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Vitiligo Treatment and Management

Vitiligo is a complex autoimmune disease that requires understanding and communication between clinician and patient. Nada Elbuluk, MD, dermatologist and clinical associate professor at the Keck School of Medicine of the University of Southern California, in Los Angeles, and David Rosmarin, MD, dermatologist and department chair at the Indiana University School of Medicine in Indianapolis, offered an overview of the condition, its prevalence, potential triggers, and treatment options in Updates in Vitiligo Management, a Dermatology Times® DermView series.

Elbuluk began by describing how she explains the disorder to patients. She tells them that because vitiligo is an autoimmune disease, their antibodies are attacking their melanocytes and when this happens, white patches appear on the skin. Elbuluk stresses that she tells patients that they did not cause their condition but rather are genetically predisposed to developing it.

“Some patients are worried they did something to cause the vitiligo,” Rosmarin said. “Maybe there were some instigating events, but we don’t want patients to blame themselves. Often, it’s idiopathic, and we don’t know why people get it. Maybe there’s a genetic predisposition, some environmental event that triggers it.”

Elbuluk and Rosmarin also discussed the common myth that vitiligo is a skin of color disease.

“It’s not,” Elbuluk noted. “It’s more visible in darker skin, so there’s a much greater contrast between vitiliginous patches in someone who has dark skin. People notice it more in darker skin. In my practice, I have patients of many different racial and ethnic backgrounds who have vitiligo.”

Elbuluk also tells patients with vitiligo that there is a 20% to 30% chance that they will develop some form of thyroid disease, and she checks thyroid-stimulating hormones (TSH) and vitamin D levels at the introductory visit. Rosmarin also screens for TSH at the first visit because 25% of patients with vitiligo go on to have an autoimmune thyroid disease.

Another topic they discuss with patients is genetic risk. According to Rosmarin, many of his patients who are in their 20s or 30s and thinking about having children tend to ask whether they will pass on vitiligo to their children and whether their parents passed it on to them.

“About 1% of the population, 0.5% to 2% in some estimates, will have vitiligo,” Rosmarin explained. “If you have a first-degree relative, then your risk is increased about 4%. It’s about sixfold higher. It’s complex, and there’s a genetic component, a predisposition.”

Wood’s lamp is a common tool used to identify vitiligo in patients with lighter Fitzpatrick skin types. According to Rosmarin, a Wood’s lamp is essential for seeing the true extent of vitiligo in fair-skinned patients. For many, the severity of disease and the extent of body surface it affects can cause emotional distress. To combat the fear of vitiligo, Rosmarin classifies patients as having either progressive or stable disease. If it is progressing, he tries to halt the process with 2-5 mg of dexamethasone, 2 days a week, for about 12 weeks.

Elbuluk always asks patients about their goals for vitiligo treatment. Many of her patients have been told that there is no way to treat vitiligo or they have been on previous treatments that failed. She tries to make each visit as educational as possible for patients.

“You hit the nail on the head,” said Rosmarin. “A lot of education takes place during these visits. I want to build on what you commented on, for quality of life. Our measures show that, when patients have [vitiligo] in exposed areas, that tends to affect their quality of life. Even more so…[with] progressive or unstable disease. They have anxiety…[about] not knowing when they’ll get a new spot. The unpredictability…[of] nonsegmental vitiligo can be quite bothersome to patients, more than even having the disease in the first place.”

In progressive vitiligo, Elbuluk and Rosmarin consider the percentage of body surface affected and the category of treatment that will work best. Combination therapy is typically more successful, especially in patients who have tried only 1 form of treatment for a brief period of time. Elbuluk also makes sure patients understand that success will not happen overnight. Phototherapy, for instance, can take at least 30 sessions or more to begin eliciting a response. Overall, Elbuluk tells her patients that with vitiligo there are 2 treatment goals: stabilization and repigmentation.

Ruxolitinib cream (Opzelura; Incyte Dermatology) is a favorite therapeutic option of both doctors. Elbuluk has transitioned many patients who failed traditional treatment to ruxolitnib cream and has seen success, and she has also seen early improvement with combination ruxolitnib and phototherapy.

