Psychodermatology of vitiligo: Psychological impact and consequences

Assessing the Relationship Between Vitiligo and Major Depressive Disorder Severity: Cross-Sectional Study

BACKGROUND

Vitiligo, a common dermatological disorder in Saudi Arabia, is associated with significant psychological impacts. This study explores the relationship between vitiligo and the severity of major depressive disorder (MDD), highlighting the broader implications on mental health among affected individuals.

OBJECTIVE

We aim to assess the prevalence and predictors of depression among adult patients with vitiligo, and to examine the relationship between MDD severity and vitiligo.

METHODS

Using a cross-sectional design, the research used the vitiligo area severity index and the Patient Health Questionnaire-9 to measure the extent of vitiligo and depression severity, respectively. This study involved 340 diagnosed patients with vitiligo from various health care settings. Logistic and ordinal regression analysis were applied to evaluate the impact of sociodemographic variables and vitiligo types on MDD severity.

RESULTS

The prevalence of MDD was 58.8% (200/340) of participants. Depression severity varied notably: 18.2% (62/340) of patients experienced mild depression, 17.9% (61/340) moderate, 11.8% (40/340) moderately severe, and 10.9% (37/340) severe depression. Female patients had higher odds of severe depression than male patients (adjusted odds ratio [aOR] 3.14, 95% CI 1.93-5.1; P<.001). Age was inversely related to depression severity, with patients aged older than 60 years showing significantly lower odds (aOR 0.1, 95% CI 0.03-0.39; P<.001). Lower income was associated with higher depression severity (aOR 10.2, 95% CI 3.25-31.8; P<.001). Vitiligo types also influenced depression severity; vulgaris (aOR 5.3, 95% CI 2.6-10.9; P<.001) and acrofacial vitiligo (aOR 2.8, 95% CI 1.5-5.1; P<.001) were significantly associated with higher depression levels compared to focal vitiligo.

CONCLUSIONS

The findings suggest that vitiligo contributes to an increased risk of severe depression, highlighting the need for integrated dermatological and psychological treatment approaches to address both the physical and mental health aspects of the disease.

Epidemiology and Treatment Patterns of Patients with Vitiligo: A Real-World Analysis

INTRODUCTION

Vitiligo, a chronic autoimmune skin depigmentation disease with an unpredictable course, has been associated with several comorbid autoimmune and psychological conditions. Our current understanding of vitiligo burden and management in the real world is limited. This real-world analysis presents data on vitiligo epidemiology, comorbidities, and treatment of patients in Israel.

METHODS

This retrospective study analyzed data from the Maccabi Health Services database. Prevalent patients with vitiligo in 2021 were matched to patients in the general population on the basis of age group, gender, and socioeconomic status. Patient demographics, vitiligo incidence and prevalence, comorbidities, and treatment patterns are reported. Data are presented as percentages, mean, median, P values, and standard mean differences (SMD).

RESULTS

In this analysis, 11,412 patients with vitiligo were matched to patients from the general population. Incidence and prevalence rates increased over time from 2005 to 2021. Compared to the general population, patients with vitiligo were more likely to have an immune-mediated comorbidity (29.7% vs 18.4% [P < 0.001; SMD 0.27]) or psychological comorbidity (18.7% vs 15.9% [P < 0.001; SMD 0.07]). Comorbidities included atopic dermatitis (patients with vitiligo vs general population 12.5% vs 8.4%), psoriasis (5.8% vs 3.6%), Hashimoto's thyroiditis (2.9% vs 1.1%), alopecia areata (2.2% vs 0.9%), depression (10.8% vs 9.5%), and sleep disorder/insomnia (5.9% vs 4.4%). Only 74.8% of all patients with vitiligo had ever received treatment, with topical corticosteroids (51.5%) and calcineurin inhibitors (36.5%) most commonly prescribed. At the end of 2021, 83.7% of patients were untreated.

CONCLUSION

Patients with vitiligo are more likely to have various immune-related and psychological comorbidities, highlighting the significant impact of the condition on well-being. Nearly a quarter of patients had never received treatment, with many receiving only topical treatments, and medication persistence was low. This highlights the lack of adequate treatment in this population and the need for more effective management options.

Microspheres Based on Blends of Chitosan Derivatives with Carrageenan as Vitamin Carriers in Cosmeceuticals

Chitosan (CS) has a natural origin and is a biodegradable and biocompatible polymer with many skin-beneficial properties successfully used in the cosmetics and pharmaceutical industry. CS derivatives, especially those synthesized via a Schiff base reaction, are very important due to their unique antimicrobial activity. This study demonstrates research results on the use of hydrogel microspheres made of [chitosan-graft-poly(ε-caprolactone)]-blend-(ĸ-carrageenan)], [chitosan-2-pyridinecarboxaldehyde-graft-poly(ε-caprolactone)]-blend-(ĸ-carrageenan), and chitosan-sodium-4-formylbenzene-1,3-disulfonate-graft-poly(ε-caprolactone)]-blend-(ĸ-carrageenan) as innovative vitamin carriers for cosmetic formulation. A permeation study of retinol (vitamin A), L-ascorbic acid (vitamin C), and α-tocopherol (vitamin E) from the cream through a human skin model by the Franz Cell measurement system was presented. The quantitative analysis of the release of the vitamins added to the cream base, through the membrane, imitating human skin, showed a promising profile of its release/penetration, which is promising for the development of a cream with anti-aging properties. Additionally, the antibacterial activity of the polymers from which the microspheres are made allows for the elimination of preservatives and parabens as cosmetic formulation ingredients.

Patient Burden of Nonsegmental Vitiligo: A US Real-World Survey of Dermatologists and Their Patients

INTRODUCTION

Vitiligo is a chronic autoimmune disease characterized by destruction of melanocytes, leading to skin depigmentation. Vitiligo can have a high quality-of-life burden and profound impact on psychosocial well-being. The objectives of this study were to describe the self-reported patient burden among patients with nonsegmental vitiligo with ≤ 10% affected body surface area, summarize the physician-reported psychosocial and psychological impact of vitiligo on patient lives, and describe disease characteristics and treatment history, goals, and satisfaction.

