Topical Therapies for Vitiligo

Topical Therapies for Vitiligo

There is no question that vitiligo is a difficult disease to treat. This is in part due to the unclear mechanisms that leads to the disease in the first place.^[1] While vitiligo may not cause any harmful or serious physiological effects, the psychological consequences due to the cosmetically significant characteristics are important to address for those suffering from vitiligo.

Steroids

Topical steroids have been used as therapy for vitiligo with suboptimal results.^[2] They may be more effective on small, depigmented (total lack of color) areas of recent onset.^[3,4] Topical corticosteroids have been considered the preferred drug for localized vitiligo.^[5]

While steroids have been effectively shown to pigment skin vitiligo, they can be associated with side effects.^[5-7] Long-term use of topical steroids is especially associated with a variety of side effects.^[3] These side effects frequently include itching, redness, telangiectasia (red marks on the skin due to widened blood vessels), hypertrichosis (excessive hair growth), and atrophy.^[3,6]

It is important to monitor steroid usage and if there is no response to the topical therapy within a pre-determined time frame (for example 3 months), the doctor together with the patient may wish to consider a different treatment strategy.^[4] If topical steroids help with repigmentation without bothersome side effects, steroid use can be continued but should still be closely monitored.^[4]

Calcineurin Inhibitors

Calcineurin inhibitors are therapies that suppress the immune system. They may potentially replace the use of topical steroids for vitiligo due to fewer side effects.

These immunosuppressive topical creams, including tacrolimus and pimecrolimus, have been well tolerated in both children and adults.^[2] Because abnormalities in the immune system may be an underlying cause of vitiligo, using immunosuppressive medications may be a good treatment strategy. Applying topical tacrolimus twice a day can help to induce repigmentation.^[8,9] Furthermore, using topical tacrolimus showed repigmentation after only four weeks of treatment.^[8] When applied on the face and eyelids twice daily, along with daily sunlight exposure for 5 to 10 minutes, repigmentation may be seen after 3 weeks leading up to complete repigmentation in 4 months following this topical therapy.^[3] In clinical trials, side effects including burning, stinging, redness, or itchiness of the skin were minimal or not experienced at all.^[3,8,9] There is a possibility that natural sunlight exposure in combination with tacrolimus ointment can result in even greater benefit of tacrolimus therapy.^[9]

Vitamin D Analogues

Vitamin D affects melanocyte and keratinocyte growth. Calcipotriol is an analog of vitamin D shown to be effective in treating children and adults with vitiligo when combined with UV light exposure.^[2] However, there have been mixed results because minimal repigmentation of the skin has also been observed using this treatment.^[2] There is evidence that topical therapy of vitamin D analog is effective for children between the ages of 5 to 17 years with vitiligo.^[10] When applied every evening, followed by exposure to sunlight the following day for 10 to 15 minutes, repigmentation of the skin starts occurring after 6 to 12 weeks of treatment.^[10] Complete repigmentation may occur. It is also rare to find any side effects or irritation upon application of vitamin D analog.^[10] In vitiligo patients ages 5 to 61, topical calcipotriol alone was effective in those who showed no benefit from topical steroids.^[11] However, it is important to note that there is also conflicting evidence that topical calcipotriol alone is not an effective treatment of vitiligo.^[1]

L-DOPA

Theories propose that L-DOPA is both a marker and defense mechanism against reactive oxygen and nitrogen elements that can harm the cells in your body.^[12] This type of stress can cause melanocyte death which in turn shows up as vitiliginous skin.^[13] Hence, there seems to be potential in applying L-DOPA as topical therapy to repigment skin from melanocyte damage in vilitgo. However, one study showed that topical application of levodopa cream may not produce significant repigmentation.^[14] As of now, there is no clear cut evidence whether or not L-DOPA can be topically applied to repigment vitiliginous skin.^[14]

To conclude, more research needs to be done on which topical therapies are the most efficacious for vitiligo yet exhibit the least side effects. As of now, the medications listed above are some that have been used and show some benefit in repigmenting vitiligo patches. Finding treatment modalities for vitiligo may be difficult due to its unclear mechanisms, but it is important to conduct research that will lead to development of topical therapeutic options.

Janus Kinase (JAK) Inhibitors

Studies exploring the use of JAK inhibitors in treatment of vitiligo have shown promising results. Cytotoxic CD8+ T lymphocytes have an important role in the pathogenesis of vitiligo. These immune cells can directly destroy melanocytes. Recruitment of cytotoxic T cells is regulated by the JAK-STAT pathway. Thus, there has been growing interest in the JAK-STAT pathway as a therapeutic target for patients with vitiligo.^[18]

A pilot study explored the effects of 2% tofacitinib cream, a JAK inhibitor, twice daily along with narrowband ultraviolet B (NB-UVB) therapy 3 times weekly for 3 months. 11 patients were recruited to this study, and all of them had facial vitiligo that did not respond to topical corticosteroids or calcineurin inhibitors. Following the intervention, all patients in this pilot study showed good to excellent repigmentation of their lesions, as defined by the Vitiligo Area Severity Index (VASI).^[19] Another pilot study that consisted of 16 patients with refractory vitiligo found that use of 2% tofacitinib cream improved vitiligo lesions on the face. However, JAK inhibitors were found to be less effective at treating non-facial vitiligo.^[20]

Use of a topical JAK inhibitor is preferred over systemic JAK inhibitors because of the potentially lower cost and better safety profile. Systemic JAK inhibitors have an increased risk for infection, malignancy, and cytopenia.^[19] Current research suggests that JAK inhibitors can be an effective treatment option, especially for those with facial vitiligo, but further research is needed on larger populations to better characterize its effects.