The JAK Inhibitor Shift in Vitiligo: A Critical Review of Clinical Data and Economic Realities

Vitiligo is a chronic, difficult-to-treat depigmenting disorder that can impose a substantial psychosocial and economic burden on patients.^1-3 Janus kinase (JAK) inhibitors have emerged as a promising treatment strategy, with a topical agent approved and oral agents expected to enter the treatment landscape soon.^4-6 During a recent Peer Exchange from The American Journal of Managed Care®, a panel of experts delved into vitiligo management, discussing real-world challenges, the clinical evidence on JAK inhibitors, and payer-related barriers impacting therapy access. The session was moderated by Ryan Haumschild, PharmD, MS, MBA, CPEL, vice president of pharmacy at Emory University in Atlanta, Georgia.

Treatment Goals in the Management of Vitiligo

Vitiligo is an acquired depigmenting disorder characterized by the progressive loss of melanocytes.^1,7 Clinically, the disease is broadly classified as segmental and nonsegmental vitiligo, with the term vitiligo historically referring to all nonsegmental forms of the disorder.^1,7 Segmental vitiligo often has a rapidly progressive course, with depigmentation spreading within the segment over a period of 6 to 24 months without subsequent further extension.⁷ In contrast, nonsegmental vitiligo lesions may become active even after prolonged periods of stability.⁸ Disease stabilization and repigmentation are distinct treatment goals in vitiligo, with disease activity and extent being key factors guiding management decisions.¹

Stakeholder Insights

“[When] we see a patient with vitiligo, we think about 3 different goals, depending on the stages that a patient is in. The first we’re assessing: Is the [disease] active or stable? Because if they’re progressing, then the first goal is [to] halt the progression. Once that’s done, the second goal…is repigmenting the patient. And then the third goal is, once we have repigmented that patient, how can we maintain that repigmentation?” explained David Rosmarin, MD, chair of the Department of Dermatology and the Kampen-Norins Scholar in Dermatology at Indiana University School of Medicine in Indianapolis. Rosmarin noted that patients worry about the spread of the disease, including that it would “spread to more visible locations, particularly the face, if that’s not already involved, or other critical locations.”

Assessing Vitiligo Severity: The Role of Body Surface Area and Other Clinical Features

Although measuring body surface area (BSA) is a necessary starting point when assessing the severity of vitiligo, BSA alone does not fully capture the disease burden.⁹ A 2026 international consensus statement recommends a 2-step approach to assessing vitiligo severity.⁹ In step 1, BSA thresholds of less than 3%, 3% to less than 10%, and 10% or higher would indicate mild, moderate, and severe vitiligo, respectively.⁹ In step 2, additional clinical and psychological criteria are integrated to further define severity in patients with moderate vitiligo.⁹ The presence of at least 1 major criterion, such as spreading or active disease, involvement of highly visible or high-impact areas, or psychological distress—or 2 or more minor criteria, such as darker skin tones, younger age, scalp or facial hair involvement, impact on career or school, or perceived loss of personal/cultural identity—would warrant upgrading to severe disease.⁹ Additionally, patients with rapidly progressing or spreading vitiligo, regardless of the level of BSA involvement, should be classified as having severe disease.⁹

Stakeholder Insights

The panelists agreed that BSA alone fails to capture the severity of vitiligo.“[When] you think of 10% [BSA], it doesn’t seem like it’s that much, [but] depending on [the location], it could be a lot. A good portion of your face, neck, and head can take up a good portion of that…. I think [BSA] tells us how many body parts are involved,” explained Karan Lal, DO, MS, FAAD, a double board–certified pediatric and cosmetic dermatologist at Affiliated Dermatology in Scottsdale, Arizona. He added, “I think when we really are worried about [BSA] is when we start getting into the 30% plus [BSA]…. [We] can get away with topical therapies for up to 10% [BSA] for what we have available at the moment, and then beyond that, we need to think outside the box.”

