What’s New in the Medicine Chest: Vitiligo

In a recent interview with Dermatology Times, James Del Rosso, DO, a dermatologist based in Las Vegas, Nevada, offered insights into the management of refractory pediatric vitiligo, emphasizing the potential of emerging therapies and the importance of real-world applications alongside clinical trials. The pearls Del Rosso shared were a portion of his presentation at Winter Clinical Miami 2025 titled, “What’s New in the Medicine Chest?”

"Vitiligo is very challenging," Del Rosso explains, highlighting the complexities of treating the condition. Current treatment modalities include topical ruxolitinib which is a Janus kinase (JAK) inhibitor available in a 1.5% formulation. Approved for use in adolescents and adults, this cream is applied twice daily and has shown significant efficacy. According to Del Rosso, "We realize that treatments for vitiligo, regardless of what they are, take time." This underscores the need for patient and provider patience in observing results over extended periods.

The focus of Del Rosso's discussion shifts to refractory pediatric cases, where standard treatments may fall short. In these cases, alternative off-label therapies have been explored. One such therapy involves topical roflumilast cream, a 0.3% phosphodiesterase-4 (PDE4) inhibitor initially approved for plaque psoriasis. "This was an off-label use for vitiligo in refractory cases," Del Rosso notes, adding that a case report series demonstrated the cream’s safety and effectiveness. The mode of action—PDE4 inhibition—may play a role in mitigating the underlying inflammation associated with vitiligo.

Data published in the Journal of Clinical and Aesthetic Dermatology supports these findings. Case studies included photographs illustrating successful outcomes, especially in areas notoriously difficult to treat, such as the dorsal hands and distal fingertips. "There are some cases shown there with some photographs," Del Rosso says, encouraging further exploration of the journal for detailed information.

One compelling example involved the use of oral upadacitinib, a tyrosine kinase 2 inhibitor, for dorsal hand vitiligo. Del Rosso recounts a young male patient without significant comorbidities who experienced favorable results after taking 15 mg daily. "This is from a friend of mine, Dr. Michael Cameron," he adds, emphasizing that all baseline testing and safety considerations were addressed. Although off-label, the treatment proved effective, broadening the horizon of potential options for refractory cases.

Another notable case shared by Del Rosso involved a 61-year-old male treated with topical ruxolitinib for dorsal hand vitiligo. "He had a very rapid response within 4 months, which is quicker than what you typically see," Del Rosso points out. This accelerated repigmentation highlights the potential for real-world applications to sometimes outperform results observed in clinical trials. Del Rosso concludes, "The proof is in the pudding, sometimes in the real world that we have to recognize what we’re doing. We have to look at risk versus benefits."

While clinical trials remain vital for establishing efficacy and safety parameters, Del Rosso noted they often include restrictions that may not fully reflect real-world scenarios. The flexibility of off-label use and anecdotal evidence offers valuable insights, particularly for refractory cases. As Del Rosso’s experiences suggest, the management of pediatric vitiligo requires a multifaceted approach, balancing evidence-based practices with innovative applications tailored to individual patient needs.

To read and listen to more of our conference coverage, click here.

Click here for more insights from Del Rosso, including the full interview with Dermatology Times on his presentation at Winter Clinical 2025.