What are the treatment options for vitiligo?

Treatment Options for Vitiligo

The treatment of vitiligo should follow a stepwise approach, with topical therapies as first-line treatment, followed by phototherapy for widespread disease, and surgical options for stable localized disease that has not responded to other treatments. 1

Initial Assessment and Management

• Diagnosis: Classical vitiligo can be diagnosed in primary care, but atypical presentations require dermatologist assessment 1
• Laboratory testing: Check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients 1
• No treatment option: For patients with skin types I and II (very fair skin), consider no active treatment beyond camouflage cosmetics and sunscreens, especially if the condition causes minimal psychological distress 1

First-Line Treatments

Topical Therapies

1. Topical Corticosteroids:

   • Potent or very potent topical steroids for recent-onset vitiligo
   • Trial period should not exceed 2 months due to risk of skin atrophy
   • Efficacy: Only a small proportion of patients achieve significant repigmentation 1
   • Major limitation: High incidence of skin atrophy and other side effects like hypertrichosis and acne 1

2. Topical Calcineurin Inhibitors (pimecrolimus, tacrolimus):

   • Preferred for facial areas and in children
   • Better safety profile than potent topical steroids
   • Similar efficacy to topical steroids but fewer adverse events 1, 2
   • Most effective when used twice daily 2

3. Vitamin D Analogues:

   • Less effective as monotherapy compared to topical steroids
   • Can increase effectiveness when used in combination with topical steroids 2

Second-Line Treatments

Phototherapy

1. Narrowband UVB (NB-UVB):

   • Indicated for patients who:
     • Cannot be adequately managed with topical treatments
     • Have widespread vitiligo
     • Have localized vitiligo with significant impact on quality of life 1
   • Preferred for patients with darker skin types
   • Should be monitored with serial photographs every 2-3 months
   • Superior to oral PUVA in terms of efficacy and safety 1
   • Safety limit: Maximum of 200 treatments for skin types I-III 1

2. PUVA (Psoralen + UVA):

   • Less preferred than NB-UVB due to greater side effects
   • Safety limit: Maximum of 150 treatments for skin types I-III 1

3. Excimer Laser:

   • As effective as NB-UVB
   • Particularly useful for localized vitiligo 2
   • Combination with NB-UVB may enhance effectiveness 2

Third-Line Treatments

Surgical Options

Candidate selection is crucial: Only for patients with stable disease (no new lesions, no Koebner phenomenon, and no extension of lesions in the previous 12 months) 1

1. Split-Skin Grafting:

   • Best cosmetic and repigmentation results
   • Uses readily available surgical facilities
   • Limitation: Scarring of donor and recipient sites 1, 2

2. Autologous Epidermal Suspension:

   • Applied to laser-abraded lesions
   • Followed by NB-UVB or PUVA therapy
   • Requires special facilities 1

3. Suction Blister Transfer:

   • Alternative transplantation method
   • Less effective coverage than split-skin grafting 1

4. Punch Grafting:

   • Not recommended due to high incidence of side effects and poor cosmetic results 1

Depigmentation Therapy

Reserved for patients with extensive vitiligo (>50% depigmentation) who cannot or choose not to seek repigmentation 1

• Monobenzyl Ether of Hydroquinone (MBEH):
  • Produces faster visible depigmentation
  • Greater side effect profile
  • Permanent effect - patients must accept never tanning 1, 2

Psychological Support

• Psychological interventions should be offered to improve coping mechanisms 1
• Cosmetic camouflage can significantly improve quality of life 1

Common Pitfalls and Caveats

1. Treatment expectations: Inform patients that complete repigmentation is rare, and treatment may take months to show results
2. Steroid overuse: Limit topical steroid use to 2 months to prevent skin atrophy
3. Patient selection for surgery: Surgical treatments will likely fail in patients with unstable disease
4. Phototherapy limits: Adhere to maximum treatment numbers to reduce risk of skin cancer
5. Depigmentation permanence: Ensure patients understand that depigmentation is permanent before proceeding

Treatment Algorithm

1. Localized vitiligo:

   • First: Topical steroids (2-month trial) or calcineurin inhibitors (preferred for face)
   • Second: Targeted phototherapy (excimer)
   • Third: Surgical options (if stable for 12 months)

2. Widespread vitiligo:

   • First: Topical therapies for selected areas
   • Second: NB-UVB phototherapy
   • Third: Consider depigmentation if >50% affected and other treatments fail

3. Vitiligo in children:

   • First: Topical calcineurin inhibitors (safer profile)
   • Second: NB-UVB (if necessary)
   • Avoid: Surgical treatments