Clinicians Weigh Vitiligo Treatment Strategies Across Age Groups

Cheri Frey, MD, FAAD, led a Dermatology Times Case-Based Roundtable dinner program in Austin, Texas, titled “Vitiligo in Practice: Case-Based Approaches for Patient Care.” Frey, residency program director and director of cosmetic dermatology at Howard University, guided attendees through 3 patient cases spanning different ages, disease presentations, and treatment histories.

Across the cases, clinicians discussed how they sequence topical therapies and phototherapy, where ruxolitinib cream may fit into treatment, emerging systemic approaches, and the practical barriers that can shape treatment decisions. Insurance coverage, work and school schedules, treatment tolerability, adherence, and the psychosocial burden of vitiligo emerged as recurring considerations.

Sequencing Topicals and Phototherapy for Limited Vitiligo

The first case involved a 33-year-old White woman with 7 months of progressive depigmentation. Her vitiligo began in the left axilla before spreading to her arms, legs, and chest, affecting approximately 8% of her body surface area (BSA). Her medical history included autoimmune thyroiditis, which attendees noted is among the most common comorbidities associated with vitiligo.

The location of the patient’s disease prompted discussion about topical corticosteroid potency and the sensitivity of areas such as the axilla. Several attendees said they would consider pairing a short course of topical corticosteroids with a calcineurin inhibitor or the topical Janus kinase (JAK) inhibitor ruxolitinib rather than relying on corticosteroids alone.

However, clinicians emphasized that treatment selection is not always determined solely by clinical preference. Insurance coverage can influence whether ruxolitinib is accessible as an initial therapy, with some clinicians first using less expensive topical options to document treatment failure before coverage is approved.

Phototherapy presented a different practical challenge. Although it may be appropriate for some patients, the need for repeated office visits can make treatment difficult to incorporate into work and other responsibilities.

“A small body surface area can still be really impactful, and the patient’s quality of life is important to consider,” one attendee said.

Frey emphasized that combination treatment is often necessary in clinical practice.

“For a lot of patients, when it comes to vitiligo, it’s not going to be just one thing,” Frey said. “Sometimes I’m doing two, three, sometimes even four things for them.”

The patient was offered twice-daily topical therapy along with phototherapy 2 to 3 times per week. Because of her work schedule, she elected to proceed with topical treatment.

Addressing Facial Vitiligo and Patient Distress

The second case involved a 29-year-old Black man whose depigmentation began on his arms approximately 2.5 years earlier. Over the previous 10 months, his disease had progressed to his face and torso. He had not previously received treatment, and the facial involvement was causing significant social distress.

Several attendees raised pulse-dose corticosteroids as a potential consideration for rapidly progressive disease, while others discussed emerging and off-label systemic JAK inhibitor approaches, including baricitinib.

The group also discussed camouflage products, including tinted BB and CC creams and products specifically designed for patients with vitiligo. However, clinicians noted that enthusiasm for camouflage products can vary substantially between the initial visit and follow-up.

“They come in wanting to treat, but sometimes when you see them at follow-up, they’re like, nah, I never want to use that,” one attendee said.

The case prompted broader discussion about the psychological burden of vitiligo, including cultural stigma, anxiety, depression, and the effect visible disease can have on patients’ social lives.

“Vitiligo, I feel like I’m not taking care of my whole patient if I do not address it, because it is very distressing for some patients,” Frey said.

Frey reviewed phase 3 data from the TRuE-V1 and TRuE-V2 trials evaluating ruxolitinib cream 1.5% in patients aged 12 years or older with nonsegmental vitiligo affecting 10% or less of total BSA. At week 24, approximately 30% of patients treated with ruxolitinib achieved at least a 75% improvement from baseline in the facial Vitiligo Area Scoring Index (F-VASI75), compared with approximately 7% to 11% of patients receiving vehicle, with statistically significant differences in both trials. Acne and application-site pruritus were among the most commonly reported adverse events and were primarily mild or moderate.

The patient ultimately initiated ruxolitinib cream 1.5%, with particular attention to addressing the facial involvement driving his distress.

Pediatric Vitiligo and Long-Term Ruxolitinib Response

The final case focused on a 14-year-old boy with a 2-year history of depigmented patches on his hands and legs and no family history of vitiligo or other pigmentary disorders.

He had previously received triamcinolone but discontinued treatment after approximately 4 months without improvement as the depigmentation continued to spread to his face and eyelids. He subsequently tried pimecrolimus but stopped shortly after initiation because of burning and stinging.

Attendees discussed several challenges that can complicate treatment in pediatric and adolescent patients, including parental concerns about long-term medication use, the logistics of fitting phototherapy around school, and the importance of ensuring that the adolescent patient is invested in treatment.

“Parents are at an all-time high in terms of their worry about what they are putting on their children,” one attendee said.

Another emphasized the importance of involving adolescents directly in treatment decisions.

“A 14-year-old boy has a lot of agency,” the attendee said. “If you do not have buy-in or motivation, it is going to be hard to adhere to any treatment.”

Following discussion with the patient and his parents, treatment with ruxolitinib cream 1.5% was initiated.

Frey also reviewed longer-term ruxolitinib data demonstrating that some patients with no or limited facial repigmentation after 24 weeks may continue to improve with prolonged treatment. In the analysis presented, approximately 40% achieved F-VASI75 by week 80, increasing to 55% by week 104.

Safety findings from pooled TRuE-V trial and long-term extension data showed low rates of adverse events associated with JAK inhibitor class warnings, including serious infections, malignancies, and thromboembolic events. The events were not considered treatment related, and no fatalities were reported.

“75% improvement is clinically meaningful,” Frey said.

The discussion highlighted that vitiligo treatment decisions extend beyond BSA alone. Disease location, progression, patient age, psychosocial burden, treatment access, tolerability, and willingness to adhere to therapy can all influence how clinicians construct an individualized treatment plan. Frey concluded the program by thanking attendees for sharing their experiences and encouraging continued feedback on areas where clinicians need additional vitiligo education.

References

1. Rosmarin D, Passeron T, Pandya AG, et al; TRuE-V Study Group. Two phase 3, randomized, controlled trials of ruxolitinib cream for vitiligo. N Engl J Med. 2022;387(16):1445-1455. doi:10.1056/NEJMoa2118828. New England Journal of Medicine
2. Harris JE, Papp K, Ezzedine K, et al. Open-label treatment extension of ruxolitinib cream in vitiligo: findings from the Topical Ruxolitinib Evaluation in Vitiligo (TRuE-V) long-term extension phase III study. Br J Dermatol. 2026;194(3):591-593. doi:10.1093/bjd/ljaf485. OUP Academic
3. Wolkerstorfer A, et al. Prolonged ruxolitinib cream treatment for vitiligo among patients with no or limited response in the first 6 months. J Eur Acad Dermatol Venereol. 2026. doi:10.1111/jdv.70402.