Treatment of Vitiligo in Teenagers
For teenagers with vitiligo, start with topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) applied twice daily as first-line therapy, given their comparable efficacy to potent corticosteroids but superior safety profile in this age group. 1
First-Line Topical Treatment Approach
Topical calcineurin inhibitors (tacrolimus or pimecrolimus) should be strongly preferred over potent corticosteroids in children and teenagers due to their better short-term safety profile, avoiding the risk of skin atrophy that commonly occurs with steroids. 1
If calcineurin inhibitors are unavailable or not tolerated, use potent or very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) for a maximum of 2 months only, as skin atrophy is a common side effect with longer use. 1
Studies demonstrate that topical pimecrolimus 1% achieves comparable repigmentation rates to clobetasol propionate 0.05%, with 15-25% repigmentation in approximately 43% of patients. 2, 3
Combination therapy with calcipotriene plus corticosteroid can enhance efficacy, achieving an average of 95% repigmentation in 83% of pediatric patients, including those who previously failed corticosteroid monotherapy. 4
When to Escalate to Phototherapy
Narrowband UVB (NB-UVB) phototherapy should be considered only when topical treatments fail, when vitiligo is widespread, or when localized disease significantly impacts quality of life. 1
NB-UVB is preferred over PUVA in teenagers due to greater efficacy, superior safety profile, and lack of clinical trial data for PUVA in children. 1
Reserve NB-UVB for darker skin types (IV-VI) where cosmetic impact is greatest, and monitor with serial photographs every 2-3 months. 1
Apply a safety limit of no more than 200 treatments for skin types I-III, with more stringent limits than used for psoriasis due to increased susceptibility to photodamage in depigmented skin. 1
Critical Management Steps
Check thyroid function at initial assessment due to high prevalence of autoimmune thyroid disease in vitiligo patients. 2
Document disease extent with serial photographs every 2-3 months using standardized scoring to objectively monitor treatment response. 2
Facial and eyelid lesions respond best to calcineurin inhibitors, making them particularly suitable for these cosmetically sensitive areas. 2, 3
What NOT to Do
Never use oral dexamethasone to arrest disease progression due to unacceptable risk of side effects. 1
Never perform surgical treatments in teenagers, as there are no safety studies in children and adolescents. 1
Never extend potent topical corticosteroid use beyond 2 months to prevent irreversible skin atrophy. 1
Do not use topical calcipotriol as monotherapy, as it has no effect on vitiligo when used alone. 2
Essential Adjunctive Care
Provide psychological interventions and counseling to improve coping mechanisms, as vitiligo can be particularly distressing and stigmatizing in adolescence. 1
Offer parents psychological counseling as well, since family support is crucial for treatment adherence and emotional well-being. 1
Recommend sunscreens for all depigmented areas due to increased sensitivity to sunburn and photodamage. 1, 2
Consider camouflage cosmetics and fake tanning products to improve quality of life while awaiting repigmentation. 2
Treatment Algorithm Summary
For limited/localized vitiligo: Start with topical calcineurin inhibitor twice daily → If inadequate response after 2-3 months, add calcipotriene or switch to potent corticosteroid (maximum 2 months) → If still inadequate and significant QOL impact, consider NB-UVB. 1, 2, 4
For widespread vitiligo: Consider NB-UVB phototherapy as primary treatment if conservative topical therapy is inadequate, particularly in darker skin types. 1