Kristen Bibeau, PhD, MSPH; Khaled Ezzedine,MD, PhD; John E. Harris, MD, PhD; Nanja van Geel, MD, PhD;
Pearl Grimes, MD; Davinder Parsad, MD; Mukta Tulpule, MBBS; Jackie Gardner, BA; Yan Valle, MSc, MBA;
Gaone Tlhong Matewa, BBA; Christine LaFiura, BA; Anouk Lindley, MBA; Haobo Ren, PhD; Iltefat H. Hamzavi, MD

IMPORTANCE Patients with vitiligo often have impaired quality of life (QOL) and experience
substantial psychosocial burden.
OBJECTIVE To explore the global association of vitiligo with QOL and mental health from the
patient perspective.
DESIGN, SETTING, AND PARTICIPANTS This qualitative study of the cross-sectional
population-based Vitiligo and Life Impact Among International Communities (VALIANT)
study was conducted from May 6, 2021, to June 21, 2021. Potential participants for this
qualitative study were recruited from an online panel in 17 countries. Of 5859 surveyed adults
(aged18 years) who reported a vitiligo diagnosis, 3919 (66.9%) completed the survey, and
3541 (60.4%) were included in the analysis.
EXPOSURES Patients were asked questions regarding their emotional well-being, including
QOL and mental health.
MAIN OUTCOMES AND MEASURES Reported analyses are descriptive and hypothesis
generating. Vitiligo Impact Patient scale (VIPs) scores ranged from 0 to 60, with higher scores
indicating more psychosocial burden.
RESULTS The median age of the 3541 patients was 38 years (range, 18-95 years), and 1933
(54.6%) were male; 1602 patients (45.2%) had more than 5%affected body surface area
(BSA; Self-Assessment Vitiligo Extent Score assessed), and 1445 patients (40.8%) had
Fitzpatrick skin types IV to VI (ie, darker skin). The mean (SD) global short-form VIPs score
was 27.3 (15.6) overall; patients from India (mean [SD], 40.2 [14.1]) reported the highest
scores (ie, most burden). The QOL burden according to the scale was profound for patients
with more than 5%affected BSA (mean [SD] score, 32.6 [14.2]), darker skin (mean [SD] score,
31.2 [15.6]), and lesions on the face (mean [SD] score, 30.0 [14.9]) or hands (mean [SD], 29.2
[15.2]). At least 40% of patients globally reported that vitiligo frequently affected aspects of
their daily lives, including choosing clothes to wear (1956 of 3541 [55.2%]). Most patients
(2103 of 3541 [59.4%]) reported concealing their vitiligo frequently. More than half of
patients (2078 of 3541 [58.7%]) reported diagnosed mental health conditions, including
anxiety (1019 of 3541 [28.8%]) and depression (866 of 3541 [24.5%]). The Patient Health
Questionnaire–9 depression screener showed that 55.0%of patients (1948 of 3541) had
moderate to severe depressive symptoms; the highest rates were in India (271 of 303
[89.4%]) and among patients with more than 5%affected BSA (1154 of 1602 [72.0%]) and
darker skin (987 of 1445 [68.3%]).
CONCLUSIONS AND RELEVANCE This qualitative study found that, globally, patients with
vitiligo reported being substantially affected in their emotional well-being, daily lives, and
psychosocial health; the burden was typically greatest among patients with more than 5%
affected BSA, darker skin types, and lesions on the face or hands. Survey findings suggest
that patients reported having altered their behavior, expressed clear discontent, and have
symptoms consistent with depression, which may be underdiagnosed.

Vitiligo is a chronic autoimmune disease characterized by the destruction of melanocytes, resulting in pale or
white patches of skin.1 Patients with vitiligo encounter significant quality-of-life (QOL) impairment in routine activities, employment, and psychosocial health.2,3 Previous reports suggest that patients with greater body surface area (BSA) involvement and visible lesions experience greater psychosocial burden.4,5 Patients with vitiligo are also more likely to have depression and anxiety than individuals without vitiligo serving as controls.6,7 Psychosocial stressors are associated with vitiligo onset or flares.8,9

There is a need to further understand the global burden of vitiligo from the patient’s perspective. Here we explore sociodemographic characteristics and QOL and describe differences in psychosocial burden across geographic regions and subgroups of disease characteristics among patients surveyed in the Vitiligo and Life Impact Among
International Communities (VALIANT) study.

Methods

Study Participants
This cross-sectional observational qualitative study provided a survey that was administered to adults (aged ≥18 years) who received a diagnosis of vitiligo from a health care professional and were recruited via an online panel from 17 countries between May 6 and June 21, 2021, using a general population sampling approach (eAppendix in Supplement 1). The study protocol received an exemption from informed consent from the Western Institutional Review Board based on survey procedures and use of deidentified data. Participants
completed a brief online screener before continuing to the 25-minute survey. The survey was designed to assess self-reported emotional well-being, QOL, and depressive symptoms in a target sample of approximately 3500 patients. Additional assessment instruments (eg, theVitiligoImpactPatient scale [VIPs] and the Patient Health Questionnaire–9 depression screener) are described in the eAppendix and eTable 1 in Supplement 1.Datawere summarizedwith descriptive statistics. This qualitative study followed the Standards forReporting Qualitative Research (SRQR) reporting guidelines.

Statistical Analysis
Analyses included comparison of the 17 countries, 7 geographic regions, and demographic and clinical characteristic
subgroups, with t tests for comparisons of mean values and χ2 tests for categorical counts. Statistical significance was conferred at P < .05 (2-sided). The software used for analysis was WinCross, version 20 (The Analytical Group).

Results

Patient Demographic Characteristics

Of 5859 participants who reported a vitiligo diagnosis were directed to the survey, 3919 (66.9%) completed the survey, 378 (6.5%)were excluded fordata quality issues (eTable2inSupplement 1), and 3541 (60.4%) were included in the analysis. The median age was 38 years (range, 18-95years); 1933 (54.6%)were male, 1603 (45.3%)were female, and 5 were nonbinary (0.1%). Race and ethnicity were not solicited in France (n = 250) or Germany (n = 250). A total of 929 of the 3041 patients with available datawere Asian (30.5%), 283were Black (9.3%), 144 were Central or South American (4.7%), 135 were Middle Eastern or North African (4.4%), and 1555were White (51.1%).