“Usually, when I have a patient come in and I tell them what they should expect with the use of the [ruxolitnib] cream, I tell them it is better to use it twice a day, even though we…[know] that even once a day can help repigment patients,” Rosmarin said. “Twice a day certainly works better. I usually see patients back in 6 months, and I don’t do any lab work beforehand or as we’re using the ruxolitnib cream because from the phase 3 data, there weren’t significant changes in lab abnormalities.”

Elbuluk and Rosmarin ended their discussion by reminding colleagues to give patients hope, let them know that there are treatment options, and referring them to a vitiligo specialist if they don’t feel qualified to treat the condition. Rosmarin added that it’s crucial to educate all physicians about the different strategies available to personalize treatment.


  1. Elbuluk N, Rosmarin D. Updates in vitiligo management. DermView. November 22, 2022. Accessed November 30, 2022.


Anxiety and depression in pediatric patients with vitiligo and alopecia areata and their parents: A cross-sectional controlled study Part 1

Department of Dermatology, University of

Health Sciences, Sultan Abdulhamid Han

Training and Research Hospital, Istanbul,



Sevil Savaş Erdoğan, Department of

Dermatology, Sultan Abdulhamid Han Training and Research Hospital, Tıbbiye Street., 34668, Usküdar, Istanbul, Turkey. Email:

2232  |  © 2020 Wiley Periodicals LLC                                                    J Cosmet Dermatol. 2021;20:2232–2239.



Anxiety and depressive disorders are the most common psychopathologies in children and adolescents.1 Alopecia areata (AA) is a common hair disorder characterized by a sudden-onset non-cicatricial but has a great negative effect on cosmetic appearance. Several studies have estimated the prevalence of AA worldwide to be 1%-2%, and in the majority, the first patch presents before the age of 20 years.2 Vitiligo is characterized by the partial or complete absence of melanocytes that cause the development of white macules or patches in various parts of the body.3,4 The worldwide prevalence of vitiligo is estimated to be 0.5%-2%, and approximately 50% of patients experience vitiligo before the age of 20 years.5,6 Since their visibility, chronic and disfiguring nature, and lack of curative therapy, AA and vitiligo may have high psychosocial effects on patients. AA and vitiligo are associated with various psychiatric comorbidities. In different studies, high anxiety and depressive disorder rates have been reported in children and adolescents with AA.7-11 Studies have shown that vitiligo patients suffer more from depression and anxiety.12-14 However, there are only a limited number of studies investigating the relationship between vitiligo and psychiatric state in children and adolescents.15-17

Skin diseases have a negative effect on family life,18-20 and the care of a child with AA or vitiligo may be associated with higher anxiety and depression in their parents than that of healthy children. Unlike other studies, in the current work, children and adolescents with AA and vitiligo and their parents were compared with each other and also with the healthy control group. Therefore, we aimed to identify psychiatric findings in children and adolescent groups with AA and vitiligo and to evaluate the levels of anxiety and depression in their parents. We also aimed to investigate the quality of life (QoL) of patients, and the impact of the disease on their parents.


2.1      | Study design and subjects

This is a prospective cross-sectional study conducted in our dermatology outpatient clinic between October 2018 and December 2019. The study was approved by the institutional ethical committee and carried out in accordance with the principles of the Declaration of Helsinki. Patients, controls, and their parents, who agreed to participate in the study, provided informed consent.

The study included children and adolescents aged seven to 17 years and their parents. Of the patients, 31 had AA and 29 had vitiligo. In addition, 30 age- and gender-matched healthy controls without any dermatological disease and their parents with a similar education level to that of the patients’ parents were included as a reference group. The following exclusion criteria were used for both the patient and control groups: systemic treatment (systemic steroid, cyclosporin and/or neuropsychiatric drugs) within the last three months prior to the study and any other chronic disease.

2.2      | Demographic variables and clinical severity

Demographic data (patient age and gender, and parental age and education level) and medical information (disease duration, disease severity, and presence of stressful life events within the past year from the onset of disease) were noted in separate forms for the patients. In addition, through a clinical examination, the Severity of Alopecia Tool (SALT) score21 was calculated for the patients with AA, and the Vitiligo Area Severity Index (VASI)22 for those with vitiligo.

The questionnaires explained below were administered in a single interview. The patients and controls completed the Revised Child Anxiety and Depression Scales-Child version (RCADS-C), and their parents completed the parent version (RCADS-P) to support the results of the child version. The parents also completed the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI). Lastly, the Children’s Dermatology Life Quality Index (CDLQI) scale was completed by the patients, and the Dermatological Family Impact Scale (DeFIS) by their parents.

