What are the treatments for repigmentation of vitiligo spots?

Treatment Options for Vitiligo Repigmentation

The most effective approach for repigmenting vitiligo spots combines topical corticosteroids with narrowband UVB phototherapy, with topical calcineurin inhibitors serving as excellent alternatives for sensitive areas like the face. 1, 2

First-Line Treatments

Topical Corticosteroids

• Potent or very potent topical corticosteroids are recommended as first-line therapy for limited areas of vitiligo 2
  • Apply a thin layer twice daily for no more than 2 consecutive weeks
  • Use on alternate weeks to minimize side effects
  • Most effective for facial lesions (up to 80% repigmentation) and less effective for other body areas (40%) 2
  • Treatment duration: Maximum 2-month trial period 1
  • Caution: Monitor for skin atrophy, which is a common side effect 1

Topical Calcineurin Inhibitors

• Tacrolimus and pimecrolimus are excellent alternatives to topical steroids 2
  • Particularly useful for facial areas and in children due to better safety profile
  • Especially effective in darker skin types
  • Similar efficacy to potent corticosteroids (50-100% repigmentation) but with fewer side effects 1, 3
  • Main side effect: Temporary stinging sensation 1

Phototherapy Options

Narrowband UVB (NB-UVB)

• Preferred phototherapy option due to superior efficacy and safety compared to other light therapies 2
• Recommended for:
  • Widespread vitiligo
  • Cases that cannot be managed with topical treatments
  • Especially beneficial for darker skin types
• Safety limit: Maximum 200 treatments for skin types I-III 2

Combination Approaches

• Combining topical agents with NB-UVB yields better results than monotherapy 2
  • Topical corticosteroids + UVA showed 31% mean repigmentation versus 9% with corticosteroids alone 1
  • Topical tacrolimus + Excimer UV enhances repigmentation for UV-sensitive sites but not for areas over bony prominences 1

Second-Line Options

Vitamin D Analogues

• Not recommended as monotherapy (Grade B recommendation) 1
• May be beneficial when combined with other treatments:
  • Calcipotriol + betamethasone showed better results than either agent alone 1, 4
  • 83% of patients responded to combination therapy with an average of 95% repigmentation 4
  • Particularly effective for eyelid and facial skin 4

Surgical Options

• Consider for stable vitiligo that hasn't responded to medical treatments 2
  • Split-skin grafting
  • Autologous epidermal suspension
  • Suction blister transfer

Treatment Algorithm Based on Vitiligo Location

1. Facial lesions:

   • First choice: Topical calcineurin inhibitors (tacrolimus/pimecrolimus)
   • Alternative: Potent topical corticosteroids (intermittent use)
   • For resistant cases: Add NB-UVB phototherapy

2. Body lesions:

   • First choice: Potent topical corticosteroids (intermittent use)
   • For widespread areas: NB-UVB phototherapy
   • For resistant cases: Combination therapy (corticosteroids + calcipotriol)

3. Hands and feet (most resistant areas):

   • Combination therapy (corticosteroids + NB-UVB)
   • Consider surgical options for stable, treatment-resistant patches

Monitoring Treatment Response

• Use serial clinical photographs to track progress 1, 2
• Follow-up every 2-3 months
• Expect better response on face and neck compared to hands and feet 2
• Consider maintenance therapy to reduce relapse risk (>40% lose response after 1 year without treatment) 2

Special Considerations

• For very fair skin (types I-II), consider cosmetic camouflage and sunscreens rather than active treatment 1
• For extensive vitiligo in darker skin types, depigmentation with p-(benzyloxy)phenol may be considered as a last resort 1
• Psychological support should be offered to improve coping mechanisms 2

Treatment Pitfalls to Avoid

• Prolonged continuous use of potent corticosteroids (leads to skin atrophy)
• Using calcipotriol as monotherapy (ineffective) 1
• Inadequate treatment duration (repigmentation is a slow process)
• Neglecting psychological aspects of the condition
• Failing to adjust treatment based on anatomical location response