Lal stated that BSA is a basic “easy way to look at the severity of vitiligo” but it is not the only factor they consider. Although vitiligo has no associated symptoms, Lal said, certain phenotypic markers of disease activity, such as trichrome vitiligo, confetti vitiligo, and Koebnerization, are associated with a worse prognosis. “The markers of disease activity sometimes actually dictate more of a treatment [course] than just BSA alone,” Lal added. Additional clinical features to consider include the anatomic location and whether the disease is segmental vs nonsegmental. If the disease is starting to spread “down the arms toward the hands and feet, where we’re going to have a not-so-good outcome with our current available therapies…[that] forces me…to be more aggressive,” he explained.

Rosmarin agreed with the limitations of BSA, stating that although BSA “measures the extent of the disease,” it fails to capture its severity, a subjective measure that should consider the disease’s impact on the patient. “If a patient has disease in certain critical locations, but it is low in [BSA], I would argue that’s more severe than a larger BSA, but in areas that aren’t bothering the patient or maybe less noticeable…. You can’t really separate out the effect on a patient from when you’re thinking about severity for vitiligo, which is different from a lot of our other disease states, making it much more challenging to make those judgments,” he said.

Seemal R. Desai, MD, FAAD, a board-certified dermatologist and president of the Global Vitiligo Foundation, said, “[It is] not just about BSA, sites of the body, anatomic distribution, instability, or activity, as well as looking at other comorbidities or psychological factors that can certainly upgrade severity.”

Rosmarin explained that halting progression is the “biggest urgency…[because] it is so hard to repigment and it’s much easier to halt the spread…. [The] anatomic location really matters a lot when it comes to vitiligo…. Areas that are dense in follicles, like the head and neck region, are easier to repigment. [Glabrous areas] that lack follicles, like the fingertips, the lips, the nipples, genitals, [are] much harder to repigment.” He added that involvement of areas lacking follicles justifies more aggressive, urgent treatment, which he tries to convey to payers.

Jason Fehr, MA, an independent consultant in market access, highlighted the pressures across managed care to control overall spending, noting that elements of step therapy would likely remain part of policies governing vitiligo treatment. He added, “The interesting thing about vitiligo is that some of the treatments are on the pharmacy benefit, and other treatments fall under the medical benefit. And unfortunately, there’s not a lot of coordination between the two…. [The] coordination of benefits across is probably going to continue to be a challenge…. [BSA] will be a key determinant of policy based on, frankly, what’s available in the evidence and how future guidelines may also support what that use looks like.”

The Psychosocial and Economic Burden of Vitiligo

In survey findings from a global study, more than 30% of patients with vitiligo agreed that the disease affected multiple aspects of their emotional well-being, including self-esteem, stigma, careers, and relationships.² Additionally, more than 40% of patients indicated that aspects of daily lives, such as determining what clothes to wear, going to the beach or pool, or attending parties or events, were frequently impacted by vitiligo.²

A retrospective cohort analysis highlighted the economic burden associated with the disease. Health care costs and all-cause and mental health–related health care resource utilization were significantly higher among patients with vitiligo than individuals without vitiligo.³

Stakeholder Insights

Lal highlighted the psychological impact of vitiligo, stating that in certain cultures, the disease is associated with guilt as family members feel responsible for their children having the condition. He also noted that the psychological impact is difficult to quantify, and that for “things that we can’t quantify, access becomes an issue.” Lal noted the financial and logistical burden experienced by patients, such as phototherapy, which requires frequent visits. And even when insurance covers therapy, some patients have out-of-pocket costs and high deductibles. “We know that when we do phototherapy, and we combine these treatments with our topical and oral therapies, people get a better response, so we still advocate for them. It’s hard to find phototherapy centers, so people have to drive farther. Some people don’t have access to phototherapy, so they [prefer] to buy a booth that has its own associated cost. The cost is dependent on how extensive you want to be. And for some people, it’s just not accessible, so they give up,” he said.

