Combining Phototherapy and Topicals to Maximize Repigmentation Success

Despite advances in understanding and treatment, management of vitiligo poses numerous challenges, including psychosocial impact, variable response to therapy, and access barriers. A recent Dermatology Times Case-Based Roundtable, led by Erik Domingues, MD, of Modern Dermatology of Massachusetts, provided a platform for clinicians to exchange insights rooted in real-world experience. The discussion highlighted current approaches and evolving therapies that are shaping modern vitiligo care across various patient populations.

Case 1: Navigating the Psychosocial and Medical Aspects of Vitiligo

The roundtable commenced with a case emphasizing the increasing societal awareness of vitiligo but underscoring ongoing stigmatization in certain cultures. The patient, a 26-year-old man, presented with progressive depigmentation on the cheeks, chin, and forearms over the course of a year. His vitiligo had become more extensive, and the distress associated with social interactions was palpable.

Attendees recognized that societal attitudes toward vitiligo are gradually shifting due to heightened disease awareness, but stigma persists, especially in specific cultural contexts. Domingues highlighted that: “Vitiligo is more stigmatizing in certain cultures, and this stigma can add further to the decreased quality of life burden of vitiligo.” This understanding influences a holistic approach to management, integrating psychological support alongside medical treatment.

On the treatment front, most clinicians in the roundtable favored ruxolitinib cream as a first-line therapy. The consensus was that its rapid efficacy for facial vitiligo makes it preferable, with some attendees noting, “most attendees prefer to use ruxolitinib cream first line due to its efficacy both for facial and non-facial vitiligo.” However, the challenge remains in insurance coverage. As Dr. Domingues pointed out, “insurance access remains an issue with TCS and TCI’s typically being required first,” which often necessitates initial regimen limitations.

The team agreed that this monotherapy approach with ruxolitinib is increasingly common, especially given its targeted mechanism and favorable safety profile. Nonetheless, setting realistic expectations and emphasizing patience during the repigmentation process, acknowledged to take as long as 2 years, remains critical.

Case 2: Addressing Comorbidities and Broad-Spectrum Management

The second case involved an adult patient with extensive vitiligo covering large areas of the body, bringing to light the importance of recognizing associated comorbidities. Clinicians delved into common autoimmune conditions such as thyroid disease and others like alopecia areata and connective tissue disorders, which often coexist with vitiligo.

Attendees learned that management must be comprehensive. Specifically, they discussed the potential role of combination therapies, including phototherapy, to enhance repigmentation in patients with larger BSA involvement. Notably, Domingues mentioned that “some payers are covering excimer laser for vitiligo as this chronic autoimmune condition is increasingly recognized as a medical and not cosmetic condition,” indicating an evolving landscape in insurance support for these treatments.

Phototherapy, either narrowband UVB (NBUVB) or excimer laser, was highlighted as a valuable adjunct, especially when combined with topical agents like ruxolitinib. The importance of early recognition of comorbidities was emphasized to tailor management plans effectively. For example, thyroid function tests and screening for other autoimmune diseases should be part of the initial workup, reinforcing a multidisciplinary approach.

Case 3: Treating Pediatric and Adolescent Patients

A particularly informative case focused on treating vitiligo in children and adolescents. Because the psychosocial impact can be profound in this demographic, clinicians emphasized the importance of early and effective intervention. The case involved an adolescent patient with vitiligo on the face and hands, where treatment goals included not only repigmentation but also maintaining the child's quality of life.

Attendees discussed the efficacy of topical ruxolitinib in pediatric patients. Domingues remarked, “treating adolescent patients with topical ruxolitinib cream is efficacious,” and stressed the importance of motivating young patients through regular follow-up and photographic documentation. Setting expectations that visible improvement might take “at least 6 months to start noticing repigmentation” was deemed essential for maintaining patient motivation and adherence.

Furthermore, the discussion touched on the psychosocial considerations—parents' concerns and the negative impact on socialization—highlighting the need for education and support. An important clinical insight was the use of photographs and frequent follow-ups to keep young patients engaged and hopeful.

Evolving Therapeutic Frontiers

Throughout the roundtable, clinicians explored new frontiers in vitiligo management. Several attendees discussed the potential of combination therapy, especially in progressive or stubborn cases. The use of phototherapy alongside topical ruxolitinib proved particularly promising, with some noting that “combo therapy with phototherapy was helpful,” especially in extensive disease.

Another noteworthy topic was the emerging role of oral JAK inhibitors, such as povorcitinib, upadacitinib, and ritlecitinib. Domingues highlighted, “the use of oral JAK inhibitors was another teaching point,” recognizing their potential for rapid and extensive repigmentation in select cases.

It was acknowledged that repigmentation can take considerable time, sometimes exceeding 1 year, but with combination approaches, responses are often expedited. Such developments signal a shift toward personalized, targeted therapy that addresses the autoimmune basis of vitiligo more effectively.

Conclusion

Domingues emphasized the importance of knowledge-sharing, stating: “these roundtables are extremely valuable as they allow attendees to share their treatment and management of a specific skin condition and without the limitations of only discussing on-label use of medications.” The discussion underscored the necessity of individualized treatment plans, patience, and comprehensive care—addressing both the physical and emotional burdens of vitiligo.

The roundtable reinforced current best practices, highlighted promising emerging therapies, and stressed the importance of holistic management. Building on shared clinical experiences, clinicians can better navigate the challenges posed by vitiligo to improve patient outcomes and quality of life.