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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.

Reference

  1. Elbuluk N, Rosmarin D. Updates in vitiligo management. DermView. November 22, 2022. Accessed November 30, 2022. https://www.dermatologytimes.com/dermview/updates-in-vitiligo-management

Source

What to know about laser treatments for vitiligo

Vitiligo can cause the skin to lose its natural color. Laser therapy can help repigment the skin, but this can also cause side effects, such as hyperpigmentation and skin lesions, in some people.

picture showing vitiligo on a person's hand
Eva Szombat/Getty Images

Vitiligo is a skin condition that causes pale patches to develop on the skin. This happens when the body stops producing melanocytes, the cells responsible for the skin pigment melanin. Vitiligo can affect any area, but it mostly occurs on the face, neck, hands, and where there are creases.

There is no cure  for vitiligo, but treatment can help even out a person’s skin tone. Dermatologists can offer a person many treatment options for vitiligo if they would like to treat it.

Laser treatment is one such option; it uses light to restore the lost color of skin. A person should consider all the pros and cons with their dermatologist before commencing treatment.

Keep reading to learn more about vitiligo laser treatments, including the effectiveness of excimer or other lasers in treating vitiligo.

Excimer lasers

Excimer lasers are a popular choice of laser treatment. Excimer laser, or XTRAC, is a type of treatment that uses an ultraviolet light form called UVB to treat vitiligo. The laser uses UVB at a 308 nanometers (nm) wavelength.

This laser can treat localized vitiligo and may be a good option for people who have not responded well to other treatments, such as topical creams or lotions.

Scientists do not fully understand the exact mechanism of action for excimer lasers. They believe that UVB light can enhance the immune response and stimulate the production of more melanocytes, cells that produce a pigment called melanin.

Dermatologists use a wand-like device to apply the light directly to the affected skin areas. This treatment can help restore color to the pale areas.

People should not feel pain, and the procedure takes less than half an hour. Dermatologists may recommendattending laser treatment sessions twice weekly for 4-6 months, but this can vary between people.

There are many advantages of using the excimer laser:

  • The laser only treats the affected areas and does not expose the surrounding areas to the radiation.
  • Dermatologists can use it in areas that can be difficult to treat with other therapies, such as phototherapy. These can include the ears and genital areas.
  • Dermatologists can use different templates depending on the areas they are treating.
  • It is safe to use on children.

Side effects

If the dermatologist uses a high dose, the excimer laser can cause blisters on the skin. Other side effects may include:

  • painful erythema or reddening of the skin
  • hyperpigmentation or darkening of the skin
  • skin lesions, if there is a burn

Different lasers for treating vitiligo have their benefits, side effects, and risks. Lasers include:

  • fractional ablative lasers
  • helium-neon lasers
  • Ti: sapphire lasers
  • UVA1 lasers
  • Q-switched nanosecond lasers for depigmentation therapies

Most of these emerging laser types have only been proved effective in a small number of studies.

A study from 2019 looking into the effects of Ti: Sapphire lasers in 21 people found that it can be as effective as excimer lasers and is a useful alternative in some cases.

A 2022 study found that conventional ablative lasers, such as CO2 and Erbium: YAG, can help promote repigmentation when dermatologists combine them with narrowband UVB light. People opting for this combination therapy may experience very few side effects.

Each laser type works differently. For example, fractional ablative lasers work by creating microscopic wounds as they pass over the affected area and ultimately produce an immune response and stimulation of melanocyte cells.

Also, fractional CO2 lasers can cause tissue to contract the area it passes over — an action that can temporarily reduce the vitiligo lesion size. Further research into the effectiveness of fractional ablative lasers for treating vitiligo alone would be beneficial.

Dermatologists may choose candidates carefully, considering the disease’s specific characteristics. These factors may include location, the extent of disease, activity, and type of vitiligo.

Effectiveness of excimer lasers for vitiligo

About 70% of people who opt for excimer laser treatment see results. However, the results may disappear in those who stop treatment within one year.

An older study found that an excimer laser can effectively treat vitiligo. Individuals who opt for this treatment may start experiencing results within a few months.

However, the researchers claim that there is limited research that determines whether people may respond better to the laser treatment depending on their skin type and hair follicle characteristics.

Suitable candidates for laser treatment

Phototherapy and laser treatments are suitable for individuals of any age group and can work on all skin tones. Some lasers might not be suitable for children; however, doctors may use narrowband UVB for children with extensive vitiligo.

A person should check with their dermatologist if they are suitable for the different types of lasers.

Laser vs. other treatment options

Laser treatments may require frequent visits to a dermatologist’s clinic. Also, side effects, such as skin lesions, hyperpigmentation, and blisters, can occur in people having laser treatment.

