[Medical Insight 63rd] Symptoms and treatments of vitiligo, which dermatologists tell us.

□ Broadcast Date and Time: December 20, 2024 (Fri) 10:20 pm
□ Producer in charge: Lee Siwoo
□ Author in charge: Kim Bae-jeong and Kim Hyun-jeong
□ Cast: Seok-jun (Dermatologist at Chung-Ang University Hospital)
□ Broadcast channel
IPTV - GENIE TV No. 159 / BTV No. 243 / LG Uplus No. 145
SkyLife Number 90
Cable - Delive No. 138 / Hyundai HCN No. 341 / LG HelloVision No. 137 / BTV Cable No. 152

* The text below may differ from the actual broadcast content, so please check the broadcast for more accurate information.


◆ Seok-jun: Hello, I'm Seok-jun, a dermatologist. What I prepared today is the symptoms and treatment of vitiligo, a disease that changes skin color white.

◇ Voice actor Park Sang-hoon: White-flowering disease vitiligo on the skin. Leukemia is caused by the destruction of melanin cells that make pigment, and it appears as white spots and white hair. Vitiligo, an autoimmune disease, affects not only melanocytes but also cancer cells, and patients with vitiligo have a 14% lower risk of cancer than the general population, especially the incidence of colon and ovarian cancer is 38%. vitiligo that occurs in every corner of the body from head to toe without pain or itching. Let's find out more about the symptoms and treatments of vitiligo.

<Understanding Vitiligo>
◆ Seok-jun: What is vitiligo? I think you'll see things around you from time to time. This vitiligo is a disease in which melanin cells, which determine the color of the skin, are lost and the skin becomes white. Depending on the patient, if the symptoms worsen, the hair may look white. It is an acquired hypochromic disease that shows bleaching reactions of various shapes and sizes, and can occur at all ages, but it is a disease that first occurs near the twenties and causes a lot of stress to patients with vitiligo. Vitiligo is famous for the disease that you know Michael Jackson had. Michael Jackson first revealed on The Oprah Winfrey Show in 1993 that he had vitiligo, and post-death autopsy results also revealed vitiligo.

<History of vitiligo>
◆ Seok-jun: Vitiligo has existed in mankind for a long time. If you look at those records, it's about 1500 B.C., Hindu Atardabeda. Records and those recorded for bleaching plastic spots in ancient Egyptian papyrus have been confirmed. Donguibogam in Korea has also recorded a disease that whitens the skin. It is recorded as a low-pigmentation disease without distinguishing vitiligo, bleaching, and nevus. Classical treatments such as applying sulfur, arsenic, and mercury are also described, but they were not effective, so I thought it was an incurable disease. In other countries, people with white skin were perceived as profane or dirty because they could not distinguish between leprosy or leprosy and vitiligo in the past. That's why it's hard to find portraits or other paintings that are expressed in vitiligo. However, due to the Joseon Dynasty's practice of emphasizing realistic descriptions as they are, we can see that portraits with vitiligo remain.

<Stress from vitiligo>
◆ Seok-jun: This vitiligo lowers the burden of life quite a lot. In fact, those who have vitiligo in places where it is revealed, such as face or hands, say that it is very difficult because they have difficulty meeting other people or shaking hands. According to the results of a numerical study, patients who suffer from circular hair loss are feeling a decrease in quality of life as much as or greater. In particular, the younger the onset age and the more women are, the more likely the onset is to be seen, such as the face and hands.

<Proliferation of vitiligo>
◆ Seokjun: So how many people are suffering from this type of vitiligo? vitiligo has a prevalence of about 1% worldwide. It is said that there is no difference between men and women. Regionally, the prevalence is highest in Central Europe and South Asia. In East Asia, where Korea belongs, the prevalence rate is a little low, so it is about 0.2 to 0.4%. In addition, the incidence of vitiligo is highest in adolescents under their 20s. In addition, according to recent research results, it is known that there are many outbreaks in people in their 50s and older.