A total of 75 patients (2.5%) reported race and ethnicity as “other,” as categorized within the survey, with no further breakdown available. Thirteen patients (0.4%) preferred not to report race and ethnicity. A total of 1445 patients (40.8%) had Fitzpatrick skin types IV toVI (ie, darker skin), and1602(45.2%)
reported more than 5% affected BSA (Table).

QOL and EmotionalWell-Being

Globally, the mean (SD) total 12-itemVIPs score was 27.3 (15.6) (Figure 1). Scale scores ranged from0to 60,with higher scores indicating more psychosocial burden. Patients in India (mean [SD] score,40.2 [14.1]), Brazil (mean [SD] score, 29.7 [17.1]), and theUS(mean[SD] score,29.4 [12.8]) reportedthe highest scores (ie, the greatest burden) among countries surveyed (eFigure 1 in Supplement 1).

Worse QOL was observed among patients with more than 5%affected BSA(Vitiligo Impact Patient scale
mean [SD] score, 32.6 [14.2] vs 24.1 [13.9] for 1%-5% BSA and 21.6 [16.4] for <1%BSA; both P < .001), darker skin (mean [SD] score, 31.2 [15.6] vs 24.5 [15.0] for fairer skin; P < .001), and facial lesions (mean [SD] score, 30.0[14.9] vs 21.8 [14.9] for no facial lesions; P < .001) or hand lesions (mean [SD] score, 29.2 [15.2] vs 22.5 [14.8] for no hand lesions; P < .001).

More than 30% of patients (range across questions, 32.8%  [1160 of 3541] to 53.5% [1893 of 3541]) reported agreeing or strongly agreeing that vitiligo affected multiple aspects of their emotional well-being, including self-esteem or stigma, relationships, and careers (eFigure 2 in Supplement 1). Among all domains evaluated, patientswith more than 5% affected BSA consistently reported being more greatly affected compared with those with less extensive disease. A total of 49.0%of patients (1735 of 3541) agreed that having vitiligo made them feel
less confident or more self-conscious. Furthermore, 46.6% of patients (1649of 3541) believed that “no one understands what it’s like to live with vitiligo.” Patients also felt frustrated with their career prospects,with 41.9%(1483 of 3541) reporting that they believed that they would have been further along in their
careers if they did not have vitiligo. In contrast, 35.5% (1258 of 3541) reported that having vitiligo made them feel
empowered, suggesting that the question may have been misinterpreted.

Abbreviation: BSA, body surface area.
a Multiple answers were accepted.
bRace and ethnicity were not solicited in France (n = 250) or Germany
(n = 250).
c Category taken from the survey with no further breakdown available.
d Fitzpatrick skin types are defined as follows: type I, pale white skin; type II,
white skin; type III, light brown skin; type IV, moderate brown skin; type V,
dark brown skin; and type VI, deeply pigmented dark brown to black skin.

More than 40% of patients (range across questions, 42.9%[1520 of 3541] to 55.2% [1956 of 3541]) reported that aspects of their daily lives were frequently affected by vitiligo. Among the most
stressful daily activities were making clothing choices, attending social activities, shaking hands, and being intimate with their partner (Figure 2).Furthermore,59.4%ofpatients (2103of 3541)
reported that they frequently concealed their vitiligo with makeup or concealer or clothing, the rates of which were higher among patients with more than 5% affected BSA (1164 of 1602 [72.7%]), darker skin (955 of 1445 [66.1%]), and facial or hand lesions (1690 of 2712 [62.3%]).

Mental Health
More than half of patients (2078 of 3541 [58.7%]) reported diagnosed mental health conditions, most commonly anxiety disorder (1019 of 3541 [28.8%]) and depression (866 of 3541 [24.5%]) (eFigure 3 in Supplement 1). Rates of diagnosed mental health conditions were highest for patients with more than 5% affected BSA (73.8% [1183 of 1602] vs 52.0% [497 of 955] for 1%-5% BSA and 40.4% [398 of 984] for <1% BSA; both P < .001), darker skin (73.4%[1061 of 1445] vs 48.5%[1017 of 2096] for fairer skin; P < .001), and facial lesions (67.2%[1441 of 2143] vs 45.8% [600 of 1311] for no facial lesions; P < .001) or hand lesions (67.2% [1527 of 2274] vs 43.6% [514 of 1180] for no hand lesions; P < .001) and for those from India (90.1% [273 of 303]; P < .05 vs other countries).

Globally, 55.0% of patients (1948 of 3541) reported moderate to severe symptoms of depression according to the Patient Health Questionnaire–9, with the highest rates among patients from India (271 of 303 [89.4%]) (eFigure 4 in Supplement
1). Rates of moderate to severe depressive symptoms were greater among patients with more than 5%affected BSA (1154 of 1602 [72.0%]), darker skin (987 of 1445 [68.3%]), and facial or hand involvement (1607 of 2712 [59.3%]) than among their counterparts (eFigure 5 in Supplement 1). previous findings, the VALIANT study demonstrated frequent avoidance behavior and concealment strategies.11,12 One quarter of patients in the VALIANT study reported diagnosed depression and approximately three-tenths reported anxiety, which may substantially affect health care resources.13Furthermore, depression may be underdiagnosed, possibly owing to lack of access to mental healthcare, with more than half of patients in theVALIANT study reporting symptoms consistent
with moderate to severe depression. Regional differences were observed in the burden of vitiligo and were particularly notable in India. There is reportedly a highly negative perception of vitiligo in India, with patients reporting how having vitiligo has affected their marriage prospects, education, and employment.14 These perceptions may be a reason why patients in India reported the greatest burden among all countries
surveyed.

Discussion

In this first international survey to date exploring the burden of vitiligo, patients, especially those with more than 5% affected BSA, darker skin, and facial or hand involvement, reported that this burden profoundly affected their emotional well-being, daily activities, and mental health. Smaller studies have reported a higher burden for patients at least 25% affected BSA or darker skin,2,10 supporting our findings that QOL impairment was greater among patients with more than 5% affected BSA and darker skin vs their counterparts. Lesion location was also associated with disease burden, with greater QOL impairment and higher prevalence of depressive symptoms among patients with vs. without facial or hand involvement, expanding on previous results.3,11 Corroborating previous findings, the VALIANT study demonstrated frequent avoidance behavior and concealment strategies.11,12

One quarter of patients in the VALIANT study reported diagnosed depression, and approximately three-tenths reported anxiety, which may substantially affect health care resources.13Furthermore, depression may be underdiagnosed, possibly owing to lack of access to mental health care, with more than half of patients in theVALIANT study reporting symptoms consistent with moderate to severe depression. Regional differences
were observed in the burden of vitiligo and were particularly notable in India. There is reportedly a highly negative
perception of vitiligo in India,with patients reporting how having vitiligo has affected their marriage prospects, education, and employment.14 These perceptions may be a reason why patients in India reported the greatest burden among all countries surveyed.

