Optimizing Vitiligo Care: Key Expert Takeaways

Vitiligo is a condition that presents unique challenges for both patients and clinicians alike. A recent Dermatology Times Case-Based Roundtable custom event, “Vitiligo in Focus: Case-Based Insights and Strategies for Optimizing Treatment,” explored various aspects of vitiligo management through case-based presentations and shared clinical experiences. Led by Michael Cameron, MD, FAAD, founder of Cameron Dermatology PLLC and an assistant clinical professor in the department of dermatology at Mount Sinai in New York City, experts discussed ways to better understand the condition, focusing on treatment strategies, patient care considerations, and emerging therapies.

Understanding Vitiligo

Experts started by discussing the prevalence of the condition, stating that vitiligo is more prevalent than many clinicians realize. The condition can manifest across all age groups and skin types, often presenting as a cosmetic concern that can significantly impact patients' quality of life. The roundtable participants emphasized the importance of recognizing the emotional and psychological aspects of vitiligo. One participant noted, “I think the burden is really on us for kids, particularly. I don't think a 30-year-old with vitiligo I'm spending 10 minutes talking about their feelings about it”. This highlights the need for tailored approaches that acknowledge the variable impact of vitiligo on different patient populations.

Treatment Challenges and Strategies

The treatment of vitiligo is complex, particularly in non-facial areas such as the hands. The discussion underscored several treatment modalities, including topical therapies, phototherapy, and systemic agents.

• Topical Calcineurin Inhibitors: Tacrolimus, a topical calcineurin inhibitor, has been used in vitiligo treatment, but its greasiness, potential for skin burning, and perceived lack of efficacy were noted as drawbacks.
• Phototherapy: Narrowband UVB phototherapy, alone or in combination with topical treatments, was identified as a valuable therapeutic option. However, access to phototherapy can be limited by insurance coverage and the availability of specialized equipment.
• Ruxolitinib Cream: Ruxolitinib cream, a topical Janus kinase (JAK) inhibitor, has emerged as a promising first-line treatment for vitiligo. The roundtable participants shared positive experiences with ruxolitinib cream, noting its tolerability and efficacy. One clinician stated, "If it's covered, it's always my first line option.”
• Systemic JAK Inhibitors: For widespread or rapidly progressing vitiligo, oral JAK inhibitors like upadacitinib were considered, although their use is currently off-label. Access to these medications can be challenging due to insurance restrictions, with some insurers considering them as biologics and imposing stringent prior authorization requirements.

Patient Counseling and Follow-Up

Effective patient communication is crucial in vitiligo management. Clinicians emphasized the importance of setting realistic expectations, as repigmentation is a slow process that can take months to achieve. Regular follow-up appointments are essential to monitor treatment response, manage potential adverse effects, and provide ongoing support.

The roundtable discussion also highlighted the significance of proper application techniques for topical medications. One participant described using a white pencil to delineate the treatment area and instructing patients to take a photo to ensure correct application. This meticulous approach underscores the importance of addressing compliance issues, which can be a common reason for treatment failure.

Special Populations and Global Perspectives

The roundtable discussed that the management of vitiligo in pediatric patients and individuals with skin of color requires special consideration. The emotional impact of vitiligo can be particularly profound in children, necessitating a sensitive and supportive approach. In patients with skin of color, vitiligo can present unique diagnostic and therapeutic challenges.

The roundtable also shed light on the global disparities in vitiligo care. Participants discussed the stigma associated with vitiligo in certain cultures, as well as the limited access to effective treatments in resource-poor settings. One clinician shared their experience of practicing in Nigeria, where vitiligo is often heavily stigmatized: “It's very interesting how they treat people, especially kids, with vitiligo or albinism. It's like a curse to the family if kids have this.”

Conclusion

The roundtable discussion provided valuable insights into the multifaceted management of vitiligo. By sharing clinical experiences and discussing treatment strategies, the participating clinicians highlighted the importance of individualized patient care, effective communication, and a comprehensive approach that addresses both the physical and emotional aspects of this challenging condition. As research in vitiligo continues to advance, the insights from this discussion can help inform clinical practice and improve outcomes for patients worldwide.