Home phototherapy for patients with vitiligo: challenges and solutions

Clinical, Cosmetic and Investigational Dermatology Dovepress open access to scientific and medical research Clinical, Cosmetic and Investigational Dermatology downloaded from https://www.dovepress.com/ by 88.198.20.149 on 17-Aug-2019 For personal use only. Open Access Full Text Article Home phototherapy for patients with vitiligo: challenges and solutions This article was published in the following Dove Press journal: Clinical, Cosmetic and Investigational Dermatology Mary Patricia Smith 1 Karen Ly 1 Quinn Thibodeaux 1 Tina Bhutani 1 Mio Nakamura 2 1 Department of Dermatology, University of California San Francisco, San Francisco, CA, USA; 2Department of Dermatology, University of Michigan, Ann Arbor, MI, USA Abstract: Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is welldemarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo. Keywords: vitiligo, pigmentation disorders, phototherapy, photomedicine Introduction Correspondence: Mio Nakamura Department of Dermatology, University of Michigan, 1910 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA Tel +1 734 936 4054 Fax +1 734 936 6395 Email Vitiligo is a chronic condition involving an immune-mediated attack on melanocytes, resulting in selective dysfunction and destruction of melanocytes in skin, hair, or both.1 It is the most common cause of depigmentation worldwide with an estimated prevalence of 1–2% and no predilection for a particular age, race, or gender.1 The typical presentation is white skin patches or hair with distinct margins between normal pigmented and involved depigmented areas.1,2 The pathogenesis of vitiligo has not been clearly established but is likely multifactorial. Hypothesized causes include autoimmune processes, genetic influences, biochemical pathways, and environmental factors.1,3 The autoimmune theory is supported by strong evidence, including the clinical association of vitiligo with autoimmune disorders of various organ systems such as endocrine, gastrointestinal, and neurologic diseases.1,4,5 Vitiligo can also have a profound negative impact on quality of life (QoL) due to psychological trauma experienced by patients with vitiligo, resulting in low self-esteem, shame, depression, anxiety, and social isolation.6,7 Furthermore, vitiligo is associated with a significant economic burden involving high direct and indirect costs, ranging from work absenteeism to expenses related to accessing care.5 Given these consequences and that early 451 submit your manuscript | www.dovepress.com Clinical, Cosmetic and Investigational Dermatology 2019:12 451–459 DovePress © 2019 Smith et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://doi.org/10.2147/CCID.S185798 Powered by TCPDF (www.tcpdf.org) REVIEW Dovepress Smith et al Clinical, Cosmetic and Investigational Dermatology downloaded from https://www.dovepress.com/ by 88.198.20.149 on 17-Aug-2019 For personal use only. disease responds best to treatment, prompt diagnosis and management of vitiligo are critical.1 Diagnosis and management of vitiligo The first step in the diagnosis and management of vitiligo includes gathering a complete disease history, including onset, progression, response to prior treatments, other medical conditions, family history, and environmental exposures. Next, disease extent must be evaluated by examining the skin with both natural light and a Wood’s lamp. Depigmented skin of vitiligo will fluoresce brightly white under Wood’s lamp. Physical exam must include inspection of common sites of vitiligo, including the lips and perioral area, periocular areas, dorsal surface of the hands, fingers, flexor surface of the wrists, and inguinal and anogenital regions.8 The next step is to discuss treatment options, which depend on the location/subtype, percent body surface area (BSA) involved, and the impact on QoL.9 Since the pathogenesis of vitiligo is not fully understood, a variety of modalities have been attempted to stabilize progression and stimulate repigmentation.9–13 These include topical therapies9 (eg, topical corticosteroids,9,12,14,15 calcineurin inhibitors,9,16,17 vitamin D analogues9,12,18), systemic therapies19 (eg, corticosteroids,9,12 methotrexate9), surgical therapies20 (eg, melanocyte-keratinocyte transplantation,21–25 hair follicle transplant,26,27 punch, blister, split thickness grafting26–28), complementary and alternative therapies29 (eg, L-phenylalanine, khellin, biloba, folic acid, zinc, copper, vitamins B12, C, D, and E), and a variety of experimental therapies (eg, FrequencyllA Optimal: 3 times/wk Acceptable: 2 times/wk Assess responsellI After 18 to 36 exposures Minimum: 48 exposures Maximum: certain slow responders may require ≥72 exposure before assessing response Outcome measureslB Serial photography, validated scoring systems (e.g. VASI, VETF) Dosing protocollB Initiation: 200 mJ/cm2 (regardless of skin type) Adjustment: Increase by 10 to 20% per treatment Alternative: fixed dosing based on Fitzpatrick skin phototypes (SPT) afamelanotide,1 (...truncated)