Topical Conversations

When patients with vitiligo ask about the potential link between thyroid issues and their condition, it’s essential for dermatologists to provide clear, accurate, and compassionate guidance. In this episode of Topical Conversations, Dr Seemal Desai emphasizes the importance of framing the conversation around thyroid disease rather than specifically focusing on thyroid cancer. Understanding the connection between vitiligo and thyroid disease A vitiligo diagnosis often prompts patients to inquire about its association with thyroid cancer. Dr Desai advises that while there is a recognized link between vitiligo and thyroid disease, it’s crucial to clarify that this connection does not necessarily equate to an increased risk of thyroid cancer. Instead, the focus should be on the broader spectrum of thyroid diseases like autoimmune thyroiditis. Screening and monitoring: a tailored strategy Dr Desai does not advocate for frequent, routine thyroid screening every 3 to 6 months for patients with vitiligo. Instead, he recommends conducting an initial screening at the first visit, including blood work to assess for thyroid function and any signs of autoimmune disease. Subsequent screenings should be based on the patient’s symptoms and overall progression. This individualized approach ensures that patients are not subjected to unnecessary tests while still receiving regular monitoring for potential thyroid issues. The patient-centered approach Counseling patients with vitiligo about the potential link to thyroid disease requires a balanced, patient-centered approach. By focusing on the broader spectrum of thyroid disease rather than just thyroid cancer, dermatologists can provide comprehensive care that addresses patients’ concerns while promoting long-term health. Dr Desai’s approach underscores the importance of individualized screening and careful monitoring, ensuring that patients receive the right care at the right time.

In this episode of Topical Conversations, Dr Seemal R. Desai emphasizes the importance of addressing the psychological impact of vitiligo on patients during dermatology consultations. He begins by highlighting key questions to ask patients regarding their emotional well-being and social interactions related to their condition. Addressing emotional responses Dr Desai suggests asking patients about their feelings of depression and how vitiligo affects their daily lives, such as social interactions, intimate relationships, and self-image without makeup. These questions not only help in understanding the patient's emotional state but also contribute to building rapport and trust during the consultation. Normalization of the psychological burden He stresses the normalization of psychological burden, stating that there's no shame in feeling depressed or impacted by vitiligo, especially in communities where the condition carries significant stigma, such as communities of color and Southeast Asia. Acknowledging these feelings can empower patients to cope better with their condition. The benefits of support groups Dr Desai encourages patients to join vitiligo patient support groups, both locally and nationally, where they can connect with others facing similar challenges. He highlights the importance of platforms like VITFriends, active on social media and affiliated with the Global Vitiligo Foundation, as spaces for sharing experiences and struggles. World Vitiligo Day Finally, Dr. Desai advocates for World Vitiligo Day, which takes place every June and is organized by the Global Vitiligo Foundation. He encourages dermatologists to mark their calendars for this event, as it brings together patients, educators, researchers, and doctors to raise awareness and advance vitiligo research and support initiatives.

In this Topical Conversations special edition 4-part series, Richard Huggins, MD, dermatologist and member of the board of directors at the Global Vitiligo Foundation, is joined by Amaris Geisler, MD, Katie O’Connell, MS, and Tonja Johnson of the Beautifully Unblemished Vitiligo Support Group, to discuss their publication on the importance of vitiligo patient support groups and how these groups can provide value to both patients and providers. In Part 3, the conversation explores how support groups transform the patient experience and how these groups can support physician education and research needs. Personal rewards and inspirations Dr Huggins shares that participating in support groups has been one of the most rewarding experiences of his life. He acknowledges that patients with vitiligo often face self-consciousness and unwanted attention due to their visible condition, making participation in such groups transformative. Witnessing patients go from discomfort leaving their homes to embracing their condition and leading fulfilling lives can be inspirational both personally and professionally. Educational insights for providers From a physician's perspective, Dr Huggins emphasizes the educational value of support groups. With medical school and residency typically focusing on treatments and medications, support groups offer practical insights into managing vitiligo that are invaluable. For example, learning about cover-up techniques and addressing common misconceptions about vitiligo allows physicians to better care for their patients and provide informed counseling during clinic visits. Participating in support groups can also help physicians learn about and address patient misconceptions directly, such as the belief that vitiligo increases the risk of skin cancer or COVID-19. Support groups as research assets From a research standpoint, support groups are invaluable for providers who participate in clinical trials. They provide a concentrated pool of potential participants and offer insights and ideas that can inform research directions. Support group members play a crucial role in recruiting participants and shaping research priorities.For more on vitiligo support groups, check out Part 1 and Part 2 of this series.For practical guidance on navigating support groups, continue on to Part 4.

