Vitiligo Treatments: What’s Available Now & What Is Coming In the Future

In this episode of Skincredible, we discuss how vitiligo care has changed dramatically in just the past few years. Now, there are treatments available to help restore pigment and offer real hope to patients and families, whereas in past years treatments were extremely limited.

Dr. Lisa Swanson takes a deep dive into everything you need to know about modern vitiligotreatment. She discusses that it is perfectly okay to embrace and observe vitiligo if that's what the patient would like, why early treatment is so important if patients do decide to treat, and what realistic expectations look like throughout the repigmentation journey.

Topics include:

• The three goals of vitiligo treatment: stopping progression, restoring pigment, and maintaining results.
• How repigmentation happens and why photos are an essential part of tracking progress.
• Traditional therapies like topical steroids and calcineurin inhibitors, and how they compare to newer treatments.
• How Opzelura® (ruxolitinib cream) has transformed vitiligo care, especially for facial involvement.
• The important role of sunlight and light therapy, including narrowband UVB, excimer laser, and home phototherapy units.
• Why combining treatments often produces the best results.
• Oral medications used for rapidly progressing vitiligo and exciting new JAK inhibitors currently on the horizon.
• Emerging treatments, including biologic medications and surgical pigment-restoration techniques.
• Long-term maintenance strategies 
• Why depigmentation is more of a last-resort option.
• Common insurance challenges, practical treatment tips, and how to navigate the path to newer therapies.

Dr. Swanson also shares a powerful patient story that highlight just how life-changing successful vitiligo treatment can be. If you, your child or someone you love is dealing with vitiligo, there is HOPE! If you're a healthcare provider looking to better support your patients, this episode offers the latest evidence-based information, practical guidance, and a hopeful look at the future of vitiligo care.  

Additional Links

Panp360.org/boston use code “SKINCREDIBLE” for free registration

Keywords

Dermatology, Marginal Repigmentation, Perifollicular Repigmentation, Difuse Repigmentation, Combined Repigmentation, Topical Corticosteroids, Tacrolimus, Pimecrolimus, Opzelura, Vitiligo, Light Therapy, Sunlight, TSW, Excimer, Narrowband Light, Heliocare, Pulsed Dose Steriods, Oral JAK Inhibitors, Surgery, Depigmentation, Xeljanz, Koebner phenomenon, confetti depigmentation, trichrome pattern depigmentation, Rinvoq, Litfulo, Povorcitinib, Vitiligo Surgery, Skin Graft, Suction Blister Grafting, Punch Biopsy Grafting, Split Thickness Skin Graft, Marginal depigmentation, Segmental vitiligo, non segmental vitiligo, Monobenzyl ether of hydroquinone (MBEH), monobenzone

Chapters

00:00 Special PANP360 Meeting Announcement for NPs and PAs

02:05 Welcome, Vitiligo Treatments 

03:50 Our Differences Make Us Special, Life Lessons

06:30 JUMP Shoutout Boise, Idaho

07:00 To Watch or Treat Vitiligo

08:30 Repigmentation Signals to Look For

10:00 Topical Steroids

12:30 Topical Steroid Withdrawal TSW

15:40 Topical Calcineurin Inhibitors: Tacrolimus, Pimecrolimus

18:40 Topical Opzelura

21:40 Mom With Vitiligo: You Gave Me My Face & Life Back

24:30 Light Therapy & Heliocare

26:30 Vitiligo and Decreased Risk of Skin Cancer

27:00 PUVA In the Past

28:00 Light Therapy

30:00 Narrowband, Excimer and Home Light Therapy

32:00 Oral Pulsed Dose Steroids 

34:18 Oral JAK Inhibitors

35:00 Coming Soon: Rinvoq, Litfulo, Povorcitinib

36:00 Biologics Coming Soon

37:15: Surgery 

40:00 Segmental vs. Non Segmental Vitiligo

41:00 Tacrolimus for Maintenance

42:00 Never Lose Hope

43:00 Depigmentation, Michael Jackson

44:00 Monobenzyl ether of hydroquinone (MBEH)

45:00 Accept Each Other, It’s Not Your Fault

46:12 Thank You & Goodbye

The information shared on this podcast is for educational purposes only and is not a substitute for personalized medical advice. Always consult your  physician regarding your health.

Transcript

SPEAKER_00 0:04

Welcome to Skin Credible, where we tell you what you should know about your skin and how to glow. Because your skin's incredible.

SPEAKER_02 0:16

All physician assistant and nurse practitioner friends, Lisa Swanson here to tell you all about the meeting that should not be missed. This is the NPPA 360 in Boston, Massachusetts. I was gonna try to say Boston in a Boston accent, but I'm not confident up Boston Boston. Boston? I don't know. How do you like them apples? Anyway, this is how you guys are gonna get Wicked SMOT. You're gonna come to this conference. You're gonna learn all about all aspects of dermatology from excellent clinicians, professors, and instructors. You're gonna learn about cosmetic dermatology, pediatric dermatology, surgical dermatology. You're gonna get all that in three days of action-packed knowledge, you guys. Plus, Boston is a wonderful place to visit. There's amazing shopping, and you can get some lobster rolls. So I don't see any reason why you guys wouldn't want to come. It seems like really the ideal setup. Skin credible listeners will get into the conference for free. Simply enter the code, skin credible, go to the website. I'm gonna read it off to you. Get your pens and pencils ready.org slash Boston. Head to that website, type in the code SkinCredible, and you will get free registration to the conference of the year in Boston, Massachusetts, August 14th to the 16th. I'll be there. I hope you'll be there. Hello, everyone, and welcome to another super amazing. I think I said amazing last time. So this one, super amazing episode of the Skin Credible Podcast. I'm one of your hosts, Dr. Lisa Swanson, and I'm here today with Anna. Hello. Hello, Anna. And we are here to talk about vitiligo treatments. This is exciting. I know. It's a whole new world that we're living in. And that is really, really great for our patients and their families to actually be able to offer some hope.

