Restoring Skin Pigmentation in Vitiligo With Advanced Treatments - Episode 10
Experts in dermatology share their impressions of ruxolitinib and approaches to vitiligo treatment in clinical practice.
Seemal Desai, MD: We’ve heard all the data. I’d love to get everyone’s feeling on initial impressions from the finding and how ruxolitinib has changed your practice in terms of your first-line topical therapy vs others.
Heather Woolery-Lloyd, MD: I’ll start because it has changed my practice. I’ve been practicing for 20 years, so I’ve had patients with vitiligo for 20 years. Patients would come in and say, “Is there anything new?” I’d just smile, “Nothing is new, but we’re going to do this.” This is the first time I could say with confidence,” There’s something new. It’s FDA approved, and it works. We have good data.” It has definitely changed my practice. I tend to use topicals more than systemics—that’s my personality—so I feel very comfortable with this new topical and also feel comfortable with the safety profile.
Seemal Desai, MD: Can I interpret that to mean that right now, if you have a new patient with vitiligo who comes in, in the first line you’re probably using ruxolitinib as your topical?
Heather Woolery-Lloyd, MD: Yes, definitely.
Seemal Desai, MD: Good to know. Brittany, what about you?
Brittany Craiglow, MD: I agree. Before ruxolitinib, I was doing a lot of these more complicated regimens for patients, like doing clobetasol but only 2 weeks out of the month. A lot of that stuff is hard to do—to have 1 topical that you can use anywhere, and you don’t have to figure out which cream is for what day and when I did it last. That’s a lot easier for patients. It’s hard to do something twice a day, and it’s important to acknowledge to our patients, “I know it’s a lot.” Now we can say, “If you do this, if you make this your job for the next 6 months, we’re going to get somewhere.” For me, depending on the patient, it’s often first line. Depending on insurance, you may have to fail or at least try a topical calcineurin inhibitor or a topical steroid. You may choose to use it on the face. If someone has more extensive stuff elsewhere, do topical steroids there. I’ve been happy to have an approved treatment. It changes the conversation.
Seemal Desai, MD: It totally changes the conversation.
Brittany Craiglow, MD: It makes it much easier.
Seemal Desai, MD: Nada, how do you approach your topicals now?
Nada Elbuluk, MD: I’m a combination of what’s been said. In some individuals, it’s first line, particularly patients who I’ve been treating where maybe treatment response is slowing down or they’re plateauing. We have something new. Let’s try this out. Let’s see how you do. I have another subset who’ve already heard about it, and they come in eager to try that. They haven’t been on anything for years, but they don’t want to retry something from the past. They want to try this new drug they’ve heard about. That’s another subset that I try it on. But I still have individuals for whom I’ll go toward the old-school stuff first. If they fail that, I know that I have ruxolitinib as my next thing to try. To Brittany’s point, insurance coverage is still an issue. Thankfully, more insurances are starting to cover it, but we still have carriers that will want them to try traditional treatments and fail that before getting approved.
Seemal Desai, MD: Ted, phototherapy in your area is poorly covered. How do you approach newer therapies? Are you having coverage, or do you still go to topical steroids and calcineurin inhibitors?
Ted Lain, MD: It’s patient dependent, but it’s usually covered in my area. The ruxolitinib cream fits in nicely with the theme in dermatology, which is moving away from steroid use all together. We have so many topicals that allow us to leave the clobetasol on the shelf and move to something that’s probably much safer. But safety is an issue, and we’d be remiss not to mention at least that there’s a black-box warning on the label of this drug. That’s something that I talk to my patients about. I’m very forward with the label with all JAKs, whether systemic or topical. I talk about it from the beginning, whether you believe it or not in terms of increased risk. We know this drug is very safe but you need to know, eyes wide open, that there’s a black-box warning. It behooves the clinician to have an open and fair conversation about it with their patient, so that you don’t have a “deer in the headlights” look when they come back. Or they call the office and say, “You never told me there was a risk of thrombosis.” You need to know that. Just be aware. All of us feel very comfortable with it, especially those of us who do clinical trials and do JAK inhibitor clinical trials, but it’s something you need to know about.
Seemal Desai, MD: I totally agree in transparency. We want to be fair and balanced because we’re trying to get the patient better but keep them safe. I love that you said you’re a safety nerd. We’re all in that camp because we’ve got to get people better, but we want to be safe. Nada?
Nada Elbuluk, MD: The other patients I treat first line are difficult-to-treat areas: genitals, areola, ventral breast. For places that have always been difficult, I now go to ruxolitinib first line.
Seemal Desai, MD: Brittany, I like that you said that you’ll use the ruxolitinib in certain areas, but then you’ll still do your topical steroid calcineurin inhibitor in other parts of the body because you can’t spread it everywhere. I do that a lot. I’ll say, “Let’s pick your target sites for ruxolitinib.” Many of us use the EMR [electronic medical record], so you can just pull up your iPad and take pictures of those sites. I’ll say, “Use it on your hands, your wrists, your elbows, and your face.” That’s going to add up to 6% or 7% of your BSA [body surface area]. But for your trunk and those follicularly rich dense areas, I may still have you do 2 weeks of clobetasol, 2 weeks of tacrolimus, and alternate back and forth. The issue is that it gets complicated.
Brittany Craiglow, MD: It’s a lot of work.
Seemal Desai, MD: It’s a lot of counseling. We’ve got to print handouts. We highlight in different colors. We’ve got a whole system down, and then you hope the patient is going to remain compliant. But you could definitely take that approach as well.
Brittany Craiglow, MD: We just ask, what’s reasonable for you? There are some people for whom that’s never going to happen, and that’s OK. Then we decide, what are your priorities? Maybe we work on those first and then move on for individuals who have greater body surface area involved.
Seemal Desai, MD: That makes sense.
Ted Lain, MD: If we compare this with the other indication for ruxolitinib cream, which is atopic dermatitis, the percentage of body surface area allowed for vitiligo is 10% but, in the AD, [atopic dermatitis] indication it’s 20%.
Seemal Desai, MD: That’s a very good point.
Ted Lain, MD: When you think about AD with the compromised barrier, you imagine there would be a higher absorption rate as well. If I have a patient who may exceed the 10%—this would be off label—I don’t worry about it because I know the safety on the AD label. I feel comfortable going a little beyond the 10% because of that.
Seemal Desai, MD: I love that you mentioned that. Dermatology is an art, and we’re all following a recipe that doesn’t have exact measurements and proportions.
Transcript edited for clarity