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.
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