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Depigmentation therapy may be appropriate for patients with vitiligo


 

EXPERT ANALYSIS FROM AAD 2019

When repigmentation therapy fails, dermatologists may offer depigmentation therapy to patients with vitiligo, Seemal Desai, MD, said at the annual meeting of the American Academy of Dermatology.

Dr. Seemal Desai

Depigmentation therapy is “an underutilized resource for those patients who have recalcitrant disease or whose disease is so bad that you have not been able to improve their clinical, visible outcome,” said Dr. Desai, clinical assistant professor of dermatology at the University of Texas, Dallas. “Some of these patients simply desire to be one uniform color.”

Therapy is administered through medications that destroy residual melanocytes with the goal of achieving a uniform appearance of the skin. Monobenzyl ether of hydroquinone (MBEH) is the most common drug used in depigmentation therapy, according to Dr. Desai. It is available in concentrations of 20% and 40% and can be compounded in other concentrations. At first, patients should apply MBEH to a nickel-sized area of the skin (such as the forearm, the back of the hand, or the thigh) for 3 or 4 days. Treatment is administered in the morning and evening, but not at bedtime. A common side effect is irritant contact dermatitis.

When the patient is able to tolerate the medication in the first area, he or she can apply it to larger areas of the skin. Parts of the body are treated one at a time, and successful treatment takes time, he noted. Hair may become depigmented, but patients can be assured that the eyes will not.

Repigmentation has been reported after sun exposure. For all patients undergoing depigmentation therapy, dermatologists should provide extensive counseling about the need for lifelong photoprotection, said Dr. Desai. Protective measures can include wide-brimmed hats and broad-spectrum sunscreen. Paradoxical repigmentation can be treated with a stronger concentration of MBEH, liquid nitrogen therapy, microdermabrasion, and peels.

For patients with vitiligo, which results from the immune-mediated destruction of melanocytes, dermatologists should assess the patient’s psychological status and discuss “the impact that the disease has on not only the patient, but also the family,” Dr. Desai said. “The psychological trauma from this disease, especially for our patients who have rapidly progressing vitiligo or who have failed multiple therapies, is something that we cannot discount.”

Patients with vitiligo often have comorbid depression, and evening of the skin tone that depigmentation provides can benefit the patient’s mental state, he observed. Patients with severe depression related to vitiligo should be referred to a psychologist or psychiatrist. Finally, counseling and appropriate patient selection for depigmentation is of paramount importance.

During the presentation, he noted that hair dyes, resin products and adhesives, detergents, and leather preservatives have been associated with vitiligo. Dermatologic drugs such as imiquimod, chemotherapeutic agents, and interferon also may cause the condition.

He referred to the thousands of reported cases of vitiligo related to rhododenol, a phenolic compound that has been used in cosmetics and topical products. Most cases resolved when those affected stopped using the product, but some developed vitiligo vulgaris. Cosmetics containing rhododenol have been recalled in Japan since 2013, but over-the-counter products in Asia and Africa have been found to contain similar compounds, so dermatologists should ask patients about their travel history and about what products they are using for their skin, Dr. Desai advised.

He reported receiving grants and research funding from AbbVie, Dermira, Dr. Reddy’s Laboratories, and Menlo Therapeutics and serving as a consultant for several pharmaceutical companies.

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