Practical Pearls for Managing Vitiligo Across Skin Types and Life Stages

In a recent Dermatology Times Case-Based Roundtable event, “Case Conversations in Vitiligo: Practical Pearls for Complex Patient Presentations,” Seemal Desai, MD, FAAD, led fellow dermatology clinicians through 3 complex patient scenarios, offering clinical insights and practical pearls for treating uniquely challenging cases of vitiligo.

Desai, founder of Innovative Dermatology in Plano, Texas, and a clinical assistant professor at UT Southwestern, moderated the session in Dallas, Texas. The discussion focused on new therapeutic approaches, especially the efficacy and use of topical ruxolitinib (Opzelura; Incyte), and the emotional, diagnostic, and long-term management challenges associated with the condition.

“We talked about treatments of vitiligo, especially using new topical therapies with an emphasis on topical ruxolitinib as the first FDA-approved treatment to repigment nonsegmental vitiligo,” Desai said. “We also talked about diagnostic techniques and also therapeutic challenges for vitiligo patients, including access, psychological burden, and understanding of the disease from a complex autoimmune perspective.”

Case 1: Initiating Topical Treatment for First-Time Therapy

The first case involved a 28-year-old African American man who initially noticed small, depigmented patches on his cheeks 2 years prior. While the disease had remained stable early on, he reported significant spread within the past 12 months, with new and larger patches appearing on both cheeks, hands, and forearms. He had never pursued treatment before but was now motivated to act, citing emotional distress and social discomfort.

“The main treatment challenge that we pointed out to attendees [was that adherence] and the need for long-term management is critical,” Desai explained.

Given the patient’s distress and the visible involvement of facial areas, attendees discussed treatment options that would support both clinical repigmentation and quality of life. The patient was initiated on topical ruxolitinib cream 1.5%, with Desai emphasizing the importance of individualized, proactive therapy regardless of disease duration.

“Patients oftentimes present with variable duration of their disease, [and] topical ruxolitinib can be incorporated into the therapeutic treatment as the first-line topical therapy for patients regardless of how long they've had their vitiligo,” Desai said.

Case 2: Stabilizing Rapidly Spreading Disease

The second case featured that of a 35-year-old White woman presenting with large, depigmented patches affecting her back and elbows, covering approximately 8% of her body surface area (BSA). Her vitiligo had spread rapidly over a matter of months, and her medical history was notable for autoimmune thyroiditis. She had used topical corticosteroids inconsistently in the past but discontinued them due to difficulty applying them to hard-to-reach areas and limited benefit.

“The need for stabilizing these patients—they have very active disease—the need for making sure the disease isn't worsening, and then how to incorporate topicals, phototherapy, and others into that treatment regimen [are all important to discuss],” Desai said.

In this case, excimer laser phototherapy was selected, with twice-weekly sessions to target the extensive areas of involvement. Attendees explored the role of excimer laser in patients with less than 10% BSA involvement, citing its ability to selectively target depigmented areas and its demonstrated synergy when used with topical calcineurin inhibitors.

“Knowing how to treat long term, really emphasizing counseling patients, also screening for comorbidities, and talking about psychological impact,” Desai said, are aims of the comprehensive care needed to treat patients, which includes autoimmune screening and patient education.

Case 3: Supporting Adolescents and Families

The third case highlighted a 15-year-old adolescent with vitiligo localized to the face and hands. The patient and her family were frustrated following unsuccessful attempts with multiple topical therapies. She had discontinued triamcinolone after 3 months due to a lack of improvement and stopped tacrolimus because of burning and stinging sensations. Her family history was negative for pigmentary disorders.

Given the psychosocial implications of facial vitiligo in adolescents, attendees discussed strategies for setting expectations and providing family-centered support. The patient was ultimately initiated on ruxolitinib cream 1.5%.

“It’s a younger patient, so you have to manage family anxiety, patient anxiety, and self-esteem issues—really talking about the need for that durable repigmentation, the fact that repigmenting vitiligo takes a long time, and [the] need to use both topicals, and, in some cases, use other therapies, as well,” Desai said.

Attendees emphasized the importance of realistic timelines for response, particularly in pediatric patients who may lose motivation without visible early results. Adherence strategies, open communication, and gradual goal-setting were discussed as key components of success.

Clinician Response and Therapeutic Enthusiasm

Reflecting on the conversation overall, Desai described strong clinician engagement, particularly around new data and therapeutic tools.

“I think we had a really great discussion,” he said. “There was a lot of discussion and a lot of excitement about ruxolitinib. There was a lot of excitement about the data from the clinical studies. There was a lot of discussion on how to incorporate phototherapy and when to use systemic steroids. I think everyone got a lot out of it.”

Attendees also considered treatment sequencing, safety considerations in pediatric and adult populations, and the challenges of treatment access and insurance coverage for newer therapies like ruxolitinib.

Conclusions

Desai’s expert-led discussion offered attendees actionable pearls for managing complex vitiligo presentations across skin types and age groups. From choosing first-line topicals and laser phototherapy to supporting psychosocial well-being and navigating treatment access, the roundtable emphasized a tailored, long-term approach to care.