What is the treatment for vitiligo in adults or adolescents with stable or slowly progressive disease?

Treatment of Vitiligo

For adults and adolescents with stable or slowly progressive vitiligo, initiate treatment with potent topical corticosteroids (such as clobetasol propionate 0.05%) applied twice daily for a maximum of 2 months, or alternatively use topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) which offer comparable efficacy with superior safety, particularly for facial involvement. 1, 2

Initial Assessment

Before starting treatment, perform the following baseline evaluations:

• Check thyroid function tests in all patients, as autoimmune thyroid disease occurs in approximately 34% of vitiligo patients 2, 3
• Document disease extent with serial photographs every 2-3 months to objectively monitor treatment response 1, 2
• Assess for Koebner phenomenon (trauma-induced lesions) and disease stability, which determines surgical candidacy later 2

Treatment Algorithm by Disease Extent

For Limited/Localized Vitiligo

First-line topical therapy:

• Potent or very potent topical corticosteroids (clobetasol propionate 0.05% or betamethasone valerate 0.1%) applied twice daily achieve 15-25% repigmentation in approximately 43% of patients 1, 2
• Critical limitation: Never extend use beyond 2 months due to high risk of skin atrophy 1, 2

Alternative first-line option:

• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) applied twice daily provide comparable efficacy with better safety profile 1, 2
• Strongly preferred for facial or eyelid involvement and in children due to superior short-term safety 1, 2

For Widespread/Generalized Vitiligo

Phototherapy is the preferred treatment:

• Narrowband UVB (NB-UVB) is superior to PUVA in both efficacy and safety 1, 2
• Reserve for patients who cannot be adequately managed with topical treatments, have widespread disease, or localized disease with significant quality of life impact 1
• Ideally reserved for darker skin types (IV-VI) where repigmentation is more visible 1
• Safety limits: Maximum 200 treatments for skin types I-III; upper limits for skin types IV-VI are not defined 1, 2
• Monitor with serial photographs every 2-3 months 1

Surgical Options for Stable Disease

Strict eligibility criteria must be met:

• Disease must be completely stable for at least 12 months with no new lesions, no Koebner phenomenon, and no extension of existing lesions 1, 2
• Never perform surgery in patients with active disease or recent progression 2

Surgical technique selection:

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

Systemic Therapy

Oral dexamethasone CANNOT be recommended due to unacceptable risk of side-effects despite some evidence for arresting progression 1, 3, 4

Depigmentation for Extensive Disease

Reserved only for severely affected patients:

• Consider depigmentation with monobenzyl ether of hydroquinone (MBEH) only for patients with >50% depigmentation or extensive facial/hand involvement 1, 2
• Only appropriate for patients who cannot or choose not to seek repigmentation and can accept permanent inability to tan 1, 2
• Topical 4-methoxyphenol produces total depigmentation in 69% within 4-12 months 2

No Active Treatment Option

For adults with very light skin (types I-II):

• After discussion, consider using no active treatment other than camouflage cosmetics and sunscreens as the initial approach 1
• This is appropriate when vitiligo causes minimal cosmetic concern 1

Essential Supportive Measures

All patients should receive:

• Sunscreen protection as depigmented skin is more susceptible to sunburn and photodamage 1
• Camouflage cosmetics which improve quality of life (DLQI improvement from 7.3 to 5.9) 2
• Psychological interventions to improve coping mechanisms, as vitiligo has quality of life impact comparable to psoriasis 1, 2
• Parents of children with vitiligo should be offered psychological counseling 1

Critical Pitfalls to Avoid

• Never extend potent topical corticosteroid use beyond 2 months to prevent skin atrophy 1, 2
• Never perform surgery in patients with active Koebnerization or recent disease progression 2
• Do not use topical calcipotriol monotherapy as it has no effect 2
• Avoid oral dexamethasone due to unacceptable side-effects 1, 3, 4

Monitoring Treatment Response

• Document with serial photographs every 2-3 months using standardized scoring systems 1, 2
• Reassess treatment choice if no response after 2 months of topical therapy 1
• Consider referral to dermatology for phototherapy if topical treatments fail 1