What are the treatment options for Vitiligo?

Treatment Options for Vitiligo

Topical treatments, particularly potent corticosteroids and calcineurin inhibitors, should be considered as first-line therapy for vitiligo, with phototherapy reserved for cases that cannot be adequately managed with topical treatments. 1

Diagnosis and Initial Assessment

• Classical vitiligo can be diagnosed in primary care, but atypical presentations require dermatologist assessment 1
• Check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients 1
• For patients with skin types I and II (very fair skin), consider whether no active treatment other than camouflage cosmetics and sunscreens may be appropriate 1

Treatment Algorithm

First-Line Therapy: Topical Treatments

1. Topical Corticosteroids

   • For recent onset vitiligo in adults, use potent or very potent topical steroid for a trial period of no more than 2 months 1
   • Monitor carefully as skin atrophy is a common side effect 1
   • Limited to moderate evidence shows benefit compared to placebo 2

2. Topical Calcineurin Inhibitors (Pimecrolimus/Tacrolimus)

   • Consider as alternatives to potent topical steroids due to better short-term safety profile 1
   • Particularly useful for facial areas and in children 3
   • Studies show comparable efficacy to topical corticosteroids but with fewer adverse events 3, 4
   • Pimecrolimus 1% has shown similar efficacy to clobetasol propionate 0.05% in repigmentation 4

Second-Line Therapy: Phototherapy

For patients who cannot be adequately managed with topical treatments, have widespread vitiligo, or localized vitiligo with significant impact on quality of life:

1. Narrowband UVB (NB-UVB)

   • Preferred over PUVA due to greater efficacy and better safety profile 1
   • Ideally reserved for patients with darker skin types 1
   • Monitor with serial photographs every 2-3 months 1
   • Safety limit: maximum of 200 treatments for skin types I-III 1

2. PUVA (Psoralen + UVA)

   • Less commonly used since the advent of NB-UVB 3
   • Topical PUVA may be effective for localized vitiligo 3
   • Safety limit: maximum of 150 treatments for skin types I-III 1

3. Excimer Laser

   • As effective as NB-UVB for localized vitiligo 3
   • Combination therapies with NB-UVB show greater effectiveness 3

Third-Line Therapy: Surgical Treatments

Reserved for cosmetically sensitive sites where there have been:

• No new lesions
• No Koebner phenomenon (development of lesions at sites of trauma)
• No extension of lesions in the previous 12 months 1

Options include:

1. Split-skin grafting - Best cosmetic results but can cause scarring of donor and recipient sites 1, 3
2. Autologous epidermal suspension applied to laser-abraded lesions (optimal but requires special facilities) 1
3. Suction blister transfer - Shows benefit over placebo but less coverage than other methods 1

For Extensive Vitiligo (>50% depigmentation)

Depigmentation therapy with p-(benzyloxy)phenol (monobenzyl ether of hydroquinone) may be considered for patients who:

• Have extensive depigmentation (>50% or extensive on face/hands)
• Cannot or choose not to seek repigmentation
• Can accept permanent inability to tan 1

Special Considerations

For Children

• Topical pimecrolimus or tacrolimus preferred over potent steroids due to better safety profile 1
• NB-UVB can be used in children who cannot be adequately managed with topical treatments 1
• Surgical treatments are not recommended in children due to lack of studies 1

Psychological Support

• Psychological interventions should be offered to improve coping mechanisms 1
• Parents of children with vitiligo should be offered psychological counseling 1

Treatment Limitations and Caveats

• Repigmentation rates are often incomplete with single-agent therapy; combined approaches may be more effective 5
• Topical corticosteroids at doses of 50g or less per week for 12 weeks appear safe but local side effects are possible 5
• Response to treatment varies by anatomical location, with better results typically seen on trunk and extremities 4
• Systemic oral dexamethasone to arrest progression is not recommended due to unacceptable risk of side effects 1
• Most studies on vitiligo treatments are poorly designed with limited follow-up, making long-term efficacy difficult to assess 2