Current Treatment Landscape

Therapies currently used for vitiligo include topical agents, systemic treatments, phototherapy, and surgical interventions.^1,10 Topical agents have traditionally included corticosteroids and topical calcineurin inhibitors (TCIs).^1,10 In 2022, the FDA approved the JAK inhibitor ruxolitinib as a topical cream for the treatment of nonsegmental vitiligo in patients 12 years and older. It was the first approved pharmacologic treatment to address repigmentation in this patient population.^4,11 Oral steroid mini-pulse therapy is the most commonly used systemic treatment for vitiligo, often reserved for patients with extensive or rapidly progressive disease.^1,10 Other systemic options include oral immunomodulating agents such as methotrexate, cyclosporine, azathioprine, and minocycline, although data supporting their use are limited.^1,10 Antioxidants—such as vitamin E or C, Ginkgo biloba, Polypodium leucotomos, and gliadin-protected superoxide dismutase—have also been used as systemic interventions for vitiligo, often in combination with phototherapy.^1,10

Vitiligo treatment selection should be based on shared decision-making, taking into consideration treatment goals, disease impact, activity, and extent.¹ In general, combination approaches, such as phototherapy with topical agents, are considered more effective than monotherapy.¹

Stakeholder Insights

Although topical ruxolitinib represents an important addition to the therapeutic armamentarium, topical corticosteroids and TCIs continue to play a role in the treatment of vitiligo, with Rosmarin explaining that, depending on the scenario, he may use topical ruxolitinib alone or in combination as first-line treatment. He added, “[There] are also patients for whom I will still use ruxolitinib cream with corticosteroids or [TCIs] in different combinations, or in others whom payers want me to use corticosteroids or [TCIs] and then utilize ruxolitinib cream…. [Depending] on certain scenarios, it is still reasonable to use agents like tacrolimus ointment as first-line therapy.”

Phototherapy remains an important treatment modality, often used in combination with other modalities, but access is a concern. “We think of treating patients with vitiligo as really a 2-step process. Not only do we need to calm the immune system down, we need something to stimulate the pigment cells,” Rosmarin explained. “[Phototherapy] helps us with that stimulation of the pigment cells…. The problem with phototherapy, like narrowband UV-B, is access and convenience. There are many dermatology practices that don’t have phototherapy, and many residents and trainees who aren’t learning how to really utilize phototherapy. And it can be inconvenient for patients; they can be plagued with high co-pays. There also is an option for home phototherapy, but oftentimes payers request [proof] that patients are successful with office phototherapy before potentially paying for home phototherapy.”

Rosmarin highlighted the need to combine treatment modalities, as achieving repigmentation is a challenge. “[It] is so challenging to repigment many people. We often have to use combination therapy and not just rely on only one. And many we’re using again, not just in an order, but we’re using them again at the same time.”

Clinical Evidence and the Evolving Role of JAK Inhibitors

The FDA approved ruxolitinib cream for nonsegmental vitiligo based on findings from 2 randomized, vehicle-controlled phase 3 trials, TRuE-V1 (NCT04052425) and TRuE-V2 (NCT04057573).^4,12 These identical trials enrolled patients 12 years and older with nonsegmental vitiligo involving 10% or less of total BSA.¹² Patients were randomly assigned to 1.5% ruxolitinib cream or matching vehicle cream twice daily, with the primary end point being a decrease of at least 75% in the facial Vitiligo Area Scoring Index (F-VASI; [F-VASI75 response]) at week 24.¹² Following the week 24 visit, all patients could apply ruxolitinib cream for an additional 28 weeks in the open-label extension phase.¹² The F-VASI75 response rates at week 24 were 29.8% with ruxolitinib vs 7.4% with vehicle (relative risk, 4.0; P < .001) in the TRuE-V1 trial and 30.9% with ruxolitinib vs 11.4% with vehicle (relative risk, 2.7; P < .001) in the TRuE-V2 trial.¹²The F-VASI75 response rates increased to 52.6% in TRuE-V1 and 48.0% in TRuE-V2 among patients who remained on ruxolitinib for 52 weeks.¹² The most common adverse events related to ruxolitinib cream were application-site acne and application-site pruritus, with all events being mild or moderate.¹²