Other treatment options that dermatologists may recommend for people with vitiligo may include:

  • Surgery: This may be a good option when medications and light therapy do not produce the desired result. It is not safe for children, but it is suitable for adults with stable vitiligo, meaning their condition has remained the same for the past 6 months. During the session, the surgeon removes the skin cells with natural color and transfers the cells to the areas requiring repigmentation.
  • No treatment. People might opt for using cosmetics, such as makeup and skin dyes, to cover the lighter patches of skin. This might be a safer option for children as serious side effects are less likely to occur. However, it can be time-consuming as individuals may have to apply the product frequently.
  • Topical medications: Individuals may opt for medications, such as corticosteroids, that they apply to the skin to add color. Doctors may prescribe topicals for people with smaller affected areas, and corticosteroids can work best on the face. People using products that contain corticosteroids for a long time are more prone to developing skin dryness and fragility.
  • PUVA light therapy: This therapy typically involves using UVA light with another drug called psoralen to treat widespread vitiligo. It is about 50-75% effective in restoring pigment to certain areas of the body, including the face.
  • Depigmentation: This involves removing the remaining pigment on the skin. It can take up to 4 years to complete the process.

Phototherapy

This treatment uses UV light but only certain wavelengths that aim to re-pigment the skin.

Phototherapy helps produce more melanocytes in the skin so that it does not form new lighter patches.

Some people may opt for a full-body phototherapy session, but the duration can vary and might depend on the severity of their condition. For example, those with moderate to severe vitiligo may have to attend more than two sessions every week.

Cost

The cost of vitiligo laser treatment can vary. It can depend on:

  • the areas being treated
  • the number of sessions that person may have to attend
  • the prices set by the clinic

However, as an estimate, clinics might charge $150 or more per session depending on the size of the depigmented area. Also, people may require between 20 to 30 sessions.

Is it safe to use the excimer laser?

A 2018 study states that the excimer laser is safe and effective in treating localized vitiligo. Combining this laser with topical agents, such as tacrolimus or tacalcitol, may provide better repigmentation results.

Research  has also shown the 308nm excimer laser does not increase the risk of skin cancer and premalignant skin lesions in people with vitiligo.

What to expect after laser treatment?

According to the American Academy of Dermatology Association (AAD), people that have dark skin pigment may notice that some of their skin areas are darker in color after the treatment sessions. This, however, should resolve within a few months.

People can return to work after excimer laser sessions, and they can continue with their daily routine.

How many sessions do people require?

This depends on the laser that a person opts for and the severity of their skin condition.

People should expect to attend their clinic frequently if their vitiligo is severe. The treatment course can last months to years.

Summary

Laser therapy can be a good treatment option for people with vitiligo.

Doctors might try a few laser treatments, and the treatment course can depend on the individual’s condition and skin type. Dermatologists may also discuss the treatment duration and decide on the number of sessions a person may need.

However, those who cannot get treated with a laser may opt for other treatment options. These may include topical medications or surgical procedures.

Source:

Anxiety and depression in pediatric patients with vitiligo and alopecia areata and their parents: A cross-sectional controlled study Part 2

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).

1.1                | Evaluation of the scales related to psychological parameters and QoL

The mean CDLQI score was 5.1 ± 5.13 (0-22) in the AA group and

2.76 ± 2.39 (0-8) in the vitiligo group; the mean DeFIS score was 12.19 ± 11 (0-54) in the AA group and 14.45 ± 9.33 (0-45) in the vitiligo group, indicating no significant difference (P = .245, P = .102, respectively).

In the AA group, the scores in the RCADS-C subscales of SAD

(P = .026), GAD (P = .021), SP (P = .049) and MDD (P = .006), and the total (P = .010) scores were significantly higher compared to the control group. According to the results of RCADS-P, the scores in the subscales of PD (P = .015) and MDD (P = .001), and the total anxiety (P = .041) and total (P = .012) scores were significantly higheramong the patients in the AA group compared to the control group (Table 2). While there was no significant difference in the vitiligo group in terms of the RCADS-C scale scores, according to RCADS-P, the PD (P = .030) and MDD (P = .014) subscores of the patients were significantly higher than the controls (Table 2). There was no significant difference between the AA and vitiligo groups in relation to the RCADS-C and RCADS-P scores. Similarly, no significant difference was observed between the AA, vitiligo, and control groups in terms of the parents’ BAI and BDI scores (Table 2).

