In an insightful session at the ODAC Dermatology Conference, leading vitiligo expert Dr. Iltefat Hamzavi—clinical associate professor of dermatology at Wayne State University and senior staff dermatologist at Henry Ford Hospital—shared key strategies for tackling this complex condition. Here is a practical summary of his top clinical pearls, from disease stabilization to emerging systemic treatments.
Vitiligo Statistics
Vitiligo affects an estimated 0.3–1% of the global population. Most patients develop vitiligo early in life—nearly two-thirds of cases occur before age 34. Two main onset peaks are commonly seen: adolescence/early adulthood and another in the 30s to mid-40s. It is quite known that vitiligo is also associated with other autoimmune diseases including thyroid disease and type 1 diabetes mellitus. Something interesting I learned was that patient’s also have an increased risk of developing sensorineural hearing loss (makes sense since outside of the skin, melanocytes are also found in the inner ear!)
Presentation
Classifying Vitiligo: Segmental vs Non-Segmental
Dr Hamzavi emphasized that one of the most important first steps in managing vitiligo is correctly classifying it. 85% of all people who have vitiligo have non-segmental vitiligo which crosses the midline. Segmental vitiligo, by contrast, affects only one part of the body. This distinction is important given its therapeutic implications.
Assessing Disease Activity
Assessing disease activity at the initial visit is also important. Clinical features such as trichrome lesions, Koebnerization, and confetti-like depigmentation serve as key markers of disease activity or stability. Trichome vitiligo normally has 3 different colors: normally pigmented, hypopigmented and depigmented and these individuals tend to have progression over time. Confetti depigmentation, characterized by many depigmented macules often appearing at the border of existing patches, is one of the most reliable indicators of disease progression.
Treatment Principles: Stabilization and Repigmentation
Stabilizing disease activity and promoting repigmentation are the two major goals of treatment. For localized disease, the gold standard therapies include ultrapotent topical corticosteroids, calcineurin inhibitors as well as topical ruxolitinib, the first FDA-approved treatment for non-segmental vitiligo. When topical therapy alone is not enough or for patients hesitant about initiating topical steroids, narrowband UVB phototherapy—usually prescribed for two to three sessions per week—remains an important treatment measure and is effective for most patients. Phototherapy is also often combined with topical agents to improve clinical outcomes. Surgical interventions are also an option for the treatment of segmental vitiligo given its localized nature. Dr. Hamzavi did briefly mention depigmentation as a therapeutic option, however, did not go into detail.
Clinical pearl: Utilize a combination of therapies when possible.
Setting Expectations and Preventing Relapse
Managing patient expectation is important since treating vitiligo can take time. Repigmentation can often take months to years. An analogy explaining the slow timeline of vitiligo treatment to patients really stuck with me. Dr. Hamzavi likened it to a stroke. Because melanocytes are neural crest derived, the recovery process can be slow similar to neuronal healing. Even after the immune attack is controlled, repigmentation takes time since the skin needs time to regenerate melanocytes. It’s a helpful way to frame expectations for patients and explain why improvement can take months to years rather than days or weeks.
Relapse can occur once repigmentation is achieved and treatment is discontinued. Maintenance regimens—such as continued topical therapy 2-3 times per week for a year—can significantly reduce recurrence.
Addressing the Psychosocial Burden
Don’t forget to address the psychosocial impact as this can be quite substantial in vitiligo. Studies demonstrate higher rates of anxiety and depression in vitiligo than many other disease states especially amongst patients with darker Fitzpatrick skin types and/or facial involvement. However, we should never assume that psychosocial distress is limited to patients with darker skin types. Although clinic can get quite hectic, assessing quality of life, discussing coping strategies, and taking the time to connect patients to support resources is key to providing well-rounded care. Quick plug, Dr Hamzavi actively supports and collaborates with several support groups including V Strong, Global Vitiligo Foundation (GVF), and MyVitiligoTeam. In addition to these support groups, Vitiligo Support International, National Vitiligo Foundation and VITFriends are also great resources to refer patients to.
Clinical pearl: Talk to your patients to assess for mental health challenges, not matter the skin disease.
When to Consider Systemic Therapy
For patients with unstable disease/activity, systemic therapy may be necessary to stop the inflammatory process. Currently there are no FDA approved therapies for treatment of active disease. Dr Hamzavi utilizes intermittent oral corticosteroid regimens, such as low-dose dexamethasone administered twice weekly, to stabilize disease while minimizing steroid-related side effects. Methotrexate is also a good backup to pulsed steroids for relapsing disease.
Understanding the Pathogenesis
Advances in our understanding of vitiligo pathogenesis have helped uncover why these lesions develop. Vitiligo represents an immune-mediated destruction of melanocytes, driven largely by CD8⁺ cytotoxic T cells. A set of triggers including oxidative stress and inflammatory signaling trigger keratinocytes and fibroblasts to release chemokines, including CXCL10, which recruit these T cells to the skin. This immune pathway is mediated through JAK-STAT signaling, which helps explain the therapeutic benefit of JAK inhibitors in vitiligo.
New and Emerging Therapies
One of the agents generating the most excitement is upadacitinib (Rinvoq). It’s an oral JAK inhibitor currently in phase 3 trials for non-segmental vitiligo, and early data suggest fairly rapid repigmentation, particularly on the face. It has already been submitted to the FDA and EMA, so it may enter clinical practice relatively soon. The phase 3 study results are expected to be presented at AAD, so that’s definitely something to keep an eye on.
Another drug being studied is ritlecitinib, an oral JAK3/TEC inhibitor that has shown strong efficacy in clinical trials for non-segmental vitiligo and is also currently in phase 3 trials.
There’s also povorcitinib, an oral JAK1 inhibitor being evaluated for extensive non-segmental vitiligo, which is likewise in phase 3 clinical development.
Take-Home Message
Vitiligo is often perceived as a cosmetic issue, however, there are considerable clinical and psychosocial implications. A thoughtful approach to management integrates disease classification, assessment of activity, and individualized treatment strategies. With the growing number of treatment options, we now have more ways to help stabilize the disease, support repigmentation, and guide patients through the psychosocial challenges that can come with it.
This information was presented by Iltefat Hamzavi, MD at the 2026 ODAC Dermatology Conference. The above highlights from his lecture were written and compiled by Ndidi Enwereji, MD, MPH.
