What oral treatment options are available for a patient with widespread vitiligo and significant impact on quality of life?

Oral Treatment for Widespread Vitiligo with Significant Quality of Life Impact

Oral PUVA (psoralen plus UVA phototherapy) should be considered as the primary oral treatment option for adults with widespread vitiligo and significant quality of life impact, particularly in patients with darker skin types (IV-VI), though narrowband UVB phototherapy without oral medication is generally preferred when phototherapy is indicated. 1

Critical Limitation of Oral Corticosteroids

• The British Association of Dermatologists explicitly recommends against oral dexamethasone for vitiligo due to unacceptable side effects (Grade B recommendation). 2
• Oral systemic corticosteroids have extremely limited evidence and significant safety concerns for isolated vitiligo treatment. 2
• Low-dose oral prednisolone may be considered only for actively spreading disease in carefully selected patients, with a maximum 4-month tapered course, and only after exhausting topical options and phototherapy. 2

Oral PUVA: When to Consider

• PUVA therapy should be reserved for adults with widespread vitiligo or localized vitiligo with significant quality of life impact who cannot be adequately managed with more conservative treatments. 1
• PUVA is not recommended in children. 1
• Ideally reserved for patients with darker skin types (IV-VI) where repigmentation is more visible and psychologically beneficial. 1

Important Counseling Points Before Starting Oral PUVA

• Patients must understand that PUVA does not alter the natural history of vitiligo. 1
• Not all patients respond to treatment—hands and feet respond poorly in all patients. 1
• At 12-month follow-up, more than 25% of PUVA-treated patients had vitiligo worse than baseline, though a similar proportion maintained >75% improvement. 1
• Treatment limits exist due to photodamage risk: arbitrary limit of 150 treatments for skin types I-III, potentially higher for types IV-VI. 1

Monitoring Requirements for Oral PUVA

• Serial clinical photographs every 2-3 months are mandatory to identify non-responders or disease progression during treatment. 1
• Discontinue if inadequate response or progression occurs. 1

Oral Ginkgo Biloba: Alternative Adjunctive Option

• Ginkgo biloba extract may be considered as an adjunctive option with minimal side effects, particularly for acrofacial vitiligo. 2
• One satisfactory RCT showed ginkgo biloba was superior to placebo for achieving >75% repigmentation (RR 4.40,95% CI 1.08 to 17.95). 3
• Has antioxidant and immunomodulatory properties that may benefit vitiligo. 2

Why Narrowband UVB is Preferred Over Oral PUVA

• If phototherapy is indicated for nonsegmental vitiligo, narrowband UVB should usually be used in preference to oral PUVA. 1
• NB-UVB demonstrates superior efficacy, better color match of repigmented skin, and fewer systemic side effects compared to oral PUVA. 1
• NB-UVB causes less nausea (RR 0.13,95% CI 0.02 to 0.69) and erythema (RR 0.73,95% CI 0.55 to 0.98) compared to PUVA. 3
• At 12-month follow-up, 36% of NB-UVB patients maintained >75% repigmentation versus only 24% with PUVA. 1

Essential Pre-Treatment Assessment

• Check thyroid function including anti-thyroglobulin antibodies before initiating any systemic treatment, as autoimmune thyroid disease occurs in approximately 34% of vitiligo patients. 4, 2
• Document baseline disease extent with photographs for objective monitoring. 2

Common Pitfalls to Avoid

• Do not prescribe oral corticosteroids for stable or slowly progressive vitiligo—topical treatments and phototherapy remain first-line. 2
• Do not start oral PUVA without first attempting topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) or calcineurin inhibitors (tacrolimus 0.1%). 4, 2
• Do not exceed 150 PUVA treatments for skin types I-III without explicit patient consent and careful risk-benefit discussion. 1
• Avoid oral dexamethasone entirely for isolated vitiligo due to unacceptable side-effect profile. 2

Treatment Algorithm for Widespread Vitiligo with QOL Impact

1. First-line: Potent topical corticosteroids or calcineurin inhibitors for 2 months maximum. 4, 2
2. Second-line: Narrowband UVB phototherapy (no oral medication required), up to 200 treatments for skin types I-III. 1, 5
3. Third-line: Oral PUVA only if NB-UVB fails or is unavailable, particularly for darker skin types. 1
4. Adjunctive consideration: Ginkgo biloba extract for minimal-risk supplementation. 2, 3
5. Rarely: Low-dose oral prednisolone for actively spreading disease, maximum 4-month taper, only after above options exhausted. 2

Psychological Support

• Offer psychological interventions as vitiligo can be cosmetically disfiguring and stigmatizing, significantly impacting quality of life. 4, 5