What are the treatment options for vitiligo?

Treatment of Vitiligo

For localized vitiligo, initiate treatment with potent topical corticosteroids (such as clobetasol propionate 0.05%) for up to 2 months, or use topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as first-line alternatives with superior safety profiles, particularly for facial involvement. 1, 2

Initial Assessment

Before starting treatment, perform the following:

• Check thyroid function tests in all patients with vitiligo, as autoimmune thyroid disease occurs in approximately 34% of cases 2, 3
• Document disease extent with serial photographs every 2-3 months to objectively monitor treatment response 1, 2
• Assess for Koebner phenomenon (trauma-induced lesions) to determine surgical candidacy 2

Treatment Algorithm by Disease Extent

Localized/Limited Vitiligo

First-line topical therapy:

• Potent or very 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 limitation: Never extend use beyond 2 months to prevent skin atrophy 1, 2

Alternative first-line therapy:

• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) applied twice daily provide comparable efficacy to corticosteroids with a superior safety profile 1, 2, 4
• Strongly preferred in children due to better short-term safety compared to potent steroids 2
• Particularly recommended for facial or eyelid involvement where steroid atrophy risk is highest 2, 4

Widespread/Generalized Vitiligo

Phototherapy is the preferred treatment:

• Narrowband UVB (NB-UVB) phototherapy should be used in preference to PUVA due to superior efficacy and safety 1, 2, 4
• Safety limits: Maximum 200 treatments for skin types I-III; evidence lacking for upper limits in skin types IV-VI 1, 4
• Best suited for darker skin types where repigmentation is more visible 1, 4

Surgical Options for Stable Disease

Strict candidacy criteria must be met:

• Disease must be completely stable for at least 12 months with no new lesions, no Koebner phenomenon, and no extension of existing lesions 1, 2, 4
• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 2, 4
• 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 specialized facilities 1, 4
• Never perform surgery in children due to lack of safety data 1, 2

Treatments NOT Recommended

• Oral dexamethasone cannot be recommended due to unacceptable risk of side-effects 1, 3
• Topical calcipotriol monotherapy has no effect and should not be used 2

Depigmentation for Extensive Disease

Reserved only for severely affected patients:

• Depigmentation with monobenzyl ether of hydroquinone (MBEH) should be reserved for patients with >50% depigmentation or extensive facial/hand involvement who cannot or choose not to seek repigmentation 1, 2
• Patients must accept permanent inability to tan 1, 2
• Topical 4-methoxyphenol (4MP) produces total depigmentation in 69% within 4-12 months 2

Special Populations

Patients with Skin Types I-II

• Consider no active treatment initially after discussion with the patient, using only camouflage cosmetics and sunscreens if cosmetic concern is minimal 1, 4

Children

• Calcineurin inhibitors strongly preferred over potent steroids 2
• NB-UVB phototherapy reserved for widespread disease or localized vitiligo with significant quality of life impact, ideally in darker skin types 1
• Surgical treatments are not recommended 1, 2

Adjunctive Management

• Sunscreens are essential as depigmented skin is more sensitive to sunburn 2, 4
• Cosmetic camouflage improves quality of life, with DLQI improvement from 7.3 to 5.9 2
• Psychological interventions should be offered to improve coping mechanisms, as vitiligo has quality of life impact comparable to psoriasis 1, 2, 4

Critical Pitfalls to Avoid

• Never extend potent topical corticosteroid use beyond 2 months to prevent skin atrophy 1, 2
• Never perform surgery in patients with active Koebnerization or recent disease progression 2, 4
• Never exceed 200 NB-UVB treatments for skin types I-III due to photodamage risk 1, 4