What are the treatment options for vitiligo?

Treatment Options for Vitiligo

For vitiligo treatment, a combination of topical corticosteroids plus narrowband UVB phototherapy is superior to either treatment alone, with combination therapy achieving successful repigmentation in approximately 27% of cases. 1

First-Line Treatments

Topical Therapies

• Potent or very potent topical corticosteroids:

  • Recommended as first-line therapy 2
  • Efficacy: Up to 80% repigmentation in facial lesions and 40% in other body areas
  • Application: Twice daily on alternate weeks for no more than 2 months initially
  • Monitoring: Regular checks for skin atrophy (common side effect)
  • Example: 0.05% clobetasol propionate 3

• Topical calcineurin inhibitors (pimecrolimus/tacrolimus):

  • Preferred for facial areas and in children due to better safety profile 2
  • Comparable efficacy to topical corticosteroids with fewer side effects
  • Studies show 1% pimecrolimus is as effective as clobetasol propionate 3

Second-Line and Combination Treatments

Phototherapy Options

• Narrowband UVB (NB-UVB):

  • Preferred over PUVA due to greater efficacy and better safety profile 2
  • Safety limit: Maximum of 200 treatments for skin types I-III
  • Best results in patients with darker skin types
  • Home-based NB-UVB treatment is a viable option 1

• PUVA:

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

Effective Combinations

1. Topical corticosteroids + NB-UVB:

   • Superior to topical corticosteroids alone (27% vs 17% success rate) 1
   • Number needed to treat: 10 patients

2. Calcipotriene (vitamin D analog) + topical corticosteroids:

   • 95% repigmentation in 83% of patients 4
   • Effective even in patients who failed corticosteroid monotherapy
   • Best results on eyelid and facial skin

3. L-phenylalanine (oral and topical) + clobetasol + UVA/sunlight:

   • 90.9% of patients showed improvement, with 68.5% achieving ≥75% repigmentation 5
   • Most effective on face (87.9% achieved ≥75% improvement)
   • Less effective for focal and segmental vitiligo

Treatment Algorithm

1. For limited areas (<20% body surface area):

   • Start with potent topical corticosteroids or calcineurin inhibitors for 2 months 2
   • For facial areas: Prefer calcineurin inhibitors to avoid skin atrophy
   • For body: Use potent corticosteroids on alternate weeks

2. If inadequate response after 2 months:

   • Add NB-UVB phototherapy to topical treatment 1
   • Monitor every 2-3 months using serial photographs 2

3. For extensive or rapidly progressing disease:

   • Consider systemic therapies 2
   • NB-UVB phototherapy combined with topical agents

4. For very fair skin (types I-II):

   • Consider camouflage cosmetics and sunscreens instead of active treatment 2

Surgical Options (for stable vitiligo)

• Split-skin grafting (better cosmetic results than minigrafts)
• Autologous epidermal suspension applied to laser-abraded lesions
• Suction blister transfer (less coverage than other surgical methods) 2

Important Clinical Considerations

Treatment Response by Location

• Face: Excellent response (highest repigmentation rates)
• Trunk and extremities: Good response
• Hands and feet: Poor response 3, 6

Treatment Adherence and Relapse

• Patients adhering to >75% of treatment protocol are more likely to achieve success 2
• Over 40% of patients lose treatment response after 1 year without treatment 1

Side Effects to Monitor

• Topical corticosteroids: Skin atrophy (avoid prolonged use)
• NB-UVB: Grade 3-4 erythema (occurs in approximately 12% of patients) 1

Special Populations

• Children: Prefer calcineurin inhibitors and avoid PUVA 2
• Patients with thyroid disease: Check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients 2

Remember that treatment success is modest even with optimal therapy, with combination treatments achieving success in only about one-quarter of patients 1. Psychological support should be offered alongside medical treatment to improve coping mechanisms 2.