Question 11. How can I treat vitiligo?

Question 11. How can I treat vitiligo?

Key points

  • Many different methods 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 methods.
  • 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!

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 a ,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 le-sions 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.

Author: Prof. Torello Lotti, MD

More information on current vitiligo treatments

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