Concerning the relationship between disease severity and total anxiety and depression scores, in the AA group, the SALT score had a positive correlation with RCADS-C depression (P = .014) and total anxiety (P = .032) and RCADS-P depression (P = .023) and total anxiety (P = .014) scores. However, in this group, no significant correlation was detected between the parents’ BAI (P = .321) and BDI (P = .161) scores. In the vitiligo group, there was no significant correlation between the VASI score and the total anxiety and depression scores, but the VASI score was found to be positively correlated with the RCADS-P SAD score (P = .048). There was no significant relationship between the parents’ BAI (P = .829) and BDI (P = .981) scores in the vitiligo group (Table 3).

In the AA group, the CDLQI score was positively correlated with the scores obtained from SALT (P = .008), RCADS-C depression (P = .012) and total anxiety (P = .041), DeFIS (P = .010), parental BAI (P = .011), and parental BDI (P = .022). In the vitiligo group, the CDLQI score had a positive correlation with the scores of RCADS-C depression (P = .001) and total anxiety (P = .007), and RCADS-P

TABLE 3 Correlation between SALT,

VASI, CDLQI, DeFIS, RCADS-C, RCADS-P, BAI, and BDI scores in patients with alopecia areata and vitiligo (Spearman rho)

Separation Anxiety .383* .271 .195 .256 .350 .489**
Generalized Anxiety .387* .307 .409* −.132 .299 .361
Panic .381* .342 .431* .104 .481** .377*
Social Phobia .236 .317 .313 −.114 .281 .162
Obsessive-Compulsive .428* .370* .330 .197 .571** .477**
Depression .438* .443* .377* .164 .589** .325
Total Anxiety .386* .370* .378* .067 .491** .455*
Total .448* .445* .425* .102 .570** .440*
RCADS-Parent

Separation Anxiety

.292 .310 .242 .371* .230 .574**
Generalized Anxiety .455* .365* .495** .061 .318 .368*
Panic .157 .127 .372* .142 .310 .396*
Social Phobia .398* .169 .428* .096 .167 .203
Obsessive-Compulsive .382* .336 .482** .238 .344 .688**
Depression .407* .228 .400* −.003 .383* .394*
Total Anxiety .435* .309 .553** .144 .332 .462*
Total .454* .331 .522** .053 .389* .424*
Parents’ BAI .184 .452* .515** −.042 .169 .262
Parents’ BDI .258 .410* .643** −.005 .255 .185
SALT .466** .602**
VASI .048 .184
CDLQI .466** .455* .048 .130
DeFIS .602** .455* .184 .130

Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CDLQI, Children’s

Dermatology Life Quality Index; DeFIS, Dermatological Family Impact Scale; RCADS-Child, Revised Child Anxiety and Depression Scales, Child Version; RCADS-Parent, Revised Child Anxiety and Depression Scales, Parent Version; SALT, Severity of Alopecia Tool; VASI, Vitiligo Area Severity

Index.

*P < .05.

**P < .01.

depression (P = .040); however, CDLQI did not have a significant relationship with parental BAI (P = .379), parental BDI (P = .183), VASI (P = .804), and DeFIS (P = .500) (Table 3).

In the AA group, the DeFIS score had a positive correlation with the SALT score (P < .0001), the RCADS-C depression (P = .037) and total anxiety (P = .036) scores, the RCADS-P depression (P = .026) and total anxiety (P = .001) scores, the parental BAI score (P = .03), and the parental BDI score (P < .0001). In the vitiligo group, the DeFIS score was positively correlated with the scores of RCADS-C total anxiety (P = .013), and RCADS-P depression (P = .035) and total anxiety (P = .012); however, no significant correlation was observed between the DeFIS score and the parental BAI (P = .169), parental BDI (P = .337), and VASI (P = .340) scores (Table 3).

2       | DISCUSSION

Psychiatric symptoms are very common in dermatology patients, and an undetected psychiatric disorder can significantly reduce the patient’s QoL since it can delay treatment or recovery. We designed this study to better understand the impact of AA and vitiligo on children and their parents. Therefore, we have attempted to study the dimensions of anxiety disorders, that is, SAD, SP, GAD, OCD, and PD. Furthermore, in the current study, the anxiety and depression scales were directly evaluated in addition to the DeFIS scale, which indirectly measures the psychological status of the parents. Present results suggest differences between AA and vitiligo pediatric patients. The presence of stressful life events before the onset of both AA and vitiligo in the pediatric group and emphasized its greater importance for the latter. In addition, anxiety symptoms were more common in AA patients than those with vitiligo.

