What are the recommended first-line treatments for vitiligo?

First-Line Treatments for Vitiligo

Potent or very potent topical corticosteroids are the recommended first-line treatment for vitiligo, used for a trial period of no more than 2 months due to potential side effects like skin atrophy. 1

Treatment Algorithm for Vitiligo

Initial Assessment

• Confirm diagnosis (classical symmetrical vitiligo can be diagnosed in primary care; atypical presentations require dermatologist referral)
• Check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients
• Assess skin type and document extent with photographs (consider Wood's light examination)

First-Line Treatment Options

1. For patients with skin types I and II (very fair skin):

   • Consider no active treatment approach with camouflage cosmetics and sunscreens
   • This is appropriate when vitiligo causes minimal cosmetic concern

2. For patients with recent onset vitiligo:

   • Topical corticosteroids (potent or very potent):

     • Trial period: maximum 2 months
     • Monitor for skin atrophy, which is a common side effect
     • Studies show variable repigmentation rates (15-100%) but generally modest results when used alone 1

   • Topical calcineurin inhibitors (pimecrolimus or tacrolimus):

     • Alternative to topical steroids with better safety profile
     • Particularly useful for facial areas and in children
     • Comparable efficacy to topical steroids but fewer adverse effects 1, 2
     • In children, tacrolimus 0.1% showed 41.3% repigmentation compared to 49.3% with clobetasol 0.05%, but without the atrophy and telangiectasia seen with steroids 3

Second-Line Treatment Options

1. Phototherapy:

   • Narrowband UVB (NB-UVB) for patients with:
     • Widespread vitiligo
     • Localized vitiligo with significant impact on quality of life
     • Failure to respond to topical treatments
   • NB-UVB is preferred over PUVA due to greater efficacy and better safety profile 1
   • Best reserved for patients with darker skin types
   • Monitor with serial photographs every 2-3 months

2. Combination therapies:

   • Topical corticosteroids combined with UVA showed better results (31% repigmentation) than either treatment alone (9% for steroid, 8% for UVA) 1
   • Vitamin D analogues can increase effectiveness of topical steroids when used in combination 2

Surgical Options (for stable vitiligo only)

Reserved for cosmetically sensitive sites where there have been:

• No new lesions
• No Koebner phenomenon
• No extension of lesions in the previous 12 months

Split-skin grafting provides better cosmetic results than minigraft procedures 1

Important Caveats and Considerations

1. Treatment expectations:

   • Complete repigmentation is rare
   • Facial and neck areas respond better than hands and feet
   • Longer disease duration correlates with poorer response

2. Monitoring:

   • Serial photographs to document treatment response
   • Limit topical steroid use to 2 months to prevent atrophy
   • For NB-UVB, limit to 200 treatments for skin types I-III due to increased photodamage risk in vitiligo skin

3. Special populations:

   • In children: consider topical calcineurin inhibitors first due to better safety profile
   • For facial areas: prefer calcineurin inhibitors to avoid steroid-induced atrophy

4. Quality of life impact:

   • Vitiligo significantly impacts quality of life, especially in those with darker skin types
   • Cosmetic camouflage can improve quality of life scores (DLQI improvement from 7.3 to 5.9) 1

5. Systemic therapy considerations:

   • Oral corticosteroids are not recommended for routine use due to unacceptable risk of side effects 1
   • However, low-dose oral prednisolone (0.3 mg/kg) may be effective in arresting disease progression in rapidly spreading vitiligo 4

Despite multiple therapeutic options, there is currently no fully effective treatment for vitiligo, and research continues into new therapeutic approaches 5.