There is no cure for vitiligo but it can be managed effectively through many different approaches. The treatment options for vitiligo have undergone a sea change over the last two or three decades and dermatologists are now in a much better position to manage this disease than in the past.
It is important to note that newly appeared depigmented spots can be efficiently treated soon after onset, typically within the first six weeks of the appearance of white lesions. Early treatment will produce better and longer lasting results, which is why medical care should be sought as soon as possible to stop the patches from spreading.
It is also important to remember there is no one therapy that works for everyone. Vitiligo is a complex disease and requires a complex, prolonged therapy. There are also some people who do not seem to respond to any therapy.
A number of conventional and experimental treatments are currently available for vitiligo that give good repigmentation results in about 70% of cases. In general, independent of the treatment used, better results are more common in younger patients and in patients who have had the condition for a shorter period. Existing therapies produce satisfactory results on the face and neck, are less effective on trunk and limbs, and poor on the hands and feet.
Early, first-line treatment options include the following:
- Topical treatments - medicines applied to the skin, such as: corticosteroid creams, immunosuppressant creams, or topical drugs.
- Phototherapy - a medical procedure in which your skin is carefully exposed to ultraviolet light.
- Climatotherapy - a natural treatment, primarily relying on the Dead Sea mineral waters and sun exposure.
Second-line treatment options include the following:
- Systemic treatments, as an injectable or oral drug.
- Surgical therapies that transfer parts of normal skin to cover vitiligo areas.
- Depigmentation, a permanent loss of the remaining color, as a last resort.
Some cover-up makeups can mask vitiligo. You may need to experiment with several brands of concealing cosmetics before finding the product that works best for you.
Vitiligo should be approached as a chronic disease - although it can not be cured at present, it can be managed successfully in many cases. Even if vitiligo is treated successfully, it may reoccur without warning at any time, and the definite causes or triggers are, as yet, not specifically known. Vitiligo patients will need a regular, life-long "maintenance" therapy that may include vitamins B6 or B12, Ginkgo biloba (see photo above) or other, typically prescribed by the dermatologist based on blood test results and regular check ups.
These are treatments that you apply to your skin. Results may vary from patient to patient, but on average 50 percent of patients have a satisfying response to topical therapies and restore pigmentation for prolonged periods. The duration of treatment is about four to six months, and patients may need maintenance therapy to prevent relapse.
The type and strength of prescribed topical treatment will depend on your vitiligo and skin, but common treatments include the following:
- Corticosteroid creams - these are widely used for localized vitiligo, but can only be used short-term because they are known for thinning the skin and other adverse effects. You must apply the cream to the white patches on the skin for at least three months before seeing any results.
- Topical immunomodulators (such as tacrolimus and pimecrolimus) - these can regulate the local immune response of the skin and stimulate melanogenesis. They can be used for longer periods or used on areas where topical corticosteroids cannot be tolerated. Tacrolimus is more potent than pimecrolimus, however, neither work effectively on depigmented lesions on joints and acral sites.
Please note that all prescriptions for topical immunomodulators contain a black box warning from the U.S. Food and Drug Administration (FDA). Because of the warning, it’s important to see your dermatologist regularly if you are using a topical immunomodulator.
Several experimental topical treatments are also prescribed for vitiligo:
- Vitamin D analogues, typically calcipotriol, are easier to use than some of the other products, but they are prone to irritating the skin and rarely used as a monotherapy due to questionable efficacy.
- Topical 5-fluorouracil (5-F) combined with spot dermabrasion is known to induce repigmentation of vitiligo in 75% of patients after 6 months, although it remains a controversial therapy due to a potential adverse effect.
- Topical application of prostaglandin E2 seems to promote repigmentation, especially around eyes.
- Pseudocatalase (PCat) requires whole body application once or twice per day, followed by a brief NB-UVB therapy to activate the medication. Combination with climatotherapy at the Dead Sea is claimed to induce quick and prolonged repigmentation effect.
- Occlusion over the skin area after an application of topical compound has been shown to improve treatment efficiency, as has been shown for tacrolimus on difficult to treat locations.
