How Can I Treat Vitiligo?

How can I treat vitiligo? 

Key points 

• Many different modalities may be used to treat vitiligo. 

• Treatment should always start with efficacious and safe approaches and at the same time with less aggressive  and cost/effective modalities. 

• A targeted UVB therapy (308 or 311 nm) alone or associated with topical steroids or with topical calcineurine  inhibitors represents the most efficacious and safe approach if less than 15% of the skin is affected. 

• Second-, third- and fourth-line therapies must be discussed by the dermatologist and vitiligo-affected subject in  an open and constructive way, keeping in mind that the less aggressive and the most cost/effective modalities  are always the first choice. 

• Don’t feel frustrated if you don’t achieve the goal with the first-line treatment: discuss other options with your  dermatologist and go on according to your new treatments. 

• Be always optimistic: you have very many chances to find the right treatment for your vitiligo! 

Answer 

Choosing a treatment for vitiligo can be  difficult, sometimes overwhelming. In general,  first-line therapy should be safe, effective,  minimally invasive, and cost efficient. More  complex, invasive, and time- consuming options  should be reserved for subjects with recalcitrant  disease. Each therapeutic modality should be tried  for a sufficient period of time because the  initiation of pigmentation varies and is in general  rather slow. An effective therapy should be  continued as long as there is an improvement or  the lesions repigment completely. 

We are in need of consistent data on  maintenance regimens or the long-term persistence of pigmentation with any of the  recommended therapies. 

How to treat vitiligo: 

First-line. There are many topical and some  oral agents that are inexpensive, easy to use, and  effective at halting disease progression and  inducing repigmentation. Corticosteroids (CSs) are  consistently reported as the most effective single  topical agent, with Calcineurine Inhibitors (CIs)  being always a close second. Due to the possibility  of local side effects of CSs, scheduled drug  holidays are recommended. 

In our experience focused micro- phototherapy  (using 308 or 311 nm emission device) is the  recommended treatment either when used alone  and in combination with topical therapy. Topical  CIs are effective as monotherapy in patients who  do not tolerate topical CSs. 

They are also effective for recalcitrant lesions  on the extremities when applied nightly under  occlusion. Current data does not support  monotherapy with topical vitamin D3 analogs, but  Vitamin D3 can augment the effect of topical  steroids even in previously steroid non-responsive  patients. Topical L-phenylalanine, topical  antioxidants and mitochondrial stimulating cream,  associated with natural sunlight with oral khellin  have all been suggested as efficacious alternative  first-line therapies. 

When administered in patients with an active  disease, a short course of oral or intravenous  steroids can arrest vitiligo progression and induce  repigmentation in the majority of patients.  However, the optimal dose to maximize benefits  and reduce the incidence of side effects has yet to  be determined. 

Second-line. A second - line treatment is  considered when “first-line” one fails. Given the  cost, time commitment required by patients and  staff, and higher incidence of side effects,  phototherapy is recommended as a second-line  therapy for patients who fail conservative first -  line treatment(s). Focused micro- phototherapy  (308 or 311 nm) should be electively offered  when cutaneous involvement is less than 15%.  Narrow Band Ultra Violet type B (NBUVB)  phototherapy produces the greatest clinical  improvement compared to other forms of light  therapy; combinations with topical therapy work  better than either alone. Topical C Is with NBUVB phototherapy have the  best clinical outcomes compared to other topical  adjuvant therapies. It is uncertain whether adding  a vitamin D3 analog to NBUVB phototherapy  enhances the effects. While inferior to NBUVB in  terms of clinical response, both UVA and  broadband UVB phototherapies with various  adjuvant therapies are beneficial as alternative  second-line treatments. 

Third-line. Targeted phototherapy with the 308  nm Monochromatic Excimer Laser (MEL) is an  effective as monotherapy, superior to NBUVB phototherapy when compared side by side.  However, it should be reserved for those patients,  who fail NBUVB phototherapy, except in very  limited disease, or in patients, who can afford the  time and cost of the therapy. MEL works best in  combination with topical CSs or CIs. 

Fourth-line. Surgery should be offered when  lesions persist despite appropriate therapy. There  are many different surgical techniques available.  While the specific technique will depend on  individual patient characteristics and the custom  practice of the expert surgeon, it can provide  excellent cosmetic results for limited lesions  recalcitrant to other modalities. Special populations. 

Although patients with  Segmental vitiligo (SV) have been studied  alongside those with Non-Segmental Vitiligo  (NSV), it is unclear how applicable study results  refer to this population. SV tends to be more  stable and recalcitrant to treatment. The He-Ne  laser seems to be more effective in this  population. Generalized/universal vitiligo may also  require tailored treatment. The extent of the  disease can be so great that it may be nearly  impossible to provide cosmetically pleasing  repigmentation. For these patients, depigmenting  agents should be offered and discussed  extensively for their non-reversible effects. Considerations. At all stages of therapy, keep in  mind that vitiligo can be a lifelong disease that  may extensively damage one’ s psychosocial sense  of wellbeing. Acknowledging this hidden impact of  the disease on quality of life and offering support  for dealing with it will improve the physician -  patient relationship greatly and promote a positive  outcome. Camouflage can always provide  temporary cosmetic relief, and psychotherapy  should be offered to help patients deal with the  psychological disease burden. 

An approach to treating a patient with vitiligo  (treatment algorithm): we have divided treatment  options into first-, second-, third-, and fourth-line  options. The treatment order was determined by  the level of evidence in literature for each  treatment. Treatment options for special cases are  also included. 

Focused Micro-Phototherapy (PMP) – 308 or 311 nm – has been included for  efficacy and safety reasons in the “first-line” offer.