In a study by Bilgiç et al, AA was shown to have a positive correlation with higher state and trait anxiety and depression scores in children.11 In another study examining children with AA aged nine to 11 years, the patients were found to have significantly higher levels of psychopathology than the controls.7 In our study, we observed a significant difference between the pediatric patients with AA and the control group in terms of the RCADS-C subscales scores in SAD, GAD, SP, and depression, as well as the total scale score, which contributes to and supports previous research. In addition, PD and total anxiety scores were significantly higher in children with AA in the RCADS-P scale. While no significant difference was found in any of the subscales of RCADS-C in the evaluation of vitiligo patients, according to RCADS-P, the PD and depression scores of the patients in the vitiligo group were significantly higher compared to the control parents. The results of studies investigating depression and anxiety scores in patients with vitiligo are variable. In a study evaluating children and adolescents with vitiligo, depression scores were found to be higher than the control groups only in the children (8-12 years) group.16 In another study, children’s level of anxiety and depression symptoms did not significantly differ from the control group.15 However, Ucuz et al reported that the state and trait anxiety scores of children with vitiligo were different from those of the controls.17 The awareness that pediatric patients with alopecia areata and vitiligo are closely related to psychological factors is essential and psychiatric evaluation is important in the management of this population. Such patients should be directed to the child and adolescent psychiatrist, and treatment of the psychological condition can contribute to the medical treatment of dermatological disease.

In a recent study involving the parents of children with vitiligo, the depressive symptoms of the parents were higher than those of the control group, but the authors did not observe a similar link for anxiety symptoms.15 In another study evaluating depression and anxiety symptoms among the carers of patients with different types of dermatoses (vitiligo, atopic dermatitis, and psoriasis), higher levels of anxiety and depression were observed compared to the general population, but no difference was observed between disease groups.18 To the best of our knowledge, there is no study in the literature examining the psychiatric state of the parents of children with AA. In the current study, there was no difference between the anxiety and depression levels of the parents of the patients with AA and vitiligo and those in the control group. Similarly, no significant difference was observed between the vitiligo and AA groups in terms of the DeFIS scores, through which we evaluated the QoL of the parents.

A small number of studies related to the pediatric cases have shown the presence of stressful life events before the onset of AA as a potential trigger of the disease at a rate of 9.5% to 81%.31-34 In studies conducted with children with vitiligo, a history of stressful life events before the onset of the disease was reported at the rates of 48.8%15 and 77%.17 In our study, 61% of children with AA and 86.2% of children with vitiligo had a history of stressful life events in the year prior to the onset of the disease.

There is only one study in the literature that evaluated the severity of AA together with psychological state in children, and the results did not show a significant relationship.11 In contrast, in our study, there was an increase in the depression and anxiety scores of the patients with AA with the increasing severity of the disease, although a positive correlation of disease severity and anxiety and depression levels was not detected for the parents. In the evaluation of patients with vitiligo, Önen et al did not report a relationship between the severity of the disease and anxiety and depression scores in parents or children.15 In other studies in which children and adolescents were examined, no significant relationship was observed between vitiligo severity and anxiety16,17 and depression16 scores. In our study, only the level of SAD was increased with the increasing severity of vitiligo, but there was no positive correlation between disease severity and parental anxiety and depression levels.

In a previous study examining the effect of AA on QoL, it was shown that the QoL of the parents decreased as the severity of the disease increases in the child.35 In a study by Bilgiç et al, AA severity was shown to have a negative effect on the QoL of children.11 Similarly, in our study, impairment in the QoL of both patients and their parents increased with the increasing disease severity in the AA group. However, there are conflicting results in studies investigating the effect of the severity of vitiligo on QoL. For example, in one study, the severity of vitiligo in adolescents was observed to affect QoL negatively16 while two other studies including children and adolescents reported no relationship between QoL and the body surface area36 and vitiligo severity.15 According to another study in which the effect of childhood vitiligo on parents’ QoL was examined, as the area of involvement of vitiligo increased, the parental QoL decreased.37 In the current study, we found no correlation between disease severity and the QoL of patients or parents.

The main limitation of this study is the small sample size and cross-sectional design, and the lack of a structured interview and psychiatric evaluation can be considered as another limitation.

The results of the study indicated that the presence of stressful life events was more common in pediatric patients with vitiligo than those with AA. On the other hand, anxiety symptoms were more prevalent in patients with AA than those with vitiligo. While the severity of AA was correlated with the QoL of the affected children and their parents, there was no such correlation in vitiligo. The QoL of the patients affected the anxiety and depression levels of their parents in the AA group, but not in the vitiligo group. It is important to identify pediatric patients with alopecia areata and vitiligo who need extra psychological support and refer them to the child and adolescent psychiatrist. In conclusion, providing a psychological evaluation and support for both patients and their parents will not only help them better cope with chronic dermatoses that cause cosmetic disorders such as vitiligo and AA but also contribute to the improvement of their QoL.

