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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2019. | This topic last updated: May 05, 2017.
INTRODUCTION
Although there is no cure for the disease, the available treatments may halt the
progression of the disease and induce varying degrees of repigmentation with
acceptable cosmetic results in many cases. This topic review will discuss the
management of vitiligo. The pathogenesis, clinical features, and diagnosis of vitiligo are
discussed separately. Other pigmentation disorders are also discussed separately.
A full-body skin examination should be performed to assess the extent of the disease,
with particular attention to sites of vitiligo predilection, such as the lips and perioral area,
periocular areas, dorsal surface of the hands, fingers, flexor surface of the wrists,
elbows, axillae, nipples, umbilicus, sacrum, groin, inguinal/anogenital regions, and
knees [9]. The percentage of the body area involved can be estimated by the so-called
1 percent rule or "palm method." In both children and adults, the palm of the hand,
including the fingers, is approximately 1 percent of the total body surface area (TBSA),
while the palm excluding the fingers is approximately 0.5 percent of the TBSA. An
alternative method is the "rule of nines":
Goals of treatment — The goals of treatment for vitiligo should be set with the
Psychosocial aspects — The patient's psychologic profile and ability to cope with a
lifelong disease should be carefully evaluated at the time of treatment planning.
Psychologic support should be offered to patients if needed. (See 'Psychologic
interventions' below.)
APPROACH
Our approach to the management of patients with vitiligo is generally consistent with
published guidelines [11,12]. Topical, systemic, and light-based therapies are available
for the stabilization and repigmentation of vitiligo (table 1) [13-17]. Treatment modalities
are chosen in the individual patient on the basis of the disease severity, patient
preference (including cost and accessibility), and response evaluation. Combination
therapies, such as phototherapy plus topical or oral corticosteroids, are usually more
effective than single therapies [18]. Despite treatment, however, vitiligo has a highly
unpredictable course, and the long-term persistence of repigmentation cannot be
predicted [18].
In adult patients, alternatives to oral prednisone include oral mini-pulse therapy with
dexamethasone 2.5 mg on two consecutive days weekly for an average of three
months or intramuscular triamcinolone 40 mg in a single administration. Treatment with
triamcinolone can be repeated in four to six weeks for a maximum of three injections.
(See 'Systemic corticosteroids' below.)
In both adults and children in whom systemic corticosteroids are contraindicated, NB-
UVB phototherapy alone may be used to stabilize active vitiligo. NB-UVB is
administered two to three times weekly. (See 'Narrowband ultraviolet B phototherapy'
below.)
There are no studies evaluating the optimal duration of treatment with topical
corticosteroids. In the author's experience, topical corticosteroids can be used safely for
two to three months, interrupted for one month, and then resumed for an additional two
or three months. Others suggest a discontinuous scheme (eg, once-daily application for
Patients must be monitored closely for adverse effects of topical corticosteroids, which
include skin atrophy, telangiectasias, hypertrichosis, and acneiform eruptions. Limited
quantities should be prescribed.
Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are the preferred first-line
therapy in patients with limited disease involving the face or areas at high risk for skin
atrophy. Topical calcineurin inhibitors are generally applied twice daily. They can also be
used in combination with a topical corticosteroid for the first month or two, applying
each one once daily. (See 'Topical calcineurin inhibitors' below.)
For patients with limited disease who do not respond to topical corticosteroids or topical
calcineurin inhibitors, targeted phototherapy administered twice weekly is an option
(picture 2). (See 'Targeted phototherapy' below.)
NB-UVB phototherapy can be used for more extensive disease affecting multiple
dermatomes. For patients who do not respond to topical or light therapies, autologous
grafting is a second-line option [21]. Given the stable nature of segmental vitiligo, long-
term repigmentation can be achieved with autologous melanocyte transplantation [22].
(See 'Narrowband ultraviolet B phototherapy' below and 'Surgical therapies' below.)
Vitiligo involving 10 to 40 percent of the TBSA — For adults and children with stable
nonsegmental vitiligo involving 10 to 40 percent of the TBSA, we suggest NB-UVB as
first-line therapy (picture 3). (See 'Narrowband ultraviolet B phototherapy' below.)
NB-UVB is administered two to three times per week for an average of 9 to 12 months.
Follicular areas of repigmentation usually begin to appear after 15 to 20 NB-UVB
treatments (picture 4). If patients are responding well with continued repigmentation,
treatment can be maintained beyond 9 to 12 months and up to 24 months or 200
sessions and then tapered off. Mid-potency topical corticosteroids or topical calcineurin
inhibitors are often intermittently used in combination with phototherapy.
Home NB-UVB phototherapy is an option for patients unable to travel to the clinician's
office for weekly treatments [23]. Whole-body or portable, handheld units are available
on the market (sample brand names include Daavlin, National Biological Solarc
Systems). Patients should be provided with detailed instructions on the use of the home
phototherapy units and return for in-office clinician follow-up on a regular basis.
