Management Strategies and New Directions in the Treatment of Vitiligo - Episode 12
Drs. Woolery-Lloyd, Rosmarin and Pandya discuss various treatment options for vitiligo and when and where they might use them.
Brett King, MD: How do you address the pros and cons of current treatments with patients? How would you personally with your peers assess the pros and cons of current treatments?
Heather Woolery-Lloyd, MD: As we've been talking about, the current treatments are something that works on the immune system and something to stimulate those melanocytes. Unfortunately, a lot of times when it comes to stimulating the melanocytes, one of the biggest issues is cost because UVB treatment narrowband UVB is usually at least twice a week. And usually, insurance companies require copay. For patients who can afford it, it's an excellent option. We haven't discussed at-home units. I have a patient who was really focused on getting an at-home unit covered, and she was able to get it covered by her insurance company. With highly motivated patients, you can get light therapy covered or even an at-home unit. Now, that is my biggest barrier I would say, is getting coverage. And then the other barrier for light therapy where people must come in twice a week is, is that compatible with their job? A lot of people don't have jobs that allow them to leave twice a week for what's probably an hour because I work in a university setting, so there's a parking lot. You walk in, you must wait for your turn, get treated, and leave. It might not be the quickest visit. And a lot of people don't have flexibility in their jobs to do that consistently. I find that when I'm doing this decision-making process, the first thing I ask is, are you able to come in twice a week? Is that realistic for you? And I sometimes try and find locations closer to their place of work. They don't necessarily have to come to my location if that's inconvenient. And the second thing is, can we get this covered? And can you afford the associated copay? That is a big, big factor that we can't overlook. The good news is that I am in a very sunny place. A lot of times when I combine, for example, topical tacrolimus, which I use frequently on the face, and other immunomodulators on the face, I can say, go outside and get ten minutes of sunlight daily. And that doesn't mean they don't wear sunscreen. Because in Florida you can burn in ten minutes without sunscreen. But I do have the benefit of living in a place where if the patient sits outside to eat lunch, they can get some stimulation and we can see repigmentation. I'm very, very fortunate to practice where I am in the management of vitiligo. The biggest take-home when it comes to managing patients with vitiligo is that it is a team effort. It's not purified prescriptions. This is what you need to do. I'll see you in a few months. It’s, these are our treatment options. Actually, let's back up a little bit. It's first, do you want to treat this? Does this really bother you? For some patients, as we mentioned, it doesn't bother them. They wanted to know what it was, and they move on, and I've had many patients like that. But for some – for many patients, I see many patients they do want to be treated. Once you establish what they want to be treated, you have to figure out is their life, their work, their finances able to pay for light therapy? Because I do think that light therapy is complicated for all the reasons I discussed. If they can, then we go ahead and set them up for light treatment in addition to their topicals. If they can't, I tell my patients ten minutes of sunlight every day, maybe sit outside and eat lunch at work. And where I live that can be quite effective.
Brett King, MD: I have a question for you about topical calcineurin inhibitors versus corticosteroids. How do you think about these 2 topicals and their role in any part of the body? Is one favored over the other? Do you think that topical corticosteroids work better? And here, I would love for others to chime in as well, but let's start with you, Heather.
Heather Woolery-Lloyd, MD: I definitely know class one steroids work beautifully, especially when people have rapidly progressing on new-onset. Oftentimes, I might start with the class one steroid and maybe a short pulse, especially if it's on a sensitive area like the face, and then switch over to something else for maintenance. I also want to mention that there is never any steadfast approach. A lot of times you adjust your treatment as you go. I wouldn't say that there's one standard approach. It has to do with – again, unfortunately, coverage, what the patient's able to use. Also, will the patient follow instructions? Because you don't want to give a class when steroids to someone who might abuse it. I'm aggressive and I do use class one steroids frequently. My patients of vitiligo, typically it's a cycle on cycle off type approach so that I can get that steroid in when I need it. Sometimes you could do it on the weekends and then something else during the week, or you can do it at new-onset the very first visit to halt the process and then transfer onto the other non-steroidal immunomodulatory treatment. I must say that there is not a one size fits all approach to my vitiligo patients and it just depends on the patient.
Brett King, MD: Amit and David, I would love your quick thoughts on topical calcineurin inhibitors versus corticosteroids? And do you think one or the other is more effective? Do you think they should be used in combination? Let us know.
