Vitiligo in Practice:​ Case-Based Approaches for Patient Care

“Sometimes vitiligo profoundly affects people’s self-esteem and identity, particularly for people of African descent; they go from looking Black to looking White, and that has profound impacts in the community,” Susan C. Taylor, MD, said at a recent Dermatology Times Case-Based Roundtable event in Aventura, Florida.

Taylor, the Bernett L. Johnson, Jr Endowed Professor of Dermatology at the Perelman School of Medicine at the University of Pennsylvania and immediate past president of the American Academy of Dermatology, moderated a roundtable discussion on topical treatment options for vitiligo, bringing together dermatology clinicians from across South Florida.

Case 1

A 35-year-old White woman presents with a 6-month history of progressive depigmentation originating in her left axilla and now covering approximately 7% of her body surface area (BSA) across both arms, legs, and chest. Her medical history is notable for autoimmune thyroiditis, and several lesions display a confetti-like appearance consistent with active, rapidly progressive disease.

Attendees identified the rapidly progressive, truncal nature of the case as its primary challenge, noting that truncal vitiligo responds less robustly to therapy than head and neck involvement, and that the confetti pattern signals ongoing disease activity requiring prompt intervention. The 7% BSA involvement raised practical concerns about systemic absorption with potent topical steroids applied broadly, and several clinicians acknowledged that insurance requirements, including the need to document prior failure of topical corticosteroids and calcineurin inhibitors, shape initial prescribing even when a newer agent might otherwise be preferred.

“A lot of my decision, unfortunately, is just based on the insurance. I usually start with a steroid and a calcineurin inhibitor, and if [that’s] not working, then I can move forward,” an attendee said.

For rapidly progressive disease, Taylor described pulse-dose oral dexamethasone—4 mg on 2 consecutive days per week for 6 weeks—as a strategy to halt activity. Attendees shared varied topical approaches: potent steroids cycled with tacrolimus 0.1% on the trunk and extremities, lower-potency agents, or tacrolimus alone on the face. Ruxolitinib cream 1.5% (Opzelura; Incyte) was widely endorsed, with several clinicians reporting strong repigmentation of the face and neck since its approval.

“With Opzelura, my experience with patients has been phenomenal. For the face and neck especially, the repigmentation results are really there,” an attendee said.

Adherence was a recurring concern throughout case 1. Attendees agreed that patients who do not see visible improvement quickly are at high risk of discontinuing therapy, and that scheduling check-in visits at 6 to 8 weeks—less to evaluate efficacy than to reinforce application habits and reset expectations—was key to sustaining engagement over the long term.

Reflecting on the first case, Taylor said, “Attendees were reminded about the signs of active vitiligo, such as confetti spots and rapid onset, as well as the use of systemic steroids to slow the progression of the disease. I think the attendees also appreciated that NB-UVB [narrowband UVB] still plays a role in the treatment of vitiligo with a large surface area.”

Case 2

A 28-year-old Black man presents with a 2-year history of vitiligo, initially stable and localized to the arms, that has spread over the past 12 months to the face and torso. He has no history of prior treatment, but the facial involvement is now causing significant psychosocial distress and social discomfort. After discussing treatment options, he started using ruxolitinib cream 1.5%.

This case prompted discussion of the disproportionate burden on the quality of life of patients with facial vitiligo and darker skin types. Taylor referenced data from the VALIANT study, a cross-sectional population-based analysis of 3541 adults with vitiligo across 17 countries, in which Vitiligo Impact Patient Scale scores were significantly higher among patients with greater than 5% BSA involvement, Fitzpatrick skin types IV to VI, and lesions on the face or hands (P < .001 for all comparisons).

Taylor reviewed efficacy data from the phase 3 TRuE-V1 (NCT04052425) and TRuE-V2 (NCT04057573) trials. In TRuE-V1, 29.8% of patients receiving ruxolitinib cream 1.5% achieved Facial Vitiligo Area Scoring Index 75% at week 24 vs 7.4% with the vehicle (P < .001); in TRuE-V2, those rates were 30.9% vs 11.4% (P < .001).¹ Attendees emphasized that shared decision-making and transparent counseling about gradual response timelines are essential for patients like this one, whose psychosocial burden may make slow repigmentation particularly frustrating.

Reflecting on the second case, Taylor said, “The attendees were reminded of the differential diagnosis of vitiligo, [such as] considering cutaneous T-cell lymphoma, and that a skin biopsy might be appropriate. Mechanisms to stop the rapid spread of the disease were reviewed, and the use of ruxolitinib for the areas of the body that trouble the patient the most.”

Case 3

A 13-year-old boy presents with a 1-year history of depigmented patches on the hands and legs. Disease progressed despite triamcinolone (discontinued after 3 months for lack of effect and disease spread to the face and eyelids) and a subsequent trial of pimecrolimus (stopped early due to burning and stinging). After discussion with the patient and his parents, he was started on ruxolitinib cream 1.5%.

The group discussed the unique challenges of pediatric vitiligo, including the adolescent’s vulnerability to identity and self-esteem effects of visible disease and the added complexity of managing parental anxiety alongside the patient’s own concerns. Taylor reviewed a published pediatric treatment paradigm supporting escalation to topical Janus kinase (JAK) inhibitors for patients with active or refractory disease. She also presented long-term safety data from the TRuE-V program showing that exposure-adjusted incidence rates for JAK inhibitor class–associated adverse events, including serious infections, malignancies, thromboembolic events, and major adverse cardiac events, were low, and none were considered related to treatment in patients using ruxolitinib cream 1.5% twice daily for up to 2 years. Long-term efficacy data also showed that patients with limited repigmentation at week 24 continued to improve in both the Facial Vitiligo Area Scoring Index and the Total Vitiligo Area Scoring Index through week 104, reinforcing the importance of counseling families to persist with treatment even when early results are modest.²

Closing out the event, Taylor noted that Case-Based Roundtable events enable colleagues to share diagnostic and treatment challenges and therapeutic approaches.

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. Harris JE, Papp K, Ezzedine K, et al. Open-label treatment extension of ruxolitinib cream in vitiligo: findings from the Topical Ruxolitinib Evaluation in Vitiligo (TRuE-V) long-term extension phase III study. Br J Dermatol. 2026;194(3):591-593. doi:10.1093/bjd/ljaf485