Vitiligo: Dr. Swanson Explains Everything You Need to Know

Vitiligo is far more common than many people realize, yet it's often misunderstood. In this episode of the Skincredible Podcast, Dr. Lisa Swanson breaks down the science behind vitiligo in a way that's easy to understand. We’ll discuss types of vitiligo, how dermatologists diagnose it and why early evaluation matters.

In this episode, you will learn how vitiligo differs from other causes of light patches on the skin (including pityriasis alba and tinea versicolor) and discover the differences between segmental and non-segmental vitiligo. Dr. Swanson also explains the autoimmune process behind pigment loss, genetic risk, and the connection between vitiligo and other autoimmune conditions.

The conversation also explores the emotional and social impact of living with vitiligo, addressing common misconceptions, cultural stigma, and why vitiligo should never be considered "just cosmetic." Finally, Dr. Swanson shares which factors can influence prognosis and offers reassurance that treatment has advanced dramatically in recent years.

This episode lays the foundation for next week's deep dive into vitiligo treatments—and why there's more reason for hope than ever before!

In this episode, you'll learn:

• What vitiligo is, types of vitiligo and why it develops
• How dermatologists distinguish vitiligo from other light patches on the skin
• The differences between segmental and non-segmental vitiligo
• Genetics, and associated autoimmune conditions
• Why early diagnosis and treatment are important
• The emotional and psychological impact of vitiligo
• What affects prognosis and what today's treatment landscape looks like

Keywords

Vitiligo, Pityriasis alba, Tinea Versicolor, Depigmented Skin, Hypopigmented Skin, Skin, Dermatology, Pigment Loss, Segmental Vitiligo, Non-Segmental Vitiligo, Michael Jackson

The information shared on this podcast is for educational purposes only and is not a substitute for personalized medical advice. Always consult your  physician regarding your health.

Transcript

SPEAKER_00 0:04

Welcome to Skin Credible, where we tell you what you should know about your skin and how to glow. Because your skin's incredible.

SPEAKER_02 0:17

Hello, everybody, and welcome to another amazing episode of the Skin Credible Podcast. I'm one of your hosts, Dr. Lisa Swanson, and I'm here with Anna. Hello. Whoa! And we are going to talk about vitiligo today. And I thought it would be nice to segue from alopiciariata to vitiligo because they're actually pretty similar processes. Interesting. Both are autoimmune. Both are examples of the immune system making a mistake and going after the wrong thing. But in allopiciata, it's going after your hair follicles. In vitiligo, it's going after your melanocytes, which are the pigment-making cells. Gotcha. But they really are very similar, and there's even a lot of overlap in their treatments. So I felt like it would be a nice, easy transition to go from allopiciariata conversations to vitiligo conversations. Very natural. Yes. Now, to set the stage, I thought it would be helpful. I'm not a huge stats person, especially on the podcast, but I thought it'd be helpful to share a couple of stats. Yeah. So the prevalence of vitiligo in the US, it varies depending on where you are in the world, but in the US, it's 1%. So 1% of people in the US and in Europe have vitiligo.

SPEAKER_01 1:27

That's not too high. Maybe some people don't notice they have it.

SPEAKER_02 1:32

Or they don't see the doctor for it. Okay. Yeah, sure. Right. So like maybe if you had a spot of vitiligo and it was in your undie area, you might not be bothered enough by it to go seek help from a from a dermatologist. So the incidence, to your point, is probably a bit higher than that. There are probably just people out there that are like, I don't care. Sure. You know, it it's hidden from the world and it doesn't bother me, sort of situation. But as I said, the prevalence varies, and the highest prevalence is in India, where almost 9% of people have vitiligo. That's significantly higher. It's significantly higher. Now, part of that I think is due to increased recognition like social stigma, maybe. Exactly. Exactly. So I think if you are living in India and you develop a patch of vitiligo, even one patch, you're gonna go seek help. Yeah. Whereas, especially in if you're a light-skinned American like myself, Fitzpatrick, half, it's usually one to six. My Fitzpatrick number is half. A vitiligo patch might not show up as well on me. And so again, I might not seek help for that. Sure. But in India, not only do they have more richly melanated skin, and so the difference shows more, it also has a big impact on their social life, their ability to marry, the um level of esteem that the people. Exactly. Okay. Exactly. So interesting. Yes, yes. And so probably anybody with a speck of vitiligo in India is seeking help. But I think part of it is it truly is more prevalent there. Yeah. Yeah. Um, so I think that kind of sets the stage. And 1% in US and Europe doesn't seem like a lot, but any airplane you're on probably has at least 100 people on it. So one person on every airplane you fly on has vitiligo.

