The landscape of vitiligo in Latin America: a call to action

Figures & data

Table 1. Characteristics of survey sample.

Participants per country	N
Argentina	48
Brazil	55
Bolivia	16
Chile	27
Colombia	36
Costa Rica	29
El Salvador	15
Guatemala	2
Mexico	34
Peru	9
Uruguay	18
Total number of participants	292
Dermatology specialty
General dermatology	242
Pediatric dermatology	34
Other dermatologic subspecialties	12
Type of institution
Public hospital only	38
Private hospital	121
Public and private hospital	111
Academic center	18

Figure 1. (a,b) A typical patient journey for a person with vitiligo in Latin America. (a) Depicts the journey to diagnosis. (b) Depicts the treatment journey. PCP: primary care physician; LA: Latin America; UV-NB: ultraviolet narrow band; PUVA: psoralen + ultraviolet A. ⁺‘Healers,’ cosmetologists, pharmacists. *Vitamin D analogs, furocoumarins, antioxidants, topical JAK inhibitors. **Methotrexate, cyclosporine, azathioprine, JAK inhibitors. ***Antibiotics, antioxidants, vitamin supplements.

Table 2. Access to vitiligo treatment as reported by dermatologists in LA.

Access to psychosocial support for patients with vitiligo in the public healthcare system	Argentina (%)	Bolivia (%)	Brazil (%)	Chile (%)	Colombia (%)	Costa Rica (%)	El Salvador (%)	Guatemala (%)	Mexico (%)	Peru (%)	Uruguay (%)
Yes	14.29	12.50	10.91	11.11	11.11	53.57	13.33	0.00	15.15	0.00	22.22
No	44.90	62.50	34.54	37.04	50.00	17.86	33.33	50.00	42.42	55.56	33.33
Scarce	40.81	25.00	54.55	51.85	38.89	28.57	53.34	50.00	42.43	44.44	44.45
Access to topical corticosteroids for vitiligo treatment in the public healthcare system
Yes	42.85	50.00	49.09	81.84	86.11	100.00	53.33	50.00	72.73	100.00	77.78
No	30.61	25.00	21.82	3.70	2.78	0.00	20.00	50.00	12.12	0.00	5.56
Some	26.54	25.00	29.09	14.46	11.11	0.00	26.67	0.00	15.15	0.00	16.66
Access to systemic corticosteroids for vitiligo treatment in the public healthcare system
Yes	30.61	50.00	69.09	84.61	86.11	93.10	73.33	50.00	67.65	8.89	88.89
No	30.61	31.25	16.36	0.00	5.55	3.45	6.67	50.00	8.82	1.11	0.00
Some	38.78	18.75	14.55	15.39	8.34	3.45	20.00	0.00	23.53	90.00	11.11
Access to calcineurin inhibitors for vitiligo treatment in the public healthcare system
Yes	20.40	11.76	14.54	7.41	38.89	28.57	0.00	50.00	33.33	55.56	22.22
No	59.18	82.35	74.54	81.84	50.00	50.00	80.00	50.00	48.48	33.33	66.67
Some	20.42	5.89	10.92	10.75	11.11	21.43	20.00	0.00	18.19	11.11	11.11
Access to phototherapy for vitiligo treatment in the public healthcare system
Yes	55.10	6.25	70.90	77.77	94.29	100.00	46.67	50.00	41.18	66.66	83.33
No	44.90	93.75	29.10	22.23	5.71	0.00	53.33	50.00	58.82	33.34	16.67
Access to JAK inhibitors for vitiligo treatment in the public healthcare system
Yes	2.04	0.00	90.70	7.41	11.43	14.29	0.00	100.00	5.88	0.00	0.00
No	97.96	100.00	9.30	92.59	88.57	85.71	100.00	0.00	94.12	100.00	100.00
Are you satisfied with the options available to patients with vitiligo in the public healthcare system
Yes	6.12	0.00	85.45	22.22	33.33	29.63	0.00	0.00	24.24	11.11	16.67
No	94.87	100	14.55	77.78	66.67	70.37	100	100	84.85	88.89	83.33

Table 3. Vitiligo perception in LA.

Is vitiligo recognized as a disease that requires medical care by a specialist in your country?	n	%
Yes	165	57.29
No, it is often mistakenly thought to be a cosmetic disease	123	42.7
Are there myths and misinformation about vitiligo (e.g., that it is contagious) that lead to stigmatization and discrimination of these patients in your country?
Yes	223	77.43
No	65	22.57

Figure 2. Time from onset of vitiligo symptoms to diagnosis in Latin America.