<Heritage of vitiligo>
◆ Seok-jun: I'm sure many people have questions about whether such vitiligo is inherited. According to the results of several studies, about 6-8% of the family members of patients with vitiligo suffer from vitiligo. In fact, parents with vitiligo in my outpatient clinic often bring their new child with vitiligo. They and young couples came and said, 'If you have vitiligo, is it possible that your child will have vitiligo? There are a lot of people who are asking. In fact, it is said that more than 90% of families do not suffer from vitiligo even if their parents are vitiligo. So what about identical twins? According to the study, the matching rate was about 23% in identical twins. This means that only one out of five identical twins developed vitiligo in both. Taking these results together, it is thought that the cause of vitiligo is likely to be affected not only by genetics but also by other acquired factors.

<Causes of vitiligo>
◆ Seokjun: Now let's find out what causes vitiligo. As mentioned earlier, the cause of vitiligo is believed to be compounded not only by genetic factors but also by a number of other factors, and various theories are currently being presented. One of them is that vitiligo is an autoimmune disease. Originally, our body's immune system protects our body by attacking bacteria, viruses, or foreign substances. However, these autoimmune diseases refer to diseases caused by the body's immune system suddenly recognizing a part of its body as an attack target, causing an abnormal immune response and destroying cells. In this case of vitiligo, melanocytes in the skin attack our body's immune system, and melanocytes are gradually lost in that area. At this time, immune cells called CD8 T cells are known to play an important role in attacking melanocytes. Let's look at this mechanism a little bit more. This is very important because it is the basis of a therapeutic approach. CD8 T cells are originally responsible for getting rid of bad things in our body. In vitiligo, these cells secrete a substance called interferon gamma, which causes keratinocytes in the epidermis to secrete a lot of substances that signal the skin. This causes more CD8 T cells to gather into the skin, and the collected cells secrete interferon gamma again, causing vitiligo to circulate in a worse and worse cycle. As a result, more and more cells attacking melanocytes are gathered in vitiligo lesions, and vitiligo becomes more and more severe. Therefore, blocking this process will be very important in the treatment of vitiligo. In addition, research on tissue resident memory T cells has been active recently. This means that T cells do not circulate throughout our body, but live directly in tissues other than lymphatic organs and survive for a long time. Among them, cells that live in skin tissue are called skin tissue resident memory T cells. These cells are known to have a decisive effect on the maintenance and recurrence of vitiligo lesions. In fact, it is said that about 40% of patients can recur if vitiligo treatment is stopped. At this time, it was found that these skin tissue resident T cells play an important role. There is a misunderstanding that vitiligo patients have a higher risk of cancer because their bodies are white. It is known that immune checkpoint inhibitors used as anticancer drugs can increase vitiligo. Interestingly, there are reports that patients who develop vitiligo from chemotherapy are more effective in treating cancer. Studies have also shown that vitiligo patients have a lower risk of developing cancer not only in skin cancer but also in other organs. In particular, the risk of colon cancer, ovarian cancer, and lung cancer is reduced. This is thought to be the result of immune monitoring of cancer cells working better in vitiligo patients than in normal people. In addition, genetic research has shown that more than 50 genes are significantly related to the development of vitiligo. Some of these genes are associated with immune cells, and they also include genes that affect the function of melanocytes. This can be the basis for supporting that vitiligo is an autoimmune disease. From now on, let's look at other causes that can cause vitiligo. The first is excessive oxidative stress. When melanin cells are stimulated by ultraviolet external pollutants or trauma, free oxygen is generated as a by-product. In the case of vitiligo patients, the balance is broken in controlling oxidative stress. There is also a theory that vitiligo is caused by neurotransmitters secreted by nerves. In the case of segmental vitiligo, there are cases where the distribution is similar to that of the skin segment. Skin segmentation is the segmentation of the body along the ganglion exiting the spinal cord. This led to the theory that some imbalance in neurotransmitters between the skin and the neurosis causes vitiligo. Excessive secretion of norepinephrine, a sympathetic neurotransmitter, can lead to melanin cell death. It is also reported that stress exacerbates vitiligo, although the tone is not clear.