Vitiligo involving >40 percent of the TBSA — NB-UVB is the first-line therapy for
patients with extensive vitiligo involving greater than 40 percent of the TBSA. The
suggested regimen and duration of treatment are similar to that discussed above for
patients with more limited disease. (See 'Vitiligo involving 10 to 40 percent of the TBSA'
above.)
However, for patients with extensive recalcitrant vitiligo that does not respond to
repigmentation regimens and for patients with extensive vitiligo who do not desire
undergoing repigmentation treatments, depigmentation of residual normally pigmented
areas utilizing topical monobenzyl ether of hydroquinone (monobenzone) may be an
option. Depigmentation therapy is usually initiated with monobenzone 10% cream for
one month and then continued with monobenzone 20% cream. Monobenzone is
applied on the areas of residual pigmentation once or twice daily; we typically treat
Side effects of monobenzone are dose-dependent and include irritant contact dermatitis
and severe xerosis. Monobenzone should never be used as a lightening agent in cases
other than vitiligo. It will induce vitiligo in normal individuals.
TREATMENT MODALITIES
Topical therapies
● In a randomized trial, 100 children (55 children with facial vitiligo; 45 with nonfacial
vitiligo) were treated with topical corticosteroid (clobetasol propionate 0.05%),
tacrolimus 0.1%, or placebo for six months [33]. Among children with facial vitiligo,
the success rate (defined as repigmentation >50 percent) was the same in the
topical corticosteroid and tacrolimus groups (58 percent); however, among children
with nonfacial vitiligo, the success rate was higher in the topical corticosteroid
group compared with the tacrolimus groups (39 versus 23 percent). The success
rate in the placebo group was 7 percent.
● Another randomized trial including 44 adult patients with stable vitiligo compared
● In a 12-week open, randomized study, 53 patients with vitiligo were treated with
308 nm monochromatic excimer light (MEL) twice weekly plus 0.1% tacrolimus and
oral vitamin E daily, 308 nm MEL twice weekly plus daily oral vitamin E, or daily
oral vitamin E alone [35]. At the end of the study, good to excellent repigmentation
was achieved in 70 percent of patients in the MEL plus tacrolimus and vitamin E
group, 55 percent of those in the MEL plus vitamin E group, and in none of the
patients in the vitamin E group.
Although the increased risk of skin cancer among transplant patients treated with
systemic calcineurin inhibitors is well recognized, the use of topical calcineurin inhibitors
does not seem to be associated with an increased risk for skin or systemic
malignancies [37-39]. However, based upon animal studies documenting an increased
risk of lymphoma and skin cancers associated with topical or systemic exposure to
calcineurin inhibitors and to reports of cancer cases in children who used topical
pimecrolimus or tacrolimus for atopic dermatitis, in 2006 the US Food and Drug
Administration placed a boxed warning on the prescribing information for these
medications. Labeling also recommends that these agents should not be used in
combination with ultraviolet (UV) light therapy.
Phototherapy
Due to its lack of systemic toxicity and its good safety profile in both children and adults,
NB-UVB phototherapy has emerged as the initial treatment of choice for patients with
vitiligo involving >10 percent of the body surface area (BSA). NB-UVB can be used for
both stabilization and repigmentation of vitiligo (picture 3).
A meta-analysis of three randomized trials comparing oral PUVA with NB-UVB found a
60 percent higher proportion of participants achieving >75 percent repigmentation in the
NB-UVB group compared with the oral PUVA group [26]. The additive effect of
tacrolimus ointment (0.1%) applied once daily combined with NB-UVB in the treatment
of vitiligo has been evaluated in one randomized trial [46]. In this study, 40 patients with
stable, symmetrical vitiligo were treated with tacrolimus ointment 0.1% on one side of
their body and a placebo ointment on the other side plus whole-body NB-UVB two or
three times weekly for at least three months. In 27 of 40 patients, a greater reduction in
the target lesion area was seen in the side treated with tacrolimus compared with the
Only a few small observational studies have evaluated the duration of repigmentation in
patients with vitiligo treated with phototherapy. In a small observational study of 11
patients followed up for two years after treatment with NB-UVB phototherapy, five
maintained areas of repigmentation and six experienced complete or partial relapse of
vitiligo at previously repigmented sites [48]. In another study including 15 children
treated with NB-UVB phototherapy and followed up for a mean of 12 months after
completing treatment, six showed stable repigmentation, four further improvement, and
three complete or partial regression of the pigmentation achieved with treatment [49].
A systematic review of six randomized trials (411 patients with 764 lesions) found that
As with NB-UVB, targeted phototherapy can work synergistically with topical therapies,
including tacrolimus ointment and topical corticosteroids [12,54].
● In a study of eight patients with vitiligo, 24 symmetric vitiliginous areas were treated
with the excimer laser three times per week for a total of 24 treatments [55]. Topical
tacrolimus ointment or placebo was applied to randomized affected areas twice
daily throughout the length of the trial. Fifty percent of the areas treated with the
combination excimer laser and topical tacrolimus achieved ≥75 percent
repigmentation compared with 20 percent of the areas treated with placebo.
