Experts review the benefits and adverse effects of off-label treatments for patients with vitiligo such as corticosteroids, tacrolimus, pimecrolimus, or calcipotriene (in combination with corticosteroids).
Heather Woolery-Lloyd, MD: Now, let’s talk a little bit about other treatments for vitiligo. We know that vitiligo can be managed with off-label treatments like corticosteroids, calcineurin inhibitors like tacrolimus and pimecrolimus, calcipotriene, all of these alone or in combination. What are the benefits and [adverse] effects when you think about these types of treatment options? Renata, we’ll start with you, but I’d love to hear also [Dr Kindred’s]perspective on this, too.
Renata Block, PA-C: With these treatments, the goal is to restore the color. We know off-label [uses], until ruxolitinib was FDA approved; we were using corticosteroids, and we have to use them for quite some time, but obviously long-term [their use] can lead to striae and atrophy of the skin. You can’t be putting it on the face or the neck long-term.... When we have calcineurin inhibitors, then people are worried about this black box warning [with regard] to the [adverse] effects and the risk of lymphoma or skin cancer. You have to be creative in your approach to these prescriptions. Again, [in] off-label use, they do work well. I’ve had great results and subpar results. I’m so excited about this new FDA-approved novel therapy that we can offer to our patients and not worry about atrophy, striae, or the other concerns with the products that we have been using.
Heather Woolery-Lloyd, MD: Right. I agree because I have used all of those, everything on that list. Corticosteroids, tacrolimus, pimecrolimus. I’ve used less calcipotriene and haven’t used it that much in my practice. [Dr Kindred], tell me a little bit more about the products that you’ve used prior to these newer FDA-approved medications.
Chesahna Kindred, MD, MBA, FAAD: Yes. [With regard] to their [adverse] effects and benefits, we’re caught between the corticosteroids being more effective and worrying about atrophy and [adverse] effects vs tacrolimus or pimecrolimus, and I don’t use calcipotriene either, where we can apply them even to normal skin and not worry about atrophy. I just don’t see the results that I would see with a corticosteroid. Then you have some patients who are unreasonably scared of cortisones and probably because of things out in popular media and having to deal with that. I deal more with people who are scared of using a corticosteroid than I do with people worried about the black box warning by the calcineurin inhibitors, actually. To get results, we end up combining it with phototherapy; we have a handheld phototherapy device, and it’s faster with the 2. Even though I live in suburb land, it is still impractical with the phototherapy. When I was training, we actually played around with vitiligo surgery. That tells you how desperate we can be to try to find that sure thing when it comes to treatment for vitiligo.
Heather Woolery-Lloyd, MD: Yes, I agree with you in that we’re always looking for things. [One] of the things that we do in my practice is we’ll even say, “get sunlight.” I’m lucky to be practicing in this very sunny climate with a very high UV index. I always try to explain to my patients that we want to first calm the immune system down, but we also need to stimulate those melanocytes to turn back on and start making pigment again. That’s where phototherapy has its strength because it really kick-starts those melanocytes. If you happen to live in a sunny climate, if the patient eats lunch outside every day for 10 minutes, I always explain [that they should do it] with sunscreen. Patients with vitiligo should definitely be wearing sunscreen, but you can get a little kick start to those melanocytes. I love this discussion of these treatment options, and we all have our little tricks and things that we do to help this very challenging condition.
Transcript edited for clarity.