SPEAKER_01 3:25

That's a different way to think about it. That does seem like a lot more, right? And when you just say 1%.

SPEAKER_02 3:30

Yeah. Yeah. Cause then you're like, oh my gosh, okay. So it is, it is really out there. Yeah. Yeah. Spontaneous repigmentation, meaning you have vitiligo and you don't treat it, but it just repigments on its own. Yeah. It can happen, but it's not very common. Just about 10% of the time does that happen? Like the body just recognizes it. Yes. Body is just like, I may, I'm, I'm overreacting here. I need to just like settle down, simmer down. Um, so 10% of the time you can have spontaneous repigmentation. Okay. Vitiligo commonly happens in young people. Half of people with vitiligo will develop their vitiligo by the age of 20.

SPEAKER_01 4:09

That's so interesting. Is it because our immune systems are making the mistake faster? Ours like I'm young.

SPEAKER_02 4:15

Right, right. Yeah. Include myself. Yes, girl. Yes, yes. You're as young as 20. Yes. Of course you are, Yana. Yes, yes. I I don't know if we fully understand.

SPEAKER_00 4:24

Okay.

SPEAKER_02 4:24

Part of vitiligo and being vulnerable to vitiligo is something that's genetic and passed down in families. So I think that could explain an earlier onset. Interesting. But not only do half of the patients have it before the age of 20, 70 to 80% have onset before the age of 30.

SPEAKER_01 4:45

Wow.

SPEAKER_02 4:46

Yes. So this is really a condition that's happening early on in a person's life, which we're going to talk about stigma and the effect on people's self-esteem and confidence. And this is popping up at pretty crucial times in a person's life.

SPEAKER_01 5:05

Yeah, they're probably dating. Exactly.

SPEAKER_02 5:07

Yes. Or they're they're a kiddo and they're developing their sense of self. You know, I think when you're young, when you're a kid, you just kind of want to be the same as everyone. You don't really want to stand out. Exactly. It's only as you get older that you're like, actually, differences are cool. But when you're young, you just want to be like everyone else. And so to have this thing that sets you apart can be really difficult. So that kind of sets the stage in terms of like how many people are dealing with this, when does it happen? And where is it most prevalent? The other point that I wanted to start with is that not every light patch of skin is vitiligo.

SPEAKER_01 5:49

Okay. Yeah.

SPEAKER_02 5:50

I have a lot of families that come in to see me for spots of lighter skin, and they're thinking, oh my gosh, this is vitiligo. Let me see if I remember one correctly. Piterisis alba? Yes. Okay. Piteris alba presents as these hypopigmented circular patches, classically on the cheeks and a kiddo, sometimes on the forehead, sometimes on the arms and legs, but classically on the cheeks and a kiddo. And pterice alba is a marker of sensitive skin. Often people with it have eczema too.

SPEAKER_01 6:20

They can kind of go in line with each other. Well, and in our eczema episode, you even mentioned that that can happen to people who had eczema underpigment.

SPEAKER_02 6:29

Yes. Yes. And one of the key differences that I'm looking for as a dermatologist in the office, when I'm evaluating a lighter patch of skin, I'm trying to determine is it hypo pigmented or is it depigmented? There's a difference. Huge difference. So depigmented means there is no pigment in the skin.

SPEAKER_01 6:54

And how do you know?

SPEAKER_02 6:55

I mean, you're a dermatologist, so you know all the things, but there are, you know, once you've looked at it enough, you can often tease that out. Depigmented is like completely white, absence of pigment. Hypopigmented just means it's a little lighter than the surrounding skin. And depigmented skin, it tends to be more well demarcated as well. Like it would be easier to take a marker and kind of circle around it. Whereas with hypopigmentation, you're like, okay, where does it start and where does it end? And it's a little bit like fuzzier. Okay. The other way you can tell the difference in the office as a dermatologist is grabbing your wood slamp.

SPEAKER_01 7:33

So remember those, they're kind of cool.

SPEAKER_02 7:36

Yes. So wood slamp, it's like a black light almost.

SPEAKER_01 7:40

It's like you're going to those laser tag places.

