What are the treatment options for progressive white patches on the hands and face, possibly due to conditions like vitiligo or fungal infections?

Progressive White Patches on Hands and Face: Diagnosis and Treatment

Immediate Diagnostic Approach

For progressive white patches on the hands and face, vitiligo is the most likely diagnosis and can be made clinically in primary care when the presentation is classical, though atypical cases require dermatologist evaluation. 1

Key Diagnostic Steps

• Check thyroid function with blood tests given the 34% prevalence of autoimmune thyroid disease in vitiligo patients 1, 2
• Rule out fungal infection (tinea versicolor) which presents differently with fine scale and KOH positivity, requiring only 2 weeks of topical ketoconazole 2% cream once daily 3
• Assess disease activity by determining if new lesions have appeared or existing patches have extended in the past 12 months 1, 4

First-Line Treatment Algorithm

For Recent-Onset, Localized Vitiligo

Start with potent or very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for a maximum trial of 2 months. 1, 2

• This achieves 15-25% repigmentation in approximately 43% of patients 2
• Critical caveat: Skin atrophy is a common side effect, so limit duration strictly to 2 months 1

Alternative First-Line Option

Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) should be considered as alternatives to topical steroids, particularly for facial involvement, due to their superior short-term safety profile. 1, 2

• These provide comparable efficacy without the atrophy risk of potent steroids 2
• Can be used for longer durations than corticosteroids 1

Second-Line Treatment for Inadequate Response

For Widespread Disease or Significant Quality of Life Impact

Narrowband UVB phototherapy (311 nm) should be used in preference to oral PUVA for patients who cannot be adequately managed with topical treatments. 1

• Reserve this for darker skin types where repigmentation will be more visible 1
• Monitor with serial photographs every 2-3 months 1, 2
• Maximum of 200 treatments for skin types I-III due to long-term skin cancer risk 2
• Do not use in patients with pale white skin (types I-II) where vitiligo may cause minimal cosmetic concern 1

Surgical Options for Stable Disease

Surgical treatments are reserved exclusively for cosmetically sensitive sites (face and hands) where there have been no new lesions, no Koebner phenomenon, and no extension for at least 12 months. 1, 4

• Split-skin grafting provides better cosmetic and repigmentation results than minigraft procedures 1
• Minigraft is not recommended due to high incidence of side effects and poor cosmetic results 1

Depigmentation for Extensive Disease

For adults with more than 50% body surface area involvement or extensive depigmentation on face and hands who cannot or choose not to pursue repigmentation, monobenzone (monobenzyl ether of hydroquinone) should be considered. 1, 5

• Patients must fully accept the permanent, irreversible nature of complete depigmentation and permanently losing the ability to tan 5
• Onset of depigmentation occurs within 4-12 months of consistent application 5
• Approximately 36% experience repigmentation recurrence requiring retreatment 5

What NOT to Do

Oral dexamethasone cannot be recommended for arresting vitiligo progression due to unacceptable risk of side effects. 1, 2

Conservative Management Option

For adults with pale skin types I-II, it is appropriate to consider no active treatment other than camouflage cosmetics and sunscreens after discussion with the patient. 1

• Cosmetic camouflage can improve quality of life (DLQI improvement from 7.3 to 5.9) 1
• Vitiligo causes minimal cosmetic concern in very pale individuals 1

Critical Monitoring Requirements

• Serial photographs every 2-3 months to objectively document progression or treatment response 1, 2
• Psychological support should be offered as vitiligo can be cosmetically disfiguring and stigmatizing 2
• Lifelong sun protection is mandatory for all depigmented areas due to lack of melanin protection 1