What are the treatment options for vitiligo and pityriasis alba?

Treatment Options for Vitiligo and Pityriasis Alba

For vitiligo, first-line treatment includes potent topical corticosteroids for limited areas and narrowband UVB phototherapy for widespread disease, while pityriasis alba responds well to topical calcineurin inhibitors and moisturizers. 1

Treatment for Vitiligo

First-Line Therapies

1. Topical Treatments

   • Potent or very potent topical corticosteroids

     • Recommended for limited areas of vitiligo
     • Maximum trial period of 2 months
     • Efficacy: Up to 80% repigmentation in facial lesions, 40% in other areas
     • Caution: Monitor for skin atrophy (common side effect) 2, 1
     • Safe dose: ≤50g per week of clobetasol propionate 0.05% for up to 12 weeks 3

   • Topical calcineurin inhibitors (tacrolimus/pimecrolimus)

     • Excellent alternatives to topical steroids
     • Particularly useful for facial areas and in children
     • Similar efficacy to potent corticosteroids (50-100% repigmentation)
     • Better safety profile with fewer side effects (mainly temporary stinging) 1
     • Studies show comparable efficacy to clobetasol propionate 4

2. Phototherapy

   • Narrowband UVB (NB-UVB)
     • Preferred phototherapy option due to superior efficacy and safety
     • Recommended for:
       • Widespread vitiligo
       • Cases not manageable with topical treatments
       • Especially beneficial for darker skin types
     • Safety limit: Maximum 200 treatments for skin types I-III 2, 1
     • Should be monitored with serial photographs every 2-3 months 2

Second-Line and Combination Therapies

1. Combination Approaches

   • Corticosteroids + Calcipotriene (vitamin D analog)
     • Effective even in patients who failed corticosteroid monotherapy
     • Regimen: Topical corticosteroids in morning, calcipotriene in evening
     • Can achieve up to 95% repigmentation in responsive patients 5
     • Particularly effective for facial and eyelid areas 5

2. Surgical Options (for stable, treatment-resistant vitiligo)

   • Split-skin grafting
   • Autologous epidermal suspension
   • Suction blister transfer 1

Treatment by Anatomical Location

• Face: First choice is topical calcineurin inhibitors; alternatives include intermittent potent corticosteroids 1
• Body: First choice is intermittent potent corticosteroids; for widespread areas, consider NB-UVB 1
• Hands/Feet: Combination therapy (corticosteroids + NB-UVB) recommended due to treatment resistance 1

Treatment for Pityriasis Alba

1. First-Line Approaches

   • Topical calcineurin inhibitors (tacrolimus/pimecrolimus)

     • Particularly useful for children with sensitive skin
     • Apply twice daily 1

   • Azelaic acid 15-20%

     • Beneficial for post-inflammatory hyperpigmentation
     • Particularly useful for darker skin types
     • Apply twice daily 1

2. Additional Options

   • Adapalene 0.1% cream/gel

     • Apply at night, starting 2-3 times weekly and gradually increasing
     • Beneficial for post-inflammatory hyperpigmentation 1

   • Regular moisturization

     • Essential for management as condition is often associated with dry skin

Important Considerations

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

Psychological Support

• Assessment of psychological and quality of life effects should be made
• Offer appropriate psychological interventions 2, 1

Common Pitfalls to Avoid

1. Prolonged continuous use of potent corticosteroids (risk of atrophy)
2. Using calcipotriol as monotherapy (less effective)
3. Inadequate treatment duration
4. Neglecting psychological aspects of the condition
5. Failing to adjust treatment based on anatomical location response 1

Special Populations

• Children under 18: Consider potent topical steroids for a trial period of no more than 2 months; tacrolimus/pimecrolimus are safer alternatives 2
• Very fair skin (types I-II): Consider cosmetic camouflage and sunscreens rather than active treatment 1
• Extensive vitiligo in darker skin types: Depigmentation with p-(benzyloxy)phenol may be considered as a last resort 1