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"Speaking of Vitiligo..."

Coronavirus and vitiligo

Sunday, March 15, 2020

Many are asking me whether individuals with vitiligo are at higher risk for contracting the novel coronavirus, COVID-19, which is responsible for an ongoing pandemic. In general, the answer is no. I figured that I would take the time to write this blog while I and my family are “socially distancing” ourselves in order to slow the spread of the pandemic in our little part of the world. So, we’re stuck in our house and thinking about everyone out there who is worried about what this pandemic means for them and their loved ones.

Vitiligo is an autoimmune disease of the skin, which means that someone with vitiligo has an immune system that is malfunctioning in a small way. The normal role of the immune system is to protect you from infections and cancer. Just like any trait that you may have (height, weight, hair color, etc), your genetic makeup can influence the quality and strength of your immune response. In vitiligo the immune cells are attacking the melanocytes, or pigment cells, even though the cells are not dangerous.

So just like some people are very tall, some are very short, and most are somewhere in the middle, some people have an immune system that is very strong in one area, very weak in an area, or somewhere in the middle. Individuals with vitiligo have an immune response that is too strong against their melanocytes, which results in these normal cells being killed and white spots appearing where that happened, because they can’t make pigment anymore. This is actually good from one perspective, because it means they have a lower risk of developing melanoma and other skin cancers (that’s what that part of the immune response is supposed to be doing – protecting from melanoma). So that “malfunctioning” immune system is causing white spots on your skin, but also decreasing your chances of getting skin cancer – I guess whether this is “good” or “bad” depends on your perspective. 

But in any way you look at it, it doesn’t mean that your immune system is weak because you have vitiligo. It actually means that it’s a little too strong, so you are most likely NOT more susceptible to coronavirus or any other virus. Some of my patients report that they get fewer infections than their friends and family, and this may reflect the fact that the immune system is a little overactive. But just because the immune system is overactive in one small aspect (against the melanocytes), it doesn’t necessarily mean that it’s strong in every aspect, so everyone is probably a little different. But overall the take home message is that having vitiligo does not mean your immune system is weak, or that you are more likely to get an infection.

Of course, there are always exceptions to the rule. In very rare cases, patients get autoimmune diseases because their immune system has a more significant malfunction that can make it more likely to get both vitiligo (or other autoimmune diseases) AND infections. This is not the case for most people, and if you had one of these syndromes you would probably know it by now. One example of this is Common Variable Immunodeficiency Syndrome (CVID), and I have only seen one or two people with this in my entire career. So again, this is very unusual, and we’re not sure why the immune system works this way in those individuals, but most of those with vitiligo do NOT have this.

Another caveat to think about is when vitiligo patients are using treatments to either prevent the spread of their disease or to reverse it. Most of these medicines suppress the immune system in some way, since the central cause of vitiligo is autoimmunity, or overactivity of the immune response. In fact, that’s why they work. Many are using topical ointments or creams, and these have a VERY low (or NO) risk of affecting your ability to fight infections, since very little, if any, of the drug goes beyond the skin. In addition, many are using narrow band UVB light treatments, which again only affect the skin and this is no more dangerous than going out in the sun (actually much LESS dangerous, but that’s another topic). 

Some people are taking low dose oral steroids, which we use to stop the spread of vitiligo in those who have very active disease. I usually use dexamethasone taken only 2 days per week for about 3 months because it seems to work very well and have no side effects for most people. In theory, this could have an effect on the immune system even beyond the skin, because it’s taken orally. However, practically we haven’t seen increased risks of infection in patients taking it this way, probably because it is such a low dose. Because it is so well-tolerated, we like to use it when necessary.

Finally, some patients are taking newer medicines either off-label (when drugs are FDA-approved for one disease but used for another) or as part of a clinical trial. Examples include the new JAK inhibitors, such as Xeljanz (tofacitinib) and Jakafi (ruxolitinib), as well as some newer versions that don't even have real names yet. Again, the ones used topically don’t appear to have any effect on the immune system outside the skin. A few people are taking oral JAK inhibitors for vitiligo, either Xeljanz off-label or newer medicines in a clinical trial. To be completely honest, we don’t yet know how these medicines will affect responses to infections like coronavirus. They are somewhat “targeted” meaning they are not just suppressing the entire immune response, they are affecting just a part of it, the part that is causing autoimmunity in vitiligo and other diseases. But we do not yet know every detail about how the immune system works, so we are working to improve this understanding. To make things even more complicated, some doctors are actually using JAK inhibitors to treat those with severe coronavirus infections, since it appears that the most severe symptoms are from an overreaction of the immune system to the virus, which injures the lungs. So these drugs may even help those who are infected in some way. 

In summary, in most cases, you are not at a higher risk of getting COVID-19 if you have vitiligo. If you are taking medicines for vitiligo and are still concerned about how it may affect you, talk to your doctor. And as we tell everybody, please do your part to prevent the spread of the virus during this pandemic, by washing your hands, not gathering in large groups, and meeting with people over the phone or videoconference instead of in person when possible. There are 3 things that affect the spread of the virus: 

  1. how many people have it today,
  2. how many people that they come into contact with each day, and
  3. how quickly the virus is able to spread.

You can affect two of those variables by limiting contact with others and washing your hands regularly.

We’ll get through this, but we have to work together and support each other. We in the Vitiligo Clinic and Research Center are thinking about how we can help with this. In line with UMass policy, we have stopped our research for a few weeks. Don’t worry – we’ll get right back to our search for a cure as soon as we can. We are also thinking about how we can limit spread in the clinic and discussing policies right now. Stay tuned!

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