What are the treatment options for vitiligo?

Treatment Options for Vitiligo

The first-line treatment for vitiligo consists of potent or very potent topical corticosteroids and topical calcineurin inhibitors, with combination phototherapy often yielding better results. 1

First-Line Topical Therapies

Topical Corticosteroids

• Potent or very potent topical corticosteroids are recommended as first-line therapy with efficacy of up to 80% repigmentation in facial lesions and 40% in other body areas 1
• Application should be twice daily on alternate weeks for no more than 2 months initially
• Monitor closely for skin atrophy, which is a common side effect 1
• Studies show topical corticosteroids perform better than placebo and topical PUVAsol in repigmenting vitiliginous skin 2

Topical Calcineurin Inhibitors

• Pimecrolimus/tacrolimus are preferred for facial areas and in children due to better safety profile 1
• Comparable efficacy to topical corticosteroids with fewer side effects 1
• More effective when applied twice daily 2
• Studies indicate that 1% pimecrolimus is as effective as clobetasol propionate in treating vitiligo 3

Combination Therapy

• Vitamin D analogues (calcipotriene) combined with topical corticosteroids can increase effectiveness 2
• This combination has shown 95% repigmentation in some patients who previously failed corticosteroid monotherapy 4

Phototherapy Options

Narrowband UVB (NB-UVB)

• Preferred over PUVA due to greater efficacy and better safety profile 1
• Safety limit: maximum of 200 treatments for skin types I-III
• Particularly effective for patients with darker skin types 1
• Can be used in children due to fewer side effects 2

PUVA (Psoralen + UVA)

• Safety limit: maximum of 150 treatments for skin types I-III
• Not recommended for children 1
• Less commonly used for generalized vitiligo since the advent of NB-UVB 2
• Topical PUVA may be effective for localized vitiligo 2

Excimer Laser

• As effective as NB-UVB and useful for localized vitiligo 2
• Combination therapies with NB-UVB show greater effectiveness in repigmentation 2

Surgical Therapies

For stable, localized vitiligo that is refractory to other treatments:

1. Split-skin grafting

   • Best cosmetic results among surgical options
   • Caution: scarring of donor and recipient sites is possible 1, 2

2. Autologous epidermal suspension

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

3. Suction blister transfer

   • Alternative method with benefit over placebo
   • Less coverage than split-skin grafting or laser and cell suspension 1

Systemic Therapies

Consider systemic therapies when:

• Disease is rapidly progressing
• There is extensive involvement
• Topical treatments and phototherapy have failed
• Disease significantly impacts quality of life 1

Oral dexamethasone is generally not recommended due to unacceptable risk of side effects 1

Depigmentation Therapy

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

• p-(benzyloxy)phenol (MBEH) can be considered
• Patients must accept permanent inability to tan
• Provides more rapid depigmentation but has greater side effect profile compared to alternatives 1

Special Considerations

Treatment Selection Based on Skin Type

• For very fair skin (types I-II), consider no active treatment other than camouflage cosmetics and sunscreens 1

Anatomical Considerations

• Treatment response varies by location:
  • Face: Better response to topical treatments
  • Trunk and extremities: Better surgical outcomes
  • Hands and feet: Generally more resistant to treatment 1, 2

Monitoring and Follow-up

• Monitor patients every 2-3 months using serial photographs
• Check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients 1
• Relapse is common (>40% after 1 year without treatment) 1

Common Pitfalls to Avoid

• Prolonged use of potent corticosteroids (risk of skin atrophy)
• Neglecting psychological support (counseling should be offered)
• Poor treatment adherence (patients who adhere to >75% of protocol have better outcomes) 1
• Failure to consider maintenance therapy to reduce relapse risk 1