Nada Elbuluk, MD, and David Rosmarin, MD, share their thoughts on future treatments in the pipeline for vitiligo.
David Rosmarin, MD: Are there other treatments that are in the pipeline that you are particularly excited about?
Nada Elbuluk, MD: I’m excited about the oral JAK [Janus kinase] inhibitors. Those are going to have a place in our treatment armamentarium. Currently, the topical ruxolitinib is limited to 10% body surface area. As you know, we have many patients who have much more than that. The oral JAK inhibitors will have a role for our patients with more widespread disease, and we’ll still probably be doing it. Although it’ll probably be able to be used as a monotherapy, but we will still have cases where we’re doing it with phototherapy specifically. I’m excited about that and some of those to get approval. Getting ruxolitinib approved was huge for the vitiligo community. People don’t realize it’s the first FDA-approved treatment for repigmentation for vitiligo. Everything else we’ve been doing is off-label because it hasn’t gained FDA approval. I’m excited about that.
There’s a treatment called afamelanotide that had its first clinical trials come out a while ago, and 1 had some nice success; it caused overall tanning and darkening to the skin more diffusely. For many patients, particularly those with darker skin, that was something many of them were OK with, because they were excited about the overall repigmentation. That’s another interesting one.
As we’re understanding the immunology of vitiligo more, there are other treatments. The data with the IL [interleukin]-15 are exciting and seeing where that study goes is exciting because—for those who don’t know—that’s related to the fact that patients can get vitiligo back in patches where they’ve already repigmented, and it’s related to your memory T cells reigniting it in the same areas. So potentially, through blockade using an antibody located on an IL-15 receptor, we might be able to reverse that. That’s from some of John Harris’ work.
I tell my patients it’s an exciting time for vitiligo. It’s garnering the attention we’d always hoped it would on different levels, particularly in the research world and the industry world. As that happens, we’re hopefully going to be seeing a lot more options coming out and a lot more immune-targeted therapies. How about yourself?
David Rosmarin, MD: I agree with those options you mentioned—some of the oral JAKs that are in development, and there’s a place for both topicals and orals. Topicals are great for those who have localized disease. We want to maximize safety. Even though the label is for up to 10%, I will use it in larger surface areas based on the fact that there are phase 2 data. There’s the MUSC [Hollings Cancer Center] trial for maximal use. It’s safer than giving an oral, even if you go beyond that body surface area.
However, orals are important for patients who have progressive disease. You have to keep a topical after new lesions. With an oral, you don’t have to do that. You’re treating everywhere. Additionally, if you have lots of little spots and the surface area is quite high, again, an oral is just a lot simpler than having to put on a cream every day. There’s a need for both.
What is also exciting in the pipeline, as you mentioned, is the anti–IL-15 to try to target those skin-resident memory T cells, which will hopefully lead to a long-lasting recurrence. There’s an ongoing study right now by the Immune Tolerance Network, where we’ll hopefully get our first patient data in the next few years. We also have a study on the blue snakeweed plant, which is a phytoceutical. It looks like it has a terrific safety profile, but we want to prove this is an effective option for patients, so that study is ongoing. There’s also a procedure that will hopefully bring melanocyte transfer into the office to make that a bit easier, which is by RECELL. That’s also exciting.
There’s a lot to look forward to, and it’s been a big milestone with the approval for ruxolitinib cream. It’s the first one for repigmentation, and what’s nice is that there’s now a pathway to follow for clinical trials and for regulatory approval for some new options. Hopefully this approval is just the start. We need more options beyond that. I completely agree.
Nada Elbuluk, MD: Yes. There are great things coming down the pipeline—more options for our patients—and it’s exciting.
Transcript edited for clarity