SPEAKER_02 7:42

Yes, yes. Or like a club. Yeah. You know, and they I remember there was once upon a time I went to a club like once or twice. Yeah, once or twice in my life. Um, but they use the light to kind of show the stamp on your on your hand. I mean, I've heard, I've heard that that's and uh, and so a woods lamp will accentuate depigmentation. Gotcha. It really lights it up. It wouldn't light up hypopigmentation. No, gotcha. So that's a key difference because there are very few other things that depigment. There are a lot of other things that hypopigment. So like petiasis alba being one, tineaversicolor is another. Oh, yeah. So tineaversicolor commonly causes these circular, very slightly scaly patches that can be hypopigmented. They can also be hyperpigmented, and they can be pink. And they're most classic on the chest and back in like a teenager or a 20-something. Gotcha. In kids, they can occur on the face, but usually like the lateral cheeks, whereas Peterizos alba likes to be on the central cheek.

SPEAKER_01 8:45

So interesting.

SPEAKER_02 8:46

And tineoverse colors due to a species of yeast called malacesia furfer.

SPEAKER_01 8:52

Ooh, we talked about that one. Have I?

SPEAKER_02 8:54

Did it come up?

SPEAKER_01 8:55

Not that one. Malacesia by itself. Is that different?

SPEAKER_02 8:58

Well, so there are different species of malacesia, but I did bring up your right, we did talk about malacesia furfer and malacesia in general in Bear's episode of eczema. Yeah. Because sometimes Dr. Cyrus taught me that sometimes malaseia can exacerbate atopic dermatitis. So you have a patient who has eczema, they definitely have eczema, but the presence of the malasseia, the immune system kind of overreacts to it, creates more eczema.

SPEAKER_00 9:25

Gotcha.

SPEAKER_02 9:25

Um, so we have discussed malasseia in the past. Slightly different context because in tineaversicolor, we all have malasseia furfur on our skin, but in patients with tinea versicolor, it becomes like there's more of it, it's overgrown, the balance is lost in the skin, and there's too much malaceia furfur. Okay. And so it causes the rash, most commonly in the summer when it's hot. Then there are also birthmarks that are hypopigmented. So there's something called a Nevis depigmentosis, which, in spite of its name, is not depigmented. It is hypopigmented. But it's called Nevis depigmented. Right? Yeah. And then there are spots called ashleaf macules, which are birthmarks that are lighter than the surrounding skin that can be a feature in genetic conditions like tuberclerosis. So if you've noticed a light patch in your child or in yourself, the first question that I will be looking for is is it hypopigmented or depigmented? Because there are lots of things that can be hypopigmented and it's good to get it checked and find out what it is. But there's really only one that produces depigmentation, and that's vitiligo. Good to know. So don't panic if you've noticed a light spot. And when patients come in to see me, even if they don't bring it up, if they come to see me, I can tell it's pitiasis alba. One of the first things I'll say is this is not vitiligo. Because whether they say it or not, a lot of parents have that on their mind. Yes. They've Googled it. Sure. And you know, you Google like light spots on the skin and vitiligo. I've never Googled it before, but it's probably in the top five things that pop up.

SPEAKER_01 11:06

Yeah.

SPEAKER_02 11:06

Okay. The clinical appearance of vitiligo. We've touched on this a little bit already. Well demarcated, depigmented patches, often symmetrical. So there's two types of vitiligo. There is segmental and non-segmental. Oh, I've never heard this before. Right? So, and it matters because a couple of the medicines that we have to treat vitiligo are approved to treat non-segmental vitiligo. So the difference does matter a little bit. Is it more common? So non-segmental is more common. 85 to 90% of patients have non-segmental vitiligo. Gotcha. About 10% of patients have segmental vitiligo. Segmental comes on just in one segment of the body. Okay. And it kind of comes on fast, developing into itself over a period of about a year or two. Okay. And then staying stable. Segmental vitiligo is less common, which is a good thing because it's harder to treat. Okay. And really your best, we're going to talk about treatment in our next episode. But your best approach with segmental vitiligo is you want to jump on that early.

SPEAKER_01 12:16

Yeah.

SPEAKER_02 12:16

Early, early, early. Otherwise, that ship has sailed and that area is going to be depigmented. Shoot. Yes. And so if you've noticed a patch of depigmented or hypopigmented skin, come see your dermatologist so that we can diagnose it properly and then provide proper treatment. Because the earlier you treat, the better things are.

SPEAKER_01 12:34

Seems like I'm hearing this with a few things.

SPEAKER_02 12:36

I know. I mean, I think that's true of like, I mean, almost everything, right? Like the earlier you catch it, the more you can impact it.

