What is it?
It is a skin color disorder caused by the destruction of melanocytes, which are the cells that produce melanin. As a result, white patches appear on various parts of the body, which can create a significant aesthetic problem, especially when they cover a large area or are located in visible spots.
Why does it appear?
The cause is unknown. There may be a genetic predisposition (25-30% of patients have a positive family history). However, other factors are also implicated, such as viral illnesses, burns and other injuries, and states of emotional stress. It can also coexist with autoimmune diseases, such as autoimmune thyroiditis.
More and more research in recent decades has significantly changed our understanding of vitiligo, recognizing it as an autoimmune disease. This change in perspective has led to a new era of treatments that directly target the immunological mechanism that causes the destruction of melanocytes.
It affects people of all races and genders equally; 50% of them develop vitiligo before the age of 20. It affects 1% of the general population.
How does it appear clinically?
It appears as asymptomatic, achromic patches and plaques of various sizes.
We distinguish between:
- Localized (one area with one or a few scattered patches)
- Segmental (asymmetrical or unilateral, sometimes in association with a sensory nerve)
- Generalized (symmetrical distribution of the white patches)
Where do they appear?
- Around natural orifices (eyes, mouth, navel, anus)
- In areas of friction (elbows, knees, armpits, femoral-genital folds, ankles)
- In areas of increased pigmentation (breast nipples, interdigital spaces)
- On the genitals
- In hair (scalp, eyebrows, beard)
What is the prognosis?
The course of the disease is unpredictable, especially the generalized form, which may remain stable for a long time after the initial manifestation before entering a progressive phase. The prognosis is better for the segmental form, with a lower likelihood of progression.
How is it treated?
Treatment depends on the size, number, and location of the white areas. Treatments are categorized as:
- Topical (topical corticosteroids, topical application of calcineurin inhibitors, topical use of vitamin D analogues, ointments containing piperine, etc.).
- Systemic (PUVA phototherapy, depigmentation of healthy skin with monobenzyl ether of hydroquinone when vitiligo covers more than 50% of the skin surface).
- Surgical (these are still in an experimental stage).
- JAK Inhibitors
JAK inhibitors are a class of drugs that target a specific protein pathway (the JAK-STAT signaling pathway) that is responsible for causing the inflammatory response in vitiligo. In simple terms, they block the signals given by the immune system to attack the melanocytes, thus allowing for the repigmentation of the skin.
The new topical treatment: Ruxolitinib cream (Opzelura)
The most important innovation in recent years is the approval of ruxolitinib cream (Opzelura) by the FDA (U.S. Food and Drug Administration) in 2022 and the EMA (European Medicines Agency) in 2023.
- Mechanism of action: This cream, as a topical JAK inhibitor, is applied directly to the white patches and inhibits the local immunological attack.
- Who benefits: It is indicated for the treatment of non-segmental vitiligo (the most common form) in adults and adolescents over 12 years of age, especially when the face is affected.
- Efficacy: It has been proven effective in restoring skin color, particularly on the face and other sensitive areas. For better results, it is often combined with narrow-band UVB phototherapy.
Other treatments and future developments
In addition to ruxolitinib cream, other treatments with a similar mechanism of action are under investigation:
- Systemic JAK inhibitors: Drugs like baricitinib (Olumiant) and tofacitinib, administered orally, have shown excellent results in clinical studies, especially in more extensive forms of the disease.
- Biological agents: Studies are examining the use of biological drugs that target other immunological pathways.
The advent of JAK inhibitors marks a significant development, as for the first time, it gives dermatologists the ability to reverse the process of vitiligo with a drug that is specifically approved for this use. However, every treatment is personalized, and the decision to use it should always be made in consultation with a specialized dermatologist.
Psychological support is important for patients who experience significant aesthetic distress. After a medical history is taken, a detailed clinical examination is performed, and sometimes a series of tests are done to rule out other pathological conditions that mimic vitiligo. The dermatologist is the specialized physician to recommend the appropriate treatment, which is usually long-term and personalized.
What should a patient with Vitiligo know?
- It is not a contagious disease.
- It is not life-threatening.
- It does not discriminate by race.
- It is not painful.
- It is easy to diagnose but difficult to treat.
- No treatment can guarantee complete repigmentation of the affected area.
- There are special camouflage products to cover the white areas (special makeup).
- Increased sun protection with a very high SPF is essential to avoid sunburn.
- Avoid skin injuries due to the possibility of vitiligo appearing in those spots (Koebner phenomenon). For this reason…
- Avoid tattoos.