Limitations

This study has some limitations. For example, the VALIANT survey is limited by factors observed with other online surveys, including selection and recall biases and reliance on self-report of physician diagnosis. Also, patients with lower disease burden may have been less likely to complete the survey. Some questions may also have been misread or misunderstood by patients. For example, 35.5% of patients (1258 of 3541) reported feeling empowered by their vitiligo in contrast to clinical experience, in which most patients express considerable disempowerment.15 This result could be because the terminology was interpreted differently across ethnic and national groups; therefore, translated survey validation across groups is warranted. Nonetheless, stratifications by BSA and skin type demonstrated similar trends in emotional well-being despite the fact that the questions were a mix of positive and negative characteristics. Finally, multivariate analysis was not undertaken; thus, confounding
cannot be excluded.

Conclusions

In this qualitative study, the results of the VALIANT survey indicate that vitiligo affects patients’ daily lives, emotional well-being, and careers. Patients altered their behavior, expressed clear discontent, and had symptoms consistent with depression, which may be underdiagnosed. Patients with more than 5% affected BSA, darker skin, and facial or hand lesions reported being more affected than their counterparts. Findings highlight the need to prioritize reduction in the psychosocial burden of vitiligo and increase efforts to educate patients and health care professionals on vitiligo, particularly in countries where patients experience the highest burden.

Source 

The 2023 Pigmentary Disorders Exchange Symposium held in Chicago, Illinois, from May 5th to May 6th, covered numerous hot topics in managing pigmentary disorders. Hosted by conference co-chairs Pearl Grimes, MD, and Jill Waibel, MD, faculty members met for the 2-day conference to discuss the pathogenesis of vitiligo, hyperpigmentation, medical and surgical treatments for vitiligo, cosmeceuticals for photodamage, and more.

Iltefat Hamzavi, MD, spoke with Dermatology Times® to review key highlights of his session, “Vitiligo Surgical Treatment Advances,” including punch graft techniques and non-cultured epidermis suspension.

Hamzavi: I’m Iltefat Hamzavi from Henry Ford Hospital, Hamzavi Dermatology, and Dermatology Specialists, and a dermatologist in the Detroit area. And we’ll get jump into some of the points of the talk today. So, I had the good fortune of joining as inaugural faculty with Pearl Grimes and the rest of the group to look at vitiligo surgery. So, we had a session on hypo and depigmentation, and I was charged with the responsibility of talking about vitiligo surgery. So, at the meeting, we talked about the role of the immune system on causing vitiligo. But the melanocytes also are an area of destruction and dysfunction. And so in order to really repigment individuals, you have to manage the immune system, but then you have to create the milieu for the melanocytes to come back into the skin. Sometimes melanocytes just don’t want to come back in there.So there’s a role for vitiligo surgery. Vitiligo surgery can provide rates of repigmentation you can almost never get with phototherapy, topical agents or systemic agents. But if you don’t manage the immune system, the transplant procedure will not work. And we covered a variety of different transplant options. There is the traditional punch grafting where you take a larger punch, then you take another punch of the recipient site that’s smaller, and you place a larger punch in that area. That can give you good results for smaller areas. Talked about blister grafting where you create a blister and transplant the blister on the recipient side. We talked about split-thickness skin grafting, which is basically what sounds like, when you take a split-thickness graft, you dermabrade the vitiligo area and place it on top.

We spent most of our time talking about non cultured epidermal suspension technique also known as MKTP, melanocyte keratinocyte transplant procedure. These non-cultured epidermal suspension techniques have become the preferred technique for many of us. It allows you to treat a larger area with a smaller donor area. And so if you’ve managed the immune system, or you have segmental vitiligo, you can often use that. So as many of the attendees knew, we categorized the ideal surgical patient as somebody whose immune system is stable, their vitiligo is not progressing. And within that group, there’s 2 subgroups. There’s the segmental vitiligo where it only covers one segment of their body, and there’s nonsegmental, vitiligo. Nonsegmental vitiligo often has an immune activity, it’s active, but it goes through active and quiescent phases, versus segmental often is burnt out. Segmental patients tend to have a better response than nonsegmental, partly because the immunomodulation that’s occurring in the skin. And so with both of these types of subgroups, if you pick the right patient and location, you can have some dramatic results. And we talked about the rates of the repigmentation, they approached anywhere from 71% to 92% repigmentation in segmental vitiligo, and around 54% to 60% for nonsegmental. And that pigmentation tends to hold over 2 years based on some studies that have been presented, and again in this systematic reviews, it showed that split-thickness skin grafts and non-cultured epidermis suspensions were the most successful techniques. But our data is still generating, it doesn’t have the same robust nature as the pharmaceutical trials.

The ideal treatment also involves an awareness of where you can treat. So generally we want to treat 40 to 100 square centimeter locations, we would like to use an appropriate dressing process. And then you also have to have a nursing team. The nursing team’s role is to help you obtain the graft where you often from the hip, you process that tissue with the non-cultured epidermis suspension technique and the MKTP technique by heating it in an incubator and stripping off the collagen and dermal cells. And then you will continue to process that until the point where you are able to scrape the dermal components from the epidermal cells and you end up with a mix of keratinocytes and melanocytes. You spin those cells down and we suspend them in a solution and you convert that solid graft into a liquid solution. And then you dermabrade or laser abrade the recipient site, let’s say in the face, and you spray that solution over there and then place a collagen dressing or a gauze dressing and over 6 to 7 days, we leave that dressing in place. And we showed pictures of the face, the legs, and arms, having significant degrees of repigmentation.

