Vitiligo Treatment

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

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

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