METHODS

Data were drawn from the Adelphi Vitiligo Disease Specific Programme™, a real-world, cross-sectional survey with retrospective data collection of physicians and patients with vitiligo, collected in the United States between October 2021 and April 2022. Separate surveys for dermatologists and patients contained questions on clinical and demographic characteristics of patients with vitiligo and burden of vitiligo. Treatment history, goals, and satisfaction were assessed together with the impact of vitiligo on quality of life.

RESULTS

Sixty-one dermatologists provided data for 326 patients with ≤ 10% affected body surface area (adults, n = 221; adolescents, n = 105); 90 of those patients also responded to the survey. The most common treatments were topical corticosteroids, topical calcineurin inhibitors, and narrow-band ultraviolet-B phototherapy, with the main treatment goal being repigmentation. Physician-reported treatment satisfaction was 56%; 25% of patients reported frustration with treatment options. Physicians reported impact of vitiligo on everyday life in 46% of patients. Patients reported 12.7% overall work impairment; mean scores for Hospital Anxiety and Depression Scale anxiety and depression domains were 3.5 and 2.2, respectively, and mean Vitiligo-specific Quality of Life index score was 26.9. Patients with facial involvement experienced higher burden than those without.

CONCLUSION

A high patient burden was reported by dermatologists and their patients with vitiligo who had ≤ 10% affected body surface area, including psychosocial and psychological consequences. These findings highlight an unmet need in the treatment of vitiligo.

Validation of the DLQI questionnaire in assessing the disease burden and principal aspects related to life quality of vitiligo patients

According to many studies, vitiligo has a negative psychological influence on the patient's life. Multiple factors contribute to the severity of the vitiligo disease burden, among which the most important are self-esteem, stress, and stigma. We aimed to measure the importance of health-related life quality in assessing disease burden in patients with vitiligo. We formulated an HA, which is the principal hypothesis, claiming a single fundamental factor that characterizes the life quality of patients with vitiligo. We also formulated 10 important research questions related to the quality of life that can be generally formulated for patients with dermatological illnesses but particularly suited for vitiligo patients. These research questions capture fundamental aspects of the health-related quality of life of vitiligo patients influenced by symptoms and feelings, daily activities, leisure, job and education, personal relationships, and treatment. These also cover specific aspects related to the quality of life, such as skin-caused sexual difficulties, difficulties in social relationships, and difficulties in performing sports, among others. The Dermatology Life Quality Index (DLQI) questionnaire measures the health-related quality of life of persons suffering from skin diseases. We applied this generic questionnaire to patients with vitiligo. Following a set of inclusion and exclusion criteria, we obtained 114 carefully selected patients who responded to all the questions. This study also validated the DLQI questionnaire on persons who suffer from vitiligo. We investigated whether DLQI has acceptable internal consistency by applying Cronbach's alpha internal consistency indicator (Cα). The obtained Cα = 0.914 indicates excellent internal consistency. We also examined whether all the questions in the questionnaire were mathematically consistent, which we finally proved. It was not necessary to remove any of the questionnaire questions. To prove our HA, a Principal Axis Factoring (PAF) was applied, verifying the assumptions regarding the Average Variance Extracted (AVE) and Convergent Validity (CV). HA proved that applying PAF on DLQI resulted in extracting a single general vitiligo latent factor of life quality, with an initial eigenvalue = 5.671, SS loadings = 5.2, and 52 % of the total cumulative variance explained. Diverse statistical analyses were applied to analyze the 10 formulated research questions. The results of the analysis of the research questions are presented and discussed in the manuscript. One of the conclusions related to the analysis of a research question was that sex had the lowest correlation with the latent life quality factor identified for vitiligo patients.

Depressive Disorder and Dermatological Autoimmune Diseases

Depressive disorders are a growing problem worldwide. They are also characterized by high comorbidity, including from the circle of dermatological diseases. Autoimmune diseases seem to be particularly correlated with depressive comorbidity, raising the question of their possible common pathomechanism. The PubMed database was searched, focusing on results published after 2016. A particular reciprocal correlation of depressive disorders with psoriasis, atopic dermatitis, alopecia areata, impetigo, lupus and systemic scleroderma was found. One possible explanation for the co-occurrence of the above diseases is that the inflammatory theory may be applicable to depression, the various elements of which also apply to autoimmune diseases.

Impact of Vitiligo on Quality of Life in Patients of Skin of Color and Its Correlation With Clinical Severity Assessment Scores Utilizing Disease Specific Scores: A Cross-Sectional Study

INTRODUCTION

Assessment of disease severity of vitiligo is exigent as it is a psychosomatic ailment. VIDA (vitiligo disease activity score) and VASI (vitiligo area severity index) were previously used for this evaluation. Recently, the introduction of two vitiligo specific tools, vitiligo impact scale (VIS)-22 and Vitiligo Quality of Life Index (VitiQoL) has aided in assessing the quality of life (QOL) in a pertinent manner.

OBJECTIVES

To measure the QOL in vitiligo using disease specific indices (VitiQoL and VIS-22), to assess their relationship with disease severity (VASI and VIDA) and to determine the correlation between QOL scores (VIS-22 and VitiQoL).

METHODS

This observational cross-sectional study included 195 patients with vitiligo, and their disease severity was calculated using VASI and VIDA scoring. Patients were asked to fill questionnaires for assessing the QOL using validated tools i.e. VIS-22 and VitiQoL.

RESULTS

Significant correlation was demonstrated between both QOL scores and VASI score (P value 0.001) with slightly higher values for VitiQoL (r = 0.824) than with VIS 22 (r = 0.693). Both scores exhibited a significant association with VIDA score (P value < 0.001). Moreover, statistically significant correlation was found between VIS-22 and VitiQoL, thereby proving the concordance between these scores.

CONCLUSIONS

The study infers that QOL seemed to be remarkably dependent on the clinical severity scores and that higher disease activity corresponds to poorer QOL. It is imperative to precisely assess burden of vitiligo and the impairments caused by it in order to aid multi-modality management and allow more standardized research.

