Nicole Ramsey, MD, PhD, assistant professor of pediatrics in the division of pediatric allergy and immunology at the Icahn School of Medicine at Mount Sinai.

Race-Neutral Spirometry May Improve Diagnostic Accuracy, With Nicole Ramsey, MD, PhD

Using race-neutral reference equations to interpret 

 may improve diagnostic accuracy and reduce disparities in respiratory care, according to Nicole Ramsey, MD, PhD, assistant professor of pediatrics in the division of pediatric allergy and immunology at the Icahn School of Medicine at Mount Sinai.

On March 2, 2026, at the American Academy of Allergy, Asthma, & Immunology (AAAAI) annual meeting in Philadelphia, Ramsey presented the session, “Using Race-Neutral Spirometry Equations Improves Diagnostic Accuracy.” She discussed the clinical implications of shifting away from race-adjusted spirometry equations, which is an approach historically used in pulmonary function testing. She emphasized that clinicians should consider adopting race-neutral reference equations, such as those derived from the Global Lung Function Initiative (GLI), to interpret spirometry results more consistently across patient populations.

“The main takeaway message from my session is that physicians should be using race-neutral reference equations to interpret their spirometry,” Ramsey told 

 “Whether that has to do with using the mixed equation from the GLI 2012 reference equations or just using the GLI ’22 or July global equations, they will improve diagnostic accuracy if they use those equations.”

Spirometry remains a foundational tool for diagnosing and monitoring obstructive and restrictive lung diseases, including conditions such as asthma and chronic obstructive pulmonary disease (COPD). Traditional interpretation of spirometry results has relied on race-specific correction factors, which adjust predicted lung function values based on racial categories. However, Ramsey noted that this approach is increasingly questioned because race is a social construct rather than a biological determinant of lung function.

Race-neutral equations aim to address this limitation by applying the same reference standards to all individuals. According to Ramsey, removing race-based adjustments can improve diagnostic accuracy by preventing misclassification of lung disease severity.

In particular, the shift may have meaningful implications for patients who identify as Black. Ramsey explained that race-adjusted spirometry equations can sometimes produce falsely normal interpretations, potentially delaying diagnosis or masking clinically meaningful impairment. Spirometry results influence a wide range of clinical and administrative decisions, including treatment selection, disability assessments, and referral for advanced interventions such as lung transplantation.

Ramsey highlighted how race-adjusted equations can lead to differences in treatment classification. For example, two children, 1 Black and 1 White, with identical symptoms and pulmonary function measurements could be categorized differently when race-specific equations are used. In some cases, the White child might be classified as having moderate impairment, while the Black child might be categorized as having only mild impairment.

“What that could potentially mean is that the White child would get better or more comprehensive treatment,” Ramsey explained. “The Black child might not receive treatment as quickly, which could lead to more long-standing detrimental effects from asthma.”

Reanalysis of existing datasets also suggests that race-neutral spirometry could alter eligibility for disability benefits. Ramsey noted that analyses indicate Black and Asian veterans with COPD may have been undercompensated when disability assessments relied on race-adjusted lung function thresholds. In some cases, monthly disability payments could differ by as much as $3000 when race-neutral equations are applied.

Modeling studies suggest the interpretation change could influence transplant referral timelines. Analyses of population datasets have estimated that Black patients could qualify for lung transplant listing sooner when race-neutral spirometry equations are used, potentially shortening wait times by several weeks in some scenarios.

Ramsey acknowledged that the transition to race-neutral spirometry may produce unintended consequences. For example, certain professions that rely on spirometry thresholds, such as firefighting or military service, could see eligibility criteria shift for some individuals if race-neutral reference standards are adopted without broader policy adjustments.

“Race-neutral reference equations are not perfect,” Ramsey said. “But because race-adjusted equations falsely consider race a biological concept, they’re the best thing that we have…they improve diagnosis… and [help patients] get to care faster.”

Ramsey, N. Using Race-Neutral Spirometry Equations Improves Diagnostic Accuracy. Session presented at the 2026 American Academy of Allergy, Asthma, & Immunology in Philadelphia on March 2, 2026.

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Using race-neutral spirometry equations such as GLI 2012 and GLI 2022 may improve diagnostic accuracy and reduce disparities in lung disease assessment.