Upadacitinib, an oral JAK inhibitor approved for the treatment of several immune-mediated diseases, including atopic dermatitis, has demonstrated promising efficacy in nonsegmental vitiligo.^5,13,14 Upadacitinib is being evaluated in the phase 3 Viti-Up trial (NCT06118411), with 2 replicate studies running at the same time, among patients 12 years and olderwith nonsegmental vitiligo and baseline scores of 0.5 F-VASI or more and total VASI (T-VASI) of 5 or more.¹⁵ The coprimary end points are F-VASI75 and improvement in T-VASI of at least 50% (T-VASI50) at 48 weeks.¹⁵Both end points were met across both trials, with T-VASI50 being achieved by 19.0% to 21.5% of patients treated with upadacitinib vs 5.9% of patients treated with placebo, and F-VASI75 being achieved by 23.0% to 25.0% of patients treated with upadacitinib vs 5.9% to 6.9% of patients treated with placebo.⁶ Through 48 weeks, safety findings were consistent with the established profile of upadacitinib across its other indications.⁶

Ritlecitinib and povorcitinib are additional oral JAK inhibitors being evaluated in phase 3 trials among patients with vitiligo.^16,17 Ritlecitinib, an inhibitor of JAK3 and the tyrosine kinase expressed in the hepatocellular carcinoma (TEC) kinase family, has been approved by the FDA for severe alopecia areata.¹⁸ In a phase 2b trial (NCT03715829), treatment with ritlecitinib led to meaningful repigmentation, as measured by F-VASI75, across various patient subgroups with active nonsegmental vitiligo.¹⁹ Ritlecitinib is being evaluated in 3 phase 3 trials (NCT05583526, NCT06163326, NCT06072183) as part of the Tranquillo program among patients with nonsegmental vitiligo.¹⁶ Povorcitinib, an oral JAK1 inhibitor under development, led to substantial facial and total body repigmentation over 52 weeks of treatment in a phase 2 trial (NCT04818346) among patients with extensive nonsegmental vitiligo.¹⁷ The 52-week phase 3 STOP-V1 and STOP-V2 (NCT06113445, NCT06113471) trials are evaluating povorcitinib among adults with nonsegmental vitiligo and total BSA 5% or more, T-VASI score 4 or more, facial BSA 0.5% or higher, and F-VASI score 0.5 or higher.^20,21

Stakeholder Insights

“JAK inhibitors are…game changers in our treatment pathway…. [In contrast to] systemic steroids or other immunomodulatory therapies, this will be the first time we’ve ever had randomized, double-blinded, placebo-controlled data,” Desai said. “[These therapies], especially in…oral form, are going to help us both stabilize and repigment. And those things are very distinct, and we’ve got to remember that you can’t expect to bring the color back if there’s still disease activity that’s ongoing.” He also noted the ease of administration of oral therapies, which is “important from [an adherence] perspective.”

Rosmarin explained the similarities and differences between the phase 3 trials evaluating ruxolitinib and upadacitinib. Regarding inclusion criteria, he stated that the BSA was up to 10% in ruxolitinib trials, whereas in the Viti-Up trials, “it was 5% or more…and there is some overlap in the population, but also largely different.” Additionally, he said, “When we look at the primary end point [in TRuE-V trials], it was at the 24-week mark, so 6 months, looking at really F-VASI75, which is the regulatory end point. And a strong key secondary was the T-VASI50…. In the case of the [Viti-Up trials], however, they had a coprimary end point of T-VASI50 and F-VASI75…at 48 weeks.” Rosmarin indicated that a meta-analysis of the patient population with BSA 5% to 10% may be helpful when comparing both treatments. However, he added, “There may not be as much overlap in the patient populations that we’re treating with these agents…because there are some patients who are going to be more conducive to a topical, and there are others [who] should be on a systemic [treatment].”

In addition to efficacy and safety data, anatomic location and disease extent are key factors that may influence the choice between topical and oral JAK inhibitors. Rosmarin asked, “What if patients have areas that are hard to reach, such as the shoulder blades on the back? Well then…an oral may make more sense. What if somebody has a very high [BSA], obviously an oral [inhibitor], and what if somebody has a lot of small dots? It’s one thing if a person has a big patch—it’s easier to use a topical. But if somebody has lots of small spots, that can be much harder to use a topical.”