SPEAKER_01 2:38

Yeah.

SPEAKER_02 2:39

For patients struggling with vitiligo.

SPEAKER_01 2:42

Because, like we mentioned last episode, when I worked in dermatology, there weren't very many options for those people.

SPEAKER_02 2:47

Yeah. And that wasn't that long ago. It really wasn't. That was not things have changed a lot recently. Yeah. Now, of course, with vitiligo, it is okay, always okay, to observe, you know? And I think we have a lot of things happening in our in our worlds and our society that are actually making it much more livable to embrace the beauty of your vitiligo. Which is good. It's great. We have Winnie Harlow, the supermodel, America's next top model.

SPEAKER_01 3:17

So beautiful.

SPEAKER_02 3:17

So beautiful. And she is proud of her vitiligo. And she actually has two different shades of makeup, of foundation. One for her depigmented skin and one for her baseline skin. Nice. Um, because she doesn't want to hide her mask or anything like that. That's amazing.

SPEAKER_01 3:32

Yeah.

SPEAKER_02 3:33

We have Barbie dolls. We doigo.

SPEAKER_01 3:37

Yes, yes, you can get a Barbie doll.

SPEAKER_02 3:39

Right. Um, really, really cool, really, really amazing. And so it is always okay to embrace the beauty of oneself and understand that it's our differences that make us unique and special.

SPEAKER_01 3:54

Which is such a hard lesson for me at this age. I'm now 36 years old and I still sometimes find myself wanting to go with the flow in some areas.

SPEAKER_02 4:02

I know. It's so true. It's so true. And sometimes I think, you know, as I'm talking about like the lesson of embracing the beauty and difference and everything, I'm reminded of an episode of Bluey.

SPEAKER_01 4:13

Oh.

SPEAKER_02 4:14

Called Ice Cream.

SPEAKER_01 4:16

I don't think I've watched that one.

SPEAKER_02 4:17

And in it, Bluey and Bingo learn a valuable life lesson. And Dad says, um, well, Blueie's like, I don't get anything. My ice cream is melted and blah, blah, blah. And dad says, Well, you get a valuable life lesson. And Blueie says, I don't want a valuable life lesson. I just want an ice cream. Yeah.

SPEAKER_01 4:38

I think, is that the one where Wendy or whatever the neighbor's name is comes over and like convinces him to go get them ice cream? Yes, I have watched that one.

SPEAKER_02 4:46

You're right, Anna. That's not the episode called Ice Cream, which is actually another classic, but it's called, I think it's called Ragdoll, where dad is just like pretending like he can't move and the girls have to like get him out to the car in order to get the ice cream. Um, so so good.

SPEAKER_01 5:02

So, so good. I love that. Did you know that online there's like this theory that like the neighbor has a crush on the dad?

SPEAKER_02 5:09

Oh my god. She's just trying to create drama out of blueies. So much drama. She is hilarious. Oh man. I mean, Bandit is something. He, yeah. I mean, he's special.

SPEAKER_01 5:21

For sure. Yeah. Typical dad, though. Like, there's so many things that he does that I'm like, oh my gosh, my dad would totally do that. Oh, yeah. Yeah. Like, teach us a life lesson when we're just trying to have ice cream.

SPEAKER_02 5:31

Although I have had one parent, one dad, tell me that he had to stop watching Bluey because the dad on Bluey was making him feel bad about his parenting skills.

SPEAKER_01 5:40

Oh no. Wait, how like because he could relate?

SPEAKER_02 5:44

No, because Bandit is such a good dad. He is a great dad. And like so present in the moment with his cool. Well, then keep watching. And like such a great, like he plays with them and everything. That's so true. I know.

SPEAKER_01 5:56

And so this one guy was like, I don't think I can watch it anymore because he just makes me feel like he's like the right balance of like funny and attentive and involved and like sometimes detached, like he's doing his own thing, but still kind of involved. Sometimes he just wants to watch cricket, but the girls are like not having it, not having it at all.

SPEAKER_02 6:14

Sounds about right.

SPEAKER_01 6:16

With my dad with soccer this week, my goodness, he was into it. Yeah. So I was like, I'm gonna watch a game just for him. Yeah, but they're long. It's a thing. Yeah, but it was a lot of fun. I watched the US game at Jump.

SPEAKER_02 6:29

Oh, that's cool. It was so much fun. That's cool. Jump for those of you who are who are listening and are unfamiliar with Boise, Idaho. Um, Jump, which did you know it stands for Jack's Urban Meeting Place? I did because I spend a lot of time there. Yes, yes. It's a really cool place where like families can go. They have free events and everything like that. So much stuff. Great for the community. Yes, yes. Um, so we know that it is okay to just leave the vitiligo alone. Yeah. Depending on location and extent and um, you know, how people feel about it. That is perfectly fine. Sure. It is also okay to want to treat your vitiligo, and we have lots of options. A couple of things that I think are important to kind of set the stage. When we're treating vitiligo, we want to achieve three things.

SPEAKER_03 7:16

Okay.

SPEAKER_02 7:16

Number one, we want to halt the progression of the vitiligo best we can. Okay. Number two, we want to bring the pigment back.

SPEAKER_03 7:25

Yeah.

SPEAKER_02 7:26

Number three, we want to maintain the repigmentation. Is that the hardest part? It well, I mean, in the past, the hardest part was bringing back the pigment. Yeah. Now I would say the hardest part is maintaining it once it's back. Yes. Um, and so we're making steps. Yeah, yeah, yeah, yeah. Um a couple other bullet points. Treatment is always more effective when started early. And so go to see your dermatologist and get help because everything works better when started early. Number two, combining any treatment with light therapy. We're going to talk about light therapy, but light therapy is rarely used all by itself. A lot of times we're using it with other treatment modalities, and that combination always produces the absolute best outcome. Um, and we'll talk about different ways that people can get light therapy for their vitiligo. Okay. Because there's different, different ways. Um, there are also different ways that the pigment comes back when it comes back. And I always like to tell my patients this because sometimes the the signs that things are working can be relatively subtle. And so I draw their attention to it at the beginning, things to look for. I also take pictures at every appointment. Okay. And I think that's really, really, really crucial because if you're seeing your own spot, yeah, every day, twice a day, it's not going to change much. Right. Or if you're seeing your kiddo's spot, you know, you're just not going to appreciate these differences over time. And so I always take pictures so that we can catalog progress. Wonderful. Um, but there are different ways the pigment will come back. One way is marginal, where it comes in from the edges.