● In a 12-week open randomized study, 53 patients with vitiligo were treated with 308
nm MEL twice weekly plus 0.1% tacrolimus and oral vitamin E daily, 308 nm MEL
twice weekly plus daily oral vitamin E, or daily oral vitamin E alone [35]. At the end
of the study, good to excellent repigmentation was achieved in 70 percent of
patients in the MEL plus tacrolimus and vitamin E group, 55 percent of those in the
MEL plus vitamin E group, and in none of the patients in the vitamin E group.
Systemic therapies
● In one study, 81 patients were treated with prednisolone 0.3 mg/kg per day for two
months, and then the dose was progressively reduced in the subsequent three
months [56]. Control of disease progression was achieved in approximately 90
percent of patients and repigmentation in 74 percent.
Oral corticosteroids are not effective as a repigmenting therapy for stable vitiligo. In a
small open-label trial, 86 patients with progressive nonsegmental vitiligo were treated
with oral mini-pulses of betamethasone (0.1 mg/kg twice weekly on two consecutive
days for three months followed by 1 mg every month for the following three months)
alone or in combination with PUVA, NB-UVB, or broadband UVB [59]. At six months,
marked or moderate improvement was achieved in 15 percent of patients treated with
corticosteroids alone versus 85 percent of patients treated with corticosteroids plus
PUVA, 81 percent of those treated with corticosteroids plus NB-UVB, and 33 percent of
those treated with corticosteroids plus broadband-UVB.
● Ginkgo biloba – Extracts from the Ginkgo biloba leaf have long been used in
traditional Chinese medicine to treat various conditions, including cutaneous,
neurologic, and vascular disorders. The two main groups of active constituents
responsible for G. biloba's medicinal effects are terpene lactones (ginkgolides and
bilobalides) and ginkgo flavone glycosides, which are present in varying
concentrations in the leaf of the ginkgo tree. (See "Clinical use of ginkgo biloba".)
• A small randomized trial reported that the spread of vitiligo was arrested in 20
of 25 subjects receiving 40 mg of G. biloba extract three times daily for six
months but in none of 22 subjects in the placebo group [63]. In addition, 10
patients in the active treatment group but only two in the placebo group
showed >75 percent repigmentation.
• Another pilot study found significant improvements in total Vitiligo Area Scoring
Index and Vitiligo European Task Force assessment in 12 participants
following 12 weeks of supplementation with twice-daily G. biloba extract [64].
In addition to repigmentation, active depigmentation ceased in all patients with
acrofacial vitiligo.
Surgical therapies — Surgical therapies have been used for vitiligo for the past 25
years and remain viable options for patients with localized depigmented areas that have
been unresponsive to medical intervention [66-69]. They include:
Experimental therapies
The safety and efficacy of afamelanotide implants combined with NB-UVB were
assessed in an observational study of four patients with generalized vitiligo [86].
Patients were treated three times weekly with NB-UVB for one month and then
administered a series of four monthly implants containing 16 mg of afamelanotide.
Follicular and confluent areas of repigmentation were evident within two days to
four weeks after the initial implant. Afamelanotide induced fast and deep
repigmentation as well as diffuse hyperpigmentation in all cases. In a subsequent
randomized trial including 55 patients with skin type III to VI and vitiligo involving 15
to 50 percent of the BSA, patients in the NB-UVB plus afamelanotide group
achieved a greater repigmentation than patients in the NB-UVB monotherapy
group at five months (49 versus 33 percent) [87].
● Topical ruxolitinib – Ruxolitinib is a Janus kinase 1 and 2 inhibitor approved for the
treatment of intermediate- or high-risk myelofibrosis and polycythemia vera. In a
phase 2, proof-of-concept trial, topical ruxolitinib 1.5% cream was administered
twice daily to 11 adult patients with vitiligo involving at least 1 percent of the body
surface area for 20 weeks [93]. Eight of 11 patients had some response to
treatment, with a mean improvement of the Vitiligo Area Scoring Index of 23
percent. The best response was observed in patients with facial vitiligo. The main
adverse effect was erythema over the treated lesion.
CAMOUFLAGE
Cosmetic camouflage can be beneficial for patients with vitiligo affecting exposed areas
such as the face, neck, and hands. Camouflage products include foundation-based
cosmetics and self-tanning products containing dihydroxyacetone (DHA). DHA-based
products are most popular because they provide lasting color for up to several days and
are not immediately rubbed off onto clothing. Tattooing or micropigmentation should be
avoided, given the risk of koebnerization and oxidation of tattoo pigment causing further
dyschromia. (See "Vitiligo: Pathogenesis, clinical features, and diagnosis", section on
'Koebner phenomenon'.)
PROGNOSIS
● For patients with vitiligo involving <10 percent of the total body surface area
(TBSA), we suggest topical corticosteroids as initial therapy (Grade 2C). Topical
corticosteroids are applied once daily for two to three months and then interrupted
for one month. Topical calcineurin inhibitors are preferred to topical corticosteroids
for body areas at increased risk of atrophy. Targeted phototherapy is an option for
patients with limited vitiligo who do not respond to topical therapies. (See 'Vitiligo
involving <10 percent of the TBSA' above.)
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