ACKNOWLEDGMENTS

We thank Esma İnan Yüksel, MD, for her valuable contribution.

DATA AVAILABILITY STATEMENT

Data openly available in a public repository that issues datasets with DOIs.

ORCID

Sevil Savaş Erdoğan               https://orcid.org/0000-0002-4392-4671

Tuğba Falay Gür              https://orcid.org/0000-0002-3233-9610

Bilal Doğan              https://orcid.org/0000-0002-0855-5209

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  5. Krüger C, Schallreuter KU. A review of the worldwide prevalence of vitiligo in children/adolescents and adults. Int J Dermatol. 2012;51(10):1206-1212.
  6. Whitton ME, Ashcroft DM, Barrett CW, Gonzalez U. Interventions for vitiligo. Cochrane Database Syst Rev. 2006;(1):CD003263.
  7. Liakopoulou M, Alifieraki T, Katideniou A, et al. Children with alopecia areata: psychiatric symptomatology and life events. J Am Acad Child Adolesc Psychiatry. 1997;36(5):678-684.
  8. Reeve EA, Savage TA, Bernstein GA. Psychiatric diagnoses in children with alopecia areata. J Am Acad Child Adolesc Psychiatry. 1996;35(11):1518-1522.
  9. Chu SY, Chen YJ, Tseng WC, et al. Psychiatric comorbidities in patients with alopecia areata in Taiwan: a case–control study. Br J Dermatol. 2012;166(3):525-531.
  10. Ghanizadeh A. Comorbidity of psychiatric disorders in children and adolescents with alopecia areata in a child and adolescent psychiatry clinical sample. Int J Dermatol. 2008;47(11):1118-1120.
  11. Bilgiç Ö, Bilgiç A, Bahalı K, Bahali A, Gürkan A, Yılmaz S. Psychiatric symptomatology and health-related quality of life in children and adolescents with alopecia areata. J Eur Acad Dermatol Venereol. 2014;28(11):1463-1468.
  12. Lai Y, Yew Y, Kennedy C, Schwartz R. Vitiligo and depression: a systematic review and meta-analysis of observational studies. Br J Dermatol. 2017;177(3):708-718.
  13. Osinubi O, Grainge MJ, Hong L, et al. The prevalence of psychological comorbidity in people with vitiligo: a systematic review and meta-analysis. Br J Dermatol. 2018;178(4):863-878.
  14. Vallerand IA, Lewinson RT, Parsons LM, et al. Vitiligo and major depressive disorder: a bidirectional population-based cohort study. J Am Acad Dermatol. 2019;80(5):1371-1379.
  15. Önen Ö, Kundak S, Özek Erkuran H, Kutlu A, Çakaloz B. Quality of life, depression, and anxiety in Turkish children with vitiligo and their parents. Psychiatry Clin Psychopharmacol. 2019;29(4):492-501.
  16. Bilgiç Ö, Bilgiç A, Akiş H, Eskioğlu F, Kiliç E. Depression, anxiety and health-related quality of life in children and adolescents with vitiligo. Clin Dermatol. 2011;36(4):360-365.
  17. Ucuz I, Altunisik N, Sener S, et al. Quality of life, emotion dysregulation, attention deficit and psychiatric comorbidity in children and adolescent with vitiligo. Clin Exp Dermatol. 2020.
  18. Manzoni APDdS, Weber MB, Nagatomi ARdS, Pereira RL, Townsend RZ, Cestari TF. Assessing depression and anxiety in the caregivers of pediatric patients with chronic skin disorders. An Bras Dermatol. 2013;88(6):894-899.
  19. Carroll CL, Balkrishnan R, Feldman SR, Fleischer AB Jr, Manuel JC. The burden of atopic dermatitis: impact on the patient, family, and society. Pediatr Dermatol. 2005;22(3):192-199.
  20. Tekin B, Gurel MS, Topkarci Z, et al. Assessment of quality of life in Turkish children with psoriasis and their caregivers. Pediatr Dermatol. 2018;35(5):651-659.
  21. Olsen EA, Hordinsky MK, Price VH, et al. Alopecia areata investigational assessment guidelines–Part II. J Am Acad Dermatol. 2004;51(3):440-447.
  22. Hamzavi I, Jain H, McLean D, Shapiro J, Zeng H, Lui H. Parametric modeling of narrowband UV-B phototherapy for vitiligo using a novel quantitative tool: the Vitiligo Area Scoring Index. Arch Dermatol. 2004;140(6):677-683.
  23. Balcı DD, Sangün Ö, İnandı T. Cross validation of the turkish version of children’s dermatology life quality index. J Turk Acad Dermatol. 2007;1(4):71402a.
  24. Chorpita BF, Yim L, Moffitt C, Umemoto LA, Francis SE. Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behav Res Ther. 2000;38(8):835-855.
  25. Gormez V, Kılınçaslan A, Orengul AC, et al. Psychometric properties of the Turkish version of the Revised Child Anxiety and Depression Scale-Child Version in a clinical sample. Psychiatry Clin Psychopharmacol. 2017;27(1):84-92.
  26. Gormez V, Kilincaslan A, Ebesutani C, et al. Psychometric properties of the parent version of the Revised Child Anxiety and Depression Scale in a clinical sample of Turkish children and adolescents. Child Psychiatry Hum Dev. 2017;48(6):922-933.
  27. Turan E, Gürel MS, Erdemir AT, Yüksel EI. Development and preliminary validation of the dermatological diseases family impact scale. Turkderm. 2014;48(2):74-81(in Turkish).
  28. Ulusoy M, Sahin NH, Erkmen H. The Beck anxiety inventory: psychometric properties. J Cogn Psychother. 1998;12(2):163-172.
  29. Hisli N. A study on the validity of Beck Depression Inventory. J Psychol. 1988;6:118-122(in Turkish).
  30. Hisli N. Validity and reliability of Beck Depression Inventory in university students. J Psychol. 1989;7:3-13(in Turkish).
  31. Manolache L, Petrescu-Seceleanu D, Benea V. Alopecia areata and relationship with stressful events in children. J Eur Acad Dermatol Venereol. 2009;23(1):107-109.
  32. Díaz-Atienza F, Gurpegui M. Environmental stress but not subjective distress in children or adolescents with alopecia areata. J Psychosom Res. 2011;71(2):102-107.
  33. Andreoli E, Mozzetta A, Provini A, Cacciaguerra M, Paradisi M, Bonda PF. Types of stress within child alopecia. Dermatol Psychosomat. 2002;3(1):26-29.
  34. Kakourou T, Karachristou K, Chrousos G. A case series of alopecia areata in children: impact of personal and family history of stress and autoimmunity. J Eur Acad Dermatol Venereol. 2007;21(3):356-359.
  35. Putterman E, Patel DP, Andrade G, et al. Severity of disease and quality of life in parents of children with alopecia areata, totalis,

