Approach

While vitiligo is not life-threatening, the quality of life and self-esteem in patients with vitiligo may be severely compromised.[39][40]

The therapeutic goal is to improve the appearance of the affected skin. This can be approached in different ways, depending on the type of vitiligo, extent of disease, and wishes of the patient.

Regardless of the chosen treatment, an assessment of the patient’s perspective should be included as part of the evaluation. An option of no treatment should be considered and discussed with the patient. Psychological or psychiatric support should be considered in all patients.[41]

Sun protection and camouflage advice

Patients should be advised to:[42]

  • Practice sun protection with high factor sunscreen offering UV-A and UV-B protection

  • Avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).

Cosmetic coverage may be an adequate choice of treatment in some patients. The strong contrast between affected and unaffected skin in people with darker pigmentation makes the disease more visible, for which make-up products can be customised to match the patient's skin tone.

Over-the-counter self-tanning products containing dihydroxyacetone may help to camouflage affected skin in patients with Fitzpatrick type I-IV skin.[43]

Segmental vitiligo/limited vitiligo

Therapeutic options for this patient population include topical therapy, phototherapy, and surgery.

Topical therapies

In segmental or non-extensive/limited vitiligo, topical corticosteroids and calcineurin inhibitors are recommended as a first-line treatment.[42] 

One Cochrane review found that topical corticosteroids are the most effective and safest treatment for localised vitiligo.[44] They work by suppressing the immune response against melanocytes, and can be used in adults and children. Topical corticosteroids have the best response on sun-exposed areas, in dark skin, and in recent lesions.[42]

Potent corticosteroids (e.g., clobetasol, mometasone) should be tested for 3 months to evaluate the response.[42] In some areas - particularly the face, genitals, axillae, and breasts - prolonged treatment with a topical corticosteroid may result in corticosteroid-induced atrophy and hypertrichosis. Therefore, patients should be evaluated regularly for adverse effects such as skin thinning, purpura, and striae distensae.[45]

Therapy can be used on a discontinuous basis to provide benefit and potentially avoid adverse effects.[42] One useful approach is to use topical corticosteroids twice daily for 1 week, and then no treatment for 1 week. 

One systematic review and meta-analysis concluded that topical calcineurin inhibitor monotherapy is effective, particularly in children and on lesions on the face and neck.[46] Topical tacrolimus can be used as an alternative to topical corticosteroid (particularly in patients with facial vitiligo), thereby avoiding corticosteroid-related adverse effects, or during the off-week when using corticosteroids discontinuously.[41][47]

Phototherapy

Phototherapy devices that deliver light in the narrow-band UV-B range (peak at 308 nm) can be considered as second-line treatment in patients who do not respond to topical therapies.[41][42][48][49]

Treatments are given 2 to 3 times weekly for several months. This avoids unnecessary adverse effects due to total body irradiation.

Surgery

Surgical options may be considered in areas that do not respond, especially those areas with a high cosmetic impact, if segmental vitiligo is stable.[41][42] Surgical procedures involve melanocyte transfer from a normally pigmented autologous donor site to the site of melanocyte loss. Several techniques are available to achieve this, including punch grafting, epidermal blister grafting, or ultrathin epidermal sheet grafting.

UK guidelines recommend that the disease be inactive for at least 12 months prior to surgery.[41] 

In meta-regression analyses, successful surgical outcome (>90% repigmentation) was associated with stable segmental disease and younger patient age.[50] 

Surgery is relatively contraindicated in areas such as dorsum of hands.[42] 

Widespread vitiligo

Patients with extensive vitiligo may benefit from phototherapy (combined with topical or systemic therapy as necessary), systemic corticosteroids, surgery, or depigmentation therapy.

Phototherapy

Narrow-band UV-B therapy is a safe and effective treatment for widespread vitiligo and is recommended as a first-line treatment option in these patients.[41] It should be continued for at least 3 months, and for up to 12 months if tolerated, to achieve maximal response.[41][42]

Narrow-band UV-B therapy can be combined with topical therapies (i.e., corticosteroids or tacrolimus) or systemic (i.e., corticosteroids) therapies as necessary, which may result in improved efficacy.

Corticosteroids

Systemic corticosteroids are recommended to stabilise disease if the condition is progressing rapidly or progresses despite therapy.[42][41]

Minipulse therapy (i.e., the intermittent administration of larger doses) or alternate-day dosing has been advocated when using systemic corticosteroids.[42][51]

Surgery

Surgical options may be considered in areas that do not respond, especially those areas with a high cosmetic impact, if widespread (non-segmental) vitiligo is stable.[41][42] Surgical procedures involve melanocyte transfer from a normally pigmented autologous donor site to the site of melanocyte loss. Several techniques are available to achieve this, including punch grafting, epidermal blister grafting, or ultrathin epidermal sheet grafting.

Guidelines recommend that the disease be inactive for at least 12 months prior to surgery, and that patients with widespread vitiligo should not have a history of Koebner's phenomenon.[6][41][42]

In meta-regression analyses, successful surgical outcome (>90% repigmentation) was associated with stable segmental disease and younger patient age.[50] 

Surgery is relatively contraindicated in areas such as dorsum of hands.[42]

Depigmentation therapy

 Depigmentation techniques could be considered as a last option in patients with unresponsive, widespread (i.e., >50%), or highly visible recalcitrant vitiligo of face or hands.[42] Monobenzone (the monobenzyl ether of hydroquinone) has been used to permanently depigment unaffected skin in patients with vitiligo. 

Treatment induces depigmentation that usually starts at the application site, but eventually affects remote areas of the body. This may take up to 1 year and is not always permanent, although re-treatment is possible if repigmentation occurs. Depigmentation is associated with permanent photosensitivity.

Assessment of depigmentation success should be measured using percentage of repigmentation quartiles (0% to 25%, 26% to 50%, 51% to 79%, 80% to 100%) and the Vitiligo Noticeability Scale.[52]

Laser-assisted melanocyte removal may be considered for areas that do not respond to chemical depigmentation, or for small pigmented islands. The Q-switched ruby laser is well suited for this approach, and works much faster than chemical depigmentation.[53][54]

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