- Dearmabrasion, skin sanding or laser ablation improves topical drug penetration and can be used prior to topical drug application to improve repigmentation.
- Needling, which is local injuring of skin with needles, is occasionally used in vitiligo treatment to bring back natural skin color.
- Topical antioxidants such as curcumin may facilitate repigmentation processes, yet their true contribution to repigmentation remains unproven.
Some evidence points to the synergistic activity of combination therapy with topical tacrolimus and UVB phototherapy. However, this combination may increase the risk of skin carcinogenesis.
Light therapy, also known as phototherapy, is a traditional treatment for vitiligo. It is most commonly offered in one of these forms: sunlight (see explanation below), ultraviolet (UV) lamps and lasers.
UV light is a part of sunlight that reaches the surface of Earth in abundance. It seemingly has two modes of action in helping to combat vitiligo: it has immunosuppressive action and it stimulates melanocyte production at the same time.
- Narrowband UV (NB-UVB, or sometimes called by the wavelength of 311 nm) is considered to be the first-line of therapy for the treatment of moderate-to-severe vitiligo. You may encounter two types of NB-UVB lamps: a booth-like standing panels for whole body treatment, and hand-held or portable devices for local use (see photo). On average, patients experience 50 percent improvement after 48 treatments, two to three times a week. The face and neck responds well to phototherapy, while the hands and feet respond poorly.
- Although rarely, UV light therapy is sometimes used in combination with psoralens that sensitize your skin to sunlight - this is known as PUVA therapy. You may have psoralen as a pill or applied directly to your skin. Most patients will see up to 55% improvement in four to six months, but PUVA therapy has age and gender limitations. NB-UVB has gained prevalence over psoralen-based phototherapy and thus we will not review it here in any more detail.
- Unlike the whole-body UVB therapy, the Excimer laser is used for targeted phototherapy, usually on the face. Dermatologists can tell within the first four weeks of treatment whether or not the therapy is working. The duration of treatment is two to six months, and the average rate of improvement is 70%. To maintain results, topical medications can be used following the treatment.
Latest research indicates that efficiency of the phototherapy is independent of age, gender and disease duration.
It is important to note that these therapies are different from tanning used in cosmetology or spa centers. They need to be supervised by a dermatologist to ensure patient safety and monitoring for skin cancer.
Light therapy often is used after surgical procedures to stimulate cells to make new pigment faster in treated areas.
Photo: courtesy of Dr. Aliya Kasumkhanova, MD. See more photo
Vitiligo is thought to be an immune-mediated disease and thus immune-suppressive or immuno-modulator medicines are used for systemic treatment, either in a tablet form or as an injection.
- Among the immuno-suppressants, systemic steroids have been the most commonly used due to ability to arrest the progression of vitiligo and lead to repigmenation. However, systemic steroid therapy using methylprednisolone, betamethasone or dexamethasonehas in oral mini-pulse form (OMP) always been associated with a high incidence of adverse effects, especially in children.
- Immuno-modulators work by normalizing your immune system, arresting or slowing down depigmentation process. In a recent study, 73% of patients observed arresting vitiligo progression for a period of more than one year, with no side-effects. However, immuno-modulators are currently not available in the US or Europe.
Often, you may be prescribed to take vitamin B6, copper and/or folic acid in addition to other treatments. Extracts of Polipodium Leukotomas or Ginkgo Biloba have shown efficacy in stopping vitiligo progression when taken orally. Similarly, the anti-psoriatic drug leflunomide has been reported to stop vitiligo progression, but due to side-effects this may seem an inappropriate treatment option.
Climatotherapy consists of the Dead Sea baths combined with sun exposure is another successful treatment modality for vitiligo, although the mode of action has escaped definition so far. The Dead Sea is the lowest place on Earth at about 1,388 ft (423 metres) below sea level and, with 33.7% salinity, it is also one of the world's saltiest bodies of water.
