What are the treatment options for scalp vitiligo?

Treatment Options for Scalp Vitiligo

For scalp vitiligo, topical corticosteroids should be considered as first-line therapy for a trial period of no more than 2 months, with topical calcineurin inhibitors as an effective alternative with a better safety profile. 1

Initial Approach

• For patients with skin types I and II (fair skin), consider whether no active treatment might be appropriate, using only camouflage cosmetics and sunscreens if the condition causes minimal cosmetic concern 1
• Before initiating treatment, consider checking thyroid function due to the high prevalence of autoimmune thyroid disease in vitiligo patients 1, 2
• Document the extent of disease with photographs to monitor treatment response 1
• Wood's light examination can be helpful in monitoring response to therapy, particularly in fair-skinned patients 2

Topical Treatment Options

First-line Treatments:

• Potent or very potent topical corticosteroids:

  • Recommended for recent-onset vitiligo for a trial period of no more than 2 months 1
  • Examples include clobetasol propionate 0.05% or betamethasone valerate 0.1% 3, 4
  • Apply twice daily to affected areas 5
  • Monitor for side effects: skin atrophy is common with prolonged use 1
  • Intermittent therapy (e.g., weekends only after initial treatment) helps avoid adverse effects 4

• Topical calcineurin inhibitors:

  • Pimecrolimus or tacrolimus should be considered as alternatives to topical steroids 1
  • Better safety profile than potent topical steroids (no skin atrophy) 1
  • Comparable efficacy to topical corticosteroids in repigmentation 5
  • Apply twice daily to affected areas 5

Combination Therapy:

• Calcipotriene (vitamin D analog) with corticosteroids:
  • Can be more effective than either agent alone 6
  • Recommended application: corticosteroid in morning, calcipotriene in evening 6
  • May achieve repigmentation even in patients who previously failed corticosteroid monotherapy 6
  • This combination has shown up to 95% repigmentation in some patients 6

Phototherapy Options

• Narrowband UVB (NB-UVB):
  • Consider for patients who cannot be adequately managed with topical treatments 1
  • Indicated for widespread vitiligo or localized vitiligo with significant impact on quality of life 1
  • Should be used in preference to PUVA due to greater efficacy and better safety profile 1
  • Best reserved for patients with darker skin types 1
  • Monitor with serial photographs every 2-3 months 1
  • Safety limit: no more than 200 treatments for skin types I-III 1

Surgical Options

• Surgical treatments should be reserved for cosmetically sensitive sites where:

  • There have been no new lesions for at least 12 months 1
  • No Koebner phenomenon is present 1
  • No extension of existing lesions in the previous 12 months 1

• Split-skin grafting:

  • Provides better cosmetic and repigmentation results than minigraft procedures 1
  • Utilizes surgical facilities that are relatively freely available 1

• Autologous epidermal suspension:

  • Applied to laser-abraded lesions followed by NB-UVB or PUVA therapy 1
  • Considered optimal surgical transplantation procedure but requires special facilities 1

Special Considerations for Scalp Vitiligo

• Response to treatment varies by anatomical location, with better results typically seen on the trunk and extremities compared to extremities 5
• Hair-bearing areas may respond differently to treatment than non-hair-bearing skin
• For extensive scalp vitiligo that cannot be adequately treated, consider camouflage options such as wigs, hats, or scalp micropigmentation

Psychological Support

• Psychological interventions should be offered to improve coping mechanisms 1
• Quality of life impact should be assessed and considered when determining treatment approach 1

Treatment Algorithm

1. Mild to moderate scalp vitiligo:

   • Start with potent topical corticosteroid for 2 months 1
   • If concerned about side effects, use topical calcineurin inhibitor instead 1
   • Consider combination therapy with calcipotriene and corticosteroid for enhanced efficacy 6

2. If inadequate response after 2-3 months:

   • Switch to alternative topical therapy or combination approach 6
   • Consider adding NB-UVB phototherapy, especially for darker skin types 1

3. For extensive or treatment-resistant scalp vitiligo:

   • NB-UVB phototherapy as primary treatment 1
   • Consider surgical options if disease has been stable for at least 12 months 1