Management Strategies and New Directions in the Treatment of Vitiligo - Episode 14

Place of Maintenance Therapy in Vitiligo

August 12, 2022
Brett King, MD

Heather Woolery-Lloyd, MD

Amit G. Pandya, MD, FAAD

David Rosmarin, MD

Vitiligo clinical experts discuss the role of maintenance therapy in preventing recurrence of vitiligo.

Brett King, MD: Let's think about maintenance therapy. We talked about treatment of acute rapidly evolving disease. We talked about treatment of a stable disease and making that better. Now we have a patient that is better or has reached a plateau in their repigmentation. Now, how are we going to think about maintenance therapy in these patients? Are we going to suggest that they, again, if they're doing phototherapy, are we going to continue that infrequently? Are we going to have patients continue to apply topical Calcineurin inhibitors to areas of repigmentation perhaps on a decreased frequency? What do you all think about this? How do you counsel your patients starting with you Amit?

Amit Pandya, MD: I agree with David. That one study out of France, which showed that once your vitiligo lesion is gone, it tends to come back in the same spot later. One way that you can prevent the vitiligo from coming back again is to apply, for example, tacrolimus twice a week, and probably corticosteroids would work in the same way, twice a week show was shown to reduce the frequency of recurrence in the same area. You can do the same in areas that are not completely repigmented, but you reached a plateau. And at this point, you can also apply it perhaps twice a week to keep it from getting worse. When it comes to phototherapy, there haven't been good studies in looking at maintenance. However, we did assemble the consensus of approximately 15 to 20 centers across the world. And we published this a few years ago, which are called the consensus guidelines for phototherapy for vitiligo. And what we recommend is once the patient has hit a plateau to reduce phototherapy from 3 times a week, to twice a week for 1 month and see if the vitiligo comes back, if it doesn't, we reduce it to once a week for a month and see if it comes back. If it doesn't, we reduce it to once every other week for 2 months and see if it comes back. If it doesn't come back, then we stop. And the reason we don't go to every 3 weeks or every 4 weeks is because the skin doesn't have a memory beyond 2 weeks of the previous UVB treatment. I don't see a point in treating patients every 3 weeks or every 4 weeks. Now, as Heather mentioned earlier, there's such a burden of phototherapy that home phototherapy, is an ideal option. It's been shown to be just as safe. and just as efficacious as in-office phototherapy, I have over 600 patients with home phototherapy, and this is something that helps them to do maintenance phototherapy, and it helps them restart treatment when they notice a new lesion which can happen in many patients. I believe that about 60 to 70% of patients will have a new lesion if they stop therapy completely at some point, within the next few years after stopping.

Brett King, MD: David, what do you tell patients about maintenance?

David Rosmarin, MD: Like Amit, I will also offer the option of tacrolimus twice a week. If patients prefer to use topical corticosteroids will just counsel about them being careful about corticosteroid atrophy, and there's not quite the same amount of data, but it likely works. I also will do phototherapy for patients at a lower frequency oftentimes at around, once a week, for patients. And again, there's some flexibility there depending on the patient and how they're doing, and there's an art there for, if a patient starts to do worse, you can always increase the frequency if they're not doing as well. If they are doing really well, then you can also try to stop it and see if they'll maintain that response.

Transcript Edited for Clarity