Management Strategies and New Directions in the Treatment of Vitiligo - Episode 9
Drs. Pandya and King discuss challenges in re-pigmentation, including glabrous skin and areas that may not re-pigment.
Brett King, MD, PhD: Amit, how glamorous skin, so fingers, wrists, lips, or body areas without hair follicles will not repigment, or will repigment more slowly and how should we be thinking about these areas of skin that I think are really distinctly different?
Amit Pandya, MD: Well, vitiligo is a very interesting disease because it's so unpredictable, I'm amazed at how some patients come in and they have deep pigmentation of the epidermis, but when you take a dermatoscope and you examine their forehead, their cheeks, the skin around their eyes, you'll see of hundreds of tiny vellus hairs that are still black. And those black vellus hairs have melanocytes at the base that when you shine light on them, they crawl up the side of the hair and fill in the epidermis with pigment. And that's an important exam that one should do when you're evaluating a patient. But then I'm amazed that there are some patients, even with the few lesions of vitiligo in which every single hair is white. It seems like the immune system has not only killed the melanocytes in the epidermis, but it has targeted those deep melanocytes at the base of the hairs causing the hair to grow out white. And those patients are going to have a poorer prognosis, and it's going to be similar to what you see on the hands in areas that don't have hairs and also the wrists, the feet, the ankles. Those tend to be some of the hardest areas as well as the lips. However, like David was talking about, there is marginal repigmentation. And in my experience, marginal repigmentation depends on the color of the patient, but many times it's unpredictable. You'll see a 1 cm lesion on the hand in a lighter-colored patient. And after 6 months of phototherapy, it'll only move in 2 to 3 ml. But if the patient is, let's say type 6 skin, it can move in 8 ml and fill it in. But then, on the other hand, there are patients who it fills in even with some lighter skin. It's unpredictable as to how much marginal repigmentation will happen. Therefore, even if a patient has hand involvement, wrist involvement, ankle involvement, foot involvement, and I know the prognosis is poor, I still think it's worthwhile to go ahead and pull out all the stops and treat them with the topical, sometimes systemic and phototherapy, just to see how much improvement we can achieve with the treatment. And so, that's how I counsel the patients that your prognosis is poor in those areas. However, we will treat because sometimes it can be better. I also emphasize the fact that the treatment has to be more aggressive. If you're treating with 800 millijoules of phototherapy on the face, you may need to treat with 1,600 millijoules of phototherapy on the hands to achieve the same type of response.
Brett King, MD, PhD: This comes back to earlier points of discussion about the discussion with patients around expectations of treatment and what to expect. As much as we can possibly predict the future of their disease, what to expect from it. If you have a little bit of lip involvement, a little bit of involvement of the hands, do you talk to patients about proactive treatment in these areas to try to prevent future disease or to try to prevent increased extensive disease? Again, David earlier talked about, for some patients, it may be enough just to halt progression, and for sites of involvement that we think have a poor prognosis should we be more proactive in just trying to halt further disease? What do you think about this?
Amit Pandya, MD: Yes, I agree. Patients have many different desires just like David talked about. And each interaction with the patient must be individualized for that patient. If the patient says that I don't like the lesions in my hands and I absolutely want them completely gone, otherwise I really don't want treatment, then you have to give them the reality that it's going to be difficult to completely get rid of it. But if the patient says, I hope for some improvement, but Doctor, what I really would like is for it not to get worse. Then absolutely, treatment will prevent it from getting worse. And once they're explained that these are T cells that are causing that and it's exacerbated by trauma, I have the electrician wear gloves, I have the gardener wear gloves. I have them reduce trauma to that area. If it's on their feet, I have them wear two socks when they're jogging and try to protect those areas from trauma. And I have them apply the creams and do phototherapy in those areas to prevent new lesions.
Brett King, MD, PhD: Again, for the listener, there's a lot of discussion here. We have to talk with our patients to understand their relationship with their disease, what they want out of it. And then we're going to think about their answers to those questions to tailor treatment. Which brings me to the next, I think, important topic of treatment.
Amit Pandya, MD: Brett, I'm sorry. I just want to make one footnote to what I said. I'm sorry. You talked about improvement, let's say on the lips. How do we see 1 ml, 2 ml, 3 ml improvement on the lips? The only way you're going to notice that is with photographs. I see my patients after two months for the first follow-up visit and every three months after that. If I don't take pictures, I can't tell if that upper lip has improved 1 or 2 ml. And I guarantee the patient can't tell either. And so, if the phototherapy is starting to close the lips or close the lesions on the hands, you must take those photographs to see that difference. That motivates the patient. It motivates me to continue with treatment.
Brett King, MD, PhD: I agree. Photography is critical. You can't document in enough words what vitiligo is, or its extent to actually capture change over time. And so, I think photography is critical.
Transcript Edited for Clarity