SPEAKER_01 12:43

My personal trainer was saying, like, if there's a check engine light on your car, you go get it checked out right away. But with our bodies, if we like have a shoulder that hurts or something, we don't often take care of those things right away until they get so bad we can't do life. Right. And I was like, that's an interesting analogy. I never thought about that. But I definitely will like just let things go until I'm like, okay, I can't live with this anymore. Then I go to the doctor. Yeah, yeah.

SPEAKER_02 13:05

Well, and I think part of the reason for that, there are some things that we go through as human beings that do get better. Of course, that's true.

SPEAKER_01 13:12

Yeah. So you can't just go to the doctor every single time you have a little bit of my knee this morning.

SPEAKER_02 13:17

Help me. And so, you know, I think, you know, that that I think makes it reasonable for us as humans to be like, let me just give this a week or two and see what happens. Sure. My dad is a doctor. And uh growing up, he never took us to the doctor. That's so interesting. And he, no matter what complaint we came to him with, his solution was ice, elevate, and take two aspirin.

SPEAKER_01 13:42

Literally for everything. Literally.

SPEAKER_02 13:43

It's like You're bleeding out.

SPEAKER_01 13:45

Take more aspirin. That'll help.

SPEAKER_02 13:46

It's like, dad, I have a headache. Ice elevate, take two aspirin. Dad, my arm sore. Ice elevate, take two aspirin. Dad, my thumb fell off. Ice elevate, take two aspirin.

SPEAKER_01 13:54

Elevate your head when your head hurts. That's an interesting concept. Yeah.

SPEAKER_02 13:57

Yeah. Yeah. Stay above. Elevate. Yeah. And so, yeah. So I think it's appropriate in some cases to like not press the panic button over our ailments. But if you've noticed something, if it's persistent, you've given it a couple three weeks, it's still there. You know, it never hurts to come in and get it checked out. Yeah. So segmental vitiligo is kind of like, I always tell families, good news, bad news. Good news is it stays in that segment. Okay. It will not appear anywhere else. Okay. And there is a sense of peace of mind for that, especially if the segment it's in is in an area that you can hide and disguise. And so if you're like, okay, I've got a patch of vitiligo on my tummy and I know it's going to stay only on my tummy, like, okay, I could probably live with that and be okay. Yeah. Yeah. Yeah. Non-segmental vitiligo, very unpredictable. So segmental vitiligo, very predictable. We know it's going to come on, it's going to stay in that segment. It's going to eventually reach its plateau. It's going to stay the same forever. Um, non-segmental vitiligo, unpredictable. It pops up in certain places. It might only be in those places for the rest of a person's life. Or down the road, it could pop up somewhere else. You could get a bunch of new spots for a little while, and then it stays the same for 20 years, and then you get a couple new spots. So very unpredictable, which can, I think, wreak havoc on a lot of people's psyche.

SPEAKER_01 15:17

Yeah. Because you're like, when is the next one going to pop up? Is it going to be on my face?

SPEAKER_02 15:21

I know. I know. Yeah. Predictable is good. Unpredictable is not good. And a lot of patients come to see me and say, like, how can I prevent it from spreading? And to date, we really don't have treatments that prevent spread. We have treatments to help us repigment.

SPEAKER_00 15:37

Yeah.

SPEAKER_02 15:38

But we don't really have a treatment that's like, okay, now it will stay exactly where it is and it's not going to spread anymore. We haven't gotten that far. Hopefully one day. Hopefully one day. Yeah. Yeah. How do you know that the vitiligo is active? So like vitiligo can come on and then can kind of just plateau and stay the same. But there are also some clinical clues that tell you, okay, this is actually in a rapidly spreading moment. And we do think about that a little bit differently. In our treatment episode, we're going to talk about what we use to stop the spread in those rapidly spreading times. And there are three clinical clues that you're in rapidly spreading vitiligo. Number one, what we call confetti-like depigmentation. Sounds kind of fun. I know, right? The party. Confetti-like. But it's like little pieces of confetti that are depigmented. Okay. Okay. Number two, what we call tri-chrome lesions. So in your area affected by your vitiligo, you have your normal skin, you have your depigmented vitiligo skin, you have hypopigmented skin as well. All of them. So trichrome, that's a sign that like it's actively evolving and depigmenting.

SPEAKER_00 16:50

Okay.

