Experts explain their approach to the treatment of a new patient with vitiligo and the role of phototherapy in their practice.
Heather Woolery-Lloyd, MD: Let’s talk a little bit about therapies and therapeutic options for patients with vitiligo. [Dr Kindred], most patients who see a dermatologist for the vitiligo treatment are looking for treatment options, right? They’re newly diagnosed or maybe they’ve been diagnosed years ago and are hearing about new treatments. How do you approach the treatment of a new vitiligo patient?
Chesahna Kindred, MD, MBA, FAAD: My treatment approach has stayed the same and some parts have changed. What’s the same is first, knowing how much it affects the patient. And we alluded to that a little bit. Where it’s located, that’s why my Wood’s [lamp] exam is important. If it affects them mentally, how severely or not. What’s new is my treatment algorithm. Now that we have topical treatments where I’m not worried about atrophy, etc, that tends to be my go-to. I’m less dependent on phototherapy. That is, the ones [who] come to the office about 2 or 3 times a week. Especially for the new patients who I may not know, it’s a discussion about the treatment options and which option fits best for them and then giving them realistic expectations. The more extensive the disease, the more likely they need chronic treatment or continuous treatment. The good news is [with] a medication such as ruxolitinib, they can continue to use it and be a little bit less concerned about a relapse.
Heather Woolery-Lloyd, MD: Yes, I agree. With phototherapy, that is a very helpful treatment, but it is a difficult treatment sometimes, depending on where your practice is, because I am in a city setting, where it’s hard for people to park, leave work, and drive into the city to get phototherapy 2 or 3 times a week; it can be a real challenge. I love that we have other treatment options that are working well, because even though I love phototherapy for a lot of patients, it can be difficult. Now, Renata, I know that phototherapy is something that you sometimes use. What is the role of phototherapy in your practice, in your patients with vitiligo?
Renata Block, PA-C: Yes, when the patient comes in, we have an algorithm as well. Patients are pretty savvy these days, and a lot of times they’ll come in and be asking about phototherapy. They say, “I want phototherapy. This is going to fix everything.” It is our job as clinicians to reel them back in and go over all the treatment options. As [Dr Kindred] said, it’s like, I’m going to give you what’s best for you, and we have to discuss that and we have to discuss that together and make a decision by the end of this visit what we’re going to do and set up those expectations. I do introduce it to everyone because they are savvy. They’re going to be looking up things. They’re going to listen to their cousin, their mother, their father, brother, and say, “Why didn’t she say phototherapy?” I definitely plug it in and let them know that it exists. A lot of times we don’t have it at the clinic, but we do refer them out for it. I agree with you. I think it’s a very, very difficult treatment. I do live in the city as well. It is inconvenient to interrupt a person’s day, to go 2 or 3 times a week for it. Narrowband UV-B is something that is used; psoralen UV-A [was] not so much anymore when narrowband UV-B completely took that over. But the cost of it can be very, very expensive and unattainable. That being said, it’s something that we have to be transparent [about] with our patients. It’s a treatment that is out there that can stop or slow down the progression of vitiligo. We know that. But there [are] other options that we can use as well.
Heather Woolery-Lloyd, MD: Yes. I love that you mentioned cost. That’s so important because a lot of times, most insurance plans require a co-pay at each visit. If you have a $40 co-pay, that’s $40 2 or 3 times a week, which can add up on top of the co-pays for the topical prescriptions that they’re using and many of the other things that our patients might be using. I think phototherapy is extremely effective and even very predictable, because I love the predictability of phototherapy, I do think that that is a huge strength of phototherapy, but it is best for a patient who can afford it because it’s expensive to pay co-pays at every visit and also have the time in their schedule to come in to an office, park, run inside, get a treatment, go back in the car, and get back to the office or wherever they’re working. They have to have a flexible schedule. For kids, most kids, unless you have...the ability to get phototherapy after hours, it’s not realistic to miss that much school. It’s a very interesting treatment option. I love that we have it. I love that it’s predictable. But I agree with you. It’s best suited for a particular patient who is able to work with those restraints.
Renata Block, PA-C: Right. And really, the expectation [is that it] can take 1 to 3 months to start seeing improvement and it could take 6 months for a full treatment. Then we have insurance restrictions of not allowing those treatments. You get going and get 3 months, and then they’ll deny it after 3 months. It can be very frustrating for the patient as well as the clinician. The patient doesn’t understand that process like we do, obviously, but it can be quite a challenge to have the treatment interrupted, which can also be a huge inconvenience.
Transcript edited for clarity.