vitiligo
VITILIGO
Vitiligo is an acquired, often familial, melanocytopenic disorder that produces focal depigmentation of the skin.
About half of the patients has onset of lesion before the age of 20.
It is a progressive disease wherein spontaneous repigmentation may occur within 6 months.
Precipitating factors include emotional stress, sunburn, chemical exposure, skin trauma, inflammation, irritation or rash that may precede the lesions by 2-3 months.
Lesions are white-colored macules or patches with well-defined borders and otherwise normal skin surface.

Pharmacotherapy

Repigmentation Therapy

Calcineurin Inhibitors

  • Eg Pimecrolimus, Tacrolimus
  • Mode of action: inhibits cytokines production & enhances melanocyte migration
  • Causes less skin atrophy compared to steroids
  • Should only be used as 2nd line treatment because of increased incidence of lymphoma & skin cancer
  • Pimecrolimus
    • Alternative therapy to Clobetasol
  • Tacrolimus (Topical)
    • Preferred agent for treating vitiligo in younger patients & in skin-sensitive areas eg eyelids
    • Several studies have shown repigmentation in localized vitiligo
    • One small study showed that topical Tacrolimus was almost as effective as topical Clobetasol in treating localized vitiligo in children

Corticosteroid (Topical)1

  • Eg Clobetasol, Desonide, Fluocinolone, Mometasone, Methylprednisone aceponate
  • May be useful for localized vitiligo
  • Lower-potency corticosteroids may be used for childn <2 yr who are not candidates for topical PUVA
  • Effects: May be effective repigmenting agents
    • 3-4 mth are needed to see optimal results
    • Clobetasol propionate may result in better repigmentation when other topical steroids have failed
  • Application is only once daily
  • Use of mid- or lower-potency corticosteroids are preferable considering side effects of long-term high-potency corticosteroids
    • Use caution when applying to the face & flexors
    • Should not be applied to eyelids or periorbital areas due to the risk of steroid-induced glaucoma & cataracts
    • Monitor response w/ Wood’s lamp exam at 6-wk intervals & examine for possible side effects
    • Photographs may assist in evaluating therapy
  • Stop treatment if no response after 3 mth
  • Treatment is continued if repigmentation occurs
1Many low-high potency topical corticosteroids are available. Please see prescribing information for specific formulations in the latest MIMS. For potency listing, please refer to the Dosage Guideline section in the Atopic Dermatitis or Psoriasis Treatment Plan.

Corticosteroid (Systemic)

  • Eg Betamethasone, Dexamethasone
  • Studies using pulse therapy w/ systemic steroids showed significant efficacy against unstable vitiligo by slowing disease activity

Photochemotherapy

  • In approximately 70-80% of patients, repigmentation occurs following Psoralens + UVA (PUVA) treatment
  • 20% of patients achieve complete repigmentation
  • Topical PUVA
    • Considered for patients w/ localized vitiligo (<20% of the BSA) or for child >5 yr old w/ localized vitiligo
    • Psoralens lotion is diluted to a 0.01-0.1% soln & is applied to affected skin prior to UVA exposure
  • Oral PUVA
    • Considered for patients w/ more extensive vitiligo (>20% of body involvement) & for persons recalcitrant to topical therapy
    • Not recommended for children <12 yr
    • Oral Psoralen is taken 90-120 min prior to UVA exposure
  • Heliotherapy/Psoralens & sunlight (PUVASOL)
    • Trioxsalen is taken 2-4 hr prior to outdoor sunlight exposure (11 am-3 pm; may start at 10 am in tropical areas)
    • Photographs may assist in evaluating therapy

Photochemotherapy

  • Khellin + UVA (KUVA)
    • Less phototoxic & mutagenic compared to PUVA
    • Topical administration of Khellin is preferred; oral Khellin administration is discouraged because of increased incidence of liver toxicity
    • Further studies are needed to establish efficacy of outdoor sunlight exposure w/ KUVA treatment

Depigmentation therapy

  • Considered for patients w/ extensive & refractory vitiligo, who are willing to undergo irreversible depigmentation
    • May also be used in patients who have facial vitiligo & are unwilling to attempt repigmentation
  • Monobenzyl ethyl ester, a Hydroquinone derivative, a bleaching agent, is used
  • Effects: Remaining pigment is removed from normal skin by destroying the melanocytes
    • Results are usually evident w/in 1 mth of therapy & complete depigmentation takes 6-12 mth
  • Patients must understand that this is a permanent & irreversible procedure
    • Permanent photosensitivity results from treatment
  • Other depigmenting agents: Methoxyphenol (Mequinol), 88% Phenol, Imatinib, Imiquimod, Diphencyprone
    • Further studies are needed to prove the efficacy of these agents for depigmentation therapy in vitiligo

Non-Pharmacological Therapy

Sunscreens

  • Patient should use sunscreen w/ SPF >15 that protects against both UVA & UVB rays on all exposed skin
    • Vitiliginous areas are easily sunburned
    • Sunburn can cause the depigmentation area to extend
  • Patient should avoid outdoor activities from 11 am-3 pm or use appropriate clothing for sun protection

Camouflage Cosmetics

  • Eg Stains/dyes, self-tanning products, whitening lotions, tinted cover creams, foundations, colorants/dyes for white hair
  • Quick-tanning preparations that contain dihydroxyacetone (DHA) may be used
    • These preparations are esp useful on areas, eg the eyelids, where potent topical corticosteroids or photochemotherapy should not be used

Phototherapy

  • Eg UVB, narrow band UVB, excimer laser
  • New onset, facial & neck lesions (except eyelids) tend to have the best results
  • Vitiligo of the hands, feet & over bony prominences respond poorly to treatment
  • Effects: Causes inflammation that promotes activation & migration of melanocytes from a melanocytic reservoir (eg hair follicles) causing repigmentation
    • At least 2-3 mth are needed to see the results & therapy should be continued for at least 1 yr to gain maximum results
  • If there is no effect after 6 mth of therapy or new/enlarged macules appear, treatment should be discontinued
  • Photographs may assist in evaluating therapy

Narrow band UVB (NBUVB)

  • Recommended 1st line treatment for patients w/ active &/or widespread vitiligo
  • W/ lesser adverse effects & more efficacious compared to PUVA & other phototherapies
  • NBUVB is a fairly effective treatment for symmetrical vitiligo esp on the face, trunk & proximal extremities

308-nm Excimer Laser

  • Targeted phototherapy w/ excimer laser may be an option for patients w/ chronic stable vitiligo
  • More prospective studies are needed to further evaluate this treatment modality

Depigmentation

  • Eg Q-switched ruby/alexandrite lasers, cryotherapy
  • Q-switched lasers are indicated for recalcitrant cases, patients w/ Koebner phenomenon
    • May be used w/ Methoxyphenol
  • Cryotherapy may be used for recalcitrant cases
    • May be given w/ or w/o Methoxyphenol
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