What are the treatment options for vitiligo?

Treatment Options for Vitiligo

For adults with recent-onset vitiligo, initiate treatment with a potent or very potent topical corticosteroid (such as clobetasol propionate 0.05% or betamethasone valerate 0.1%) for no more than 2 months, or alternatively use topical calcineurin inhibitors (tacrolimus or pimecrolimus) which offer comparable efficacy with superior safety profiles. 1

Stepwise Treatment Algorithm

First-Line Topical Therapy

For localized, recent-onset vitiligo:

• Potent/very potent topical corticosteroids remain the primary treatment option, with clobetasol propionate 0.05% showing 90-100% repigmentation in over 80% of facial lesions and over 40% of body lesions in darker-skinned patients 1, 2
• Limit treatment duration to 2 months maximum to prevent skin atrophy, which has been a common side-effect 1
• Facial and neck lesions respond best to all therapeutic approaches, while acral areas (hands/feet) are least responsive 3

Topical calcineurin inhibitors as alternatives:

• Pimecrolimus or tacrolimus should be considered as alternatives to topical steroids, offering comparable repigmentation rates with better short-term safety profiles 1
• These agents are particularly valuable for facial or eyelid involvement where steroid atrophy risk is highest 4
• Studies demonstrate equivalent efficacy between 1% pimecrolimus and 0.05% clobetasol propionate 5

Second-Line Phototherapy

For widespread vitiligo or inadequate response to topical therapy:

• Narrowband UVB (NB-UVB) phototherapy should be used preferentially over PUVA, demonstrating greater efficacy and superior safety profile 1
• Reserve phototherapy for patients who cannot be adequately managed with topical treatments, those with widespread disease, or localized disease with significant quality of life impact 1
• Ideally target darker skin types (IV-VI) for phototherapy, as these patients achieve better outcomes 1
• Monitor treatment response with serial photographs every 2-3 months 1

Critical safety limits:

• Impose a maximum of 200 treatments for skin types I-III with NB-UVB, as vitiligo skin has greater susceptibility to sunburn and photodamage due to absent melanin 1
• For PUVA, limit to 150 treatments for skin types I-III 1
• Evidence is lacking to define upper limits for skin types IV-VI 1

Surgical Options for Stable Disease

Strict patient selection criteria:

• Reserve surgical treatments only for cosmetically sensitive sites where there have been no new lesions, no Koebner phenomenon, and no extension of existing lesions for at least 12 months 1
• This stability requirement is critical—performing surgery during active disease will exacerbate the condition 4

Surgical technique hierarchy:

• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures and utilizes readily available surgical facilities 1
• Minigraft is not recommended due to high incidence of side-effects and poor cosmetic outcomes 1
• Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA represents the optimal surgical transplantation procedure, but requires specialized facilities 1
• Suction blister transfer shows benefit over placebo but provides less coverage than split-skin grafting 1

Special Considerations

For patients with minimal cosmetic concern:

• In adults with skin types I and II, consider no active treatment other than camouflage cosmetics and sunscreens after discussion 1
• Cosmetic camouflage, including fake tanning products, can improve quality of life 4

For extensive vitiligo (>50% depigmentation):

• Depigmentation with monobenzyl ether of hydroquinone (MBEH) should be reserved for severely affected patients who cannot or choose not to seek repigmentation and who accept permanent inability to tan 1

Systemic therapy:

• Oral dexamethasone cannot be recommended to arrest vitiligo progression due to unacceptable risk of side-effects 1

Essential Baseline and Monitoring

• Check thyroid function before initiating treatment due to high prevalence of autoimmune thyroid disease in vitiligo patients 1, 4
• Document disease extent with photographs using VASI or VETF scoring systems for objective monitoring 4

Psychological Support

• Offer psychological interventions to improve coping mechanisms, as vitiligo has quality of life impact comparable to psoriasis 1
• This is particularly important for women, those with darker skin types, and patients with facial involvement 1

Critical Pitfalls to Avoid

• Never extend potent topical steroid use beyond 2 months—skin atrophy is a common complication 1
• Never perform surgical treatments in patients with active disease progression or Koebner phenomenon—this will create new depigmented areas 4
• Do not use minigraft procedures—they produce poor cosmetic results with high side-effect rates 1
• Avoid oral corticosteroids for disease stabilization due to unacceptable systemic side-effects 1
• Do not overlook sunscreen use—vitiliginous areas are highly susceptible to sunburn due to absent melanin protection 6