 

and universalis: a prospective, cross-sectional study. J Am Acad Dermatol. 2019;80(5):1389-1394.

  1. Silverberg JI, Silverberg NB. Quality of life impairment in children and adolescents with vitiligo. Pediatr Dermatol. 2014;31(3):309-318.
  2. Andrade G, Rangu S, Provini L, Putterman E, Gauthier A, CasteloSoccio L. Childhood vitiligo impacts emotional health of parents: a prospective, cross-sectional study of quality of life for primary caregivers. J Patient Rep Outcomes. 2020;4(1):1-5.

Source

Factors affecting quality of life in patients with vitiligo Part 2

Patients and methods

Participants and settings

A nationwide questionnaire-based study was conducted in 21 hospitals and clinics in Korea from July 2015 to June 2016. All patients aged ≥ 20 years diagnosed with vitiligo by dermatologists, and who provided written informed consent prior to the survey were enrolled. We restricted the participants to adult patients, because different questionnaires should be applied to children and adults. We explored demographic characteristics and vitiligo phenotypes and determined Skindex-29 scores. All patients first completed the questionnaires in paper-and-pencil format, and dermatologists then confirmed the clinical profiles after interviewing and examining the patients. The study protocol was designed in accordance with the Declaration of Helsinki and was approved by the institutional review board of each hospital.

Demographic characteristics

Demographic characteristics recorded included age, sex, marital status (single or married) and educational background (elementary school graduate, middle school graduate, high school graduate or college graduate).

Vitiligo phenotypes

The vitiligo phenotypes included subtype (segmental or nonsegmental), disease duration (< 1, 1–4, 5–9 or ≥ 10 years), affected body surface area (BSA; < 05, 05–09, 1–4, 5–9, 10–19 or ≥ 20%), involvement of visible body parts (yes or no) and the particular body parts involved (face and neck, scalp, upper extremities, lower extremities, trunk and genital area).

The Skindex-29 questionnaire

QoL was assessed using the Korean version of Skindex-29. This instrument is employed extensively to measure the effects of skin disease on a patient’s life;8,9 the Korean version was cross-culturally adapted by Ahn et al.10 The semantic equivalence of all back-translated items has been confirmed,10 and the Korean version has been validated by several previous studies.11–13 The questionnaire contains 29 items exploring the influence of skin disease on daily life using a five-point scale: 0 (never), 1 (rarely), 2 (sometimes), 3 (often) and 4 (all the time). The responses were transformed into linear scores varying from 0 (no effect) to 100 (effect always experienced). Each item belongs to one of three domains (symptoms, functioning and emotions); the scores of the three domains were calculated as the mean score of the items included in each domain.

