Dr Dunn leads a discussion outlining frontline therapies for the treatment of vitiligo.
Jeffrey D. Dunn, PharmD, MBA: What therapies are being used? Are they generally covered by different books of business: commercial, Medicare, or Medicaid? Are you having any problems with access to therapies at this point?
David Rosmarin, MD: The 3 most common treatments are topical corticosteroids, topical calcineurin inhibitors, and phototherapy. All 3 are viewed as first-line treatments for patients. There are some others that are used. These can be used in combination, or all 3 in combination. Those are the main 3 that are used in practice.
Many of the corticosteroids are inexpensive. There are certainly generic options. Vitiligo repigmentation takes time and is often on sensitive areas of the skin, such as the face, which makes it harder to use corticosteroids over the longer term. Calcineurin inhibitors, such as tacrolimus [Protopic], is great, particularly for trying to repigment the face. But it’s a large molecule too. It doesn’t work nearly as well at repigmenting the body, and it doesn’t work for all patients on the face.
Phototherapy is also a great treatment, stimulating those pigment cells to come back, in addition to trying to tell the immune system to calm down. But it can be quite inconvenient for patients to have to come in 2 or, ideally, 3 times a week for treatments. Some patients don’t have access. They have to come from far away. That can lead to missed work. There are a lot of challenges around phototherapy and patients having access to it.
In terms of coverage, it’s rare, but occasionally we see that we have trouble even covering the diagnosis of vitiligo, let alone the treatment. Sometimes a patient will come in and we’ll make a diagnosis of vitiligo, and the insurance will deny covering the visit for the patient. That can rarely happen, so I appreciate Dr Epstein commenting that he considers it a medical disease, as all providers do. The more common problem we face is covering of treatment. Usually, corticosteroids are covered because we aren’t asked for prior authorization. But even calcineurin inhibitors are often denied for patients with vitiligo. Similarly, with phototherapy, it’s a mixed bag. Some will cover it and some won’t. That has been my personal experience.
Brett King, MD, PhD: Treatment is frequently denied in my clinic, except for topical steroids, because they cost basically pennies. Topic calcineurin inhibitors are frequently denied in my clinic. Phototherapy is fairly commonly denied as well. Having an approved treatment [would help]. Topical corticosteroids, topical calcineurin inhibitors, and phototherapy aren’t FDA approved for vitiligo. There aren’t any FDA-approved therapies to improve or repigment vitiligo. Having one will be a shift. It will be interesting to see how it plays out in terms of the standard of care that we’re talking about relative to something brand new.
David Epstein, MD, MBA: I looked through the small list of what’s covered under the current policy. As you mentioned, steroids are obviously covered. Topical tacrolimus is covered. PUVA [psoralen plus ultraviolet A] is covered. The narrowband ultraviolet is covered. At the top of the list—I hadn’t heard it mentioned—was excimer laser. That’s also covered under the current policy.
David Rosmarin, MD: To chime in here so we’re on the same page, most of the phototherapy used is either narrowband UV-B [ultraviolet B] phototherapy or the excimer laser, which is a similar wavelength to phototherapy but in a targeted laser form. PUVA is becoming increasingly less used than the other 2 options, but historically has been used. There can be more adverse effects from PUVA as well.
Jeffrey D. Dunn, PharmD, MBA: I’m guessing that access to the calcineurin inhibitors has maybe gotten better as they become generically available. Maybe not. My expectation is that they would be. These types of conversations are going to be fascinating as we get into talking about the biologics and specialty drugs that are coming. How do we redefine standard of care? Does this change how we have access to not only those new drugs but also older drugs?
Transcript edited for clarity.