Systemic Prednisone for Vitiligo
Systemic prednisone (or other oral corticosteroids) cannot be recommended for vitiligo due to an unacceptable risk of side-effects, according to the British Association of Dermatologists guidelines. 1, 2
Why Oral Corticosteroids Are Not Recommended
The British Journal of Dermatology explicitly states that oral dexamethasone—and by extension other systemic corticosteroids like prednisone—should not be used to arrest vitiligo progression because the side-effect profile is unacceptable (Grade B recommendation, Level 2++ evidence). 1
This recommendation applies despite some research studies showing that systemic corticosteroids can arrest disease progression and induce repigmentation, because the risk-benefit ratio does not favor their use in routine clinical practice. 2
The Evidence Paradox
While the guidelines firmly recommend against systemic corticosteroids, several research studies have shown potential efficacy:
High-dose methylprednisolone pulse therapy (8 mg/kg IV for 3 consecutive days) stopped disease progression in 85% of patients with active vitiligo and achieved repigmentation in 71%, though one patient developed arterial hypertension. 3
Oral mini-pulse betamethasone (5 mg on 2 consecutive days per week) arrested progression in 89% of patients with active disease and induced repigmentation in 80%, with relatively mild side effects including weight gain and transient weakness. 4
Combination therapy with high-dose prednisolone plus PUVA showed 36% of patients achieving >50% repigmentation, with mild and transient side effects. 5
However, guideline bodies have determined that these potential benefits do not outweigh the well-established risks of systemic corticosteroid therapy, including weight gain, hypertension, glucose intolerance, osteoporosis, and immunosuppression. 1, 2
What to Do Instead
Start with topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as first-line therapy, which have comparable efficacy to potent corticosteroids but superior safety profiles. 6
If calcineurin inhibitors fail or are unavailable, use potent or very potent topical corticosteroids for a maximum of 2 months only, as skin atrophy is a common side effect with longer use. 1, 6
For widespread or refractory disease, escalate to narrowband UVB phototherapy rather than systemic corticosteroids, as NB-UVB has demonstrated efficacy with a more acceptable safety profile. 1, 6
The Only Acceptable Oral Option
- Ginkgo biloba extract may be considered as an adjunctive option with minimal side effects, particularly for acrofacial vitiligo, based on one satisfactory randomized controlled trial showing it can arrest disease activity. 1, 2
Critical Pitfalls to Avoid
Never prescribe oral corticosteroids for stable or slowly progressive vitiligo—topical treatments and phototherapy remain first-line and have far better risk-benefit profiles. 2
Do not be swayed by older research studies showing efficacy of systemic steroids; the guideline bodies have weighed this evidence and determined the side-effect risk is unacceptable for routine use. 1, 2
Check thyroid function before initiating any treatment, as autoimmune thyroid disease is highly prevalent in vitiligo patients. 1, 2