Management of the refractory vitiligo patient: current therapeutic strategies and future options

Vitiligo is an autoimmune disease that leads to disfiguring depigmented lesions of skin and mucosa. Although effective treatments are available for vitiligo, there are still some patients with poor responses to conventional treatment. Refractory vitiligo lesions are mostly located on exposed sites such as acral sites and lips, leading to significant life stress. Understanding the causes of refractory vitiligo and developing targeted treatments are essential to enhance vitiligo outcomes. In this review, we summarized recent treatment approaches and some potential methods for refractory vitiligo. Janus kinase inhibitors have shown efficacy in refractory vitiligo. A variety of surgical interventions and fractional carbon dioxide laser have been widely applied to combination therapies. Furthermore, melanocyte regeneration and activation therapies are potentially effective strategies. Patients with refractory vitiligo should be referred to psychological monitoring and interventions to reduce the potential pathogenic effects of chronic stress. Finally, methods for depigmentation and camouflage may be beneficial in achieving uniform skin color and improved quality of life. Our ultimate focus is to provide alternative options for refractory vitiligo and to bring inspiration to future research.

A triple combination of latanoprost, fractional CO2 laser, and platelet-rich plasma in localized vitiligo: A clinical and histopathologic study

BACKGROUND

Several treatment modalities are available for the treatment of vitiligo due to the lack of a uniformly effective therapy. Topical latanoprost 0.005% is an effective topical treatment. Fractional CO2 laser alone or combined with platelet-rich plasma (PRP) has been proposed as effective adjunctive therapies.

OBJECTIVES

We aimed to compare the efficacy of topical latanoprost 0.005% (Ioprost®, Orchidia, Egypt) combined with either add-on fractional CO2 laser or fractional CO2 -PRP versus topical latanoprost monotherapy in the treatment of localized stable vitiligo.

PATIENTS/METHODS

The study included 60 patients randomly assigned into three equal groups. Group A patients received topical latanoprost drops only. Group B patients received topical latanoprost drops and fractional CO2 laser sessions at 2-week interval for 3 months. Group C patients received topical latanoprost drops and fractional CO2 laser sessions combined with PRP at a 2-week interval for 3 months. The mean improvement score by the physician was calculated 4 months after the start of the study. Punch skin biopsies were obtained before treatment and 4 months from the beginning of the study and stained with H&E and HMB-45 antibody for evaluation of pigmentation.

RESULTS

Significant clinical improvement of vitiligo lesions with significant increase of re-pigmentation were reported in the three treated groups. Latanoprost in combination with fractional CO2 and PRP was associated with more significant therapeutic outcomes than either combined latanoprost and fractional CO2 or latanoprost alone.

CONCLUSION

Fractional CO2 laser-PRP enhances the therapeutic efficacy of latanoprost 0.005% in the treatment of localized stable vitiligo.

Exploratory axis factoring for identifying the self-esteem latent factors and their correlation with the life quality of persons suffering from vitiligo

Objective

Our research aimed to measure the importance of self-esteem in assessing the disease burden in patients with vitiligo, which, according to our knowledge, had not been studied earlier. The purpose of this research study was to expand the state of knowledge regarding the influence of vitiligo on the quality of patients' life, with a particular focus on their self-esteem. We have formulated the following two hypotheses which include H1: two latent factors characterize the self-esteem of patients with vitiligo; H2: the self-esteem of the patients with Vitiligo is correlated with their life quality, by influencing it to a high degree.

Methods

We have used two validated questionnaires called Rosenberg (Q1), for the evaluation of self-esteem (for proving H1), and Dermatology Life Quality Index (DLQI) (Q2), to measure the health-related quality of life of patients (for proving H2). Both questionnaires with 10 questions were applied to the same set of 114 carefully selected patients with no missing values to questions. An in-depth statistical and reliability analysis was performed on the outcomes provided by Q1, applying a scale and subscale reliability analysis, using the Cronbach's alpha reliability indicator (Cα). An exploratory analysis called Principal Axis Factoring (PAF) with Oblimin with Kaiser Normalization rotation was applied to prove H1, verifying the assumptions regarding the average variance extracted (AVE) and convergent and discriminant validity (CDV). A scale reliability analysis of outcomes provided by Q2 was performed for proving H2, by calculating Cα. Additionally, a nonparametric correlation analysis was performed, by calculating the Spearman r correlation coefficient between the Rosenberg index and DLQI index, and the 95% confidence interval (CI).

Results

Based on the provided data, the value of Cα obtained in Q1 was 0.84. As a result of applying PAF on Q1, H1 has been proven and two latent factors of self-esteem have been extracted. These factors were named competence (eigenvalue = 4.126; 41.258% of total variance explained) and value (eigenvalue = 1.857; 18.57% of total variance explained). For the two subscales determined by the two factors, we have obtained the Cα values of 0.848 and 0.8, all indicating good reliability. For testing H2, on Q2 data we obtained Cα = 0.914. The Spearman correlation coefficient r = -0.734 (p < 0.0001), between the self-esteem questionnaire evaluation result and the life-quality index result indicated the existence of a strong negative correlation, which is significant according to 95% CI [-0.81, -0.63].

Discussion

The study focused on analyzing the self-esteem of patients with vitiligo. In addition, the psychometric properties of the Q1 questionnaire were analyzed and Q1 proved to have good internal consistency. PAF indicated a two-factorial structure, with factors called competence and value, proving H1, with a moderate correlation of 0.427 between the two latent constructs. The competence factor includes motivation, self-efficacy, initiative, and persistence in action. The value factor is much more complex, indicating a feeling, a personal evaluation, or a positive or negative attitude toward one's person, which better captures the entire phenomenology of self-esteem. The statistical analysis of the results provided by the self-esteem questionnaire included questions that proved to be internally consistent. The AVE and CDV assumptions were met. Q2 was proved to have excellent scale reliability. H2 proved a statistically significant strong negative correlation between the Rosenberg score and DLQI score.

