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Vitiligo Diagnosis Determining Treatment Pathways


Key opinion leaders discuss how diagnosing vitiligo can lead to myriad treatment options.

Jeffrey D. Dunn, PharmD, MBA: Is diagnosing vitiligo pretty straightforward? Are there examples where it isn’t clear-cut that a patient has vitiligo?

Brett King, MD, PhD: It’s a fairly straightforward diagnosis to make clinically the vast majority of the time. Uncommonly, we’ll do a skin biopsy to help make the diagnosis, but the list of diagnoses that we consider when we see somebody with what appears to be depigmented skin or a white patch is relatively limited. Sometimes we’ll wonder, “Did you have some inflammation in these areas? Did you have a rash? A red rash? When that rash went away, did the melanocytes, the color cells, respond by lessening their output of color, making hypopigmentation or less color?” That’s different from depigmented skin. Sometimes we use something called a Wood lamp, which is nothing more than a black light, to help us ascertain whether somebody is hypopigmented or depigmented.

It’s a straightforward diagnosis to make the vast majority of the time. If you take 100 patients from 100 providers and the provider has given all of those people a vitiligo diagnosis, my guess is that if you had vitiligo experts look at those 100 patients, 98 to 100 are going to have vitiligo.

Jeffrey D. Dunn, PharmD, MBA: That helps some other decision-making that would follow on to that. Dr Rosmarin, along those lines, once a patient has been diagnosed and treatment is deemed necessary or appropriate, how would you explain the goals of treatment for a patient with vitiligo?

David Rosmarin, MD: That’s a great question. The goals vary depending on the patient. There are some patients who come in and only want to know what’s happening and what they have. They may not want treatment. They want to be accepted for who they are. That’s important. We need to make sure we aren’t making assumptions. For others, it could be that they only want to stop the spread of vitiligo. In some ways, that can create more anxiety than the actual lesions themselves, not knowing if they’re going to get new lesions and how far this is going to progress. We also know that halting the progression of disease is easier than repigmenting patients.

Some patients only want their disease stabilized and then they’ll be happy. Another goal for some patients is to repigment. It may be certain areas. Patients may say, “I’m OK if I don’t repigment on my hips, but I want the area around my eyes to get their pigment back.” That can be a different goal. Once a patient is repigmented, there are some studies that show a topical calcineurin inhibitor twice a week can help maintain the repigmentation that’s been achieved over the previous year. Those are the main goals of therapy: stabilization of disease, repigmentation, and maintenance.

Jeffrey D. Dunn, PharmD, MBA: You said something there. Is this lifelong? Once you’re on therapy, are you on therapy for the foreseeable future?

David Rosmarin, MD: Right now, we consider it a chronic disease like high blood pressure or diabetes, where we can try to control things, but patients can develop new spots at any time and it can be unpredictable. We can’t cure people of their vitiligo, but we can help treat it.

Jeffrey D. Dunn, PharmD, MBA: Is it safe to say then that the therapies we have are treating the disease and not treating the underlying cause of the disease? Is that fair?

David Rosmarin, MD: We’re treating the underlying problem of having an overactive immune system. We just can’t permanently correct that.

Brett King, MD, PhD: I want to jump in quickly and add to what David said. Although we think of this as a chronic disease, and with the state of medicine these days, as good as our treatments are for psoriasis, we aren’t curing anybody of psoriasis, but vitiligo is often a bit different in that we can sometimes treat somebody to a point where they’ll achieve a remission without treatment.

Let’s put ourselves in somebody else’s shoes for a second. You don’t have to go very deep to imagine, if somebody tasks you with putting a cream on twice a day for a period of 6 months or a year, you’re highly motivated. We don’t want the white spots on our face. We all agreed earlier. Nobody wants to deal with that every day, so you’re very committed. You achieve repigmentation. You get to a great place. You could take the position that it’s a chronic disease, therefore you need to continue to put this on every day for maintenance. But realistically, what happens? “I’ve been good for the last 3 months, or I’ve been great for the last 6 months, so now I don’t put it on every day,” and I see where I can get with the maintenance phase of treatment that David mentioned. You see where you can get with less.

It ends up being a cost savings mechanism in a sense, but it’s also natural. You don’t want to tend to something constantly if you don’t need to. The vast majority of patients do that very naturally, so we end up learning whether somebody needs to be on maintenance or whether they’re one of the 40% of people or so who achieve remission without treatment.

Transcript edited for clarity.

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