Surgical Therapies for Vitiligo

In this interview, Loren D. Krueger, MD, met with The Dermatologist to discuss the benefits and risks of surgical treatments for patients with vitiligo based on a recent systematic review and meta-analysis. Dr Krueger’s areas of expertise include pigmentary disorders, hair loss disorders, and skin of color dermatology. She has published numerous journal articles on topics ranging from bias in dermatology to the history of hair care practices in the United States.

The Dermatologist: Can you elaborate on the repigmentation benefits of the surgical treatments for vitiligo in your recent systematic review and meta-analysis?

Dr Krueger: Initially, vitiligo was one of the more difficult to treat diseases in dermatology, yet it is so impactful on patients’ lives. We are rapidly expanding our treatment options in vitiligo, which is exciting. For example, in addition to the medical treatments that we have now, such as topical and oral Janus kinase (JAK) inhibitors, we are learning that some vitiligo responds well to procedural treatments. In our systematic review and meta-analysis, we looked at different modalities, including platelet rich plasma (PRP), microneedling, and ablative laser therapies, as well as surgical techniques in the treatment of vitiligo.

We learned that it is important to select your patient population correctly. These modalities work better for patients with segmental vitiligo or stubborn patches that have not responded to treatment, not in patients who have active vitiligo with actively depigmenting lesions. Microneedling, in combination with narrow-band UVB, can be helpful, as can ablative laser therapy with CO2 laser or erbium:YAG laser. This seems counterintuitive because we have always thought of vitiligo as exhibiting the Koebner phenomenon, with new disease activity when the skin is injured. However, using procedures in patients with stable vitiligo, we are seeing repigmentation.

The Dermatologist: How does your systematic review of the efficacy of nonphototherapy surgical treatments help expand dermatologists’ therapeutic repertoire for vitiligo?

Dr Krueger: Procedures such as PRP, ablative laser therapy, and microneedling are done every day in the dermatologist’s office, but provider’s may not be aware that these procedures can be used to treat vitiligo. We want to make providers aware of the protocols for treatment and that there are good outcomes with these treatments to expand who is treating vitiligo surgically and procedurally.

The Dermatologist: What future research is needed to understand the benefits and risks of surgical treatments for vitiligo?

Dr Krueger: Vitiligo is a challenging disorder that can be hard to treat and unpredictable. Sometimes, you get a patient who has a great response; other times, not so much. We have expanded treatment options with the topical and oral JAK inhibitors, the 308-nm laser, and phototherapy. But now learning more about procedures, I am hopeful that more dermatologists will be interested in treating vitiligo and, therefore, also researching it. I do think we need more larger studies that can look at the side effect profile of some of these procedures. There can be some complications, such as pain, redness, scarring, Koebnerization, and limited response. We also need to solidify who the right patient population is and conduct more head-to-head comparative studies on the different procedures, especially in the surgical realm.

The Dermatologist: Is there anything else you want to share with your colleagues about surgical treatments for vitiligo?

Dr Krueger: There are a handful of experts across the United States who specialize in these surgical treatments. Using procedures in vitiligo is really a skill and a craft. We want to make sure the treatment is done by an expert and that the patient is selected properly to avoid Koebnerization. It is important that we continue to educate dermatologists about the treatment options that exist and empower the expansion of treatment options. I am hopeful that we can get some good procedural therapies going for our patients with vitiligo.

Reference

McCrary MR, Gibbs DC, Alharthi M, Krueger LD. Utilization of our toolkit: a systematic review and meta-analysis of surgical therapies in vitiligo treatment. Dermatol Surg. 2022;48(8):815-821. doi:10.1097/DSS.0000000000003503