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With the availability of new therapies for vitiligo, such as the topical Janus kinase (JAK) inhibitor ruxolitinib (Opzelura), it may not be clear which older treatments can still provide benefits. Are older treatments obsolete now? Should older and newer therapies be used together to get better results? And what does the future of vitiligo treatment look like?
MyVitiliigoTeam talked to four dermatologists who lead the way in treating vitiligo. They offered clarity on these questions and more. We spoke to:
 | Dr. Amit Pandya, past president and medical advisory board chair of Global Vitiligo Foundation, as well as the director of the Pigmentary Disorders Clinic at the Palo Alto Medical Foundation |
 | Dr. John Harris, founding director of the Vitiligo Clinic and Research Center and professor and chair in the department of dermatology at UMass Chan Medical School |
 | Dr. Nada Elbuluk, founder and director of the University of Southern California’s Skin of Color and Pigmentary Disorders Program at Keck Medicine of USC |
 | Dr. Iltefat Hamzavi of Hamzavi Dermatology and senior staff physician in the department of dermatology at Henry Ford Health |
These dermatologists described what they see as the cutting edge of vitiligo treatment now and what they see coming for the future.
When asked how JAK inhibitors are more effective or better than older therapies used to treat vitiligo, our panel of dermatologists was quick to point out that there haven’t yet been studies to compare the two. However, they shared that results so far have been very promising.
Dr. Harris: The newer treatments haven’t been directly compared to the older ones yet, so we don’t have data to inform this. I certainly believe they work better and faster just from using them with patients and seeing the rapid improvement, and the clinical trial results are impressive.
Dr. Pandya: We don’t know if they are more effective than existing treatments. Until we have head-to-head studies, this question remains unanswered. However, the phase 2 and 3 studies with ruxolitinib were the best studies using a topical for vitiligo that were ever done, with strong evidence of efficacy and safety — much more robust than studies with existing topicals, which is a compelling reason to use ruxolitinib for patients with vitiligo.
Apart from effectiveness, the side effect profiles for JAK inhibitors so far also make them seem safer to use than steroids.
Dr. Harris: The JAK inhibitors also don’t have the same side effects as steroids that we used to use frequently. So we feel better having them used on all parts of the body, whereas steroids had to be used carefully with regular breaks to avoid the side effects. So, overall, they seem to work better and to be easier to use.
Dr. Elbuluk: JAK inhibitors provide immune targeted therapy, which can be safely and effectively used for longer periods without the long-term side effects of steroids and some of the older treatments for vitiligo.
MyVitiligoTeam asked all four dermatologists about the limits of what JAK inhibitors can do for people with vitiligo and whether older therapies are still needed. All agreed that JAK inhibitors need to be combined with phototherapy to get the best results.
Dr. Hamzavi: The new treatments work slowly, and not in everyone. Adding phototherapy will increase the number of people who respond, along with the degree of repigmentation.
Dr. Harris: Light treatments like narrowband UVB [ultraviolet B] phototherapy are the oldest treatments we have for vitiligo and are very effective. It seems that combining light treatments with any other treatment helps them work better, so I recommend combining the new JAK inhibitors with phototherapy for best results.
Dr. Pandya: All newer treatments will work better when combined with exposure to UV light, either through sun exposure or through phototherapy using an NB-UVB [narrowband ultraviolet B] lamp. Newer treatments mainly work by inhibiting the autoimmune attack on melanocytes, but they don’t stimulate melanocytes to regenerate and produce melanin to bring the color back to the skin. Phototherapy is the only currently approved treatment that does that.
Since people with vitiligo are concerned about the safety as well as the effectiveness of vitiligo treatments, we asked our panel what’s known so far about the side effects of JAK inhibitors.
Dr. Harris: The primary side effect we’re seeing from JAK inhibitors is acne in the areas being treated. This wasn’t very common with old treatments, so it’s a new side effect.
Dr. Hamzavi: So far we’re not seeing increased side effects when we combine narrowband phototherapy and topical or oral JAK inhibitors. However, it will take a few years to ensure this initial impression holds up for [the rates of] skin cancers. When I speak to my patients, I try to remind them that the probability of side effects is much lower than daily activities such as driving a car or eating seafood.
Dr. Pandya: Thus far, I don’t think the newer treatments are causing more side effects when combined with older therapies like phototherapy, but we need to follow patients over more time to confirm this observation. Patients are concerned about the black box warning associated with the topical JAK inhibitor ruxolitinib, but I explain that these side effects were seen with older oral JAK inhibitors, not topical JAK inhibitors. The main side effect with topical JAK inhibitors is acne, which occurs in less than 10 percent of treated patients.
With the availability of JAK inhibitors, dermatologists have more tools than ever to fight vitiligo. MyVitiligoTeam asked our panel whether there are any older treatment options they’re using less or no longer using at all.
Dr. Harris: After decades of use, it was discovered that PUVA [psoralen + ultraviolet A phototherapy] increases the risk of skin cancer significantly. Now we primarily use NB-UVB instead of PUVA. Importantly, many traditional holistic treatments for vitiligo involve topicals that include a chemical called psoralen followed by sun exposure, which is the same thing as PUVA. So it’s important to know that these “natural” treatments can be effective but dangerous.
Dr. Hamzavi: I don’t use PUVA much anymore. I reduced my use of topical steroids.
Dr. Pandya: I don’t use topical vitamin D or oral antibiotics like minocycline for vitiligo, as I don’t think they have strong evidence of efficacy. I also don’t use PUVA treatment, as it has more side effects than NB-UVB phototherapy, which has equal or greater efficacy than PUVA.
