Considerations for Topical Therapeutics and Clinical Excellence in Vitiligo

At the 2024 Revolutionizing Alopecia Areata, Vitiligo, and Eczema (RAVE) conference in Chicago, Illinois, Nanette Silverberg, MD, chair of the Revolutionizing Vitiligo (ReV) portion of RAVE, chief of pediatric dermatology for the Mount Sinai Health System, and site director of pediatric and adolescent dermatology at Mount Sinai West and Mount Sinai Beth Israel in New York, presented 2 sessions on topical therapeutic considerations for vitiligo and how to achieve clinical excellence while treating patients with vitiligo.

In her topical therapeutics discussion, Silverberg reviewed the social determinants model of vitiligo, which included genetic susceptibility, environmental triggers, the recognition of diagnosis and initiation of therapy in a timely manner, and access to care. According to data Silverberg shared, there is still a 2.4-to-4-year gap before patients with vitiligo receive a diagnosis, and 40% of patients have previously been misdiagnosed. Additional barriers to care include challenges with prior authorizations, failure of inferior regimens, co-pays, and location of dermatologic care of physicians.¹

When considering topical treatments, Silverberg first reviewed topical calcineurin inhibitors (TCIs) of topical tacrolimus and pimecrolimus that can be used as first-line therapy for children and adolescents aged 2 to 18 years with vitiligo, as TCIs are off-label use for vitiligo. Additional topical therapeutics that can be considered for the off-label treatment of vitiligo include topical corticosteroids and topical calcipotriene. The current FDA-approved first-line treatment for patients aged 12 years and older with vitiligo is topical ruxolitinib.

“However, we have no FDA-approved products for patients under the age of 12. Essentially everything we do with kids under the age of 12 is off-label, and that is a real problem because about 25% of vitiligo starts before the peak of 11,” said Silverberg.

Silverberg also stressed the importance of counseling patients about the realistic expectations of when patients may begin to see repigmentation. In many cases, it can take up tp 6 months to see meaningful repigmentation, and “6 months is a long time for patients to wait,” said Silverberg.

She added, “If patients really understand what’s waiting for them at the end of the 6 months, they can keep up. Sometimes, bringing patients back in the middle of that 2- or 3-month visit and looking for early repigmentation with them can help give them that sense that it’s working.”

In her second session, Silverberg discussed how to establish clinical excellence in your practice when treating patients with vitiligo. Treating patients is more than handing them a prescription, it’s about treating them in a holistic manner and coming up with a tailored treatment approach, according to Silverberg.²

Being aware of both on- and off-label therapeutics for vitiligo is crucial for clinicians, however. Silverberg also encouraged attendees to consider combination therapies by including devices.

“How we incorporate all of these options together is what creates excellence in care. Caring for your patients is the most important first step in excellence in care; you have to think of them as individuals,” concluded Silverberg.

References

1. Silverberg N. Topical therapeutics for vitiligo. Presented at: 2024 Revolutionizing Alopecia Areata, Vitiligo, and Eczema; June 8-10, 2024; Chicago, IL.

2. Silverberg N. Excellence in vitiligo clinical practice. Presented at: 2024 Revolutionizing Alopecia Areata, Vitiligo, and Eczema; June 9-10, 2024; Chicago, IL.