. diffuse, which symmetrically affects certain areas of the skin such as the eyes, knees and feet.

Then there is segmental vitiligo, which affects one side of the body, the right or the left.

Recently, a third form, ‘mixed’ vitiligo, has been identified, which starts out as segmental vitiligo and then evolves into vulgar vitiligo.

This shows how the course of the different types of vitiligo differs.

Vulgar vitiligo affects several skin areas and is unpredictable and capricious as it is unstable.

Segmental vitiligo, on the other hand, has a rapid onset, with the spot appearing within a year, and then tends to stabilise and rarely affects other areas of the skin.

A higher incidence is recognised in the female sex but there are no precise statistics.

There is also no precise rule regarding the age of onset of the disease.

Previously the age of adolescence was considered to be the age of onset, but it is not so mathematical to establish this.

Unfortunately, today we can observe very young children suffering from vitiligo, but thanks to the excimer laser it is possible to treat children as young as 4 or 5 years old, and this is a remarkable achievement for the child’s compliance.

In short, it’s another opportunity to treat them early.

THE CAUSES OF VITILIGO, THE DIFFERENCE BETWEEN THE SEXES AND TREATMENTS

What can be the causes and is there a genetic predisposition?

“Vitiligo can be defined as a disease with a constitutional and autoimmune predisposition. The causes are multifactorial.

The therapeutic approach, in recent years, has evolved and it has been understood that the patient suffering from vitiligo also has a real oxidative stress linked to cell presenescence that today can be mitigated thanks to innovative therapeutic approaches.

I confirm that there is a genetic predisposition to the disease.

This is why, when the specialist examines the patient, he or she must check for correlation with other associated pathologies: such as chronic autoimmune thyroiditis and coeliac disease, i.e. gluten intolerance.

But there are no preventive investigations that help us to understand whether that person will develop vitiligo.

We proceed with a skin check supported by the ‘Wood’s lamp’ in the dark to highlight the spots and proceed, if there are elements, to screening for thyroid pathologies and for coeliac disease.

There is no great difference but there is a slight prevalence of the disease in females.

It is difficult to establish a standard age of onset.

We used to say from 20 and up, but now we see even very young children with vitiligo.

Fortunately, we now have the excimer laser, which allows us to treat children at an early age.

Turning now to treatments … what are the new frontiers in this field?

“The approach is not one-size-fits-all and can be divided into two strands.

On the one hand, the aim is to stabilise the disease by using special mixtures of antioxidants to combat oxidative stress.

There are new and natural molecules such as black pepper extract, beta-carotene, curcumin, saffron and mango extract, which combat oxidative stress in order to ‘block’ the disease.

To re-pigment spots, the gold standard therapy is represented by narrow-band UVB phototherapy, carried out with total body equipment if more than 20% of the skin is affected.

If, on the other hand, vitiligo is more localised on small and difficult areas such as the hands and feet, the latest narrow-band UV microphototherapy with excimer laser is used.

This method allows us to selectively treat the patches while sparing the surrounding healthy skin.

This is the most innovative phototherapy approach.

If the patient does not respond to these phototherapy treatments, the real new frontier is the autologous transplant of epidermal cell suspension.

In this case, it is necessary to select the patient carefully, as the transplant is not for everyone.

The technique involves harvesting from a pigmented area, generally using a small flap of skin, and then using kits to extract the melanocytes, which are then implanted on the vitiligo patches after dermabrasion with a CO2 laser.

After a couple of weeks of medication, the area can be treated with phototherapy, i.e. laser therapy to stimulate the implanted cells.

So the transplant and the excimer laser are the two absolute novelties in the treatment of vitiligo”.

VITILIGO: IS THE SUN GOOD FOR YOU?

Is it true that the sun is good for you and how should you expose yourself to it if you suffer from this disease?

“This is a really important point.

Up until a few years ago, when people were not particularly familiar with the condition, the patient would go to the dermatologist and be advised to apply SPF 50 cream to the whole body.

Today things have evolved and there is a specific photo-protection for the disease.

The most correct approach for stimulating the cells and preserving the skin’s aesthetic appearance while avoiding accentuating the colour contrast between healthy tanned skin and skin affected by vitiligo (which is less pigmented) is to apply a 50+ cream to healthy skin and then apply a dedicated sunscreen, i.e. one with a higher protection on the uva ray, which has no stimulating action on melanocytes, and a lower protection on the uvb ray, which can stimulate pigmentation.

The protective sunscreen specific for vitiligo is able to let through the ‘good rays’, which help pigmentation, and block those that are not good for vitiligo.

I also recommend exposing yourself to the sun for two or three hours a day, i.e. for a limited amount of time, and avoiding the usual times of day when the sun is strong and not good for you.

These ‘golden’ rules apply to everyone but even more so to darker phototypes in order to avoid accentuating the colour contrast between the spots and ‘healthy’ skin.

A false myth to be dispelled is that the patient, on the part of the skin affected by vitiligo, is less protected from external agents such as the sun.

On the contrary, data from international literature show that this is not the case.

Skin with vitiligo would put in place constant defensive mechanisms against the sun and therefore, paradoxically, would be better protected from tumour pathologies precisely in the areas affected by vitiligo”.

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