SPEAKER_01 9:06

Okay.

SPEAKER_02 9:06

Another way is perifollicular, where it almost looks like freckles. Okay. A third way is diffuse, where it just kind of all fills in. And the last way is combined, where it's a little bit of a little bit of each of these. Okay. Now, a couple of stats. The most stable repigmentation, meaning the least likely to have recurrence, is marginal.

SPEAKER_01 9:28

Interesting. Right? When it's coming together.

SPEAKER_02 9:30

Where yeah, if you see it like that, that's actually a good sign. The fastest is perifollicular. And I think I observe that in my clinic. That's usually the first sign that our treatment is working, is we'll start to see those little freckles of repigmentation within the patch of vitaligo. Um, so that kind of sets the stage for like how repigmentation happens, some basic rules about early treatment and integrating light therapy.

SPEAKER_03 9:53

Yeah.

SPEAKER_02 9:53

Now let's go into our treatment options. So we've got topical corticosteroids, um, which have been around around forever, super cheap. Um, you do need to be mindful of long-term use, and treating vitiligo requires long-term use.

SPEAKER_01 10:11

Okay.

SPEAKER_02 10:12

No treatment on this board is going to be fast. Okay. None of them is going to be fast. And I think it's really important to set up realistic expectations. Um, I heard somebody say something recently that I really resonated with. If you warn somebody about something ahead of time, it's an explanation. If you tell them about it afterwards, it's an excuse. Yes. So setting up the fact that this is a marathon, not a sprint. And how I frame it is I say your pigment-making cells are under attack by your immune system.

SPEAKER_01 10:47

Yeah.

SPEAKER_02 10:47

Because of that, they've gone into hiding. They're in the bunkers. Yeah. What we're doing with our treatment is we're telling the immune system to knock it off. And then our little melanocytes have to come out of hiding. Yeah. And then they have to start making pigment again.

SPEAKER_01 11:05

Okay.

SPEAKER_02 11:05

And that's not something that can happen overnight. Sure. So set those realistic expectations. When we're using topical steroids to treat vitiligo, we know it's a longer-term deal. And we know that we have to be cautious about long-term use of topical steroids. And so we're careful about the type of topical steroid we use, how frequently we have the family use it. Um, we will sometimes combine it with some of our non-steroid topicals. And we also do follow-up. So let's say I'm treating a patient. This is the first treatment they've ever had, and they have fitiligo on their elbows and knees, not on their face. So I'm likely to choose clebatazole, which is a stronger topical steroid. I'm gonna have them use it once a day, whereas for psoriasis and eczema, we use it twice a day.

SPEAKER_01 11:51

Yeah.

SPEAKER_02 11:51

I'm gonna have them use it once a day at bedtime.

SPEAKER_01 11:54

Okay.

SPEAKER_02 11:54

I'm gonna say, we're gonna give this six months to see if it works, but I'm gonna see you back every two months for safety checks.

SPEAKER_01 12:01

Okay.

SPEAKER_02 12:02

So assess like, yeah, is it improving yet? But also just like, are we observing any side effects of the topical steroid? Are we okay to continue? Because when you do have a side effect of a topical steroid and you recognize it early on, you can stop that topical steroid and everything can be okay. Any skin thinning can be reversed. But if you don't realize that's happening and you just keep on doing it, then you can reach a point of no return.

SPEAKER_01 12:26

Okay. So topical steroid withdrawal, is that something that you also consider with photoligal, not just eczema, maybe?

SPEAKER_02 12:32

It's so interesting because topical steroid withdrawal is um something that is on social media and in some spheres with regards to eczema patients. It doesn't, the fear of topical steroids does not seem as broad when we're treating other conditions. Interesting. Which is very interesting. Um, and I can't fully explain that phenomenon.

SPEAKER_03 12:57

Yeah.

SPEAKER_02 12:58

Um I think also most of the time with Vitiligo these days, I mean, we used to have to use these topical steroids if people wanted to treat because we just didn't have much else. Things are different now.

SPEAKER_01 13:10

Yeah.

SPEAKER_02 13:10

And there's a topical treatment that we're gonna talk about that works so much better than the topical steroids. So most of the time in today's age of practice, I'm prescribing a topical steroid just to kind of check that box with an insurance company so that I can move on to something else. Yeah. And it actually really benefits me if a patient comes to me and has been prescribed one of these by their pediatrician or family medicine doc or internist. If I have record that a topical steroid has been prescribed, then I don't have to go through that again.

SPEAKER_01 13:43

I can't I think that's something that's important to mention because a lot of people are just like, oh, this topical cream, really make note or bring it in so that you can have for insurance purposes too. Like we've actually already gone down this road and you don't have to waste time.

