Vitiligo Treatment
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
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