Vitiligo in Latin America

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Providing timely vitiligo treatment in Latin America (LA) requires regionwide efforts to educate physicians and the public, collect and deploy necessary data, and streamline access to therapies, according to a review published in the Journal of Dermatological Treatment.

Due to cultural and ethnic differences and the vagaries of each country’s healthcare system, wrote Londoño-García et al., LA presents a patchwork of challenges and opportunities in vitiligo management. As a result, authors said, the journey of a typical patient with vitiligo is winding and rife with barriers that create delays in diagnosis and treatment that may alter prognosis.¹

To begin addressing the above issues, study sponsor Americas Health Foundation (AHF) assembled a panel of 6 vitiligo experts from Argentina, Brazil, Colombia, and Mexico. These experts conducted a literature review and surveyed 292 Latin American dermatologists to formulate the following call to action.

1. Raise regional awareness

Vitiligo represents an underrecognized burden for patients, healthcare systems, and Latin American society, authors wrote. Beyond cosmetic concerns, vitiligo brings severe emotional and psychological effects that greatly impair quality of life (QOL) and often go unappreciated. In Mexico, prevalence of anxiety and depression among people with vitiligo is 60% and 34%, respectively.² Meanwhile, ignorance about vitiligo’s causes and non-transmissibility promotes stigma and discrimination.³ The high-impact, chronic nature of vitiligo demands dermatological management, authors said, and vitiligo’s psychosocial consequences and comorbidities require multidisciplinary care. Awareness campaigns could incorporate videos, disease days, celebrity spokespeople, and social media.

2. Increase physician training, promote use of clinimetric tools

“Lack of training on vitiligo diagnosis and management at both the primary and specialized levels frequently contribute to delays in diagnosis and treatment initiation,” authors wrote. According to 2/3 of dermatologists surveyed, primary care physicians lack sufficient training to diagnose vitiligo, although most can accurately identify referral situations. As for dermatologists, the proportions who reported always using instruments such as the Dermatology Life Quality Index and the Vitiligo Area Scoring Index in clinical practice were less than 5% for each type of instrument. Conversely, the proportions of respondents who rarely or never use QOL and severity metrics were 76.46% and 85.11%, respectively.

3. Address maldistribution of resources and specialists

As in other locations, Latin American dermatologists concentrate in major cities, leaving outlying areas underserved. On a national level, only Argentina (8.0) and Brazil (4.6) have at least 4 dermatologists per 100,000 inhabitants (the estimated number needed to serve a population).^4,5 A dearth of training opportunities and public-sector jobs drives many dermatologists toward cosmetic practice and/or leaving the region, authors added. Accordingly, 2/3 of dermatologists polled said it took 3 to 12 months for referred patients to see them.

4. Increase access to vitiligo treatments

Although timely treatment can help preserve melanocyte reservoirs, a single-center cohort study showed that among patients who experienced a mean 4.46-month treatment delay, 40.7% experienced disease progression, and 32.1% experienced recurrence.⁶ The corresponding figures for patients who got quicker treatment were both around 12%. “Access to vitiligo topical and systemic therapy varies across LA and is frequently limited,” the authors wrote. In Brazil and Colombia, topical calcineurin inhibitors are unavailable through public healthcare.⁷ Topical and systemic corticosteroids are “theoretically accessible” through public healthcare in Brazil, Colombia, and Mexico, authors said, although these medications are not always available for dispensing. Not surprisingly, 83% of dermatologists surveyed were unsatisfied with vitiligo treatments available through public healthcare. Affordability is also problematic, as regionally, out-of-pocket spending for vitiligo therapies ranges up to 50%.⁸

5. Develop national or regional practice guidelines

“Standardized vitiligo diagnosis and treatment recommendations are essential in improving patient outcomes,” according to Londoño-García et al. But a lack of national or regional clinical practice guidelines in LA means that most treatment decisions rest on physician experience, resulting in unstandardized care that also varies by country, city, or facility.

6. Create vitiligo patient organizations

Review authors found no official patient organizations or advocacy groups for vitiligo in LA. Patients and caregivers would benefit from having groups that provide education and support, like those that serve patients with other skin diseases such as psoriasis and atopic dermatitis.

7. Generate local data

Authors found insufficient data, particularly at the regional level, regarding vitiligo epidemiology, disease course, outcomes, disease burden, and QOL effects. “Increasing local data on vitiligo will benefit the patient and provide crucial insights into regional disease behavior.”

Study limitations

Scarcity of previous Latin American research on vitiligo limited the search and supporting data. Additionally, to counter the fact that not every Latin-American nation was represented on the expert panel, authors included as many dermatologists as possible in their survey.

Accordingly, authors said, other middle- and low-income regions might benefit from the above recommendations as well. For such efforts to succeed, they added, governments, medical societies, academicians, patient organizations, the pharmaceutical industry, and the public must collaborate to coordinate efforts and find solutions.

References

1. Londoño-García A, Arango Salgado A, Orozco-Covarrubias ML, et al. The landscape of vitiligo in Latin America: a call to action. J Dermatolog Treat. 2023;34(1):2164171. doi:10.1080/09546634.2022.2164171

2. Morales-Sánchez MA, Vargas-Salinas M, Peralta-Pedrero ML, Olguín-García MG, Jurado-Santa Cruz F. Impact of vitiligo on quality of life. Impacto del vitíligoen la calidad de vida. Actas Dermosifiliogr. 2017;108(7):637-642. doi:10.1016/j.ad.2017.03.007

3. Bergqvist C, Ezzedine K. Vitiligo: a review. Dermatology. 2020;236(6):571-592. doi:10.1159/000506103

4. Borzutzky A, Larco JI, Luna PC, et al. Atopic dermatitis in Latin America: a roadmap to address data collection, knowledge gaps, and challenges. Dermatitis. 2022;33(6S): S83-S91. doi:10.1097/DER.0000000000000904

5. Glazer AM, Farberg AS, Winkelmann RR, Rigel DS. Analysis of trends in geographic distribution and density of US dermatologists. JAMA Dermatol. 2017;153(4):322-325. doi:10.1001/jamadermatol.2016.5411

6. Xu X, Zhang C, Jiang M, Xiang LF. Impact of treatment delays on vitiligo during the COVID-19 pandemic: a retrospective study. Dermatol Ther. 2021;34(4): e15014. doi:10.1111/dth.15014

7. Feltes R, Floristán U, Sendagorta E, Ramírez P, Diez-Sebastian J, Laguna RDL. Treatment during a year with 0.1% tacrolimus ointment in young patients with vitiligo. Rev Asoc Colomb Dermatol Cir Dermatol. 2019;19(1):26-32. https://revista.asocolderma.org.co/index.php/asocolderma/article/view/383

8. Singh H, Kumaran MS, Bains A, Parsad D. A randomized comparative study of oral corticosteroid minipulse and low-dose oral methotrexate in the treatment of unstable vitiligo. Dermatology. 2015;231(3):286-290. doi:10.1159/000433424

Disclosures

Study authors reported no conflicts of interest. The study was funded by AHF through an unrestricted grant from The Pfizer Foundation.