The major items affecting patients with vitiligo

The proportions of patients affected by each item (sometimes, often and all the time) were calculated. The items of most concern were identified based on the answers.

Quality-of-life impairment

The outcomes of the study were mild or severe impairment of QoL, as determined by each domain (symptoms, functioning and emotions) of Skindex-29. Mild and severe QoL impairments were defined using the cut-off scores suggested by Prinsen et al.:14,15 ≥ 39 (mild) and ≥ 52 (severe) for symptoms, ≥ 21 (mild) and ≥ 37 (severe) for functioning, and ≥ 24 (mild) and ≥ 39 (severe) for emotions.

Statistical analyses

Absolute and percentage frequencies were determined for categorical variables, and position (mean and median) and scattering (SD, range) were described for continuous variables. Univariate and multivariate logistic regression analyses were sequentially performed to identify the factors independently associated with QoL impairment in each domain of Skindex29. All analyses were performed using R 3.3.1 (R Foundation for Statistical Computing, Vienna, Austria).

Results

In total, 1123 patients with vitiligo were recruited from 21 hospitals and clinics. Of the participants, 609 (542%) were male and 514 female (458%), with a mean age of 498  152 years (range 20–84). The median duration of disease was 30 years (range 0–60). The detailed clinical characteristics of the enrolled patients are summarized in Table 1.

The results of Skindex-29

The Skindex-29 items of most concern to patients with vitiligo were as follows: no. 13: I worry that my skin condition may get worse (746% of patients); no. 3: I worry that my skin condition may be serious (629%); no. 22: My skin condition is a problem for the people I love (556%); and no. 6: My skin condition makes me feel depressed (535%) (Table 2).

Impaired quality of life and associated factors in terms of the symptoms domain

Of the patients with vitiligo, 146% (164 of 1123) had mild and 52% (58 of 1123) had severe QoL impairment in terms of the symptoms domain (Fig. 1). On multivariate logistic

Table 1 The clinical characteristics of the 1123 patients with vitiligo included in the present study

 

 

 

 

 

 

regression modelling, the involvement of visible body parts (OR 153) and a larger affected BSA (compared with < 05%; 5–9%: OR 278, 10–19%: OR 284 and ≥ 20%: OR 469) were associated with mild symptom impairment (Table 3). A larger affected BSA was also associated with severe symptom impairment (compared with < 05%; ≥ 20%: OR 810).

Impaired quality of life and associated factors in terms of the functioning domain

Of the patients with vitiligo, 488% (548 of 1123) had mild and 282% (317 of 1123) had severe QoL impairment in terms of the functioning domain. The factors associated with

Table 2 The Skindex-29 items that affected > 25% of patients with vitiligo

Affected

Items (in order of frequency)                        patients     Domain

13. I worry that my skin condition may          746%         Emotions get worse

3. I worry that my skin condition may            629%         Emotions be serious

22. My skin condition is a problem for          556%                Functioning the people I love

6. My skin condition makes me feel               535%         Emotions depressed

9. I worry about getting scars from my           498%         Emotions skin condition

12. I am ashamed of my skin condition        497%       Emotions

28. I am annoyed by my skin condition        476%       Emotions

5. My skin condition affects my social           450%                Functioning life

15. I am angry about my skin condition        448%       Emotions

24. My skin is sensitive                                 433%          Symptoms

4. My skin condition makes it hard to            427%                Functioning work or do hobbies

21. I am embarrassed by my skin 410%         Emotions condition

19. My skin is irritated                                  379%          Symptoms

23. I am frustrated by my skin condition      356%       Emotions

20. My skin condition affects my 354%         Functioning interactions with others

11. My skin condition affects how close       328%       Functioning

I can be with those I love

17. My skin condition makes showing           305%                Functioning affection difficult

26. I am humiliated by my skin    296%         Emotions condition

10. My skin itches                                         291%          Symptoms

14. I tend to do things by myself  275%         Functioning because of my skin condition

30. My skin condition makes me tired          264%       Functioning

8. I tend to stay at home because of my          263%                Functioning skin condition

 

Source

 

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,

Turkey

Correspondence

Sevil Savaş Erdoğan, Department of

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

2232  |  © 2020 Wiley Periodicals LLC                                                       wileyonlinelibrary.com/journal/jocd       J Cosmet Dermatol. 2021;20:2232–2239.

 

1       | INTRODUCTION

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       | MATERIAL AND METHOD

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

 

Groups

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).