Comparison of the efficacy of tacrolimus 0.1% ointment vs calcipotriol/betamethasone in combination with NBUVB in treatment of vitiligo

Purpose: Vitiligo is an idiopathic depigmenting skin disorder. The study compares the efficacy of topical tacrolimus 0.1% with calcipotriol/betamethasone dipropionate in vitiligo patients receiving NB-UVB treatment.Materials and methods: Forty-one adult patients with generalized type vitiligo were recruited. Patients were assigned to phototherapy and then classified into either group one (20 patients), receiving calcipotriol/betamethasone dipropionate cream (D group), or group two (21 patients), receiving tacrolimus 0.1% ointment (T group). They were followed-up at 3 and 6 months.Results: The D group witnessed an increase in the repigmentation area from 35.4% in the third month to 54.7% in the sixth month (p = 0.001) and the T group from 32.2% to 45.6% (p = 0.011). However, the differences between the treatment groups were not statistically significant. Body sites demonstrated different levels of improvement ranging from the highest in the face to the lowest in the Hand & Feet with the other body sites in between. A negative correlation was identified between the duration since diagnosis and the response to D treatment (3 months: r = -0.612, p = 0.007; 6 months: r = -0.755, p = 0.001).Conclusions: Although both combinations are efficacious, they did not significantly differ in efficacy at three and six months follow-up points.Clinical trial registration: The study was registered at clinicaltrials.gov (NCT04440371).

The value of adding platelet-rich plasma (PRP) to noncultured epidermal cell suspension (NCECS) in surgical treatment of stable resistant vitiligo: A self-controlled randomised double-blinded study

BACKGROUND

Noncultured epidermal cell suspension (NCECS) is a commonly used surgical treatment for resistant stable acral vitiligo and vitiligo overlying joints. Platelet-rich plasma (PRP) has been reported to enhance the repigmentation response of different therapeutic modalities for vitiligo, including vitiligo surgery.

OBJECTIVE

To assess the value of adding of PRP to NCECS in the surgical treatment of acral vitiligo and vitiligo overlying joints.

PATIENTS AND METHODS

This self-controlled randomised trial included 15 patients with 30 lesions in which NCECS suspended in PRP was performed for one lesion and NCECS in ringer's lactate for another comparable lesion. Following NCECS, patients underwent thrice weekly excimer light sessions for 3 months. After 8 weeks, patients underwent preliminary assessment. By the end of the 3 months, both lesions were compared as regards improvement in surface area and pigmentation. Additionally, physician global assessment was made by a blinded investigator.

RESULTS

Significant improvement was reported in both lesional extent and pigmentation (after PRP and lactated ringer NCECS) with no statistical difference between them.

CONCLUSION

Despite previous promising results, suspending NCECS in PRP offered no privilege in surgical treatment of acral vitiligo and vitiligo overlying joints, which are quite resistant to treat.

PAN AFRICAN CLINICAL TRIAL REGISTRY ID

PACTR202108873035929, Date: 16 August 2021.

"Mens Sana in Cute Sana"-A State of the Art of Mutual Etiopathogenetic Influence and Relevant Pathophysiological Pathways between Skin and Mental Disorders: An Integrated Approach to Contemporary Psychopathological Scenarios

The negative socioeconomic impact of mental health disorders and skin diseases has increased in part due to the conflict between Russia and Ukraine, which has been a fertile ground for the emergence of psychopathologies. It is firmly established that there is a direct thread of etiopathogenetic communication between skin diseases and neuropsychiatric disorders, and the literature has tried to reveal the pathophysiological mechanisms governing such bidirectionality. This paper discusses this complex network of molecular pathways that are targeted by conventional and biological pharmacological agents that appear to impact two pathological spheres that previously seemed to have little connection. This molecular discussion is supplemented with a literature review, from a clinical viewpoint, regarding skin-brain etiopathogenetic bidirectionality. We focus on post-traumatic stress disorder (PTSD), which can be considered for all intents and purposes a systemic inflammatory disease that also affects the skin. A brief overview is also provided on the diagnostic-therapeutic and follow-up potential of oxidative and inflammatory markers potentially involved in the pathophysiological mechanisms treated. The aim is to clarify how these mechanisms may be useful in defining different stress-coping strategies and thus individual phenotypes of stress sensitivity/resistance in order to promote personalized medicine in the field of psychodermatology.

Comparative Analysis of the Most Used Versus the Recently Developed Vitiligo Activity and Extent Scores and Their Change with Treatment

INTRODUCTION

There are diverse assessment tools for vitiligo, with no standardized approach that helps unify treatment outcome measures. Thus, comparing different treatment modalities and developing evidence-based recommendations for vitiligo management has been quite challenging.

OBJECTIVES

We compared the most commonly used tools assessing both vitiligo activity and extent, namely, Vitiligo Disease Activity Score (VIDA) and Vitiligo Area and Severity Index (VASI) score to their newly developed counterparts, namely, Vitiligo Extent Score Plus (VES plus) and Vitiligo Signs of Activity score (VSAS), to provide insights that would help set recommendations for a unified outcome assessment protocol for vitiligo patients.

METHODS

Thirty-six active non-segmental vitiligo cases were recruited, 30 of whom completed 48 sessions of narrow band ultraviolet B (NB-UVB). Patients were assessed for both extent and activity both before and after treatment with NB-UVB. Scores were correlated. Additionally, VES plus was assessed for its reliability in comparison to VASI score.

RESULTS

Both extent (VASI and VES plus) and activity scores (VIDA and VSAS) showed significant improvement following treatment. Additionally, VES plus and VASI were positively correlating both before and after treatment as well as their percent change. Furthermore, VES plus proved as reliable as VASI. Regarding activity scores, total, hypochromic and Koebner VSAS only correlated with VIDA following treatment. Confetti VSAS neither correlated with VIDA before nor after treatment.

CONCLUSIONS

VES plus and VASI scores have proven of comparable reliability. While examination-based VSAS score comes as an additive tool to the history-based VIDA score.

