What are the treatment options for a child with vitiligo, especially with a family history of the condition?

Treatment of Childhood Vitiligo

For children with vitiligo, topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) should be used as first-line treatment for localized disease, with narrowband UVB phototherapy reserved for extensive or refractory cases after topical therapy fails. 1

Initial Assessment and Documentation

Before starting treatment, perform the following evaluations:

• Thyroid function tests including anti-thyroglobulin antibodies are essential given the high prevalence of thyroid autoimmune disease in vitiligo patients, particularly relevant with a positive family history 1
• Document disease extent with serial photographs to objectively monitor treatment response every 2-3 months 1, 2
• Assess skin phototype as this guides therapeutic decisions and determines which treatments are most suitable 1
• Conduct psychological evaluation of both the child and parents, as vitiligo significantly impacts quality of life and this should be the most important outcome measure 3, 1

Treatment Algorithm for Localized Vitiligo

First-Line: Topical Calcineurin Inhibitors

Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) are preferred over corticosteroids due to their superior safety profile and comparable efficacy 3, 1:

• Response rates: 58% for facial lesions, 23-39% for non-facial lesions 1
• No risk of skin atrophy, making them ideal for long-term use in children 3

Alternative: Potent Topical Corticosteroids

If calcineurin inhibitors are unavailable or ineffective:

• Use potent corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) for a maximum of 2 months only 3, 1
• Response rates: 15-25% 1
• Critical pitfall: Do not exceed 2 months to prevent skin atrophy, which has been a common side-effect 3, 2

Treatment for Extensive or Refractory Vitiligo

Narrowband UVB Phototherapy

NB-UVB phototherapy should only be considered after failure of topical treatments, or in cases of widespread vitiligo with significant quality of life impact 1, 2:

• NB-UVB is strongly preferred over PUVA due to greater efficacy, superior safety, and complete lack of clinical trials of PUVA in children 3, 2
• Ideally reserved for patients with darker skin phototypes where contrast is more evident 1, 2
• Limit cumulative dose to 200 treatments for skin phototypes I-III to minimize photodamage risk 1
• Monitor with serial photographs every 2-3 months 2

Important Contraindications

Never use systemic corticosteroids in children due to unacceptable toxicity 1, 4

Surgical treatments are not recommended in pediatric patients due to lack of evidence supporting efficacy and safety 1

Psychological Support

Psychological interventions must be offered to improve coping mechanisms in children, with counseling for parents to support their child's treatment 1, 2:

• Regular assessment of psychological impact is essential 1
• Consider camouflage cosmetics for children with skin types I-II and limited disease 4

Family History Considerations

While genetic transmission is minimal at 5-6% in first-degree relatives 5, the family history increases the importance of:

• Screening for associated autoimmune conditions (thyroid disease, celiac disease) 5, 6
• Early intervention to prevent psychological impact during formative years 6

Common Pitfalls to Avoid

• Do not start phototherapy as first-line treatment - this violates guidelines requiring failure of conservative treatments first 2
• Do not prolong potent corticosteroid use beyond 2 months to prevent skin atrophy 1, 2
• Do not underestimate psychological impact - offer interventions early 2
• Do not forget to screen for comorbidities, particularly thyroid disease which occurs in 25% of cases 6