Clinical Pearls for Vitiligo and Pigmentation Complexities: Part 1

In a series of Dermatology Times Case-Based Roundtable events, 4 dermatologists led discussions for local colleagues to delve into complex cases of vitiligo. Clinicians reviewed clinical considerations for care, effective management and treatment strategies, and more. Each meeting allowed participants to engage in thought-provoking discussions related to vitiligo care and collaboratively delve into varying presentations of vitiligo. These insights from the events held in New York; Washington, DC; Texas; and California highlighted the combined expertise and commitment to enhancing patient care.

Andrew Alexis, MD, MPH, FAAD, a board-certified dermatologist and professor of clinical dermatology at Weill Cornell Medicine, hosted a Case-Based Roundtable discussion in New York, New York.

Case 1: 60-Year-Old Man With Family History

The first case involved a man aged 60 years with a 5-year history of vitiligo. The patient reported a positive family of vitiligo, with both his mother and sister also having vitiligo. The patient reported dissatisfaction with previous health care providers and treatment options.

“There was an overwhelming agreement that this is a pretty common scenario in our practices, where patients come in having this diagnosis for quite some time and have not found a therapy that they’re satisfied with,” Alexis said.

Patient Adherence

Previously, the patient had been treated with tacrolimus 0.1% ointment and mometasone cream without clinical success. Mometasone cream was applied on a 2-weeks-on/2-weeks-off basis. Clinicians had also recommended excimer laser therapy as an adjunct to topical therapy, but the patient did not complete this.

Roundtable attendees discussed the importance of considering treatment adherence when initially evaluating a patient and their treatment history.

Facial Depigmentation and Stigma

The patient had presented with depigmentation affecting approximately 50% of the body surface area (BSA) of his cheeks, chin, forehead, and scalp. Androgenetic alopecia had partially exposed the lesions localized to his scalp.

“We had a robust discussion about the challenges of patients who suffer from facial vitiligo and other highly visible areas and the stigmatization these patients face,” Alexis said.

Alexis noted that the patient expressed embarrassment and stated that he often felt the need to cover areas of depigmentation with cosmetics.

Shared Decision-Making

Alexis and the patient discussed next steps for treatment and decided to start with topical ruxolitinib 1.5% (Opzelura; Incyte) cream to be used twice daily.

“We had a discussion about what is an appropriate follow-up period,” Alexis said. “Most of us agreed that 3 months is a pretty good time point to check in on early progress, even though we know that there’s a lot more progress to be achieved with additional months.”

Six months later, the patient returned with almost complete facial repigmentation and excellent clinical response. The patient reported a strong sense of overall satisfaction with the treatment’s ease of application and lack of resulting skin irritation.

Case 2: 49-Year-Old Woman With New Onset Vitiligo

Alexis speaks with dermatology clinicians from New York.

The next case involved a 49-year-old Black woman with a history of vitiligo whose depigmented lesions had developed over the course of 2 months. She had previously achieved repigmentation, and her condition had been under control until the onset of lesions on her abdomen, thighs, and forearms. She had previously been treated with tacrolimus ointment.

Varying Clinical Presentations

Her new lesions presented as macules measuring 1 to 3 mm in diameter, or a confetti-like presentation of vitiligo.

“This is one of the various clinical markers of unstable, rapidly progressive vitiligo,” Alexis said. “This is something that requires escalation beyond just topical therapy.”

Attendees discussed clinical subsets and markers of vitiligo associated with rapid disease progression, including confetti-like lesions, Koebner phenomenon, and trichrome vitiligo.

Treatment Escalation

The patient was then prescribed therapy with 4 mg of oral mini-pulse dexamethasone to be taken once daily for 6 weeks. This treatment was followed by narrowband (NB) UVB treatment combined with simultaneous tacrolimus 0.1% ointment. Following insurance approval, ruxolitinib 1.5% cream was added.

Within 6 weeks, the patient experienced stabilization of disease. In the following months, her vitiligo lesions had demonstrated gradual repigmentation.

Case 3: 66-Year-Old Woman With Widespread Disease

Alexis’ third patient case involved a 66-year-old Black woman with a history of vitiligo. She presented with depigmented patches affecting her upper back/neck, face, chest, and axillae, and she had previously been treated with tacrolimus ointment. After 3 months of phototherapy, she returned for follow-up, and topical ruxolitinib 1.5% cream was added to the regimen.

Body Surface Area Considerations

Alexis and attendees used this case to delve into clinicians’ comfort levels with BSA application thresholds for ruxolitinib.

“We know the label says 10% for vitiligo,” he said. “We also know the label says 20% for atopic dermatitis. There were some varying degrees of comfort around the table about pushing the limits beyond 10% off label.”

Treatment Dissatisfaction Resolved

Three months into treatment, the patient was dissatisfied with the limited clinical response. Alexis emphasized that it was important to engage in re-education with patients and emphasize the chronic, complex nature of vitiligo.

“With vitiligo, it’s typically a marathon, not a sprint,” Alexis said.

Alexis shared that he and the patient discussed the option to continue NB-UVB therapy, emphasizing the importance of greater consistency, such as increasing to 2 sessions per week, which may have been easier with an at-home phototherapy unit.

The patient opted to continue in-office NB-UVB treatment in combination with topical ruxolitinib cream. She then decided to start using an at-home NB-UVB unit to remain consistent with treatment. After 10 months, she returned with considerable follicular repigmentation. Use of an at-home unit allowed the patient to remain consistent with treatment.

Read part 2 featuring Chesahna Kindred, MD, MBA, FAAD