<Symptoms of vitiligo>
◆ Seok-jun: Now we're going to look at the clinical features of vitiligo. vitiligo is usually a disease characterized by clearly drawn boundaries and white bleached skin without pain or itching. It begins with circular or irregular-shaped lesions of various sizes. It can occur in any part of the skin and appears in bones, such as the face, hands, feet, knees, and elbows, protruding areas, and genitals. Also, the hair that is present on the skin can turn white.

<classification of vitiligo>
◆ Seok-jun: Next, let's look at the classification and subtyping of vitiligo. Vitiligo is largely divided into non-segmented vitiligo and segmented vitiligo. The reason for distinguishing this is that there are differences in clinical features. First, non-segmental vitiligo accounts for the largest proportion. Approximately 85 to 90% of people suffer from this type of vitiligo. Since it is the most common type, non-segmental vitiligo was often referred to as just vitiligo, and this was recently included in the criteria for vitiligo classification. From now on, let's look at the subtype of non-segmental vitiligo vitiligo. I'll tell you while looking at the pictures. As you can see, bleaching spots are observed on the tips of the lips and fingers. These terminal facial vitiligo results in bleaching of the hands, feet, and face at the extremities of the limbs. The vitiligo spreads around the area where the vitiligo first occurred. As you can see in the following picture, systemic vitiligo is a subtype that can occur anywhere throughout the body, including the face and groin. It also appears symmetrically on both sides of the body. If you look at the next picture, you can see that your whole body is almost white. This subtype is called pan-type vitiligo, and this subtype refers to a state in which vitiligo has progressed more than 80% of the body's surface. Next, mucosal vitiligo refers to subtypes in which mucosal areas, including lips and genitals, turn white. So far, we've looked at non-segmental vitiligo or vitiligo and its subtypes. Next, let's look at segmental vitiligo. As you can see in the picture, the bleaching progressed to one side with the navel as the boundary. This segmental vitiligo is the most distinct form from non-segmental vitiligo, accounting for about 10 to 15% of all vitiligo, and as I mentioned earlier, it is distributed mainly along the skin segment on one side of the body. These segmental vitiligo are mainly characterized by early development and rapid progression to the surrounding area within 12 months, followed by stabilization of the lesion. In the case of segmental vitiligo, melanin stem cells in hair follicles may be invaded early, causing white hair. In this case, the response to medication and phototherapy may decrease.

<Diagnosis of vitiligo>
◆ Seokjun: So, how is vitiligo diagnosed? Diagnosis is known to some extent only by typical appearance, but wood back tests and biopsy help differentiate it from other low-pigmentation diseases. Wood back test is one of the diagnostic tools used in dermatology to test for various diseases. When ultraviolet rays that have passed through the Udoo filter wipe the skin in a dark space, they absorb energy such as collagen, elastin, and melanin and emit blue fluorescent light. In the case of vitiligo, melanin cells are lost on the skin, so white light with clear boundaries can be observed. When vitiligo is confirmed, autoimmune diseases may be accompanied, so depending on the patient, we check whether there are other autoimmune diseases accompanied by blood tests.

<Similar disease of vitiligo>
◆ Seok-jun: So if your body turns white, is it all vitiligo? Of course, that's not the case. Other diseases such as white nasal dust, goose, and idiopathic polio hypochromia also need to be discriminated because the skin becomes white. First of all, white nasal discharge is a common disease that occurs mainly at a young age. Unlike vitiligo, the boundaries are unclear and accompanying soap distinguishes it from vitiligo. It usually occurs on the face and often occurs after sun exposure in summer or during dry seasons. Next, goose is a disease that occurs mainly in the upper part of the body with a lot of sebaceous glands. It is caused by an infection caused by fungus. On the wood lamp test, it appears as golden fluorescence, and a test called KOH helps to discriminate. This test called KOH will be a test to get keratinocytes and see if they have fungal hyphae in them. Idiopathic polio hypochromia is also thought to be an aging phenomenon and may be related to trauma such as sunlight exposure, bathing, and towels. White plaques with clear boundaries of an average size of about 5ml usually occur in exposed areas such as shins or lower arms. It tends to increase in number or size with age.