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Tim Smith joined the MJH Life Sciences team in 2022 and is currently an associate editor for HCPLive. He is also the executive producer of two podcasts: Skin of Color Savvy and The Medical Sisterhood. Previously, he was the producer of the Lungcast podcast. He graduated from UC Berkeley and worked in multimedia journalism as a staff writer prior to joining MJH. You can contact him at tsmith@mjhlifesciences.com.

 with bimekizumab led to significant improvements in patients’ International Hidradenitis Suppurativa Severity Score System (IHS4) outcomes during the BE HEARD I and II studies.

These data on patients with HS and their IHS4 outcome improvements following bimekizumab therapy were authored by such investigators as Thrasyvoulos Tzellos, MD, PhD, a dermatologist in Norway at Nordland Hospital Trust. Tzellos and coauthors highlighted bimekizumab’s design as a humanized monoclonal immunoglobulin G1 (IgG1) antibody, selectively inhibiting interleukin (IL)-17F as well as IL-17A.

The team also described IHS4 as a validated clinician-rated tool.

 It includes draining tunnels to evaluate HS severity and can be implemented in routine clinical practice as well as clinical trials.

“While IHS4 assesses all key HS lesions, it places the greatest weight on draining tunnels, allowing the differences in efficacy of novel drug treatments in reducing HS severity to be observed,” the investigators wrote.

 “Here, the efficacy of bimekizumab in reducing HS severity, measured using IHS4 outcomes, is reported in patients with moderate to severe HS over 1 year in BE HEARD I and II.”

In the phase 3 BE HEARD I and BE HEARD II studies, Tzellos et al used a randomized, double-blind, placebo-controlled, multi-center trial design. They conducted their research between March 2020 - September 2022, carrying out their analyses via pooled data from both studies. Each study consisted of a 16-week placebo-controlled induction phase, and this was followed by a 32-week maintenance period, for a total duration of 48 weeks.

In the initial treatment phase, Tzellos and colleagues assigned participants in a 2:2:2:1 ratio to 1 of 4 groups: bimekizumab 320 mg provided every 2 weeks (Q2W) through Week 48; bimekizumab 320 mg every 4 weeks (Q4W) through Week 48; bimekizumab 320 mg Q2W through Week 16 followed by 320 mg Q4W through Week 48; or placebo through Week 16 followed by bimekizumab 320 mg Q2W through Week 48. Their eligibility criteria for the study were published previously.

Across both studies, there were 1014 individuals included in the analysis. Baseline disease severity, assessed by the IHS4, indicated substantial disease burden among subjects. Mean (standard deviation [SD]) IHS4 scores for those placed in the bimekizumab arms ranged from 33.4 (25.4) in the Q2W/Q2W group to 36.0 (34.0) in the Q2W/Q4W group, compared with 30.6 (21.8) in the placebo group. By the 16-week mark, Tzellos and coauthors found those treated with bimekizumab showed greater reductions in IHS4 scores from baseline than those receiving placebo.

Mean (SD) decreases ranged from −17.2 (24.8) in the Q4W/Q4W group to −17.8 (21.1) in the Q2W/Q2W cohort, whereas the placebo cohort were shown to have a diminished reduction of −6.1 (16.3). At the study’s point of entry, the proportion of those classified as having severe HS was high, ranging from 83.7% in the Q2W/Q2W arm to 88.4% in the Q2W/Q4W arm.

 By the 48-week mark, Tzellos et al noted a decline in this proportion by approximately half across treatment arms, falling to between 28.6% among individuals who transitioned from placebo to bimekizumab Q2W and 34.3% in the Q2W/Q2W cohort.

In addition, the percentage of individuals attaining an IHS4 score of 0 by Week 48 ranged from 23.7% in the Q2W/Q4W group to 26.7% among those who initially were given a placebo before switching to bimekizumab. Treatment via bimekizumab also resulted in increased response rates at multiple IHS4 improvement thresholds by Week 16.

 Greater proportions of subjects on active therapy achieved IHS4-55, IHS4-75, IHS4-90, and IHS4-100 compared with those assigned to placebo. From the 16 through 48-week marks, however, Tzellos and coauthors noted improvements became more similar across treatment groups as those originally assigned to placebo began receiving bimekizumab.