SPEAKER_02 13:56

Yeah. My favorite is when people take a picture of a product they've been prescribed or bring it in with them because there are different strengths of almost all of these things. Sure, yeah. And I want to know what the name of it is, what the percentage of it is. I want to know if it was a cream or an ointment. So often we hear something like, Oh, yeah, the pediatrician gave us a cream, um, but it didn't do anything, so we stopped it. Right. And and I'm like, okay, do you remember the name? And they're like, no, but it came in a tube. Yeah, it had a red line. It had a red line, it had some black print on it. And you're like, well, that narrows it down. That's like all that's like everything. I understand completely. If you've tried something and it didn't work, we can absolutely move on. But documenting that is really important on my end for insurance purposes. I'm gonna be able to get a better treatment for your child the more I know about what's been tried and failed, because it it builds that um tried and failed trail for me. Yeah. Um, and so really important. Even if it didn't work and you don't want to try it again, that's cool. Yeah, that's fine. But tell me what it was. So topical series can work, but I think have largely been replaced by some of the other things we're gonna discuss. Appropriate use needs to be monitored with regular follow-up appointments. In the days when this was all we had, I was never like blown away by its success. My level of enthusiasm to treat vitiligo with with topical steroids is like at an all-time low. I really don't think it'll help. And it's more of just like a proving to insurance this has been done sort of situation. Um then topical calcineurin inhibitors, which are pimicrolimus and tachrolimus. So these have been around a while, 25 years. We talked about them in our eczema episodes. These are non-steroids that have been appropriately used for vitiligo in sensitive areas. So face and folds.

SPEAKER_01 15:52

What's calciumurin?

SPEAKER_02 15:54

So all of these creams that we use for eczema and various inflammatory conditions, they're all working in an anti-inflammatory way, but their exact mechanism of action is different. So, like we're gonna talk about obsolure being a topical jack inhibitor. Um pemicrolimus and tachrolimus are calcineurin inhibitors. In the eczema episodes, we talked about uh Zorev, which is a phosphodesterase IV inhibitor. So the end result is the same, anti-inflammatory, but just different mechanisms of action to get you there. Okay. Yeah. Gotcha. But tachylimus and permicrolimus, they have come in handy. They are safe for sensitive areas. A lot of people will get vitiligo around their eyes and around their mouth, and tacrolimus and permicrolimus work great for that. A lot of people also get vitiligo in their underwear area, and these are safe options in those necks of the woods as well. Tacrolimus comes in two strengths, 0.03 and 0.1. Don't even bother with the.03. It's meaningless, it doesn't do anything. Always the point one is what you want. And while there is controversy and differing opinions, I think the general consensus is that tacrolimus.1 is more effective than pimicrolimus.

SPEAKER_01 17:06

Interesting.

SPEAKER_02 17:07

I again, and I also think there can be individual variations in terms of a patient. One patient might respond better to pimicrolimus, another patient might respond better to tacrolimus. But if you asked a groom full of dermatologists, I bet the majority of them would rate tacrolimus point one as a stronger agent than pimicrolimus.

SPEAKER_01 17:26

And doesn't, oh, unless I'm not remembering correctly, doesn't tachyleemus come in an ointment and pimicrolimus comes in a cream that sometimes burns? Exactly right.

SPEAKER_02 17:34

So tacrolimus is an ointment, pimicrolimus is a cream. Some people have preferences based on that, but either one can produce some burning and stinging.

SPEAKER_01 17:44

But ointments are generally more effective.

SPEAKER_02 17:46

That is true for topical corticosteroids. Oh. Not necessarily true for other things. Like obsolura is a cream, but it's very effective for eczema. Sure. Um, Zuree is a cream, VTama is a cream. So not across the board. Not across the board, but you're absolutely right that in the topical steroid world, ointments produce less burning and stinging and are generally thought of as being more effective than creams. Gotcha. Um, and so we have our topical calcinurin inhibitors, tachrolimus pemicrolimus. Again, for most of the other options, insurance is gonna make us prescribe one of those. Um, whether we try it and how long we try it, you know that's a little bit different for every patient, every insurance company area of involvement, et cetera. Sure. But chances are if you have vitiligo or your child has vitiligo, chances are one of these two is gonna get prescribed for you somewhere along the road.

SPEAKER_03 18:33

Okay.

SPEAKER_02 18:34

Um and they're fine. There's there's really nothing negative about them. It's just I think we have more effective therapies out there. Uh, which brings us nicely to obsolura. So obsolura completely changed the game when it came to vitiligo. So obsolura is approved down to the age of 12 for vitiligo. Okay. It's approved specifically for non-segmental vitiligo. So we talked in the previous episode about segmental and non-segmental. This is approved for non-segmental, which is 85 to 90% of the cases of vitiligo. Okay. It is approved to treat up to 10% body surface area. So for our big fans who followed us and listened to all of our episodes, they might remember that for eczema, you can use it on 20% body surface area.

SPEAKER_01 19:20

Ah.

SPEAKER_02 19:21

When all of this happened, it was kind of interesting because eczema is regarded as a skin barrier issue. Yeah. And so you can get increased absorption if you have a skin barrier issue. Okay. So a lot of us, myself included, were like, huh. Why is it higher for eczema than for vitiligo, where vitiligo has a perfectly intact barrier? Sure. It was explained to me that when you're treating eczema with obsolura, you're using it twice a day as needed, and you're stopping once the rash is better. Oh. You're using it intermittently. Sure. But for vitiligo, you're applying it to the same spots twice a day for months, if not years. So they thought it to be more reasonable and safe, conservative, conservative to put the BSA lower for vitiligo.

SPEAKER_01 20:10

Um, a palm of like my size is 5%. Uh your palm is 1% of your body surface energy.

SPEAKER_02 20:17

Yes. Yeah.

SPEAKER_01 20:18

So 10 palms.