David Rosmarin, MD: Sure. Like Heather, I also use both. And can’t predict why one over the other works better in a particular patient, but that's what I've observed. Certainly, when it comes to more sensitive areas of the skin, like the face, we have to be careful about overusing our corticosteroids also in the pediatric population as well, especially because repigmentation takes a long time. We have to be more concerned about the overuse of corticosteroids if patients are using it over a full year. Certainly, I like it in combination as well. And I also want to comment how I like calcineurin inhibitors, such as tacrolimus when we think about maintaining treatment as well. There was a study done that showed that the use of tacrolimus twice a week can help patients maintain the repigmentation that they've gained. But certainly, when I'm trying to repigment, I will try things in combination. I will use corticosteroids, calcineurin inhibitors, and always offer patients phototherapy if they want it.
Brett King, MD: And Amit?
Amit Pandya, MD: I never do monotherapy. I do combination therapy. Like I explained before, one pillar is to remove the T cells and the other pillar is to stimulate melanocytes. When it comes to topical calcineurin inhibitors, the data shows that it tends to work best above the neck, basically on the face. It doesn't tend to work as well below the neck. In my opinion, the strong corticosteroids, like Heather said are more effective. I do use class one, class 2 corticosteroids on the body. I tend to use it in a pulse fashion. Like Heather, I tend to use it just once a day, 5 days a week. And even then, I will sometimes see thinning of the skin even if it's once a day, 5 days a week, especially in children. I do have to adjust sometimes. When it comes to the face, especially the upper face around the eyelids, I tend to use topical calcineurin inhibitors, or now I'm using JAK inhibitors in that area because I don't want to cause any effect on the eyes, especially the upper face with corticosteroids, especially strong topical corticosteroids.
Brett King, MD: I feel like I'm hearing repeatedly from all of you that in a world where everything was accessible, we would do combination topical therapy and phototherapy, topical calcineurin inhibitors are maybe more effective on the face than on other body sites. But fundamentally, underlying this combination treatment process is this idea that, again, we keep coming back to, which is we need to stop destruction of melanocytes by the immune system. And in part two, stimulate repigmentation of vitiligo-affected skin. And that phototherapy is a good way to do that. Does everybody agree with that summary of what we've been talking about?
Amit Pandya, MD: Yes. I agree with that summary. I would like to add the role of systemic steroids.
Brett King, MD: Perfect. Thank you. Go for it.
Amit Pandya, MD: Systemic steroids are important in patients who have signs of activity, what was mentioned earlier the confetti-like lesions, trichome lesions, Koebner phenomenon, and the rare inflammatory vitiligo. Those patients are in great danger of expanding their vitiligo. And many times, topical therapy will not be enough to prevent permanent deep pigmentation, especially in areas of glabrous skin that does not have hair. I consider it like a vitiligo emergency and in those patients, I will use systemic corticosteroids. Now there are multiple studies that have been done using prednisone, prednisolone, dexamethasone, betamethasone, oral, and even intramuscular. And after multiple studies in Asia, Europe, as well as United States, dexamethasone has been shown to have the best evidence of good response as well as lower side effects. Dexamethasone has a 72-hour half-life as opposed to prednisone, which is lower. And so, giving a low dose of dexamethasone, for example, 2.5, 3, 4 mg on two consecutive days a week for 12 weeks has been shown to stabilize in 90% of patients in the studies that have been done. Very few patients need more than 12 weeks of dexamethasone for active vitiligo, it will stabilize their disease. However, about a quarter of those patients will have weight gain, insomnia, and adverse effects that are intolerable and that either their dose has to be adjusted or it has to be stopped. One has to be aware of those adverse effects.
David Rosmarin, MD: Like Amit, I will also use dexamethasone 2.5 mg, 2 consecutive days of the week. I start out for about 12 weeks. And if patients need more, we'll continue that. I find that's particularly helpful as Amit said for preventing progression of disease and stabilizing it, but not as helpful at the repigmentation process itself.
Brett King, MD: Exactly. We've covered acute rapidly evolving disease, we're going to think about oral corticosteroids, maybe dexamethasone as the treatment of choice, also Amit earlier you mentioned also adding their full-body phototherapy, and then for treatment of ongoing not acute disease but for treatment for repigmentation, as you just alluded to David, we're going to use topical corticosteroids, topical calcineurin inhibitors, if possible, in combination with phototherapy.
Transcript Edited for Clarity