What is the treatment for vitiligo?

Treatment of Vitiligo

The first-line treatment for vitiligo is potent or very potent topical corticosteroids for limited areas, with narrowband UVB phototherapy recommended for widespread disease. 1

First-Line Treatments

Topical Therapies

• Topical Corticosteroids

  • Recommended as first-line therapy for limited areas of vitiligo 2, 1
  • Apply a thin layer twice daily for no more than 2 consecutive weeks 3
  • Maximum 50g per week should not be exceeded 3
  • Treatment should be limited to 2 months, with application on alternate weeks 1
  • Efficacy: Up to 80% repigmentation in facial lesions and 40% in other body areas 1
  • Monitor for skin atrophy, a common side effect 1

• Topical Calcineurin Inhibitors (Tacrolimus, Pimecrolimus)

  • Alternative to topical steroids, especially for facial areas and in children 1
  • Better safety profile than potent steroids (no skin atrophy) 2, 1
  • Particularly effective for facial lesions and in darker skin types 1
  • May cause stinging as a side effect 2

Phototherapy

• Narrowband UVB (NB-UVB)
  • Preferred phototherapy option for widespread vitiligo 1
  • Superior efficacy and safety compared to PUVA 2, 1
  • Maximum 200 treatments for skin types I-III 1
  • Especially beneficial for darker skin types 1

Second-Line Treatments

Combination Therapies

• Topical Agents + Phototherapy
  • Combining topical treatments with NB-UVB often yields better results than monotherapy 1
  • Tacrolimus with Excimer UV radiation enhances repigmentation for UV-sensitive sites 2
  • Topical betamethasone and calcipotriol combination may be more effective than either agent alone 2, 4

Surgical Options

• Consider for stable vitiligo that hasn't responded to medical treatments 1
• Options include:
  • Split-skin grafting
  • Autologous epidermal suspension
  • Suction blister transfer 1

Depigmentation

• p-(benzyloxy)phenol (MBEH) may be considered for extensive vitiligo 1
• Only for cases where repigmentation treatments have failed 5
• Patients must accept permanent inability to tan 1

Treatment Algorithm

1. For Limited Areas:

   • Start with potent topical corticosteroids twice daily for 2 weeks, then alternate weeks for up to 2 months 1, 3
   • For facial areas or in children, use topical calcineurin inhibitors instead 2, 1
   • If no improvement after 2 months, reassess diagnosis or move to next option 3

2. For Widespread Disease:

   • Narrowband UVB phototherapy as primary treatment 1
   • Can be combined with topical agents for enhanced efficacy 1

3. For Resistant Cases:

   • Consider combination therapies (e.g., topical agents + phototherapy) 1
   • Evaluate for surgical options if disease is stable 1
   • For extensive vitiligo recalcitrant to other treatments, consider depigmentation 1, 5

Important Considerations

• Treatment response varies by anatomical location - face and neck respond better than hands and feet 1
• Maintenance therapy should be considered to reduce relapse risk (>40% lose response after 1 year without treatment) 1
• Psychological interventions should be offered to improve coping mechanisms 1
• Treatment adherence is crucial - patients adhering to >75% of protocol are more likely to achieve success 1
• Monitor response with serial clinical photographs every 2-3 months 1

Common Pitfalls to Avoid

• Unrealistic Expectations: Educate patients that repigmentation is often slow and may be incomplete
• Overuse of Topical Steroids: Strictly adhere to recommended duration to prevent skin atrophy 3
• Neglecting Psychological Impact: Address the psychosocial burden of vitiligo alongside physical treatment 1
• Inappropriate Treatment Selection: Consider anatomical location and skin type when selecting therapy 1
• Premature Treatment Discontinuation: Emphasize that treatments may take months to show significant results