Clinical Pearls for Vitiligo and Pigmentation Complexities: Part 4

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.

Pearl E. Grimes, MD, FAAD, director of The Grimes Center of Medical and Aesthetic Dermatology, clinical professor of dermatology at UCLA, and founder and director of the Vitiligo & Pigmentation Institute of Southern California in Los Angeles, hosted a Case-Based Roundtable discussion in Beverly Hills, California.
Case 1: 45-Year-Old White Woman With Comorbidity
To start the discussion, the colleagues discussed the case of a 45-year-old White woman who had received a diagnosis of vitiligo 10 years ago. The patient had patches of depigmentation on her hands, periorbital area, face, neck, and extremities. Grimes noted her BSA was 10% and that she had a 20-year history of atopic
dermatitis (AD).

Case Challenges and Considerations
“When you address any patient with vitiligo, it’s so important to understand
vitiligo’s impact on quality of life and burden of disease,” Grimes said.

The patient was previously treated with clobetasol propionate, with which she had no adverse effects but also experienced low efficacy. With this in mind, the patient was then prescribed tacrolimus ointment and recommended NB-UVB phototherapy due to the extent of her disease. She initially showed some success with the treatment, but the results were not sustained, and she reported mild sunburn after several sessions.
Treating Comorbid AD and Vitiligo
Grimes stated that this is not an uncommon comorbidity in her practice, and she often works to control the AD first. In her experience, she has found success with a course of steroids first, such as dexamethasone, or a systemic steroid for quick response.

Looking at the available therapies, Grimes noted that ruxolitinib is not only approved for vitiligo but atopic dermatitis as well. When combined with NB-UVB phototherapy, Grimes said this becomes the best-case scenario for this patient. “In my opinion, this is the ideal approach for this patient. I don’t have to worry about steroid-related adverse effects. We can use it on the face, the truck, and the extremities,” Grimes said.

Grimes speaks with fellow California-based dermatology clinicians.

Case 2: 35-Year-Old Man with Long-Standing Vitiligo

For her second case, Grimes discussed a 35-year-old man with vitiligo since adolescence. He had well-defined white patches on his face, neck, and torso. Grimes noted that he was a bank teller who often interacted with clients and felt uncomfortable with the extent of presentation of his disease.

Over-the-Counter Medications and Makeup

Before seeking medical treatment, Grimes said the man attempted to control his disease with over-the-counter topicals, none of which had any effect. He also attempted to conceal his patches with makeup, but he did not see this as a long-term solution.

“Patients really want a permanent treatment. They want repigmentation. I find that the majority of my patients want something substantial beyond camouflage,” Grimes said.

Patient Relapse and Reassessment
Initially, the patient was treated with topical vitamin D and betamethasone dipropionate. Upon relapse, Grimes said the patient had increased burden of disease and self-consciousness.

Following this relapse, the patient was prescribed topical ruxolitinib. Grimes stated that the patient had significant repigmentation, a response that was sustained even after discontinuing the drug.
“Ruxolitinib has clearly moved to the forefront of how we manage patients
with vitiligo,” Grimes said. “It’s such a welcome addition to our therapeutic
armamentarium for patients with this psychologically devastating and therapeutically challenging condition.”
Impact vs Disease Duration
To end their discussion, Grimes spoke about the burden of disease for patients with new diagnoses vs patients who had received a diagnosis decades before. “Never make the decision to not treat an individual who has long-term disease,” Grimes said. “You have to keep your patients motivated. Everyone responds at a different rate.”

Read part 1 featuring Andrew Alexis, MD, MPH, FAAD

Read part 2 featuring Chesahna Kindred, MD, MBA, FAAD

Read part 3 featuring Ted Lain, MD, MBA, FAAD