Can the new drug Apremilast really repigment even hands and feet?

In vitiligo, hands and feet are always the toughest parts to treat. Even the existing drugs which can reverse vitiligo, like JAK inhibitors, could never fully repigment the fingers. This is unfortunate because using our hands is a major way we interact with the world and communicate, and they are always exposed.

Apremilast (Otezla) is an already-existing drug which is currently FDA-approved for the treatment of psoriasis and psoriatic arthritis. So why should we be interested in it? Two researchers from the University of Toledo (Ohio) tested this drug on a 52 year-old woman with a severe case of vitiligo. She had vitiligo for 20 years, and she literally tried every treatment available, but unfortunately nothing proved successful in her case. She was so willing to get rid of her extensive vitiligo that she started experimenting even drugs not specifically designed for it, hoping they might work even if nobody had ever used them for vitiligo. The doctors of the Toledo clinic who followed her eventually decided to try the new drug Apremilast on her because its broad effect on inflammation might be a good bet treating vitiligo. The dosage consisted in a 30mg pill twice a day. The patient reported she started seeing repigmentation after only six weeks. If true, this is pretty remarkable as JAK inhibitors don’t even act that quick (it normally takes about three months to start noticing signs of improvement). What makes it even more remarkable is that several months of steroids injections led to zero repigmentation in her case, but only six weeks of apremilast showed initial positive results, even in the hands. Having said that, repigmentation for the following months was extremely slow, however, as after five months she wasn’t showing significant repigmentation. But after eight months she showed incredible repigmentation on every part of her body. It then appeared that after 13 months from the moment she started the drug she was fully repigmented, and I am talking about hands and feet as well. Another thing to note is that the patient did not report any side effects from taking the drug.

Apremilast seems to target some of the pathways of the immune system which are now known to cause vitiligo, but it has fewer side effects than the well know JAK inhibitors which can already treat vitiligo. What’s even more exciting is that, thanks to this remarkable case of repigmentation, there is already a phase two clinical trial at the University of Nice (France) to study the potential of apremilast in the treatment of vitiligo on 80 patients, 40 of which are receiving placebo. The phase two clinical trial should complete in March 2019, and we are all looking forward to knowing the results!



Some Thoughts

As much as the prospect of an already-existing drug that can reverse vitiligo and has fewer side effects than JAK inhibitors can be incredibly exciting, all this is based on the experience of only one patient. In order to really know if apremilast can be a new viable treatment for vitiligo, we need larger-scale clinical trials, which are fortunately already in progress (as mentioned). Until then, I would be very cautious in getting too excited about it. Having said that, a few things to note which are really impressive: first of all, this woman really tried every possible treatment, and nothing worked for her. Unfortunately, even if a lot of cases of vitiligo can be treated successfully, some are just stubborn, and her case was definitely one of them. Secondly, she had no pigments on her hands for as long as 20 years, yet she repigmented anyway, and this is pretty astonishing.
If the current clinical trials are successful, this could be a very effective treatment for vitiligo, although it would not be a cure, meaning vitiligo may or may not come back if you stopped using the drug, or it could come back years later. Still, it would be a very convenient way of keeping your vitiligo away by just taking a pill twice a day.
We will report the results of the clinical trials as soon as we know them!



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