Derm Topics

Diagnosing & Treating Vitiligo in 2022 and What’s To Come

As a former vitiligo clinical trials research fellow, I have attended more than my fair share of presentations on vitiligo. Yet, I am amazed at how each additional lecture continues to teach me new and exciting concepts and treatment options for vitiligo. Dr. Seemal Desai’s lecture at the 2022 Skin of Color Update Conference was no exception to this rule.

During the SOCU Conference held in New York, NY from September 9-11th 2022, Dr. Desai provided attendees with a comprehensive lecture entitled “How Do I Diagnose & Treat Vitiligo in 2022 and What’s to come.” Dr. Desai began his lecture by emphasizing that if there is one thing we can and absolutely do as healthcare providers for our patients it is to provide them with hope. Meeting a new doctor for vitiligo treatment can be a stressful and anxiety provoking situation for the patient. Therefore, Dr. Desai recommends always beginning the visit with a positive outlook letting the patient know that there are some good things about having vitiligo. The points he suggests are as follows:

    • Discussing the decreased melanoma risk- patients with vitiligo have an approximate 3 fold less risk of developing melanoma compared to the general population according to sources.
    • The face can often be the primary source of distress for patients with vitiligo but emphasizing that the “Face is actually fabulous!”- seventy to eighty percent of lesions on the face can re-pigment with aggressive therapy.

Other questions that patients may commonly ask during visits include:

    • Family risk- in general, there is about a 6% risk of passing vitiligo onto offspring
    • When the patient is the only one in the family affected, the risk to develop vitiligo for his/her children is below 10%
    • The risk of full re-depigmentation after achieving complete or almost complete re-pigmentation is between 40-50%

Further, Dr. Desai highlights that vitiligo should not be considered a rare condition, with a prevalence between 1 in 250 to 1 in 50. Over half of patients affected show signs before the age of 20, and Dr. Desai encourages practitioners to treat patients early and aggressively to halt progression, emphasizing that the longer the presence of depigmentation, the harder it is to re-pigment.

Identifying unstable vitiligo can be a challenge and Dr. Desai offers the following signs and tips to help clinicians determine what is unstable:

    1. Asking the patient if over the last 1-2 months they have noticed any new light or white patches-If they had, the size of the patches should be estimated and if they cover more than 1% of the body surface area of the patient, this may represent unstable disease, in Dr. Desai’s personal opinion.
    2. Confetti-like depigmentation (depigmented spots appear like confetti or snowflakes on the skin)
    3. Trichrome (a pattern of lesions containing a ring of normal pigmentation, followed by lighter skin, followed by depigmented skin)
    4. If someone has full depigmentation of their fingertips, this can also be a sign of unstable vitiligo.

The number one action that Dr. Desai recommends for clinicians to take to help stop the progression of unstable vitiligo is oral mini-pulse therapy (OMP). OMP involves the use of 4 mg dexamethasone on 2 consecutive days per week for 6-8 weeks; the dose can be halved in children less than 16 years of age. In addition to oral steroids, anti-oxidants such as polypodium leucotomos and alpha lipoic acid, and narrow-band ultraviolet B therapy should be added to the treatment regimen for unstable vitiligo.

As Dr. Desai states early on in his lecture that “this is the best time to talk about vitiligo in his career,” there are a multitude of emerging treatments and diagnostics for vitiligo that we should look forward to in the future. CXCL10 is a potential up and coming predictive biomarker of vitiligo stability and activity. Studies have been recently published on the role of IL-15 signaling and antibody blockade of IL-15 potentially reversing vitiligo. Of course, no talk would be complete without mentioning the recent U.S. Food and Drug Administration approval of the first medication for vitiligo- topical ruxolitinib cream, a JAK-inhibitor, approved for patients 12 years and older.

Dr. Desai shared his personal experiences with topical ruxolitinib cream regarding re-pigmenting not only the face, but also has demonstrated good improvement in re-pigmenting hands and feet. He generally uses it for vitiligo less than 10% body surface area and does not perform a medication laboratory workup unless warranted. A myth may exist that topical JAK-inhibitors only have efficacy when combined with phototherapy, but Dr. Desai dispels this myth and emphasizes that while a greater response may be seen with the combination, phototherapy is not mandatory to the use of topical JAK inhibitors.

If phototherapy is used in combination with topical treatments, a timeline of approximately 50 treatments should be suggested to the patient as a realistic timeframe for determining treatment response. 25% improvement may be seen after 3 months, 50% improvement after 6 months, and 75% improvement after 9 months.

Finally, while as providers we may think that our vitiligo patients want us to re-pigment 100% of their skin, Dr. Desai advises against making this assumption. He encourages us to have an upfront discussion with our patients regarding re-pigmentation of which body parts are most important to them and to plan our treatment recommendations accordingly.

This information was presented by Dr. Seemal Desai at the Skin of Color Update Conference held September 9-11, 2022. The above highlights from his lecture were written and compiled by Dr. Shanthi Narla.

Disclaimer: The content here should not be interpreted as medical advice and any actual treatment and/or treatment approach should be discussed with a qualified healthcare provider. Scientific content is presented based on personal experience and what is found in medical literature which is continuously evolving and may not be accurate depending on the time of review.

Photo Credits: The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas, a resource developed by co-editors Misty Eleryan, MD, MS, and Adam Friedman, MD, and published by SanovaWorks and Educational Testing & Assessment Systems.

Did you enjoy this article? You can find more highlights from the Skin of Color Update conference here.