Vitiligo can appear in different regions, cover more or less of the body, and progress slowly or rapidly. These and many other factors will influence a person’s treatment options and how likely they are to work. Treatment options also depend on your age, your goals for treatment, and whether you can stick with the recommended therapies. For these reasons, vitiligo treatment is always tailored to the individual.
Unfortunately, some people have vitiligo that doesn’t respond well to available treatments. We asked the four dermatologists on our panel whether the newer treatments offer more effective options for people with difficult-to-treat vitiligo.
Dr. Harris: The most difficult-to-treat areas are parts of the body without hair growth, or where the hair has turned white from the disease. This is because the pigment returns to the skin from pigmented hair. This observation is the same for the newer treatments, so right now we don’t have a solid solution for these difficult-to-treat areas.
Dr. Hamzavi: The most challenging cases are often the rapidly progressive variant and the acral (hands and feet) variant of vitiligo. Early treatment can help both, and soon even the most difficult progressive cases will be managed. However, the basic science behind the treatment of hand vitiligo has still not been worked out. So that area will take some more time.
Despite the fact that some vitiligo remains difficult to treat, Dr. Elbuluk and Dr. Pandya urged optimism.
Dr. Elbuluk: These newer therapies give us expanded options. We hope that with the creation of new treatments for vitiligo, we will have even more options for those who have more recalcitrant vitiligo that may not have responded as well to older, traditional treatments.
Dr. Pandya: While some patients have a poorer prognosis due to age, lighter skin type, long duration, or lack of pigmented hair in lesions, all patients should have the opportunity to be treated, despite the presence of the above factors. I have been amazed during my career at the positive response to treatment of patients who did not have a good prognosis based on these factors.
It’s also vital to prepare yourself for treatment to take a long time. If you and your dermatologist carefully note your progress, it may give you the incentive to stick with your treatment regimen.
Dr. Pandya: Treatments for vitiligo work, it’s just that they take time, often one to two years. Most patients and physicians don’t take good images of the lesions at two- to three-month intervals. Therefore, small amounts of progress they may have had between visits are not appreciated, and both the patient and physician give up on treatment. Careful monitoring of vitiligo lesions with serial photography is the key to successfully undergoing treatment for this condition.
Our panel of dermatologists confirmed that combination therapy (a topical drug to stop immune attacks, plus phototherapy to return pigment) is currently the mainstay of vitiligo treatment. As people living with vitiligo know, it can be burdensome to stick to applying topical medication and undergoing phototherapy.
We asked whether it’s possible there will be an all-in-one treatment for vitiligo.
Dr. Hamzavi: We do anticipate the ability to fuse these two pathways into one solution at some point in the future. That path is becoming clearer, but that timeline is still some years away.
Dr. Pandya: There may be a drug in the future that will inhibit the autoimmune attack on melanocytes and at the same time stimulate healthy melanocytes to proliferate and produce more melanin. Currently, a study is ongoing with a topical pan-bromodomain BET inhibitor which might have these characteristics, and I look forward to seeing the study results.
Dr. Harris: We’ll have to watch the clinical trials closely to see! It’s hard to imagine that phototherapy won’t continue to add benefit to the new treatments, but it’s cumbersome to use, so it would be great to find a simpler approach to replace it.
Given the recent advances in vitiligo treatment and more in development, we asked the dermatologists whether they anticipated a possible cure for vitiligo in our lifetime.
Dr. Harris: I’m starting to envision the possibility of a cure for vitiligo based on exciting research being conducted now. It was hard to imagine even only five years ago. But achieving this will require a ramping up of research intensity that will require funding and other resources, which may be challenging in the future.
Dr. Hamzavi: I think it can be cured, but I don’t know the timeline. I do know we have many pieces of the puzzle identified. We just need to put them together.
Dr. Pandya: If a cure means that the spread of vitiligo can be stopped and the majority of the body can be repigmented, then I believe this is possible soon. However, some areas of the body that lack hair follicles, like the hands, feet, wrists, ankles, elbows, and knees, remain very difficult to treat, due to the fact they are devoid of melanocytes. If gentle methods to transplant melanocytes to these areas can be developed, then there is hope for a true cure in our lifetime.
Each of the dermatologists MyVitiligoTeam spoke to expressed hope about the future of vitiligo treatment.
Dr. Elbuluk: There are so many new treatments on the horizon, including multiple oral JAK inhibitors. This is a very exciting time for vitiligo, and individuals with vitiligo should have increasing hope that they will have more options for safe and effective treatments in the coming years.
Dr. Pandya: Oral JAK inhibitors have a potential of being much safer than oral steroids and could be used for years. This will be of benefit for the many people with active disease who don’t know where the next lesion will appear. Moreover, the oral JAK inhibitors will be useful for patients with over 10 percent body surface area involvement, since topical ruxolitinib can only be used on 10 percent of the body surface area or less. Another new treatment undergoing study right now is afamelanotide, which stimulates melanocytes to proliferate and make more melanin. This treatment is enhanced with concomitant phototherapy.
Meanwhile, there are steps you can take to bring the future of vitiligo treatment closer.
Dr. Hamzavi: Please participate in clinical trials, and advocate for new treatments with your elected representatives and health insurance companies. If we can do that work, then new advances will come.
Dr. Pandya: We should all advocate not only for better funding of vitiligo research and coverage for new treatments, but also better coverage for older treatments. It’s a shame that home phototherapy and skin grafting are not covered by many insurance policies. These are treatments that work, but insurance companies often deny them because they are deemed “experimental.”
On MyVitiligoTeam, the social network for people with vitiligo and their loved ones, members come together to ask questions, give advice, and share their stories with others who understand life with vitiligo.
Have you tried newer treatments for vitiligo? What do you hope for the future of vitiligo treatment? Share your story in a comment below, or start a conversation by posting on your Activities page.
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