And then we talked a little bit about adjunct techniques to preserve the level of pigmentation. But there is nothing that we have today for vitiligo that repigments to the degree and the speed that the vitiligo surgery can offer. We finished up by talking about some new commercial options, which are going to FDA review, using kits that will allow this technique to be much more accessible. And we presented an FDA-approved trial, where I believe it’s around 56% of patients had greater than 75% pigment. They’re not able to use a VASI score yet for these areas. But we’re working on that. But the VASI is the primary outcome measure for many of the topical systemic trials. But this measure of degree of repigmentation, more than 56% of people achieved that more than 75% pigmentation rate versus 0% in one arm, and about 12% was given to the other arm. So a great degree of improvement that was sustained with very few side effects ever noted. And we showed pictures of that. The patients served as their own control in these trials. And so this was comparing the area that did not receive treatment compared to treatment area that did receive treatment. So we finished the lecture summarizing the appropriate candidates, we talked about the appropriate expectations of the degree response. We talked about what patients to avoid, we talked about the upcoming new research. And we talked about how to continue to maintain the immunostability of the patient so that you don’t get a recurrence of vitiligo after you do the surgery. And hopefully at the end of it, the audience was able to at least have an understanding of vitiligo surgery. And then hopefully, over time, develop the techniques we can apply that to that patient whose immune systems is managed, they just cannot repigment them.

Dermatology Times: What are a few highlights from the 2023 Pigmentary Disorders Exchange Symposium?

Hamzavi: I’m just so excited that we are able to actually have a conference on pigmentation. So there are some excellent talks on dermal pigmentation done by Dr. Heather Woolery Lloyd, and she talked about the different classifications and different agents that we can use. She talked about oral agents that might trigger pigmentation. This is very disfiguring pigmentation that can occur. We had some great talks on melasma options and treatment of hyperpigmentation with Dr. Andrew Alexis. And he gave us an extensive summary of treatment options and other from the therapeutic ladder of photoprotection, topical intervention, systemic interventions and procedural based interventions. And then we also had some great lectures by Dr. Berson, and she spoke about the numerous agents that help manage hyperpigmentation and where they might be useful. And Pearl Grimes also gave a very, very strong overview of these pigmentary options across the different disease states. And those are the portions that I was able to attend. But really an in-depth conference. If you really want to improve your ability to treat hyperpigmentation and depigmentation, I haven’t seen a conference like this.

[Transcript edited for clarity]

Image Credit: Envato Elements

Source

Pandya gives an in-depth overview of his vitiligo treatment pearls from the 2023 Pigmentary Disorders Exchange Symposium.

Background: Vitiligo is a common, acquired depigmenting disorder. The pathogenesis is not clear, neuropsychological factors may be involved. Vitiligo will affect the individual’s physical and psychological health, leading to different levels of psychological behavior problems. However, there are few research on psychological symptoms in patients with vitiligo in China.
Methods: Adult patients with vitiligo were selected in convenient sampling method from March 2019 to November 2019 from the dermatology clinic. They were evaluated by the DLQI (Dermatology Life Quality Index), SCL-90 (Symptom Checklist-90), SADS (Social Avoidance and Distress Scale) and MCMQ (Medical Coping Modes Questionnaire).
Results: The DLQI score was 7.56 ± 6.11, which was in the third level. The SCL-90 score of patients with vitiligo was 136.44 ± 39.19, significantly higher than the Chinese norms (P < 0.05), and it mainly manifested as interpersonal sensitivity, depression, anxiety and phobia, which may be affected by the patient’s gender, marital status, severity of disease, stage and location of skin lesions. The total score of SADS in patients was 10.30 ± 6.38. The total score and scores in all dimensions of SADS were significantly higher than the Chinese norms (all P < 0.05), which were related with the patient’s gender, educational attainment, severity, type and stage of skin lesions. For MCMQ, the facing score was significantly lower than the Chinese norms (P < 0.05), and the avoiding and yielding scores were significantly higher than the Chinese norms (all P < 0.05).
Conclusion: In China, vitiligo affects the patient’s quality of life to varying degrees, resulting in a series of psychological and behavioral problems. We should actively concern and improve the psychological health status and behavior of patients, and multidisciplinary treatment strategies and education about vitiligo should be given to the patients.

Keywords: vitiligo, quality of life, psychological health status, behavioral and psychological symptoms

Introduction

Vitiligo is a common depigmentation skin disease due to the loss of melanocytes.¹ The clinical manifestations are depigmentation spots of different sizes in skin and mucosa, which can be involved in any part of the body and hair. The incidence of vitiligo in the whole world is about 0.5–1% and the incidence varies from race to region and population.^2,3 Skin lesions range from very limited to generalized. It also is a disfigurement disease. In addition to affecting individual mental and physical health, it also increases the economic burden of patients and their families, and affects the quality of life of patients.⁴

The etiology and pathogenesis of vitiligo are very complex. It is generally believed that individuals with genetic tendency show abnormalities in autoimmunity, oxidative stress, endocrine metabolism, neuropsychiatric and other aspects under the stimulation of a variety of inflammatory factors, resulting in melanin synthesis disorder or melanocyte destruction, and finally lead to depigmentation.¹ Vitiligo is often misunderstood as a cosmetic disease.⁵ A large number of clinical practices have shown that patients with vitiligo often have stress events such as overwork, tension, anxiety and mental trauma before the onset of vitiligo.^6,7 Psychosocial conditions affect the immune system and play a role in the disease process. More and more attention has been paid to the role of psychosocial factors in the occurrence and development of psychosomatic diseases. Research on the psychosocial factors in vitiligo has been reported.^7–9 Therefore, vitiligo is a skin psychological disease that will not directly lead to physical damage but will lead to serious psychological problems in daily life.¹⁰

In general, clarifying the psychological and behavioral characteristics of patients with vitiligo, understanding their potential psychological and behavioral symptoms (such as anxiety, depression and social disorder), can help optimize the management of vitiligo, improve the treatment effect, improve the quality of life and promote their physical and mental health development.¹¹

However, there are few researches on psychological symptoms in patients with vitiligo in China. This study aim to investigate the psychological and behavioral status in patients with vitiligo in China through psychological and behavioral related questionnaires, analyze the influencing factors of psychological and behavioral problems, and provide theoretical basis for comprehensive treatment and clinical intervention of vitiligo.

Methods

Ethics

The study and protocols were approved by the Institutional Review Board of the Xi’an Jiaotong University, and performed according to guidelines governing ethics care in China. This study was performed in accordance with the rules laid down in the Declaration of Helsinki. Informed consent has been obtained from all patients for study participation, data collection and publication.

