What is the primary treatment for vitiligo (skin condition characterized by loss of pigment) caused by skin trauma?

Treatment of Trauma-Induced Vitiligo (Koebner Phenomenon)

For vitiligo caused by skin trauma (Koebner phenomenon), initiate potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) for no more than 2 months as first-line treatment, but only after ensuring disease stability with no new lesions, no active Koebnerization, and no extension of existing lesions for at least 12 months. 1, 2

Initial Assessment and Stabilization

Before initiating active treatment for trauma-induced vitiligo, you must first address the underlying Koebner phenomenon:

• Avoid all trauma to unaffected skin areas to prevent new lesion formation, as the Koebner phenomenon will continue to generate new depigmented patches with ongoing injury 2
• Apply adequate lubrication to reduce friction-related trauma and minimize mechanical stress on the skin 2
• Document disease extent with photographs using the VASI or VETF scoring systems to monitor treatment response objectively 3, 1
• Check thyroid function before starting treatment due to high prevalence of autoimmune thyroid disease in vitiligo patients 1, 4

First-Line Topical Treatment

Once disease stability is confirmed (no new lesions for 12 months), proceed with medical management:

• Potent or very potent topical corticosteroids are the primary treatment option, with clobetasol propionate 0.05% or betamethasone valerate 0.1% applied for a trial period of no more than 2 months 1, 2, 5
• Studies show 15-25% repigmentation in approximately 43% of patients, with >75% repigmentation in about 9% of cases using highly potent steroids 3
• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) should be considered as alternatives with comparable efficacy but better safety profiles, particularly for facial or eyelid involvement 1, 5

Combination Therapy for Enhanced Response

If monotherapy proves inadequate after 2-3 months:

• Calcipotriene combined with corticosteroids demonstrates superior efficacy, with 83% of patients achieving an average of 95% repigmentation by body surface area 6
• This combination works even in patients who previously failed topical corticosteroid monotherapy, with calcipotriene applied in the evening and corticosteroids in the morning 6
• Facial and eyelid skin respond best to this combination approach 6

Second-Line Phototherapy

For inadequate response to topical treatments or more extensive involvement:

• Narrowband UVB (NB-UVB) phototherapy is preferred over PUVA, offering greater efficacy and better safety profile, particularly for darker skin types 1, 2, 5
• Safety limit of no more than 200 treatments for skin types I-III 1
• NB-UVB can be combined with topical therapies for enhanced outcomes 7, 8

Surgical Options (Only for Stable Disease)

Surgical interventions are reserved for highly specific circumstances:

• Surgical treatments should only be considered when there have been no new lesions, no Koebner phenomenon present, and no extension of existing lesions for at least 12 months 1, 2
• Split-skin grafting provides better cosmetic results than minigraft procedures 1
• Autologous epidermal suspension is optimal but requires special facilities and should be followed by NB-UVB or PUVA therapy 1

Critical Pitfalls to Avoid

• Never perform surgical treatments in patients with active Koebnerization or recent disease progression, as this will exacerbate the condition and create new depigmented areas 2
• Do not extend potent topical steroid use beyond 2 months to avoid skin atrophy 2
• Failing to prevent ongoing trauma will result in continued disease progression regardless of treatment efficacy 2
• Do not overlook the psychological impact, as trauma-induced vitiligo can be particularly distressing; offer psychological interventions to improve coping mechanisms 1, 2

Maintenance and Prevention

• Apply calcineurin inhibitors following successful repigmentation to prevent recurrences 8
• Continue trauma avoidance strategies indefinitely to prevent reactivation of the Koebner phenomenon 2
• Use high SPF sunscreens to prevent burning of depigmented areas and tanning of normal skin 9, 7
• Consider cosmetic camouflage including fake tanning products, which can improve quality of life 3