What are the treatment options for vitiligo?

How to Treat Vitiligo

For localized vitiligo, start with potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for a maximum of 2 months, or use topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as first-line alternatives with superior safety profiles, particularly for facial involvement. 1, 2

Initial Assessment

Before initiating treatment, perform the following:

• Check thyroid function tests in all patients, as autoimmune thyroid disease occurs in approximately 34% of vitiligo patients 2, 3
• Document disease extent with serial photographs every 2-3 months using VASI or VETF scoring systems to objectively monitor treatment response 2, 4
• Assess for Koebner phenomenon (trauma-induced lesions) to determine surgical candidacy later 4

Treatment Algorithm by Disease Extent

For Localized/Limited Vitiligo

First-line topical therapy:

• Potent or very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for no more than 2 months achieve 15-25% repigmentation in approximately 43% of patients 1, 2
• Critical pitfall: Never extend potent steroid use beyond 2 months to prevent skin atrophy 2, 4

Alternative first-line therapy:

• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) applied twice daily provide comparable efficacy to clobetasol with a superior safety profile 1, 2
• Strongly preferred in children due to better short-term safety profile 2
• Particularly recommended for facial or eyelid involvement where steroid atrophy risk is highest 2, 4

For Widespread/Generalized Vitiligo

Narrowband UVB (NB-UVB) phototherapy is the preferred treatment over PUVA, offering superior efficacy and safety 1, 2, 4

Safety limits:

• Maximum 200 treatments for skin types I-III 1, 4
• Ideally reserved for darker skin types (IV-VI) where repigmentation is more visible 1
• Can be combined with topical therapies for enhanced efficacy 2

Indications for phototherapy:

• Patients who cannot be adequately managed with topical treatments 1
• Widespread vitiligo 1
• Localized vitiligo with significant quality of life impact 1

Surgical Options (Highly Selective)

Strict candidacy criteria - all must be met:

• No new lesions for at least 12 months 1, 4
• No Koebner phenomenon present 1, 4
• No extension of existing lesions for 12 months 1, 4
• Localized disease in cosmetically sensitive sites 1

Surgical technique selection:

• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 4
• Minigraft is NOT recommended due to high incidence of side-effects and poor cosmetic results 1
• Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA is optimal but requires specialized facilities 1, 4

Critical pitfall: Never perform surgery in patients with active Koebnerization or recent disease progression, as this will exacerbate the condition and create new depigmented areas 4

Treatments NOT Recommended

• Oral dexamethasone cannot be recommended due to unacceptable risk of side-effects 1, 3
• Surgical treatments in children are not recommended due to lack of safety data 1, 2
• Topical calcipotriol monotherapy has no effect 2

Depigmentation for Extensive Disease

Reserved only for:

• Adults with >50% depigmentation 1, 2
• Extensive facial or hand involvement 1, 2
• Patients who cannot or choose not to seek repigmentation 1
• Those who can accept permanent inability to tan 1, 2

Depigmentation agents:

• Monobenzyl ether of hydroquinone (MBEH) produces total depigmentation in 69% within 4-12 months 2
• Q-switched ruby laser achieves total depigmentation in 69% within 7-14 days 2

Option of No Active Treatment

For adults with skin types I and II, after discussion, the initial approach may be to use no active treatment other than camouflage cosmetics and sunscreens, as vitiligo may cause little concern in very pale skin 1

Essential Supportive Measures

• Sunscreens are mandatory as depigmented skin is more sensitive to sunburn 2
• Cosmetic camouflage (including fake tanning products) improves quality of life, with DLQI improvement from 7.3 to 5.9 2, 4
• Psychological interventions should be offered to improve coping mechanisms, as vitiligo has a quality of life impact comparable to psoriasis 1, 2
• Parents of children with vitiligo should be offered psychological counseling 1

Newer Treatment Option

Topical ruxolitinib cream (a Janus kinase inhibitor) is now available as a topical therapy option 5