Participants

The convenient sampling method was used to select adult patients with vitiligo who came to the dermatology clinic of the Second Affiliated Hospital of Xi’an Jiaotong University from March 2019 to November 2019 as the research object. The inclusion criteria were: 1. All patients were over 18 years old. 2. The diagnosis of vitiligo was made by two dermatologists and wood lamp. 3. All patients had no previous history of mental illness. 4. All patients had no cognitive orientation disorder, had primary school education or above, and could understand the meaning of the questionnaires. 5. All patients voluntarily participated, and expressed their willingness to cooperate to complete the questionnaires carefully. Exclusion criteria were: 1. Patients were under 18 years old. 2. Patients with other skin diseases or major physical or neurological diseases (tumors, heart problems, liver and kidney dysfunction, epilepsy, etc.) that may impair their quality of life or psycho-behavioral status.

Measures

The initial sample consisted of 120 participants, after eliminating the questionnaires invalidated by their incorrect completion, the final sample was 117 (97.5%) in this study. The researcher gave explanation and guidance when necessary. All questionnaires were filled in on site and completed by the patients themselves. All patients who met the inclusion criteria were evaluated by general information questionnaire, dermatology quality of life index (DLQI), symptom checklist 90 (SCL-90), social avoidance and distress scale (SADS) and medical coping style scale (MCMQ). All questionnaires were in Chinese and the validated forms were used.

DLQI is currently the most widely used dermatological life quality questionnaire. It includes 10 questions related to symptoms and feelings, daily activities, leisure, work and school, interpersonal relationship and treatment, to evaluate the impact of skin diseases on patients’ quality of life during the previous 1 week.¹² According to the total score of DLQI, the score is divided into 5 grades. 0~1 indicates almost no influence, 2~5 indicates small influence, 6~10 indicates moderate influence, 11~20 indicates very large influence, and 21~30 indicates extremely large influence.

The SCL-90 scale is used for self-assessment by people over the age of 16 and is one of the most well-known mental health testing scales in the world. It consists of 90 items, assessed from 10 factors of somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobia, paranoid ideation, psychoticism, sleeping and eating state. According to their self-perception of the psychological state, the subjects rate their symptoms using a scale ranging from 1 to 5 on a scale corresponding to “none”, “very light”, “moderate”, “heavy”, and “severe”. The higher the score, the worse the mental health of the subject.¹³

SADS was compiled by Waston et al in 1969, and the Chinese version was revised by Hong Ma et al, which has been proved to have good reliability and validity.¹⁴ The scale consists of 28 items, including two dimensions of social avoidance and social distress, with 14 questions for each dimension and the score range from 0 to 28 points. The higher the score, the more severe the degree of social avoidance and distress.

MCMQ was formed into a formal Chinese version of the questionnaire by Qianjin Jiang et al, combined with the original Chinese translation version and revised several times.¹⁵ Twenty items are assigned to three coping styles: facing (8 items), avoiding (7 items) and yielding (5 items). Using a four-point scoring method (1–4 points), the total score is 20 to 80 points, and the higher the subscale score, the more obvious the coping style.

Statistical Analyses

The collected data were entered into excel and checked by two investigators, and the data were statistically analyzed by SPSS 18.0 statistical software. The mean ± standard deviation was used to describe the measurement data. Single sample t-test, one way analysis of variance (ANOVA) and two independent sample t-test were used to compare the differences. Spearman two-variable correlation analysis was used to analyze the correlation. P < 0.05 was statistically significant.

Results

Basic Demographic Data

As shown in Table 1, a total of 117 patients completed the questionnaires, including 49 males (41.9%) and 68 females (58.1%). The ratio of men to women was 1:1.39. Most patients (67.5%) were younger than 40 years old and had no positive family history (76.9%). For severity of disease, 65.8% patients were mild. More than half of the patients (58.1%) were in progressive stage and 12.0% in rapid progress stage.

Table 1 Demographic Data of Patients with Vitiligo

 

DLQI Scores of Patients with Vitiligo

The DLQI scores of 117 patients with vitiligo in this survey ranged from 0 to 26 points, and the mean score was 7.56 ± 6.11. 15 of 117 patients (12.8%) had a score of 0–1, indicating that vitiligo had almost no impact on their quality of life, and 39 patients scored 2–5, up to 33.3%, 31 patients (26.5%) had a score of 6–10, meaning that vitiligo had a moderate impact on them. There were 25 (21.4%) patients with 11–20 points. 7 (6.0%) scored more than 20, which impacted of the quality of life greatly, see Figure 1.

Figure 1 The distribution of DLQI (dermatology quality of life index) scores of patients with vitiligo.

 

Mental Health Status and Univariate Analysis of Patients with Vitiligo

The mental health status of 117 patients with vitiligo was evaluated by SCL-90 questionnaire. As shown in Table 2, the mean score was 136.44 ± 39.19, which was significantly higher than the Chinese norm of SCL-90 (129.19 ± 40.25)¹³ (P < 0.05). Among the 10 factors, the scores of depression, anxiety, interpersonal sensitivity and phobia were significantly higher than the Chinese norms¹³ (all P < 0.05).

Table 2 Comparison Between SCL-90 Score in Patients with Vitiligo and Chinese Norms (mean±SD)

 

For Single factor analysis, as shown in Table 3, in terms of the total score of SCL-90 and the scores of interpersonal sensitivity, depression, anxiety and phobia, it was found that female patients were significantly higher than those of men (P < 0.05), the married group were lower than those in the unmarried group (P < 0.05), the patients in rapid progression stage were significantly higher than those in progressive and stable stage (P < 0.05), and patients with skin lesions on the exposed site also scored significantly higher compared with those without exposed lesions (P < 0.05). In addition, it was found that there were significant differences in interpersonal sensitivity and depression scores among patients with different diseases severity (both P < 0.05).

Table 3 Univariate Analysis of Patients with Vitiligo in the Score of Total SCL-90 and Interpersonal Sensitivity, Depression, Anxiety and Phobia (Mean ± SD)

 

Social Status and Univariate Analysis of Patients with Vitiligo

The scores of SADS in 117 patients with vitiligo in this survey ranged from 0 to 26, the mean score was 10.30 ± 6.38, and the mean score of social avoidance was 5.13 ± 3.38 and social distress was 5.17 ± 3.67. Compared with the Chinese norm,¹⁴ it was found that the differences were statistically significant (P < 0.05), see Table 4.