Lal highlighted the advantages and limitations of topical therapy, stating, “It’s easy and safe to apply topical therapy because we know that the drug itself is limited by its absorption into the skin. We know that topical JAK inhibitors, for example, have better bioavailability in the skin than the oral JAK inhibitors that we have coming to the market. We know that there is speed of onset with the appropriate use of these topical therapies…. People feel safer using topical therapies. They know that they’re not going to be systemically absorbed. We also have good data to show that there is some efficacy even upon withdrawal of topical JAK inhibitors, and there is catch-up when people are restarted on therapy.” However, adherence is a key limitation, Lal noted, adding, “It sounds really easy to give someone a topical, but to have them actually follow through, apply twice a day, and wait 4 to 6 months to see a response, it’s kind of a hard thing to sell to people.” He also noted that for patients younger than 16 years, oral therapy is often easier from an adherence perspective.

In terms of phase 3 trial findings, Rosmarin highlighted the importance of comparing the same time points, while recognizing the different trial populations, stating, “The year data for ruxolitinib cream are T-VASI 50 and F-VASI75 of about 50%,” whereas “for upadacitinib, the year data are about 25%.” He also noted that phase 2 data support the use of ruxolitinib cream at up to 20% BSA, but using it at more than 10% BSA is considered off-label. Rosmarin also highlighted the long-term data supporting early initiation of ruxolitinib cream, stating that “even at the 2-year mark, the arm that was initially on vehicle still has not caught up...[so] that 6-month delay mattered 2 years later…. [That’s] why I do offer ruxolitinib cream early in the treatment for many of my patients.”

Optimizing Long-Term Treatment Adherence

In patients with vitiligo, meaningful repigmentation may take 6 to 24 months with consistent therapy use, and lesions can recur within the first year without maintenance therapy.^1,12,22 Thus, long-term treatment adherence is essential for disease control and prevention of recurrence.²² However, factors such as long therapy duration, time burden, perceived inefficacy, adverse events, and patient’s negative experiences and misconceptions are among the key barriers to vitiligo therapy adherence.²² Addressing modifiable barriers and counseling patients on treatment expectations, including delayed response, can help avoid premature therapy discontinuation.²²

Stakeholder Insights

Repigmentation takes time, Rosmarin noted, highlighting the slower response in patients with vitiligo compared with those with other dermatologic conditions, and the importance of counseling patients about treatment expectations. He explained, “Many patients are giving up on their treatment way too early, [when] we don’t know if they’ve had a response or not. But a discussion with the patient on the expectations can have a dramatic effect in having them spend more time to give the drug a chance…. [As we] educate our peers and our patients, I’m optimistic that we will see better outcomes from our claims data…. Three months is not long enough to know if a treatment like ruxolitinib cream is working. It needs to be 6-plus months to really decide.” He added, “Many patients [are] continuing to benefit from [ruxolitinib] use beyond the year,” underscoring the importance of treatment persistence.

Desai added, “Adherence to therapy is key,” emphasizing the importance of counseling patients on the long-term nature of vitiligo treatment. He explained that it is “also important to recognize that patients get tired and exhausted of doing things,” and “taking a break is not the end of the world.” He noted that “customizing the approach” is key, given that, in some cases, such as patients with unstable disease, interrupting treatment would negatively impact prognosis.

Lal explained that in “the TRuE-V1 and TRuE-V2 studies, most…patients started to notice improvement on the face and on the body starting at 24 weeks. Areas of the face will always repigment faster, areas of the body will repigment slower, [and they should] wait at least 6 months to see something on the face…[and] for the body, wait 9 months to a year.” Lal highlighted that treatment responses in clinical trials may be inconsistent with real-world outcomes, as trials are the “best-case scenario” with patients using their medication and having regular follow-up. He added that “consistency and treatment adherence [are] the most important things…. [And] the goal is long-term evaluating patients at appropriate intervals, so evaluating them at 4 to 6 months, not as early as 2 to 3 months, and really giving people a full year before dictating whether someone has a treatment failure.”

