Roundtable Discussion Weighs Access and Adherence Challenges in Vitiligo Care

Raj Chovatiya, MD, PhD, MSCI, clinical associate professor at Rosalind Franklin University Chicago Medical School and founder and director of the Center for Medical Dermatology and Immunology Research in Chicago, recently led a Dermatology Times Case-Based Roundtable event in Nashville, Tennessee, guiding a discussion among dermatology clinicians on vitiligo care across age groups, skin types, and disease extent. The program reviewed 3 patient cases spanning newly progressive disease, widespread facial involvement, and pediatric onset.¹

Choosing First-Line Therapy for Newly Progressive Vitiligo

The first case was a 37-year-old woman whose depigmentation had spread from her left axilla to her arms, legs, and chest over 6 months, now covering approximately 8% of her body surface area (BSA), with a history of autoimmune thyroiditis. Attendees discussed how much extent should push treatment toward a systemic approach versus topical monotherapy.

"I still think topical therapy is absolutely within reach," an attendee said.

Several attendees described insurance pushback when combining topical ruxolitinib (Opzelura; Incyte) with phototherapy, noting payers often cite the absence of a labeled statement supporting the combination. Others raised recurring denials for home phototherapy units, with vitiligo sometimes classified as cosmetic rather than medically necessary. On systemic options for stabilizing active disease, Chovatiya noted the evidence base is limited.

"Methotrexate, mycophenolate, cyclosporine; the data's pretty poor actually for vitiligo," Chovatiya said.

The group also discussed steroid phobia among patients considering traditional topicals, with several attendees noting patients increasingly resist corticosteroids after encountering warnings about withdrawal on social media. The patient ultimately chose topical ruxolitinib therapy twice daily along with phototherapy 2 to 3 times weekly, preferring to try the topical approach first given her work schedule.

Addressing Facial Vitiligo and Its Psychosocial Toll

The second case involved a 29-year-old man whose depigmentation had been stable and localized to his arms for 2 years before spreading to his face and torso over the prior 9 months. The new facial involvement was causing him significant distress and social avoidance.

"It's very widespread, so I feel like topical therapy here is going to be very challenging," an attendee said. "You're going to have to pick an area if you're going to do topical."

Chovatiya walked through the textbook markers of active disease, including confetti-like depigmentation, trichrome vitiligo, and Koebner phenomenon, though he noted he relies more on patients' own reports of progression in daily practice. Attendees compared shared decision-making in vitiligo with more established paradigms in psoriasis and alopecia areata, and several mentioned early data on oral JAK inhibitors such as povorcitinib (Incyte) and ritlecitinib (Pfizer) moving through the pipeline. One attendee said patient preference between topical and oral options is often the deciding factor.

"I think it'll be patient-specific. I have patients who hate topicals and all they want is oral: ‘Just give me a pill,’" an attendee said.

The conversation turned to psychosocial burden, referencing VALIANT study data showing burden on the Vitiligo Impact Patient Scale rises with greater BSA, darker skin types, and facial or hand involvement.¹ Chovatiya framed the stakes beyond the visible lesions.

"It's fascinating, right? Because in the case of vitiligo and alopecia, it's not really a situation of life and death. It's almost the situation of identity," he said.

The patient was started on ruxolitinib cream 1.5% after a discussion of treatment options at his first visit.

Navigating Pediatric Vitiligo Treatment and Adherence

The third case was a 12-year-old boy with depigmented patches on his hands and legs first noticed a year earlier, with no family history of vitiligo or other pigmentary disorders. He had discontinued triamcinolone after 3 months due to lack of effect and spread of depigmentation to his face and eyelids, and stopped pimecrolimus shortly after starting it because of burning and stinging.

Attendees discussed the practical barrier of topical ruxolitinib not being labeled for younger children, with several relying on samples or compounded formulations depending on a child's age. One attendee said Medicaid coverage is a recurring obstacle in this population.

"For the kids, I try to preempt them. Say, ‘Hey, kids must be talking to you at school. I say this is part of your external, but you're more important than the skin disease,’" an attendee said.

On expectations for response, Chovatiya emphasized repigmentation with topical ruxolitinib tends to be a question of timing rather than whether it works at all.

"It really usually isn't a matter of if they respond or if they don't. It's a matter of when," he said.

Following a discussion with the patient and his parents, the case concluded with the patient starting on ruxolitinib cream 1.5%.

Across all 3 cases, attendees returned repeatedly to insurance coverage and patient expectations as the practical forces shaping how vitiligo treatment unfolds over time. Chovatiya closed by noting patients who see partial improvement often pull back on therapy before disease has fully stabilized, only to see depigmentation return.

References

1. Chovatiya R. Vitiligo in practice: case-based approaches for patient care. Presented at: Dermatology Times Case-Based Roundtable event; June 18, 2026; Nashville, TN
2. Ezzedine K, Parsad D, Harris JE, et al. Depression and depressive symptoms among people living with vitiligo: findings from the cross-sectional, population-based global VALIANT survey. J Dermatolog Treat. 2025;36(1):2504082. doi:10.1080/09546634.2025.2504082