Role of HCPs in the Management of Vitiligo

Amit G. Pandya, MD, FAAD: When I’m talking with patients, I make several points. One of the most important points I tell them is that it takes time for melanocytes to migrate and repigment areas of depigmentation, it doesn’t happen quickly. Melanocytes can come in from the edges, but can also come from the base of black hairs, migrate up the sides of the hair and the outer root sheath, and then fill in the epidermis, and this takes time. I must set expectations with patients and inform them that, with treatment that includes topicals, phototherapy, and oral therapy, they can expect on average a 25% improvement in 3 months, 50% improvement in 6 months, and 75% improvement in 9 months; after that, it often plateaus. I can’t guarantee that they will have 90% or 100% repigmentation, but on average those are the numbers that we see in various studies. Areas like the hands will do less well, and areas like the face will do better, and I let them know that.

I also discuss different aspects of prognosis. For example, if they have areas with white hairs, and I use a dermatoscope to look at the small vellus hairs, if I see that most of their hairs are white, they have a poorer prognosis versus those who have all pigmented hairs. Younger patients tend to have a better prognosis than older patients. If they’ve had vitiligo for less than 2 years, they also have a better prognosis than those who have had it for more than 2 years, especially for 10 years or longer. Areas that are prone to trauma, such as elbows, knees, ankles, wrists, hands, and feet, tend to do worse than areas that are not exposed to trauma. Areas that have less concentration of hair follicles, such as the clavicle, do worse than areas that have a higher concentration of hair follicles, such as the face. These are some of the points that I communicate. I also tell patients that I look for signs of activity. I look at their skin and see if they have confetti-like lesions, or trichrome vitiligo, where the borders of the vitiligo lesions are hypopigmented or blurred. I also look for the Koebner phenomenon. If they have those type of lesions, then I know they have more active disease. I talk to them first about stabilization, then repigmentation, and finally maintenance of therapy. I tell them that we must stop the disease from spreading, and then we must try to repigment the lesions. Once we have repigmented, we must reduce the frequency of phototherapy and the application of topicals, and find what type of maintenance treatment will maintain their disease in that improved state without it returning.

Compliance is extremely important to achieve success in the treatment of vitiligo. When I see patients come back, I try to evaluate several things. I ask them how many treatments they are getting, and if they’re getting phototherapy. Typically I treat 3 times a week, for example, Monday, Wednesday, and Friday, and I ask them if they’re getting 12 treatments per month. I often look at their medical record if they come into my clinic to see how many times they have come in. Patients must try to come in for the majority of their treatments, I would say 75% or more, in order to get good results. I look for compliance from that standpoint. I also look for refills, are they asking for refills of the topicals on a routine basis or are they still on that first tube 6 months later? In which case I know that they’re not using it properly, and I’ll ask them how many times a week they apply it, and how many applications they get in 1 week with their topical. I’ll also ask about the oral therapy, for example, we’ll give dexamethasone mini-pulse therapy for patients with very active vitiligo, and I’ll ask them how they’re doing with that, and whether they’ve had any adverse effects. With the examination of their skin, I’m often able to correlate the improvement with their compliance. Patients who are less compliant will not show improvement percentage wise when it comes to stabilization and repigmentation of their skin.

Transcript Edited for Clarity