Table 4 Comparison Between SADS Score in Patients with Vitiligo and Chinese Norms (mean±SD)

 

For single factor analysis of social status of patients with vitiligo, the score of social avoidance in women was higher than that in men (5.69 ± 3.39 vs 4.35 ± 3.24, t = 2.156, P = 0.033). The total scores of SADS and social distress in the junior middle school group were significantly higher than those in the other three groups (all P < 0.05). For severity of disease, the total SADS and social avoidance scores in mild group were significantly lower than that of severe group (all P < 0.05). The total score of SADS, social avoidance and social distress score of patients in rapid progressive stage were significantly higher than those in the other two groups (P < 0.05), see Table 5.

Table 5 Univariate Analysis of Patients with Vitiligo in the Score of Total SADS, Social Avoidance and Social Distress (mean±SD)

 

Medical Coping Mode in Patients with Vitiligo

The score of face coping was lower than the Chinese norm,¹⁵ and the scores of yield coping and avoidance coping were higher than the Chinese norm (P < 0.05), see Table 6.

Table 6 Comparison Between MCMQ Score in Patients with Vitiligo and Chinese Norms (mean±SD)

 

Impact of Medical Coping Style on Patients’ Mental Health

As shown in Table 7, yield coping and avoidance coping were positively correlated with the scores of interpersonal sensitivity, depression, anxiety and phobia (all P < 0.05). Face coping was negatively correlated with social avoidance and distress (P < 0.05), and yield coping and avoidance coping were positively correlated with social avoidance and distress (all P < 0.05), see Table 8.

Table 7 Impact of Medical Coping on Patients’ Mental Health

Table 8 Impact of Medical Coping on Patients’ Social Status

 

Discussion

Vitiligo is a common acquired depigmentation skin and mucous membrane disease, which can involve hair follicles. This disease is easy to diagnose, but difficult to treat. Repeated recurrence, and the change of appearance will damage the physical and mental health of patients to varying degrees.

Vitiligo will not bring serious health problems to patients, but lead to serious cosmetic problems. Many studies have shown that vitiligo lesions have a certain impact on the quality of life of patients.^16,17 Consistent with the DLQI score in the world,¹⁷ the overall average score was 8.2, which was in the third level. The DLQI score of the 117 patients investigated in our study was (7.56 ± 6.11), in the third-level effect, indicating that vitiligo had a moderate impact on the quality of life of patients. DLQI scores are concentrated in 2–20 points, which is in the second to fourth level of influence. It is worth noting that 32 (27.4%) patients had DLQI scores higher than 10 in our research, indicating that the disease had a great impact on their quality of life. The change of appearance will affect the personality characteristics and social relations of patients to a certain extent. Studies have shown that the quality of life of patients with vitiligo is significantly related to their psychological distress and mental health.¹⁸ Importantly, the quality of life of vitiligo may be largely affected by psychosocial comorbidity.¹⁹

Skin plays an essential role in our interaction with the world, and skin color is important in perceiving someone’s health.²⁰ The results of our study showed that the total score of SCL-90 was 136.44, which is significantly higher than the Chinese norm. The mental health problems of patients with vitiligo in China are mainly manifested as interpersonal sensitivity, depression, anxiety, and phobic anxiety. In this study, the total scores and all dimensions of SADS in vitiligo patients were significantly higher than the Chinese norms, indicating that compared with the general population, vitiligo patients had obvious social distress and social avoidance.

Many studies have shown that vitiligo has a greater impact on women’s mental health, and women are more prone to have mental symptoms and social disorders. Vitiligo sufferers experience limited participation in social interactions, job opportunities, religious activities, making friends, etc., showing significant social anxiety and avoidance.²¹ Compared with men, women experienced severe social distress, anxiety, and avoidance. In the study of Sawant,²² it was found that the degree of helplessness, depression and anxiety, social anxiety/avoidance and participation restriction of women were significantly higher than that of men. In our study, the scores of interpersonal sensitivity, depression, anxiety, phobia and social avoidance in women were significantly higher than men. Men and women have different psychosocial reactions to vitiligo. Women may pay more attention to their self-image, have more sensitive thoughts, and are more likely to feel embarrassed and ashamed of the reactions of people around them. Adverse emotional reactions make them become more helpless and negative when face to diseases. They take the initiative to avoid some social activities and avoid going out to contact with people. Moreover, men and women have different understanding and value to the relationship between marriage and love. Female patients are more worried about the impact of vitiligo on their mate selection and marital status, and the social acceptance of women suffering from vitiligo is low, which makes them more vulnerable.

Studies have shown that vitiligo has a negative impact on patients’ life and marital status. Patients with vitiligo feel troubled and ashamed when they start sexual relations and emotional experience.¹⁰ Our study showed that unmarried patients have more negative symptoms of interpersonal sensitivity, depression, anxiety and phobia than married patients. The score of social avoidance and distress were slightly higher than that of married people, but the difference is not significant, indicating that both unmarried people and married people all suffer from social distress and avoidance. Education level is an important demographic characteristic of an individual, which affects person’s cognitive behavior to a great extent. A study showed that the higher the level of education, the more the patients can rationally understand the disease and reduce the burden caused by the disease.²³ Consistent with the results of our study, the scores of interpersonal sensitivity, depression, anxiety, phobia, social avoidance and distress of patients with junior high school education are higher than those with senior high school, junior college, undergraduate, graduate and above education. With the increase of disease severity, the scores of vitiligo patients in interpersonal sensitivity, depression, anxiety, phobia, social avoidance and distress showed an upward trend. Patients with severe pigmented diseases have an increased frequency of mental illness.²⁴ The scores of interpersonal sensitivity, depression, anxiety, phobia, social avoidance and distress in skin lesions with rapid progression were significantly higher than those in progressive and stable stage. The scores of interpersonal sensitivity, depression, anxiety, phobia, social distress and avoidance of patients with skin lesions at the exposed site were higher than those without skin lesions at the exposed site, but only significant difference in the level of mental health, indicating that the mental health status of patients with the exposed lesions was worse than that of patients without lesions at the exposed site.²³

In this study, the face coping score of patients with vitiligo was significantly lower than the Chinese norm, and the yield and avoidance coping scores were significantly higher than the Chinese norms. And face coping was negatively correlated with patients’ social avoidance and distress, and yield and avoidance coping were positively correlated with patients’ interpersonal sensitivity, depression, anxiety, phobia, social avoidance and distress. Scholars believe that the psychological intervention treatment of vitiligo should start with the treatment education of patients. Through the education of disease and standardized treatment, we can improve patients’ cognitive level of disease, significantly reduce the anxiety and fear, and increase their belief in actively facing disease.¹¹

Participants with a good understanding of vitiligo were more likely to show a positive attitude toward vitiligo patients than those with insufficient knowledge of the disease.²⁵ In addition to psychotherapy and/or counseling for patients, general education on vitiligo for unaffected people may help to reduce the stigma associated with vitiligo and improve the psychosocial health of patients and their caregivers.

