DermView: Innovations in the Treatment of Vitiligo - Episode 5
Seemal Desai, MD, FAAD, and William Damsky, MD, PhD, discuss methods for managing a patient’s motivation and expectations when on therapy for vitiligo.
William Damsky, MD, PhD: I want to pick your brain about how you explain expectations of treatment with the patient and what you go over with a patient with a new diagnosis of vitiligo who’s going to be pursuing treatment. How do you walk them through that?
Seemal Desai, MD, FAAD: The first thing I try to do is turn it into a positive discussion. If someone has, let’s say, facial involvement, I have an adage in my practice where I enthusiastically say, “Oh, you’ve got facial involvement, that’s fabulous. The face is fabulous,” is what we say. Because facial disease is the one area of the body where we can really make strides to get 80%, 90%, even close to 100% repigmentation. If you use combination therapies of topical modalities with phototherapy, you can achieve that, and that’s been shown in studies. That’s one of the first talking points.
The other thing is, I try to alleviate a lot of the stress on family history and passing it on to children and other family members because that comes up a lot. What I tell my patients is there’s about a 6% chance that you’ll pass this on to your child, and that alone, from the early onset of the consult, leads to a lot of that tension dropping. Just because you have it does not mean at all that your child is going to get it, or if one child has it, that the other child is going to get it.
I start with as many positive talking points as I can. Another really positive one, by the way, as you know, is you’re 3 times less likely to have melanoma if you have vitiligo. There are some positive sound bites we can share with our patients. The other thing I share is that it’s not a quick process, and it’s going to take time. For example, in phototherapy, I tell my patients, “You need to do a minimum of 45 to 50 sessions before we even say if this is a great success or not. If you see results at treatment 15 and we’re starting to see little dots of pigment, then that’s great. But we’re not going to make a judgment call until we get to about 45 to 50.” Phototherapy needs to be continued long term.
Then the last thing, at least in this stage of our discussion, I tell my patients is if their vitiligo is spreading, and I ask the question, “How many new white or light spots have you noticed within the past month?” And they say, “I have one on my cheek and, oh, yeah, I’ve got a white spot on my shoulder and one on my thigh.” I look at the size of those areas, and I try to estimate if that’s 1% of their BSA [body surface area]. If it’s approximately 1% of their BSA, and this is a rough estimate, I would call that rapidly progressing, in a 4- to 6-week period, of hypopigmentation to depigmentation. Those are the patients who need the systemic steroid stabilization, which I prefer to do as a pulse dexamethasone, Saturday/Sunday therapy usually, for about 8 weeks. That’s sort of broad; I’d be happy for you to give your pearls and add on to that.
William Damsky, MD, PhD: Again, I think you summarized it beautifully. I think that it’s really important to set expectations and acknowledge that treatment is difficult and treatment will be chronic, and it may take time to see improvement. Phototherapy, which is a mainstay of treatment of vitiligo, may take time to work. It’s important to set the expectation that it’s going to take time, and don’t get discouraged and keep with it. We’re here for you. All that stuff is really important. I couldn’t agree more.
Transcript edited for clarity.