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Pigmentary disorder experts welcome research explosion


AT ODAC 2023

Research on pigmentary disorders has entered an overdue era of increased attention, resulting in more treatment options and the promise of improved quality of life for patients, a panel of experts said in a session on this topic at the ODAC Dermatology, Aesthetic & Surgical Conference.

The arrival of ruxolitinib cream, a topical JAK inhibitor – and oral JAK inhibitors, including ritlecitinib, a JAK3/TEC (tyrosine kinase expressed in hepatocellular carcinoma) inhibitor in clinical trials – is a welcome development for treatment of vitiligo, said John E. Harris, MD, PhD, chair of dermatology and director of the Vitiligo Clinic and Research Center at the University of Massachusetts, Worcester. Also in the pipeline is a kit for melanocyte-keratinocyte transplantation, which involves transplanting epidermal cells from one part of the body to another. This can be a challenging procedure but a kit would make it easier for a wider range of practitioners. (Topical ruxolitinib was approved by the Food and Drug Administration for treating nonsegmental vitiligo in July, 2022.)

John E. Harris, MD, PhD, department of dermatology, University of Massachusetts, Worcester

Dr. John E. Harris

“In the last 10 years, it’s just blown up and people care about vitiligo now,” Dr. Harris said, noting that vitiligo is more than a cosmetic issue, like gray hair or wrinkles. “Vitiligo is an autoimmune disease and now is being treated as such.”

Nada Elbuluk, MD, MSc, associate professor of dermatology at the University of Southern California, Los Angeles, said she’s pleased at the increasing availability of treatment options for hyperpigmentation, aside from hydroquinone, which is associated with an increased risk of adverse effects.

Dr. Nada Elbuluk, a dermatologist who directs the University of Southern California Skin of Color Center and Pigmentary Disorders Program

Dr. Nada Elbuluk

“We have more and more nonhydroquinone agents ... which is really nice because it expands our treatment armamentarium and what we can use to cycle people off of hydroquinone,” she said.

Some of these options include tranexamic acid and products containing azelaic acid or vitamin C.

Iltefat H. Hamzavi, MD, senior staff physician at Henry Ford Health System, Detroit, said that pigmentary disorders are receiving the recognition they deserve.

Dr. Iltefat H. Hamzavi, dermatologist, Henry Ford Health System, Detroit

Dr. Iltefat H. Hamzavi

“I’m excited just about the intersection of society and science, the awareness that pigmentary abnormalities mean something, and they mean something across our society,” he said.

Dr. Elbuluk said that hyperpigmentation has “profound effects on quality of life” for patients.

“They are often more bothered by the darkening of the skin than the primary process that caused it,” she said. “It’s not uncommon that the chief complaint will say ‘dark spots’ and I walk in a room and it’s a patient who has acne. They don’t even say they’re here for acne. They just put ‘dark spots’ [down] because that’s what bothers them. That’s what lasts for so long after the acne is gone.”

The experts offered suggestions for managing these cases. Among her tips, Dr. Elbuluk said that for hyperpigmentation, physicians should not be afraid to biopsy the face – but suggested small, 2-millimeter specimens. In addition, “you can get common conditions in uncommon places,” she noted. “If you see something that looks like melasma off the face, it actually could be, so keep that in your differential.”

Dr. Hamzavi, who spoke about hypopigmentation disorders, said clinicians need to use an algorithm for diagnosis, considering features such as localized or diffuse, scale or no scale, as well as patient history, and other factors. For instance, a hypopigmented area that is localized and has a reddish central papule might lead a clinician to a diagnosis of hypopigmented sarcoidosis.

Using the algorithms, “you actually have to categorize these and then use your own experience. ... All of these elements can help you become a really good taxonomist – ultimately that’s what physicians are.”

He said it’s also important to know when it’s time to reconsider a diagnosis, such as when patients do not respond to traditional treatments. “If they don’t respond, re-categorize,” he said.

Speaking about vitiligo, Dr. Harris said it’s crucial to differentiate active vitiligo from inactive vitiligo and if it’s active, steps need to be taken to keep it from worsening..

Four signs of active vitiligo are a “confetti” pattern of clustered tiny macules of depigmentation, which will coalesce quickly into huge patches; tri-chrome vitiligo that includes a hypopigmented zone; linear areas of depigmentation (Koebner’s phenomenon) that look like scratches on the skin; and inflammatory vitiligo, with an erythematous ring around the edges of a depigmented area.

Dr. Harris disclosed ties with Incyte, Pfizer, Abbvie, Genzyme/Sanofi and other companies. Dr. Elbuluk disclosed ties with Avita, Incyte, Beiersdorf, and other companies. Dr. Hamzavi disclosed ties with AbbVie, Pfizer, Incyte, and other companies.

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