A year after celebrating the approval of the first treatment for repigmentation of vitiligo, dermatologists describe how ruxolitinib cream (Opzelura) has advanced the outlook for patients with the disease and what’s next in the pipeline.
The US Food and Drug Administration (FDA) approved topical ruxolitinib for repigmentation of nonsegmental vitiligo in July 2022 for people aged 12 years and older.
Phototherapy Helpful in Combination
Raj Chovatiya, MD, PhD, assistant professor of dermatology at Northwestern University, Chicago, said that he likes to use ruxolitinib cream in combination with other treatments.
“In the real world with vitiligo patients, we’re oftentimes doing combinatorial therapy anyway. So phototherapy, specifically, narrow-band UVB, is something that we have a lot of clinical evidence for over the years, and it’s a modality that can combine with topical steroids and topical calcineurin inhibitors.”
He said trials to study combinations will yield better guidance on optimal use of ruxolitinib cream. “In general, vitiligo patients can really benefit from phototherapy,” he said in an interview. (Labeling recommends against combination with other JAK inhibitors, biologics, or potent immunosuppressants, such as azathioprine or cyclosporine.)
This first year has shown that ruxolitinib is an effective option, but counseling patients to expect slow improvement is important so that patients stick with it, he noted.
Documenting what treatments patients with vitiligo have used before is important, he said, as is counseling patients that ruxolitinib is approved only for use on up to 10% of a person’s body surface area. (Product labeling recommends that a thin layer be applied twice a day to affected areas up to 10% of body surface area.)
Ruxolitinib has brought a “louder voice” to vitiligo and has opened up options for patients with the disease, Chovatiya said. “Having the ability to topically treat people who have very extensive disease really gives us a lot more flexibility than we have had before.”
Good Experiences With Payers at Safety-Net Hospital
Candrice Heath, MD, assistant professor of dermatology at Temple University, Philadelphia, said that real-world experience with topical ruxolitinib will be more evident after its been on the market for 18–24 months.
Heath says she, too, encourages use of narrow-band UVB phototherapy in conjunction with the treatment.
From an insurance reimbursement standpoint, she said that she is glad that there have been fewer hurdles in getting ruxolitinib to patients than she has experienced with other medications.
In her safety-net hospital, she told Medscape Medical News, she sees patients with many types of insurance, but most have Medicaid. “So, I’m always expecting the step therapies, denials, pushbacks, etc,” she said. But she says the path has been smoother for ruxolitinib coverage.
Her colleagues are committed to documenting everything the patient has tried, she added, and that helps with prior authorization.
She said that pointing out to insurers that ruxolitinib is the only approved treatment for repigmentation helps facilitate coverage.
“The science is advancing, and I’m happy to be practicing during a time when we actually have something approved for vitiligo,” she said. But she pointed out that phototherapy often is not covered for vitiligo, “which is horrible, when it is readily approved for psoriasis and atopic dermatitis.”
To document progress, Heath said that she always takes photographs of her patients with vitiligo because “the pictures remind us how far we have come.”
Data Spotlight Success in Adolescents
Data from two trials give a clinical picture of the drug’s safety and efficacy in younger patients.
Adolescents had particularly good results in the first year with ruxolitinib, according to pooled phase 3 data from TRuE-V1 and TRuE-V2, Medscape Medical News reported last month.
The findings, presented at the 25th World Congress of Dermatology in Singapore, indicate that more than half of the participants achieved at least a 50% improvement from baseline in the total Vitiligo Area Scoring Index (T-VASI50) at 52 weeks.
The percentages of young patients aged 12–17 years taking twice-daily ruxolitinib who achieved T-VASI 50 at weeks 12, 24, and 52 were 11.5%, 26.9%, and 57.7%, respectively. The corresponding percentages for all in the study population were 10.7%, 22.7%, and 44.4%, respectively.
At the meeting, the presenter, Julien Seneschal, MD, PhD, professor of dermatology and head of the vitiligo and pigmentary disorders clinic at the University of Bordeaux, France, said, “This suggests that younger patients can respond better to the treatment.” He noted, however, that there were few adolescents in the studies.
New Excitement in the Field
Daniel Gutierrez, MD, assistant professor of dermatology at New York University, New York City, said the treatment has brought new excitement to the field.
“Patients with vitiligo are very motivated to treat their disease,” he said, because it typically is on the face and other highly visual areas, which can affect their overall perception of self.
Previously, he noted in an interview, the only FDA-approved treatment was monobenzone, but that was for depigmentation rather than repigmentation.
Otherwise, treatments were being used off-label, and patients were receiving compounded formulations that often weren’t covered by insurance and often had shorter shelf life.
He said that he still occasionally gets denials from payers who consider vitiligo a cosmetic condition.
“I’ve had more luck with insurance, at least in the New York state area.” He added that sometimes payers require use of a topical calcineurin inhibitor for about 12 weeks before they will cover ruxolitinib.