Improving Access to Vitiligo Therapy and Adapting to the Shifting Landscape

An estimated 30% to 50% of patients with vitiligo do not receive treatment following diagnosis, with factors such as perception of disease burden and treatment efficacy, lack of definitive guidelines, and insurance-related barriers likely contributing to undertreatment.^23,24 Prior authorization requirements from insurers are common across medication classes in dermatology, consuming clinical resources and resulting in some patients delaying or abandoning treatment.²⁵ As the treatment landscape evolves, efforts are needed to ensure eligible patients have access to new therapies for improved outcomes.^25,26

Stakeholder Insights

Rosmarin stated that, although oral steroid mini-pulse therapy is often accessible for patients with active vitiligo, “We do sometimes face barriers when we want to start different options, including JAK inhibitors, phototherapy, even sometimes for [TCIs] as well…. [That] is often frustrating to patients, certainly if they hear any kind of messaging that their disease is cosmetic rather than medical or autoimmune; that certainly causes frustration.” He added, “However, I have to say that access has improved greatly over the past few years from where we were 10 years ago. And I remain very optimistic about a future where we have increased access to treatments to better help patients.”

Commenting on the anticipated approval of oral JAK inhibitors, Rosmarin stated that it is “exciting, but many of us are [already] using the oral JAK inhibitors off-label. Sometimes we get those approved from foundations, and those can be very helpful, especially for patients with more significant involvement” or who are not suitable for topical therapy.

Desai highlighted the accumulating safety data on JAK inhibitors, with benefits outweighing the risks. He noted the need to carefully select patients while adequately interpreting the implications of the boxed warning, adding, “We really must be careful…[to] not inappropriately withhold treatment as well.” Desai anticipates that “these systemic treatments are also going to be helpful to the ecosystem dollars because we’re going to get data that many of them also can help with other comorbidities that are associated with vitiligo.” The accumulating long-term data, he said, are “only going…to further cement the need for being able to offer systemic therapy.”

In terms of navigating cost barriers, Desai explained that for topical ruxolitinib, his staff works closely with prior authorization support,using specialty pharmacies and manufacturer rebates and trying to remain on-label, which has been helpful in obtaining coverage. “[Reporting] back and studying claims data and having conversations both with the manufacturers and payers through our advocacy efforts are very important,” he added. “The Global Vitiligo Foundation [is] actively involved in advocacy, looking at coverage decisions at the payer level, also looking at Medicaid [and] Medicare coverage, letter writing, and direct advocacy when possible to CMS, both statewide and federally…. [Many] of these patients have [not succeeded with] other therapies, and it’s important to get that history whenever possible so you can document [it in] the medical record.”

Fehr stated that, from a payer perspective, the clinical evidence, consensus guidance, trial inclusion criteria, and approved label indication would be key factors determining coverage of topical vs oral JAK inhibitor therapy. He said, “When I look at the criteria, that 10% [BSA] vs the 5 to 50 [T-VASI], I come back to…80% of vitiligo falls within that 10% range.” If 80% of the vitiligo coming through in claims can be managed with a topical at a fraction of the cost of an oral JAK inhibitor, Fehr said, he would go with the topical—while recognizing that for cases that are “progressive, are not responsive, or are [difficult to] reach, there is absolutely a case to cover the oral JAK [inhibitor].”

Fehr added that the coverage policy would not be based on phase 2 data, as policy “tends to stick to FDA label…[and] to the most restrictive use that’s documented in either label or trials.” However, he added, “There’s always a path” to access therapy for off-label use, “but the path to yes isn’t always a smooth one…. I think the documentation piece, the BSA, the reasons why are important.” In the near future, he said,“I could see scenarios…where the pathway to go from first-line generic therapy to first-line topical JAK [inhibitor] is something like an attestation, which is a less onerous way to access the medication for the patient.”

From the payer’s perspective, Fehr said, 3 numbers are key: “the prevalence of the condition…the utilization of therapy, and the unit cost.” He added, “[Having] more therapies allows me a lever to go into a negotiation…with the manufacturers” surrounding net price, but getting oral therapy to a lower or comparable net price to topical therapy can be difficult.