In this Topical Conversations special edition 4-part series, Richard Huggins, MD, dermatologist and member of the board of directors at the Global Vitiligo Foundation, is joined by Amaris Geisler, MD, Katie O’Connell, MS, and Tonja Johnson of the Beautifully Unblemished Vitiligo Support Group, to discuss their publication on the importance of vitiligo patient support groups and how these groups can provide value to both patients and providers. In Part 4, the group gives an overview of the tips and resources detailed in their paper on starting and running a successful vitiligo support group. Insights from a patient and support group leader Tonja Johnson, patient advocate and executive director of the Beautifully Unblemished Vitiligo Support Group, shares her experiences and advice for those interested in starting a vitiligo support group. She emphasizes the importance of perseverance and patience, acknowledging the challenges but highlighting the potential for success in fostering a supportive community for patients with vitiligo. Practical guidance on support group management The conversation also highlights the comprehensive nature of the group’s publication, covering the background of support groups and previous research showing the positive impact of support groups on patient mental health. The manuscript includes detailed appendices with information on support group development processes, meeting agendas, legal considerations, promotion strategies, member engagement, and retention techniques. Key takeaways for support group leaders They also discuss the valuable resources and guidance for support group leaders detailed in their publication, including practical tips on running meetings, handling group dynamics and disagreements, promoting the group, recruiting new members, and maintaining member engagement and retention.For more on vitiligo support groups, check out the rest of the series here: Part 1, Part 2, Part 3

In this Topical Conversations special edition 4-part series, Richard Huggins, MD, dermatologist and member of the board of directors at the Global Vitiligo Foundation, is joined by Amaris Geisler, MD, Katie O’Connell, MS, and Tonja Johnson of the Beautifully Unblemished Vitiligo Support Group, to discuss their publication on the importance of vitiligo patient support groups. In Part 1, they explore how these groups can provide value to both patients and providers and provide some tips on how to start incorporating support groups and related resources into your practice. A window into the patient experience In dermatology, disease and its impact is often measured by morbidity and by patient experience. It is crucial for healthcare providers (HCPs) to make time to listen to patients and create treatment plans that incorporate the social aspects of cutaneous diseases. Support groups offer HCPs an invaluable opportunity to engage more deeply with patients, allowing for extra time to understand their experiences and concerns. One of the most significant benefits HCPs can derive from support groups is the wealth of knowledge gained about patients' lives. For example, consider a patient who neglects other aspects of their health due to the embarrassment associated with a skin condition. Support groups help HCPs recognize that the patient experience extends beyond the visible symptoms. These groups offer HCPs the chance to share experiences with patients, bringing back the emotional connection to medicine that may sometimes be lost over time. Valuable research opportunities for enhanced patient care Support groups also serve as excellent hubs for research. Discussions within these groups can be a basis for qualitative research, and surveys can provide additional valuable data. Participation in support groups gives HCPs profound insights into patients' lives and their experiences, which can enhance patient care. Incorporating support groups and resources into your practice To begin integrating support groups and related resources into your daily practice, consider the following tips: Distribute informational flyers. Provide flyers from organizations such as the Global Vitiligo Foundation or Hope for HS during clinic visits. Handing out these flyers can help patients feel supported, addressing their emotional burden and potentially increasing patient satisfaction. Provide online resources. If you don't have physical flyers, verbally provide website information, write it down for patients, or include it in their discharge notes. This simple gesture can help guide patients towards support. Encourage participation and seek feedback. Encourage patients to participate in support groups and ask for their feedback. Even if HCPs can't attend the groups personally, patient feedback can still offer significant insights into their experiences and needs. For a deeper understanding of how to effectively incorporate vitiligo support groups into your practice, don't miss Part 2, where the discussion explores the critical importance of integrating mental health support within a support group setting.