2.3      | Scales on psychological parameters and QoL

CDLQI is a four-point Likert scale that evaluates the state of the patients and can be used in children aged four to 17 years. Higher scores indicate a greater level of deterioration in QoL. In this study, we used the Turkish version of this scale, for which validity and reliability studies have been previously conducted.23

RCADS-C and RCADS-P are self-report questionnaires, each containing 47 items designed to assess DSM-IV depression and anxiety disorders in children and adolescents. Response options are based on four-point Likert scales. Both versions have six subscales [separation anxiety disorder (SAD), social phobia (SP), obsessive-compulsive disorder (OCD), panic disorder (PD), generalized anxiety disorder (GAD), and major depressive disorder (MDD)] and provide a total anxiety score (sum of the score in five anxiety scales) and a total internalizing score (sum of the six scores in subscales).24 In this study, we used the Turkish versions of these questionnaires. The validity and reliability studies of the Turkish versions have been previously conducted.25,26

DeFIS is a 15-item, five-choice response scale to investigate how the family QoL of patients with chronic dermatosis has been affected within the last month and produces a score of 0-4. Higher scores indicate greater impairment in QoL. The scale was developed for the Turkish society by Turan et al, and the validity and reliability studies have been undertaken by the same authors.27

BAI is a 21-item self-report scale that was used to measure parents’ anxiety levels in this study. The items include symptoms of anxiety and higher total scores indicating greater anxiety levels. BAI was previously adapted to the Turkish society, and the Turkish version of the scale was in the current study.28

BDI is a 21-item self-report scale that was used to measure the level of depression in parents. There are four statements for each symptom, and a higher total score indicates a higher level of depression. The validity and reliability studies of the Turkish adaptation of the 1979 version of BDI have been undertaken.29,30

2.4      | Statistical analysis

As the statistical method, descriptive analyses (frequency distributions, percentage, mean, and standard deviation) were used. For the analysis of continuous data, conformance to normal distribution was checked using the Kolmogorov-Smirnov test. For the data that were normally distributed, the comparison of more than two groups was undertaken with ANOVA and the post hoc Bonferroni test and the comparison of two groups using the t-test.

In the absence of normal distribution, Kruskal-Wallis and MannWhitney U tests were performed, the chi-square test was used for discrete data, and Fisher’s exact test was conducted depending on the data compatibility. Relationships were investigated by the

TABLE 1 Characteristics of patients and controls

Spearman rho correlation coefficient. The results were evaluated at the 95% confidence interval and P < .05 significance level.

3       | RESULTS

3.1                | Demographic and clinical characteristics of the study groups

Thirty-one patients with AA, 29 patients with vitiligo, and 30 age- and gender-matched controls were included in the study. The mean (± standard deviation) ages of the in the AA, vitiligo, and control groups were 12.5 ± 3.6, 13 ± 3, and 12.6 ± 3.1 years, respectively. There was no statistically significant difference between the patient and control groups in terms of age, gender, number of siblings, parental education level, and parental marital status (Table 1). All patients with AA had the patchy type, and their mean SALT score was 6.3 ± 13.1. In the vitiligo group, the type of disease was vulgaris in 51.7% (n = 15), focal in 44.8% (n = 13), and segmental in 3.4% (n = 1). The mean VASI score of the vitiligo group was 3.6 ± 7.4. The mean disease duration was 6.5 ± 15.5 (range, 1-84) months in the AA group and 31.4 ± 35.5 (range, 2-132) months in the vitiligo group.

