What are the treatment options for vitiligo?

Vitiligo Treatment

For adults with recent-onset vitiligo, initiate treatment with potent or very potent topical corticosteroids (such as clobetasol propionate 0.05%) for a maximum of 2 months, or alternatively use topical calcineurin inhibitors (tacrolimus or pimecrolimus) which offer comparable efficacy with superior safety profiles, particularly for facial involvement. 1

Initial Assessment

Before starting treatment, perform the following evaluations:

• Check thyroid function in all patients due to high prevalence of autoimmune thyroid disease in vitiligo 1, 2
• Document disease extent with serial photographs every 2-3 months to objectively monitor treatment response 1, 3
• Assess for Koebner phenomenon (trauma-induced lesions) which impacts surgical candidacy 2, 4

Treatment Algorithm by Disease Extent

Limited/Localized Vitiligo

First-line topical therapy:

• Potent or very potent topical corticosteroids applied for no more than 2 months achieve 15-25% repigmentation in approximately 43% of patients 1, 2
• Never extend steroid use beyond 2 months to prevent skin atrophy 1
• Topical calcineurin inhibitors (pimecrolimus 1% or tacrolimus 0.1%) should be considered as alternatives, offering comparable efficacy with better safety profiles, especially for facial or eyelid involvement 1, 2

In children:

• Strongly prefer calcineurin inhibitors over potent steroids due to better short-term safety profile 1, 2
• Surgical treatments are not recommended in children due to lack of safety data 1

Widespread/Generalized Vitiligo

Phototherapy is the preferred treatment:

• Narrowband UVB (NB-UVB) should be used in preference to PUVA due to greater efficacy, superior safety profile, and lack of clinical trials of PUVA in children 1
• NB-UVB is particularly effective for darker skin types 1, 3
• Safety limit: maximum 200 treatments for skin types I-III; evidence lacking for upper limits in skin types IV-VI 1
• PUVA has a safety limit of 150 treatments for skin types I-III 1

Combination approach:

• Phototherapy can be combined with topical therapies for enhanced efficacy 3

Surgical Options for Stable Disease

Surgical treatments are reserved for specific circumstances:

• Only perform when disease has been completely stable for at least 12 months with no new lesions, no Koebner phenomenon, and no extension of existing lesions 1, 2
• Never perform surgery in patients with active Koebnerization as this will exacerbate the condition 2, 4

Surgical techniques in order of preference:

• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 2
• 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 special facilities 1, 3

Treatments NOT Recommended

• Oral dexamethasone cannot be recommended due to unacceptable risk of side-effects 1, 2
• Topical calcipotriol monotherapy has no effect 2

Depigmentation for Extensive Disease

Reserved for severely affected patients:

• Depigmentation with monobenzyl ether of hydroquinone (MBEH) should only be used in 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, 2

No Active Treatment Option

For patients with minimal cosmetic concern:

• In adults with skin types I and II, consider no active treatment after discussion, using only camouflage cosmetics and sunscreens 1

Supportive Care

Essential adjunctive measures:

• Sunscreens are mandatory as depigmented skin is more sensitive to sunburn 1, 5
• 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 QoL impact comparable to psoriasis 1, 2
• In children, parents should also be offered psychological counseling 1

Common Pitfalls to Avoid

• Do not extend potent topical corticosteroid use beyond 2 months to prevent skin atrophy 1, 2
• Never perform surgery in patients with active disease progression or Koebner phenomenon 2, 4
• Do not overlook psychological impact - always assess and address QoL effects 1, 2
• Avoid ongoing trauma in patients with Koebner phenomenon as this will continue generating new lesions regardless of treatment efficacy 4