First line therapies for the treatment of vitiligo
Jeffrey D. Dunn, PharmD, MBA: What therapies are used? Are they generally covered by different business books: commercial, Medicare or Medicaid? Do you currently have problems accessing therapies?
David Rosmarin, MD: The 3 most common treatments are topical corticosteroids, topical calcineurin inhibitors, and phototherapy. All 3 are considered first line treatments for patients. There are others that are used. These can be used in combination, or all 3 in combination. These are the 3 main ones that are used in practice.
Many corticosteroids are inexpensive. There are certainly generic options. The repigmentation of vitiligo takes time and is often located on sensitive areas of the skin, such as the face, which makes it more difficult to use corticosteroids over the long term. Calcineurin inhibitors, such as tacrolimus [Protopic], is great, especially for trying to repigment the face. But it is also a large molecule. It doesn’t work as well for repigmenting the body, and it doesn’t work for all patients on the face.
Phototherapy is also an excellent treatment, stimulating the reappearance of these pigment cells, in addition to trying to tell the immune system to calm down. But it can be quite inconvenient for patients to have to come 2 or ideally 3 times a week for treatments. Some patients do not have access to it. They must come from very far away. This can lead to missed work. There are many challenges around phototherapy and the patients who have access to it.
In terms of coverage, it is rare, but sometimes we see that it is difficult to cover even the diagnosis of vitiligo, let alone the treatment. Sometimes a patient comes in and we make a diagnosis of vitiligo, and the insurance refuses to cover the visit for the patient. This can rarely happen, so I appreciate Dr. Epstein stating that he considers it a medical condition, as all providers do. The most common issue we face is treatment coverage. Usually corticosteroids are covered because we are not asked for prior authorization. But even calcineurin inhibitors are often denied to vitiligo patients. Likewise, with phototherapy, it’s a mixed bag. Some will cover it and some won’t. This has been my personal experience.
Brett King, MD, Ph.D.: Treatment is often turned down in my clinic, with the exception of topical steroids, because they basically cost pennies. Topical calcineurin inhibitors are frequently turned down in my clinic. Phototherapy is also quite often refused. Have an approved treatment [would help]. Topical corticosteroids, topical calcineurin inhibitors, and phototherapy are not FDA-approved for vitiligo. There are no FDA-approved therapies to improve or repigment vitiligo. Having one will be a change. It will be interesting to see how this will reflect on the standard of care that we are talking about versus something brand new.
David Epstein, MD, MBA: I went through the small list of what is covered by the current policy. As you mentioned, steroids are obviously covered. Topical tacrolimus is covered. PUVA [psoralen plus ultraviolet A] is covered. Narrowband ultraviolet is covered. At the top of the list – I hadn’t heard of it – was the excimer laser. This is also covered by the current policy.
David Rosmarin, MD: Coming back here so we’re on the same page, most phototherapy used is either narrowband UV-B [ultraviolet B] phototherapy or excimer laser, which is a similar wavelength to phototherapy but in a targeted laser form. PUVA is used less and less than the other 2 options, but it has always been used. There may also be more side effects from PUVA.
Jeffrey D. Dunn, PharmD, MBA: I guess access to calcineurin inhibitors may have improved as they become generically available. Maybe not. I expect them to be. These types of conversations are going to be fascinating as we get into the discussions of biologics and specialty drugs that are coming. How to redefine the standard of care? Does it change the way we access not only these new drugs but also older drugs?
Transcript edited for clarity.