SPEAKER_02 20:19

10 palms. Yes. And some of my patients will come in and maybe they have more than 10% BSA of their vitiligo. And I tell them, okay, let's choose the 10% we want to treat. The more noticeable areas, let's focus our energy there. Okay. And that's also, I think, just generally more practical. Okay. Like if you have 50% BSA, that's a lot of work to twice a day apply obsolura to the other caveat I wanted to say is that we are going to see the age indication get younger for Opsalura for Vitiligo. It's coming. Um it's coming. Okay. It's approved down to two for eczema right now. Okay. And we're expecting it to go down to two for Vitiligo as well. So that's exciting. Obsolura is the best thing we've ever had to date for Vitiligo. Like in general or topically? Like in general. Oh, wow. In general. Okay. Um, my excitement over treating patients with vitiligo increased exponentially with Obsolura's arrival and approval because this is really the first medicine where I can tell a patient, I think I can bring your pigment back. And that's true, especially if the vitiligo is on their face. That's going to repigment so beautifully. That's cool. I remember that I was seeing this set of teenage girls in clinic, and their mom was with them, and their mom, I noticed, happened to have some vitiligo around her mouth and around her eyes. And I said, Oh, I noticed that you deal with a little bit of vitiligo. You know, there's this topical cream now that's very effective. It she started crying, like tears of hope that, like, oh my God. Maybe there's something that I can do. She had been really burdened by the condition. She was facing a lot of embarrassment as a result because it was on her face. And even family members were being mean to her about it. That's so rude. I know. And so we got her that day, we made her a patient officially in the computer. I prescribed her Opsolora. And I saw her back at three months. And w sometimes, uh, depending on what my lovely helpers are doing, audience members you've met, Anna and Olivia, but depending on what they're doing and where I'm at with my day, if I can go out and grab the patient from the waiting room, I will.

SPEAKER_03 22:37

Yeah.

SPEAKER_02 22:37

And I distinctly remember that day. She was coming back for her three-month check. And again, we tell people like this could be six months, this could be a year.

SPEAKER_00 22:45

Sure.

SPEAKER_02 22:46

But I go out and see her, and the smile on her face, just when I called her name and she came back, it was like, oh my gosh, it was everything. So cool. And she said, You gave me my face back. You gave me my life back.

SPEAKER_01 23:03

That's a huge thing. Like your face is your business card. Yes. Like, yes. Oh, that's amazing. Yes. No wonder you tear up.

SPEAKER_02 23:12

I mean, it's really special. It's really special. And I've gotten a chance to see like so many examples of that. And it's so wonderful. You just see the sparkle come back in a person's eyes, and it's just so great. So if you have vitiligo in a sun-exposed area, obsolure is going to work particularly well. There are two things that really allow a medicine to work well for vitiligo. Number one, sun-exposed area. Number two, hair follicles. Um, it's really hard if you have vitiligo on your palm. I hate to say impossible, but it's like really hard to get pigment back there.

SPEAKER_01 23:50

You can tell when you have vitiligo, because your palms are pretty pale, even those those of us who are darker, my palm is like paler than my skin.

SPEAKER_02 23:57

Yes. And of course, it it probably wouldn't be the area of the body where it like bothered you the most. Sure, sure. But there are no follicles here. Yeah. And even pre people who get a lot of people get vitiligo on the dorsum of their hands. And if they get it there, there aren't very many follicles there. There are some. So repigmentation, even though the hands are so chronically exposed to sunlight, yeah, the hands are one of the most challenging areas to treat and bring the pigment back. So if you have vitiligo in an area that is sun exposed and rich in follicles like your face, we can bring that pigment back. That's cool. Now, the other thing I wanted to talk about and segues nicely to the next kind of category, which is light therapy, is that I will routinely recommend helio care for patients starting Upsolora. And let me tell you why. So helio care is a natural supplement based in a fern leaf extract from South and Central America. You can buy it on Amazon. It's natural. It's one pill a day in the morning before you go outside. Yeah. It's a capsule, but for young kids, they can open it up, sprinkle the powder on food or in juice. I have a lot of patients that add it to orange juice in the morning. We know that Obsolura works better with sunlight. We also know that sunlight works better with helio care. So helio care. That's interesting because it protects you from the sun. Exactly right. Wow. So helio care protects your skin from the sun. We talked about it in our sunscreen episode. Wow. But counterintuitively, it makes light therapy work better.

SPEAKER_01 25:35

So why not take it every single day? That's amazing. Absolutely.

SPEAKER_02 25:38

Absolutely. And you know, I think the evidence is mounting that everybody should take helio care every day. They even have anti-aging data and all that kind of stuff. Very cool. Um, and so we have studies where patients have psoriasis or vitiligo. They're getting light therapy for those conditions. Yeah. And the patients who are on helio care, they get better faster, they require fewer treatments. That's like such an easy thing to add, too.

SPEAKER_01 26:01

Very cool. And just available over the counter.

SPEAKER_02 26:03

Available over the counter. Some stores will sell it in the summer, but not in the winter, whereas Amazon has it all the time.

SPEAKER_01 26:10

Plus, I feel like it gives the dermatologist peace of mind because it's actually also protecting them if there's an added light exposure.

SPEAKER_02 26:16

Yes, yes, yes, definitely, definitely. So we used to think that vitiligo affected areas had an increased risk of skin cancer because there was no pigment there, no defenses, that there would be an increased risk of skin cancer. We actually now understand that the areas affected by vitiligo have a decreased risk of skin cancer.

SPEAKER_01 26:38

That makes no sense in my brain. Why is that?

SPEAKER_02 26:40

I think I can help you make sense of it. Our immune system is fighting cancer every day. Oh every day it's fighting cancer. And it's an overdrive in these conditions. Yes. And so you have more immune system involvement and presence in an area of vitiligo. And so it is actually preventing skin cancer. That's fascinating. Right. That's just so amazing.

SPEAKER_01 27:04

The body is really cool.

SPEAKER_02 27:06

And that's really important when we think about using light to treat vitiligo because a lot of people were like, oh gosh, should we be doing that again? Yeah, protection. But actually, they're more protected in those areas. So we feel quite comfortable using light therapy. However, we want it to be the right kind of light. Okay.

SPEAKER_01 27:24

Not PUVA.

SPEAKER_02 27:25

Not PUVA. So PUVA, have we talked about PUVA before?

SPEAKER_01 27:29

Well, you just said it was probably not the best anymore. Like we have better things.

SPEAKER_02 27:32

Oh, yeah. I'd be surprised if anybody's doing PUVA these days. So PUVA stands for sorolin, which starts with a P. Sorolin plus UVA light. And we used it a lot to treat psoriasis, which was probably the most common reason. And so you would bathe in these sorolin baths, or you would take oral sorrelin and then you would be in front of light. And it did produce better efficacy, but like all those patients got skin cancer.

