Experts Develop Evidence and Consensus-Based Recommendations for Diagnosing and Treating Vitiligo in Young Patients

Experts recently developed evidence and consensus-based recommendations for the diagnosis and treatment of vitiligo, particularly regarding the use of topical therapeutics, in pediatric, adolescent, and young adult patients. The consensus statement, published in JAMA Dermatology,¹ fulfills an unmet need, as researchers Renert-Yuval et al noted that guidelines for vitiligo have not been developed since 1996--yet not for pediatric patients.

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In October 1996, guidelines for the care of vitiligo were published in the Journal of the American Academy of Dermatology.² To the knowledge of researchers, this is the most recent set of guidelines developed for the treatment of vitiligo. However, they note that prior to these new recommendations, there are no known, published guidelines that address vitiligo in a young patient population.

Researchers developed and reviewed a protocol for the development of questions prior to consulting a medical librarian who developed additional protocol for identifying relevant literature. Using PubMed and related search terms including, "pediatric," and "vitiligo," researchers conducted a literature search. Two researchers reviewed the findings, vetting published papers that involved data related to pediatric vitiligo, a case series with a minimum of 6 patients, and those that were published in English.

Upon determining which papers met criteria, the articles were graded utilizing the Strength of Recommendation Taxonomy and regraded using the Oxford Centre for Evidence-based Medicine's Levels of Evidence and Grades of Recommendation. Evidence was graded with quality, patient-oriented nature, and other evidence such as consensus guidelines, disease-oriented evidence, and more.

Based on evidence available to researchers, clinical guidelines were developed. After the development of guidelines, researchers and stakeholders completed a Likert scale survey, with statements achieving 70% agreement or strong agreement being considered consensus.

General Definition, Diagnosis, and Recommendations

Experts agreed upon a definition of vitiligo, including methods for diagnosis and confirmation of diagnosis. These include Wood lamp examination for confirmation of diagnosis and extent of disease and biopsy, conducted at the edge of a lesion, in instances where a diagnosis cannot be clinically determined, such as with Wood lamp examination in an in-office setting.

In addition to defining best practices for diagnosis and evaluation, experts noted it is crucial to consider closer observation for more concerning signs, which may require more aggressive therapy. These include confetti depigmentation, halo nevi, Koebner phenomenon, leukotrichia, non-hair-bearing anatomical sites, and young age coupled with diffuse nonsegmental disease.

Experts agreed upon the use of topical steroids, topical calcineurin inhibitors, and UV-B light therapy as the standard of care in young patients. Combination therapy, they noted, may enhance the initial repigmentation response in some patients.

Topical Calcineurin Inhibitor Recommendations

Regarding topical calcineurin inhibitors, experts agreed that topical tacrolimus and/or pimecrolimus are to be considered first-line therapies for pediatric patients ages 2 to 18 years and young adults, with standard protocol of application in this population being twice daily for 3 months minimum.

Additionally, experts agreed that this class of topicals are effective in most areas of the body, with the most efficacy in the head and neck regions. They also appear to be effective in patients of all Fitzpatrick skin types, they noted, with a potential for greater efficacy in patients with darker skin types.

It was also recommended that clinicians counsel patients on the risk of adverse events such as burning, itching, and stinging, particularly upon initiation of treatment.

Topical Corticosteroid Recommendations

Topical corticosteroids may also be utilized as a first-line therapy, experts agreed. However, it should be noted that in instances of lesions affecting thinner skin, clinicians may need to consider this class of topicals to be a second-line therapy.

Clinicians are also advised to counsel patients regarding a risk of atrophy, with regular monitoring for atrophy recommended while topical corticosteroids are in use.

Topical JAK Inhibitor Recommendations and Psuedocatalase Recommendations

In patients ages 12 years and older, experts recommended that topical JAK inhibitors be considered a first or second-line therapy, though not for patients of a younger age due to more limited evidence. Off-label use may be warranted in younger children, but it is recommended that it be used in cases of limited body surface area affect pursuant to future absorption data. It is also possible for topical JAKs to be applied to areas of the body with thinner skin and risk of atrophy.

Counseling for this class of topicals was also recommended in this age group, particularly with mention of adverse events such as application site reactions and acne.

However, experts concluded that there is not yet sufficient evidence to recommend pseudocatalase in this young patient population due to variability between formulations.

Future Directions

"To our knowledge, these guidelines are the first to address the addition of tJAKi in topical therapeutics," experts concluded. "Suggested next steps include development of a long-term vitiligo registry and head-to-head short- and long-term comparisons of all 3 major classes of topical therapy. Future studies of vitiligo should aim to identify the role of early intervention as a means of controlling long-term disease activity and preventing T-memory cell accumulation."

References

1. Renert-Yuval Y, Ezzedine K, Grimes P, et al. Expert recommendations on use of topical therapeutics for vitiligo in pediatric, adolescent, and young adult patients. JAMA Dermatol. Volume 160 (4). March 13, 2024. Accessed March 20, 2024. doi:10.1001/jamadermatol.2024.0021
2. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for vitiligo. American Academy of Dermatology. J Am Acad Dermatol. 1996;35(4):620-626. October 1996. Accessed March 20, 2024. doi:10.1016/s0190-9622(96)90691-x