Vitiligo, a chronic autoimmune disorder characterized by the loss of skin pigmentation, affects approximately 70 million people worldwide. Beyond being a dermatological condition having a profound impact on an individual’s quality of life and self-esteem, it has also long been a challenge for health care professionals to manage effectively. However, despite there being no cure, recent years have seen significant advancements in the understanding of vitiligo’s pathogenesis and paved the way for a wider range of treatment options.
Vitiligo Treatment Options
The selection of appropriate treatment options for vitiligo depends on several factors, including the specific type of vitiligo, its extent and distribution, patient demographics, and the desired therapeutic goals. In some cases, the main aim may be to stop the progression of existing spots and patches and prevent new ones from appearing. At other times, the primary goal could be to promote repigmentation.
Additionally, to some extent, the specific type of vitiligo will also have a say in dictating the treatment approach. For those with localized or segmental vitiligo, topical therapies may be appropriate, whereas it may be more beneficial for those with widespread vitiligo to opt for systemic treatments or phototherapy.
Regardless of the treatment type, the management of vitiligo requires a multifaceted approach, and dermatologists must work with their patients to find the strategies that best suit their individual needs and circumstances.
Topical Therapies
The use of topical corticosteroids and calcineurin inhibitors like tacrolimus and pimecrolimus have long been used as first-line treatments for vitiligo. They work to reduce the inflammation in the skin, thereby slowing down the pigmentation loss.
These topical treatments are often considered first-line due to their efficacy, safety profile, as well as the fact that they are relatively low risk when it comes to side effects compared to other types of treatments. That said, their overall success may vary depending on factors such as the extent and duration of vitiligo, skin type, and the individual’s response to treatment.
Phototherapy
Phototherapy is believed to be an effective treatment for vitiligo as it is able to stimulate repigmentation of the skin. According to the International Vitiligo Task Force (IVTF), narrowband UVB therapy (NB-UVB) is the preferred first-line therapy for widespread or rapidly progressive vitiligo. They recommend early initiation of NB-UVB as it has the ability to halt disease activity.
Excimer lasers, which use highly focused and precise beams of UVB, are also a good option for localized vitiligo. It is also useful for pediatric patients who cannot tolerate undergoing treatment in a phototherapy booth. During a 2022 study by Sumit Sethi and Nanette B. Silverberg, MD, published in the Journal of Drugs in Dermatology, authors examined the use of excimer laser in pediatric patients with vitiligo and found that repigmentation was noted to be retained in 80% of facial, 40% of the body, and 20% of extremity lesions during the average follow up time of 3.38 years.
Surgical Interventions
Surgical therapy is also an option for vitiligo with the goal of transplanting functional melanocytes to the depigmented area to cause repigmentation.
Systemic Therapies
Systemic treatments such as oral steroid minipulse (OMP) therapy can help suppress the autoimmune response. One of IVTF’s suggestions is the use of oral minipulses of moderate doses of betamethasone or dexamethasone for the treatment of rapidly progressive vitiligo in order to stop disease progression.
JAK Inhibitors
JAK inhibitors represent a promising new class of therapeutic agents in the treatment of vitiligo. Currently, ruxolitinib (Opzelura™) is the first and only U.S. Food and Drug Administration-approved treatment for vitiligo. However, studies evaluating the efficacy of other JAK inhibitors are also currently in progress.
A recent scoping review published in the International Journal of Dermatology examined the efficacy and safety of JAK inhibitors in vitiligo based on available literature. The authors revealed, “treatment of vitiligo with oral or topical JAKi seems to be promising and the growing evidence shows a favorable risk-benefit profile.”
A study of upadacitinib published in the British Journal of Dermatology, found that “treatment with upadacitinib for 24 weeks resulted in greater improvements vs placebo in the clinical outcomes of adults with extensive non-segmental vitiligo. Observed clinical efficacy continued to improve through week 36 with upadacitinib treatment”.
A phase 2b trial of oral ritlecitinib further demonstrated the efficacy of JAK inhibitors in treating vitiligo. Authors of this study concluded that, “ritlecitinib is an effective and well-tolerated treatment for patients with active NSV’.”
Emerging Therapies
In addition to the promising outlook of JAK inhibitors, VYNE Therapeutics recently announced their pre-clinical and phase 1b data demonstrating the positive results of the BET inhibitor, VYN201. This 16-week open-label study included 29 patients with active nonsegmental vitiligo (NSV) who were randomly assigned to receive one of three doses of topical VYN201 (0.5%, 1% or 2%). Results from the biomarker analysis revealed a downregulation of matrix metalloproteinase-9 (MMP-9) levels and an upregulation of melanocyte-related transcription factors (MRTFs).
Speaking recently to Dermatology Times, Iain Stuart, PhD, chief scientific officer at VYNE Therapeutics, states, “VYN201 is a very differentiated therapy. The vast majority of drugs that are currently in development for vitiligo are JAK inhibitors and come along with all the associated safety precautions that come along with that class of molecule. There’s a tremendous unmet need in vitiligo in general, and within the therapeutic space, there’s basically no differentiation. We really think that there’s a space here for VYN201”.
Combination Therapies
Numerous studies have shown that combining various therapies provides more effective outcomes for vitiligo treatment. According to Seemal R. Desai, MD, FAAD, “Although improvements have been made with monotherapy topicals, the combination of phototherapy, oral antioxidants, and oral and topical medications together are what’s needed.”
Moving Forward
It is essential for providers to evaluate each patient’s unique circumstances in a comprehensive manner, considering the many factors involved. This includes the extent and distribution of vitiligo, their age, and overall health status, when selecting the most appropriate treatment approach. Furthermore, personalized treatment plans may be necessary to optimize outcomes and improve the quality of life for individuals living with vitiligo.
Sources:
- https://globalvitiligofoundation.org/vitiligo-facts/
- https://www.aad.org/public/diseases/a-z/vitiligo-treatment#:~:text=Ruxolitinib%20(Opzelura%E2%84%A2)%20is%20the,who%20have%20non%2Dsegmental%20vitiligo.
- https://www.dermatologytimes.com/view/treatment-of-vitiligo-with-phototherapy
- Short and Long-Term Outcomes of 308-nm Laser for Pediatric Vitiligo
- Janus kinase inhibitors and the changing landscape of vitiligo management: a scoping review
- Thierry Passeron, Khaled Ezzedine, Iltefat Hamzavi, Nanja van Geel, Bethanee J Schlosser, Xiaofei Hu, Xiaohong Huang, David Rosmarin, John E Harris, Heidi S Camp, Amit G Pandya, 501 – Efficacy and safety of upadacitinib in a phase 2 randomized, double-blind, dose-ranging study of adults with extensive non-segmental vitiligo, British Journal of Dermatology, Volume 190, Issue Supplement_2, February 2024, Pages ii65–ii66, https://doi.org/10.1093/bjd/ljad498.066
- VYNE Therapeutics Announces Positive Biomarker Data from Successful Phase 1b Trial of VYN201 for the Treatment of Vitiligo
- VYN201 for Vitiligo: Promising Data Showcases Potential of BET Inhibition
- New and Upcoming Treatment for Vitiligo, Atopic Dermatitis
- Efficacy and safety of oral ritlecitinib for the treatment of active nonsegmental vitiligo: A randomized phase 2b clinical trial
