Vitiligo Management
Initial Assessment
For all patients with vitiligo, check thyroid function due to the high prevalence of autoimmune thyroid disease in this population 1, 2. Document disease extent with serial photographs every 2-3 months to objectively monitor treatment response 2. In patients with trauma-induced vitiligo, assess for Koebner phenomenon, as this will determine surgical candidacy 2.
Treatment Algorithm by Disease Extent and Skin Type
For Limited/Localized Vitiligo
Start with potent or very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for a maximum trial period of 2 months 1, 2, 3. This achieves 15-25% repigmentation in approximately 43% of patients, with >75% repigmentation in about 9% of cases 2. However, skin atrophy is a common side effect, so do not extend treatment beyond 2 months 1.
Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) should be considered as first-line alternatives to corticosteroids, particularly for facial or eyelid involvement, as they provide comparable efficacy with a superior safety profile 1, 3. Studies demonstrate equivalent repigmentation rates to clobetasol propionate, with better results on trunk and extremities than acral areas 4. The main side effect is transient stinging 1.
For Widespread/Generalized Vitiligo
Narrowband UVB (NB-UVB) phototherapy is the preferred treatment for widespread vitiligo that cannot be adequately managed with topical treatments, offering superior efficacy and safety compared to PUVA 1, 2. This should be reserved for patients with darker skin types (IV-VI) who have significant quality of life impact 1.
Critical safety limits: Do not exceed 200 treatments for skin types I-III, as vitiligo skin is more susceptible to photodamage due to absent melanin 1, 2. Evidence is lacking for upper limits in skin types IV-VI 1.
For Patients with Pale Skin (Types I-II)
In adults with skin types I and II, consider no active treatment initially after discussion, using only camouflage cosmetics and sunscreens, as vitiligo may cause minimal cosmetic concern in very pale skin 1, 3.
Surgical Options
Surgical treatments should only be performed when disease has been completely stable for at least 12 months—no new lesions, no Koebner phenomenon, and no extension of existing lesions 1, 2. This is critical because performing surgery during active disease will exacerbate the condition and create new depigmented areas 2.
When surgery is appropriate:
- Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 3
- 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 is optimal but requires specialized facilities 1, 3
Treatments NOT Recommended
Oral dexamethasone cannot be recommended due to unacceptable risk of side effects 1. Topical calcipotriol monotherapy has no effect and is not recommended 1. Surgical treatments in children are not recommended due to lack of safety data 1.
Depigmentation for Extensive Disease
Depigmentation with monobenzyl ether of hydroquinone should be reserved only for adults with >50% depigmentation or extensive facial/hand involvement who cannot or choose not to seek repigmentation and can accept permanent inability to tan 1.
Critical Pitfalls to Avoid
- Never extend potent topical corticosteroid use beyond 2 months to prevent skin atrophy 1, 2
- Never perform surgery in patients with active Koebnerization or recent disease progression 2
- In trauma-induced vitiligo, failing to prevent ongoing trauma will result in continued disease progression regardless of treatment efficacy 2
- Face and neck respond best to all treatments, while acral areas are least responsive—adjust expectations accordingly 5
Psychological Support
Offer psychological interventions to improve coping mechanisms, as vitiligo can be particularly distressing and stigmatizing 1, 2, 3. Parents of children with vitiligo should be offered psychological counseling 1.