What are the treatment options for vitiligo?

Vitiligo Treatment

For 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 use topical calcineurin inhibitors (tacrolimus or pimecrolimus) as first-line alternatives with comparable efficacy but superior safety profiles. 1

Initial Assessment

Before starting any treatment, perform the following:

• 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 using VASI or VETF scoring systems to objectively monitor treatment response 3, 2
• Assess for Koebner phenomenon (trauma-induced lesions) to determine surgical candidacy 2, 4

Treatment Algorithm by Disease Extent

For Localized/Limited Vitiligo (< 20% body surface area)

First-Line Topical Therapy:

• Potent/very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for maximum 2 months only to prevent skin atrophy 1, 2

  • Achieves 15-25% repigmentation in approximately 43% of patients 2
  • Critical pitfall: Never extend beyond 2 months due to risk of skin atrophy 1, 2

• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) applied twice daily provide comparable efficacy with better safety profile 1

  • Strongly preferred for children over potent steroids 2
  • Particularly recommended for facial or eyelid involvement 2

If inadequate response after 2-3 months:

• Switch to alternative topical therapy or add narrowband UVB phototherapy 3

For Widespread/Generalized Vitiligo (> 20% body surface area)

Narrowband UVB (NB-UVB) phototherapy is the preferred treatment 1, 5, 6:

• Superior efficacy and safety compared to PUVA, especially in children 1
• Safety limit: maximum 200 treatments for skin types I-III 1
• Particularly effective for darker skin types 1, 3
• Can be used as monotherapy or combined with topical treatments 6

PUVA phototherapy:

• Less preferred than NB-UVB 1
• Safety limit: maximum 150 treatments for skin types I-III 1
• Lacks clinical trial data in children 1

Surgical Options for Stable Disease

Surgical treatments should only be considered when ALL of the following criteria are met 1, 2:

• No new lesions for at least 12 months 1, 2, 4
• No Koebner phenomenon present 1, 2, 4
• No extension of existing lesions in previous 12 months 1, 2, 4
• Reserved for cosmetically sensitive sites 1

Surgical technique selection:

• 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
• Surgical treatments are NOT recommended in children due to lack of safety data 1

Depigmentation for Extensive Disease

Depigmentation with monobenzyl ether of hydroquinone (MBEH) should be reserved ONLY for patients meeting ALL criteria 1:

• >50% depigmentation or extensive depigmentation on face/hands 1, 2
• Cannot or choose not to seek repigmentation 1
• Can accept permanent inability to tan 1

Treatments NOT Recommended

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

Special Populations

Children

• Topical calcineurin inhibitors strongly preferred over potent steroids due to better short-term safety profile 1, 2
• NB-UVB phototherapy should only be considered when conservative treatments fail, for widespread disease, or significant QoL impact 1
• Surgical treatments NOT recommended 1
• Psychological interventions and parental counseling should be offered 1

Adults with Skin Types I-II

• Consider no active treatment after discussion, using only camouflage cosmetics and sunscreens if minimal cosmetic concern 1, 3

Essential Supportive Care

All patients should receive:

• High SPF sunscreens to prevent burning of depigmented areas 7, 8
• Cosmetic camouflage (including fake tanning products) improves quality of life with DLQI improvement from 7.3 to 5.9 2, 7, 8
• Psychological interventions to improve coping mechanisms, as vitiligo has QoL impact comparable to psoriasis 1, 2, 5

Critical Pitfalls to Avoid

• Never extend potent topical corticosteroid use beyond 2 months to prevent skin atrophy 1, 2, 4
• Never perform surgery in patients with active Koebnerization or recent disease progression as this will exacerbate the condition 2, 4
• Never exceed 200 NB-UVB treatments for skin types I-III due to increased photodamage risk in melanin-deficient skin 1
• Do not overlook psychological impact - always assess and offer support 1, 2