What are the recommendations for oral management of vitiligo?

Oral Management of Vitiligo

Oral systemic therapies for vitiligo have extremely limited evidence and significant safety concerns, with oral dexamethasone specifically not recommended due to unacceptable side-effects, while low-dose oral corticosteroids may be considered only for actively spreading disease in carefully selected patients. 1

Primary Recommendation Against Oral Dexamethasone

The British Association of Dermatologists explicitly states that oral dexamethasone cannot be recommended for arresting vitiligo progression due to unacceptable risk of side-effects (Grade B recommendation, Level 2++ evidence). 1

Limited Role for Oral Corticosteroids

While high-dose oral dexamethasone is contraindicated, there is some evidence for low-dose oral prednisolone in specific circumstances:

• Low-dose oral prednisolone (0.3 mg/kg body weight daily) may arrest disease progression in 87.7% and induce repigmentation in 70.4% of patients with actively spreading vitiligo. 2

• The dosing protocol involves: initial dose for 2 months, then halved for month 3, and halved again for month 4 (total 4-month course). 2

• This approach should only be considered for patients with active, rapidly spreading disease who cannot be managed with topical treatments or phototherapy. 2

• Better responses occur in males, patients ≤15 years old, and disease duration ≤2 years. 2

Ginkgo Biloba Extract

The only satisfactory randomized controlled trial of any oral systemic treatment for vitiligo evaluated Ginkgo biloba extract, which demonstrated cessation of disease activity in patients with acrofacial vitiligo. 1

• Ginkgo biloba has antioxidant and immunomodulatory properties. 1

• Evidence remains limited to this single RCT. 1

Other Oral Agents with Emerging Evidence

Recent literature identifies additional oral systemic options, though these lack guideline-level recommendations:

• Oral mini-pulse corticosteroid therapy, methotrexate, minocycline, ciclosporin, and Janus kinase inhibitors have been used systemically, but evidence remains insufficient for routine recommendation. 3, 4

• These agents are increasingly being investigated as monotherapy or adjunctive therapy. 3

Critical Clinical Algorithm

For patients requiring systemic therapy:

1. First, exhaust topical options (potent corticosteroids for ≤2 months or calcineurin inhibitors) and phototherapy (narrowband UVB preferred). 1, 5

2. If disease is actively spreading and extensive, consider low-dose oral prednisolone (0.3 mg/kg/day) for a maximum 4-month tapered course, monitoring closely for side effects. 2

3. Never use oral dexamethasone due to unacceptable safety profile. 1

4. Consider Ginkgo biloba extract as an adjunctive option with minimal side effects, particularly for acrofacial vitiligo. 1

Essential Pitfalls to Avoid

• Do not prescribe oral corticosteroids for stable or slowly progressive vitiligo - topical treatments and phototherapy remain first-line. 1, 5

• Do not extend oral corticosteroid courses beyond 4 months to minimize systemic side effects. 2

• Do not use oral systemic therapy as monotherapy - it should be combined with topical treatments or phototherapy for optimal outcomes. 3, 6

Baseline Assessment Before Oral Therapy

Check thyroid function (including anti-thyroglobulin antibodies) before initiating any systemic treatment due to high prevalence of autoimmune thyroid disease in vitiligo patients. 7, 5, 8

• Document disease extent with serial photographs every 2-3 months to objectively monitor response. 7, 5

Context: Why Oral Therapy Has Limited Role

The evidence base for oral systemic treatments in vitiligo remains weak, with only one satisfactory RCT (Ginkgo biloba) identified in comprehensive guideline reviews. 1

• Topical immunosuppressants and phototherapy remain the evidence-based standard of care. 1, 5, 6

• Oral therapies are rarely prescribed in current practice due to concerns about systemic side effects and unclear efficacy compared to established topical and phototherapy options. 4