Public Knowledge and Attitude towards Vitiligo: A Cross-Sectional Survey in Jordan

BACKGROUND

Vitiligo is an autoimmune disease affecting approximately 2% of the world's population. Besides vitiligo cosmetic issues, patients suffer from psychological comorbidities. This results from the stigmatization they encounter from surrounding individuals. Accordingly, the current study was the first to assess Jordanians' knowledge and attitude toward vitiligo.

METHODS

Data collection was completed by an online questionnaire consisting of four sections to capture participants' sociodemographic characteristics, previous exposure, and knowledge and attitude toward vitiligo. The analysis took place through R and RStudio.

RESULTS

Of our 994 surveyed participants, only 8.45% and 12.47% had a low level of vitiligo knowledge and negative total attitude score, respectively. Moreover, independent predictors of positive attitudes included younger age (18-30), high school education or lower, hearing about or living with a vitiligo patient, and higher knowledge scores. The highest prevalence of positive attitudes was observed when physicians were the source of knowledge.

CONCLUSION

Some critical misconceptions were identified despite the Jordanian public having sufficient overall knowledge. Furthermore, higher knowledge reflected a higher prevalence of positive attitudes toward the patients. We recommend that future efforts target the public understanding of the nature of the disease and its being non-communicable. Moreover, we emphasize that medical knowledge should be communicated through qualified healthcare providers.

Vitiligo, from Pathogenesis to Therapeutic Advances: State of the Art

Vitiligo is an acquired hypopigmentation of the skin due to a progressive selective loss of melanocytes; it has a prevalence of 1-2% and appears as rounded, well-demarcated white macules. The etiopathology of the disease has not been well defined, but multiple factors contribute to melanocyte loss: metabolic abnormalities, oxidative stress, inflammation, and autoimmunity. Therefore, a convergence theory was proposed that combines all existing theories into a comprehensive one in which several mechanisms contribute to the reduction of melanocyte viability. In addition, increasingly in-depth knowledge about the disease's pathogenetic processes has enabled the development of increasingly targeted therapeutic strategies with high efficacy and fewer side effects. The aim of this paper is, by conducting a narrative review of the literature, to analyze the pathogenesis of vitiligo and the most recent treatments available for this condition.

Does the Saudi Population Have Sufficient Awareness of Vitiligo in Southwest Saudi Arabia? A Cross-Sectional Survey, 2022

Background: Vitiligo is a common acquired hypopigmentation skin condition defined by an idiopathic, gradual, and restricted loss of melanin pigment from otherwise healthy-looking skin. The present study aims to evaluate the knowledge and perceptions of and attitudes toward vitiligo among the general population of Jazan Province, Saudi Arabia. Methods: An observational cross-sectional survey targeting adults of the Jazan region was conducted in 2022. The data were collected using an electronic questionnaire distributed through social media in the region. Statistical analysis was performed using the SPSS computer program. Knowledge and attitude scores were computed. Results: Most of the respondents (83.7%) had an adequate knowledge level of vitiligo, and almost half of the respondents (46.8%) had a positive attitude toward the disease. The majority of the respondents (84.5%) knew that vitiligo is not contagious. However, the majority of the participants (78.6%) did not know that vitiligo is an autoimmune disease. Most of the respondents (93.1%) do not avoid shaking hands with a vitiligo patient to prevent infection, accept food prepared by a vitiligo patient (69.4%), accept sharing a plate with a vitiligo patient (73.6%), and accept to be helped by a vitiligo patient (86.7%). However, about half of the participants (50.4%) refused to marry a person diagnosed with vitiligo. The knowledge of vitiligo in the study population was not correlated with any of the demographic characters, such as age, gender, education, or occupation (p > 0.05). The most important factors associated with good attitudes were male gender (COR = 1.92; 95% CI: 1.92−2.84; p = 0.001) and being aged over 50 years (COR = 3.06; 95% CI: 1.53−6.13; p = 0.002). Conclusions: The population in Jazan had a good level of knowledge of vitiligo and a positive attitude toward patients with vitiligo. Social media is the source of information for vitiligo for the majority of the study population. The good attitude toward patients with vitiligo was more prevalent in males and older people. More efforts are needed to improve the knowledge of and attitudes toward vitiligo.

Psychiatric Consequences of Skin Conditions: Multiple Case Study Analysis with Literature Review

This review of current literature demonstrates the psychological implications of skin conditions. Skin conditions of varying severity can impact the quality of patients' lives and have psychiatric consequences. This impact provides a need for healthcare providers to consider the psychological implications of one's skin conditions and their effect on quality of life. The psychological challenges that arise from varying skin conditions show the potential need for both dermatological and psychiatric interventions. The following literature review details the psychiatric consequences of skin conditions under various conditions. It first looks at literature highlighting the psychiatric consequences experienced through various age ranges, from adults to adolescents and children. The paper then explores multiple skin conditions and their psychological effect before highlighting some of the interactions that stress has on the skin that could further exacerbate one's condition. Finally, it examines how patients characterize their experience with their skin condition and goes into some clinical case studies of patients with psychological implications as a result of their skin disorder. The paper also highlights the magnitude of dermatologic patients experiencing psychological conditions in conjunction with their skin conditions.

The association between social support and depression among patients with vitiligo in China

Vitiligo is a common depigmenting skin disease with profound psychosocial impacts. Depression is one of the most common mental distress. Social support has a significant impact on the psychological status of patients. The aim of this study is to investigate the depression and social support status of patients with vitiligo in China, and further explore the correlation between social support and depression. The outpatients with vitiligo were investigated face to face with SDS (Self-rating depression scale) and SSRS (Social support rate scale). The mean SDS score of the patients was 44.05 ± 6.76, which was significantly higher than Chinese norms (p = 0.000). Female patients, unmarried, disease at rapid progressive stage and skin lesions at the exposed site had higher SDS scores (all p < 0.05). The scores of total social support, subjective support, objective support and support availability were lower than Chinese norms (all p < 0.01), and all were negatively correlated with SDS scores (all p < 0.001). In conclusion, low social support is one of the risk factors for depression in patients with vitiligo in China. More support and acceptance should be given to the patients.

