In this installment of Topical Conversations, Dr. Iltefat Hamzavi sits down to discuss the results of the VALIANT study, which explored the natural treatment history of vitiligo and was published in the British Journal of Dermatology in July 2023.

Vitiligo and the VALIANT study

The VALIANT (Vitiligo and Life Impact Among International Communities) aimed to investigate the natural treatment history of vitiligo, a pigmentary disorder causing color loss in areas of the skin that can be socially stigmatizing for patients. The study focused on understanding the patient and healthcare provider experiences related to this condition.

The study was based on a survey distributed globally across Africa, Asia, Latin America, North America, and Europe. Around 3,500 patients participated in a 25-minute survey, and around 1,200 clinicians (primary care physicians and dermatologists) completed a 30-minute survey. Results were then compared across the different populations.

Patient profiles

Among the 3,541 patients who completed the full analysis, the average age was 38, and 59% of participants reported Fitzpatrick skin types I-III. The mean duration of the disease was 12.7 years, taking 2.4 years to receive a diagnosis. In survey participants, lesions appeared on the hands and face in about 40% and 38% of cases, respectively.

Physician profiles

Of the 1203 clinicians who completed the survey, 91% specialize in dermatology and 8% are primary care physicians or other care physicians. Around 60% identified themselves as vitiligo specialists. Clinician respondents had on average 8 years of experience treating vitiligo. 

Survey results: misdiagnoses

Of the patients surveyed, 44% reported being misdiagnosed. Patients with vitiligo occurring on more than 5% of their body surface, patients with darker skin, and patients with facial lesions particularly noted difficulty with receiving a diagnosis.

Misdiagnoses included sun damage, fungal infections, and atopic dermatitis. About 17% of both primary care physicians and dermatologists reported encountering patients referred to them who were misdiagnosed. 

While there were geographic variations among these findings, similar results were found globally.

Survey results: treatment

Fifty-seven percent of patients reported being told by their healthcare practitioner that their vitiligo could not be treated, and 44% reported they had given up on finding an effective treatment. Treatments that were reported to be used or suggested by the primary care physician or dermatologist were topical medications, photoprotection, laser therapy, and surgical options.

Survey results: effective care

Two-thirds of patients reported receiving effective care, defined by the patient as a reduction or cessation of spread and repigmentation.

A core element that patients sought to achieve was a reduction of the psychological burden of vitiligo, with mental effects of the disease going well beyond just what is happening in the skin.

Implications for dermatology

The results of the VALIANT study show that there is a profound burden associated with vitiligo with nearly half of patients reporting greater than 5% body surface area affected and a time of 2.4 years to diagnosis for a condition that should be easy to identify.

The survey results also revealed that there is a common misperception that vitiligo cannot be treated. Although many publications have disproved this, it is nonetheless a widely held belief among both the patient community and healthcare practitioners.

With these factors considered, this global survey emphasizes the significant frustration that is mounting among patients and the practitioners who treat them that can hopefully be addressed with future developments and advances in vitiligo education and management.

To read the full study published in the British Journal of Dermatology, click here.

Key points from the VALIANT study

• It is the first global survey to explore the natural history and treatment of vitiligo from both a patient and HCP perspective
• 3,541 patients and 1,203 were surveyed
• Mean time to diagnosis was 2.4 years
• 45.2% of patients had >5% affected BSA
• 44.9% of patients reported an initial misdiagnoses
• Reported rates of misdiagnoses were greater among patients with darker skin, >5% affected BSA, and facial lesions
• 56.7% of patients reported being told vitiligo could not be treated
• 26.3% of HCPs did not believe an effective therapy for vitiligo exists
• 44.6% of patients reported giving up on finding an effective therapy
• HCPs most commonly recommended prescription topicals, sun protection, and phototherapy, but comparatively few patients reported using these
• 34.4% of patients reported having surgery or other procedures, but only 14% of surveyed HCPS recommended surgery