What are the treatment guidelines for non-segmental vitiligo?

Treatment Guidelines for Non-Segmental Vitiligo

Narrowband UVB (NB-UVB) phototherapy should be used in preference to PUVA for treating non-segmental vitiligo when phototherapy is indicated, due to its greater efficacy and better safety profile. 1

First-Line Therapies

Topical Treatments

• Potent or very potent topical corticosteroids

  • Recommended as first-line therapy 2, 1
  • Application: Twice daily on alternate weeks for a maximum trial period of 2 months 1
  • Efficacy: Up to 80% repigmentation in facial lesions and 40% in other body areas 1
  • Monitoring: Regular checks for skin atrophy, which is a common side effect 2, 1
  • Evidence shows that highly potent (clobetasol) or potent (betamethasone) topical steroids can repigment vitiligo, but only in a small proportion of cases 2

• Topical calcineurin inhibitors (tacrolimus/pimecrolimus)

  • Preferred for facial areas and in children due to better safety profile 1
  • Comparable efficacy to topical corticosteroids with fewer side effects 1, 3
  • Particularly useful for sensitive areas where steroid atrophy is a concern

Phototherapy

• 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 1
  • Most effective for patients with darker skin types 1
  • Monitor response using serial photographs every 2-3 months 2, 1

Second-Line Therapies

Photochemotherapy

• PUVA (Psoralen + UVA)
  • Consider only for adults with widespread vitiligo or localized vitiligo with significant impact on quality of life 2
  • Not recommended for children 2, 1
  • Safety limit: Maximum of 150 treatments for skin types I-III 2, 1
  • Less effective than NB-UVB with poorer color match of repigmented skin 2
  • Patients should be informed that:
    • Not all patients respond to treatment
    • Hands and feet respond poorly in all patients
    • There is no evidence that PUVA alters the natural history of vitiligo 2

Surgical Therapies

For stable vitiligo that has not responded to medical treatments:

• Split-skin grafting - Better cosmetic results than minigraft procedures 1
• Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA 1
• Suction blister transfer - Alternative method with benefit over placebo 1

Special Considerations

For Extensive Vitiligo

• Consider p-(benzyloxy)phenol (MBEH) for depigmentation when vitiligo is extensive and other treatments have failed 1
• Patients must accept permanent inability to tan 1

For Very Fair Skin (Types I-II)

• Consider no active treatment other than camouflage cosmetics and sunscreens 2, 1

Monitoring Treatment Response

• Use serial clinical photographs to monitor response to treatment 2
• For research settings, the VASI and VETF tools offer more accurate measurement of disease extent 2
• Monitor every 2-3 months using serial photographs 1

Treatment Algorithm Based on Disease Presentation

1. Localized Non-Segmental Vitiligo:

   • Start with potent topical corticosteroids (alternate weeks) or calcineurin inhibitors (for face/sensitive areas)
   • If inadequate response after 2 months, add NB-UVB phototherapy
   • For resistant cases, consider surgical options if disease is stable

2. Widespread Non-Segmental Vitiligo:

   • Start with NB-UVB phototherapy
   • Consider adding topical treatments for resistant areas
   • For extensive cases unresponsive to repigmentation therapies, consider depigmentation with MBEH

3. Rapidly Progressing Vitiligo:

   • Consider systemic treatments when the disease is rapidly progressing 1
   • Monitor closely with serial photographs every 2-3 months 2, 1

Important Caveats

• Treatment response varies by anatomical location, with extremities often showing better results than hands and feet 1
• Relapse is common, with over 40% of patients losing treatment response after 1 year without treatment 1
• Treatment adherence is crucial for success 1
• Psychological support should be offered to improve coping mechanisms 1

The evidence for vitiligo treatments is still evolving, with newer options like topical JAK inhibitors (ruxolitinib) showing promise in recent research 4, though these are not yet included in major guidelines for non-segmental vitiligo.