SPEAKER_01 27:59

It's on the internet in the depths of the darkness of the internet, but maybe not being used. Yeah.

SPEAKER_02 28:04

Well, and it could be just dated articles because we did use to the truth is sunlight makes all treatments work better. So even if you're just doing topical steroids or tachylimus or pymicroleemus, you're going to see better efficacy if that patient is also getting some sunlight on their skin. And we can use light therapy in a variety of different ways to help our patients repigment. We know that light therapy is actually working via a couple different mechanisms in the skin. One is that it actually decreases the immune system presence in the skin. Interesting. Which is why over time, too much sun decreases your immune protection and you get skin cancers. Okay. But we can use it therapeutically in small doses to decrease the inflammation of conditions like vitiligo without hopefully taking it so far as to cause skin cancer. Sure. We also think that the light therapy works to stimulate the melanocytes in the skin. So the ones that are there, the ones that are coming back to life because of the topical treatment that we're doing, the sunlight says, okay, melanocytes, let's do this thing. Okay. There are different ways that a patient can receive light therapy. A lot of times for my pediatric patients living here in Boise, Idaho, where it's sunny in the summertime, I just tell them, like, go outside and be a kid, like swim and play and go down to the river and do all that kind of stuff. Yeah. And chances are you're going to get enough natural sunlight to help us out. Cool. Now I don't want sunburns. I don't want people blistering or anything like that. And so if they're going outside purely for the purposes of getting sun for their vitiligo, I tell them 15 minutes, two or three days a week, that sort of thing. Okay. We can also do light therapy in the office. And in the office setting, it's a little bit more regulated, right? Like we have more control over exactly what's being delivered and exactly how much is being delivered. You can come to the office and get what we call narrowband UVB.

SPEAKER_01 29:59

Do you guys actually have this? Like this.

SPEAKER_02 30:01

We do, yes. We have a couple units at two of our three offices.

SPEAKER_03 30:04

Cool.

SPEAKER_02 30:05

And narrowband UVB is a particular wavelength of UVB light, 311 nanometers. And that's been shown to be the most effective and the most safe. Okay. So you can stand in this booth. It's called a light booth. And you stand there, it's kind of 360 degrees of light to kind of hit the areas that you want to treat. Yeah. You can also utilize what's called eczemer laser in the office. And eczema laser, we had that at our old practice in Colorado. That's right, the little circle. The little circle thing. And you hear the word laser, you think it's going to hurt. It doesn't hurt at all. It's basically just focus sunlight on the patches. Yeah. And that is 308 nanometers. Okay. The one nice thing about eczemer is that it's just working on the spots. Sometimes when you are in the midst of treatment for your vitiligo, you're doing narrowband UVB, it's getting all over. Yeah. You get tanner. Sure.

SPEAKER_01 30:57

So then it makes it maybe more apparent.

SPEAKER_02 30:59

More apparent. So it's like you're helping the vitiligo spots, but you're also making it a little bit more noticeable. Oh man. Whereas the eczema laser, you're just focused right on the spots. Yeah. These treatments, whether it's narrow band UVB or eczema laser in the office, they're typically done two or three days a week.

SPEAKER_01 31:14

Yeah.

SPEAKER_02 31:15

There is a time commitment. Yeah. It doesn't fit into everybody's schedule. Sure. But it can be a very useful treatment modality. We can even try to get patients home light units.

SPEAKER_00 31:26

Those are cool.

SPEAKER_02 31:27

They're cool. Now you can't do eczema laser at home, but you can get a home light unit, which could just be like a wand. So if your vitiligo is relatively localized and all you need is a wand, then that's great. You can also get a panel where it basically you stand in front of it and then you turn around and stand in front of it. And those things can be more convenient. Insurance can be a hassle with regards to all of this. Sometimes they don't want to cover light therapy, or they'll cover it, but they won't cover certain aspects of it. You know, there are nuances to the whole thing. I'm sensing a theme. Insurance is a pain. I know. Insurance is a big pain. We should have named this insurance is a real pain. Like that would have been that would have been great. Um, and so we we know we do what our what we can and what will fit into patients' lives and patients' schedules. Um, but again, always encouraging helio care in combination with the light theory because you're gonna get the best results, the fastest results. And so light can be a really cool thing for the treatment of vitiligo. Cool. Now, oral options. Okay. So I put oral pulse dose steroids on the list. This is not for your general vitiligo. Okay. This is something that we utilize when we're seeing rapidly spreading vitiligo. Okay. On the previous episode, we talked a little bit about patterns that imply that the vitiligo is really spreading.

SPEAKER_03 32:43

Yeah.

SPEAKER_02 32:43

So there's confetti-like depigmentation where little spots of depigmentation. There's trichrome vitiligo, where you have the normal skin, you have the depigmented skin, you have hypopigmented skin, so trichrome. And then patients who are actively demonstrating the Keviner phenomenon where every time they fall or scratch their skin, vitiligo pops up. Those are features of rapidly spreading vitiligo. And so we want to shut that down. And we do that with oral pulse dosteroids. So what this is is we use dexamethasone or beta-methasone two days a week. Okay. So a lot of people will do it on the weekends, but you could choose your days. Okay. Two days a week for anywhere from 12 to 24 weeks, just depending on how we're feeling, how aggressive we want to be. Does it have to be consecutive days? Yes. Okay. It does have to be consecutive days. I don't know why, but it does have to be consecutive days. That's how it's written. An important thing about this is that the oral pulse dose steroids are not a repigmentation strategy. Gotcha. They are a halt the progression strategy.

SPEAKER_03 33:46

Okay.

SPEAKER_02 33:46

And so this is not the only treatment modality we're using. We're doing the oral pulse dose steroids and we're starting topical obsolura.

SPEAKER_03 33:55

Yeah.