The longer the stay at the Dead Sea the better is the result. Repigmentation begins after one or two weeks of climatotherapy and major improvement starts towards the end of a four-week treatment course, although it usually continues after returning home. In most patients repigmentation is maintained for over one year. After repeated courses of the Dead Sea treatment, usually over a period of three to five years, excellent repigmentation results with almost perfect color match have be achieved.
It has very few side-effects and generally suitable for children, the elderly and pregnant women. The Dead Sea is accessible at either the Israeli or Jordanian side. Be aware that climatotherapy may be expensive (around $5,000 on average) due to an extended stay at the resort hotels or clinics.
Ethno-pharmacological elements - or more commonly used, 'traditional' or 'folks' medicine - have been used in vitiligo treatments for centuries, sometimes quite effectively. Clinical research has shown that some plant extracts have significant antioxidant, melanogenic or photoprotective properties. Several plant extracts can temporarily enhance skin pigmentation and may be considered as an adjuvant to other therapies.
Further research is needed to examine effects of Gingko Biloba, Polipodium Leukotomas or Pyrostegia Venusta, whether they can be used as a potential source for plant-based pharmaceutical products for vitiligo.
Surgical therapies are appropriate only for carefully selected patients who have vitiligo that has been stable for at least one year (three years recommended) and is not responding to other medical treatments. Surgical techniques are expensive and usually not paid for by insurance companies.
Surgical therapies include autologous suction blister grafting, split-thickness grafting, punch grafting, smash grafting, single follicular unit grafting, cultured epidermal suspensions and autologous melanocyte culture grafting. Subsequent local treatment of treated lesions with phototherapy or tacrolimus will promote skin coloration and might prevent depigmentaion of the graft.
Skin grafting has a high success rate — 80% to 90%. However, there are several possible complications of skin grafting - infections may occur at the donor or recipient sites, while the recipient and donor sites may develop scarring, a cobblestone appearance, or a spotty pigmentation, or may fail to repigment at all. This procedure is not widely used in the United States but is common in other countries, particularly in South America, Southeast Asia, India and China.
Few dermatological centers in the United States are offering melanocyte transplant therapy. In this procedure, doctor takes a sample of your normal pigmented skin and places it in a laboratory dish containing a special cell-culture solution to grow melanocytes. When the melanocytes in the culture solution have multiplied, they are transplanted to your depigmented skin patches. This procedure is currently experimental and is impractical for the routine care of people with vitiligo, and its side effects are not known.
Almost all treatments produce temporary results - typically lasting for three to five years and followed by gradual reappearance of lesions. In some cases - especially for active, unstable vitiligo - color may return in treated areas and disappear in other areas at the same time. This is why surgical treatments are suggested only for continuously stable vitiligo.
In severe cases, when over 50% percent of the body surface area is covered with white patches, patients cannot use these repigmentation treatments (with a few notable exceptions.) They can, however, opt for stripping their skin of color completely, which gives skin a permanent, even, milky white color. This irreversible treatment is a form of skin bleaching using a strong topical medication called monobenzone (a monobenzyl ether of hydroquinone.) Depigmentation procedure can be done at home by applying monobenzone cream twice daily, with a doctor's periodic supervision. It is sometimes done in combination with Q-switched ruby laser for faster results.
The process of depigmentation is gradual. The length of procedure using monobenzone ranges from four months to a year. The major side effect of depigmentation therapy is inflammation of the skin, while approximately 15% of patients develop contact dermatitis and are unable to complete treatment. A lifelong limitation of sun exposure is essential following depigmentation therapy, to avoid occasional perifollicular re-pigmentation and burns of unprotected skin.
Remember, there is no one therapy for everyone. Vitiligo is a complex disease and requires a complex, prolonged therapy. What works for one person may not work for another. There are people who do not seem to respond to any therapy and this is a drawback that stimulates us to continue our research and efforts in new therapy development.
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Please be advised that all information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician or health practitioner. Users are warned against changing any aspects of their treatment, diet or lifestyle based on this information without first consulting a registered medical practitioner. While every precaution is taken to ensure accuracy, VRF makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the content which reflect personal opinion of the authors.
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