Clinical Pearls for Vitiligo and Pigmentation Complexities: Part 3

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.

Ted Lain, MD, MBA, FAAD, a board-certified dermatologist and chief medical officer of Sanova Dermatology, hosted a Case-Based Roundtable discussion in Austin, Texas.

Case 1: 28-Year-Old Man in a Rush

The first case discussed was that of a 28-year-old South Asian man who noticed whitening of his skin roughly 3 years prior. Lain stated that primary care doctors originally diagnosed it as a fungal infection but saw no improvement with treating it as such. The man was engaged to be married and expressed a strong desire to get his condition under control before the wedding.

Misdiagnosis Among Skin Types

Although misdiagnosis from a primary care doctor is not uncommon, Lain and the participants debated the likeliness of misdiagnosis in different Fitzpatrick skin types. “In a patient with a higher Fitzpatrick skin type, where the depigmentation is more obvious, we don’t see a misdiagnosis as often,” Lain said.

In terms of clinical clues that may be helpful to their primary care colleagues in diagnosing vitiligo, the participants mentioned trichrome appearance, confetti depigmentation, Koebner phenomenon, and true whitening of the skin.

Treatment Options for Active Vitiligo

Because the patient was interested in rapid repigmentation, the forum noted that treatment would need to be started as soon as possible. The patient stated his self-confidence was rapidly decreasing due to his condition.

Previously, the patient was started on a combination therapy of topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI), with which he saw slight but short-lived success. With this in mind, the cohort agreed that the therapy needed to be much more aggressive.

When to Change a Treatment Plan

Lain stated that the roundtable landed on the topic of when to adjust or end a specific type of treatment. Although Lain said the answers seemed to be across the board, he noted the most common response was when results were not occurring quickly or plateaued.

For this patient, the cohort discussed pulse systemic steroids, a topical Janus kinase (JAK) inhibitor, phototherapy, or even a systemic JAK inhibitor. Overall, most felt comfortable starting the patient on a topical JAK inhibitor, with or without phototherapy or pulse steroids, for 3 months before reassessing his condition.

Lain discusses patient cases with fellow Texas clinicians.

Case 2: 50-Year-Old Woman With Facial Vitiligo

The second patient discussed was a 50-year-old Black woman who was experiencing extensive vitiligo on her face, genitals, and axillae. Although the other affected areas did not bother her, she stated her facial vitiligo made her client-facing public relations job difficult.

Challenges and Concerns

Lain stated that the patient had never previously seen a dermatologist, only ever using over-the-counter products and makeup to treat or cover her condition. The cohort discussed the difficulty of treating facial vitiligo, which they stated often looks worse before it looks better and can be difficult for the patient to deal with. Although Lain recognized the draw of over-the-counter medications and makeup to cope with the condition, he also noted the time commitment that comes with these options.

Because the patient was only concerned about her facial vitiligo, the colleagues discussed BSA within the decision-making process. The patient had a history of depression, leading them to decide that although only a small BSA was being targeted, they still wanted to be aggressive due to the location and her emotional health concerns.

Treatment Resistance and New Therapies

This patient originally had been started on a TCS and TCI treatment plan, with little to no success. Similarly, the patient saw no improvement with a vitamin D analog or UV light therapy. Finally, the participants discussed the topical JAK inhibitor ruxolitinib. Lain said the patient had success with the drug, noting signifi cant repigmentation and, even after discontinuing, maintaining a positive response. The participants did not see any restrictions on using ruxolitinib due to the safety data, but they did note the difficulty of educating patients on the drug’s mechanism of action. Lain stated he encouraged the patient to utilize the therapy long-term in any affected areas due to its overall efficacy and safety data.

Read part 1 featuring Andrew Alexis, MD, MPH, FAAD

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