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The epigenetic control of the gene expression linked to these phenomena can be an integrator of these processes since environmental and dietary factors, behavioral response patterns to stress, and the increasing exposure to industrialized compounds are intensely present in modern life, especially air pollution and aromatic compounds.108,109 The regulation of pathways related to transport vesicles (exosomes) between keratinocytes, melanocytes, and inflammatory cells constitutes another factor that should elucidate the interaction between the cell damage process, melanogenesis, and the immune response in vitiligo.110 The role of intestinal dysbiosis in inflammation modulation, OS, and autoimmunity may disclose susceptibility profiles and the clinical expression of vitiligo, as increased intestinal permeability favors the activation of innate immunity and promotes systemic inflammatory stimulation.111 Finally, the importance of hypovitaminosis D, a modern epidemic, in the immune response regulation, as well as the effect of its supplementation as an adjunct to treatment, must be explored since patients with vitiligo have lower levels of vitamin D.112 In conclusion, the pathogenesis of vitiligo results from an interaction of elements (multifactorial), which suggests a genetic susceptibility basis, affected by environmental factors, oxidative stress, psychological factors, and patterns of autoimmune response
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