New Therapies Offer Hope for Vitiligo, an Often Misunderstood and Undertreated Disease

Am J Manag Care. 2026;32(Spec. No. 6):SP279-SP281. https://doi.org/10.37765/ajmc.2026.89969

Vitiligo carries a well-documented burden of mental health effects and social stigma, and it now has an FDA-approved targeted therapy.¹ And yet, dermatologists, nurse practitioners, and physician assistants gathered at a recent population health roundtable hosted by The American Journal of Managed Care in Phoenix, Arizona, described a specialty still fighting the same foundational battles: insurers that classify the disease as cosmetic, prior authorization processes that can take months and end in unexplained denials, and patients who have been told for decades that nothing can be done.

The event brought together clinicians from across the Phoenix metropolitan area for a candid discussion on disease burden, treatment pathways, access barriers, and the emerging systemic therapy pipeline. The conversation revealed a specialty at a turning point, buoyed by new science but constrained by structural inequities that prevent proven therapies from reaching the patients who need them most.

A Disease Caught Between Science and Payers

From the opening discussion, a core tension dominated: Clinicians unanimously view vitiligo as an autoimmune disease, but the payer community frequently treats it as an aesthetic concern. “Among my colleagues, both within and outside of my specific institution, it is considered an autoimmune disease, but our payers consider it a cosmetic condition,” said David Seiter, FNP-C, a nurse practitioner at Epiphany Dermatology. “So there’s a big disconnect there.”

That disconnect has concrete consequences. Darren West, PA-C, a physician assistant at Pinnacle Dermatology, argued that the framing of vitiligo as a condition rather than a disease was itself part of the problem. “When you look at it like a condition, you’re downplaying it, and you’re making it look cosmetic, when we know that this has a very amazing psychological burden, and anxiety and depression [are] associated with this disorder, and so we have to embrace the fact that this is a psychological disease component,” he said.

Jennifer Fernandez, MD, a dermatologist at Medical Dermatology Specialists Phoenix who is also completing a clinical informatics fellowship at the University of Arizona College of Medicine Phoenix, pointed to the unpredictability of insurer requirements as an additional burden on clinical teams. “There are very heterogeneous rules with different insurance companies. They’ll deny for this, and you have to try X, Y, Z for that insurance company, but it’s different for that insurance company,” she said. “And so it’s hard to counsel the patient ahead of time about what X, Y, Z things they need to do, because you don’t quite know.”

Michael McBride, DO, a dermatologist at Saguaro Dermatology, described a clinical habit that, although pragmatic, reveals how far the system has strayed from ideal care: “When I see somebody for vitiligo, honestly, the first thing I’ll sometimes look at is what insurance do they have? Because I think some of these [insurers] I know are going to be a harder burden. It’s a different conversation.”

The Real Burden: Psychological, Cultural, and Economic

Speakers devoted significant time to the nonphysical toll of vitiligo—a disease that produces no pain or itch yet can devastate quality of life. Research cited during the session shows that over half of patients globally had been told their disease was untreatable, and 36% had not pursued or were unaware of treatment options.

Arun Sood, MD, an adult and pediatric dermatologist at the Center for Dermatology and Plastic Surgery, spoke of the heavy toll of vitiligo among patients with skin of color.² “It’s really hard, especially [for patients with] skin of color, where there’s a lot of socioeconomic impact,” he said, “and I think sometimes that is lost in the general community.”

Moderator and pediatric dermatologist Karan Lal, DO, who runs a dedicated vitiligo clinic at Affiliated Dermatology in Scottsdale, described the cultural weight of the disease among South Asian and Latino communities, in which a vitiligo diagnosis can carry devastating social consequences. He recounted a patient who had traveled from the United Kingdom to Massachusetts for treatment. The patient told him, “My options are either to come to you and see what’s available, or cut this part of my arm off, because my chance of getting married was better being with half an arm than [with] vitiligo on my arm.”

David Israel “Izzy” Andrews, MD, a pediatric and general dermatologist at Arizona Dermatology, captured the uniquely isolating experience of individuals living with visible depigmentation: “They’re always going to be looked at as different. You can’t make this go away; you can improve it, but they’re always going to have something that separates them, that usually isn’t invisible to other people.”

Seiter put the stigma into global context, saying, “There are countries, and especially in Asia, where if you have vitiligo, you’re shamed, you’re shunned, you’re put out. So, on a worldwide global aspect, not thinking of just the US, you’re getting some pretty serious psychological symptomatology.”

Treatment Pathways: Creative, Constrained, and Unequal

Despite noting that the treatment landscape now includes ruxolitinib cream (Opzelura)—the only FDA-approved therapy for vitiligo—the panel described daily clinical realities shaped by resource shortages, insurance denials, and patient adherence challenges.

