What are the treatment options for vitiligo?

Treatment Options for Vitiligo

The most effective treatment approach for vitiligo involves topical corticosteroids as first-line therapy, with narrowband UVB (NB-UVB) phototherapy or topical calcineurin inhibitors as alternatives, depending on patient characteristics and disease presentation. 1

Initial Assessment and Treatment Selection

• For very fair skin (types I-II): Consider whether no active treatment other than camouflage cosmetics and sunscreens may be appropriate 2, 1
• Check thyroid function: Due to high prevalence of autoimmune thyroid disease in vitiligo patients 1

Topical Treatments

First-Line Options:

1. Potent or very potent topical corticosteroids

   • Trial period: No more than 2 months 2, 1
   • Application: Twice daily on alternate weeks 3
   • Efficacy: Up to 80% repigmentation in facial lesions and 40% in other body areas 4
   • Caution: Monitor for skin atrophy, which is a common side effect 2, 1

2. Topical calcineurin inhibitors (pimecrolimus/tacrolimus)

   • Preferred for facial areas and in children due to better safety profile 1, 5
   • Application: Twice daily dosing is more effective 5
   • Comparable efficacy to topical corticosteroids with fewer side effects 6, 5

3. Combination therapy

   • Topical corticosteroids plus calcipotriene (vitamin D analog)
     • Can achieve repigmentation even in patients who failed corticosteroid monotherapy 7
     • Application: Corticosteroids in morning, calcipotriene in evening 7

Phototherapy Options

For Widespread Vitiligo:

1. Narrowband UVB (NB-UVB)

   • Preferred over PUVA due to greater efficacy and better safety profile 2, 1
   • Best for patients with darker skin types 2, 1
   • Safety limit: Maximum of 200 treatments for skin types I-III 2, 1
   • Monitor with serial photographs every 2-3 months 2
   • Can be used in children who don't respond to topical treatments 1

2. Home-based NB-UVB

   • Can be combined with topical corticosteroids for enhanced efficacy 3
   • Combination treatment showed 27% success rate vs. 17% for topical corticosteroids alone 3

3. PUVA (less preferred)

   • Safety limit: Maximum of 150 treatments for skin types I-III 2
   • Not recommended for children 2

Surgical Treatments

Reserved for stable vitiligo (no new lesions or progression for at least 12 months) on cosmetically sensitive sites 2, 1

1. Split-skin grafting

   • Better cosmetic results than minigraft procedures 2
   • Caution: Can cause scarring of donor and recipient sites 1

2. Autologous epidermal suspension

   • Applied to laser-abraded lesions followed by NB-UVB or PUVA 2
   • Requires special facilities 2, 1

3. Suction blister transfer

   • Alternative method with benefit over placebo 2
   • Less coverage than split-skin grafting or laser and cell suspension 2

Depigmentation Therapy

For extensive vitiligo (>50% depigmentation or extensive on face/hands) 2, 1

• p-(benzyloxy)phenol (MBEH)
  • Patients must accept permanent inability to tan 2, 1
  • More rapid depigmentation but greater side effect profile compared to alternatives 5

Treatment Pitfalls and Considerations

• Avoid systemic oral dexamethasone due to unacceptable risk of side effects 2, 1
• Minigraft procedures are not recommended due to high incidence of side effects and poor cosmetic results 2
• Surgical treatments are not recommended in children due to lack of studies 1
• Treatment response varies by anatomical location - trunk and extremities often show better results than hands and feet 6
• Treatment adherence is crucial - patients who adhere to >75% of treatment protocol are more likely to achieve success 3
• Relapse is common - over 40% of patients lose treatment response after 1 year without treatment 3

Psychological Support

• Psychological interventions should be offered to improve coping mechanisms 2, 1
• Parents of children with vitiligo should be offered psychological counseling 2, 1