Dr David Rosmarin Discusses the Economic Burden on Patients With Vitiligo

Coverage of vitiligo treatments is variable and patients can face an economic burden in the form of direct and indirect costs, explained David Rosmarin, MD, vice chair, education and research at Tufts Medical Center.

In this second part of the interview, Rosmarin discusses the economic burden of vitiligo, insurance coverage of treatments, and more.

Check out part 1, which includes the incidence and prevalence of vitiligo, patient characteristics, comorbidities, and the impact on a patient’s quality of life.

The American Journal of Managed Care^® (AJMC^®): Could you please discuss the economic burden associated with vitiligo specifically the direct costs and how it might impact indirect costs, as well?

Rosmarin: Cost of vitiligo patients come in different ways. One can be the money that's spent on products such as cosmetics in order to camouflage—self-tanners as well. Patients also may buy other supplements including antioxidants, Ginkgo biloba, and polypodium to try to treat their disease. There are different devices that they may purchase online, particularly those pertaining to different light treatments. Then there's also costs in terms of our prescription therapies as well: corticosteroids, calcium neuron inhibitors, and Janus kinase [JAK] inhibitors. There's burn in terms of office visits where patients have to leave work and also in terms of the phototherapy treatments, which patients may have to travel into a dermatologist's office to receive. We often will recommend that 2 or, more ideally, 3 times per week. If patients work nearby, that's usually not too much of a problem for them to go on a lunch break, for example, but if they work a little bit farther away from a phototherapy booth, it can be very burdensome if they have to leave work, school, or their other functions in order to receive treatment.

AJMC^®: Are treatments for vitiligo typically covered by commercial or Medicare or Medicaid insurance plans, and are they considered cosmetic or are they considered treatments?

Rosmarin: Dermatologists and the medical community are in unanimous agreement that vitiligo is not a cosmetic disease. It is a medical disease. It's an autoimmune condition. Coverage for vitiligo is very variable. Treatments are usually covered by Medicare and Medicaid. There are some commercial insurances that have denied coverage for treatments for vitiligo. Historically that's partly because not a single medicine up until July 2022 have been FDA approved for re-pigmenting patients with vitiligo. Since that time, we have found that plans have mostly changed, and there is better coverage of treatments for vitiligo.

I think there is a trend to recognizing that this truly is a medical disease and not a cosmetic one. Insurers may say that anything that has to do with pigment, they don't want to cover, because as a broad blanket statement, they may not want to cover, for instance, hair grain or some brown spots in the skin, lentigos. I think that that is more broadly considered in the cosmetic realm, but vitiligo we absolutely consider a medical condition.

AJMC^®: How would you like to see a change now that we have FDA-approved products in the market? If you could decide, how would insurance cover it? What would be your goal for the future?

Rosmarin: Well, I think the goal for coverage of medication should be evidence-based and we need to be cautious about how we are using medicines. We don't want to use medicines that are unproven or ineffective and force patients to use that with time. We want to make sure we offer patients options that are proven to work. When it comes to facial vitiligo, we know that calcineurin inhibitors such as tacrolimus can be effective. I think it is reasonable for insurance companies to say, “Why don't we try a calcineurin inhibitor first? If the patient has a side effect or it's not effective, then we will cover another option such as a JAK inhibitor.”

I think it's not reasonable for insurance companies to require corticosteroids to the face first because we know it takes a long time for re-pigmentation, and there can be side effects from those treatments, and they may not work quite as well. If patients have vitiligo though on the trunk or extremities, where we know that tacrolimus may not work as well, because it's larger molecular size, and we have JAK inhibitors that are proven to be effective, I would hope that they would cover them early on in the treatment algorithm.

I think we need to use common sense, be reasonable, rational, and use the evidence that's out there so that we provide patients the treatments that they need, and we are not using things that have very little likelihood of working.

AJMC^®: What are you working on in vitiligo that you are excited to share?

Rosmarin: There's a lot of great treatments that are in development for patients with vitiligo. It's an exciting time. Ruxolitinib cream is our first topical JAK inhibitor that has been approved for re-pigmenting patients, but there are other JAK inhibitors that are in development, particularly oral JAK inhibitors. Most notably ritlecitinib, which is a JAK3 inhibitor from Pfizer, as well as upadacitinib, a JAK1 inhibitor from AbbVie. There's a need for both topicals and oral JAK inhibitors. Topicals we will often use first-line because of safety, but for patients who have a very large body surface area, or they have very progressive disease so it's hard to keep chasing with a topical, an oral may make sense.

Other agents that are in development for treatments include an anti–interleukin 15 antibody, which will hopefully help remove some of the skin-resident memory T cells that keep recruiting the disease back to the skin, so patients can have a longer-term remission. It has not been proven to work yet, but it's currently in studies, so we're eagerly awaiting those results. There's also a device to transfer melanocytes from one part of the body to the depigmented patches. That's also very exciting. To be able to make that process more acceptable in offices and available is quite exciting for those who have particularly stable vitiligo. That's another option to look forward to.