Extent Of Depigmentation Research Articles

Perception of skin cancer risk and sun protective practices in individuals with vitiligo: a prospective international cross-sectional survey

Many individuals with vitiligo are uncertain about their skin cancer risk, phototherapy risks, and recommended sun protective practices. This study examined the perceived skin cancer risk and sun protective practices among individuals living with vitiligo. A secondary objective was to understand where participants obtain this information. This was a prospective cross-sectional study. An online survey was distributed to vitiligo support group leaders globally who shared the survey with their members. Individuals over the age of 18 and with vitiligo were included. There were 209 survey respondents, the majority were between the ages 35–54 (45.5%, n = 95), female (70.8%, n = 148), White (66.0%, n = 138). Nearly half of respondents believed they were at increased risk of skin cancer because of their vitiligo (45.5%, n = 95) and nearly a quarter (22.5%, n = 47) believed that phototherapy increased their risk of skin cancer. Having vitiligo affected sun protective practices with less than a quarter (24.4%, n = 51) of respondents using sunscreen daily or often prior to their vitiligo diagnosis in comparison to the majority of respondents (60.3%, n = 126) using it after their vitiligo diagnosis. The three most common sources where patients obtained information were the internet and social media (46.4%, n = 97), vitiligo support groups (23.4%, n = 49), and dermatologists (20.6%, n = 43). Despite evidence indicating a decreased risk of skin cancer in individuals with vitiligo and supporting the safety of narrowband ultraviolet B phototherapy, many participants believed they were at an increased risk of skin cancer. Findings were sub-stratified and showed differences in sunscreen usage based on gender, skin color, and percent depigmentation. This study also found nearly half of respondents obtained information related to vitiligo from the internet and social media. The number of participants may limit the generalizability of the findings. Survey questionnaires are also subject to response bias. The findings from this study highlight demographic variations in sunscreen usage which may help guide the development of targeted interventions to improve sun protective behaviors among diverse populations with vitiligo. In addition, this study suggests certain sun protective practices and skin cancer risk perceptions may vary based on extent of depigmentation. Lastly, this study also demonstrates the internet and social media as a popular source for obtaining information, emphasizing the need for dermatologists to leverage various online communication channels to help disseminate accurate information.

IDEOM vitiligo work group: an update on our first year

Abstract The new Vitiligo Work Group of IDEOM was created in October 2021 and met at the annual IDEOM meetings of 2021 and 2022. The mission of the workgroup is to develop core outcome measures in vitiligo that meet three criteria: to meet the needs of stakeholders of all types, to be validated for clinical trials and studies, and to be used in all age groups of patients. The Vitiligo Work Group met November 2021 and June 2022, yielding a list of 10 potential core domains for voting. Voting was conducted at the Annual Meeting of IDEOM on 18 June 2022. Voting members of IDEOM included 23 dermatologists, 1 rheumatologist, 3 dermatologists and rheumatologists, 11 industry partners, 9 patients, 8 patient association representatives and 15 researchers. Core domains meeting 75% consensus threshold included: health-related quality of life (95·35%), extent of depigmentation (93·632%), treatment satisfaction including treatment burden (92·86%), location (83·67%), colour matching (82·69%) and maintenance of pigmentation (76·47%). Two domains met 50% threshold including primary diagnosis/comorbidities (59·62%) and trajectory of disease/stabilization (57·45%) and one domain, itch, failed to reach a consensus (38·46%). Using an approach of inclusion of stakeholders from all walks of life, six core domains reached a consensus for inclusion, two achieved partial consensus but required revision to break down the elements (e.g. primary diagnosis and comorbidities should be separated) and itch failed to achieve inclusion. The group continues to work on its core domains set using a broad range of stakeholders to produce a practical set of domains that are of importance to all stakeholders.

Psychosocial impact of vitiligo in patients with skin of color

AbstractVitiligo exerts a significant negative effect on patients quality of life. Patients with skin of colour have a more negative attitude towards vitiligo than those with fairer skin. Many myths and misconceptions about vitiligo are prevalent in certain societies in South‐east Asia and the middle east. Confusion with leprosy further adds to the stigma. Vitiligo impacts several spheres of life due to the cosmetic disfigurement as well as the prevailing socio‐cultural factors. Patients with vitiligo suffer from low self‐esteem, and often face discrimination, and difficulties in social life and relationships. Quality‐of‐life measures such as Dermatology Life Quality Index and Vitiligo Impact Scale‐22 indicate that vitiligo has a moderate‐to‐large effect on patients life. Psychiatric comorbidities such as anxiety and depression are more prevalent among patients with vitiligo as compared to general population. The psychosocial burden of vitiligo should be evaluated separately from the clinical severity separately because it may not correlate with the extent of depigmentation, and may not improve in proportion to the repigmentation. Apart from the treatment of vitiligo patches, patients may benefit from measures specifically aimed at reducing the psychosocial distress.