In this Topical Conversations special edition 4-part series, Richard Huggins, MD, dermatologist and member of the board of directors at the Global Vitiligo Foundation, is joined by Amaris Geisler, MD, Katie O’Connell, MS, and Tonja Johnson of the Beautifully Unblemished Vitiligo Support Group, to discuss their publication on the importance of vitiligo patient support groups and how these groups can provide value to both patients and providers. In Part 2, the conversation explores the critical importance of integrating mental health support within a support group setting. Providing a structured and safe space Support groups offer a structured environment where patients can share their thoughts on mental health topics, offering a valuable benefit to this population. These groups provide a community where individuals can discuss how vitiligo affects them personally, as well as its impact on their family members and caregivers. It is paramount when starting or joining a support group to create a safe space from day one. Setting clear ground rules ensures that all members feel comfortable discussing sensitive topics, coping with a new diagnosis, and managing vitiligo as a condition. Integrating mental health support One critical recommendation for designing an effective patient support group is to have a mental health provider connected to the group to address mental health wellness. While the physical aspects of vitiligo are important, the mental aspects are equally crucial. In typical clinical practice, patient interactions often last only 10 to 15 minutes, limiting the depth of conversation about how patients are coping with the mental health aspect of their condition. Support groups, however, offer a way for patients to connect and form a community where they can address these important topics. Having a mental health provider as part of the group can help facilitate discussions on mental well-being, providing a more comprehensive support system for patients. Continue to Part 3, where the discussion explores how support groups can provide invaluable educational insights for physicians and benefit clinical trial and research work. Missed Part 1? Check it out here.

Advancements in Vitiligo: 2024 and BeyondVitiligo has long been a challenging condition to manage effectively. However, recent years have seen significant strides in understanding and treating this condition. In this Topical Conversations segment, Seemal Desai, MD, FAAD, shares his excitement about the evolving landscape of vitiligo treatment.Innovations in management and treatment of vitiligoOver the past several years, there have been notable innovations in the management and treatment of vitiligo. One of the most significant milestones was the introduction of the first FDA-approved therapy for repigmenting vitiligo, topical ruxolitinib 1.5% cream. Topical ruxolitinib 1.5% cream is currently the only FDA-approved treatment for nonsegmental vitiligo repigmentation. In the TRuE-V1 and TRuE-V2 trials of ruxolitinib cream 1.5%, nearly 1 in 3 patients achieved at least 75% improvement in the Facial Vitiligo Area Scoring Index (F-VASI75) and 24 weeks. Also at 24 weeks, ~15% of patients achieved complete or nearly complete repigmentation in F-VASI (F-VASI90).Emerging research on oral therapeutics for vitiligoLooking ahead to 2024 and beyond, Dr Desai anticipates the emergence of new data on oral JAK inhibitors for vitiligo. While topical treatments have shown promise, oral JAK inhibitors present a new frontier in vitiligo treatment. Among these, oral upadacitinib has shown promising results in recent studies. Additionally, research is underway on oral povorcitinib and other oral therapeutics, offering potential benefits beyond repigmentation.UpadacitinibAt week 24 of a 52-week, Phase 2b multicenter, randomized, double-blind, placebo-controlled study evaluating upadacitinib in adults with nonsegmental vitiligo, upadacitinib met the primary endpoint of percent change from baseline in F-VASI with 11-mg and 22-mg doses versus placebo in adults with nonsegmental vitiligo.At week 52, the percent reduction from baseline in F-VASI was numerically greater than results at week 24 for all upadacitinib doses.The safety profile was consistent with the known safety profile for upadacitinib.PovorcitinibIn a Phase 2b randomized, double-blind, placebo-controlled, dose-ranging clinical trial evaluating the safety and efficacy of povorcitinib, an oral small-molecule JAK1 inhibitor, results showed that treatment for adult patients with extensive nonsegmental vitiligo was associated with substantial total body and facial repigmentation at Week 52.Povorcitinib was well tolerated at all doses and also shows evidence of potential durability of response following treatment discontinuation, with 32 patients who completed the follow-up period through Week 76 maintaining total body and facial repigmentation.Future prospectsThe landscape of vitiligo treatment is rapidly evolving, with exciting developments on the horizon for 2024 and beyond. From the introduction of FDA-approved topical therapies to the emergence of oral JAK inhibitors for vitiligo, dermatology is witnessing unprecedented progress in the management of this challenging condition.