Consistent with these data, lesion counts were shown to be lower in the bimekizumab groups than in the placebo group at the 16-week mark, though by Week 48 lesion numbers were comparable among all study groups.

“The promising improvements seen with bimekizumab treatment highlight an opportunity to address the need for effective treatments against draining tunnels,” the team concluded.

Tzellos T, Giamarellos-Bourboulis EJ, Zouboulis CC, et al. Bimekizumab efficacy using IHS4 outcomes in hidradenitis suppurativa: Results from BE HEARD I and II. J Eur Acad Dermatol Venereol. 2026 Feb 14. 

Zouboulis CC, Tzellos T, European Hidradenitis Suppurativa Foundation Investigator Group, et al. Development and validation of the International Hidradenitis Suppurativa Severity Score System (IHS4), a novel dynamic scoring system to assess HS severity. Br J Dermatol. 2017 Nov;177(5):1401-1409. doi: 10.1111/bjd.15748. Epub 2017 Oct 30. PMID: 28636793.

Articles

Pooled phase 3 BE HEARD I/II data showed bimekizumab (dual IL‑17A/IL‑17F blockade) produced clinically meaningful reductions in HS severity by IHS4, a tunnel-weighted clinician score suited to trials and practice. Among 1014 patients with high baseline burden (mean IHS4 ~33–36; predominantly severe disease), bimekizumab achieved larger Week 16 IHS4 decreases versus placebo (≈−17 vs −6). Improvements were sustained through Week 48, halving severe HS proportions, with ~24%–27% reaching IHS4=0.

Bimekizumab was assessed using the International Hidradenitis Suppurativa Severity Score System (IHS4) outcomes in the BE HEARD I and II studies.

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Bimekizumab-Treated Patients with HS See IHS4 Outcome Improvement Over 1 Year

Segment 2

The notion of “gradient reduction therapy,” originally articulated by James Udelson,MD, is presented as a logical next step in the management of oHCM.

In this video, Matthew Martinez, MD, raises the question of whether it is acceptable to leave patients with high resting or provocable LVOT gradients (eg, ≥130 mm Hg) if they appear asymptomatic and have preserved exercise capacity. Both he and Mariko Harper, MD, argue that although definitive outcomes data are not yet available, it is physiologically plausible that sustained severe obstruction promotes adverse remodeling, including progressive left ventricular hypertrophy, left atrial enlargement, mitral regurgitation, and myocardial fibrosis, all of which may increase long-term cardiovascular risk.

Harper emphasizes that emerging long-term data from mavacamten—the first FDA-approved cardiac myosin inhibitor—demonstrate favorable cardiac remodeling, with reductions in left ventricular mass, left atrial size, and systolic anterior motion of the mitral valve, as well as sustained biomarker improvement over several years. This experience suggests that earlier gradient elimination may have disease-modifying potential, though conclusive data on atrial fibrillation, heart failure events, and other hard outcomes are still pending. In parallel, both clinicians note the similarity to the evolution of aortic stenosis care, where earlier intervention has been associated with improved long-term outcomes as procedural risk declined.

Traditional agents, including β-blockers, non-dihydropyridine calcium channel blockers, and disopyramide, remain part of background therapy but no longer dominate the treatment algorithm in expert practice. Martinez explains that he still initiates these agents given their low upfront risk, but he no longer escalates to high doses or complex combinations before switching to a myosin inhibitor. Instead, he introduces a cardiac myosin inhibitor relatively early and, once gradient and symptoms improve, often de-escalates or discontinues background drugs. In this segment, Martinez and Harper present a nuanced, forward-looking view of gradient reduction as a primary therapeutic goal and outline how cardiac myosin inhibitors are displacing escalating polypharmacy with traditional negative inotropes.

Experts explore the concept of “gradient reduction therapy,” the remodeling effects of cardiac myosin inhibitors, and the evolving role of traditional agents in oHCM.

Video Series

Understanding Gradient Reduction Therapy and Cardiac Myosin Inhibitors in oHCM Care

Bernard Kadosh, MD, is the medical director of the ventricular assist device and cardiogenic shock programs at NYU Langone Health.

Eiran Gorodeski, MD, MPH, is a professor of medicine and section head of the section of advanced heart failure at Case Western Reserve University School of Medicine, as well as the director of the advanced heart failure and transplant center at University Hospitals.

