Treatment Insights and Evolving Care Options in Vitiligo

In a recent Dermatology Times Expert Perspectives custom video series filmed during the 2024 Fall Clinical Dermatology Conference, Karan Lal, DO; Lisa Swanson, MD; James Song, MD; Andrew Alexis, MD, MPH; and Lawrence Eichenfield, MD, discussed the complexities of vitiligo care and the potential of innovative topical therapies.

In the series titled “Exploring Disease Burden and Advancements in Topical Therapies for Vitiligo,” the clinicians explored individualized treatment approaches, the importance of family education, and the evolving landscape of therapeutic options that promise to enhance the quality of life for those living with vitiligo.

Individualized Treatment for Pediatric Vitiligo

Lal, the first and only dual fellowship-trained pediatric and cosmetic dermatologist at Affiliated Dermatology in Scottsdale, Arizona, emphasized individualized approaches to manage vitiligo in children and adolescents.

While treatment options are particularly limited for younger patients, Lal said he often combines topical therapies with phototherapy for enhanced outcomes. For children younger than 12 years, for whom FDA-approved treatments are unavailable, he typically employs a cyclical routine of topical steroids and calcineurin inhibitors along with an excimer lamp to increase efficacy.

“When we use topical therapies with phototherapy, you get better results,” he explained.

For patients 12 years and older, topical ruxolitinib is a viableoption, though Lal carefully monitors for potential adverse effects, including acneiform eruptions in acne-prone patients. He further tailors treatment plans based on severity, body area, and psychosocial impact, with Wood lamp imaging used in follow-ups to visualize progress, supporting adherence by allowing patients and parents to see gradual repigmentation.

Family Engagement and Education

Swanson, a dermatologist and pediatric dermatologist in Boise, Idaho, working at Ada West Dermatology and St Luke’s Children’s Hospital, focuses on educating families to create a supportive environment for children with vitiligo.

“I try to give them the nitty-gritty of vitiligo in the exam room,” she shared, explaining vitiligo as an autoimmune process where the body mistakenly targets pigment-producing cells. Swanson said she also clarifies misconceptions around the condition, noting, “It’s very common, and we have treatment available.”

Swanson highlights the importance of parental modeling, recounting her own experience with a visible hemangioma during childhood to emphasize that family perspective shapes a child’s self-image. She said she envisions systemic advances like Janus kinase (JAK) and IL-15 inhibitors as promising options for stopping vitiligo progression, particularly in widespread cases, while also underscoring telehealth’s potential to assist with follow-ups.

Advances in JAK Inhibition

Song, the chief medical officer at Frontier Dermatology, discussed advances in vitiligo treatment, particularly the success of topical ruxolitinib 1.5% cream, which has been FDA-approved as a repigmentation therapy option.

He shared that after a year of regular application, nearly 50% of patients experience significant facial repigmentation, although response on the hands may be limited due to the presence of fewer hair follicles. Song said he also sees potential in new oral JAK inhibitors, such as upadacitinib and povorcitinib, which may eventually replace systemic steroids and offer safer, long-term solutions.

He explained that JAK inhibitors target specific cytokines including IL-15, CXCL9, and CXCL10, which could make them safer than broader immunomodulators. Discussing findings from the phase 3 TRuE-V trial (NCT04896385), Song emphasized the therapy’s safety, noting minimal systemic absorption and only mild side effects, such as occasional acne, over a 2-year period.

Addressing Emotional Impact and Patient Expectations

Alexis, a board-certified dermatologist and professor of clinical dermatology at Weill Cornell Medicine, underscored the need to address the emotional aspects of vitiligo and manage patient expectations. By fostering open-ended discussions about treatment goals, dermatology clinicians can better develop personalized plans that meet individual needs. Alexis suggests ruxolitinib cream and narrowband UV-B phototherapy as initial treatments, while systemic therapies or autologous transplants are considered in more severe cases.

He differentiated approaches between segmental and nonsegmental vitiligo, noting the importance of targeted strategies for segmental cases, which are typically more stable. He also emphasized follow-up appointments to adjust care as needed and establish a trusting, supportive environment, reminding patients that lasting repigmentation is a gradual process.

Evolving Landscape of Pediatric Vitiligo

Eichenfield, a pediatric dermatologist at the University of California, San Diego, and Rady Children’s Hospital, discussed the key differences of vitiligo onset and progression in children and adolescents compared with adults. He emphasized early detection, especially with signs of high-risk progression such as halo nevi or trichrome depigmentation, and outlined the initial evaluation process to differentiate vitiligo from other skin conditions.

Psychological support is essential because vitiligo can significantly impact self-esteem and social interactions, particularly in teenagers. Eichenfield advocates for proactive and open communication between families and health care providers, stressing the importance of shared decision-making in managing all aspects of the disease. He also highlighted new topical therapies and systemic treatments, including ruxolitinib, that can provide hope for improved patient outcomes.

“We want to explain [to parents] that we continue to have evolution in the field of interventions, which will give both a positive perspective towards management and treatment,” he noted.