What is the recommended treatment for a patient with vitiligo?

Vitiligo Treatment

For localized vitiligo (<10% body surface area), initiate treatment 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 first-line alternatives with comparable efficacy but superior safety profiles. 1

Initial Assessment

• Document disease extent with serial photographs every 2-3 months using standardized scoring systems to objectively monitor treatment response 2, 3
• Check thyroid function in all patients due to high prevalence of autoimmune thyroid disease in vitiligo 2, 3
• Assess for Koebner phenomenon (trauma-induced lesions) as this determines surgical candidacy and requires trauma avoidance strategies 4
• Evaluate skin type, as darker skin types (IV-VI) respond better to phototherapy 1

Treatment Algorithm by Disease Extent

Localized Vitiligo (<10% BSA)

First-line topical therapy:

• Potent topical corticosteroids achieve 15-25% repigmentation in approximately 43% of patients, with >75% repigmentation in 9% of cases 3, 5
• Apply clobetasol propionate 0.05% or betamethasone valerate 0.1% twice daily for no more than 2 months to prevent skin atrophy 1
• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) provide comparable efficacy to clobetasol with better safety profiles, particularly recommended for facial or eyelid involvement 1, 6

In children:

• Strongly prefer topical calcineurin inhibitors over potent steroids due to better short-term safety profile 1
• If using corticosteroids, limit to 2 months maximum 1

Response by anatomical location:

• Face and neck respond best to all treatments 7
• Trunk and extremities show moderate response 6
• Acral areas (hands, feet) are least responsive 7

Generalized Vitiligo (>10% BSA)

Narrowband UVB (NB-UVB) phototherapy is the preferred treatment:

• Superior efficacy and safety compared to PUVA 1, 3
• Reserved for patients who cannot be adequately managed with topical treatments or have significant quality of life impact 1
• Ideally used in darker skin types (IV-VI) 1
• Safety limit: no more than 200 treatments for skin types I-III 1, 2
• Monitor with serial photographs every 2-3 months 1

Alternative phototherapy:

• PUVA is second-line if NB-UVB unavailable, with safety limit of 150 treatments for skin types I-III 1
• Topical PUVA-sol shows 93% of patients achieving moderate to excellent repigmentation but has more phototoxic reactions 5

Surgical Options

Strict candidacy criteria (all must be met):

• No new lesions for at least 12 months 1, 4
• No Koebner phenomenon present 1, 4
• No extension of existing lesions in previous 12 months 1, 4
• Reserved for cosmetically sensitive sites 1

Surgical techniques in order of preference:

• Split-skin grafting provides superior cosmetic and repigmentation results compared to minigraft procedures 1, 3
• Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA is optimal but requires specialized facilities 1, 2
• Minigraft is NOT recommended due to high incidence of side effects and poor cosmetic results 1
• Surgical treatments are NOT recommended in children due to lack of safety data 3

Treatments NOT Recommended

• Topical calcipotriol monotherapy has no effect and should not be used 1
• Oral dexamethasone cannot be recommended due to unacceptable risk of side effects despite showing 81% moderate to excellent repigmentation 1, 3, 5
• Combination of topical calcipotriol with NB-UVB adds no benefit 1

Depigmentation for Extensive Disease

Reserved only for:

• Adults with >50% depigmentation or extensive facial/hand involvement 1, 3
• Patients who cannot or choose not to seek repigmentation 1
• Those who can accept permanent inability to tan 1

Options:

• Monobenzyl ether of hydroquinone (MBEH) 1
• Topical 4-methoxyphenol produces total depigmentation in 69% within 4-12 months 3

Adjunctive Management

Essential supportive measures:

• Sunscreens are mandatory as depigmented skin is more sensitive to sunburn 3, 8
• Cosmetic camouflage (including fake tanning products) improves quality of life, with DLQI improvement from 7.3 to 5.9 3
• Psychological interventions should be offered to improve coping mechanisms, as vitiligo has quality of life impact comparable to psoriasis 1, 2, 3

Special Populations

Patients with skin types I-II:

• Consider no active treatment after discussion, using only camouflage cosmetics and sunscreens if minimal cosmetic concern 1, 2

Children:

• Topical calcineurin inhibitors preferred over corticosteroids 1
• NB-UVB preferred over PUVA due to lack of safety data for PUVA in children 1
• Parents should be offered psychological counseling 1

Critical Pitfalls to Avoid

• Never extend potent topical corticosteroid use beyond 2 months to prevent skin atrophy 1, 4
• Never perform surgery in patients with active Koebnerization or recent disease progression as this will exacerbate the condition 1, 4
• Do not overlook thyroid screening, as autoimmune thyroid disease is highly prevalent 2, 3
• Failing to prevent ongoing trauma in Koebner-positive patients will result in continued disease progression regardless of treatment efficacy 4