Computerized Intensity Values to Objectivize Dummett–Gupta Classification of Physiologic Gingival Pigmentation

Focused Clinical Question: Often, there is a clinical dilemma in classifying patients based on the Dummett–Gupta oral pigmentation index (DOPI). Can the subjectivity of DOPI classification be overcome?Summary: DOPI classification, although time tested, is dependent on the visual acuity of the examiner and hence is subjective. Because of this, there is room for clinical uncertainty when classifying mild (Class I), moderate (Class II), and severe (Class III) pigmentation. This problem can be overcome by using image analysis software to assign intensity values to every class of gingival pigmentation.Conclusions: Objectivizing DOPI classification will eliminate clinical uncertainty and interexaminer variability in classifying patients. This value will give a precise idea about the extent of depigmentation and degree of repigmentation when various techniques are considered and compared.

Vitiligo impact scale: An instrument to assess the psychosocial burden of vitiligo

Vitiligo is a disease that significantly impairs quality of life. Previous studies have shown that vitiligo has an impact that may not correlate with the size and extent of depigmentation, indicating a need for an independent measure of the psychosocial burden. To develop a rating scale to assess the psychosocial impact of vitiligo. The study was undertaken in three broad phases: item generation, pre- and pilot testing, and test administration. Items were generated largely from a qualitative study using semi-structured interviews of patients. Face and content validity were assessed through pre- and pilot testing in 80 patients and the final version was administered to 100 patients who also received the Dermatology Life Quality Index (DLQI) and the Skindex-16. Each patient also underwent a physician global assessment (PGA) of the impact of vitiligo. Test-retest reliability was assessed in 20 patients. Of 72 items initially generated for the scale, 27 were retained in the final version. Subjects were able to comprehend the items and took about 5-7 min to complete the instrument. The scale was internally consistent (Cronbach's α = 0.85). Scores on the scale correlated moderately well with the DLQI and the Skindex (Spearman rank correlation: 0.51 and 0.65, respectively). The scale was able to discriminate between patients having mild and those having moderate and severe impact as assessed by PGA. The test-retest reliability coefficient (Spearman rank correlation) was 0.80. The Vitiligo Impact Scale appears to be a valid measure of the psychosocial impact of vitiligo and this instrument may be useful both in the clinic and in clinical trials.

Commentary 5

Studies on the pathogenesis focussing on melanocyte biology, melanin biochemistry or skin immunity have yielded a variety of hypotheses to explain the disappearance of melanocytes in vitiligo, including a genetic predisposition, increased oxidative stress and toxic metabolites, neurochemical factors and autoimmunity (1). Whereas these factors probably all contribute to the development of depigmentation (convergence theory) (2), their interaction is not clearly defined. This commentary presents a multidisciplinary view of the pathogenesis of vitiligo (Fig. 1). Schematic overview of the pathogenesis of vitiligo. Melanin synthesis in melanocytes is a tightly regulated process. Defects in the protective mechanism in the skin that scavenge radicals and toxic intermediates of melanin production may lead to vitiligo. The increased levels of oxidative stress in the vitiligo skin leads to the deactivation of catalase (3). H202 can also oxidize (6R)-l-erythro-5,6,7,8-tetrahydrobiopterin to 6-biopterin, which is cytotoxic to melanocytes. Although this melanocyte death may account for part of the depigmentation, dying melanocyte fragments will be taken up by epidermal Langerhans cells. The uptake of self-antigens from dying melanocytes in the absence of activation signals does not activate the Langerhans cells and will therefore not lead to immunity against melanocytes. Concurrent external stress factors, such as wounding, high dose of UV radiation or hormonal changes, however, activate Langerhans cells and dendritic cells in the skin, leading to breakage of tolerance (4). Clinically, these stress factors induce progression of depigmentation. The Koebner phenomenon results from stress factors at remote skin sites that induce local activation of Langerhans cells and reactivation of anti-melanocyte immunity, leading to the formation of new lesions. The lower threshold for breakage of tolerance in patients with vitiligo is illustrated by the increased incidence of autoimmune diseases in patients with vitiligo (5-12). Normally, regulatory T cells maintain peripheral tolerance by suppressing autoreactive T-cell activity. In patients with vitiligo, however, decreased levels of regulatory T cells in the skin lower the threshold for autoimmunity. Activated Langerhans cells containing melanocyte antigens migrate to the lymph nodes and present melanocyte antigenic peptides bound to HLA molecules to T cells. The association of vitiligo vulgaris with certain HLA class II alleles (13-15) indicates the dominance of peptides binding to these HLA types in inducing immunity. In the lymph nodes, melanocyte-reactive CD8+ and CD4+ T cells are activated to proliferate and migrate to the skin, resulting in increased levels of T cells reactive with tyrosinase, gp100 or MART-1 in peripheral blood (16-19), as well as autoantibodies against these antigens (20-22). Moreover, the number of circulating MART-1-reactive T cells expressing CLA in patients with vitiligo correlated with the extent of depigmentation (18). In perilesional skin, CD8+ T cells, macrophages and to a lesser extent CD4+ T cells were found (23, 24). Infiltrating CD8+ T cells expressed skin homing, cutaneous leukocyte-associated antigen (CLA) and T-cell activation markers CD25, perforin and granzyme B (25), and colocalized with disappearing melanocytes. Finally, perilesional melanocyte-reactive CD8+ cytotoxic T cells were shown to be capable of actively killing melanocytes in autologous skin tissue (J.G. van den Boorn, D. Konijnenberg, T.A.M. Dellemijn, J.P.W. van der Veen, J.D. Bos, C.J.M. Melief, F.A. Vyth-Dreese and R.M. Luiten, unpublished data). Taken together, the pathogenesis of vitiligo results from changes in biochemical processes in the skin that trigger autoimmunity, which is enhanced by genetic predisposition to autoimmunity.

