Maureen Salamon

August 01, 2017

NEW YORK CITY — Vitiligo is a "complex trifecta" of oxidative stress, genetics, and autoimmunity, according to new research  that hints that there are  treatment options on the horizon.

Of the more than 50 genetic loci identified that predispose a person to vitiligo, most are considered to be immune-regulating genes that affect melanocyte function, said Pearl Grimes, MD, director of the Vitiligo & Pigmentation Institute of Southern California in Los Angeles.

"Vitiligo is one of the conditions that causes a disintegration of self," she told the audience during a wide-ranging plenary session here at the American Academy of Dermatology (AAD) 2017 Summer Meeting.

"Pigmentation is often a passport to society. If patients feel that passport has been revoked, it's pretty devastating," she explained.

There are 2 million to 5 million people in the United States affected by vitiligo, but there is not a single drug for repigmentation approved by the US Food and Drug Administration.

"That's the big frustration," said Dr Grimes.

And despite common misconceptions, vitiligo does not affect only people with darker skin.

Pigmentation is often a passport to society. If patients feel that passport has been revoked, it's pretty devastating.

The use of biomarkers has emerged as a way to examine clinical outcomes and monitor patients. In fact, CXCL10 level, in combination with the Vitiligo Area Scoring Index, has been used as a marker for successful treatment, Dr Grimes reported.

And promising agents being tested include Wnt agonists, Nrf2 activators, and JAK inhibitors, such as ruxolitinib 1.5% cream.

"My hope is that 5 years from now, vitiligo will be like psoriasis," she said. "We'll have multiple new agents we can pick and choose from based on the clinical features of a patient with vitiligo."

Understanding the Burden of Skin Disease

"We know there's an enormous social and emotional burden with our diseases that's more profound than that associated with many diseases," said Marta Van Beek, MD, from University of Iowa Hospitals and Clinics in Iowa City, during another plenary presentation.

This is a serious concern, she said, especially given a recent report showing that 85 million Americans were seen by a physician for at least one skin disease in 2013 — a prevalence that exceeds current annual estimates for all cardiovascular diseases and diabetes.

"We know that skin disease is much more common in patients over 65, and that we'll soon be outpaced in the number of diseases we can treat," she added, noting that "the majority of skin disorders are not diagnosed or treated by dermatologists."

Nearly 23,000 people died as the result of skin disease in 2013, the vast majority from skin cancers, but also from wounds, burns, and cutaneous infections. And the total healthcare cost of skin diseases — the most common of which were noncancerous skin growths (defined as benign neoplasms, keloids, scars, and cysts) — was estimated to be nearly $75 billion.

This information should be used "to advocate for insurance companies to continue to cover skin disease," she said.

The burden of skin disease drives home the notion that medical students should be better educated on skin disease, "since most cases are being treated by nondermatologists," said audience member Lori Wilcox, MD, who is a dermatologist at the Beatrice Keller Clinic in Peoria, Arizona.

"That was really brought home in that lecture, especially with the aging of our population and the fact that the elderly are more predisposed to skin disease," Dr Wilcox told Medscape Medical News.

The methodical process undertaken to compile the skin disease report is compelling, said Mercy Alexis, MD, a dermatologist in private practice in Toronto who was also in the audience.

She said she is surprised that nonmalignant skin growths are the most common diagnosis.

"I thought psoriasis or warts would be up there," Dr Alexis told Medscape Medical News.

"It also struck me that vitiligo was so low. That's probably because fewer people seek treatment for that. We never really know the real burden of disease because only those who go for diagnosis are counted. Certainly not everyone is able to see a doctor and get a diagnosis."

Dr Grimes reports financial relationships with Allergan, Clinuvel, Galderma Laboratories, Kythera, Merz, Obagi Medical Products, Procter & Gamble, and Suneva Medical. Dr Van Beek, Dr Wilcox, and Dr Alexis have disclosed no relevant financial relationships.

American Academy of Dermatology (AAD) 2017 Summer Meeting. Presented July 28, 2017.

Follow Medscape Dermatology on Twitter @MedscapeDerm and Maureen Salamon @maureensalamon

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