Treatment Options for Vitiligo

Heather Woolery-Lloyd, MD: Vitiligo is luckily gaining a lot of attention and research. It’s an exciting time for vitiligo. What treatment options do you consider? Is there a standard of care when it comes to treating our vitiligo patients?

Ted Lain, MD: Until recently, there wasn’t a standard of care because nothing was FDA-approved. Everybody had their own basket of treatment options that you would pull from depending on what you have in your office. For those of us who have the full body Narrow UVB [narrowband ultraviolet B] or a PUVA [psoralen plus ultraviolet A], that was a good option, especially for someone like Tarasha who has vitiligo affecting her full body. Light bots would be a great option for her.

Others of us have Exuma laser, which is more meant for smaller areas. We use that UVB wave light just on smaller areas. We have tried topical steroids and topical calcineurin inhibitors [TCIs]. Of course, you can’t use steroids for very long, so you are going to have to get on and off of those and cycle them with the TCIs. But now we have what I consider the true standard of care, which is the topical ruxolitinib, which is the only FDA-approved treatment for vitiligo. It’s approved for the nonsegmental vitiligo, which is the vitiligo that tends to affect the vast majority of our vitiligo patients, thankfully. Segmental vitiligo usually occurs in very young patients that tends to happen very quickly in one half of the body or one area of one half of the body versus nonsegmental, which takes a more indolent course and affects maybe a larger area of the body. It tends to respond better to treatment than segmental vitiligo. There’s the difference there. So right now, long-winded answer. But I think ruxolitinib topically is the standard of care. Then again, it’s only FDA-approved for 10% or less of body surface area.

Heather Woolery-Lloyd, MD: What do you do when someone isn’t responding as expected?

Ted Lain, MD: A lot of it has to do with patient request. I’ll give a new treatment at least 3-4 months before deciding if we need to alter or change. I try and really hand hold with the patient through that time so that the expectations are set correctly. If between the 4-6 months we are not seeing much, I will either completely change course or add more treatments to the whole regimen in order for us to achieve some kind of re-pigmentation. Honestly, much of what we do now is off-label and some of it can be difficult to get covered by insurance. It’s important to be sure the patient is insured appropriately for their treatment. If they are underinsured or uninsured, what can I do to get them the treatment? Is it going to be covered by a patient assistance program? There’s so many thoughts going through my head as I think about treatment options for my patients.

Heather Woolery-Lloyd, MD: If we are offering the best treatments, we have to hope it’s covered by insurance. We have to be patient because it takes a long time to re-pigment, so we don’t want to switch therapies too soon because that therapy might work. It really is a complex disease to treat because there are so many variables that influence efficacy of a treatment.

Transcript edited for clarity