Restoring Skin Pigmentation in Vitiligo With Advanced Treatments - Episode 6
Brittany Craiglow, MD, discusses the lengthy nature of vitiligo treatment response and how to approach communicating with patients who want to see change quickly.
Seemal Desai, MD: Britt, let’s come back to you. Let’s talk a little bit about how do you measure that treatment response. Is there a way to tangibly talk about what to expect when? Is there a way to look for treatment milestones or benchmarks? How do you sort of counsel the patient on that and what to expect?
Brittany Craiglow, MD: I agree it’s hard to predict. But in general, treatment of vitiligo is a marathon, and not a sprint. A lot of people come in and you’ll suggest something and they say, “Oh, I tried that before.” I’ll ask, “OK, well, how long did you use it?” “I don’t know. Maybe a few weeks.” Well, you’re not going to see improvement within a few weeks. So, we have to sit down again. This is kind of shared decision-making. This is going to be seen. You’re doing a topical. This is going to be something you need to do ideally twice daily for months. I’m actually probably not going to see you back for 4 to 6 months because I’m not going to change anything because we still are going to have a ways to go.
If we look at clinical trials, even after 6 months people get continued repigmentation beyond that. I think one thing I like to do is ahead of time–speaking of the hairs, make sure they have darkly pigmented hairs or pigmented hairs, because that’s a good sign that maybe we’ll get to see that beautiful follicular repigmentation. But sometimes, if they’re like I can’t do it everywhere, we decide OK, we’re going to do the face. If that’s the most important to you, great. And even if you don’t get phototherapy, you can probably get light on it because we’re learning more and more that light is really an important part of treatment. That’s why we see places like the face and unexposed areas do better. People can do home phototherapy plus their topicals. It’s amazing, but it’s a lot of work. I think we want to see something. I like to see something happening by about 4 months. But for sure, patients aren’t generally happy until they’re pretty close to repigmented, but that could take a year or more.
Seemal Desai, MD: Absolutely.
Brittany Craiglow, MD: And so, photos are really important because I think, especially if they’re getting that marginal repigmentation, sometimes it’s kind of hard for the patient to tell, even though they’re with themselves every day and having the photos is good. I think you keep going as long as you’re seeing continued forward progress. You just keep going. And even when you get complete repigmentation, you don’t stop because you’re going to go backwards. So most of us do this kind of intermittent use if you’re doing topicals to try to keep things the way they are.
Seemal Desai, MD: Ted, did you want to add something?
Ted Lain, MD: She brings up a really good point. Britt, you bring up a couple of really good points. The degree and the speed of pigmentation, of repigmentation also relies on the density of hair follicles because, as we mentioned, most of the pigment occurs because of that perifollicular repigmentation. The face in particular, especially in men, has a high density of hair follicles. We expect the face, when we look at clinical trial results for example, we expect the face to do better than the rest of the body in which there are areas that have very…a small density of hair follicles; you could imagine the elbows, the knees, the palms, for example, and then areas with a higher density. So, when you look at clinical trial results in particular and you look at the F-VASI, the facial Vitiligo Area Scoring Index, versus the body VASI, or the total VASI, you’ll see a difference totally expected based on the target of the JAK [Janus kinase] inhibitor or the topical that we’re talking about, which is essentially the hair follicles.
Seemal Desai, MD: Absolutely. I’m glad you mentioned that because we have to tell patients upfront that I may be able to get your face and neck. I’m pretty confident I’m going to make it better. But your hands and your fingertips are…I’m pretty confident I won’t make them much better. But I’d rather have that discussion upfront because with the advent of some of these new therapies like the JAK inhibitors, which we’re going to get into, for the first time ever we’re actually seeing some pretty decent results on acral sites which we’ve never seen before. I’d rather set up for less of expectation on acral sites, like you said, early on and then if you get some impact, then great and we’re all winning together.
Transcript edited for clarity