SPEAKER_02 33:55

The steroids to shut it down, the obsolura to bring the pigment back, that sort of thing. Um, but they tend to be very well tolerated, just two consecutive days a week, pretty easy peasy. Don't tend to see many side effects from that. Um statistically, it stops the progression in about 90% of patients that this regimen is used in. So that's pretty good. That's pretty good. Then we have our oral jack inhibitors, which we've talked a lot about in our allopigiariata episodes because they have really changed the game. And as I alluded to earlier, alapiciariata and vitiligo actually have a lot of similarities. They're both autoimmune. They both involve the immune system being misdirected and attacking a component of the skin. Yeah. In allopiciariata, it's the follicle. In vitiligo, it's the melanocyte. And so just as oral jack inhibitors have been revolutionary for allopiciata, they're about to be revolutionary for vitiligo. Right now, we don't have any yet approved. Some people, myself included, have used Zelljans in the past off label for the treatment of vitiligo, especially when it's extensive, because we are limited with the 10% BSA for opsalora. Sure. There are three jack inhibitors that we're going to see in the really near future get approved for vitiligo. Rinvoke, which we've talked about for eczema, as well as for alopiciariata. Yeah. Litful, which we talked about in our allopiciata episodes, and then povor sitinib, a new jack on the block that actually doesn't have a fancy name yet. So it's still povorsitnib. A lot of us call it Povo. All three of these are pill jack inhibitors, and we're so excited to have something for folks that have more than 10% BSA that they would like to treat. That's cool. So this will be a really, really cool thing that'll really revolutionize the way we're able to help patients. Do we know when or no? We don't know when. No, they don't tell us. Nobody tells us. But we are eagerly anticipating. Yes, yes. You'll tell us as soon as you know. Exactly, exactly. And so stay tuned to Skin Credible because we'll update you as soon as these approvals come through. We'll definitely let our listeners know. We also have a biologic that is further down the line. So I didn't even put it up on the board. It doesn't even have a name, it's just a series of numbers and letters. But it, interestingly enough, so biologics for the listeners, biologics are typically shots, and they typically work by inhibiting one or two cytokines. They're very focused therapies. Whereas Jack inhibitors are a little bit more broad therapies. They can impact multiple different cytokines. Gotcha. Biologics like dupixent for eczema, ebglis for eczema, these are working in a very focused way.

SPEAKER_01 36:31

Gotcha.

SPEAKER_02 36:32

Because they're so focused, biologics tend to offer incredible safety. So we are hoping to see our first biologic for vitiligo. It's an IL-15 inhibitor. Okay. I mentioned in the previous episode that IL-15 is thought to be a key player in the inflammatory milieu of vitiligo. And so we're really looking forward to this. Yeah. Only one study's been done so far. It was just kind of a um will this work sort of study, a test of the theory of the hypothesis. I've heard through the grapevine that results were favorable. It would be really, really nice to have a biologic to treat vitiligo. Exciting. That would be really, really cool. And then I put surgery on the list. So I think there's there's a part of me that believes that this will become a bigger part of our treatment algorithm in future years. So this is basically where through different techniques, I'll talk about three of them. Basically, where you take skin from an unaffected area and you put it on an affected area. So like grafting? Kind of like grafting. Yes. So we talked about the ways that a LIGO repigments. Like it can be periflicular, you know, and you have the little freckles, it can be marginal.

SPEAKER_03 37:50

Yeah.

SPEAKER_02 37:50

So if you put little islands of normal skin, you can hopefully get marginal repigmentation spreading out from it. Really? Yes. That's the interesting. It's very interesting. Like tiny or like so there are three techniques. Okay. So one is to do suction blister grafting. So you actually take like a pencil eraser on an unaffected area, like a normal skin area, and you rub it to create a blister. And you then lift off the top of that blister and put it on a vitiligo area.

SPEAKER_01 38:25

Doesn't sound too invasive. Not too invasive. Okay, not like not like punch biopsy sutures, like put the skin.

SPEAKER_02 38:31

So that's number two.

SPEAKER_01 38:32

Oh, just kidding.

SPEAKER_02 38:33

So number two is punch biopsy grafting. Okay. Where you take little punch biopsies from a normal area and you kind of transplant them to the vitiligo area. Okay. And you hope that from there you get some marginal repigmentation.

SPEAKER_01 38:48

So back to the blister, really quick. The blister, like just the superficial part of the blister. So the top little layer, and that's enough. Yeah. But you have to open up the other part to put it there. Okay.

SPEAKER_02 39:00

Yeah. It's interesting. Yeah. And then the third is the most aggressive. This is where you do like an actual split thickness skin graft. So this is done under anesthesia, traditionally for like larger affected areas. And they actually use that machine that like basically shreds a piece of your skin off, usually from your thigh. And then they they kind of transplant it to another area.

SPEAKER_01 39:23

No wonder you're under anesthesia.

SPEAKER_02 39:24

I know you're under anesthesia for that. Yeah. But these things have come a long way. In fact, I've seen at conferences like devices to make something like this easier, where they have like kind of a grid system to do a bunch of little micro punches, and then you take that and you put it there. So I think this is something that we're going to see a lot more of in the future.

SPEAKER_01 39:45

I have so many questions like do you glue it? Do you like how do you attach to shavings and how do you attach to blister?

SPEAKER_02 39:51

Yeah, yeah, yeah. Typically little stitches. Okay. Yeah. Yeah. And so it's, you know, the future maybe. We'll see how it all pans out. The one thing is that these surgical modalities are really something to think about for somebody with segmental vitiligo. So so far, everything we've talked about is really with regards to non-segmental vitiligo, whereas segmental vitiligo is very difficult to treat.

SPEAKER_03 40:14

Yeah.

