What are the treatment options for vitiligo?

Treatment Options for Vitiligo

For vitiligo treatment, topical calcineurin inhibitors (tacrolimus/pimecrolimus) are the first choice for facial lesions, while potent topical corticosteroids are recommended for body lesions, with narrowband UVB phototherapy reserved for widespread disease not responding to topical treatments. 1

Diagnosis and Initial Assessment

• Diagnosis is typically straightforward in primary care for classical presentations, but atypical cases should be referred to a dermatologist 2
• Consider thyroid function testing due to high prevalence of autoimmune thyroid disease in vitiligo patients 2, 1
• Serial clinical photographs are essential for tracking treatment progress 1

Treatment Options by Anatomical Location

Facial Lesions

• First choice: Topical calcineurin inhibitors (tacrolimus/pimecrolimus) 1
  • Better side effect profile than potent corticosteroids
  • Similar efficacy to corticosteroids (50-100% repigmentation in 8/10 patients with pimecrolimus vs 7/10 with clobetasol) 1, 3
• Alternative: Potent topical corticosteroids (limited duration) 1
• For resistant cases: Add narrowband UVB phototherapy 1

Body Lesions

• First choice: Potent topical corticosteroids 1
  • Use for a maximum of 2 months to avoid skin atrophy 2
• For widespread areas: Narrowband UVB phototherapy 1
• For resistant cases: Combination therapy (corticosteroids + calcipotriol) 1

Hands and Feet (Most Resistant Areas)

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

Phototherapy Options

• Narrowband UVB (311 nm) is superior to PUVA with better repigmentation rates and fewer side effects 1, 4
  • Recommended frequency: 2-3 times weekly on non-consecutive days 1
  • Maximum cumulative dose: 200 treatments for skin types I-III 1
  • Best suited for patients with darker skin types (III-VI) 1
  • Monitor with serial photographs every 2-3 months 2

Special Considerations

For Very Fair Skin (Types I-II)

• Consider cosmetic camouflage and sunscreens rather than active treatment 2, 1

For Children

• Prefer topical calcineurin inhibitors over potent corticosteroids 1
• Consider NB-UVB if topical therapies are inadequate 1

For Extensive Vitiligo in Darker Skin Types

• Depigmentation with p-(benzyloxy)phenol may be considered as a last resort 2, 1

Treatment Response Expectations

• Face and neck respond best to all therapeutic approaches 4
• Acral areas (hands and feet) are least responsive 4
• Response varies by anatomical location - better results typically seen on trunk and extremities 3

Psychological Support

• Assess psychological and quality of life effects of vitiligo, particularly in children 2
• Offer psychological interventions to improve coping mechanisms 2
• Parents of children with vitiligo should be offered psychological counseling 2

Common Pitfalls to Avoid

• Prolonged continuous use of potent corticosteroids (limit to 2 months) 2, 1
• Using calcipotriol as monotherapy (ineffective) 1
• Inadequate treatment duration 1
• Neglecting psychological aspects of the condition 2, 1
• Failing to adjust treatment based on anatomical location response 1, 4

Treatment Algorithm

1. Initial approach:

   • For limited areas: Start with topical therapy based on location
   • For widespread disease: Consider NB-UVB phototherapy

2. If inadequate response after 2-3 months:

   • Switch to alternative topical agent or
   • Consider combination therapy or
   • Add phototherapy for resistant cases

3. For stable disease resistant to conventional treatments:

   • Consider surgical options for localized areas 1, 5