Improving Heart Failure Awareness and GDMT Prescription, With Bernard Kadosh, MD, and Eiran Gorodeski, MD, MPH

Recent studies have highlighted shortcomings in both patient awareness and guideline-directed medical therapy (GDMT) prescription in 

HF is a condition with an enormous patient population, affecting >6 million adults in the US and 64 million worldwide. However, research has long since shown that patients with HF have a substantial lack of understanding about the disease, including its development, definition, and trajectory. This is naturally associated with poorer outcomes, as patients are far less likely to make proper lifestyle changes if they are unaware of how it could affect them.

“Other conditions and diseases may be more linear. People get sick and they either improve or they don’t improve,” Bernard Kadosh, MD, medical director of the ventricular assist device and cardiogenic shock programs at NYU Langone Health, told 

 in an exclusive interview. “With heart failure, it’s quite different. There are points in the disease where the risk of bad outcomes accelerates, and there are points where the risk of bad outcomes decelerates. And I think that teaching patients about that aspect of the disease is very important.”

A 2023 study from the American Heart Association (AHA), conducted via a survey of sociobehavioral measures across study participants with HF, highlighted the significant percentage of patients who are unaware of their diagnosis. This questionnaire, consisting of 1 question asking if patients had or had experienced 

Of the survey recipients, 1114 completed the survey; of those who responded, 71% had validated HF (n = 787). These patients were included in the analysis, which ultimately proved that 37% were aware of their diagnosis (n = 293). After adjustment, the study found that being a woman (OR, 1.56; 95% CI, 1.1-2.22), having HFrEF (OR, 1.58; 95% CI, 1.13-2.22) or coronary artery disease (OR, 1.65; 95% CI, 1.16-2.37), and attending the HF clinic (OR, 4.07; 95% CI, 2.25-7.36) were associated with increased diagnosis awareness.

Similarly, a 2022 study published in the 

examining GDMT prescription in patients with HF uncovered a substantial percentage of patients who are not given 1 or more of the 4 pillars of HF treatment, including ACE inhibitors/angiotensin receptor blockers (ACEi/ARBs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors.

Based on an investigation of prescription history, a very small proportion (17% to 54%) are prescribed the target dose of ACEi/ARBs and beta-blockers in community settings. This has been attributed in large part to therapeutic inertia.

“Clinicians need an implementation playbook, and it needs to be protocolized in the same way as other diseases like myocardial infarction and ST elevation. These are protocol-driven therapies, and nothing is missed,” Eiran Gorodeski, MD, MPH, professor of medicine and section head of the section of advanced heart failure at Case Western Reserve University School of Medicine, as well as the director of the advanced heart failure and transplant center at University Hospitals, told 

. “We need to do a better job in creating and implementing a playbook in heart failure. Some of those playbook steps include identifying people who are admitted for compensated heart failure and then starting medications early and aggressively before discharge.”

Kadosh and Gorodeski went on to describe suggestions for clinicians in combatting these significant setbacks, educating both patients and other clinicians about this debilitating condition.

“I think it’s important to frame where the patient lies on the trajectory of the disease, and I usually do so in terms of stages,” Kadosh said. “If they come to me in Stage C, I say, ‘You have Stage C heart failure, but that doesn’t mean you necessarily will progress. There are a lot of therapies we have to help you prevent progression, to stabilize your symptoms, and to ensure that it doesn’t get worse.’ It’s our job to make sure that the patient understands the potential.”

Editors’ Note: Kadosh and Gorodeski report no relevant disclosures.

Shropshire SJ, Fabbri M, Manemann SM, et al. Patient awareness of heart failure diagnosis: A community study. 

Rastogi T, Duarte K, Huttin O, Roubille F, Girerd N. The Prescription Pattern of Heart Failure Medications in Reduced, Mildly Reduced, and Preserved Ejection Fractions. 

Kadosh and Gorodeski discuss 2 of the major challenges facing both patients and clinicians dealing with HF and how to address them.

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 exhibiting minimal 6-month response to ruxolitinib cream may still attain substantial repigmentation with prolonged treatment extending to 2 years, new findings suggest.

These findings resulted from an analysis assessing the long-term efficacy and safety of continuous treatment with ruxolitinib cream through 104 weeks in participants with vitiligo who had shown little or no clinical response by 24 weeks in the TRuE-V1 and TRuE-V2 trials.

