Autoimmune diseases: care and treatment of vitiligo
Vitiligo is an autoimmune disease characterized by the destruction of melanin-producing cells (melanocytes) by immune cells (cytotoxic T lymphocytes)
It is manifested by the presence of white patches on the skin: these are hypochromic/achromic patches due to the absence of melanic pigment at the affected areas of skin.
Like all autoimmune diseases, vitiligo has an unpredictable course and its therapeutic management is very complex
Patients with vitiligo suffer greatly from this condition in which aesthetic impairment can have harmful psychological and social consequences.
Patients consider this condition disfiguring, a reason for a reduction in their self-esteem and quality of life, particularly when the most visible areas, such as the face, are affected.
For this reason, a proper therapeutic approach that integrates drug therapies with psychological support is essential.
There is evidence to support the importance of cognitive-behavioral psychological support in order to return to acceptance of one’s image, resulting in an improvement at the psychological level that is reflected in the course of the disease.
Vitiligo therapy aims to restore the original appearance of the skin, stabilizing the depigmentation process and promoting repigmentation of the patches.
Given that melanocytes respond slowly to therapy, a time frame of 6-12 months should be budgeted for satisfactory results.
Local therapy for vitiligo
Local therapy for vitiligo relies on the application at the level of the patches of cortisone-based creams (topical corticosteroids) 1-2 times daily for a variable period of 2-4 months or calcineurin inhibitors (tacrolimus and pimecrolimus).
Treatment with topical corticosteroids is recommended only in localized vitiligo.
In children, lower potency corticosteroids or calcineurin inhibitors are recommended, particularly in the more sensitive areas where corticosteroids are contraindicated.
Encouraging results have also been obtained with the excimer laser, which is capable of emitting monochromatic light similar to UVB used in phototherapy with the difference of greater selectivity for vitiligo patches.
It is therefore particularly indicated in patients with localized forms, also in combination with local topical therapy.
UVB phototherapy and heliotherapy for the treatment of vitiligo
In the presence of a more diffuse form of vitiligo, the treatment of first choice is narrow-band UVB phototherapy (NB-UVB), a therapy that makes use of lamps through which the beneficial effects of UVB rays on the stimulation of melanocytes are exploited to promote repigmentation of the patches.
Microphototherapy is based on exposure to UVB light only at the level of the affected areas, with a reduction in the total dose of exposure and the advantage of not increasing the color contrast between the healthy skin and the patches.
It is recommended only if the affected area does not exceed 20 percent of the body surface.
Phototherapy is often combined with topical therapy and the intake of supplements containing vitamins and a pool of antioxidants (alpha lipoic acid, Polypodium leucomotos extract, vitamin C, vitamin E) that promote the repigmentation process.
Many different supplements aimed at stimulating pigmentation are currently available commercially, to be taken alone or in combination with phototherapy or heliotherapy.
It may be useful to administer vitamin D, which is recommended in the presence of an autoimmune disease for its immunomodulating effect.
In addition, it also has receptors present at the melanocyte level, leading to speculation that its beneficial effect could also be exerted directly at the melanocyte level. The dosage of vitamin D administration should be determined after measuring basal values.
During the summer period, photoexposure can be considered as a real treatment
To enhance the therapeutic efficacy of UVB rays on the patches, it may be useful to apply vitiligo-specific photoprotectors at the level of the depigmented areas, which have the function of avoiding sunburn by stimulating the heliotherapeutic effect in compensation.
In association, it is essential to apply an spf 50+ sunscreen to healthy areas to reduce their pigmentation and thus minimize color contrast.
In the absence of response to therapies, teaching camouflage techniques with opaque cosmetics may be helpful in improving the cosmetic appearance resulting in improved quality of life for the patient.
In universal forms of vitiligo, the possibility of depigmenting areas of residual pigmentation with specific products may be considered, to be reserved, however, only for carefully selected cases because of the possible side effects of such substances, the psychological impact of permanent depigmentation, and the resulting high photosensitivity.
Is anything new planned for the treatment of vitiligo?
Currently, a drug with a specific indication for vitiligo has not yet been approved.
One hope is provided by JAK kinase inhibitors, Ruxolitinib and Tofacitinib, drugs that can suppress the activity of cytotoxic lymphocytes responsible for melanocyte destruction in vitiligo patients.
Tofacitinib, currently approved for the treatment of rheumatoid arthritis, has been shown to be effective in repigmenting vitiligo patches in patients being treated for rheumatoid arthritis.
Given the serious adverse reactions of these drugs when administered systemically, interest has focused on the development of formulations to be applied topically.
A recent study in which the efficacy of a cream containing Ruxolitinib was investigated provided encouraging results and opened new perspectives for the topical treatment of vitiligo.
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