Diverse approaches to the diagnosis and treatment of paediatric vitiligo: a survey of paediatric dermatologists
Authors: Weingarten Mark , Schwartz Michelle , Silverberg Nanette B 
Published: January 2023

Abstract
There is a paucity of research concerning the diagnosis and treatment of paediatric vitiligo. This reality parallels published patient reports of profound dissatisfaction with the state of knowledge and available treatments. This study was meant to assess the attitudes of paediatric dermatologists towards the therapeutics of paediatric vitiligo. A survey was designed and approved by the survey committee of the Pediatric Dermatology Research Alliance to be distributed to the members. The study was exempted by the IRB of the Mount Sinai Hospital and posted to an online survey system. A total of 56 dermatologists completed the survey, a majority of whom practiced in the US (n = 44, 78·6%), followed by Mexico (n = 6, 10·7%). Most were board-certified (n = 48, 85·7%). Practitioners reported seeing an average of eight paediatric and adolescent vitiligo patients per month. Providers surveyed reported feeling most comfortable treating older patients 13–17 (n = 48, 85·7%), 9–12 (n = 47, 84%), 5–8 (n = 40, 71·4%), 2–4 years (n = 18, 32·1%), 13–23 months (n = 12, 21·4%), 7–12 months (n = 4, 7·1%), and 0–6 months (n = 1, 1·7%). Among the 8 (14·3%) respondents who used an oral JAK inhibitor, the age of the patients ranged from 4 months to 16 years. Most providers surveyed (n = 50, 89·3%) used an interview with the patient and parents to assess for quality-of-life impairments in children and adolescents. Bloodwork was performed always or usually (n = 25, 44·6%), sometimes (n = 11, 19·6%), and rarely (n = 9, 16·1%). Full thyroid panels (n = 38, 67·8%) and 25-OH vitamin D levels (n = 27, 48·2%) led tests ordered. For children under 8 years with &lt;25% +/− eyelid localization TCI (n = 52, 92·9%; n = 46, 82%), TCS (n = 17, 30·3%; n = 29, 51·7%), Narrow band UVB (NB-UVB, n = 11, 19·6%; n = 5, 8·9%), topical JAK inhibitors (tJAK-i) (n = 6, 10·2%, n = 5, 8·9%), cover-up makeup (n = 7, 11·9%; n = 6, 10·7%), and excimer laser (n = 5, 8·5%; n = 9, 16·1%) were prescribed. For &lt;8 with &gt;25% vitiligo +/− eyelid involvement TCI (n = 48, 85·7%; n = 45, 80·3%), TCS (n = 21, 37·5%; n = 30, 53·6%), excimer laser (n = 8, 85·7%; n = 11, 19·6%), NB-UVB (n = 6, 10·7%; n = 7, 12·5%), and cover-up makeup (n = 7, 11·9%; n = 8, 14·3%) were used. For 8+ with body depigmentation &lt;25% or 25%+, TCI (n = 29, 51·8%, n = 22, 39·3%), TCS Class 1 (n = 24, 42·8%), and NB-UVB (n = 17, 30·4%; n = 31, 55·4%), oral steroids (n = 10, 17·9%; n = 12, 21·4%), tJAK-i (n = 5, 8·9%; n = 16, 28·6%); TCS (n = 13, 23·2%), NB-UVB/home phototherapy units (n = 8, 14·3%; n = 22, 39·2%), oral methotrexate (25%+ only; n = 10, 17·9%), TCS (n = 9, 16·1%), and Class 3 TCS (n = 5, 8·9%). Paediatric segmental vitiligo localized to the face was predominantly treated by TCI (n = 46, 82·1%), excimer laser (n = 14, 25%), and occasional tJAKi (n = 8, 14·3%). Treatments identified for segmental vitiligo of the body included TCS (n = 48, 85·7%), TCI (n = 24, 42·9%), NB-UVB (n = 15, 26·8%), and tJAKi (n = 5, 8·9%). Methodologies for assessing vitiligo improvement were clinical photographs, measurement of lesion size (n = 48 each, 85·7%), subjective patient-reported satisfaction (n = 41, 73·2%) and percent re-pigmentation (n = 34, 60·7%). A total of 94·6% reported occasional to constant frustration due to a lack of treatment options and insurance barriers and always or often experiencing challenges in procuring appropriate therapies for patients, including tJAKi and TCI. Parental phobia of topical corticosteroid in paediatric patients was noted at least occasionally (n = 29, 51·8%) to regularly (n = 10, 17·8%). Topical calcineurin inhibitors are favoured for the youngest patients as well as for segmental vitiligo. Topical steroids and UVB light sources are used for older children with more extensive and body disease. The diverse treatment modalities represented underscore the need for a systemized approach to this disease. Even paediatric dermatologists are uncomfortable with infants and small children with vitiligo and more data are needed for guidance in all children, especially infants and toddlers.