What are the treatment options for vitiligo?

Treatment Options for Vitiligo

Topical corticosteroids and calcineurin inhibitors are the first-line treatments for vitiligo, with narrowband UVB phototherapy recommended for widespread disease or when topical treatments fail. 1

First-Line Treatment Options

Topical Treatments

1. Potent or Very Potent Topical Corticosteroids

   • Recommended for recent-onset vitiligo
   • Trial period should not exceed 2 months
   • Significant side effect: skin atrophy is common 1
   • Better results seen in:
     • Young patients
     • Lesions less than 1 year old
     • Facial and neck lesions 2

2. Topical Calcineurin Inhibitors (Pimecrolimus/Tacrolimus)

   • Recommended as alternatives to topical steroids
   • Better short-term safety profile than potent steroids 1
   • Comparable efficacy to clobetasol propionate in repigmentation 3
   • Particularly effective for facial lesions 4

Treatment Algorithm for Localized Vitiligo (<20% body surface area)

• First choice: 2-month trial of potent/very potent topical corticosteroid OR topical calcineurin inhibitor 1, 4

  • Apply twice daily for localized lesions
  • Monitor for skin atrophy with corticosteroids
  • Consider calcineurin inhibitors for sensitive areas (face, genitals, skin folds)

• If inadequate response: Consider combination therapy

  • Morning application of topical corticosteroid + evening application of calcipotriene (vitamin D analog)
  • This combination has shown 95% repigmentation in patients who previously failed corticosteroid monotherapy 5

Second-Line Treatment Options

Phototherapy

• Narrowband UVB (NB-UVB)
  • Recommended when:
    • Conservative treatments fail
    • Vitiligo is widespread
    • Localized vitiligo has significant impact on quality of life 1
  • Particularly effective for darker skin types
  • Should be monitored with serial photographs every 2-3 months
  • NB-UVB is preferred over PUVA due to greater efficacy 1
  • Safety limit: 200 treatments for skin types I-III 1

Combination Approaches

• Phototherapy + Topical Agents
  • NB-UVB or excimer laser combined with topical treatments shows enhanced efficacy 4
  • Tacrolimus is particularly effective when combined with excimer laser 4
  • Pimecrolimus shows good results with NB-UVB and excimer laser for facial lesions 4

Third-Line Treatment Options

Surgical Treatments

• Reserved for stable vitiligo (no new lesions, no Koebner phenomenon, no extension for 12 months) 1
• Best options:
  • Split-skin grafting (better results than minigrafts) 1
  • Autologous epidermal suspension applied to laser-abraded lesions 1
  • Suction blister transfer (alternative method) 1

Depigmentation Therapy

• For extensive vitiligo (>50% depigmentation or extensive facial/hand involvement)
• Monobenzyl ether of hydroquinone (MBEH) can be used
• Only for patients who cannot or choose not to seek repigmentation 1
• Patients must accept permanent inability to tan 1

Special Considerations

Psychological Support

• Psychological interventions should be offered to improve coping mechanisms 1
• Vitiligo can significantly impact quality of life, causing social anxiety, depression, and stigmatization 1

No Treatment Option

• For patients with skin types I and II (very fair skin), consider no active treatment
• Camouflage cosmetics and sunscreens may be sufficient 1

Monitoring

• Check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients 1
• Use serial photographs to monitor treatment response 1

Common Pitfalls to Avoid

1. Prolonged use of potent topical steroids - Limit to 2 months to prevent skin atrophy
2. Neglecting psychological impact - Always address quality of life concerns
3. Treating unstable vitiligo surgically - Surgical options should only be considered for stable disease
4. Unrealistic expectations - Inform patients that complete repigmentation is not always achievable
5. One-size-fits-all approach - Treatment response varies by anatomical location, with face and neck responding best 2