<Treatment of vitiligo>
◆ Seok-jun: Now, we will learn how to treat vitiligo. In the case of vitiligo, different treatment strategies should be established for each individual, taking into account various factors such as individual characteristics of the patient, disease activity, area of the affected area, and impact on quality of life, rather than performing the same treatment on all patients. Treatment goals include stabilizing the disease, re-depositing pigment on whitened skin, and preventing recurrence, and it is important to communicate with patients to determine the direction of treatment. Finding out if the lesion is active plays an important role in determining the direction of treatment. Clinical findings such as Koebner's phenomenon of vitiligo in areas with a lot of trauma or friction, tricolor vitiligo in which the boundaries are intermediate between normal skin and vitiligo, and confetti-shaped small bleaching plaques scattered around the paper patch are thought to have developed or spread recently. The most curious thing is the treatment. First, let's look at the coating agent, which is a medicine to apply. Topical steroids and calcium neuron inhibitors are typical applicants. It inhibits immune activity to stabilize the disease and induce redeposition of the pigment. It increases the effectiveness of the treatment in parallel with the phototherapy described later. In addition, if it is determined that the lesion spreads quickly, immunomodulators such as systemic steroids or cyclosporine are used to induce stabilization of the lesion. Let's take a quick look at the new drug that was recently approved in the United States. It is a coating agent with the name of Luxor Tinib. This application is a jack-related inhibitory application related to the immune response, and jack inhibition acts to prevent immune cells from being activated. In clinical trials, more than 50% of patients showed improvement in lesions when this application was used. In addition, many drugs are being studied, including JAK inhibitors that are currently being taken to treat vitiligo. Let's find out about phototherapy, which is as important as the medicine you apply. Phototherapy suppresses excessive immune responses and promotes melanin cell proliferation and migration, allowing the skin color to return. At this time, melanin cells in the hair follicle are transferred to the vitiligo area, resulting in redeposition of the pigment. Therefore, if vitiligo progresses and the hair becomes white, the treatment effect may decrease. In the treatment of vitiligo, narrow-wavelength ultraviolet B treatment is widely used because of its excellent effectiveness and stability. When vitiligo is present, UV rays of a specific wavelength of UVB are irradiated to suppress various immune responses and affect melanin cell activation, showing a therapeutic effect. This wavelength is known to also affect the activation of stem cells. Treatment requires a treatment period of more than 6 months, twice a week. Target light therapy with a wavelength of 308nm is used in areas where lesions are limited or where ultraviolet light is difficult to reach. This light treatment is effective if it is combined with the coating agent mentioned earlier. Many people are worried that skin cancer will increase if they keep getting ultraviolet rays to treat vitiligo. It is said that tanning the skin increases skin cancer. Then, is phototherapy used to treat vitiligo the same? It is said that the treatment called 'PUVA', which was mainly used in the past, can actually increase the likelihood of cancer. Fortunately, however, several papers have revealed that phototherapy currently in use does not increase the risk of skin cancer. This is believed to be because the current treatment only uses specific wavelengths of UVB. Compared to UVA, UVB causes less damage to cells present in the skin, less impact on the production of free oxygen, and less depth of penetration into the skin. Therefore, there is no need to be afraid of the phototherapy used to treat vitiligo. If the lesion is stable for a long period of time and is limited in scope, surgical treatment may be considered. Surgery is a method of inducing pigmentation by collecting tissue from normal skin and transplanting it into vitiligo skin. However, it has also been confirmed that phototherapy is essential for pigmentation re-deposition even after surgery. Tissue transplantation through surgical treatment is largely divided into micro-punch transplantation and aspiration blister epidermal transplantation. First, micro-punch transplantation refers to a procedure in which melanocytes are implanted in the area of vitiligo by obtaining normal skin around vitiligo using micro-punch. It would be good to think of it as 'the same reason as spraying seeds in the field'. Next, aspiration blister epidermal transplantation applies negative pressure to normal skin to artificially create blisters and separate the skin. In the lesion, the skin is cut off using a laser and the unfavorable skin is implanted on top of it. In addition, various studies are currently being conducted, such as collecting normal skin, grinding it, and applying it directly to the vitiligo area, and applying the collected normal skin to the vitiligo area after cultivation. These various treatment methods are determined by looking at the location, size, and shape of vitiligo.