Gutierrez also recommends using phototherapy with topical ruxolitinib “because they work on slightly different pathways.”
When he starts patients on a new therapy such as ruxolitinib, he asks them to come back in 3 months, and often by then, progress is evident. Facial areas show the most response, he said, while hands and feet are less likely to show significant improvement.
He said that it’s important for physicians and patients to know that improvements can take weeks or months to be noticeable. “I tell patients not to give up,” he added.
Showing the patients pictures from the current appointment and comparing them with pictures from previous appointments can help them better understand their progress, he said.
Lead Investigator Adds Observations
David Rosmarin, MD, chair of the Department of Dermatology at Indiana University, Indianapolis, was the lead investigator of the pivotal TruE-V1 and TruE-V2 trials for vitiligo. In that role, he has been treating vitiligo patients with topical ruxolitinib since 2015.
In an interview, he said that many patients “don’t hit their optimal results at 3 months, 6 months, even the year mark. With continued use, many can see continued benefit.”
Other patients, he said, don’t respond within the first 6 months but with continued use may eventually respond, he said.
“Unfortunately, we have no way of knowing, based on clinical characteristics or baseline demographics, whether a patient will be a delayed responder or not or an early responder,” Rosmarin added.
He provided several observations about people who have stopped taking the medication.
“When people stop,” he said, “some maintain their response, but some start to depigment again. Again, we have no way of predicting who will be in which category.”
He said that once patients have hit their desired response, he usually advises them to taper down to maybe twice a week or to stop treatment, but if they see any recurrence, they should start reusing the medicine.
“We have some patients who have gone 6 or 7 years now before they had a recurrence, but others may start to depigment again in 2 to 3 months,” Rosmarin said.
As for phototherapy, he said, the combination with topical ruxolitinib is being studied.
“We think the combination is synergistic and better than either alone, but we’re still waiting for data to prove that,” he said.
In his practice, he offers patients the option either to use just ruxolitinib cream or the combination early on. Many patients, because of convenience, say they’ll first try the cream to see if that works.
“The challenge with light [therapy] is that it can be very inconvenient,” he said. Patients have to live close to a phototherapy unit to receive therapy 2–3 times a week or have a phototherapy product in their home.
Next in the Pipeline
Experts say the progress doesn’t stop with ruxolitinib cream. Current trials of several medications show there’s more to come for patients with vitiligo.
Chovatiya said that next up may be oral ritlecitinib (Litfulo), a JAK inhibitor that was approved for severe alopecia areata in June for people aged 12 years and older. Phase 2 results have been published for its use with vitiligo.
“This would be an oral medication that may be able to help people with much more extensive disease as far as vitiligo goes,” he said, adding that he expects approval for a vitiligo indication within a few years.
He pointed out that longer-term safety data will be available because it is already on the market for alopecia.
Upadacitinib (Rinvoq), an oral JAK inhibitor, is approved for atopic dermatitis but is being studied for vitiligo as well, he noted. “I’m very excited to see what that holds for patients as well,” Chovatiya said.
Gutierrez said that he also is excited about oral JAK inhibitors but sees potential in finding new ways to transplant melanocytes into areas where there are none.
The pigmentation field has seen new energy since last year’s approval, he said, particularly among people of color.
“We have new options for vitiligo that were lacking compared with other conditions, such as atopic dermatitis and psoriasis,” he said. “Hopefully, there will be more promising breakthroughs.”
Rosmarin is the chief investigator for the pivotal trials that led to FDA approval of ruxolitinib. He received honoraria as a consultant for Incyte, AbbVie, Abcuro, AltruBio, Arena, Boehringer Ingelheim, Bristol -Meyers Squibb, Celgene, Concert, CSL Behring, Dermavant, Dermira, Janssen, Kyowa Kirin, Lilly, Novartis, Pfizer, Regeneron, Revolo Biotherapeutics, Sanofi, Sun Pharmaceuticals, UCB, and VielaBio. He has also received research support from Incyte, AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Dermira, Galderma, Janssen, Lilly, Merck, Novartis, Pfizer, and Regeneron and has served as a paid speaker for Incyte, AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Incyte, Janssen, Lilly, Novartis, Pfizer, Regeneron, and Sanofi. Chovatiya has served as an advisory board member, consultant, and/or investigator for Incyte, AbbVie, Arcutis, Arena, Argenx, Beiersdorf, Bristol-Myers Squibb, Dermavant, Eli Lilly, EPI Health, L’Oréal, National Eczema Association, Pfizer Inc, Regeneron, Sanofi, and UCB. He has been a speaker for Incyte, AbbVie, Dermavant, Eli Lilly, LEO Pharma, Pfizer Inc, Regeneron, Sanofi, and UCB. Heath and Gutierrez report no relevant financial relationships.
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.
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