Vitiligo in Clinical Practice: Expert Insights on Diagnosis, Comorbidities, and Treatment

"When you think about diseases that really impact someone's quality of life...vitiligo is right up there with alopecia areata and cystic acne," said an attendee at a recent Dermatology Times Case-Based Roundtable event. The event, led by Marc Serota, MD, a triple board-certified clinician in dermatology, pediatrics, and immunology/allergy, as well as the CEO of MD Integrations, focused on a patient-centered approach to vitiligo management. During the discussion, attendees analyzed 3 real-world cases presented by Serota, highlighting best practices in diagnosis, patient counseling, and emerging treatment strategies.

Case 1: A Woman With Vitiligo on the Face and Hands

A 35-year-old Black woman presented with depigmented patches on her face and hands, which had been progressively worsening over 6 months. She had a history of acne and autoimmune thyroiditis. The patient expressed significant distress about the visibility of her condition.

Autoimmune Link and Disease Explanation

Vitligo is often associated with other autoimmune conditions, and this case underscored the importance of evaluating patients holistically. One participant noted, "Autoimmunity begets autoimmunity. If you have one autoimmune disease, you're more likely to have another." The presence of autoimmune thyroiditis was a key factor in assessing the patient's overall immune function.

Challenging Areas for Treatment

Treating vitiligo on the hands is notoriously difficult due to the absence of hair follicles, which store melanocyte stem cells necessary for repigmentation. “The hands are difficult, [and are] probably the No. 1 area that we struggle with,” one expert explained. “The stem cells of your pigment cells are stored in the follicles. The more hair follicles you have in an area, the easier it is to get those stem cells to regenerate melanocytes. Where do you not have a lot of hair follicles? Your hands.”

Treatment Approach

The initial treatment plan included tacrolimus 0.03% ointment applied twice daily. However, some participants questioned whether this was the optimal choice. “Would you have picked tacrolimus, or would you have started with something else?” one dermatologist asked. The consensus leaned toward newer, more effective treatments such as ruxolitinib cream (Opzelura; Incyte Corporation).

Case 2: A 50-Year-Old Man With Progressive Vitiligo and Metabolic Syndrome

The next case was that of a 50-year-old man with a 2-year history of vitiligo affecting his trunk, limbs, and face. His medical history included type 2 diabetes, hypertension, and a body mass index score of 35. The patient expressed concern about the spreading nature of his vitiligo and its impact on his self-esteem.

Inflammation and Obesity in Autoimmune Disease

Obesity and metabolic syndrome contribute to systemic inflammation, which may influence autoimmune conditions such as vitiligo. A panelist noted, “One of the most hyperinflammatory cells in your body is a hypertrophied large fat cell.” The inflammatory state of obesity could exacerbate autoimmune processes, making treatment more challenging.

Phototherapy Considerations

The panelists discussed phototherapy as a potential treatment option, but raised concerns about its risks. One expert stated, “The thing I don’t like about phototherapy for vitiligo is...it is incredibly easy to burn someone. If you’re irradiating the skin with UV radiation over an extended period of time, you will cause someone to have skin cancer.” This highlights the importance of carefully selecting patients for phototherapy and closely monitoring their response.

Treatment Plan and Insurance Barriers

Given the patient’s widespread vitiligo, systemic treatments were considered, but access remained a significant barrier. “If the pharmacy says this costs $1000, we need alternative solutions,” one clinician remarked. Specialty pharmacies and patient assistance programs were suggested as potential solutions for affordability issues.

Case 3: A Woman With Facial and Hand Vitiligo With Irritation From Topicals

A 45-year-old woman with vitiligo affecting her face and hands experienced significant burning and irritation from previous treatments, including topical steroids and calcineurin inhibitors. She expressed frustration with the discomfort and lack of improvement.

Managing Adverse Events of Treatments

Topical treatments, especially calcineurin inhibitors, can cause burning and stinging. “Sometimes it’s not the efficacy but the tolerability that determines a treatment’s success,” one expert explained. “Tacrolimus and pimecrolimus can be very irritating, especially on delicate areas like the face and eyelids.”

Psychosocial Considerations and Camouflage Techniques

Addressing the emotional impact of vitiligo is essential. One dermatologist asked, “Do you walk into the room and say, ‘I can put myself in this person’s shoes’?” Although medical treatments are crucial, some patients benefit from immediate cosmetic solutions. “Dermablend is a great resource for patients. It provides instant gratification while they wait for longer-term therapies to take effect.”

Transition to Ruxolitinib Cream

Given her previous difficulties, the patient was transitioned to ruxolitinib cream, which she tolerated well. One clinician noted, “For me, [ruxolitinib] is first line in general, unless there’s a reason not to use it.”

Cross-Case Insights and Future Directions

Clinicians agreed that educating patients on the slow but steady progress of vitiligo treatment is crucial. “Unlike psoriasis, vitiligo treatment outcomes improve over time, so sticking with therapy is crucial,” an expert advised. Patients should be counseled to maintain adherence, as improvements may take months.

The group noted that access to newer treatments remains challenging. Clinicians discussed strategies for overcoming insurance denials, including using specialty pharmacies and manufacturer programs. “We have to fight to get these covered,” one participant emphasized, urging providers to advocate for their patients.

The discussion concluded with optimism about future systemic therapies. “We hope in the future we’re going to have some systemics as well,” one participant stated, referencing ongoing research into Janus kinase inhibitors and other targeted treatments.