<A habit to watch out for>
◆ Seok-jun: Then let's take a quick look at what vitiligo patients should keep as their lifestyle habits. It is known that vitiligo patients are vulnerable not only to vitiligo but also to melanin cells in normal skin to ultraviolet rays and external stimuli. Therefore, it is very important to block UV rays by evenly applying sunscreen not only to vitiligo but also to normal areas. According to a survey of vitiligo patients, about a third of patients have experienced a Koebner phenomenon in which vitiligo spreads to wounds or stimulated areas. Therefore, you should refrain from the habit of scratching or pushing hard and avoid causing chronic friction or irritation to exposed areas such as face or elbow. Also, some people get tattoos and their surrounding skin becomes white, so it's good to be careful about this.

<Medical AI Q&A>
◆ Seok-jun: Many people have sent me questions related to vitiligo. Let's check it out together.

◇ Y-ON (AI Anchor): I've heard that taking vitamins helps with vitiligo. What vitamins should I take to help?

◆ Seok-jun: There are a lot of people who are actually wondering if vitamins and other nutritional supplements are helpful. There are research reports that vitamin B, vitamin D, and vitamin E are helpful. However, most studies have found that supplementation with nutrients alone does not improve vitiligo. Therefore, it would be helpful to take nutritional supplements in parallel with treatment.

◇ Y-GO (AI Anchor): Is it true that vitiligo occurs a lot in patients with atopy or psoriasis?

◆ Seok-jun: Yes, atopy and psoriasis are also well known as diseases caused by abnormalities in our body's immune system. It has been reported that the rate of atopic or psoriasis in vitiligo patients is higher than that of normal people. Likewise, vitiligo occurs in atopic patients in a large proportion, and vitiligo occurs more in psoriasis patients. The basis is not clear, but I think diseases are related to each other due to abnormalities in various immune pathways involved in T cells.

◇ Y-ON (AI Anchor): I heard that people with vitiligo have a lot of circular hair loss. Is it true?

◆ Seok-J: Yes, that's right. Some people are wondering if circular hair loss is more likely to occur. In fact, many of my patients have two diseases. As mentioned earlier, vitiligo patients are more likely to be accompanied by other autoimmune diseases than normal people. Circular hair loss is also known as an autoimmune disease, and the two diseases are often accompanied because they occur as an immune standard in a similar pathway to vitiligo.

◇ Y-GO (AI Anchor): For women, can vitiligo worsen during pregnancy or childbirth?

◆ Seok-jun: Many people with vitiligo are worried that their disease will get worse if they become pregnant. However, many autoimmune diseases are often stabilized and improved during pregnancy. Similarly, vitiligo has a study result that 'the lesion improves during pregnancy'. However, after childbirth, about a third of the cases have been reported as 'deteriorated lesions', so careful observation is required.

<Let's just remember this>
◆ Seok-jun: I often give up treatment because I think vitiligo is difficult to cure. However, vitiligo can be improved if you trust the medical staff and continue to treat them without giving up. I hope my story today helped you live a healthy and happy life. Thank you.