Patients with vitiligo have a distinct affective temperament profile: A cross-sectional study using Temperament Evaluation of Memphis, Paris, and San Diego Auto-Questionnaire

Background

Vitiligo is a skin disease associated with significant psychiatric comorbidities. Affective temperaments represent the inherited foundation of personality and represent the biologically stable part of emotional reactivity. Studies assessing the temperament profile of patients with vitiligo are still scarce.

Method

This was a cross-sectional study enrolling 34 patients with vitiligo and 34 age and sex-matched healthy controls. Affective temperament profile was investigated using the Temperament Evaluation of Memphis, Paris, and San Diego Auto-questionnaire. Dermatology life quality index was used to evaluate disease impact on patients' quality of life.

Results

We found significant differences with vitiligo patients scoring higher in anxious (11.5 ± 4.76 vs. 9.06 ± 6.22; p = 0.036) and lower in hyperthymic (5.79 ± 3.82 vs. 7.5 ± 3.64; p = 0.027) temperaments. Vitiligo worsening reported by patients was associated with recent psychological stressors in 18 cases (52.9%) and Koebner phenomenon in 20 cases (58.8%). Koebner phenomenon was more frequently associated with the hyperthymic temperament (p = 0.035). Cyclothymic temperament was positively correlated with Dermatology life quality index (rho = 0.417, p = 0.014).

Conclusions

This study demonstrated that patients with vitiligo have a distinct premorbid temperament profile. Having low hyperthymic and high anxious temperament traits seem to predispose patients to be less resilient to psychological stressors. A better understanding of the affective traits of vitiligo patients would be vital in personalising and adapting the management of this chronic skin disease.

Gene polymorphisms and serum levels of BDNF and CRH in vitiligo patients

Background

Vitiligo is one of the most common hypomelanoses, in which the destruction of functioning melanocytes causes depigmentation of the skin, hair and mucous membranes. The genes encrypting brain-derived neurotrophic factor (BDNF) and corticotropin releasing hormone (CRH) might be the conceivable contributors to the development of vitiligo. This study was aimed at investigation of the serum levels of BDNF and CRH as well as their selected single nucleotide polymorphisms (SNPs) in vitiligo patients in comparison with the healthy controls.

Methods

The cross-sectional study was carried out between October 2020 and June 2021 in 93 vitiligo patients (age range from 23 to 48 years) and 132 healthy controls (age range from 24 to 52 years). The psychological status of study participants was evaluated using the Generalized Anxiety Disorder-7 (GAD-7) scale. Serum levels of BDNF and CRH were measured with the help of a commercially available sandwich enzyme-linked immunosorbent assay (ELISA) kit. Genotyping for the rs11030094 polymorphism of the BDNF gene and for the rs242924 polymorphism of the corticotropin releasing hormone receptor 1 (CRH-R1) gene was performed by a real-time polymerase chain reaction (PCR).

Results

There was a significant relationship between the CRH-R1 rs242924 and BDNF rs11030094 polymorphisms and vitiligo. Moreover, serum levels of neurotransmitters differed significantly between vitiligo and control groups and were associated with the CRH-R1 rs242924 and BDNF rs11030094 SNPs.

Conclusions

Our findings demonstrated the association between CRH-R1 rs242924 and BDNF rs11030094 polymorphisms and vitiligo. Further studies need to be carried out in vitiligo patients to confirm the results observed.

Neuroticism, stress, and rumination in anxiety and depression of people with Vitiligo: An explanatory model

Psychological impacts of Vitiligo have been demonstrated, and associations of the skin disease with anxiety and depression disorders have already been shown. However, it is still unclear the role of individuals' personality factors, such as neuroticism, stress, and rumination, as well as sociodemographic characteristics of people with Vitiligo in such disorders. We conducted a study in a community sample of individuals with Vitiligo (N = 324) aiming to test the hypothesis that neuroticism, stress, and rumination are subjacent to these individuals' anxiety and depression symptomatology. We also explored whether individuals' gender might favor the onset or worsening of the psychological consequences of such disorders. Results showed that the relationship between neuroticism, anxiety and depression was mediated by stress and rumination (brooding), being this effect moderated by the participants' gender. Specifically, women's reflection and stress seemed to be important mechanisms to predict their anxiety and depression symptoms, whereas brooding predicts such disorders' symptomatology in men with Vitiligo. These findings may guide future research and clinical interventions for this population, for which it is necessary to consider the psychological consequences of the disease and not just its physiological aspects.

Associations between serum levels of brain-derived neurotrophic factor, corticotropin releasing hormone and mental distress in vitiligo patients

Vitiligo is clinically characterized by the appearance of non-symptomatic depigmented macules, but the disorder is highly correlated with a wide range of psychiatric disorders and psychological problems. The aim of our study was to investigate serum brain-derived neurotrophic factor (BDNF) and corticotropin releasing hormone (CRH) levels in vitiligo patients and healthy controls in relation to the observed symptoms of depression and anxiety disorders. This study comprised 96 vitiligo patients and 96 healthy controls who filled out the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales. Serum levels of BDNF and CRH were measured using enzyme-linked immunosorbent assay (ELISA) technique. There was a significant increase of depression and anxiety scores in vitiligo patients as compared with healthy controls (P < 0.05). The serum levels of BDNF were significantly lower in vitiligo patients than in healthy individuals (Z = 4.002; P < 0.001), while the serum levels of CRH were markedly higher in cases than those in controls (Z = 3.764; P < 0.001). The significant positive correlations between serum CRH levels and GAD-7, PHQ-9 scores were observed. However, the aforementioned psychometric scales did not correlate significantly with serum BDNF level. Vitiligo is associated with the depression and is closely linked with lower BDNF levels.

