26966 Tofacitinib treats unresponsive vitiligo and elevated thyroid peroxidase antibodies

A 56-year-old female presented with expanding vitiligo to 35% total body surface area (TBSA) despite treatment with alpha lipoic acid, vitamin C, vitamin E, polypodium leucotomus, topical pimecrolimus, narrowband ultraviolet B, and excimer laser for 2 months. Past medical history was pertinent for Hashimoto thyroiditis treated with levothyroxine with normal levels of thyroid stimulating hormone (TSH) and free thyroxine (FT4), psoriatic arthritis, alopecia, and localized psoriasis on the elbows. Notably, lab tests confirmed normal levels of serum TSH and FT4 but elevated thyroid peroxidase antibodies (TPO) of 795 and elevated thyroglobulin antibodies (TG) of 3. Her endocrinologist denied necessity of treating patients for elevated TPO but stated that patients were only treated with increased dosages of levothyroxine. Because of reported case reports of success in treating vitiligo and FDA-approval for psoriatic arthritis, tofacitinib 5 mg (Tofa) twice daily (BID) was added to the treatment regimen. Serum levels of TPO and TG normalized within 1 month, with simultaneous improvement in vitiligo. Because of gastrointestinal side effects after BID dosing for 5 months, Tofa was decreased to once daily, with continued vitiligo repigmentation. By then, vitiligo had decreased to 12% TBSA, with accompanying improvement in alopecia, psoriatic arthritis, and psoriasis. This case suggests that unstable vitiligo may be associated with elevated TPO and TG, because of a disregard of endocrinologists to treat elevated antibodies, and should be tested in patients with unresponsive vitiligo. Tofacitinib may ameliorate vitiligo not only as a Janus kinase inhibitor but also through an effect on TPO and TG.