Case Based Roundtables Part 2: Valorizing Topical Treatment Options for Patients With Vitiligo

Read Part 1 here.

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 additional cases that the roundtable participants delved into.

Case 4: Giving a Hand for Ruxolitinib

A 35-year-old Whiteman with Fitzpatrick skin type II and vitiligo on multiple areas of his body, particularly the dorsal hands and forearms, was presented to Chicago roundtable participants. The focus was on unstable vitiligo, characterized by changing depigmented patches. The challenges that were discussed included managing the inflammation that causes vitiligo to worsen. The group reached a consensus on usingoral dexamethasone as the primary treatment for actively depigmenting or unstable vitiligo.

The patient, an outdoor enthusiast and guitarist, faced challenges with topical treatments due to lifestyle constraints. The discussion emphasized the significant benefits of light therapy for vitiligo, recommending sunlight exposure when possible or using specific narrowband wavelengths and UVB light boxes. The contradictory nature of advising careful sun protection while using ultraviolet radiation for treatment was highlighted.

The stability of vitiligo was discussed in terms of satellite lesions, sharp borders, and pigment network absence as markers of stability. The patient had previously used topical corticosteroids and calcineurin inhibitors but, due to his lifestyle, switched to topical ruxolitinib, which showed improvement in adherence and repigmentation.

The conversation touched on the challenges of obtaining insurance coverage for topical ruxolitinib despite its US Food and Drug Administration (FDA) approval. The group shared experiences from different regions.

“I know just from a policy perspective [that] there [are] still some states that consider vitiligo a cosmetic condition. But we all experienced that patients really like the vehicle of topical ruxolitinib and are seeing results with it. The biggest hesitation with using it is—simply there’s no hesitation with using it. The biggest [universal] pause was [that]...unfortunately, sometimes it can be hard to get covered,” Kiracofe said.

Despite coverage difficulties, the group expressed the positive response from patients to topical ruxolitinib, emphasizing its importance as a novel therapy.

Case 5: Alternative Therapies Due To Medicaid Restrictions

Lal presented a case involving a 51-year-old African American man with persistent depigmented patches, impacting his self-esteem. Despite considering topical ruxolitinib as the ideal treatment, Medicaid limitations categorized vitiligo as a cosmetic disease, hindering insurance coverage. The patient initially underwent alternative therapies, including topical steroids and tacrolimus, with minimal improvement.

“In our discussion, most patients [of colleagues] were using topical mometasone and topical hydrocortisone 2.5% both in ointment formulations as topical steroids of choice for starting their treatment regimen for vitiligo, and including topical tacrolimus as steroid sparing therapy, where people alternate topical tacrolimus along with topical steroids to reduce the side effects from topical steroids specifically clench acacias, skin thinning, atrophy and stretch marks,” Lal explained.

Challenges in accessing phototherapy due to Medicaid restrictions were also discussed. After 3 months, the patient received topical ruxolitinib, resulting in focused improvements on cosmetically sensitive areas. The discussion emphasized the success of topical ruxolitinib, but acknowledged challenges in insurance approval for Medicaid recipients. Side effects, specifically folliculitis with topical ruxolitinib, were addressed, emphasizing management strategies without discontinuing therapy. The discussion concluded with insights into prior authorization processes and the use of specific pharmacies for medication access. Overall, the Scottsdale roundtable participants expressed success with combination therapies and emphasized the need for a holistic approach in vitiligo management.

Case 6: A Close Look at Skin of Color

A 23-year-old African American man with Fitzpatrick skin type VI presented with deep pigmented patches on visible areas such as thehands, arms, neck, and face. The contrast between normal skin and vitiligo patches were particularly noticeable due to his dark complexion, impacting his quality of life, especially as an active sports enthusiast. The continued discussion in Seattle focused on treating patients with different skin colors, considering that darker skin may make vitiligo more noticeable.

Initial treatment involved topical corticosteroids and calcineurin inhibitors, with the addition of phototherapy when the response was limited. However, the patient developed extensive vitiligo involvement, prompting a shift to alternative treatments. Stable vitiligo was defined as 1 to 2years without new areas of vitiligo.

The panel discussed oral steroids as an option for unstable vitiligo, with varying dosing regimens. The patient received 12 weeks of weekly dexamethasone dosing, followed by repigmentation efforts. Later, due to the patient’s preference and difficulty with topical treatments, they switched to topical ruxolitinib.

Concerns were raised about the box warning associated with topical ruxolitinib, and the discussion highlighted strategies to communicate the warning to patients without causing undue alarm. Absorption rates of the topical form compared with the oral version were discussed, indicating lower systemic exposure and reduced risk of cumulative effects.

Access to topical ruxolitinib was a significant point of discussion, with practitioners sharing their experiences. “It’s important to make sure we always prescribe a topical corticosteroid and a topical calcineurin inhibitor. Then we document that this is nonsegmental vitiligo in the note, rather than segmental vitiligo, which topical ruxolitinib is not approved for,” Song said.“We also…need to be very clear when we write topical ruxolitinib for vitiligo. It shouldn’t be greater than 10% BSA [body surface area], which is different than what we see with atopic dermatitis, which is no greater than 20% BSA.Sometimes if you mix those 2up, that can lead to a drug denial. Lastly, there are some payers that consider vitiligo to still be cosmetic, so sometimes they will deny ruxolitinib.... We talked about resources we can use to get these medications approved. The patient can get a passive letter of medical necessity that we can print out, [going] over why vitiligo is not a cosmetic disease.”

Vitiligo Treatment Pearls to Put Into Practice

Case-Based Roundtable moderators across the country reflected on 3 main take-home points to remain cognizant of when meeting a patient with vitiligo.

1. Set expectations early on. If this is segmental vitiligo, ensure patients understand that medical intervention may not be the best, as sometimes surgical intervention is the best option. Timelines for repigmentation should also be explained for each affected area.
2. Recognize the quality-of-life impact. Vitiligo has a significant impact on a patient’s quality of life.Initiating the conversation to understand its direct impact on their lifestyle, validate their feelings, and provide further support as needed can be reassuring and encouraging for the patient. 
3. Use FDA-approved medications. Drugs like topical ruxolitinib continue to show positive safety and efficacy data in studies and clinical trials. Several moderators encourage their colleagues to not get discouraged by the limited access to medication or let it deter them. Clinicians should know about resources tohelp overcome denials and advocate for patients who are severely impacted by the condition or cost of treatment solutions.