SPEAKER_02 40:15

I have had a few patients where like they came to see me early and we jumped on it. Yeah. And I did the pulse-dosed oral steroids and I started obsolete right away and I did the helio care and I encouraged sunlight. Yeah. And I have seen several cases of segmental vitiligo where we were able to stop it. Yeah. But the more common scenario is that people don't get in right away. Yeah. And it settles into itself. And then we're really stuck because at that point there's not much that can help. The only real option for a person in that situation is one of these surgical modalities. It has to be stable, meaning you haven't noticed any spread outward for I think it's six months to consider it a good candidate. A lot of these surgical modalities are being done in other countries, uh, including Iran and India. In fact, if you look at the literature on vitiligo, the most advanced, most up-to-date, most kind of think outside the box and solve Vitiligo articles are coming out of India and Iran. And it's because in those countries, like Vitiligo is a very stigmatizing, very big deal.

SPEAKER_01 41:14

So they're like in a hurry to figure it out.

SPEAKER_02 41:16

They're in a hurry to figure it out. Patients are desperate to figure it out. And so we're seeing much more novel things coming out of that realm. And then we all of these options can help us bring pigment back. Once it's back, what do we do? So if you treat studies on tachyrolemus showed that if you achieved repigmentation and then stopped the treatment, a third of patients will have recurrence. We know that we can bring that recurrence rate down to 10% by using tacrolimus twice a day for two days a week. Maintenance. Maintenance. So that's often what we've been doing. Like say I use Obsolura to repigment, then do TacroLemus twice a day for two days a week for maintenance.

SPEAKER_03 41:58

Yeah.

SPEAKER_02 41:58

However, there are studies in progress using Obsolura in a similar fashion. Oh, cool. And so I think one day relatively soon, I think we could see a maintenance routine with Obsolura. The one other thing I want to mention is that patients with Vitiligo who are in the Obsolura trials, they were instructed to use it on their vitiligo areas, keep using it on the vitiligo areas twice a day for up to three years.

SPEAKER_01 42:20

Oh, it's gonna say is that forever.

SPEAKER_02 42:22

So we know it's safe to use that long, and we know that the patients continue to improve. Okay. The the pictures are impressive. There will even be patients where, like at one year of use, no change has occurred. Yeah. And then at two years, they're completely repigmented. Amazing. So never lose hope. Like keep doing it. Yeah. And I think one day we'll have a good maintenance routine with Obsolura, which I'm looking forward to. I think that would be lovely. We talked a little bit about depigmentation with respect to Michael Jackson. This is a treatment of last resort. Okay. In my opinion. Yeah. A treatment of last resort for patients with really extensive vitiligo.

SPEAKER_03 43:04

Yeah.

SPEAKER_02 43:04

Um, who just want to be all one color, even though that one color is a little bit funny. Sure. Uh it is permanent, it is irreversible. And so it is a big decision.

SPEAKER_03 43:19

Yeah.

SPEAKER_02 43:20

Um, we do not take this decision lightly in clinic. I have talked about depigmentation with a couple of patients through the years. I have never actually done it.

SPEAKER_03 43:30

Yeah.

SPEAKER_02 43:31

And I think in this day and age, especially now that we have some new therapies coming out, yeah. I think jumping to that would be really not a great idea. Sure. Like we can we have more advances than ever before to bring pigment back. We don't need to settle for depigmentation.

SPEAKER_03 43:45

Yeah.

SPEAKER_02 43:46

Um like topical defense. It's topical. Okay. It's topical. And it's called monobenzyl ether of hydroquinone, 20%. You apply it twice a day for four to twelve months.

SPEAKER_01 43:55

Of course monobenzy ethyl of hydroquinone. Whoa.

SPEAKER_02 44:01

Yeah. Yeah. And um, and you know, of course, you have to have strict sun avoidance because you've you've taken all the pigment out of your skin. So it is not something to jump into. I I even thought of not even putting it on the board. Sure. But Michael Jackson comes up commonly.

SPEAKER_03 44:17

Yeah.

SPEAKER_02 44:18

Um, whenever I'm talking to patients about vitiligo, and that was the treatment that he chose at a very different time in history. Um, and so I think it is worth mentioning just so people know kind of the backstory of that um and why we don't we certainly don't jump to that treatment. Sure. Yeah. So the future is bright in the treatment of vitiligo. Lovely. And it's really an exciting time, as with all the things we've had a chance to discuss on the pod, you know, our treatments for alopecia areata for atopic dermatitis. I mean, this is the golden age of of dermatology and the golden age of medicine, and we're really able to help people better than ever before. The sky is opalite. Yes. The sky is opalite. Yes. Any other questions, Anna, that you think our listeners are wondering about? Anything that you read, you know, as you're going through social media and everything that might be worthwhile to mention to folks?

SPEAKER_01 45:10

No, definitely tune into our last episode if you haven't heard some of the myths, like being contagious, being some kind of spiritual weird something, just some ignorance, it sounds like in the general public. And yeah, just remember to accept each other, even if we have differences, because it's hard.

SPEAKER_02 45:26

It's hard for them. And the other question I get sometimes from parents is is there something nutritionally deficient in the child that is causing this? And the answer to that is no. You know, having a balanced diet, of course, is important. Sure. But that is not playing a role with the vitiligo.

SPEAKER_01 45:43

Sounds like the moral of the story here is it's not your fault. It's not your fault. You didn't do anything to cause it.

SPEAKER_02 45:48

You didn't do anything to cause this or to bring it on. And with the therapies we have available, we can get you repigmented, especially if it's on your face. So, like I used to be, I used to feel downtrodden when I saw a patient with vitiligo on their face. Now I'm like, yes, like we can do this. Yeah. It's very exciting. It's exciting. It's exciting. Well, thank you guys so much for joining us. I hope you've learned a lot about vitiligo, everything you need to know about it, and its treatments. And if you are a healthcare provider, you can go into your clinics and help encourage your patients to seek treatment for their vitiligo. While it's okay to live with it, we can bring their pigment back. Keep tuning in because we're going to have episodes with some of my patients talking about their vitiligo journey. Keep liking, keep subscribing, keep listening. Thank you guys so much.