What are the symptoms and treatment options for a patient with vitiligo, a history of skin pigmentation concerns, and potential autoimmune comorbidities, such as thyroid disease?

Vitiligo: Symptoms and Treatment

Clinical Presentation

Vitiligo presents as well-defined white patches of depigmented skin, often symmetrically distributed, most commonly affecting the fingers, wrists, axillae, groins, and body orifices (mouth, eyes, genitalia). 1

• The depigmented areas lack melanin pigment, making them more sensitive to sunburn 2
• Hair within affected patches may turn white, including eyelashes 1
• A "trichrome" appearance (white center with intermediate pale area) may be present 1
• The skin surface typically shows no texture changes or redness, though occasionally inflammation appears at advancing edges 1
• Mucosal areas such as the mouth can be affected, particularly prominent in darkly pigmented individuals 1

Autoimmune Screening

Check thyroid function in all patients with vitiligo, as 34% have autoimmune thyroid disease. 1, 3

• Vitiligo is increasingly recognized as an autoimmune disease with familial traits in approximately 18% of cases 1
• Screen for other autoimmune conditions and obtain family history of autoimmune disease (present in 32% of patients) 1

Treatment Algorithm

For Limited/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 of 2 months, achieving 15-25% repigmentation in approximately 43% of patients. 1, 3

• Never extend potent topical corticosteroid use beyond 2 months due to high risk of skin atrophy 1, 3
• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) should be considered as first-line alternatives, particularly for facial or eyelid involvement, providing comparable efficacy with superior safety profile 1, 3
• In children, strongly prefer calcineurin inhibitors over potent steroids due to better short-term safety profile 1, 3

For Widespread/Generalized Vitiligo

Narrowband UVB phototherapy is the preferred treatment for widespread vitiligo, offering superior efficacy and safety compared to PUVA. 1, 3

• Reserve phototherapy for patients who cannot be adequately managed with topical treatments, have widespread disease, or have localized disease with significant quality of life impact 1
• Ideally reserve for patients with darker skin types 1
• Monitor with serial photographs every 2-3 months 1, 3
• Consider excimer laser for localized areas 1

For Pale Skin (Types I-II)

In adults with very pale skin, consider no active treatment other than camouflage cosmetics and sunscreens after discussion, as vitiligo may cause minimal cosmetic concern. 1

• Cosmetic camouflage improves quality of life (DLQI improvement from 7.3 to 5.9) 3
• Sunscreens are essential as depigmented skin is more sensitive to sunburn 3, 4

Surgical Options for Stable Disease

Surgical treatments should only be performed 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, 3

• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 3
• Reserve for cosmetically sensitive sites 1
• Never perform surgery in patients with active Koebnerization or recent disease progression 3
• Surgical treatments in children are not recommended due to lack of safety data 3

Depigmentation for Extensive Disease

Depigmentation with monobenzyl ether of hydroquinone should be reserved only for 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, 3

• Topical 4-methoxyphenol produces total depigmentation in 69% of subjects within 4-12 months 3

Treatments NOT Recommended

• Oral dexamethasone cannot be recommended due to unacceptable risk of side effects 1, 3
• Topical calcipotriol monotherapy has no effect and is not recommended 3

Monitoring and Support

Document disease extent with serial photographs every 2-3 months using standardized assessment tools (VASI or VETF) to objectively monitor treatment response. 1, 3

• Offer psychological interventions to improve coping mechanisms, as vitiligo can be particularly distressing and stigmatizing with quality of life impact comparable to psoriasis 1, 3
• Assess psychological and quality of life effects at initial consultation 1

Critical Pitfalls

• Skin atrophy is a common side effect with prolonged topical steroid use—strictly limit to 2 months 1
• Spontaneous repigmentation is uncommon; response to treatment should be considered in context of natural history 1
• Early initiation of treatment is associated with more favorable prognosis 5