What is the recommended treatment for a patient with vitiligo?

Treatment of Vitiligo

For localized vitiligo, start with potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily for a maximum of 2 months, or use topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as equally effective alternatives with superior safety profiles, particularly for facial involvement. 1

Initial Assessment

Before initiating treatment, perform the following:

• Check thyroid function in all patients due to high prevalence of autoimmune thyroid disease in vitiligo 2
• Document disease extent with serial photographs every 2-3 months using VASI or VETF scoring systems to objectively monitor response 2, 3
• Assess for Koebner phenomenon (trauma-induced lesions) to determine surgical candidacy 2, 3
• Determine skin type as darker skin types respond better to phototherapy 1

Treatment Algorithm by Disease Extent

Localized Vitiligo (<10% Body Surface Area)

First-Line Topical Therapy:

• Potent topical corticosteroids achieve 15-25% repigmentation in approximately 43% of patients, with >75% repigmentation in 9% of cases 2, 4

  • Clobetasol propionate 0.05% or betamethasone valerate 0.1% applied twice daily 1, 2
  • Critical limitation: Use for maximum 2 months only to prevent skin atrophy, which is a common side effect 1
  • Best results on trunk and extremities 5

• Topical calcineurin inhibitors provide comparable efficacy to clobetasol with better safety profile 1, 2, 5

  • Tacrolimus 0.1% or pimecrolimus 1% applied twice daily 1, 2, 6
  • Preferred for facial or eyelid involvement due to no risk of skin atrophy 2, 6
  • Strongly preferred in children and teenagers over corticosteroids 1, 6
  • Common side effect: stinging sensation 1

What NOT to Use:

• Topical calcipotriol monotherapy has no effect and is not recommended 1, 2

Widespread/Generalized Vitiligo (>10% Body Surface Area)

Phototherapy (Second-Line):

• Narrowband UVB (NB-UVB) is the preferred phototherapy over PUVA, offering superior efficacy and safety 1, 2
• Reserve for patients who:
  • Cannot be adequately managed with topical treatments 1
  • Have darker skin types (better cosmetic impact) 1, 2
  • Have significant quality of life impact 1

Safety Limits for Phototherapy:

• Maximum 200 treatments with NB-UVB for skin types I-III (more stringent than psoriasis due to increased photodamage susceptibility in depigmented skin) 1, 6
• Maximum 150 treatments with PUVA for skin types I-III 1
• Evidence lacking for upper limits in skin types IV-VI 1

Surgical Options (Third-Line)

Strict Eligibility Criteria - All Must Be Met:

• Disease completely stable for at least 12 months 1, 2, 3
• No new lesions in past 12 months 1, 2, 3
• No Koebner phenomenon present 1, 2, 3
• No extension of existing lesions 1, 2, 3
• Reserved for cosmetically sensitive sites only 1

Surgical Techniques:

• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 2, 3
• Minigraft is NOT recommended due to high incidence of side effects and poor cosmetic results 1, 2
• Autologous epidermal suspension with laser abrasion followed by NB-UVB or PUVA is optimal but requires special facilities 1, 3

Treatments NOT Recommended

• Oral dexamethasone cannot be recommended due to unacceptable risk of side effects 1, 2, 6
• Topical calcipotriol monotherapy has no effect 1, 2
• Surgical treatments in children are not recommended due to lack of safety data 1, 6

Depigmentation for Extensive Disease

Reserved only for:

• Adults with >50% depigmentation or extensive facial/hand involvement 1, 2
• Patients who cannot or choose not to seek repigmentation 1, 2
• Patients who can accept permanent inability to tan 1, 2

Options:

• Monobenzyl ether of hydroquinone (MBEH) 1
• Topical 4-methoxyphenol (4MP) produces total depigmentation in 69% within 4-12 months 2
• Q-switched ruby laser achieves total depigmentation in 69% within 7-14 days 2

Special Populations

Children and Teenagers

• Topical calcineurin inhibitors are first-line due to better short-term safety profile 1, 6
• If corticosteroids used, maximum 2 months only 1, 6
• NB-UVB preferred over PUVA due to lack of clinical trial data for PUVA in children 1, 6
• No surgical treatments in this age group 1, 6
• Provide psychological counseling to both patient and parents 1, 6

Trauma-Induced Vitiligo (Koebner Phenomenon)

• Avoid all trauma to unaffected skin to prevent new lesion formation 3
• Apply adequate lubrication to reduce friction-related trauma 3
• Never perform surgery in patients with active Koebnerization 3
• Continue trauma avoidance indefinitely to prevent reactivation 3

Essential Adjunctive Care

• Sunscreens are mandatory for all depigmented areas due to increased sensitivity to sunburn and photodamage 2, 6
• Cosmetic camouflage (including fake tanning products) 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, 6

Critical Pitfalls to Avoid

• Never extend potent topical corticosteroid use beyond 2 months - skin atrophy is a common and potentially irreversible complication 1, 6
• Never perform surgery in patients with active disease, Koebnerization, or recent progression - this will exacerbate the condition 1, 2, 3
• Never exceed phototherapy safety limits - vitiligo skin is more susceptible to photodamage than psoriatic skin 1, 6
• Never overlook psychological impact - offer interventions even if patient doesn't explicitly request them 1, 2, 6

Response Monitoring

• Face and neck respond best to all therapeutic approaches 7
• Acral areas (hands and feet) are least responsive to treatment 7
• Monitor with serial photographs every 2-3 months 1, 2
• Family history of vitiligo does not affect response rate 4