What are the treatment options for vitiligo?

Treatment Options for Vitiligo

The first-line treatment options for vitiligo include topical corticosteroids and calcineurin inhibitors for limited areas, and narrowband UVB phototherapy for widespread disease, with treatment selection based on anatomical location and patient characteristics. 1

First-Line Treatment Options

Topical Therapies

• Topical Corticosteroids

  • Potent or very potent topical corticosteroids are recommended as first-line therapy for limited areas of vitiligo 1
  • Maximum 2-month trial period with monitoring for skin atrophy
  • Efficacy: Up to 80% repigmentation in facial lesions and 40% in other body areas
  • Best used intermittently to avoid side effects
  • Studies show clobetasol propionate can achieve 90-100% repigmentation in more than 80% of facial lesions and 40% of lesions on other body parts 2

• Calcineurin Inhibitors (Tacrolimus/Pimecrolimus)

  • Excellent alternatives to topical steroids, particularly for facial areas 1
  • Similar efficacy to potent corticosteroids (50-100% repigmentation)
  • Better safety profile with fewer side effects (main side effect: temporary stinging)
  • Comparative studies show 1% pimecrolimus is as effective as clobetasol propionate 3

Phototherapy

• Narrowband UVB (NB-UVB)
  • Preferred phototherapy option due to superior efficacy and safety 1
  • Recommended for:
    • Widespread vitiligo
    • Cases that cannot be managed with topical treatments
    • Especially beneficial for darker skin types
  • Safety limits: Maximum 200 treatments for skin types I-III
  • More effective than PUVA therapy 1, 4

Treatment Algorithm by Anatomical Location

Facial Lesions

1. First choice: Topical calcineurin inhibitors (tacrolimus/pimecrolimus) 1
2. Alternative: Potent topical corticosteroids (intermittent use)
3. For resistant cases: Add NB-UVB phototherapy

Body Lesions

1. First choice: Potent topical corticosteroids (intermittent use) 1
2. For widespread areas: NB-UVB phototherapy
3. For resistant cases: Combination therapy (corticosteroids + calcipotriol)

Hands and Feet (Most Resistant Areas)

1. Recommended approach: Combination therapy (corticosteroids + NB-UVB) 1
2. For stable, treatment-resistant patches: Consider surgical options

Second-Line Treatment Options

Systemic Therapies

• Oral Corticosteroids
  • Reserved for rapidly progressing disease 4
  • Short courses to halt disease progression
  • Not recommended for long-term use due to side effects

Additional Phototherapy Options

• PUVA Therapy

  • May be considered for widespread vitiligo with significant impact on quality of life 1
  • Not recommended for children
  • Maximum 150 treatments for skin types I-III
  • Less effective than NB-UVB

• Targeted Phototherapy

  • For localized resistant lesions 4
  • Includes excimer laser and excimer light

Surgical Options

• Consider for stable vitiligo unresponsive to medical treatments: 1
  • Split-skin grafting
  • Autologous epidermal suspension
  • Suction blister transfer
  • Better cosmetic results than minigraft procedures

Special Considerations

Skin Type Considerations

• Very fair skin (types I-II): Consider cosmetic camouflage and sunscreens rather than active treatment 1
• Darker skin types with extensive vitiligo: Depigmentation with p-(benzyloxy)phenol may be considered as a last resort 1

Treatment Response Variations

• Face and neck show better response to treatment 1, 2
• Hands and feet are more resistant to treatment 1

Common Pitfalls to Avoid

• Prolonged continuous use of potent corticosteroids (leads to skin atrophy)
• Using calcipotriol as monotherapy (insufficient efficacy)
• Inadequate treatment duration (minimum 3-6 months needed to assess response)
• Neglecting psychological aspects of the condition
• Failing to adjust treatment based on anatomical location response 1

Monitoring and Follow-up

• Use serial clinical photographs to track progress
• Follow-up every 2-3 months
• Consider maintenance therapy to reduce relapse risk (>40% lose response after 1 year without treatment) 1

Adjunctive Therapies

• Antioxidants: Can be used in association with other therapeutic options 4
• Psychological support: Should be offered to improve coping mechanisms 1
• Camouflage cosmetics and sunscreens: Important for all patients, especially those with fair skin 1, 5