Rosmarin noted that “treatments are only good if we have access to them.” He emphasized the need for systemic options, noting that as oral JAK inhibitors become available, guidelines surrounding their use would be important. “How do we best use these medicines?” he asked. “We have to be good stewards, and when is it appropriate to use which medicines, and for how long, and in what combinations?”

Fehr also noted the lack of treatment guidelines in vitiligo, indicating that such guidelines would be helpful in developing coverage policies. However, he said, guidelines “lag in innovation. So new therapies coming to market do tend to lag on being added to guidelines. And as a payer…that helps me manage cost because it’s going to help me put off potentially higher costs from innovative new therapies, which is not necessarily in your clinical best interest.”

Lal added that topical therapy will remain an important option and that in an ideal world, he would do both topical and oral therapies. He explained that once oral JAK inhibitors are approved for vitiligo, the label indication would guide patient eligibility, and it remains to be seen how strict the eligibility criteria would be.

Fehr concluded, “We’re on the doorstep of additional new therapies. From a managed care perspective, that’s a double-edged sword. More therapies and increased competition allow me to drive lower net costs. But it also changes the utilization dynamics and potentially puts pressure on an already strained health care dollar.”

References

1. van Geel N, Speeckaert R, Taïeb A, et al. Worldwide expert recommendations for the diagnosis and management of vitiligo: position statement from the International Vitiligo Task Force part 1: towards a new management algorithm. J Eur Acad Dermatol Venereol. 2023;37(11):2173-2184. doi:10.1111/jdv.19451

2. Bibeau K, Ezzedine K, Harris JE, et al. Mental health and psychosocial quality-of-life burden among patients with vitiligo: findings from the global VALIANT study. JAMA Dermatol. 2023;159(10):1124-1128. doi:10.1001/jamadermatol.2023.2787

3. Ezzedine K, Soliman AM, Li C, Camp HS, Pandya AG. Economic burden among patients with vitiligo in the United States: a retrospective database claims study. J Invest Dermatol. 2024;144(3):540-546.e1. doi:10.1016/j.jid.2023.08.025

4. Opzelura. Prescribing information. Incyte Corporation; 2026. Accessed August 10, 2026. https://www.opzelura.com/opzelura-prescribing-information

5. Hebebrand M. AbbVie files for vitiligo indication, putting systemic therapy under regulatory review. Dermatology Times. February 3, 2026. Accessed August 14, 2026. https://www.dermatologytimes.com/view/abbvie-files-for-vitiligo-indication-putting-systemic-therapy-under-regulatory-review

6. Bader K. Phase 3 data show upadacitinib drives progressive repigmentation in non-segmental vitiligo. Dermatology Times. April 10, 2026. Accessed August 11, 2026. https://www.dermatologytimes.com/view/phase-3-data-show-upadacitinib-drives-progressive-repigmentation-in-non-segmental-vitiligo

7. Ezzedine K, Lim HW, Suzuki T, et al; Vitiligo Global Issue Consensus Conference Panelists. Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference. Pigment Cell Melanoma Res. 2012;25(3):E1-E13. doi:10.1111/j.1755-148X.2012.00997.x

8. Taneja N, Sreenivas V, Sahni K, Gupta V, Ramam M. Disease stability in segmental and non-segmental vitiligo. Indian Dermatol Online J. 2021;13(1):60-63. doi:10.4103/idoj.IDOJ_154_21

9. Eleftheriadou V, Desai S, Bae JM, et al; INTERCEPT Study Group and the Global Vitiligo Atlas. Definition of severity and relapse for vitiligo: an international consensus statement. JAMA Dermatol. 2026;162(5):515-524. doi:10.1001/jamadermatol.2026.0294

10. Seneschal J, Speeckaert R, Taïeb A, et al. Worldwide expert recommendations for the diagnosis and management of vitiligo: position statement from the International Vitiligo Task Force-part 2: specific treatment recommendations. J Eur Acad Dermatol Venereol. 2023;37(11):2185-2195. doi:10.1111/jdv.19450

