What is the treatment for vitiligo?

Treatment of Vitiligo

Start with potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for a maximum of 2 months for localized disease, or narrowband UVB phototherapy for widespread vitiligo. 1

Initial Assessment Before Treatment

• Check thyroid function tests (including anti-thyroglobulin antibodies) in all patients, as autoimmune thyroid disease occurs in approximately 34% of vitiligo patients 2, 3
• Document baseline disease extent with serial photographs using VASI or VETF scoring systems, repeating every 2-3 months to objectively monitor treatment response 1
• Assess for Koebner phenomenon (trauma-induced lesions) to determine future surgical candidacy 1

Treatment Algorithm Based on Disease Extent

For Limited/Localized Vitiligo

First-line options:

• Potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily achieve 15-25% repigmentation in approximately 43% of patients 1, 2
• Critical pitfall: Never extend potent corticosteroid use beyond 2 months to prevent skin atrophy 1

Alternative first-line (especially for face/eyelids):

• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) applied twice daily provide comparable efficacy to clobetasol with superior safety profile 1, 2
• In children, strongly prefer calcineurin inhibitors over potent steroids due to better short-term safety 1
• Facial and eyelid lesions respond particularly well to this approach 1, 4

Combination therapy:

• Calcipotriene combined with corticosteroids can achieve 95% repigmentation in 83% of patients, even in those who previously failed corticosteroid monotherapy 5
• Apply corticosteroid in morning and calcipotriene in evening 5
• Important: Calcipotriol monotherapy has no effect and is not recommended 1

For Widespread/Generalized Vitiligo

• Narrowband UVB phototherapy is the preferred treatment, offering superior efficacy and safety compared to PUVA 1, 2
• Maximum of 200 treatments for skin types I-III 2

Surgical Options for Stable Disease

Strict eligibility criteria:

• Disease must be completely stable for at least 12 months with no new lesions, no Koebner phenomenon, and no extension of existing lesions 1
• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1
• Never perform surgery in children due to lack of safety data 1
• Never perform surgery in patients with active Koebnerization or recent disease progression 1

Treatments Explicitly NOT Recommended

• Oral dexamethasone cannot be recommended due to unacceptable risk of side effects 1, 2, 3
• Topical calcipotriol monotherapy has no effect 1
• Oral corticosteroids should not be prescribed for stable or slowly progressive vitiligo 3

Depigmentation for Extensive Disease (>50% involvement)

• Reserve depigmentation only for adults with >50% depigmentation or extensive facial/hand involvement who cannot or choose not to seek repigmentation 1
• Topical 4-methoxyphenol (4MP) produces total depigmentation in 69% of subjects within 4-12 months 1
• Q-switched ruby laser achieves total depigmentation in 69% within 7-14 days 1
• Patients must accept permanent inability to tan 1

Adjunctive Therapies

• Ginkgo biloba extract may be considered as adjunctive option with minimal side effects, particularly for acrofacial vitiligo 3
• Cosmetic camouflage (including fake tanning products) improves quality of life, with DLQI improvement from 7.3 to 5.9 1
• Sunscreens are essential as depigmented skin is more sensitive to sunburn 1

Mandatory Psychological Support

• Offer psychological interventions to improve coping mechanisms, as vitiligo has a quality of life impact comparable to psoriasis and can be particularly distressing and stigmatizing 1, 2