Figure 3. Typical period elapsed from referral to appointment with a dermatologist in Latin America.

Table 4. Diagnosis and use of clinimetric tools for vitiligo in Latin America.

Do primary care physicians have sufficient training about vitiligo to diagnose the disease?	n	%
Yes	89	30.79
No	190	65.74
Do primary care physicians know enough about vitiligo to identify appropriate referral situations?
Yes	190	65.74
No	99	34.25
Do you use clinimetric instruments, such as DLQI or VitiQoL to assess the impact of vitiligo on a patient’s QoL in routine clinical practice?
Yes, always	12	4.15
Sometimes	56	19.37
Rarely	79	27.33
No	142	49.13
Do you use clinimetric instruments, such as VES, VETF, or VASI to assess the severity of vitiligo in routine clinical practice?
Yes, always	6	2.07
Sometimes	42	14.53
Rarely	66	22.83
No	180	62.28

DLQI: Dermatological Life Quality Index; VitiQoL: Vitiligo-specific Health-related Quality of Life Instrument; VES: Vitiligo extent score; VETF: Vitiligo European Task Force assessment; VASI: Vitiligo Area Scoring Index.

Figure 4. Reasons given for lack of use of clinimetric scale for vitiligo severity and QoL impact assessment by dermatologists in Latin America.

Figure 5. Call to action: Vitiligo treatment barriers and recommendations.

Data availability statement

This is a narrative review, with results taken from the literature and professional experience of the panel. The data from the survey is available from the corresponding author.

Box 1. Recommendations to improve the landscape of vitiligo in Latin America.

1. CREATE REGIONAL DISEASE AWARENESS

   • Recognize vitiligo as a high-impact chronic and systemic disease requiring dermatological management and multidisciplinary care for psychosocial consequences and comorbidities.

   • Develop widespread awareness campaigns to educate the public on the non-contagious nature of the condition, advocate inclusivity, and fight discrimination and stigmatization. Videos, disease days, celebrities, and social media are examples.

2. INCREASE PHYSICIAN TRAINING

   • Primary Care Level (PCPs and pediatricians)

     •     ^ Recognize vitiligo and be aware of possible comorbidities

     •     ^ Recognize appropriate referral situations and understand the importance of referring to a dermatologist to decrease diagnostic delays and allow for early intervention

     •     ^ Dispel misconceptions surrounding vitiligo, including that it is untreatable

   • Dermatologists

     •     ^ Obtain a complete medical history and classify the disease based on its clinical characteristics (7)

     •     ^ Carry out a differential diagnosis from other entities that lead to hypopigmentation (8)

     •     ^ Actively investigate mental health impact and other comorbidities to involve the necessary specialists to provide a holistic approach posteriorly

     •     ^ Use clinimetric instruments to assess the impact on QoL and disease severity, as they allow objectivity in evaluating progression and treatment response. Using apps available for mobile phones may facilitate the use of these tools

     •     ^ Ensure adequate follow-up and reevaluation of disease progression and impact on QoL continuously throughout the disease course to guide treatment decisions

     •     ^ Provide comprehensive education to patients and caregivers on the disease course, proper care, and preventive measures, and create realistic treatment expectations.

3. ADDRESS MALDISTRIBUTION OF RESOURCES AND SPECIALISTS

   • Create job opportunities for dermatologists within public healthcare systems and provide incentives to work in non-central cities in need of specialists

   • Teledermatology can be implemented as a tool to increase access to specialized care in distant and rural areas when in-person visits are not an option (62,63). It can potentially be a tool for the early detection and intervention of vitiligo (9)

   • Increase local training opportunities for aspiring dermatologists

4. INCREASE ACCESS TO VITILIGO MANAGEMENT

   • Ensure continuous access to multidisciplinary care and follow-up

   • Ensure continuous access and reimbursement of indicated treatments, psychosocial support, and complementary measures

5. DEVELOP NATIONAL OR REGIONAL CPG

   • Develop CPG for vitiligo to promote evidence-based and standardized care through collaboration between medical societies, government, and academia. If this is not possible in the short-to-medium term, each country’s leading medical society should recommend an international guideline to adopt.

6. CREATE PATIENT ORGANIZATIONS

   • Create an official PO dedicated to advocating for vitiligo to be recognized as a chronic disease, providing peer support, informing, and advising its members on disease-related issues, advocating for treatment approvals and reimbursement, and sensitizing society on the

7. GENERATE LOCAL DATA

   • Encourage local and regional research regarding vitiligo epidemiology, patient outcomes, disease course, disease burden, impact on QoL, and genetic, environmental, and immunologic dynamics.