11. FDA approves topical treatment addressing repigmentation in vitiligo in patients aged 12 and older. FDA. July 19, 2022. Accessed August 11, 2026. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-topical-treatment-addressing-repigmentation-vitiligo-patients-aged-12-and-older

12. Rosmarin D, Passeron T, Pandya AG, et al; TRuE-V Study Group. Two phase 3, randomized, controlled trials of ruxolitinib cream for vitiligo. N Engl J Med. 2022;387(16):1445-1455. doi:10.1056/NEJMoa2118828

13. Passeron T, Ezzedine K, Hamzavi I, et al. Once-daily upadacitinib versus placebo in adults with extensive non-segmental vitiligo: a phase 2, multicentre, randomised, double-blind, placebo-controlled, dose-ranging study. eClinicalMedicine. 2024;73:102655. doi:10.1016/j.eclinm.2024.102655

14. Rinvoq. Prescribing information. AbbVie Inc; 2026. Accessed August 11, 2026. https://www.rxabbvie.com/pdf/rinvoq_pi.pdf

15. A study to assess adverse events and effectiveness of upadacitinib oral tablets in adult and adolescent participants with vitiligo (Viti-Up). Updated June 9, 2026. Accessed August 10, 2026. https://clinicaltrials.gov/study/NCT06118411

16. Lukic T, Ghosh P, Napatalung L, et al. Description of the Tranquillo phase 3 clinical trial designs/study protocols to assess ritlecitinib in adults and adolescents with nonsegmental vitiligo. Dermatol Ther (Heidelb). 2026;16(7):3709-3727. doi:10.1007/s13555-026-01724-y

17. Pandya AG, Ezzedine K, Passeron T, et al. Efficacy and safety of the oral Janus kinase 1 inhibitor povorcitinib in patients with extensive vitiligo in a phase 2, randomized, double-blinded, dose-ranging, placebo-controlled study. J Am Acad Dermatol. 2025;93(4):946-955. doi:10.1016/j.jaad.2025.06.027

18. Litfulo. Prescribing information. Pfizer Inc; 2026. Accessed August 12, 2026. https://labeling.pfizer.com/ShowLabeling.aspx?id=19638

19. Pandya AG, Hamzavi I, Ghosh P, et al. Efficacy of ritlecitinib for vitiligo treatment stratified by baseline demographic and clinical characteristics: post hoc analysis of a phase 2b study. JEADV Clin Pract. 2026;5(2):571-576. doi:10.1002/jvc2.70193

20. A study to evaluate efficacy and safety of povorcitinib in participants with nonsegmental vitiligo (STOP-V1). Updated March 23, 2026. Accessed August 12, 2026. https://clinicaltrials.gov/study/NCT06113445

21. A study to evaluate efficacy and safety of povorcitinib in participants with nonsegmental vitiligo (STOP-V2). Updated March 31, 2026. Accessed August 12, 2026. https://clinicaltrials.gov/study/NCT06113471

22. Gawey L, Joshi A, Rahman M, et al. Barriers to and strategies for improved treatment adherence in vitiligo: a systematic review. JAAD Rev. 2025;6:75-77. doi:10.1016/j.jdrv.2025.09.004

23. Adiri R, Gauthier G, Kurosky SK, et al. Clinical characteristics and treatment patterns in patients with vitiligo. JAMA Dermatol. 2026;162(7):720-725. doi:10.1001/jamadermatol.2026.0971

24. Rosmarin D, Soliman AM, Li C. Real-world treatment patterns in patients with vitiligo in the United States. Dermatol Ther (Heidelb). 2023;13(9):2079-2091. doi:10.1007/s13555-023-00983-3

25. Petitt CE, Kiracofe E, Adamson A, Barbieri JS. Prior authorizations in dermatology and impact on patient care: an updated survey of US dermatology providers and staff by the American Academy of Dermatology. Dermatol Online J. 2021;27(1):13030/qt990631n9.

26. Blundell A, Sachar M, Gabel CK, Bercovitch LG. The scope of health insurance coverage of vitiligo treatments in the United States: implications for health care outcomes and disparities in children of color. Pediatr Dermatol. 2021;38(suppl 2):79-85. doi:10.1111/pde.14714