PracticalDermatology

Although there are still gaps in our medical knowledge about vitiligo, dermatologists are slowly learning more about the pathogenesis of this complicated disease and finding better and more targeted treatments. Here, Dr. Nada Elbuluk, MD, MSc, FAAD, Clinical Assistant Professor at USC Department of Dermatology as well as director of the USC Skin of Color Center and Pigmentary Disorders Clinic, discusses some of the advances.

1. We Do Know JAK.

“As we understand more about the pathogenesis of vitiligo, we are able to target specific pathways, instead of treating the condition with broader-acting medications. Janus kinase (JAK) inhibitors are showing promise in the treatment of vitiligo. We know that the JAK pathway is involved in the pathogenesis of vitiligo, and we have seen cases of successful repigmentation in several small studies examing oral and topical JAK inhibitors. At this time, no JAK inhibitors are FDA approved for vitiligo, but clinical trials with both topical and oral JAK inhibitors are underway. Vitiligo experts hope that if these trials are successful, JAK inhibitors can be covered by insurance companies as another vitiligo treatment option.”

2. Combinations are king.

“Multi-modal therapy is the best way to treat vitiligo in my opinion. For example, phototherapy in combination with topical steroids and/or immune modulating creams tends to provide better improvements in repigmentation than using those treatments as monotherapies. Similarly, early studies on JAK inhibitors have found them thus far to be more successful in combination with low dose phototherapy.”

3. There’s no one-size-fits-all vitiligo treatment.

“Vitiligo can be more complicated than people realize. There are many subtypes, including segmental vitiligo and non-segmental vitiligo. Non-segmental vitiligo can also include subtypes, such as confetti, trichrome, koebnerizing, and inflammatory vitiligo, all of which can indicate more disease activity and which may require more aggressive therapy.”

4. Vitiligo is more than skin deep.

“Vitiligo can have profound effects on self-esteem and psychological well-being. It’s important to assess where patients are emotionally and psychologically during their visits to better guide treatment decisions. In addition to psychotherapy, support groups can be extremely helpful for vitiligo patients.

“The disease can be very isolating, and talking to others who know how you feel and sharing tips can make a big difference.”

5. Patients may be happier with less.

“Not every patient wants full body treatment for vitiligo. Some may just be bothered by visible patches on exposed areas like the face. An open discussion with patients about their goals for treating their vitiligo and expectations about prognosis can lead to better overall patient experiences. In one study, when doctors were asked what percentage of repigmentation vitiligo patients wanted in order to feel satisfied with their treatment, the doctors’ answers were different than the patients’ signifying physicians and patients may have different definitions of treatment success.”

6. Compliance and combination therapy are key.

“If a patient is dissatisfied with the results of treatment, it could be that they didn’t use the therapy long enough to see a result. Some will say ‘I tried X once for two months and didn’t see any improvements.’ They may need to use it longer or be on it with other treatments to see a benefit.”

7. Better surgeries exist.

“Surgical treatment options for vitiligo continue to be modified and improved. A noncultured melanocyte-keratinocyte transplant procedure can provide excellent results for segmental vitiligo or focal areas of nonsegmental vitiligo in patients who have had no change in disease state for at least six months to a year.”

8. Vitamins and supplements are a mixed bag.

“The data is quite limited, but certain antioxidants may help stabilize disease including ginkgo biloba, polypodium leucotomos, khellin, vitamins C and E, and alpha lipoic acid. It’s important to ask patients what supplements they may already be taking and to ensure the supplements don’t interfere with other medications or medical conditions.”

9. The future looks bright.

“There are a host of new targeted therapies and biologic drugs aimed at various pathways involved in psoriasis, and I hope that in the future we will see a similar paradigm in vitiligo. In addition to JAK inhibitors, other new drugs are being studied. For example, amelanotide is an emerging treatment that is a long-lasting synthetic analog of alpha-melanocyte–stimulating hormone (α-MSH). It is delivered as a subcutaneous implant, and the results are promising. When we combine this implant with phototherapy, we have seen positive results. One limitation of this drug, however, may be diffuse darkening of normal skin tone as well.”

10. Insurance coverage for vitiligo treatments is still lacking.

“We still need better insurance coverage for vitiligo treatments. It is really frustrating that we have to battle with insurance companies for vitiligo treatments—even those that are standard therapies that we have been using for years with success. I’d like to see more treatments with FDA approval and insurance coverage.”