This study also has some limitations: 1. This study only conducted a sampling survey in one hospital. 2. The sample size is limited, resulting in a small number of cases collected in some age, diseases severity and stage. Multicenter and large sample research should be done in the future. 3. We not used VitiQoL tool to analyze the quality of life of patients with vitiligo.²⁶ 4. There is no research on the effect of psychotherapy in patients with vitiligo.

Conclusion

In China, vitiligo affects the quality of life of patients to varying degrees, resulting in a series of psychological and behavioral problems, including interpersonal sensitivity, depression, anxiety, phobia, social avoidance and distress, which are mainly affected by the patients’ social demographic situation (gender, marital status, educational level), disease-related situation (stage, severity, whether there are skin lesions at the exposed site) and coping style. At the same time of routine treatment, clinicians should also actively pay attention to and improve the mental health and behavior of patients with vitiligo.

Other Reads : Factors Affecting Quality Of Life In Patients With Vitiligo Part 1

Disclosure

The authors declare no conflict of interest.

References

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By Xiaoying Ning, Yanfei Zhang, Wei Wang, Huling Yan, Yumin Xia

Department of Dermatology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China

Correspondence: Yanfei Zhang, Department of Dermatology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, People’s Republic of China, Email zhangyanfei723@163.com

Image Credit: Elf Moondance(Pixabay)

Managing vitiligo has been a challenging journey. There have been limited options available for dermatologists to offer to help treat the chronic, inflammatory, autoimmune skin condition affecting approximately 2-3 million people¹, including more than 1.5 million diagnosed, in the United States². Vitiligo involves more than simply cosmetic issues, reinforcing the need for further research and management options for these patients and the dermatologists who care for them.

Progress in Research Around Vitiligo Management

In recent years, researchers have made important progress in understanding the underlying pathology of vitiligo. Based on preclinical data, the JAK/STAT pathway has been shown to mediate the production of IFNγ. IFNγ producing cytotoxic T lymphocytes have been shown to mediate melanocyte destruction in human vitiligo³. The relevance of inhibition of specific JAK enzymes to therapeutic effectiveness is not currently known.

As JAK inhibition is linked to reduced skin inflammation and T-cell-mediated melanocyte destruction, a logical approach is to diminish local inflammation and facilitate endogenous repigmentation in patients with vitiligo. Proof of concept of JAK inhibition was demonstrated in small studies⁴, leading to Phase 3 trials and the recent U.S. Food and Drug Administration (FDA) approval of the first topical JAK inhibitor for the topical treatment of nonsegmental vitiligo in patients 12 years of age and older.

“For patients who want to be repigmented, we had limited options to help,” explains David Rosmarin, M.D., Vice Chair of Research and Education, Department of Dermatology at Tufts Medical Center. “With the first approved pharmacologic treatment for nonsegmental vitiligo repigmentation now available, we now have a new option to offer our patients to help them manage their condition should they choose to treat their disease.”

Opzelura: The First and Only Topical JAK Inhibitor

In July 2022, the FDA approved Opzelura™ (ruxolitinib) cream 1.5% for the topical treatment of nonsegmental vitiligo in adult and pediatric patients 12 years of age and older. A nonsteroidal JAK inhibitor, Opzelura is applied topically on up to 10% body surface area (BSA) twice daily⁵.

The TRuE-V clinical trial program enrolled adults and adolescents 12 years of age and older with nonsegmental vitiligo affecting at least 0.5% facial BSA and 3% nonfacial BSA. Results from the Phase 3 TRuE-V clinical trial program demonstrated that the proportion of subjects achieving a 75% improvement in the facial Vitiligo Area Scoring Index (F-VASI75) was significantly greater at Week 24 (primary analysis) compared to vehicle, with further improvement in an open-label extension at Week 52.

• In the randomized Phase 3 TRuE-V1 and TRuE-V2 studies, the primary endpoint of F-VASI75 (the proportion of patients achieving a 75% improvement in the facial Vitiligo Area Scoring Index) at Week 24 was attained by significantly more patients who applied Opzelura versus vehicle in TRuE-V1/TRuE-V2, respectively (approximately 30% vs. approximately 8%/13%, P<0.0001)⁶. At Week 52, approximately 50% of Opzelura-treated patients achieved a 75% improvement in F-VASI75.
• Additionally, at Week 24, more than 15% of patients treated with Opzelura achieved ≥90% improvement from baseline in F-VASI (F-VASI90), compared to approximately 2% of patients treated with vehicle. At Week 52, the percentage of Opzelura-treated patients who achieved F-VASI90 doubled to approximately 30%.

In clinical trials, the most common adverse reactions (incidence ≥ 1%) are application site acne, application site pruritus, nasopharyngitis, headache, urinary tract infection, application site erythema, and pyrexia⁶. The labeling for Opzelura includes a Boxed Warning for serious infections, mortality, malignancy, major adverse cardiovascular events and thrombosis. See additional Important Safety Information below.

The Future of Vitiligo Management

While the management of vitiligo was often previously seen as cosmetic, new research and management approaches are increasingly focused on treating vitiligo as an immune-mediated disease.

“The approval of Opzelura for the treatment of nonsegmental vitiligo presents a new option and an opportunity to revisit discussions with appropriate patients who are seeking repigmentation,” adds Dr. Rosmarin. “By working closely with our patients to determine their treatment goals, we can help ensure those looking to treat their vitiligo are aware of what is now available.”

An individualized plan is important to help manage the disease, and novel approaches can offer new options to help some patients successfully achieve their desired goals.

Opzelura may work for some, but not all, patients. To learn more, visit www.Opzelurahcp.com.

