Modern, Multi-Modal Approaches to Repigmentation in Patients with Vitiligo

“Vitiligo is really hard to treat. There’s no right or wrong. I think the best is yet to come… there’s still a lot more that needs to be done,” Christopher Bunick, MD, PhD, said at a recent Dermatology Times Case-Based Roundtable event.

Bunick, Associate Professor of Dermatology at Yale School of Medicine and Editor-in-Chief of Dermatology Times, led an interactive discussion on vitiligo management in New Haven, Connecticut. The program’s 3 real-world cases focused on topical therapies, integration with phototherapy, psychosocial burden, and real-world barriers such as access and adherence.

Case 1: Periocular Vitiligo in a 7-Year-Old Boy

The first case involved a 7-year-old boy with a 4 to 5-month history of new-onset periocular depigmentation at the right lateral canthus and a family history of vitiligo. Audience polling showed a near-unanimous preference for topical calcineurin inhibitors (tacrolimus 0.1%) as initial therapy in pediatric facial disease.

“Many attendees utilize tacrolimus in combination with topical corticosteroids, and this combination is a valid cost-effective approach for patients who may not have access to, afford, or must pass through step-therapy to get to ruxolitinib,” Bunick noted. This case presented in Bunick’s clinic before topical ruxolitinib (Opzelura; Incyte) was available, so he utilized a combination approach:

• Tacrolimus 0.1% ointment twice daily, Monday to Friday
• Triamcinolone acetonide 0.1% cream once daily, Saturday to Sunday
• 10 to 15 minutes of natural sunlight, 3 times weekly (as feasible in Connecticut)

The clinicians promoted pulsed topical corticosteroids to balance efficacy and long-term safety around the eyes, noting potential risks of glaucoma and cataracts with prolonged use. At 18 months, the periocular lesion had fully repigmented, and the patient remained clear on a prolonged maintenance regimen with pulsed weekend steroid use, without significant safety concerns.

“Not all depigmented patches will have the melanocytes completely dead… but the longer you go, the greater the chance it goes from quiescent to gone. I think that's why I'm aggressive with kids, they do better,” Bunick said at the event.

Case 2: 24-Year-Old Male with Facial and Forearm Vitiligo

The second case highlighted an adult with progressive nonsegmental vitiligo involving the cheeks, chin, and forearms over 12 months, with significant psychosocial distress related to head and neck involvement. This higher body surface area (BSA) raised questions about topical feasibility and durability of response, prompting a discussion on when to add phototherapy versus relying on topicals alone.

Many attendees favored topical ruxolitinib cream, 1.5%, as a first-line or early-line facial therapy, when insurance permitted, citing simplicity of use, safety, and tolerability. Phase 3 data from the TRuE-V1/V2 trials showed ~30% of patients achieving F-VASI75 at 24 weeks on the face and gradual gains out to 104 weeks, with roughly half of patients achieving clinically meaningful facial responses at 2 years.

For larger BSA and extremity disease, attendees commonly combined topical ruxolitinib, calcineurin inhibitors, and/or topical steroids (often pulsed) with narrowband UVB or excimer laser, when access allowed. However, cost and insurance denials were considered major barriers to newer agents.

The group also discussed societal awareness—from historical depigmentation therapy (eg, monobenzone) to evolving representation in media and advertising—and its impact on patient perception, stigma, and willingness to pursue treatment. “How to properly counsel on the psychosocial impact of vitiligo was identified as a practice gap, and clinicians need to have the proper resources to help patients deal with the psychosocial impacts,” Bunick noted.

Expectations must always be set regarding clearance and stabilization, particularly in notoriously refractory areas like the hands and feet. “I never promise I'll get 100%. I like the under‑promise, over‑deliver approach,” Bunick told attendees. “Our goal is to keep things stable. That's the first victory. If we get repigmentation, that's a great bonus.”

Case 3: Truncal and Elbow Vitiligo in a 29-Year-Old Female

The third case was a 29-year-old woman with rapidly spreading vitiligo of the back and elbows, involving ~8% BSA and an underlying autoimmune thyroiditis. She had tried topical corticosteroids but discontinued due to difficulty applying them to the back and achieving minimal repigmentation. Given the non-facial location, BSA approaching 10%, and the practical challenges of self-application, the group favored phototherapy, particularly excimer laser or narrowband UVB. In this case, twice-weekly excimer laser (≈308 nm UVB) was selected as a way to:

• Deliver targeted therapy to depigmented patches
• Spare normal skin
• Achieve responses comparable to narrowband UVB in some studies, especially when combined with topical calcineurin inhibitors

However, some practical barriers were emphasized by attendees, including copays per session, multiple weekly visits, travel distance, and limited phototherapy availability. “I love phototherapy…combining everything together – topical plus phototherapy – is just superior,” one clinician said. “The problem is there are a lot of logistical challenges: copays, time, work schedules.”

Photographic documentation is important to demonstrate incremental gains along with regular follow-up to sustain adherence. Home phototherapy units could also be considered in selected, motivated patients.

Conclusion

Across all 3 cases, the clinicians repeatedly returned to core principles: early and aggressive treatment in children, realistic timelines, combination topical–phototherapy strategies, and robust psychosocial support and education to sustain long-term management in a chronic, stigmatizing disease. Bunick praised the tremendous educational value in getting multiple providers together to hear about their approaches to vitiligo in this case-based setting.

“There is no better way to learn than through the collective experience of your colleagues, and round tables offer a unique way to hear from and discuss with your peers exactly how they currently manage skin disease, but also how they anticipate changing with forthcoming innovation. I certainly found it very educational and helpful for my future vitiligo care,” he concluded.