In this episode of Topical Conversations, Naiem Issa, MD, PhD, explores the use of microneedling as a promising approach to facilitate repigmentation in patients with vitiligo. Looking beyond topical anti-inflammatory agents in challenging cases After months or years of treatment, vitiligo may reach a stable phase or burn out, rendering topical anti-inflammatory agents, such as ruxolitinib, tacrolimus, and pimecrolimus, and topical and oral corticosteroids, ineffective in promoting repigmentation. Dr Issa emphasizes the need to shift focus towards melanocyte or melasome regeneration in these cases. Identifying melanocyte reservoirs: three key locations In these challenging cases, Dr Issa emphasizes the need to allow for melanocyte or melanosome regeneration and repigmentation. Melanocyte stem cell niches and reservoirs are pivotal for repigmentation, utilizing chemotaxis to enter vitiliginous lesions to begin proliferating and dropping pigment through melanosome generation. Dr Issa highlights 3 primary locations where stem cell niches are found: The hair follicle bulge: in the bulge, stem cells can awaken through a number of inflammatory cytokines, called the cytokine milieu, to grow, divide, and mature into melanocytes and migrate into vitiliginous lesions The outer edges of vitiliginous patches: with an active lesion, some melanocytes may persist at the rim The dermal papillae: some melanocytes and melanocyte precursors may be present below the epidermis; this is typically found on acral sites such as the hands and feet, which are often more difficult to repigment The role of microneedling: repigmentation stimulation Microneedling, utilizing controlled wounds typically ranging from 1.5 to 2.5 millimeters in depth, serves 2 crucial purposes in vitiligo therapy: Enhanced medication delivery: By creating microchannels, microneedling facilitates the effective delivery of medications, including topical anti-inflammatories and agents promoting regeneration like bimatoprost Proinflammatory milieu activation: The process triggers an increase proinflammatory milieu, involving cytokines such as platelet-derived growth factors and TNF beta. These signals jump-start the melanocyte and melanosome reservoirs, fostering an environment conducive to repigmentation Clinical insights: microneedling techniques Dr Issa shares his experience with microneedling using the skin pen, detailing a technique that uses it on the lesion itself and also extends use 1 cm beyond the vitiliginous lesion to maximize melanocyte recruitment and increase the chances of successful repigmentation. As a cost-effective alternative, Dr Issa highlights cases where manual microneedling, using an 18 or 20 gauge needle, has yielded impactful results at low cost. Microneedling as a viable step in vitiligo repigmentation Microneedling has emerged as a promising step in the therapeutic ladder for patients with vitiligo who have exhausted traditional treatments. By harnessing controlled wounds and activating a proinflammatory milieu, microneedling opens new avenues for repigmentation.