SPEAKER_02 16:50

Number three, vitiligo demonstrates something called the Kevner phenomenon. And I forget if we've ever talked about the Kevner phenomenon on the podcast. There are a few rashes and skin things that demonstrate the Kevner phenomenon. What that means is that in an area where your skin has been traumatized, the condition likes to appear. Vitiligo is one of those. So classic example would be a kiddo falls, skins their knee, it heals, and now there's a vitiligo spot there. Other conditions that demonstrate kebnerization, psoriasis and like in planis are two other biggies. And we'll get to some episodes on psoriasis in the future because there's so much to talk about with psoriasis. And again, getting to a dermatologist, because we can use some things to make it stop. Pathophysiology is a term we use to describe like, what's going on under the hood? Yeah. Like, why, why is this happening? What's going on that's making the pigment go away? So vitiligo is an autoimmune condition, meaning that your body makes a mistake, goes after the pigment-making cells. Your pigment-making cells are called melanocytes. There's a lot of inflammation involved in this process. And there are a few key drivers of it. There are cytokines like IL-2 and IL-15, and there's something called interferon gamma. And while there are even more, you know, kind of keeping it high level, those we think are like the big deal players in this. Gotcha. We also know that a couple particular types of cells are playing a big role.

SPEAKER_01 18:38

Okay.

SPEAKER_02 18:38

What we call cytotoxic T cells, CD8 positive cytotoxic T cells. So it's got toxic in the name, right? So everybody, okay, those are probably bad. Those are the ones that are actually attacking your melanocytes. Okay.

SPEAKER_01 18:51

The other kind of appropriately named.

SPEAKER_02 18:53

Right. Yes. Because they're toxic. Yeah. The other kind of cell that we are increasingly paying attention to is the memory T cell. So our T cells can remember what they think their mission is. Wow. And so if we suppress them for a little while with treatment and then we discontinue treatment, they still remember. Oh, shoot. And will do it and will like continue on their mission. You know? That's their job. Remember. Yeah. Yeah. It's kind of like if you uh what's the little spinny vacuum roomba? Oh, rumbus. Yeah. It's like, you know, the room bus doing its thing, doing its thing, doing its thing. And then if you stand in its way and it's just like rotating in motion, just like in one stable position. Yeah. And then you take your foot away, it will, it will continue on its mission. Yes. And so there's a lot of talk in dermatology about how can we really get at these memory T cells to tell them like, no, this was a mistake. You need to just like not remember this and not do this again. Yeah. And in the treatment episode, we'll talk about some tricks we have to try to prevent recurrence because we've gotten to a point where we can we're pretty good at repigmenting the skin. Which was not the case like years ago. 100%. Even that's really cool.

SPEAKER_01 20:15

More than five, six years ago, it was not the case. When I was working in dermatology, it was really hard for people to be treated.

SPEAKER_02 20:21

Yes. Yes. And so things are different now. And so now we've kind of worked into our second kind of phase. Okay, now we've gotten pretty good at repigmenting. How can we keep the pigment there? Yeah. And memory T cells are playing a crucial role in that. So a lot of people are talking about okay, how can we, how can we help? How can we make the memory T cells not remember? You know? Let me see here if there's anything else science-y that's important. Those are really the biggest players. The next thing I want to talk about is triggers. What could bring vitiligo out? A lot of time it's nothing. A lot of times it's nothing you did. It's just one of those things that one day the immune system starts to attack those melanocytes. And so you get these white spots. I know. Yeah. But family history, as I mentioned before, plays a big role. So 25 to 50% of patients with vitiligo will have family history of vitiligo. And some of those patients will have family history of people in the family who've had other autoimmune conditions. So when you have one autoimmune condition, you're more likely to have another. And people related to you are more likely to have autoimmune conditions. It might be the same autoimmune condition as you, or it might be something different.

SPEAKER_01 21:33

Okay.

SPEAKER_02 21:33

The most common association with vitiligo is autoimmune thyroid disease, which is in general super common. And so sometimes a patient with vitiligo will have an aunt who has hypothyroidism to that.

SPEAKER_01 21:48

That's interesting. But but is it like connected to anything metabolic? Doesn't your thyroid have something to do with your metabolism?

