Putting Progress Into Practice for Patients With Vitiligo: Part 1

Across a trio of Dermatology Times Case-Based Roundtable events held nationwide, 3 board-certified dermatologists joined peers in Texas and California to dissect the clinical challenges and treatment nuances of vitiligo. Through lively, in-depth conversations, participants tackled real-world patient scenarios, offering diagnostic insights, therapeutic strategies, and practical pearls from their own experiences.

The roundtables were moderated by Seemal Desai, MD, FAAD; Ted Lain, MD, MBA, FAAD; and Pearl Grimes, MD, FAAD. Desai, founder of Innovative Dermatology in Plano, Texas, and a clinical assistant professor at The University of Texas Southwestern, led the Dallas-based session. Lain, chief medical officer at Sanova Dermatology in Austin, facilitated the Austin event, while Grimes, founder and director of the Vitiligo & Pigmentation Institute of Southern California, hosted the discussion in Los Angeles.

Each clinician guided peers through 3 complex patient cases, highlighting differences in disease severity, comorbidities, psychosocial impact, and treatment history.

Case 1: Early Progression, Facial Involvement, and Initiating Topical Therapy

In the first scenario, all 3 roundtable moderators presented a similar case: a young adult patient with vitiligo affecting the cheeks, forearms, and hands, with initial stability followed by noticeable spread. The shared challenge across the cases involved how to initiate treatment—particularly topical therapy—in a patient newly motivated to seek care, with visible lesions contributing to emotional distress and reduced quality of life.

In Dallas, Desai presented the case of a 28-year-old African American man who had never pursued treatment but was now concerned about spreading lesions on the face and forearms.

Desai emphasized the need for durable treatment planning and adherence: “The main treatment challenge that we pointed out to attendees [was that adherence] and the need for long-term management [are] critical.”

He noted that facial repigmentation often has higher success rates, and the patient was initiated on topical ruxolitinib cream 1.5%. “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.

In Los Angeles, Grimes moderated a similar discussion involving a 25-year-old Black man with progressive vitiligo. While the patient had lesions on multiple body areas, the facial involvement and its psychosocial impact became a focal point.

“I started the discussion by defining vitiligo as the trifecta of genetics, oxidative stress, [and] autoimmunity,” Grimes explained. “And I told the attendees that the tenets of treatment are stabilization, repigmentation, and then being able to maintain repigmentation long term.”

Grimes also referenced a large global study in JAMA Dermatology that explored vitiligo’s impact on quality of life, reinforcing the importance of clinician sensitivity to patient distress and aesthetic goals.¹ Like Desai, she recommended topical ruxolitinib as a first-line treatment, citing its favorable safety profile in the TRuE-V1 (NCT04052425) and TRuE-V2 (NCT04057573) phase 3 trials.² She acknowledged payer barriers but advised that proactive prior authorization can often secure access.

Grimes also outlined her approach to lab monitoring—typically annual or biennial—and stressed the value of prompt intervention to optimize outcomes.

In Austin, Lain led the case discussion with a similar clinical profile. During the exam, erythema within the patient’s lesions raised the possibility of an inflammatory subtype, prompting attendees to discuss treatment responsiveness.

“We weren’t sure how that would affect his response to treatment—whether it’s inflammatory, not stable, or progressive,” Lain said. “There are various different articles to support the idea that each one is more resistant than the other, so it’s really difficult to say.”

Attendees also considered follicular density and how that influences repigmentation success.

“We knew that this patient, while just starting treatment on his face, might get a better response than on his arms, and how that may affect his [adherence],” he added.

Lain also highlighted a major theme shared across all 3 events: limited access to phototherapy.

“Most of us don’t have full-body units anymore, or if they are available, the coverage from payers is horrible,” Lain said. “So we really have to lean into the different topicals and/or systemic agents that are available to us.”

Read part 2 here

References

1. Bibeau K, Ezzedine K, Harris JE, et al. Mental health and psychosocial quality-of-life burden among patients with vitiligo: findings from the global VALIANT study. JAMA Dermatol. 2023;159(10):1124-1128. doi: 10.1001/jamadermatol.2023.2787

2. Rosmarin D, Passeron T, Pandya AG, et al. TRuE-V Study Group. Two phase 3, randomized, controlled trials of ruxolitinib cream for vitiligo. N Engl J Med. 2022;387(16):1445-1455. doi: 10.1056/NEJMoa2118828