What are the recommended first-line treatments for vitiligo?

First-Line Treatments for Vitiligo

Potent or very potent topical corticosteroids should be considered the first-line treatment for adults with recent onset vitiligo, used for a trial period of no more than 2 months due to risk of skin atrophy. 1

Treatment Algorithm for Vitiligo

Initial Assessment

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

First-Line Treatment Options

1. For adults with recent onset vitiligo:

   • Potent or very potent topical corticosteroids
     • Trial period: Maximum 2 months
     • Efficacy: Studies show 15-25% repigmentation in approximately 43% of patients, with >75% repigmentation in about 9% of patients 1
     • Caution: High risk of skin atrophy (observed in all patients using clobetasol for 8 weeks in one study) 1
     • Monitor for: Skin atrophy, hypertrichosis, acne

2. Alternative first-line options:

   • Topical calcineurin inhibitors (tacrolimus, pimecrolimus)
     • Better safety profile than potent steroids
     • Similar efficacy to topical steroids (41.3% repigmentation with tacrolimus vs 49.3% with clobetasol in children) 2
     • Particularly useful for facial areas and in children 3
     • Twice daily application recommended 3
     • Side effects: Burning sensation in some patients 2

3. No active treatment option:

   • For patients with skin types I and II (pale skin)
   • Focus on cosmetic camouflage and sunscreens
   • Can improve quality of life (DLQI improvement from 7.3 to 5.9) 1

Second-Line Treatment Options

1. Phototherapy:

   • Narrowband UVB (NB-UVB)
     • For patients who cannot be adequately managed with topical treatments
     • For widespread vitiligo or localized vitiligo with significant impact on quality of life
     • Preferred for darker skin types
     • Monitor with serial photographs every 2-3 months
     • NB-UVB preferred over PUVA due to greater efficacy and fewer side effects 1
     • Safety limit: 200 treatments for skin types I-III 1

2. Surgical treatments:

   • Reserved for stable vitiligo (no new lesions, no Koebner phenomenon, no extension for 12 months)
   • Split-skin grafting preferred over minigrafting (better cosmetic results) 1

Important Considerations and Pitfalls

• Treatment duration: Limit topical steroid use to 2 months to prevent skin atrophy
• Combination therapy: Vitamin D analogues can increase effectiveness of topical steroids 3
• Location-specific approaches:
  • Facial areas: Prefer calcineurin inhibitors over steroids due to lower risk of atrophy
  • Sensitive areas (eyelids): Tacrolimus preferred over steroids 2
• Monitoring: Use serial photographs to track treatment response 1
• Depigmentation option: For severely affected patients (>50% depigmentation), depigmentation with monobenzyl ether of hydroquinone may be considered rather than repigmentation 1

Special Populations

• Children:
  • Topical calcineurin inhibitors preferred due to better safety profile 1, 2
  • Tacrolimus 0.1% nearly as effective as clobetasol 0.05% without causing atrophy 2
  • NB-UVB can be considered for widespread disease not responding to topicals 1

The evidence for vitiligo treatment is limited by small studies and methodological issues, but topical corticosteroids remain the mainstay of first-line therapy despite their side effect profile. Calcineurin inhibitors offer a safer alternative with comparable efficacy, particularly for sensitive areas and in children.