SPEAKER_02 21:55

It does, but the autoimmune kind of attack on your thyroid. Is unrelated. Genes are family genes. They they do play a big role in determining kind of what we are most vulnerable to. If I'm seeing a child with vitiligo, a lot of times parents will wonder, okay, what's the chance that their sibling will get vitiligo? Six percent. If the overall prevalence in the US and Europe is 1%, you know, so if you if you kind of play the math numbers, that's a six times increased risk. But it's just six percent chance that the sibling will have it too. Yeah. So that's something I'll commonly tell families in the office. Other things that can kind of trigger it, stress, illness. So like a lot of times people will notice vitiligo after they've been sick with like the flu or COVID. Um, they'll notice it come on. Anything that kind of activates your immune system to fight one thing, could inadvertently activate your immune system to create this autoimmune condition. Oxidative stress, whether that be from poor air quality or uh depending on if you're working in an environment where maybe you're working with chemicals and those chemicals can cause oxidative stress on your skin. Um, we sometimes see that. And there are a few medicines that can trigger vitiligo. Now, a lot of these medicines are being used to treat melanoma. And so interesting. The medicines are trying to actually get your immune system to attack these bad melanocytes, right? In the melanoma. But then sometimes the immune system will say, Oh, we're gonna attack more of, you know, we're gonna attack these over here and these over here. And so actually, when you get vitiligo when you're on these medicines, it's actually a positive sign that the treatment is is gonna work really well. Yeah. So we kind of like that when that happens. So most of the time, it's nothing a person has done to bring it on. But those are the some of the things that can kind of set it off. Some people ask, because thyroid is the most common associated autoimmune condition, do we need to be doing labs in our patients with vitiligo? In my opinion, no, unless the child has symptoms and is going through something. So if I see an otherwise healthy kiddo who happens to have some patches of vitiligo, I'm not mandatorily gonna, you know, subject them to a blood test. If they are hot all the time or cold all the time, if they are gaining weight or losing weight, if they are having diarrhea all the time or constipation all the time, if they're having any of these things, then it's like, okay, let's go ahead and check. Sure. And sometimes I will also check if like a parent has hypothyroidism. Sure. You know, if it's like a primary family member, I'll be like, okay, probably worth it, you know, a check. Yeah. But in general, I'm not putting all kids through labs. You're just kind of screening them. Yes, screening, taking what we call the review of systems, like how's your general health? Are there any other health issues that you're dealing with? And there are, that's my viewpoint on it in terms of doing labs or not doing labs. There are other very great and excellent dermatologists that have a different perspective on it. And that's totally cool and totally okay. Whatever people want to do to take best care of their patients, that's totally cool. But just wanted to share my viewpoint on it. Yeah. And one of the biggest ways that kind of shaped my viewpoint on it is there was an article that said that you would have to screen a thousand otherwise healthy kids with vitiligo to find one with autoimmune thyroid disease. And so to me, it's not necessarily worth it to put those thousand kids through the blood draw, especially if they're young and all that kind of stuff. Yeah. Yeah.

SPEAKER_01 25:35

They don't, they don't love it.

SPEAKER_02 25:36

Right.

SPEAKER_01 25:36

Anyways. Right.

SPEAKER_02 25:38

Yes, yes. Now we're going to talk in our treatment episode about some oral jack inhibitors coming for the treatment of vitiligo. And in the patients that I've already started on those medicines, when we do blood work for those medicines, because we have to do blood work for the jacks, oftentimes I'll throw like a TSH on there, which is a thyroid stimulating hormone, or what we call a TPO antibody, thyroid peroxidase antibody. If I'm drawing blood anyway, sure, you know, sometimes I will add it on there, but I'm I'm hesitant to do a blood draw solely for the purpose of screening for thyroid disease in an otherwise healthy and asymptomatic kid who just happens to have vitiligo.

SPEAKER_01 26:14

That's fair.

SPEAKER_02 26:16

One important thing that I think needs to be said as often as possible is that vitiligo is not a cosmetic condition. It is not a cosmetic condition. It is an autoimmune condition associated with other autoimmune conditions.

SPEAKER_00 26:34

Yeah.

SPEAKER_02 26:34

And it has serious ramifications for a person and their family. We talked a little bit before about the stigma, depending on where your vitiligo is, and the noticeability of it, and based on your baseline pigment. Sure. You know, as I mentioned before, if I got a patch of vitiligo, it probably wouldn't show that much.

SPEAKER_01 26:56

Sure.

SPEAKER_02 26:57

Because I'm so fair.

SPEAKER_01 26:58

However, if I got a patch of vitiligo, I probably want you to do something about it. Yes. I know a gal. Yes, right.

SPEAKER_02 27:05

Yes. And so, you know, all of those things play into how much of a burden it is for a patient. But it's important to make it very, very clear: vitiligo is not cosmetic and the treatment of it is not cosmetic. We talked a little bit before about the particular issues that are true for patients of Indian descent. Yeah. Um, and and that's a big deal. A lot of the patients that I see in clinic with vitiligo are Indian patients. Interesting. Um, I think it's because there is such an increased awareness of it. And if a parent notices a spot, like they're bringing them in ASAP because they're concerned. Yeah. Um it can in some cultures be mistaken for something contagious.

