Improving Care and Innovations in Vitiligo and Atopic Dermatitis: Part 1

In a recent Dermatology Times Case-Based Peer Perspective custom video series, “Patient Cases Shedding Light on Vitiligo Management,” Terry Faleye, MPAS, PA-C, shared perspectives on managing difficult cases of vitiligo. Faleye, a dermatology physician assistant practicing at DermSurgery Associates in Houston, Texas, presented patient cases to colleagues at a roundtable event to invite discussion on complex manifestations.

Case 1: A 35-Year-Old Female Patient With Vitiligo

The first patient case discussed was a woman aged 35 years who presented with depigmented patches on her face and hands. She had experienced these symptoms for 6 months before seeking dermatological evaluation. According to Faleye, this presentation is typical, with many patients delaying care.

Initial treatment involved tacrolimus 0.3% ointment, but results were modest. Faleye noted, “In clinical practice, many of us were having truly seen that type of benefit with using tacrolimus monotherapy.” After several months, however, the patient began to show some signs of repigmentation.

To enhance results, they added phototherapy, but accessibility posed challenges. “There were probably 3 to 4 other colleagues who had phototherapy...the rest of us either had to send patients to another facility or academic centers,” Faleye explained. Many patients may struggle to maintain phototherapy sessions due to their demanding schedules, Faleye noted.

Despite these barriers, the combination of tacrolimus and phototherapy yielded impressive results. “After instituting phototherapy, along with tacrolimus, it was observed that the patient had noticeable follicular repigmentation. After 4 months, there was complete repigmentation,” Faleye reported. This significant improvement was maintained for 9 months after treatment discontinuation.

Terry Faleye, MPAS, PA-C

Case 2: A South Indian Female Teacher With Vitiligo

Faleye also discussed the case of a South Indian female teacher aged 42 years with significant depigmented patches on her face, neck, and hands, having dealt with vitiligo for 5 years. “The visibility of her spots on her face, on her neck, and really in places where she really couldn’t hide was of concern to her,” she said.

The emotional impact of vitiligo is especially pronounced for professionals like teachers, who face constant visibility, Faleye remarked. This case highlighted the emotional toll of living with progressive skin conditions.

Faleye also explored the cultural aspects of vitiligo. She noted, “It was interesting talking about the cultural implications...we know that vitiligo affects all Fitzpatrick types, but we dialogued the difference between South India and North India.” She pointed out that lighter skin is often viewed as more desirable, affecting patients’ treatment preferences.

Some patients may choose to depigment rather than seek repigmentation therapies. Faleye explained, “Some patients get to a place where they’re like, ‘I’m now trying to depigment some of the other areas on the skin to even out the area.’”

Initially treated with a topical steroid and calcineurin inhibitor, the patient experienced significant irritation, leading the team to switch to pimecrolimus. Unfortunately, this approach also failed to deliver lasting results. Faleye recounted, “Patient went on to pimecrolimus and achieved mild repigmentation for about 2 months, then started developing more spots.”

The discussion raised the question of how to help patients who experience diminishing treatment returns. “What do we do [for] patients like [them]?” Faleye emphasized the importance of addressing the emotional and psychosocial challenges alongside medical management.

The group agreed to transition the patient to ruxolitinib cream, a Janus kinase inhibitor. The patient started on ruxolitinib 1.5% twice daily, with an emphasis on the importance of vehicle choice for adherence and satisfaction. Faleye noted, “Transitioning to something more elegant, like a cream, would be a better option,” especially for patients with complex skin care routines.

The discussion also highlighted the challenges of obtaining prior authorization for ruxolitinib. “Many found challenges in regards to prior authorization...sometimes the fear of not getting approval can be disheartening,” Faleye said.

This led to a broader discussion about the burden of insurance barriers on patient care and the potential for bridging programs and specialty pharmacies to help alleviate these challenges. Faleye emphasized the need for ongoing advocacy to ensure patients receive timely access to necessary treatments.