INDICATION

OPZELURA is indicated for the topical treatment of nonsegmental vitiligo in adult and pediatric patients 12 years of age and older.

Limitations of Use: Use of OPZELURA in combination with therapeutic biologics, other JAK inhibitors, or potent immunosuppressants such as azathioprine or cyclosporine is not recommended.

IMPORTANT SAFETY INFORMATION

SERIOUS INFECTIONS

Patients treated with oral Janus kinase inhibitors for inflammatory conditions are at risk for developing serious infections that may lead to hospitalization or death. Reported infections include:

• Active tuberculosis, which may present with pulmonary or extrapulmonary disease.
• Invasive fungal infections, including cryptococcosis and pneumocystosis.
• Bacterial, viral, including herpes zoster, and other infections due to opportunistic pathogens.

Avoid use of OPZELURA in patients with an active, serious infection, including localized infections. If a serious infection develops, interrupt OPZELURA until the infection is controlled. Carefully consider the benefits and risks of treatment prior to initiating OPZELURA in patients with chronic or recurrent infection. Closely monitor patients for the development of signs and symptoms of infection during and after treatment with OPZELURA.

Serious lower respiratory tract infections were reported in the clinical development program with topical ruxolitinib.

No cases of active tuberculosis (TB) were reported in clinical trials with OPZELURA. Cases of active TB were reported in clinical trials of oral Janus kinase inhibitors used to treat inflammatory conditions. Consider evaluating patients for latent and active TB infection prior to administration of OPZELURA. During OPZELURA use, monitor patients for the development of signs and symptoms of TB.

Viral reactivation, including cases of herpes virus reactivation (e.g., herpes zoster), were reported in clinical trials with Janus kinase inhibitors used to treat inflammatory conditions including OPZELURA. If a patient develops herpes zoster, consider interrupting OPZELURA treatment until the episode resolves.

Hepatitis B viral load (HBV-DNA titer) increases, with or without associated elevations in alanine aminotransferase and aspartate aminotransferase, have been reported in patients with chronic HBV infections taking oral ruxolitinib. OPZELURA initiation is not recommended in patients with active hepatitis B or hepatitis C.

MORTALITY

In a large, randomized, postmarketing safety study in rheumatoid arthritis (RA) patients 50 years of age and older with at least one cardiovascular risk factor comparing an oral JAK inhibitor to tumor necrosis factor (TNF) blocker treatment, a higher rate of all-cause mortality, including sudden cardiovascular death, was observed with the JAK inhibitor. Consider the benefits and risks for the individual patient prior to initiating or continuing therapy with OPZELURA.

MALIGNANCIES

Malignancies were reported in patients treated with OPZELURA. Lymphoma and other malignancies have been observed in patients receiving JAK inhibitors used to treat inflammatory conditions. In RA patients treated with an oral JAK inhibitor, a higher rate of malignancies (excluding non-melanoma skin cancer (NMSC)) was observed when compared with TNF blockers. Patients who are current or past smokers are at additional increased risk.

Consider the benefits and risks for the individual patient prior to initiating or continuing therapy with OPZELURA, particularly in patients with a known malignancy (other than successfully treated non-melanoma skin cancers), patients who develop a malignancy when on treatment, and patients who are current or past smokers.

Non-melanoma skin cancers, including basal cell and squamous cell carcinoma, have occurred in patients treated with OPZELURA. Perform periodic skin examinations during OPZELURA treatment and following treatment as appropriate. Exposure to sunlight and UV light should be limited by wearing protective clothing and using broad-spectrum sunscreen.

MAJOR ADVERSE CARDIOVASCULAR EVENTS (MACE)

In RA patients 50 years of age and older with at least one cardiovascular risk factor treated with an oral JAK inhibitor, a higher rate of major adverse cardiovascular events (MACE) (defined as cardiovascular death, myocardial infarction, and stroke), was observed when compared with TNF blockers. Patients who are current or past smokers are at additional increased risk. Discontinue OPZELURA in patients who have experienced a myocardial infarction or stroke.

Consider the benefits and risks for the individual patient prior to initiating or continuing therapy with OPZELURA, particularly in patients who are current or past smokers and patients with other cardiovascular risk factors. Patients should be informed about the symptoms of serious cardiovascular events and the steps to take if they occur. Discontinue OPZELURA in patients that have experienced a myocardial infarction or stroke.

THROMBOSIS

Thromboembolic events were observed in trials with OPZELURA. Thrombosis, including pulmonary embolism (PE), deep venous thrombosis (DVT), and arterial thrombosis have been reported in patients receiving JAK inhibitors used to treat inflammatory conditions. Many of these adverse reactions were serious and some resulted in death. In RA patients 50 years of age and older with at least one cardiovascular risk factor treated with an oral JAK inhibitor, a higher rate of thrombosis was observed when compared with TNF blockers. Avoid OPZELURA in patients at risk. If symptoms of thrombosis occur, discontinue OPZELURA and treat appropriately.

Thrombocytopenia, Anemia, and Neutropenia

Thrombocytopenia, anemia, and neutropenia were reported in the clinical trials with OPZELURA. Consider the benefits and risks for individual patients who have a known history of these events prior to initiating therapy with OPZELURA. Perform CBC monitoring as clinically indicated. If signs and/or symptoms of clinically significant thrombocytopenia, anemia, and neutropenia occur, patients should discontinue OPZELURA.

Lipid Elevations

Treatment with oral ruxolitinib has been associated with increases in lipid parameters including total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides.

Adverse Reactions

In nonsegmental vitiligo, the most common adverse reactions (incidence ≥1%) are application site acne (6%), application site pruritus (5%), nasopharyngitis (4%), headache (4%), urinary tract infection (2%), application site erythema (2%), and pyrexia (1%).

Pregnancy

There is a pregnancy registry that monitors pregnancy outcomes in pregnant persons exposed to OPZELURA during pregnancy. Pregnant persons exposed to OPZELURA and healthcare providers should report OPZELURA exposure by calling 1-855-463-3463.

Lactation

Advise women not to breastfeed during treatment with OPZELURA and for approximately four weeks after the last dose (approximately 5-6 elimination half-lives).

Please see Full Prescribing Information, including Boxed Warning, and Medication Guide for OPZELURA.

Aug 30, 2022

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Photo Credit: Armin Rimoldi