SPEAKER_01 27:51

Yes, I read about that.

SPEAKER_02 27:52

Yes. Like leprosy. I know. When leprosy can present with hypopigmented patches, it can even be mistaken for like a sexually transmitted infection in some cultures, which of course it is not.

SPEAKER_01 28:06

Yeah.

SPEAKER_02 28:08

There are some cultures where I wrote this down because I didn't want to forgive the wording. It can affect expectations for the destiny of the soul after death.

SPEAKER_01 28:17

That was one of the things that I read about. It was like, you know, like the person is cursed or there's some like negative connotation spiritually. Yes. And that's sad.

SPEAKER_02 28:27

Yes. And so you can de you can you can see and potentially feel how devastating it could be to be a person that's like, oh my gosh, not only is this affecting my life, but it could affect my afterlife. And it could affect, you know, who I get to marry and my prospects and everything. Huge psychological burden that's similar and equivalent to eczema, which we know very impactful, as we've covered extensively on the pod.

SPEAKER_00 28:52

Yeah.

SPEAKER_02 28:52

Psoriasis and acne. So equally impactful to these things, it affects your self-esteem and your confidence.

SPEAKER_00 28:59

Yeah.

SPEAKER_02 29:00

Especially if you're a young person dealing with this. Remember that half of the patients have onset before age 20. And then the risk of depression is higher in patients that were diagnosed prior to the age of 30, which is 70 to 80% of vitiligo patients have onset before the age of 30.

SPEAKER_00 29:14

Wow.

SPEAKER_02 29:14

So having the condition escalates your risk that you're going to suffer from depression. Which is probably multifactorial. Sure. But certainly the vitiligo is not helping, right?

unknown 29:26

Yeah.

SPEAKER_02 29:26

Um, prognostic indicators, because some patients will have vitiligo and it's just in one spot and it stays in one spot and it's not a big deal. And maybe it's even in a location that's easy to treat, as we'll talk about in treatment episodes. So what is what are signs that like you have a good prognosis with your fitiligo versus like, oh, this might be a tougher road to run, you know? So poor prognostic indicators. If you have mucosal involvement, so sometimes fidiligo occurs on the lip and can even extend inside the mouth. Um, it can also involve the undie area and extend inside areas in that neck of the woods. So mucosal involvement has a poorer prognosis in terms of success with treatment. Family history implies a poorer prognosis. But I think that's even variable because like if I hear from a kiddo and their parent that like Aunt Susie has vitiligo, but it's just on her elbows, it's always just been on her elbow. She's never needed any treatment for it, you know, then I don't necessarily put things in the poor prognosis category. Gotcha. Whereas if I hear, oh yeah, Uncle Joe has vitiligo, it covers, you know, 70% of his body. He's never had treatment and he works from home and doesn't really interact socially, then I'm I'm much more thinking, like, okay, this is gonna be a bigger struggle for us. If it affects the distal extremity, so uh when we're speaking medical talk, proximal means closer to the body, closer to the center of the body, distal means further. So your distal extremity is like your hands and your fingers, whereas proximal extremities would be like your shoulder, that sort of thing. More favorable prognostic indicators, being younger, that's actually favorable, a recent onset, so going towards early treatment is better. Yeah. Darker skin types actually have a more favorable prognosis, which makes sense because they're much there's much more melanin to make the pigment. Exactly, exactly. And so we can actually kind of bring that pigment back much more easily. Involvement of the face, neck, and trunk are actually good prognostic indicators. Oh yeah. Especially now with treatments. As we'll talk with treatment, like I love it. I used to dread when I saw a patient with facial vitiligo, and now I'm like, yes, because we know that all of our treatments work the best on the face. All of our treatments work better when there's a little bit of sun exposure involved. Sure. And so now when I see people with facial vitiligo, I was like, we got this, we got this. Yeah. Yeah. And so those I think were kind of like the big take homes that I wanted to make sure we covered for everybody in the audience.

SPEAKER_01 32:09

Tell me what you've read online. You honestly covered most of them. I read that people are afraid that it's contagious. There's like a religious or spiritual stigma of like what that means about the person, maybe. And then people that just assume that it's gonna take over. Right. There's people who talk a lot about Michael Jackson when they talk about vitiligo. I don't know if that's like real or not.

