Treatment Goals in Vitiligo

Seemal Desai, MD: I love that we talked about quality of life, but let’s tie that into now treatment goals. How does quality of life and outlook tie into the patient’s treatment goals, versus your treatment goals as the doctor? And how do you do that shared decision-making? Because I think this is a really interesting dynamic in vitiligo.

Heather Woolery-Lloyd, MD: It is. It’s really important because what happens with vitiligo is we have, luckily now, a lot of treatments available, and we weren’t that fortunate in the past. So, I spend the time to sit down and say, “This is what’s available.” I write it down, I go through the list and say, “We can do this, we can do this.” Every treatment option has benefits and some drawbacks. For example, ultraviolet light, we can do light therapy and it’s great, but it’s time-consuming and I think it’s a little costly, because a lot of times people have to pay a co-pay every single time. But for someone who’s very motivated, it’s a great treatment option. I basically go through all of these options: I talk about topical therapy, systemic if needed, but generally I’m focused on topicals, light therapy. Then together we decide, “OK, this is what we’re going to try.” And it can change. It can fluctuate at every visit. The patient might say, “I didn’t realize how time-intensive UV light therapy would be. Now I want to kind of change gears. Let’s change directions.” Or look at home devices, because there’s home light also.

Seemal Desai, MD: Absolutely.

Heather Woolery-Lloyd, MD: I spend a lot of time discussing this with my patient, and together we come up with the best plan for that patient. There’s not one perfect treatment for vitiligo. It’s the best one for that patient.

Seemal Desai, MD: That is right on the money because I think this disease is so individualized, and I’m not saying other diseases in dermatology aren’t. But I feel like vitiligo is a very unique disease where every patient has a different interest. I want to share a comment on that that I had with a patient right before our filming just a couple days ago. But Nada, I think Heather teed you up perfectly because we were talking about treatment strategies. I want you to talk about your conventional treatment strategy approach. What is your layered approach to treating this disease? How effective are some of these conventional therapies, obviously most of which have been FDA off-label in our therapy experience?

Nada Elbuluk, MD: Yes, we certainly have a lot of things in our treatment armamentarium that can be very effective. It’s exciting that new things are coming out because we need to expand our options. And to Heather’s point, there’s not one recipe cookie-cutter thing for all people. You have to look at each case and see one, what are their goals. Some people don’t even want treatment, or they just want to treat a certain area. Then based on that, decide on what makes the most sense for them. I am a big fan of combination therapy, I think studies have shown that that’s the most effective approach.

Typically, with the topical therapies, I talk to them about topical steroids and topical immune-modulating creams, particularly calcineurin inhibitors, and using those, either one or both, depending again on body location, body surface area. If they’re 90% covered, you can’t be putting creams on all those areas, so you have to be realistic as well. I talk about the safety profile with them. Then phototherapy, I’m a huge fan of narrow-band UV-B therapy, either in the form of excimer for small, localized areas or full-body phototherapy if it’s more widespread. So, combining the topicals with the phototherapy at least 2 or 3 times a week ideally. Then I usually talk to them about vitamins and supplements, and there are some antioxidants that can help with disease stabilization and faster repigmentation. So that’s an easy thing to add. Then for people who are rapidly spreading, going back to what I was mentioning earlier about active disease, sometimes we bring in systemic medications like steroids to try to halt the progression of the disease. Those are usually things we talk about.

For a smaller subset of patients who either have segmental vitiligo or very stable nonresponsive vitiligo that’s localized, we can think about surgical therapies. There are multiple types of surgical therapies, the most recent and advanced being MKTP, or melanocyte-keratinocyte transplantation. Again, you have to assess everything and look at that spectrum to see what’s best for them and what they want to do.

Seemal Desai, MD: Speaking of the systemic steroids, because for those vitiligo emergencies, as I coined them, everyone probably has a different way of approaching that. Do you like the oral mini-pulse dexamethasone treatment, the Saturday/Sunday that we all like to do? Or do you like to do the intramuscular triamcinolone injections? The good old 60 mg/cc once a month. I know some people do it that way.

Nada Elbuluk, MD: Some people do, they still do that. I prefer the mini-pulse, 2 days in a row. I let them pick what 2 days they’re going to be. Weekends are often easier to remember. But I find that tends to work with lower adverse effect profiles, so I prefer that.

Seemal Desai, MD: I do too. Is everyone on board with that? I was trained to stabilize using….

Heather Woolery-Lloyd, MD: I was about to say that.

Seemal Desai, MD: You were, exactly, right? It worked.

Heather Woolery-Lloyd, MD: Yes. That’s how I was trained. But you’re right, the newer trend is to do the mini-pulse.

Seemal Desai, MD: I think that works really well. And I know you do that a lot also in alopecia areata [AA], right, Brit, when you first get started with that?

Brittany Craiglow, MD: Yes. In AA, I usually have a longer duration and not weekly, but yes.

Seemal Desai, MD: Yes, it works as well.

Transcript edited for clarity