Autoantibodies in vitiligo patients are not directed to the melanocyte differentiation antigen MelanA/MART1.

Recent studies have demonstrated the presence of circulating MelanA (MART1)-specific cytotoxic T lymphocytes in a significant number of vitiligo patients when compared to control subjects. High levels of the skin-homing receptor cutaneous lymphocyte-associated antigen were expressed on the T cells and their frequency correlated with the extent of depigmentation and disease activity in the vitiligo patients. The present study was designed to examine vitiligo patient sera for the presence of autoantibodies to MelanA. The incidence of autoantibodies to MelanA in patients with vitiligo (n = 51) and in healthy individuals (n = 20) was examined using a radiobinding assay with 35S]-labelled MelanA and using Western blot analysis with a glutathione S-transferase (GST)-MelanA fusion protein. Autoantibodies to MelanA could not be detected in any of the vitiligo patient sera or control sera analysed using either of these detection systems. It is therefore possible that MelanA only induces cellular rather than humoral autoreactivity in vitiligo.

Peripapillary pigment epitheliopathy as a sequel of multiple evanescent white-dot syndrome

Multiple evanescent white-dot syndrome (MEWDS) is a self-limited disease in most patients. We report three young female patients with unilateral persistent blind spot enlargement after MEWDS. All three patients had flu-like symptoms before blurred vision occurred. After the disappearance of the white dots, the patients had persistent dense visual field defect with photopsia. Although the visual acuity recovered in two patients after one year of follow-up, the visual field defect of blind spot enlargement persisted in all three. The fluorescein angiography examinations showed a variable extent of depigmentation on the peripapillary area, which is compatible with an enlargement of the blind spot. Most patients with MEWDS often have a fair prognosis, although this syndrome may cause permanent blind spot enlargement and peripapillary pigment epitheliopathy in some patients.

Vitiligo.

Vitiligo involves a progressive loss of melanocytes from the epidermis and hair follicles. Milky-white patches appear resulting in cosmetic disfiguration that is most apparent in dark-skinned individuals. The disease is further classified according to distribution pattern and extent of depigmentation. The presence of several clinical subtypes may reflect the diversity in causative factors. To select appropriate therapeutic measures it is important to distinguish vitiligo from other disorders that affect melanocyte function. Although vitiligo has a characteristic clinical appearance and histological features, the presence of early or atypical lesions often requires the exclusion of other disorders such as postinflammatory hypopigmentation and piebaldism. Multiple hypotheses have been put forward to explain vitiligo. An inherited tendency to develop depigmentation may involve the inherent aberrancies that have been observed in nonlesional vitiligo melanocytes in vivo as well as in vitro. These abnormalities potentially render vitiliginous melanocytes more vulnerable to assaults from extracellular factors. Such factors include keratinocyte physiology, extracellular matrix composition, humoral and cellular immunity, and environmental agents. Therapies aimed at repopulation of lesional skin include phototherapy, application of topical corticosteroids, and transplantation of skin or skin cells. Moreover, micropigmentation or camouflage can be used to restore a pigmented appearance to lesional skin. In patients in which vitiligo affects extensive areas of the body, depigmentation may be the treatment of choice. In all, this acquired pigmentary disorder can be treated in a variety of ways and should not be regarded as an untreatable affliction.

Correlation between vitiligo antibodies and extent of depigmentation in vitiligo

We correlated the level of vitiligo antibodies to the extent of depigmentation in thirty-two patients with vitiligo. Vitiligo antibodies were assayed by protein A-sepharose immunoprecipitation method. Antibodies were present in four of eight (50%) patients with minimal vitiligo (less than 2% body surface involved), in nine of ten (90%) patients with moderate vitiligo (2 to 5% surface involved), and in thirteen of fourteen (93%) patients with more extensive disease (greater than 5% surface involved). The level of vitiligo antibodies in the three groups expressed as a binding index was 2.9% +/- 2.03, 5.6% +/- 2.92, and 8.0% +/- 3.03 SD, respectively. These results suggest that there is a relation between the incidence and level of vitiligo antibodies and the extent of depigmentation in vitiligo.