The October Case-Based Peer Perspective supplement of Dermatology Times includes a collection of thought-provoking discussions and strategies surrounding tips for managing complex vitiligo cases from Andrew Alexis, MD, MPH; Ted Lain MD, MBA; Chesahna Kindred, MD, MBA; and Pearl E Grimes, MD. Be sure to read the highlights from the supplement below. Also, don’t miss a moment of Dermatology Times by signing up for our eNewsletters and subscribing to receive the free print issue and supplement each month.

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.

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Part 2

Chesahna Kindred, MD, MBA, FAAD, a board-certified dermatologist and founder of Kindred Hair & Skin Center in Marriottsville, Maryland, hosted a Case-Based Roundtable discussion in Washington, DC.

Case 1: 35-Year-Old Woman With History of Acne

Kindred’s first case involved a 35-year-old Black woman who presented with depigmented lesions on the hands approximately 6 months after onset. She had a history of acne and autoimmune thyroiditis.

Topical Ruxolitinib for the Hands

“We noted how difficult it is to treat vitiligo on the hands,” Kindred said. “There are just not as many hairs to donate melanin.”

Kindred and attendees discussed the flexibility of ruxolitinib monotherapy to be used on various locations such as the face and hands—a challenge with traditional corticosteroids.

Insurance and Other Barriers

Roundtable attendees also discussed insurance barriers inhibiting ruxolitinib access for patients. Many of the clinicians shared that topical tacrolimus tends to be their first-line treatment option.

Phototherapy, another preference of clinicians, can be challenging due to location of depigmented lesions. Patients with skin of color more often than not forgo treatment due to concerns about the contrast in pigmentation.

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Part 3

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.

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Part 4

Pearl E. Grimes, MD, FAAD, director of The Grimes Center of Medical and Aesthetic Dermatology, clinical professor of dermatology at UCLA, and founder and director of the Vitiligo & Pigmentation Institute of Southern California in Los Angeles, hosted a Case-Based Roundtable discussion in Beverly Hills, California.

Case 1: 45-Year-Old White Woman With Comorbidity

To start the discussion, the colleagues discussed the case of a 45-year-old White woman who had received a diagnosis of vitiligo 10 years ago. The patient had patches of depigmentation on her hands, periorbital area, face, neck, and extremities. Grimes noted her BSA was 10% and that she had a 20-year history of atopic dermatitis (AD).

Case Challenges and Considerations

“When you address any patient with vitiligo, it’s so important to understand
vitiligo’s impact on quality of life and burden of disease,” Grimes said.

The patient was previously treated with clobetasol propionate, with which she had no adverse effects but also experienced low efficacy. With this in mind, the patient was then prescribed tacrolimus ointment and recommended NB-UVB phototherapy due to the extent of her disease. She initially showed some success with the treatment, but the results were not sustained, and she reported mild sunburn after several sessions.

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