Updates in the Treatment of Vitiligo - Episode 5

Role of JAK Inhibitors in Vitiligo Treatment

JAK inhibitors’ effectiveness as a frontline treatment option for vitiligo is discussed by a key opinion leader in vitiligo treatment.

David Rosmarin, M.D.: When I see a patient with vitiligo, I usually offer topical corticosteroids or calcineurin inhibitors, and I always offer phototherapy in combination. We believe that repigmenting vitiligo is a two-step process. First, we need to tell the immune system to calm down. Second, we need to try to stimulate those pigment cells to come back. The phototherapy or light treatment helps do that. Even natural sunlight can help those patients.

There was a time when we were a little concerned about combining calcineurin inhibitors with phototherapy. In fact, the label warns against it. But now we have larger studies that aren’t showing increased risk of cancer when we combine topical calcineurin inhibitors with phototherapy. Many patients can’t do phototherapy because of the inconvenience but can do the topicals, but I always offer the two in combination. If patients start by using the topicals alone and don’t respond, we may then see whether they’re willing to try phototherapy as an add-on. If yes, and it works, then great. If no, I may move on to JAK inhibitors.

Ruxolitinib cream is our first FDA-approved medicine to help repigment patients with vitiligo. There’s a treatment that’s approved to depigment patients, monobenzone, but this is the first one to get them better from their disease. The medicine works particularly well at all body sites, including the head, neck, trunk, and extremities. It’s hardest to treat the hands and feet in general, and the same is true when we use ruxolitinib cream. When we ask adults whether they have a response where their vitiligo is a lot less noticeable or no longer noticeable, about a third to 40% of patients who use the cream for about a year [say yes]. In adolescents, it’s over 50% of patients. Over half of them will say their vitiligo is no longer noticeable or a lot less noticeable at the year mark. Ruxolitinib cream is a great option, particularly to help repigment patients with both facial and body involvement.

Besides corticosteroids, calcineurin inhibitors, and phototherapy, as well as ruxolitinib cream, those four are our first-line options for patients. We have other agents that we sometimes use. One can be over-the-counter antioxidants. The data aren’t great for this, but oftentimes we feel that it doesn’t do any harm for patients to take these antioxidants. That can be a good option. Some patients may take some alternative medicine, such as ginkgo biloba as well as polypodium. There’s some evidence that those two can help as well. For some patients, we use micropigmentation, which is almost tattooing to try to mask the vitiligo. The areas that may be used for this are nipples, fingertips, or lips. It’s important to have somebody who’s very experienced and do a good job. The skin is dynamic. It changes color from the sun. But when you have these tattoos, they don’t change color in response, so it can be very hard to precisely match the pigmentation in these areas. Only a minority of patients may want that option.

Depigmentation is done for patients who have pigment loss in most of their body or most of a section of their body when it’s very hard to get their pigment back. If their hands are involved and they have only a little [pigment] left, and they want to get rid of those few dark spots of their normal skin that are there, then we may use monobenzone. Many patients can be very satisfied with that treatment, but a small minority are candidates for depigmentation.

In terms of other systemic immunosuppressants, there are some limited data on the use of methotrexate. We usually don’t use those other oral immunosuppressants as often. But oral JAK inhibitors are certainly in development and are being used off label to help patients with their vitiligo, halt the progression of disease, and get their pigment back. As with our other treatments, it’s being combined off label with combination phototherapy, which we believe may be synergistic.

Once we get patients’ pigment back, it’s important to maintain it. Our studies show that many patients will lose their pigment if they don’t do anything. One regimen we recommend is topical tacrolimus twice a week, which has been shown to help maintain the pigment that patients get back. Some people will even try phototherapy once a week or maybe intermittently throughout the year as a way to try to keep their pigment. In terms of ruxolitinib cream, there are only limited data for how well people maintain their pigmentation. We know that there are some people who lose it but some who maintain it. Those numbers will come out of subsequent trials, which we’ll hopefully have soon.

Transcript edited for clarity.