The domain of dermatology is as much an art as it is a science, where practitioners follow a recipe without always having precise measurements or proportions.

Recently, the JAK inhibitor Ruxolitinib, commercially known as Opzelura, has taken center stage in vitiligo treatment due to its promising safety and efficacy profile. Some dermatologists opt to use it first on the face or difficult-to-treat areas like the genitals, areola, or ventral breast. However, the drug comes with a black-box warning, necessitating open patient-doctor discussion about potential risks.

Yet, the availability of this new-age medication hinges on insurance stipulations. Patients may need to trial run a topical calcineurin inhibitor or a topical steroid before being granted access to this innovative and pricey drug.

A challenging aspect of this treatment is the calculation of maximum body surface area (BSA) involvement. Topical ruxolitinib is approved for up to 10% of BSA for vitiligo treatment, with usage beyond this limit considered "off-label".

To estimate BSA, the palm's surface area is commonly used, representing roughly 0.5-1% of total BSA based on factors like age, sex, and body size. The arithmetic for vitiligo becomes complicated when combining the commonly exposed areas like face, neck, hands, wrists, and elbows, which can quickly account for 7% of BSA, leaving a slim margin for other affected areas.

Interestingly, for atopic dermatitis, another condition treated with ruxolitinib cream, the BSA indication for Opzelura extends to 20%. Given the relative safety of topical JAK inhibitors, some dermatologists are willing to extend usage slightly beyond the 10% BSA guideline for vitiligo patients.

In cases of extensive vitiligo, especially on the trunk and follicularly rich areas, dermatologists often turn to a composite therapeutic strategy. For example, Seemal Desai, MD, alternates between clobetasol and tacrolimus every two weeks.

Navigating the intricate landscape of dermatology resembles a journey through a sophisticated maze, where every explorer requires a map. For a guided expedition through this intricate terrain, consult Vitiligo Patient Journey Map.