Update on the pathogenesis of vitiligo

Vitiligo is a complex disease whose pathogenesis results from the interaction of genetic components, metabolic factors linked to cellular oxidative stress, melanocyte adhesion to the epithelium, and immunity (innate and adaptive), which culminate in aggression against melanocytes. In vitiligo, melanocytes are more sensitive to oxidative damage, leading to the increased expression of proinflammatory proteins such as HSP70. The lower expression of epithelial adhesion molecules, such as DDR1 and E-cadherin, facilitates damage to melanocytes and exposure of antigens that favor autoimmunity. Activation of the type 1-IFN pathway perpetuates the direct action of CD8+ cells against melanocytes, facilitated by regulatory T-cell dysfunction. The identification of several genes involved in these processes sets the stage for disease development and maintenance. However, the relationship of vitiligo with environmental factors, psychological stress, comorbidities, and the elements that define individual susceptibility to the disease are a challenge to the integration of theories related to its pathogenesis.

Keratinocytes take part in the regulation of substance P in melanogenesis through the HPA axis

BACKGROUND

Clinical findings have shown that skin depigmentation disorder such as vitiligo may be closely associated with the release of central and peripheral substance P (SP) resulted from chronic psychological stress or sudden mental blow. But the regulatory role of SP and its receptor, tachykinin receptor in the pathogenesis of vitiligo is unclear.

OBJECTIVES

To investigate the function and mechanism of SP in melanogenesis.

METHODS

The chronic mental stress was used to explore the intrinsic association between psychological factors, SP and melanogenesis disorder. The effect of SP on melanogenesis through hypothalamic pituitary adrenocortical (HPA) axis was studied by skin culture in vitro. The conditioned medium experiment demonstrated the indirect effect of SP on melanogenesis of B16F10 cells through HaCaT cells. The ability to produce melanin was evaluated by detecting melanin and tyrosinase activity. qRT-PCR, western blotting and immunohistochemistry were used to detect the expression of related genes and proteins in melanogenesis and HPA axis.

RESULTS

Increased SP expression and reduction of melanogenesis in the skin of mice were observed under mental stress. Melanogenesis was suppressed in the cultured human skin treated with SP due to the down-regulation of melanin-related proteins and HPA axis genes. The melanogenesis of B16F10 cells was inhibited by the conditioned medium of HaCaT cells treated with SP.

CONCLUSIONS

Overall, these results indicate that excess SP originated from mental stress interferes with melanogenesis through keratinocytes in the skin. The HPA axis is the key downstream to perceive the SP signaling and furtherly regulate the melanogenesis.

Ocular Abnormalities in Patients with Vitiligo: A Systematic Review and Meta-Analysis

BACKGROUND

Vitiligo is a skin depigmentation disorder that results from the autoimmune destruction of cutaneous melanocytes. Several ocular abnormalities, including uveitis, dry eye, glaucoma, and retinal diseases, have been reported in patients with vitiligo. The aim of our study was to investigate the association of ocular abnormalities with vitiligo.

METHODS

This meta-analysis was registered in PROSPERO (CRD42021224167) and adhered to MOOSE checklist and PRISMA guidance for all processes. PubMed, Embase, Web of Science, and Cochrane databases were searched for studies examining the association between ocular abnormalities and vitiligo from inception to December 10, 2020. Studies recruiting patients with Sjogren's syndrome or Vogt-Koyanagi-Harada syndrome were excluded. The primary outcomes were the Schirmer test, tear film break-up time (TBUT), and ocular surface disease index (OSDI) of vitiligo patients compared to the controls. The risk of bias of the selected studies was assessed using the Newcastle-Ottawa Scale (NOS) of case-control studies.

RESULTS

This meta-analysis of 16 case-control studies showed that patients with vitiligo had significantly lower Schirmer test values (mean difference [MD], -1.65; 95% CI, -2.81 to -0.49), shorter TBUTs (MD, -4.66; 95% CI, -7.05 to -2.26), higher ocular surface disease indices (MD, 18.02; 95% CI, 5.7-30.35), and thinner subfoveal choroidal thicknesses (MD, -53.10; 95% CI, -69.84 to -36.36). No significant differences were found in the prevalence of glaucoma and the level of intraocular pressure.

CONCLUSIONS

Our study supports an association between dry eye and thinner subfoveal choroidal thickness in patients with vitiligo. Dermatologists should be aware of these possible comorbidities and refer vitiligo patients with ocular symptoms to ophthalmologists for further management.

Early localized vitiligo, a medical emergency: Long-term follow-up study

In spite of multiple therapeutic regimens for vitiligo, disease relapse remains a challenge. Most guidelines consider systemic treatments only in rapidly progressive disease with wider surface areas. This delay in halting the immune attack, may give the chance for further disease progression as well as establishment of resident memory T-cell population predisposing to future relapses. To assess the ability of early systemic therapy of localized (<2% BSA), recent onset (<6 months) vitiligo to control disease activity and minimize the possibility of recurrence. Twenty-five patients with recent onset (<6 months), localized (<2% BSA) vitiligo were included. Patients received pulse dexamethasone therapy for 6 months plus topical treatments and NB-UVB sessions. Patients were followed monthly as regards percent of repigmentation and VIDA score. To detect recurrence, biannual assessment was done for 4 years. Eighty-four percent of patients had acrofacial lesions and 44% had facial lesions. Arrest of activity was achieved after 3.65 ± 2.19 months. Complete repigmentation was achieved in a mean duration of 6.88 ± 0.2 months. At the end of the 4-year follow up, recurrence occurred in 32% of patients. In spite of recurrence, localized disease (<2% BSA) was secured. A significantly higher incidence of recurrence was associated with cases with bilateral distribution of lesions. Early systemic immunomodulation for recent localized vitiligo is a successful approach to achieve early control of disease activity and minimize the incidence of recurrence. Such cases should not be overlooked but managed as early as possible; it is a race against time.

Addressing Climate-Related Health Impacts During the Patient Encounter: A Practical Guide for Pediatric Dermatologists

Pediatric populations are expected to bear most of the climate change impacts, with racial minorities and children living in poorer countries being particularly vulnerable. Given their relevance to cutaneous disease, dermatologists should be aware of these climate-sensitive health impacts and the ways in which they intersect with social factors. Strategies including targeted risk communication, motivational interviewing, and storytelling can help facilitate climate discussions during the patient encounter. In this article the authors summarize common dermatologic health impacts related to environmental exposures and provide sample scripts for climate messaging.

