Are there internal treatments available for vitiligo?

Internal Treatments for Vitiligo

Yes, there are several internal (systemic) treatments available for vitiligo, though they are typically reserved for specific cases such as rapidly progressing or extensive disease that hasn't responded to topical therapies. 1, 2

First-Line Approaches

Before considering systemic therapies, it's important to understand the treatment hierarchy:

1. Topical therapies are the first-line treatment:
   • Potent or very potent topical corticosteroids (for no more than 2 months)
   • Topical calcineurin inhibitors (pimecrolimus/tacrolimus) for facial areas and in children
   • Combination with phototherapy often yields better results 1, 2

Available Systemic (Internal) Treatments

Oral Corticosteroids

• Oral mini-pulse therapy with betamethasone/dexamethasone can arrest disease progression in 89% of patients with extensive or rapidly spreading vitiligo 3
  • Typical regimen: 5 mg betamethasone as a single oral dose after breakfast on 2 consecutive days per week
  • Can induce spontaneous repigmentation within 2-4 months in 80% of patients
  • Side effects include weight gain, headache, and general weakness

Other Systemic Options

• Oral dexamethasone is generally not recommended due to unacceptable risk of side effects 1, 2
• Azathioprine with PUVA shows significantly better repigmentation (>75%) compared to PUVA alone 4
• Oral minipulse of prednisolone (OMP) plus NB-UVB is more effective than OMP alone 4
• Ginkgo biloba has shown better results than placebo in controlled studies 4

When to Consider Systemic Therapy

Systemic treatments should be considered when:

• The disease is rapidly progressing
• There is extensive involvement (>10% body surface area)
• Topical treatments and phototherapy have failed
• The disease significantly impacts quality of life 5

Phototherapy Options

While not strictly "internal," phototherapy is a systemic approach:

• Narrowband UVB (NB-UVB) is preferred over PUVA due to greater efficacy and better safety profile
• Safety limit: maximum of 200 treatments for skin types I-III
• Best for patients with darker skin types 1, 2

Emerging Treatments

• JAK inhibitors: Topical ruxolitinib cream has been recently approved in the US and Europe, and oral JAK inhibitors are being studied 6
• Combination therapies generally show better results than monotherapies 4

Important Considerations

• Treatment should focus on repigmentation or stabilizing progression rather than depigmentation 5
• Maintenance therapy may help reduce the risk of disease relapse 5
• Psychological interventions should be offered to improve coping mechanisms 1, 2
• Monitor disease progression with serial photographs every 2-3 months 2

Caution

• Systemic corticosteroids can cause significant side effects and should be used judiciously
• Long-term use of oral immunosuppressants requires monitoring for potential adverse effects
• Treatment response varies by anatomical location, with extremities often showing better results than hands and feet 2

Internal treatments for vitiligo exist and can be effective, particularly for extensive or rapidly progressing disease, but should be considered after topical options have been tried or alongside them as part of a comprehensive treatment plan.