SPEAKER_02 32:32

So we'll talk about that in the treatment episode. Michael Jackson had, I wasn't, of course, his doctor, but but from what I understand, he had vitiligo and he chose a very unique treatment, which is depigmentation, permanent depigmentation, so that all of your skin is the same color. Yeah. It is a slightly odd color when you depigment. Gotcha. Not like natural, the same thing. Not like natural, right. And so that's where Michael Jackson's kind of complexion kind of came from. So he chose a very unique path to treat his vitiligo. Sure. The vitiligo itself did not do that, you know? So he had vitiligo, but he chose a treatment that created that kind of unique color.

SPEAKER_01 33:20

But a pigment is protective to some extent, no? Oh, very much so. Yeah, yeah. So like if you depigment, you could argue almost that you're increasing your risk maybe of melanoma or something.

SPEAKER_02 33:29

Yes. Yes. And we'll talk about how depigmentation is permanent.

SPEAKER_01 33:34

Like you can never go back.

SPEAKER_02 33:36

It's irreversible.

SPEAKER_01 33:37

Yeah, like botanic or it's gone. Yeah. Okay. Interesting. Yeah. Um, yeah, that and then uh people were talking about like thyroid association, like thyroid causes the vitiligo, as opposed to like what you were saying.

SPEAKER_02 33:53

That's an important differentiator. So if you have vitiligo, you're more likely to have thyroid disease. That is true. Okay. But the thyroid disease is not causing the vitiligo. So even if you treat your thyroid disease, that's not going to fix the vitiligo. So they're associated conditions, meaning if you have one, you're more likely to have the other the other, but they are not a cause and effect relationship. Is there anything that puts your immune system into like overdrive that in addition to what we already discussed that would maybe kick you into vitiligo or some sort of basically some of the things that that I touched on in terms of like, you know, viral illness, recent viral illness, some medications that are working to kind of rev up your immune system, particularly towards the melanocytes, oxidative stress or exposure to chemicals that might kind of activate these things in your body. But overall, for the overwhelming majority of patients with vitiligo, they are not doing anything to cause it. They did not do anything to bring it on. It was a vulnerability that got passed down in their family and something kind of tipped it off. Yeah. Yeah.

SPEAKER_01 34:54

So if we don't know where it comes from, there's probably no like prevention or like way to try to get ahead of it if your family member has it.

SPEAKER_02 35:01

No. But I think, you know, earlier treatment is better. It yields better outcomes. And while we don't have anything that protects you against new spots, at least we can help with the spots you do have, which I mean that's really great. Yeah. Yeah. That is great. Much better than it used to be, much to your point. Yeah. Yeah. Anything else? I always want to know what's on the internet, but I'm afraid to look myself.

SPEAKER_01 35:21

Those are the big ones. I don't think you need to be venturing out. You have plenty of problems already. I know. Right?

SPEAKER_02 35:26

I know.

SPEAKER_01 35:27

Yeah. I try to protect your brain when I can because there's a lot out there that you just don't need cluttering in there, you know?

SPEAKER_02 35:33

Right. Yes. Yes. Yeah. And and so many of these conditions, you know. I mean, that's why we started the podcast. So many of these conditions are so poorly misrepresented. Yeah.

SPEAKER_01 35:44

That was another thing. Like movies, like evil people have like depigmentation or like kind of like the alopecia thing that you guys were discussing.

SPEAKER_02 35:52

Very much so.

SPEAKER_01 35:53

Our other episode. It's kind of sad that there is a lot of social stigma.

SPEAKER_02 35:56

It's true. It's true. Like the evil characters are more likely to have alopecia, have um acne scars, if you think about it, um, which we'll talk about when we start talking about acne and stuff, and then vitiligo or some other skin condition. Yeah. Yeah. Yeah. It's true. I know.

SPEAKER_01 36:14

Like they're not dealing with enough already. These people who just didn't choose this life.

SPEAKER_02 36:18

Yes, yes. But we can turn that right around. You can. It's so exciting. Turn their skin condition into their superpower. That's right. Yeah. I love it. Well, thank you guys so much for joining us for this conversation on vitiligo. Stay tuned for the next episode, which will get into treatments of vitiligo, which, again, as Anna, as I have mentioned, whole new world in the treatment of vitiligo. We can truly bring pigment back. So keep watching, keep liking, keep subscribing because there's more fun to come as we dive in deeper to vitiligo. Thanks so much, you guys. Thank you.