U.S. guidelines focus on topical therapies for vitiligo in children and young adults

Vitiligo is an acquired and often progressive chronic, relapsing pigmentation disorder characterized by depigmented patches that are associated with a substantial loss of functioning melanocytes. This condition affects more than 591,000 children and adolescents in the United States. It has a significant impact on quality of life, with high rates of depression, stigmatization, and long-term psychological and developmental problems.1 Vitiligo that starts in childhood has a more progressive and extensive course. It is important to optimize care in children, adolescents and young adults with vitiligo to minimize disease progression and to limit the extent of depigmentation.1No specific published guidelines have focused on the care of young patients with vitiligo, despite the fact that half of all cases of vitiligo begin in the first two decades of life. To address this care gap, a group of dermatology experts developed consensus recommendations based on currently published evidence, to promote early, effective and sustained therapeutic interventions in children, adolescents and young adult patients with vitiligo. Statements achieving at least a 70% “strongly agree or agree” (combined) score met the threshold for consensus.1General therapy recommendationsTopical steroids, topical calcineurin inhibitors and UVB light therapy (light box or excimer laser) are standard of care in young patients; emerging data on topical Janus kinase (JAK) inhibitors for nonsegmental vitiligo are promising.The combination of UVB sources and topical therapies, including topical calcineurin inhibitors or topical corticosteroids with home phototherapy, may enhance initial repigmentation response.For pediatric patients, short outdoor UV exposure (10–15 min) may enhance response to topical therapy.1Recommendations for Topical Calcineurin Inhibitors (TCIs) Topical tacrolimus or pimecrolimus can be used as first-line therapy for vitiligo in children and adolescents (2–18 years of age), and young adults.The standard protocol for TCI use for pediatric vitiligo is twice-daily application for a minimum of three months.Alternate agents should be considered if there no evidence of repigmentation at three months. TCI usage trials support continued use for six to 12 months when evidence of repigmentation is seen.Counselling on risk of burning, stinging or itching in the first month of application is recommended; discontinue if there are visible signs of irritation or inflammation.Current databases do not show statistically significant increases in lymphoma and skin cancer in children receiving TCI therapy; however, counselling on theoretical risk based on TCI labelling is recommended.The use of TCIs in children younger than two years with vitiligo has limited supporting evidence.TCIs appear effective in all pediatric Fitzpatrick skin types, but may be more effective in darker phototypes.TCIs are effective in most body areas without risk of atrophy, but are most effective on the head and neck, with intermediate response on the trunk and extremities, and the most limited response on the hands and feet.TCIs can be used twice weekly to maintain colour for locations with concern for relapse.1Recommendations on Topical Corticosteroids (TCSs)TCSs may be used as first-line therapy.TCSs may be considered as second-line therapeutic agents for areas with thin skin (e.g., face, groin, intertriginous).Choice of corticosteroid class depends on the site and duration of planned use. Daily class 2 (high-potency) TCSs and intermittent or short-term continuous class 1 (ultra-high potency) TCSs can be effective in leading to repigmentation.Counselling about risk of atrophy and monitoring for atrophy are recommended for class I and II TCSs. Due to risk of atrophy with long-term use of TCSs, short-term use or overlap with calcineurin inhibitors is needed.High-potency TCSs are effective for eyelid vitiligo, but risk of glaucoma and atrophy of the eyelid skin precludes prolonged use.There is limited evidence supporting the addition of topical calcipotriene to a TCS regimen to enhance repigmentation.As with all topical agents in vitiligo, facial response to TCSs is best, followed by response on the torso, the arms and legs, and lastly, the hands and feet.1 Recommendations for Topical JAK Inhibitors (tJAKi) tJAKi should be considered as first-line or second-line therapy for patients ≥ 12 years of age; topical ruxolitinib 1.5% cream applied twice daily has the best data (see “Note” below regarding availability of tJAKi in Canada).tJAKi may be used off label in younger children but there is limited evidence; they should be used on a limited body surface area until absorption data are better understood.Patients may need more than three months of tJAKi therapy to see initial repigmentation; treatment beyond one year may be needed before maximal repigmentation is achieved.Counselling patients treated with tJAKi should include mention of the product label adverse events derived from trials of systemic JAK inhibitors, but focus on common adverse events reported with topical use, including acne and application site reactions.tJAKi can be applied to areas with risk of atrophy, including the face, eyelids and groin.Combination of tJAKi and phototherapy (natural sunlight or narrowband-UVB) may be synergistic based on evidence in adults, but needs to be confirmed in pediatric patients.1Note: Topical ruxolitinib 1.5% cream was recently approved by the US Food and Drug Administration for the treatment of atopic dermatitis and nonsegmental vitiligo in adults and children ≥ 12 years of age. (It is not yet approved in Canada, but is being studied in clinical trials.) The recommended dosage for nonsegmental vitiligo is a thin layer applied twice daily to affected areas (up to 10% body surface area).2SummaryThree main classes of topical therapies are effective for vitiligo in young patients, with good safety profiles. Prompt intervention in new-onset vitiligo is recommended, especially in children, to control disease spread and promote repigmentation. Effective therapy requires a focus on long-term therapeutic interventions, with a trial period of twice-weekly application, to maximize therapeutic efficacy and retention of pigmentation. Counselling should include a discussion of the chronicity of vitiligo and the need for long-term care.1References:Renert-Yuval Y, Ezzedine K, Grimes P, et al. Expert recommendations on use of topical therapeutics for vitiligo in pediatric, adolescent, and young adult patients. JAMA Dermatol 2024. Published online March 13, 2024. (accessed March 21, 2024).Incyte Corporation. Opzelura (ruxolitinib cream) prescribing information. Wilmington, DE; September 2023. (accessed March 21, 2024).

U.S. guidelines focus on topical therapies for vitiligo in children and young adults

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