Update on vitiligo

Vitiligo remains a highly heterogeneous disorder, and its management requires a nuanced understanding of disease presentation, treatment expectations and comorbidities. During the recent vitiligo session at the EADV, where prof Speeckaert gave the first presentation, several key aspects were discussed.

The first presentation was on patient stratification. Disease extent and lesion location are critical prognostic factors. Early intervention improves therapeutic outcomes, whereas extensive disease poses greater challenges. Facial lesions generally respond more favourably, although periocular and perioral areas are less responsive compared to the cheeks or forehead. Similarly, forearms repigment more easily than wrists. Communicating these site-specific differences to patients is essential for managing expectations. Treatment goals also vary: some patients seek only disease stabilisation, achievable with topical or systemic therapy depending on activity, while those aiming for repigmentation require phototherapy, currently the only modality capable of inducing melanocyte proliferation. The introduction of topical ruxolitinib, the first treatment specifically approved for vitiligo, represents an important advance. Attention to comorbidities is equally important, particularly autoimmune thyroid disease, alopecia areata, and psoriasis. Biologics used in psoriasis can sometimes trigger vitiligo, highlighting the need for careful therapeutic choices.

A second presentation addressed vitiligo mimickers. Depigmentation in children warrants careful differential diagnosis, as vitiligo never presents congenitally. Genetic disorders, pityriasis alba, and pityriasis versicolor should be excluded. Segmental vitiligo, more common in paediatric patients, shows a distinct course—remaining active for two years before stabilising—and may be amenable to pigment cell transplantation once stable. In atypical adult cases, especially late-onset depigmentation, differential diagnoses include melanoma-associated leukoderma and mycosis fungoides. In such scenarios, a biopsy is advisable.

Emerging therapies formed the third theme. Beyond JAK inhibitors, which are entering clinical practice, biologic agents are under investigation. Interleukin-15 blockade is the first biologic strategy currently being tested in phase II trials. While phototherapy remains the standard for stimulating melanocyte proliferation, future innovations may shift the therapeutic paradigm toward more effective pigment cell stimulation.

The final presentation emphasised paediatric vitiligo. Children generally respond better to treatment, although adherence to phototherapy is challenging. Topical therapies remain the first-line approach, with phototherapy reserved for extensive disease. Importantly, the child’s own motivation and psychosocial context must guide treatment decisions; not all children wish to pursue therapy, and physicians should balance parental expectations with the child’s preferences. Psychosocial factors such as bullying may remain hidden but should be actively addressed in consultations.

Overall, the session underscored the necessity of individualised treatment, recognition of comorbidities, and anticipation of new therapeutic developments. Increasing scientific and clinical attention to vitiligo reflects its growing prominence in dermatology.