management

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No treatment is entirely satisfactory.

Who to treat (6)

  • patients very unlikely to benefit from treatment include those with vitiligo at the extremeties eg hands and forearms, and those with longstanding vitiligo
  • patients more likely to respond to treatment include:
    • more central vitiligo eg the face, and recent onset vitiligo
  • other considerations - vitiligo in darker skin is likely to have a greater impact on the patient as it is harder to disguise. In pale skin, avoiding tanning often gives good camouflage

Topical artificial tanning creams containing dihydroxyacetone may achieve good cosmetic results.

Phototherapy:

  • narrow band ultra violet B (NB-UVB) phototherapy or PUVA should be considered in adult patients:

    • with vitiligo who do not respond to conservative therapy
    • who have widespread vitiligo
    • with localised vitiligo associated with poor quality of life
    • with darker skin types

  • serial clinical photographs (every 2-3 months) should be used to monitor the efficacy of treatment (4)
  • narrowband UVB has been used in the treatment of vitiligo (1)
    • this form of phototherapy can safely induce long remissions (3)
    • should be considered in patients (children or adults) who cannot be effectively managed with conservative treatment
    • hands and feet react poorly to NB-UVB therapy (4)

  • PUVA therapy may also be beneficial in some patients, perhaps by the photostimulation of residual melanocytes
    • however, the treatment must be maintained for several months, and there are concerns over the possible side-effects of exposure to high-intensity ultraviolet light for long periods, particularly in younger patients (1,2)
    • should be used only in adults who cannot be effectively managed with conservative treatment. PUVA is not recommended for children. If phototherapy is required for the treatment of non-segmental vitiligo, narrowband-UVB should be preferred over oral PUVA (4)

Topical therapy:

  • potent topical steroids may also promote repigmentation in recent onset vitiligo, but they make the skin very susceptible to sunburn and should not be used for more than 2 months (4)

    • as many as 64% of pediatric patients respond at least partially to the application of medium-strength to potent topical corticosteroids - however the risk of cutaneous atrophy and telangiectasia, particularly on the face and in intertriginous areas, and of ocular adverse events when applied to periorbital sites, precludes the prolonged use of topical corticosteroids (2)
    • however a review states that topical steroids reman the treatment of first choice (3)

  • topical calcineurin inhibitors (tacrolimus and pimecrolimus ointment) (5)
    • is a potential alternative therapy for childhood vitiligo - there is study evidence of the efficacy of topical tacrolimus in the treatment of childhood vitiligo (particularly involving the head and neck). There is less evidence for the less potent pimecrolimus (3)
    • in adults with symmetrical vitiligo topical pimecrolimus can be used as an alternative to a topical steroid (4)
    • neither tacrolimus or pimecrolimus are licensed for use in vitiligo (5)
    • side effects like erythema and itching can be seen for the first couple of days (5)

    • a systematic review and meta-analysis found that topical calcineurin inhibitors (tacrolimus and pimecrolimus) increased repigmentation in people with vitiligo, particularly for lesions on the face and neck (6)
      • further analyses suggested that topical calcineurin inhibitors may be more effective in children, although this was based on a small number of studies
      • the review found that combination treatment with phototherapy was also effective, however the summary of product characteristics for the topical calcineurin inhibitors advise that people using these medicines should avoid excessive ultraviolet light exposure (including solariums and phototherapy)
      • a commentary on this evidence noted (7):
        • the new evidence suggests that topical calcineurin inhibitors may be a promising treatment for vitiligo affecting the face and neck, especially in children
        • long-term safety studies of the topical calcineurin inhibitors for atopic dermatitis are reassuring, data are still lacking for vitiligo. Clinicians and patients will need to weigh up the benefits and risks of topical calcineurin inhibitors in comparison to those of other therapies
        • optimal duration and regimen of topical calcineurin inhibitors treatment are not known, although they are usually prescribed twice daily for 6 months at first instance
        • also notes the general principle that location of the depigmentation is the most important prognostic factor in predicting response to treatment for vitiligo - head-and-neck region generally demonstrates superior repigmentation compared with the extremities and trunk

Surgical treatment:

  • underlying idea of surgical intervention is to harvest and transplant functional melanocyte to the affected areas

    • should be considered for cosmetically sensitive sites in patients who do not develop new lesions, no Koebner phenomenon and no extension of the lesion in the previous 12 months
    • surgical options include - punch grafts, full-thickness skin grafts, split thickness skin grafts (best option if surgery is required), autologus epidermal dell suspension, autologus skin equivalent (4)

Bleaching of the remaining pigemented skin (depigmentation)

  • patients who have failed to respond to any treatment modality and particularly in patients with widespread loss of colour, regular daily application of 20% monobenzyl ether of hydroquinone to the remaining pigmented skin will result in removal of the pigment from normal skin making the skin all in one colour (5,8)
    • used twice a day for at least four months, response to treatment can be very slow. If it is helping, patients may need to use for much longer to reach their desired outcome (6)

Skin camouflage

  • The British Red Cross society provides specialist camouflage cover creams for individuals with scarring (from burns accidents, acne etc), vitiligo, rosacea, birthmarks, leg veins, pigmentation problems and many others.
  • trained red cross volunteers help out patients in choosing the best colour match for individuals natural skin tone and also teach them how to apply the cover creams effectively
  • these camouflage cover creams are waterproof and can be applied on all areas of the body and is suitable for men, women and children
  • when applied correctly, the cream may remain on the body for up to 4 days and on the face for 12-18 hours
  • a letter of referral from a GP, consultant or dermatology nurse specialist is necessary before carrying out treatment (5)

It should also be considered that spontaneous recovery may sometimes occur, especially in young children.

Psychological support should be offered for people with vitiligo (4)

Reference:

Last edited 10/2019