DermView: Innovations in the Treatment of Vitiligo - Episode 3
A comprehensive breakdown of the different classifications of vitiligo and how these may present clinically.
William Damsky, MD, PhD: I’m curious if we could focus a little on the different clinical presentations of vitiligo. Oftentimes, there are different clinical classifiers we use to describe vitiligo. Would you be able to talk about those a little?
Seemal Desai, MD, FAAD: I like to lump vitiligo into a variety of different buckets. I find that lumping them into various buckets can help in the dialogue with our patients. In my experience, the most common type of vitiligo is what I would refer to as nonsegmental vitiligo, oftentimes referred to as vitiligo vulgaris. That term, we don’t like to use that as much because the vulgaris term, as you know, just has a negative connotation for patients. Nonsegmental vitiligo, or sometimes even chronic vitiligo, which the vast majority of our patients are, by the way, those patients who are in that chronic phase. They’re not getting better, but they’re not spontaneously repigmenting, and nothing’s really happening for about a year, they’re just kind of coasting along. Those are the vast majority of people we see.
There are, of course, those patients who have segmental vitiligo, which affects 1 segment, or 1 dermatome, or a unilateral area of the body. That is a type of vitiligo where I’d tell the patients, “If you had to get a type of vitiligo, this is a good type to get,” in the sense that it rarely spreads into chronic refractory vitiligo, meaning the disease tends to be localized to one area. We think that’s more of a localized melanocyte response and possibly some epigenetic phenomenon there that fully hasn’t been elucidated yet. And of course, as you know, Bill, the nonsegmental type is one of the most challenging to treat.
Now, segmental is good in the sense that it doesn’t spread, but it’s not so good in that our traditional topical therapies, phototherapies tend to be a little more challenging for that. I know we’ll come back to that in a moment. I try to tell my patients to view it as a glass half full kind of picture. We have this 1 area, it’s likely not going to spread, and let’s try to focus on managing it. By the way, there are examples of segmental vitiligo, we’ve published some of those, they’re in the textbooks as well from previous vitiligo experts, where you can get it repigmented and it does happen, and surgical therapy is one new, exciting way to do that as well.
The last thing I’ll say is, the really sad cases are what I would call the patients with refractory vitiligo, which no matter what you do, their disease just continues to spread despite immunologic immunosuppression with systemic steroids, for example, oral anti-inflammatories, phototherapy. No matter what you do, their disease just continues to spread. Those are tough cases and oftentimes lead to natural depigmentation based on the body’s own immune system. I’d love your thoughts if you have anything to add or any comments on the classification.
William Damsky, MD, PhD: I agree. I think segmental vitiligo is really, from a scientific perspective, potentially very informative. If we can understand why vitiligo is affecting a very restricted patch of skin, often just on one side of the body, I think we may garner additional insight into vitiligo pathogenesis as a whole. So I think there’s a lot of work that remains to be done despite the exciting progress that we’ll talk about soon that’s been made in the field. I agree with everything that you said. We’ll talk about diagnosis first, but I’m really curious to pick your brain about how you approach treatment in patients with refractory vitiligo. As you described, they’re kind of progressing through everything.
Transcript edited for clarity.