 Investigators such as Albert Wolkerstorfer, MD, PhD, of Amsterdam University Medical Center authored these data.

Wolkerstorfer and coauthors described the aims of the TRuE-V1 and V2 trials as determining whether those who initially responded poorly to the medication could still see meaningful repigmentation with extended use of this therapy.

“Here, efficacy and safety of continuous ruxolitinib cream treatment over 104 weeks were evaluated among patients who had no or limited response to treatment at Week 24 in TRuE-V1/TRuE-V2,” Wolkerstorfer and colleagues wrote.

In the original studies, those involved were randomized in a 2:1 ratio to be treated either with 1.5% ruxolitinib cream twice daily or a vehicle control for the initial 24 weeks. Following this double-blind period, all trial subjects entered a 28-week open-label extension in which they used ruxolitinib twice each day. Those who had not attained a 90% improvement in their facial Vitiligo Area Scoring Index (F-VASI90) at minimum by Week 52 continued therapy with ruxolitinib cream twice daily for an additional 52 weeks.

Wolkerstorfer et al’s current analysis was aimed specifically at participants who had originally been assigned to ruxolitinib cream but demonstrated less than a 25% improvement from the point of baseline in either the facial or total Vitiligo Area Scoring Index (F-VASI or T-VASI) at the 24-week mark. To be included, patients also needed to have available VASI assessments at the 52, 80, and 104-week marks.

Investigators evaluated shifts in F-VASI and T-VASI scores among those with either no repigmentation or worsening depigmentation (defined as ≤0% improvement) as well as those with limited improvement (>0% to <25%) at Week 24. Among the 443 individuals in the efficacy-evaluable population who were initially randomized to ruxolitinib cream, the mean baseline F-VASI score was 0.92 (SD, 0.55), while the mean baseline T-VASI score was 6.64 (SD, 2.04).

Of these individuals, 127 had shown either no facial repigmentation or only minimal improvement by the 24-week mark. Continued use of ruxolitinib cream was linked with progressively increased facial repigmentation rates over time.

 At the 52-week mark, 71.7% of these patients (n = 113) had achieved some level of improvement in F-VASI. This proportion was shown by the investigators to have risen to 87.5% at Week 80 (n = 80) and attained 90.1% by the 104-week mark (n = 71).

When stratified by Week-24 response status, improvement by the 104-week mark was seen in 97.1% of those who had no repigmentation at Week 24 and in 83.3% of subjects with limited early improvement.

 The investigators also found the proportion of patients attaining at least a 75% reduction in F-VASI from baseline rose steadily during follow-up. Specifically, F-VASI75 was reached by 13.3% of patients at 52 weeks, 38.8% at 80 weeks, and 54.9% by 104 weeks.

A similar pattern was observed for total body repigmentation outcomes. Among 193 patients who had demonstrated no or minimal improvement in T-VASI at Week 24, the percentage showing subsequent improvement increased over time.

 By Week 52, 68.8% (n = 173) had experienced some degree of improvement in T-VASI. This rose to 81.4% at Week 80 (n = 118) and 84.9% at Week 104 (n = 106).

In their subgroup analyses, Wolkerstorfer and coauthors found improvement at Week 104 took place in 93.3% of individuals who initially had no total body repigmentation and in 81.6% of those showing a limited level of improvement at Week 24.

 T-VASI50 attainment, defined as at least a 50% reduction in T-VASI from baseline, also rose throughout the study period. The investigators noted the proportion of patients reaching this endpoint was 23.1% at Week 52, 42.4% at Week 80, and 50.0% at Week 104.

“In conclusion, >80% of patients with no or limited repigmentation at 6 months who continued to apply ruxolitinib cream over an additional 18 months achieved F-VASI or T-VASI improvements,” the investigative team concluded.

 “Half of the patients achieved clinically meaningful F-VASI75 or T-VASI50 at 2 years.”

Wolkerstorfer A, Gooderham M, Sebastian M, Harris JE, et al. Prolonged ruxolitinib cream treatment for vitiligo among patients with no or limited response in the first 6 months. J Eur Acad Dermatol Venereol. 

Rosmarin D, Passeron T, Ezzedine K et al. Two Phase 3, Randomized, Controlled Trials of Ruxolitinib Cream for Vitiligo. N Engl J Med. 2022 Oct 20;387(16):1445-1455. doi: 10.1056/NEJMoa2118828. PMID: 36260792.

