What are the treatment options for vitiligo?

Treatment Options for Vitiligo

Topical corticosteroids and calcineurin inhibitors are the first-line treatments for vitiligo, followed by phototherapy for those with widespread disease or who fail to respond to topical treatments. 1

First-Line Treatment Options

Topical Treatments

1. Potent or Very Potent Topical Corticosteroids

   • Recommended for recent-onset vitiligo in adults and children
   • Trial period should be limited to 2 months maximum
   • Application: Twice daily for 10 days, then once daily for 10 days
   • Efficacy: Can achieve repigmentation but only in a small proportion of cases (15-25% repigmentation in some patients, >75% in fewer patients)
   • Caution: Skin atrophy is a common side effect with prolonged use 1

2. Topical Calcineurin Inhibitors (Pimecrolimus/Tacrolimus)

   • Preferred alternative to topical steroids, especially in children
   • Better safety profile than potent topical steroids
   • Fewer side effects (no skin atrophy)
   • Should be considered particularly for sensitive areas like face and neck 1, 2

3. Cosmetic Options

   • Sunscreens with high SPF to prevent burning of depigmented areas
   • Cosmetic camouflage can improve quality of life (DLQI improvement from 7.3 to 5.9)
   • Self-tanning products 1

Second-Line Treatment Options

Phototherapy

1. Narrowband UVB (NB-UVB)

   • Indicated for:
     • Patients who cannot be adequately managed with topical treatments
     • Widespread vitiligo
     • Localized vitiligo with significant impact on quality of life
   • More effective than PUVA (psoralen with UVA) with fewer side effects
   • Better suited for patients with darker skin types
   • Safety limit: Maximum 200 treatments for skin types I-III
   • Monitoring: Serial photographs every 2-3 months 1, 3

2. PUVA (Psoralen + UVA)

   • Less preferred than NB-UVB due to higher side effect profile
   • Side effects include nausea and erythema
   • Safety limit: Maximum 150 treatments for skin types I-III 1, 3

Surgical Options

1. Split-Skin Grafting

   • Best cosmetic and repigmentation results among surgical options
   • Utilizes widely available surgical facilities 1

2. Autologous Epidermal Suspension

   • Applied to laser-abraded lesions
   • Followed by NB-UVB or PUVA therapy
   • Considered optimal surgical transplantation procedure but requires specialized facilities 1

3. Cultured Melanocyte Transplantation

   • Can treat larger areas without additional phototherapy
   • Requires specialized laboratory facilities 1

Other Treatments

1. Depigmentation

   • Reserved for severely affected patients (>50% depigmentation)
   • Using p-(benzyloxy)phenol (monobenzyl ether of hydroquinone)
   • For patients who cannot or choose not to seek repigmentation
   • Patient must accept permanent inability to tan 1

2. Systemic Therapy

   • Oral corticosteroids are not recommended due to unacceptable risk of side effects
   • Ginkgo biloba has shown some efficacy in clinical trials 1, 3

3. Combination Therapies

   • Generally more effective than monotherapies
   • Examples with proven efficacy:
     • Calcipotriol plus PUVA
     • Hydrocortisone-17-butyrate plus excimer laser
     • Oral minipulse prednisolone plus NB-UVB 3

Treatment Algorithm

1. Initial Assessment

   • Confirm diagnosis (Wood's lamp examination may be helpful)
   • Check thyroid function due to high prevalence of autoimmune thyroid disease
   • Assess skin type, extent of disease, and psychological impact 1

2. Treatment Selection Based on Disease Characteristics:

   • For limited/early disease:

     • Start with topical corticosteroids or calcineurin inhibitors
     • Trial for 2 months, then reassess

   • For widespread disease or topical treatment failures:

     • Proceed to phototherapy (preferably NB-UVB)
     • Monitor with serial photographs every 2-3 months

   • For stable lesions (no progression for 12 months) in cosmetically sensitive areas:

     • Consider surgical options

   • For extensive vitiligo (>50% body surface area):

     • Consider depigmentation therapy if repigmentation treatments have failed 1, 2

3. Special Considerations:

   • For children: Prefer calcineurin inhibitors over potent steroids; offer psychological support
   • For fair-skinned patients (types I-II): Consider no active treatment beyond sunscreens and camouflage
   • For darker skin types: More aggressive treatment may be warranted due to greater psychological impact 1

Monitoring and Follow-up

• Use serial photographs to monitor treatment response
• Assess for side effects, particularly with topical steroids (skin atrophy) and phototherapy
• Consider psychological interventions to improve coping mechanisms 1

Important Caveats

• No treatment can cure vitiligo; the goal is repigmentation or halting progression
• Treatment response is typically better in:
  • Younger patients
  • Recent-onset disease (<1 year)
  • Lesions on face and neck 4
• Most studies show limited efficacy of available treatments
• Long-term follow-up studies on permanence of repigmentation are lacking 3
• Psychological impact should be addressed alongside physical treatments 1