Vitiligo: Understanding Your Options 

Showing up is half the battle, it has often been said. According to dermatologist Nanette Silverberg, MD, FAAP, FAAD, chief of pediatric dermatology at Mount Sinai Health System in New York, that adage applied to the attendees at a recent YoungMD Connect virtual session featuring two expert presentations on treating vitiligo. 

“Those of you attending are already doing something more than many of your colleagues because you are taking the time to think about vitiligo and to invest in how to treat it,” Dr. Silverberg said. 

THE LATEST IN VITILIGO TREATMENTS 

Dr. Erik Domingues, a dermatologist at Southcoast Health in Massachusetts, gave the first talk, “Vitiligo Uncovered: Exploring the Latest Advances in Treatment and Care.” His presentation included a summary of his own protocol for vitiligo patients, which starts with a review of systems. 

“We know that patients with vitiligo can have other autoimmune conditions,” he said, citing as examples type 1 diabetes, anemia, thyroid disease, atopic dermatitis (AD), connective tissue disease, alopecia areata, hearing loss, and uveitis. Dr. Domingues said he then performs a complete skin examination to rule out melanoma using a Wood’s lamp. 

“They could actually have a response to the melanoma where now the melanocytes in the rest of the skin are being affected as well,” he added. 

Dr. Domingues noted that he often does not spend much time checking lab work because most of his patients are screened frequently by their primary care physicians, but that he may sometimes check TPO antibodies or screen for CBC. 

Dr. Domingues emphasized the importance of looking for signs of rapidly progressing disease is critical, particularly for those signs that require the dermatologist to “really jump on their treatment.” He recommended looking for confetti-like macules, Koebner phenomenon, trichrome vitiligo, and involvement of all 10 fingertips. 

Dr. Domingues also discussed treatment options, including camouflage with makeup, topical steroids, topical calcineurin inhibitors, narrowband UVB therapy, excimer laser therapy, ruxolitinib 1.5% cream, and oral mini pulse dexamethasone. 

IMPORTANCE OF EARLY TREATMENT 

Dr. Silverberg’s presentation (entitled “Vitiligo: Treat Early, Treat Often”) focused on the need for early treatment and different treatment options, as well as barriers to care. She stressed the importance of early diagnosis and initiation of therapy before the condition spreads, suggesting treating with multiple agents to speed repigmentation. Dr. Silverberg called her approach the “ice cream sundae” model, consisting of the following steps: starting with approved anti-inflammatory medications or other topical agents that have been demonstrated to work, adding treatments such as narrow-band UVB to control the spread, and finally emphasizing maintenance after achieving stabilization and repigmentation. 

Dr. Silverberg also suggested combining agents and minimizing the risk of high-risk agents through short-term usage, and highlighted a JAMA Dermatology article that she co-authored in 2024 providing evidence supporting the use of topical calcineurin inhibitors, topical corticosteroids, and topical Janus kinase (JAK) inhibitors as effective therapeutics.¹ She was careful to caution that various therapies should be used with caution in patients under the age of 12, and that “everything, under the age of 12, is off-label for vitiligo so no matter what you choose, it will be off-label.” 

Dr. Silverberg conceded that some patients or parents will not agree to the suggested therapy or level of therapy, but advised that doctors should leave the door open, as JAK inhibitors and grafting can be effective many years later. 

Disclosures: Dr. Domingues is a consultant and speaker for Pfizer, Incyte, Bristol Myers Squibb, Galderma, and Arcutis; he is a consultant for AbbVie, Janssen, and Castle Biosciences. Dr. Silverberg is an advisor and speaker for Incyte, L’Oréal, Pelthos, Regeneron/Sanofi, and Verrica, and an investigator for Avita; she has received grants from ACDS, Incyte, PeDRA, and Vitiligo Research Foundation. 

YoungMD Connect (YMDC) is an editorially independent platform. YMDC would like to extend its gratitude to Incyte as a Silver platform sponsor. Sponsorships help us bring these valuable workshops to our members. 

1. Renert-Yuval Y et al. Expert Recommendations on Use of Topical Therapeutics for Vitiligo in Pediatric, Adolescent, and Young Adult Patients. JAMA Dermatol. 2024;160(4):453-461. doi: 10.1001/jamadermatol.2024.0021. 

NANETTE SILVERBERG, MD, FAAP, FAAD 

• Chief of Pediatric Dermatology, Mount Sinai Health System, New York, NY 

ERIK DOMINGUES, MD, FAAD 

• Board-certified dermatologist, Southcoast Health, Fall River, MA