LAUSR

Vitiligo, an autoimmune condition affecting approximately 0 5–2% of the world’s population, causes white patches of the skin due to loss of melanocytes. Vitiligo can have a devastating impact on quality of life and self-esteem, and psychiatric comorbidities such as depression and anxiety have been frequently reported. The natural history of vitiligo is unpredictable and most patients with vitiligo experience alternating periods of disease worsening and stability, which can be stressful and cause a negative impact on quality of life. There has been a recent surge in enthusiasm for treatment of patients with vitiligo due to pilot feasibility studies showing that targeted therapies can repigment vitiliginous skin, and well-powered clinical trials are underway. However, at the moment the therapeutic management of vitiligo is complex and treatments are often long and costly and allow only partial repigmentation. In recent years there have been attempts to take into account patient willingness and treatment aims, although evidence-based guidelines for vitiligo are still lacking and published guidelines are mostly based on expert recommendations. In this issue of the BJD, Eleftheriadou and colleagues propose practical guidelines for the management of adult patients with vitiligo in both primary and specialty care. The guidelines were developed following a rigorous methodological framework provided by the British Association of Dermatologists based on the AGREE II instrument (www.agreetrust.org) and the GRADE methodology. One of the crucial steps in this process was the formation of a guideline development group (GDG) consisting of consultant dermatologists, dermatology specialist registrars, clinical psychologists and, most importantly, patient representatives. This GDG established several clinical questions pertinent to the scope of the guidelines and a set of outcome measures of importance to patients, ranked by the patient representatives according to the GRADE methodology. The proposed outcomes were in agreement with the core outcomes set, which was developed based on international consensus. Overall, these guidelines are the first to date to embrace not only treatment but also pertinent items in the daily management of vitiligo for both patients and physicians. These include several issues related to patient wellbeing, long-term side-effects and fear of treatment from the patient’s perspective, such as the risk of skin cancer related to the use of phototherapy. The strength of these guidelines, which were developed over a long period of time, is related to the strong methodology used. Several stakeholder organizations were involved, including the British Photodermatology Group, the British Dermatological Nursing Group, the Primary Care Dermatological Society, the British Society for Paediatric Dermatology, the British Society for Dermatological Surgery, the Royal Pharmaceutical Society and the Vitiligo Society. In addition to practical recommendations for the management of vitiligo, these guidelines also attempt to address gaps in knowledge by providing a list of future research recommendations that can serve as guidelines for the development and conduct of future research efforts. In this era of ever-increasing randomized clinical trials for patients with vitiligo, these guidelines and their recommendations for future research are more than welcome. However, a few gaps remain to be solved or answered in the next version of these guidelines. Of these, the issue of the diversity and/or ethnic background of patients involved in the development of the guidelines is of prime importance as the burden of vitiligo may depend upon skin phototype and cultural background. Furthermore, any guideline document for vitiligo will surely have to be modified in the near future due to the explosion in understanding of vitiligo pathogenesis, resulting in the many clinical trials that are being performed, as well as those currently being planned throughout the world.