Case Based Roundtables Part 1: Valorizing Topical Treatment Options for Patients With Vitiligo

Leading experts in vitiligo recently hosted a series of Dermatology Times Case Based Roundtables in cities around the country to discuss approaches to complex cases, understand challenges across different age groups and skin types, and explore the condition’s impact on patient well-being.

Roundtable hosts included Benjamin Lockshin, MD, FAAD, in Washington, DC; Heather Woolery-Lloyd, MD, in Miami, Florida; Elizabeth Kiracofe, MD, FAAD, in Chicago, Illinois; James Song, MD, in Seattle, Washington; and Karan Lal, DO, FAAD, in Scottsdale, Arizona. Here are a few cases that the roundtable participants delved into.

Case 1: Saving Face With Awareness

A 23-year-old Hispanic woman with Fitzpatrick skin type IV presented with vitiligo affecting 75% of her face, including complete depigmentation of the eyelids, chin, cheeks, and perioral skin. The condition had progressed over 2 years, and she had a history of moderate atopic dermatitis for the past 20 years.

The discussion among roundtable participants in Miami evaluated the challenges this patient faces, exploring potential treatments and addressing the emotional impact of vitiligo on the patient’s life. The patient is exploring treatment options due to concerns about the rapid progression and substantial change in her facial appearance.Questions arose about whether to bleach or repigment the affected areas and whichtype of labs to consider.Several clinicians expressed the value of laboratory tests to detect autoimmune diseases and thyroid antibodies.

Because this patient is young, she recognizes there is a societal awareness of vitiligo, citing the example of models like Winnie Harlow. Awareness may influence patients’ perceptions and acceptance of the condition.“ The new generation of children are very lucky that,[through]social media, [they are]able to see other…people who…they can relate to. We didn’t have social media growing up,” one participant said in the conversation with Woolery-Lloyd.

Despite increased awareness, participants agreed that healthcare professionals should discuss the impact of vitiligo on the patient’s quality of life, especially psychological aspects of depigmentation on visible areas such as the legs and face. 

Participants discussing the case said they would use topicals such as mometasone furoate, tacrolimus, orruxolitinib (Opzelura) for treatment, with a consistent follow-up schedule.

Case 2: Considerations for Comorbidities

An active 71-year-old woman who spends a lot of time outdoors has extensive vitiligo, particularly on her face, genital area, and axilla. The patient has comorbidities such as hypothyroidism, hypertension, and osteoporosis. Washington, DC, roundtable participants discussed various treatment options, including topical medications such astacrolimus and ruxolitinib cream, phototherapy, and systemic options such as oral steroids and Janus kinase(JAK) inhibitors.

Clinicians shared their experiences and preferences for managing vitiligo in sensitive areas.“The eyelids can be sensitive and will dictate what kind of treatments we start off with,” one participant said. “I like to use nonsteroids in that area, like tacrolimus ointment or ruxolitinib. As far as the challenges go, that would also go with treating vitiligo. My main thing is talking about expectations—how it’s a difficult condition to treat, how it’s longterm, chronic, and then what to expect.” 

Lockshin mentioned this patient’s rapid progression of vitiligo and the discussion delved into a variety of treatment modalities, including the use of phototherapy, topical steroids, and the potential risks associated with certain medications.

This group shared experiences with the challenges of patient adherence, treating vitiligo on the hands, and the consideration of factors such as age, lifestyle, and cost when choosing treatment options. The providers discussed the importance of managing patient expectations, the potential for relapse, and the psychological impact of vitiligo on patients. A common frustration was the denial of ruxolitinib during the authorization process. One participant shared the importance of advocacy for low-income patients.

“You can fill out a form [for patients to get ruxolitinib], and they can get it for free. I’ve done it multiple times. They almost always get it as long as you fill out the income-based form,” they said.

Case 3: Segmental Vitiligo’s Unique Challenges

A 14-year-old Chinese boy with Fitzpatrick skin type III experienced a sudden eruption of deep pigmented patches on the right side of his face, causing teasing and bullying at school. Despite the patient downplaying the impact on his quality of life, physical cues suggested potential depression.

Song and Seattle roundtable participants highlighted the need for dermatology clinicians to consider the psychological aspects of vitiligo, especially in adolescents who may struggle to express their feelings. The consensus among the panelists was to start with topical therapies, followed by phototherapy after 3 months. However, the patient, diagnosed with segmental vitiligo affecting only the right side, showed little improvement after 9 months.

The discussion then turned to alternative treatments, such as surgical interventions and camouflaging. The societal stigmatization of vitiligo, particularly in certain cultures, was emphasized, influencing patients’ perceptions and treatment decisions.

This case underscored the importance of recognizing segmental vitiligo’s unique challenges and managing patient expectations regarding treatment efficacy and stabilization. The need for dermatologists to address the psychological impact and societal beliefs surrounding vitiligo was a key takeaway, along with the importance of thorough screening for associated conditions in younger patients.

“What’s really important is that, yes, we recognize [segmental vitiligo] is a different type of vitiligo [and] is not amenable to the same type of medical treatments that nonsegmental vitiligo is.It’s important that we set expectations early on about what’s likely to work and not likely to work, but also that this is going to stabilize pretty quickly,” Song said. “Over the course of maybe 6 to 12 months, it’s not going to get any worse than what we see.”