Prolonged twice-daily ruxolitinib 1.5% cream can yield meaningful repigmentation in vitiligo despite minimal response at 24 weeks. In a 104-week evaluation of TRuE-V1/V2 participants with <25% early improvement in F-VASI or T-VASI, repigmentation rates increased progressively through Weeks 52, 80, and 104. By 2 years, most patients demonstrated facial and/or total-body VASI improvement, and approximately half reached clinically meaningful thresholds (F-VASI75 or T-VASI50), supporting extended treatment beyond 6 months in initial poor responders.

New data suggest those who exhibit minimal early response to ruxolitinib cream may still achieve repigmentation with prolonged use extending to 2 years.


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Prolonged Ruxolitinib Cream Effective for Vitiligo in Early Non-Responders

Anna Nowak-Wegrzyn, MD, PhD, of NYU Grossman School of Medicine.

At AAAAI 2026, Nowak-Wegrzyn presented FPIES diagnosis in infants, emphasizing clinical recognition and updated oral food challenge protocols.

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OFC Updates for FPIES in Infants, With Anna Nowak-Wegrzyn, MD, PhD

Stay updated with the latest healthcare breakthroughs, FDA actions, and new trial data, in this week’s essential news roundup.

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, IBS and IBD, Crohn's disease, and more.

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The HCPFive: Top News for Healthcare Providers from the Week of 03/01

Abigail Brooks is an assistant managing editor for 

She joined MJH Life Sciences in August 2023 shortly after graduating from Monmouth University where she earned her BA in Communication with a concentration in Public Relations/Journalism and later an MA in Interactive Digital Media. She enjoys traveling, running, and reading books. She can be reached at abrooks@mjhlifesciences.com.

The FDA approval of milsaperidone and a pair of positive trials in depression signal a month of progress in psychiatry.

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5 Psychiatry Headlines You Missed in February 2026

Karen Maddox, MD, MPH, is a professor of medicine and public health and co-director of the Center for Advancing Health Services, Policy & Economics Research at the Washington University School of Medicine.

Maddox discusses the AHA’s recent statement indicating that, should current trends continue, 6 in 10 US women will have cardiovascular disease by 2050.

Arrhythmia

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6 in 10 US Women Predicted to Have Cardiovascular Disease by 2050, With Karen Maddox, MD, MPH

Barbara Gillespie, MD, is Chief Medical and Strategy Officer of the International Society of Glomerular Disease and Adjunct Professor at the University of North Carolina.

Experts outline a 2026 vision for glomerular disease care, including new endpoints, combination therapies, and gene therapy advances.

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Strategic Alliance Partnership

Clinical Trial Summit 2026: Advanced Therapies, Equity, Global Outlook For Glomerular Diseases

The PARASOL initiative is reshaping glomerular disease trials through shared data and improved surrogate endpoints.

PARASOL, Endpoints, and Rethinking Clinical Trials in Glomerular Disease

PLA2R antibodies are advancing precision care in membranous nephropathy and informing new surrogate endpoints through PARASOL.

PLA2R, Membranous Nephropathy, and the PARASOL Membranous Project

Anti-nephrin autoantibodies are redefining minimal change disease and enabling more precise, steroid-sparing treatment strategies.

Anti-Nephrin Autoantibodies, Precision in Nephrotic Syndrome

APOL1 kidney disease highlights the need for community trust, increased screening, and stronger clinical trial participation.

APOL1 Kidney Disease: Community, Trust, and Trial Participation

Rapid advances in glomerular disease, from single-cell tech to biomarkers and phase 3 trials, are reshaping diagnosis and treatment.

Latest News

Race-Neutral Spirometry May Improve Diagnostic Accuracy, With Nicole Ramsey, MD, PhD

Bimekizumab-Treated Patients with HS See IHS4 Outcome Improvement Over 1 Year

Understanding Gradient Reduction Therapy and Cardiac Myosin Inhibitors in oHCM Care

Improving Heart Failure Awareness and GDMT Prescription, With Bernard Kadosh, MD, and Eiran Gorodeski, MD, MPH

Prolonged Ruxolitinib Cream Effective for Vitiligo in Early Non-Responders