Vitiligo treatment updates

Dr. John Harris discusses the current and future landscape for vitiligo treatment.

John E. Harris, MD, PhD, is Professor and Chair, Department of Dermatology, as well as Director of the Vitiligo Research Center at University of Massachusetts Medical School in Worcester, Mass.

“We’ve been using the same [vitiligo] treatments for about 3400 years: sunlight and light-activated chemicals, while now we use narrowband UVB, which is a small improvement,” said John E. Harris, MD, PhD, who discussed vitiligo treatment updates at the 4th Inflammatory Skin Disease Summit.

“We have good treatments for vitiligo, but they’re really cumbersome. They take a long time. Patients have to really commit to 12 to 14 months of treatment to get decent improvement.”

However, research over the past decade into what causes vitiligo has led to new treatment opportunities, said Dr. Harris. There are two signaling cytokine pathways that can be targeted for vitiligo: JAK inhibitors for interferon gamma signaling and biologics to target IL-15 signaling.

“A phase II and then phase III clinical trial have now been conducted using topical ruxolitinib [Opzelura] to treat vitiligo, and both showed that it was very effective….1 The FDA has approved it for atopic dermatitis and now we’re hoping in the next few months it will be approved for vitiligo. That would be the first FDA-approved treatment for vitiligo, ever.”

In terms of biologics, a clinical trial is currently recruiting patients to address disease relapse, which is about 40% within a year of stopping any treatment, said Dr. Harris.

“We wanted to know why—why does vitiligo come back? And importantly, why does it come back in exactly where it was before?”

According to Dr. Harris, they found that resident memory T cells form within vitiligo lesions.

“You can take a JAK inhibitor or any other treatment and turn off these cells, and everything gets better. But then if you stop the treatment, they’re still there. They wake back up and reinitiate everything.”

Those memory T cells require IL-15 signaling for long-term maintenance and survival, said Dr. Harris.

“When we blocked IL-15 signaling, not only did vitiligo get better in a mouse model, but those… memory T cells were erased from the skin. Short-term treatment gave us long-term effects. We’re hoping that blocking IL-15 with an antibody… will last not just for a short period of time but actually give a durable, long-term response.”

In their research, Dr. Harris and colleagues also have found hundreds of other activated pathways to potentially target for vitiligo treatment.

“We’re pursuing those. There’s some promise that that maybe someday we’ll have even better [treatments]. Could the cure for vitiligo be in that data somewhere? We’re hoping so.”

According to Dr. Harris, treatments under consideration include a bi-specific antibody and RNA interference (RNAi).

“We know we can treat psoriasis [and] atopic dermatitis with an antibody. We showed some data… [with] a bi-specific antibody, where one antibody targets two different things. We can bring the treatment into the skin, tether it there, and create a high local concentration that might be both safer and have higher efficacy for patients.”

RNAi may also be an option for treating vitiligo and other inflammatory skin diseases, said Dr. Harris.

“It’s a new way to turn off proteins in different tissues, and we found a way to deliver this specifically to the skin.”

Despite all these up-and-coming treatments, Dr. Harris has a key message for dermatologists who may believe they do not currently have viable treatment options for their vitiligo patients.

“There’s plenty you can do even now with the tools that we have, the drugs, the treatment approaches…. It’s just cumbersome and difficult and not everybody has access.”

Current off-label treatment options include tofacitinib (Xeljanz XR) and ruxolitinib, said Dr. Harris.

“Oral tofacitinib works for vitiligo. It’s tough to get because it’s not FDA approved for vitiligo. It’s very expensive. So, trying to get that approved for use in patients can be difficult, although not impossible.”

The oral JAK inhibitor also recently received a black box warning for safety concerns.

According to Dr. Harris, he has topical ruxolitinib compounded at a compounding pharmacy.

“I’ve used [ruxolitinib] over the last few years. But as soon as that gets FDA approved for vitiligo, we’ll have it from the pharmacy and be able to prescribe it on label which would be exciting.”

References

  1. Rosmarin D, Pandya AG, Lebwohl M, et al. Ruxolitinib cream for treatment of vitiligo: a randomised, controlled, phase 2 trial. Lancet. 2020 Jul 11;396(10244):110-120. doi: 10.1016/S0140-6736(20)30609-7. PMID: 32653055.
  2. Gellatly KJ, Strassner JP, Essien K, et al. scRNA-seq of human vitiligo reveals complex networks of subclinical immune activation and a role for CCR5 in Treg function. Sci Transl Med. 2021 Sep 8;13(610):eabd8995. doi: 10.1126/scitranslmed.abd8995. Epub 2021 Sep 8. PMID: 34516831; PMCID: PMC8686160.

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