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Management Strategies and New Directions in the Treatment of Vitiligo - Episode 6

Role of Providers in Setting Expectations for Vitiligo

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Drs. Pandya and King discuss patient’s visit and how providers can help set expectations about the disease course.

Brett King, MD, PhD: Amit, can you describe the role that you perceive for yourself and for other healthcare providers in helping patients understand both their vitiligo and the expectations of treatment? Can you walk us through a patient encounter? We've just heard about the quality-of-life impairment and acknowledging that and then leading that into and this is what we can do, walk us through what a visit looks like and when do we talk about what it is and how we're going to make it better?

Amit Pandya, MD: When I talk to a patient about treatment, I first explain the pathogenesis of vitiligo which we have talked about in terms of the T cells destroying the melanocytes. Then I say, now that we know what causes vitiligo, I want to talk to you about the 2 pillars of treatment. There are 2 pillars of treatment. Number 1, we want to remove the CD8+ T cells that are attacking your skin, and number 2, we want to stimulate the melanocytes to repigment your skin. If we don't do both, you're not going to have success in improving your vitiligo. You may have just been putting this cream on all this time, but all you're doing is keeping your vitiligo stable or somewhat stable, but you're not repigmenting because you're not getting enough light to that area, especially below the neck. As Heather said, if you live in a sunny climate and you're getting sun on your face that can improve, even with creams, for example, even with topicals. But I talk to them about the 2 pillars of therapy. With the 2 pillars of therapy– it's going to be trying to remove those T cells and then usually phototherapy or some type of light to stimulate the good cells. However, this can take months, sometimes years. One of the questions that we just discussed is how do you live with vitiligo while you're going through this? That's something I learned by attending the World Vitiligo Day Celebrations and support group meetings, where I got a chance to hear and talk to many individuals with vitiligo who are trying to live in this world with vitiligo. Now, that's an important part of my patient education. How are you going to live with this vitiligo while I'm trying to make your lesions better? First of all, how do you even leave your home? Or you may need to use Dermablend® cosmetics to cover it. You may want to do that. Secondly, you may want to use dihydroxyacetone or an artificial tan that you apply or spray paint on your skin so that you can live with vitiligo while I'm trying to get it better. Thirdly, you may be sad. You may feel like you're the only person in the world with vitiligo. Well, here is the website for the Global Vitiligo Foundation and for my vitiligo team. These are 2 wonderful websites where you can get information, but you can also find a friend with vitiligo, someone who has walked down the path that you are walking on but is 5 years ahead of you down that path, 10 years ahead of you down that path, who has been through a lot of the emotions that you have already been through. Wouldn't it be nice for you to talk to someone like that? Well, you can do that. I provide multiple websites livingdappled.com for young women with vitiligo, where they can find these links, find these social networks so that they can live with this condition while I'm trying to get them better.

Brett King, MD, PhD: And we heard about this earlier, but it comes up again here and it's important. I feel like it comes up often in the patient visit. Inevitably, you're going to talk about or you just mentioned, right? You're going to talk about removing those immune cells from the skin that are making this happen, but the patient is going to ask, and they might ask a few times in a visit if it's long enough, but what can I – do I need to eat certain foods? Do I need to avoid certain foods? Do I need to take vitamins? How do you talk about that part with them? Because they ask this over and over again. And it's an important point, to just come out and address ahead of time. What do you say about that?

Amit Pandya, MD: What I tell them is that it is known that there are certain proteins in the cells of your melanocytes that are called reactive oxygen species that create reactions in oxygen species, which is what all the antioxidant industry is trying to quench. It's trying to quench various molecules in your cells that cause damage to your cells. And your melanocytes have reacted oxygen species due to sun exposure, due to chemicals, due to toxins, due to stress. And we know that antioxidants help that. However, we don't have good evidence that you need to take expensive broad-spectrum antioxidants for your vitiligo. I can't tell you exactly that you need to take this dose of this particular one. However, we have some soft evidence that simple antioxidants, such as vitamin C, vitamin E, alpha-lipoic acid, ginkgo Biloba. Those are the ones that have had controlled studies in which it's shown some benefit for vitiligo. What about diet? I don't believe that there's IGA antibodies that are being made because you have a gluten-sensitive antipathy in your intestine, and those antibodies are going to your skin causing vitiligo. That's never been shown. You don't have to do it. Especially if it's a child, you don't have to do it. Elaborate dietary manipulation, which could perhaps even affect the growth of that child because you're removing dairy, you're removing wheat and gluten. You're removing all citrus foods because that's been,told to many patients to remove citrus. You don't need to do that to yourself or your child. However, why don't you eat 5 servings of fruits and vegetables every day and a handful of nuts? Half an apple is one serving. Eat 5 servings of fruits and vegetables every day, and a handful of nuts and you'll get vitamin E, you'll get vitamin C, you'll get vitamin A, you'll get some antioxidants that can potentially help your vitiligo. And there is some scientific evidence that oxidative free radicals do make it worse, so why not do that?

Transcript Edited for Clarity