What is the recommended treatment algorithm for vitiligo, including topical corticosteroids, topical calcineurin inhibitors, narrowband UVB phototherapy, systemic corticosteroids, and JAK inhibitors for limited versus extensive disease?

Treatment Algorithm for Vitiligo

Initial Assessment and Classification

Begin with topical therapy for limited disease and escalate to phototherapy for extensive or refractory cases, with JAK inhibitors now available as first-line topical therapy for facial involvement. 1, 2

Before initiating treatment, document disease extent with serial photographs using VASI or VETF scoring tools every 2-3 months, assess skin type (I-VI), and check thyroid function due to high prevalence of autoimmune thyroid disease in vitiligo patients. 1, 2, 3

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First-Line Topical Treatment

For Adults with Recent-Onset or Limited Disease

• Topical ruxolitinib cream is now approved as first-line therapy for non-segmental vitiligo with facial involvement in adults and children ≥12 years, representing the most recent advancement in vitiligo management. 4

• Potent or very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) should be used for a maximum of 2 months only due to high risk of skin atrophy as a common side effect. 1, 2

• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) are preferred alternatives with comparable efficacy but superior safety profiles, particularly for facial or sensitive areas. 1

  • Pimecrolimus demonstrated similar repigmentation to clobetasol (50-100% for trunk/extremity lesions) with better side-effect profile (only stinging vs. atrophy). 1

For Children and Teenagers (<18 years)

• Topical calcineurin inhibitors should be strongly preferred over corticosteroids as first-line therapy due to their comparable efficacy but superior safety profile, avoiding irreversible skin atrophy. 1, 2, 5

• If calcineurin inhibitors are unavailable, use potent corticosteroids for maximum 2 months only. 1, 2, 5

What NOT to Use

• Topical calcipotriol (vitamin D analogue) as monotherapy is not recommended due to lack of efficacy—21 of 23 patients showed no repigmentation after 3-6 months. 1

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Second-Line Phototherapy

Indications for Escalation

Phototherapy should be considered when: 1, 5

• Topical treatments fail after adequate trial (2-3 months)
• Widespread/extensive vitiligo is present
• Localized disease significantly impacts quality of life
• Patient has darker skin types (IV-VI) where cosmetic impact is greatest

Phototherapy Protocol

• Narrowband UVB (NB-UVB) is preferred over PUVA due to greater efficacy, superior safety profile, and established evidence in all age groups. 1, 5

• Safety limits are more stringent than psoriasis due to increased susceptibility to photodamage in depigmented skin: 1

  • Maximum 200 treatments for skin types I-III with NB-UVB
  • Maximum 150 treatments for skin types I-III with PUVA
  • Evidence lacking for upper limits in skin types IV-VI

• Combination therapy with topical corticosteroids or calcineurin inhibitors during phototherapy is generally more successful than monotherapy. 6, 4

• Monitor response with serial photographs every 2-3 months. 1, 2, 5

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Systemic Therapy

What NOT to Use

• Oral dexamethasone to arrest progression cannot be recommended due to unacceptable risk of side-effects. 1, 5

Emerging Options

• Oral JAK inhibitors are the most advanced emerging therapeutic option for extensive non-segmental vitiligo in clinical development, though not yet standard of care. 4

• Oral corticosteroid mini-pulses may be combined with whole-body NB-UVB in rapidly progressive cases, though this requires careful risk-benefit assessment. 4

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Surgical Treatment

Patient Selection Criteria

Surgical treatments are only appropriate when ALL of the following are met: 1, 3

• No new lesions for at least 12 months
• No Koebner phenomenon present
• No extension of existing lesions for 12 months
• Cosmetically sensitive sites
• Patient age ≥18 years (no studies in children/adolescents)

Surgical Techniques (in order of preference)

1. Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA is optimal but requires special facilities. 1

2. Split-skin grafting gives better cosmetic and repigmentation results than minigraft procedures. 1, 3

3. Suction blister transfer shows benefit but gives less coverage than split-skin grafting. 1

4. Minigraft is NOT recommended due to high incidence of side-effects and poor cosmetic results. 1

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Depigmentation (Last Resort)

Depigmentation with p-(benzyloxy)phenol (MBEH) should be reserved for patients with: 1

• 50% depigmentation OR

• Extensive depigmentation on face/hands AND
• Cannot or choose not to seek repigmentation AND
• Can accept permanence of never tanning

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Special Populations

Light Skin Types (I-II)

For adults with skin types I-II, it is appropriate to consider no active treatment initially, using only camouflage cosmetics and sunscreens after discussion with patient. 1

Trauma-Induced Vitiligo (Koebner Phenomenon)

• Avoid all trauma to unaffected skin to prevent new lesion formation—ongoing injury will continue generating new patches regardless of treatment efficacy. 3
• Apply adequate lubrication to reduce friction-related trauma. 3
• Never perform surgical treatments in patients with active Koebnerization, as this will exacerbate the condition. 3

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Essential Adjunctive Care

Psychological Support (Critical Component)

• Psychological interventions should be offered to improve coping mechanisms, as vitiligo causes significant psychological distress and impairment of quality of life. 1, 2, 3

• For children/teenagers, offer psychological counseling to both patient AND parents, as family support is crucial for treatment adherence. 1, 2, 5

Sun Protection

• Recommend high SPF sunscreens for all depigmented areas due to increased sensitivity to sunburn and photodamage from absence of melanin. 2, 3

Cosmetic Camouflage

• Cosmetic camouflage and fake tanning products can significantly improve quality of life and should be offered to all patients. 3, 6

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Maintenance and Relapse Prevention

Following successful repigmentation, application of calcineurin inhibitors is recommended to prevent recurrences. 6

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Critical Pitfalls to Avoid

• Never extend potent topical corticosteroid use beyond 2 months—skin atrophy is a common and potentially irreversible side effect. 1, 2, 3

• Never use oral dexamethasone for disease stabilization due to unacceptable systemic side effects. 1, 5

• Never perform surgery in children/adolescents—no safety studies exist in this population. 1, 5

• Never start phototherapy as first-line in children without trying topical treatments first. 5

• Never ignore psychological impact—quality of life should be the most important outcome measure in vitiligo treatment. 1, 2

• Early initiation of treatment is associated with more favorable prognosis—do not delay therapy once diagnosis is established. 6