Most clinicians described a de facto first-line regimen of topical corticosteroids and calcineurin inhibitors, followed by topical ruxolitinib when access can be secured. Annie Dai, MD, a general dermatologist at the Center for Dermatology and Plastic Surgery, said that after the first-line options, “I assume that they could be able to get [ruxolitinib], which is easier said than done. I’ve even had tacrolimus denied last week for facial vitiligo.”

Phototherapy, although highly effective, emerged as a consistent access failure point. Few practices offer it on-site, and fewer patients can realistically attend 2 to 3 sessions per week. “Most patients don’t want it,” Dai said. “They just don’t have the time or the bandwidth to go get phototherapy. They can barely be adherent with their topical therapies twice a day, let alone go physically to a different location.”

Andrews offered a stark summary of how the system functions on paper vs in practice. “For me, I think everybody [with] vitiligo in a perfect world should be on phototherapy,” he said, but between “accessibility, paperwork, burdensome stuff—I’m not in an academic center—it’s very hard for me to do it.”

West endorsed the FDA-approved targeted therapy enthusiastically, saying, “It has revolutionized the way I treat. It’s amazing how well it works. I now have something I can actually tell my patients [about] that [is] clinically effective [and] FDA approved.”

The Prior Authorization Gauntlet

No topic generated more frustration than the prior authorization process, which clinicians described as opaque, inconsistent, and increasingly automated in ways that disadvantage patients. Fernandez described an experience with an artificial intelligence (AI)–powered authorization platform that illustrates the dysfunction: “I just had a patient get denied for Rinvoq [upadacitinib]. He has to come in person and sign a paper for Medicaid for us to be able to send an appeal.… I have to get his permission to get an appeal for medication that I ordered.”

McBride acknowledged that the practice of using AI tools to fight AI-generated denials has become normalized. “I just feel like it’s going to be a battle of AIs, because insurance is using AI to deny these medications,” he said.

Working within the confines of specific health system policies can also pose a challenge. “I’ve had some adult patients from the VA [Veterans Affairs], and they just will not cover [ruxolitinib]. They say it’s purely cosmetic, and the answer is just no,” Sood said. “And there’s no way that I can argue or get my way around it. It’s really difficult.”

A Pipeline and a Promise

The latter half of the discussion turned to the emerging pipeline of oral Janus kinase inhibitors, including upadacitinib, povorcitinib, and ritlecitinib, which panelists viewed with cautious optimism. Phase 3 data for upadacitinib, as mentioned by Lal, showed clinically meaningful improvements in facial and total body vitiligo scores at 48 weeks,³ although the panel acknowledged that slower response timelines and lingering questions about long-term maintenance and safety monitoring remained significant considerations.

Seiter offered a perspective grounded in the evolution of the disease over his career: “We finally have something that we can talk about to these patients. We have legitimate data, and I think that is huge. It’s comforting. Patients might now actually come into the office talking about it because before, a lot of people with this disease never really thought there was much to do for it.”

For West, the philosophical takeaway from the session was as important as any clinical protocol: “We have to give our patients a sense of hope and also realistic expectations. Patients have to understand it’s not going to be an overnight success, but it will be something that we can move closer to the goal over time.”

As the roundtable concluded, panelists named concrete actions they planned to bring back to their practices. Fernandez intends to document and quantify the prior authorization burden in her office to justify additional staff. Sood pledged to adopt a more aggressive, multimodal approach—particularly for high body surface area disease in pediatric patients. Dai said she will be committed to having deeper conversations about mental health and better supporting her own staff through the burden of the authorization process.

McBride offered a challenge to payers that encapsulated the room’s mood: “They have to ask themselves as payers, ‘What are we doing for our patients? If we’re going to help them, if we’re going to give them access to care, what should their end points be? Is it quality of life? Is it that their disease is remitted?’ They should be asking themselves—trying to put themselves in the patient’s shoes—what would make the patients healthier in all aspects of life?”

The consensus of the room was perhaps captured by Seiter, who called for a shift in how health systems categorize the disease at every level: “Health systems need to know it’s an actual disease. It’s not a condition that’s cosmetic or optional.”

References

1. Gavidia M. FDA approves ruxolitinib cream as first repigmentation therapy for vitiligo. AJMC. July 19, 2022. Accessed May 12, 2026. https://www.ajmc.com/view/fda-approves-ruxolitinib-cream-as-first-repigmentation-therapy-for-vitiligo

2. Grimes P, Hamzavi IH, Bibeau K, et al. Mental health and psychosocial burden among patients with skin of color living with vitiligo: findings from the global VALIANT study. Dermatol Ther (Heidelb). 2025;15(7):1931-1939. doi:10.1007/s13555-025-01412-3

3. Bader K. Phase 3 data show upadacitinib drives progressive repigmentation in non-segmental vitiligo. Dermatology Times. April 10, 2026. Accessed May 12, 2026. https://www.dermatologytimes.com/view/phase-3-data-show-upadacitinib-drives-progressive-repigmentation-in-non-segmental-vitiligo