The difference between the AA, vitiligo, and control groups in terms of the presence of stressful life events was statistically



Alopecia areata

Vitiligo Controls P-value
Age, mean ± SD 12.54 ± 3.56 13 ± 3.03 12.6 ± 3.06 .85
Sex Female, n (%) 14 (45.16) 13(44.82) 14(46.66) .98
Male, n (%) 17 (54.83) 16(55.17) 16(53.33)
Mother’s educational level Illiterate, n (%) 1 (3.2) 3(10.3) 0 .56
Primary school, n (%) 12 (38.7) 9(31) 12(40)
Middle School, n (%) 5 (16.1) 5(17.2) 8(26.7)
High school, n (%) 9 (29) 6(20.7) 7(23.3)
University, n (%) 4 (12.9) 6(20.7) 3(10)
Father’s educational level Illiterate, n (%) 11 (35.5) 6(20.7) 13(43.3) .6
Primary school, n (%) 5 (16.1) 6(20.7) 4(13.3)
Middle School, n (%) 8 (25.8) 11(37.9) 9(30)
High school, n (%) 7 (22.6) 5(17.2) 4(13.3)
University, n (%) 0 1(3.4) 0

Parental marital status                                         Married, n (%)                                 27 (87.1)                                   25(86.2)                       30(100)                                                                    .11

Separated, n (%)                            4 (12.9)                                        4(13.8)                                                                                                               0

Number of siblings 1, n (%) 4 (12.9) 3(10.3) 4(13.3) .56
2, n (%) 12 (38.7) 17(58.6) 18(60)
3, n (%) 10 (32.3) 7(24.1) 6(20)
4, n (%) 3 (9.7) 2(6.9) 2(6.1)
5, n (%) 2 (6.5) 0 0

TABLE 2 Comparison of groups’ psychological test scores and presence of stressful life event

Groups P-value
                                             Alopecia areata                       Vitiligo                                          Controls AA-Vi                         AA-C                         Vi-C

Stressful life event, n (%)                        19 (61.3)                                      25 (86.2)                                      9 (30)                                                                               .041                                               .014                                         <.0001

RCADS-Child, mean ± SD

Separation Anxiety

55.61 ± 12.94 50.21 ± 9.6 48.83 ± 9.9 .116 .026 .291
Generalized Anxiety 48.61 ± 11.37 45.14 ± 9.09 42.5 ± 7.41 .195 .021 .261
Panic 49.65 ± 12.3 47.31 ± 10.9 44.67 ± 8.17 .454 .177 .470
Social Phobia 46.19 ± 12.48 43.66 ± 8.72 39.93 ± 8.34 .625 .050 .069
Obsessive-Compulsive 48 ± 12.58 48.03 ± 11.56 46.93 ± 8.89 .935 .874 .952
Depression 49.68 ± 12.21 47.38 ± 14.3 41.07 ± 7.55 .314 .006 .162
Total Anxiety 49.03 ± 12.96 45.69 ± 10.5 42.43 ± 7.88 .287 .057 .295
Total 49.13 ± 12.9 45.86 ± 11.63 41.47 ± 7.95 .245 .010 .261

RCADS-Parent, mean ± SD

Separation Anxiety 57.55 ± 15.3 54.38 ± 9.8 51.03 ± 8.43 .700 .167 .181
Generalized Anxiety 54.81 ± 9.64 52.9 ± 11.55 51.6 ± 10.8 .415 .133 .660
Panic 55.06 ± 12.64 54.24 ± 11.82 48.57 ± 9.9 .795 .014 .030
Social Phobia 49.26 ± 12.09 49.45 ± 10.91 45.83 ± 8.47 .900 .291 .199
Obsessive-Compulsive 57.39 ± 11.18 55.86 ± 11.17 54.97 ± 11.18 .573 .422 .558
Depression 58.74 ± 14..95 56.24 ± 14.15 47.37 ± 8.23 .529 .001 .014
Total Anxiety 55.06 ± 10.92 53.9 ± 12.39 50.2 ± 10.65 .569 .041 .316
Total 56.32 ± 11.1 54.72 ± 12.24 49.43 ± 10.22 .428 .012 .074
Parents’ BAI, mean ± SD 11.71 ± 8.78 11.45 ± 10.21 8.97 ± 8.71 .667 .169 .235
Parents’ BDI, mean ± SD 10 ± 6.72 9.83 ± 5.79 7.53 ± 5.78 .906 .110 .093

Abbreviations: AA, Alopecia Areata; Vi, Vitiligo; C, Controls; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; RCADS-Child, Revised Child Anxiety and Depression Scales, Child Version; RCADS-Parent, Revised Child Anxiety and Depression Scales, Parent Version.


significant (P < .0001). Furthermore, this parameter was statistically significantly higher in the vitiligo group compared to the AA and control groups (P = .014 and P < .0001, respectively) (Table 2).