Addressing Emotional Issues in an Adolescent with Vitiligo and Early Child Sexual Abuse-Therapeutic Challenges

Chronic medical conditions in children and adolescents have a significant impact on development and quality of life. Children with vitiligo experience depression, anxiety and guilt, body image concerns, and conflicts of acceptance-rejection among peers. Understanding issues of relevance through a developmental perspective is pivotal. Here, we report the experiences of working with an adolescent who presented with depressive symptoms, mood dysregulation, and self-harm, in the background of vitiligo and child sexual abuse. We describe the unique therapeutic challenges, focusing on the interplay between depressive psychopathology, childhood trauma, and normative adolescent development. Therapeutic strategies for patient-centered psychological interventions are discussed. The therapy processes focused on a narrative approach, with the active involvement of the family.

Location, Spreading and Oral Corticosteroids are Associated with Insomnia in Vitiligo Patients: A Case-Control Study

Background

Vitiligo can cause disfiguration, impair the social function of the patients and induce physiological burdens. However, limited research about the health-related quality of life has been conducted in vitiligo patients’ sleeping conditions.

Objective

To evaluate the prevalence, severity, and risk factors of insomnia in vitiligo patients.

Methods

This case–control study was performed in March 2021. An online survey questionnaire including baseline information and the sleep-related instrument was sent to 762 vitiligo patients. The vitiligo-related evaluation was conducted by online video interview. According to whether having insomnia or not, patients were grouped and compared their clinical and demographic characteristics. The logistic regression model was conducted to analyze the risk factors for insomnia.

Results

A total of 409 patients were included. About 49.9% of patients (204/409) experienced insomnia. About 55.9% (114/204) of the insomnia in vitiligo patients was adjustment sleep disorder caused by vitiligo. Development, aggravation, or recurrence of vitiligo were deemed as the first reason for insomnia in 71.1% of the sample (81/114). There were significant differences in age (32.1±4.1 vs 27.9±4.2 years, P < 0.001), the percentage of female (62.8% vs 49.3%, P=0.006) and working in the urban areas (77.0% vs 66.3%, P = 0.017), vitiligo in face and neck (67.2% vs 48.8%, P < 0.001), progression in vitiligo (65.7% vs 49.3%, P=0.001), oral corticosteroids (25.0% vs 16.6%, P=0.036) and depression (5.4% vs 0.5%, P = 0.003) between groups. After adjusting for gender, age and comorbidity, the multivariate logistic regression revealed that vitiligo in face and neck (OR=2.62; P=0.032), progression in vitiligo (OR=2.50; P=0.002), and oral corticosteroids (OR=2.71; P=0.021) remained risk factors for insomnia in vitiligo patients.

Conclusion

Insomnia is prevalent in vitiligo patients. Dermatologists should identify this condition carefully, especially humanistic factors in social life, and perform individualized “non-drug” treatment.

Can it make me white again? A case report of 88% phenol as a depigmenting agent in vitiligo

Vitiligo is the most common depigmenting disorder. However, therapies prove to be time-consuming, costly, or slow to show efficacy. Here, we present a case of a 74-year-old female with vitiligo who underwent full-body depigmentation treatment 50 years ago. Brown patches of repigmentation appeared on the patient’s face and arms and were eventually treated with 88% phenol. Patient was later switched to compounded 3% glutathione cream for a more sustained effect. Phenol was an accessible, economical, and easily administrable therapeutic option that can result in short-term depigmentation.

Vitiligo: An Updated Narrative Review

BACKGROUND

Vitiligo is a relatively common acquired pigmentation disorder that can cause significant psychological stress and stigmatism.

OBJECTIVE

This article aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis, and management of vitiligo.

METHODS

A Pubmed search was conducted in Clinical Queries using the key term "vitiligo". The search included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English language. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Approximately one quarter of patients with vitiligo have the onset before 10 years of age. Genetic, immunological, neurogenic and environmental factors may have a role to play in the pathogenesis. Vitiligo typically presents as acquired depigmented, well-demarcated macules/patches that appear milk- or chalk-white in color. Lesions tend to increase in number and enlarge centrifugally in size with time. Sites of predilection include the face, followed by the neck, lower limbs, trunk, and upper limbs. The clinical course is generally unpredictable. In children with fair skin, no active treatment is usually necessary other than the use of sunscreens and camouflage cosmetics. If treatment is preferred for cosmesis, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the mainstays of treatment.

CONCLUSION

The therapeutic effect of all the treatment modalities varies considerably from individual to individual. As such, treatment must be individualized. In general, the best treatment response is seen in younger patients, recent disease onset, darker skin types, and head and neck lesions. Topical corticosteroids and calcineurin inhibitors are the treatment choice for those with localized disease. Topical calcineurin inhibitors are generally preferred for lesions on genitalia, intertriginous areas, face, and neck. Narrowband ultraviolet B phototherapy should be considered in patients who have widespread vitiligo or those with localized vitiligo associated with a significant impact on the quality of life who do not respond to treatment with topical corticosteroids and calcineurin inhibitors.

Management of psychocutaneous disorders: A practical approach for dermatologists

Psychodermatology is a growing specialty which is gaining momentum in different parts of the world. It focuses on the connection between skin and psyche. Psychocutaneous conditions are characterized by those disorders where stress is the key element in exacerbating skin conditions or flare ups of dermatoses like psoriasis and atopic dermatitis. There is a direct relationship of stress with the course, and prognosis of the skin disease. In some situations, there is no skin condition but the lesions are self-inflicted and such disorders are always associated with underlying psychopathology or psychological conflicts. Sometimes emotional problems are more prominent as a result of having skin disease, and the psychological consequences may be more severe than the physical symptoms. Management of these conditions require a combination of psychpharmacology, psychotherapy, and liaison clinics of psychiatry and dermatology. This review focuses on the common management approach which can be adopted by dermatologists in treating patients with psychodermatological disorders, improving doctor-patient relationship and therapeutic bond.