In this installment of Topical Conversations, Naiem Issa, MD, PhD, FAAD, discusses oxidants and antioxidants and their role in the development and resolution of vitiligo. Why do oxidants and antioxidants matter in vitiligo? Vitiligo starts with an insult that can come in many forms, including sun damage, major stress, traumatic incidents, medications, and other autoimmune disorders that cause inflammatory destruction. This kind of stress manifests in a reduction in the immune privilege of the melanocytes in the skin. Melanocytes are typically immune privileged, meaning that the immune system does not recognize the antigens on the melanocytes and do not attack them. The stress initiates a reduction in the immune privilege of the melanocytes, which triggers production of CD8+ T cells that cause destruction of the melanocytes, leading to vitiligo. This mechanism is similar to that seen in alopecia areata, in which hair follicle immune privilege becomes decomposed. During this destructive stress, there is an increase in oxidants, which causes the formation of reactive oxygen species that affect the cell membrane of melanocytes and the organelles of the cell and cause overall oxidative destruction. This destruction, in turn, causes apoptosis and increased expression of antigens by the dying melanocyte that the immune system recognizes. As a compensatory response, antioxidants such as catalase or superoxide dismutase try to act, but with malfunctioning machinery, there is a reduction in the utility of those antioxidants. Catalase expression in vitiligo A paper by Kassab et al published in the Journal of Clinical Medicine looked specifically at the antioxidant enzyme catalase. The study found that in vitiliginous lesions, when compared to normal lesions, there was a reduction in the catalase expression in the serum of these patients and more so in unstable vitiligo, which showed even less catalase than in stable vitiligo. This demonstrates there is an effect on reducing the amount of antioxidants in the system to allow for compensation. However, the study also showed a paradoxical increase in those patients in superoxide dismutase, also known as the anti-aging protein. This could be a compensatory methodology to make up for the lack of catalase and for the increase in the oxidative molecules, representing the interplay present between oxidants and antioxidants to try to prevent the destruction of the melanocyte, thus the antigen presentation. The future of antioxidants in vitiligo research While the data in this area is still premature, there are studies currently looking into the use of antioxidants like n-acetylcystein and other types of supplements to mop up oxidants and prevent the formation and progression of vitiligo. Current knowledge does support that the progression of oxidants leads to the development of vitiligo, and future research is warranted to determine if the use of antioxidants can prevent it.

In this installment of Topical Conversations, Tina Bhutani, MD, MAS, provides her thoughts on the article, “Perspectives of Vitiligo Patients: Voices from National Vitiligo Conferences,” published in SKIN: The Journal of Cutaneous Medicine by O’Connell et al.Study background This study looked at surveys taken by participants who attended the virtual US World Vitiligo Day in 2020 and 2021. Study results When polled about acceptance of their disease, 40% responded that they are accepting of their vitiligo on most days. However, most participants (76% in 2020 and 92% in 2021) reported that they would like a cure for vitiligo. Impact on patient conversations and treatment approach Dr Bhutani comments on the importance for clinicians to recognize that even though a patient may be accepting of their condition, comfortable with it, and show it publicly (as 40% reported doing), they would still like to find a treatment that would decrease their disease burden. The survey showed that 20% of patients were interested in trying treatments even if they included moderate side effects. Dr Bhutani remarks that this highlights the importance of having open discussions with patients and considering individualized care, since some patients may be open to attempting more aggressive therapy while others are not interested in treatments or only willing to attempt treatments without side effects. The future of vitiligo treatments With many new treatments for vitiligo in the pipeline, Dr Bhutani reflects that this is an exciting time for patients and a good time for providers to start these conversations with patients to provide hope for this condition that has a significant impact on quality of life but has long been understudied. Read the full article in SKIN: The Journal of Cutaneous Medicine. Key points “Perspectives of Vitiligo Patients: Voices from National Vitiligo Conferences” was published in SKIN: The Journal of Cutaneous Medicine The study examined results of a poll that solicited information from participants regarding their quality of life with vitiligo Results showed that a majority of patients would like a cure for vitiligo, even though 40% reported they are accepting of their condition on most days 20% of patients were interested in trying treatments even with moderate side effects Clinicians should have open discussions with their patients with vitiligo and consider individualized care

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 studyThe 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 profilesAmong 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 profilesOf 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: misdiagnosesOf 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: treatmentFifty-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 careTwo-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 dermatologyThe 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 studyIt is the first global survey to explore the natural history and treatment of vitiligo from both a patient and HCP perspective3,541 patients and 1,203 were surveyedMean time to diagnosis was 2.4 years45.2% of patients had >5% affected BSA44.9% of patients reported an initial misdiagnosesReported rates of misdiagnoses were greater among patients with darker skin, >5% affected BSA, and facial lesions56.7% of patients reported being told vitiligo could not be treated26.3% of HCPs did not believe an effective therapy for vitiligo exists44.6% of patients reported giving up on finding an effective therapyHCPs most commonly recommended prescription topicals, sun protection, and phototherapy, but comparatively few patients reported using these34.4% of patients reported having surgery or other procedures, but only 14% of surveyed HCPS recommended surgery

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