Nonsegmental Vitiligo: A Real-World Case Review

Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by Incyte. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to DermConsult on ReachMD. I'm Dr. Charles Turck, and joining me to share a patient case in nonsegmental vitiligo care is Dr. Jeffrey Weinberg, who's a dermatologist at Mount Sinai Beth Israel in New York City. Dr. Weinberg, welcome to the program.

Dr. Weinberg:
Thank you very much for having me today.

Dr. Turck:
Before we dive into your patient case, Dr. Weinberg, would you explain the difference between nonsegmental and segmental vitiligo?

Dr. Weinberg:
There are a few different manifestations clinically of vitiligo. What we see most of the time is nonsegmental vitiligo, which can occur on either side of the body, different parts of the body can be limited, or diffuse all over the body. Segmental vitiligo is when we see vitiligo usually located to one side of the body, usually along a dermatome. There's also a mixed form of vitiligo, in which you can see nonsegmental and segmental together.

Dr. Turck:
With that background in mind, let's turn to your patient case. To start, would you tell us a bit about your patient and the symptoms they were experiencing?

Dr. Weinberg:
So my patient is a 12-year-old, African American young male. He's had vitiligo for several years. Actually, we know him very well because he comes to the clinic several times a week. He was and is receiving narrowband ultraviolet B therapy, as well as excimer laser. So he gets the laser once weekly and he gets phototherapy once to twice weekly. In addition, he has a history of using topical steroids, as well as topical tacrolimus off label for his vitiligo.

Dr. Turck:
And based on his symptoms, what questions and methods did you use to diagnose your patient?

Dr. Weinberg:
Well, vitiligo is a diagnosis made on a clinical basis. Now for those of us who have treated a lot of vitiligo, we know that the manifestations can be very clear on darker skin, and they can be more subtle on lighter-skinned patients. Basically, if we have a question about the disease, we can use a Wood’s lamp; we turn the lights off, we turn the Wood’s lamp on, and what we will see is that in cases of vitiligo, the skin will accentuate that porcelain white color under the Wood’s lamp versus other things that could be in the differential. Tinea versicolor or hypopigmentation generally will not accentuate to the same degree under the Wood’s lamp.

Now in this young gentleman's case, again dark skin type 5, looking at the distribution of disease, seeing a very porcelain white color, it was clear that in his case that this was vitiligo.

Dr. Turck:
For those just tuning in, you're listening to DermConsult on ReachMD. I'm Dr. Charles Turck, and here with me today is Dr. Jeffrey Weinberg. Together, we're taking a look at the patient's journey in nonsegmental vitiligo care through the lens of a real-world case.

So Dr. Weinberg, if we take a step back from your patient case for just a moment, what are the treatment options available for nonsegmental versus segmental vitiligo?

Dr. Weinberg:
Well, most of the patients we see have nonsegmental vitiligo. A small number have segmental vitiligo. And the treatment options are fairly similar. We don't really have a different set of therapeutic options for segmental vitiligo. And part of the issue is it was assumed at some point that the pathogenesis of segmental vitiligo might be different than that of nonsegmental vitiligo. But I think at this point, we feel that the pathogenesis is fairly the same. It may be a result of mosaicism that just one area is involved versus a wider area.

So our treatment options include topical agents. These in the past include topical corticosteroids. We had to use caution with topical corticosteroids because these can cause hypopigmentation and other skin side effects as well. About 20 years ago, with the advent of the TCI class there was a good amount of literature talking about topical tacrolimus especially on the face or in combination with narrowband ultraviolet B in terms of being very helpful for repigmentation. So we have used topical tacrolimus extensively.

The other mainstay of therapy has been narrowband UVB in a box for full body narrowband UVB in individuals with extensive disease. For more localized disease, what we have done is excimer laser therapy when available for both narrowband and laser. A patient comes to the office, usually two to three times a week, to receive their therapy. So while this can be helpful and aid in repigmentation, it is certainly not convenient. And if the patient has an out-of-pocket cost with a copay each time or coinsurance, it can be rather expensive as well.

Recently, we have had the approval of topical ruxolitinib cream. This is the first topical specifically approved for vitiligo and the first at-home therapy for vitiligo. This drug has really set a new bar in terms of topical efficacy for the disease. And it's especially effective for the face. And this is important because if you were to ask patients who had extensive involvement, the area that is most important for them to repigment would be the face. Other areas are easier to cover or camouflage. So again, it's an exciting time to really have a new mechanism of action and especially an at-home way to treat this disease.

Dr. Turck:
Now before we close, Dr. Weinberg, what are some key lessons we could all learn from the patient case you shared with us today?

Dr. Weinberg:
Well, first we need to understand the psychosocial impact of vitiligo. This can be a devastating disease, especially since darker-skinned patients can be ridiculed. So I'll give you the example of my patient, who’s 12 years old. With the pandemic, he's been at school less over the last few years than he otherwise would. But in an individual like this, I would worry about ridicule from peers that he was spotted and looked abnormal. I would worry that peers might be afraid of him, might be afraid that this would be infectious or something that they could catch.

This is important especially in where we've seen managed care companies tell us often that we can't get therapies for vitiligo approved, especially the laser for vitiligo, because they consider this disease “a cosmetic disease.” It certainly is not a cosmetic disease, and it has a broad impact on a patient's development and health.

Dr. Turck:
Those are some great lessons to take with us. And as that brings us to the end of today's program, I want to thank my guest, Dr. Jeffery Weinberg, for joining me to share this patient case in nonsegmental vitiligo care. Dr. Weinberg, it was great having you on the program.

Dr. Weinberg:
Thank you so much.

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This episode of DermConsult was sponsored by Incyte. To access this and other episodes in this series, visit ReachMD.com/Derm Consult, where you can Be Part of the Knowledge. Thanks for listening!