While vitiligo is an incurable condition, it is manageable through various treatment options. These include FDA-approved and off-label medications, light therapy, microsurgery, and adjunctive therapies. The effectiveness of these treatments varies based on factors such as the patient's age, time since disease onset, skin phototype, genetic background, and other considerations.

Leading the drug treatments are advanced JAK inhibitors like Opzelura® from biotech firm Incyte, and Litfulo® from pharmaceutical giant Pfizer, in the last phase of clinical trials. These drugs act as immune system regulators, targeting specific communication pathways to control irregular immune responses.

Opzelura® (1.5% ruxolitinib), notably the first FDA-approved drug for vitiligo, is a topical treatment suitable for individuals aged 12 and above. Recommended usage involves twice-daily application to affected areas, especially on the face, with no fixed limit on duration of use, provided there are visible improvements. Results vary; some may see benefits within 24 weeks, while others might need up to a year. Dermatologists often prioritize its use on the face and sensitive areas like the genitals, areola, or ventral breast. Research suggests that low-level light exposure may enhance the drug's effectiveness, although the drug alone can maintain repigmentation.

The drug development pipeline for vitiligo treatments is promising. Currently, a dozen pharmaceutical and biotech companies are actively investing in vitiligo research and development programs. This ongoing research holds the potential for new and more effective treatments in the future.

Here are some of the vitiligo treatment protocols that must be further adjusted to suit a patient’s situation and local drug availability:

• If an adult patient just has a few, relatively stable spots, topical steroid – such as 0.1% betamethasone valerate – is commonly tried first, b.i.d. It is often alternated with tacrolimus every two weeks for six months, to minimize the risk of skin atrophy. For spots on an adult’s face, eyelids, genitals, breasts or underarms a less irritating medicine like 0.1% tacrolimus, b.i.d., is preferable, and 0.03% tacrolimus is reserved for the sensitive skin of kids aged 2-15 years.
• If a patient does not respond to the previous option, then high-potency drugs such as 0.05% clobetasol propionate can be used b.i.d. for up to 8 weeks, after which it should be slowly reduced to a lesser strength. On sensitive areas like face, neck or groin it should be used once daily. A pulse treatment with 0.1% clobetasol, alternating with 0.1% tacrolimus ointment in a one week on/one week off regimen is often reported to provide good repigmentation.
• If a patient has rapidly expanding vitiligo, with new spots appearing every week or existing ones getting bigger, a dermatologist may suggest taking oral steroids until the disease is stabilized. Adults may be prescribed an oral minipulse dexamethasone 4 mg, to be taken after a meal, two days a week for 16 weeks. Children get a half dose for 12 weeks.

Although still frequently prescribed, vitamin D analogs, particularly calcipotriol and tacalcitol, demonstrate only a partial efficacy.

The results of the first line therapy are moderately successful. Topical treatments have the best effect on the upper body, with dark skin, and with recent lesions. Nearly half of adult patients and three-quarters of children report vitiligo stabilization and substantial repigmentation, especially in the sun-exposed areas.

Second-line therapies primarily focus on improving skin appearance with a combination of topical, systemic and UVB phototherapy treatments. Such treatment duration varies from 8 to 24 months of two- to trice-weekly treatments, with an average 65-75% success rate.

Narrowband UVB (NB-UVB) phototherapy is the treatment of choice for non-segmental, generalized vitiligo. NB-UVB produces better repigmentation than PUVA, with better color match and fewer side effects. NB-UVB therapy is also better tolerated, and could be used on expecting or nursing women, and children. Home therapy with portable NB-UVB devices is a viable alternative for most vitiligo patients; eligibility, protocols and precautions are essentially the same as for clinic-based treatments.

Combination interventions are superior to monotherapies, like NB-UVB with 0.1% tacrolimus ointment.

Intermittent oral administration of steroids like betamethasone ⁄ dexamethasone has been sparingly reported as an emergency tool to arrest the activity of fast spreading vitiligo. Within one to three months a progressive disease is usually stabilized, and within four months repigmentation is observed in the majority of patients. However, they are not effective in repigmenting a stable vitiligo, and long-term adverse effects contraindicate their common use. The drawback is a higher relapse when reducing these medications.

In the dynamic field of dermatology, there is growing interest in experimental treatments for vitiligo. Experienced dermatologists often consider these novel approaches, either due to their unique availability in certain regions or because their potential benefits may surpass the associated risks.

However, approaching these treatments requires careful consideration. Drugs like azathioprine, HSP70i, prostaglandin, pseudocatalase, 5-fluorouracil, methotrexate, methylprednisolone, mynocycline, and simvastatin show promise in treating vitiligo. Yet, there's still a lack of clear understanding regarding who the ideal candidates for these treatments are and their comprehensive safety profiles. This uncertainty necessitates a cautious approach, balancing the potential for significant benefits against the unknown risks.