DoctorsTreatment Guidelines

Disease

Vitiligo is a non-lethal, non-communicable, immune-mediated and generally progressive skin disease that creates milky white patches of irregular shape on the skin. A specific type of leukoderma, vitiligo is the most common form of pigmentary disorders, equally affecting all races, age groups and social strata.

The ethiopathogenesis is complex and involves the interplay of multiple factors; however, the exact pathogenesis is not well known. Other than the appearance of the spots and occasional itchiness, vitiligo does not cause any discomfort, irritation, soreness, or dryness of the skin. Vitiligo has negative and often devastating effect on the quality of patients’ lives and their socio-economic status.

While the true prevalence of vitiligo is masked from both researchers and the healthcare industry, the consensus prevalence number is close to 1% of the population in the USA, and 0.5-2% worldwide. There are pockets of India (Gujarat) that are estimated to have an incidence of 8.8%.

There are two major types of vitiligo:

  • Segmental, also called unilateral vitiligo, happens on one part of the body. It often starts at a young age and usually stops spreading after a year.
  • Non-segmental, also called bilateral or generalized vitiligo, may appear on all body parts, especially areas that are bumped or rubbed frequently. These patches often extend slowly over time if left untreated.

An early distinction between these two basic types of vitiligo is very important in predicting disease activity and choosing the right treatment.

Triggers

On the outside, severe sunburn, physical skin damage, prolonged contact with certain chemicals containing:

  • p-phenylenediamine (also known as para-phenylene diamine or PPD)
  • para-tertiary butylphenol (PTBP)
  • monobenzylether of hydroquinone (MBH)

may induce or worsen vitiligo. Industrial items with PPD or PTBP include permanent hair dyes, fabric and leather colorants, printing inks, motor oil additives, fiberglass products, plywood, masonry sealant, insecticides and commercial disinfectants. Medical items with PTBP include hearing aids, prosthesis and athletic tape. Skin lighting creams and soaps in certain countries may contain MBH in excessive concentrations.

On the inside, psychological stress is the most frequent trigger for vitiligo. Hormonal changes during pregnancy, delivery and menopause may also be the culprit, as can excessive pressure and friction from lingerie, shoes, or sporting equipment. Parasites and chronic gastritis that impair absorption of vital elements by the digestive system may also precipitate vitiligo.

Treatments

Vitiligo is incurable but manageable disease. Treatment options currently available include medication, light therapy, microsurgery and adjunctive therapies. Efficiency of various therapeutic modalities depends on the age of patient and time since disease onset, skin photo type, genetic background and a number of yet unknown factors.

No product or therapy is able to modify the course of the disease and produce a long lasting effect. In our studies it was shown that certain immunomodulators could be effective at stopping vitiligo progression. About a quarter of patients never respond to any treatment. In a few cases this is due to breaks in treatment protocol, while some stubborn patches simply defy explanation.

Although many treatments are being used for its management, none is licensed specifically for vitiligo, in the EU or the US. Further, there is no universally effective drug or even a common viewpoint on vitiligo therapy at present, due to extreme variability of the disease and environmental conditions. Consensus treatment guidelines are offered at national or regional levels. VRF has published it's own collection of treatment protocols, links are provided here below.

Drug development pipelines are thin, with no drug candidate in the late phase of development at a dozen of pharmaceutical or biotech companies that are currently funding vitiligo R&D programs.

First-line Treatments: Topical Medicines

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 Treatments: Medicines and Light Combinations

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.

Experimental Treatments

There are several experimental treatments that are showing promising results but are not quite ready for a wider use, such as:

  • Topical janus kinase (JAK) inhibitors, such as ruxolitinib and tofacitinib,
  • Afamelanotide, a synthetic analog of alpha-melanocyte–stimulating hormone (α-MSH),
  • Placenta extracts.

Climatotherapy therapy at the Dead Sea is considered to be the only treatment that’s safe for nearly all vitiligo patients – regardless of age, and including pregnant and nursing women. Therapeutic factors are mostly attributed to the unique spectrum of sunlight at the bottom of the basin, water composition and air rich with oxygen, bromide and other minerals. Treatment includes short swim and measured sunbathing twice a day, for 3-4 weeks between March and October. Repigmentation begins after one or two weeks, then major improvement is often seen towards the end of the fourth week. Repigmentation usually continues after returning home for another six to eight weeks.

Relapse

There is no solid retrospective data on the symptomatic recurrence rate after a successful treatment. Available evidence suggests a high chance of over 50% recurrence rate within a 4-year period. Sometimes new lesions appear while patients are busy treating other patches. A high disease recurrence rate suggests that a life-long supporting skincare is necessary to achieve acceptable and continuous cosmetic results.

The Vitiligo Research Foundation (VRF) does not endorse or recommend any commercial products, processes, or services.

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. 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.

FAQOther Questions

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