Clinical Pearls for Vitiligo and Pigmentation Complexities: Part 2

In a series of Dermatology Times Case-Based Roundtable events, 4 dermatologists led discussions for local colleagues to delve into complex cases of vitiligo. Clinicians reviewed clinical considerations for care, effective management and treatment strategies, and more. Each meeting allowed participants to engage in thought-provoking discussions related to vitiligo care and collaboratively delve into varying presentations of vitiligo. These insights from the events held in New York; Washington, DC; Texas; and California highlighted the combined expertise and commitment to enhancing patient care.

Read part 1 here

Chesahna Kindred, MD, MBA, FAAD, a board-certified dermatologist and founder of Kindred Hair & Skin Center in Marriottsville, Maryland, hosted a Case-Based Roundtable discussion in Washington, DC.

Case 1: 35-Year-Old Woman With History of Acne

Kindred’s first case involved a 35-year-old Black woman who presented with depigmented lesions on the hands approximately 6 months after onset. She had a history of acne and autoimmune thyroiditis.

Topical Ruxolitinib for the Hands

“We noted how difficult it is to treat vitiligo on the hands,” Kindred said. “There are just not as many hairs to donate melanin.”

Kindred and attendees discussed the flexibility of ruxolitinib monotherapy to be used on various locations such as the face and hands—a challenge with traditional corticosteroids.

Insurance and Other Barriers

Roundtable attendees also discussed insurance barriers inhibiting ruxolitinib access for patients. Many of the clinicians shared that topical tacrolimus tends to be their first-line treatment option.

Phototherapy, another preference of clinicians, can be challenging due to location of depigmented lesions. Patients with skin of color more often than not forgo treatment due to concerns about the contrast in pigmentation.

Societal and Cultural Differences

“Regarding the awareness of vitiligo amongst our society, [the roundtable participants] noted that there is a popular model [Winnie Harlow] with vitiligo who doesn’t hide her vitiligo,” Kindred said. “It’s made these patients more comfortable with their vitiligo compared to, say, 10, 20 years ago.”

Attendees also discussed how some cultures may view vitiligo as strongly negative, with some patients expressing emotional, psychological, and lifestyle concerns, such as fears they will not be able to get married. Clinicians discussed the importance of culturally competent care and how they often conduct depression screenings and refer patients to psychiatric care providers.

Combined Therapeutic Approaches

Kindred engages with dermatology clinicians from the Washington, DC, area.

Several participants, including Kindred, discussed the advantages of combining NB-UVB phototherapy with topical ruxolitinib.

“For myself, using the combination of the 308-nm lamp plus topical ruxolitinib has now become the go-to treatment in my practice,” Kindred said.

Facial Repigmentation Solutions

Kindred and attendees discussed being cautious about utilizing topical corticosteroids for vitiligo lesions on the face. Kindred noted that she often opts for topical clobetasol.

“Dermatologists should really have experience using topicals such as clobetasol on the face because we all know there is a risk of atrophy and other untoward effects when used on the face,” she said.

Case 2: 43-Year-Old Woman With Cultural Worries

The second case Kindred discussed was that of a 43-year-old South Asian woman who presented with depigmented lesions on her face, hands, and neck. Her vitiligo had first onset approximately 5 years prior, first appearing as small spots on her hands before gradually spreading. As a school teacher, she expressed significant concerns about the lesions’ appearance.

Cultural Competency and Considerations

Attendees discussed the urgency surrounding this case, particularly regarding the patient’s culture and ethnicity, returning to their discussion on the importance of culturally competent care. Kindred emphasized that in some parts of the world, vitiligo is considered a devastating diagnosis.

“We all shared personal experiences we’ve had with patients with the same background as this woman,” she said. “I’ve had cases as far back as residency where a patient and her fiancé were hiding her vitiligo from her in-laws because if her in-laws found out before the wedding, they wouldn’t be allowed to get married.”

Adverse Effects and Treatment Adjustment

Kindred and colleagues also discussed the role of phototherapy in providing clinicians with a greater opportunity to hear from their patients about unwanted adverse effects such as irritation, since most patients receive NB-UVB treatment in the office.

However, they discussed that since the FDA approval of ruxolitinib, clinicians are less concerned about effects such as irritation and hypopigmentation, which may be more common in cases of topical corticosteroid use.

Support Amid Setbacks

Attendees also discussed the importance of listening and patient education in instances where patients begin to exhibit improvement, only for setbacks and depigmentation to occur.

“At the first visit, when explaining what the treatment options are, let the patient know that they’re going to have some good days, they’ll have some bad days,” Kindred said. “They can have a flare or an exacerbation....Setting expectations from the beginning seems to make dealing with the setbacks a lot easier.”

Part 3 coming soon featuring Ted Lain, MD, MBA, FAAD