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Review
1
British Association of
Dermatologists, London, UK
2
Therapy, Guidelines and Audit
subcommittee of the British
Association of Dermatologists,
London, UK
3
Departments of Dermatology
and Paediatric Dermatology,
Bristol Royal Infirmary, Bristol,
UK
4
The Vitiligo Society, London,
UK
5
Department of Dermatology,
Whipps Cross Hospital, London,
UK
6
British Photodermatology
Group, British Association of
Dermatologists, UK
7
Clinical Standards Department,
Royal College of Physicians of
London, London, UK
Correspondence to
Professor David J Gawkrodger,
Department of Dermatology,
Royal Hallamshire Hospital,
Sheffield S10 2JF, UK; david.
gawkrodger@sth.nhs.uk
Received 27 October 2009
Accepted 7 April 2010
466
Vitiligo: concise evidence based guidelines
on diagnosis and management
David J Gawkrodger,1 Anthony D Ormerod,2 Lindsay Shaw,3 Inma Mauri-Sole,3
Maxine E Whitton,4 M Jane Watts,5 Alex V Anstey,6 Jane Ingham,7
Katharine Young7
ABSTRACT
Vitiligo is a common disease that causes a great degree
of psychological distress. In its classical forms it is easily
recognised and diagnosed. This review provides an
evidence based outline of the management of vitiligo,
particularly with the non-specialist in mind. Treatments
for vitiligo are generally unsatisfactory. The initial
approach to a patient who is thought to have vitiligo is to
make a definite diagnosis, offer psychological support,
and suggest supportive treatments such as the use of
camouflage cosmetics and sunscreens, or in some cases
after discussion the option of no treatment. Active
therapies open to the non-specialist, after an explanation
of potential side effects, include the topical use of potent
or highly potent steroids or calcineurin inhibitors for
a defined period of time (usually 2 months), following
which an assessment is made to establish whether or
not there has been a response. Patients whose condition
is difficult to diagnose, unresponsive to straightforward
treatments, or is causing psychological distress, are
usually referred to a dermatologist. Specialist
dermatology units have at their disposal phototherapy,
either narrow band ultraviolet B or in some cases
photochemotherapy, which is the most effective
treatment presently available and can be considered for
symmetrical types of vitiligo. Depigmenting treatments
and possibly surgical approaches may be appropriate for
vitiligo in selected cases. There is no evidence that
presently available systemic treatments are helpful and
safe in vitiligo. There is a need for further research into
the causes of vitiligo, and into discovering better
treatments.
INTRODUCTION
Vitiligo is a disease that results in depigmented skin
with loss of functioning melanocytes within the
epidermis. It usually begins after birth and,
although it can develop in childhood, the average
age of onset is about 20 years.1 The treatment of
vitiligo is acknowledged as being difficult, especially
for the non-dermatologist. There is evidence to
suggest that in some patients vitiligo is an auto-
immune disease and that it shows a familial trait in
about 18% of cases.2 The genetic basis for vitiligo
postulates a contribution from multiple recessive
alleles at unlinked autosomal loci.3 Vitiligo occurs
in all races and has an estimated prevalence of
0.5e1%. In this paper our objective is to provide
a concise and evidence based review of the
management of vitiligo in a shorter form than the
full published guideline.4
The process of development of the full guideline
involved the guideline development group defining
the questions and interrogating the literature in an
evidence based manner. Reference is made to the
recently updated Cochrane review on the treat-
ment of vitiligo.5 The guidance has been developed
using SIGN methodology (http://www.sign.ac.uk/
methodology/index.html) and in accordance with
AGREE principles (http://www.rcplondon.ac.uk),
which allow a designation of the level of recom-
mendation and of evidence.
Textbooks usually do not comment on the
natural history of vitiligo. Although some patients
report spontaneous repigmentation, this is rare.
More typically, vitiligo is a chronic persistent
disorder that progresses in a stepwise fashion with
long periods when the disease is static and rela-
tively inactive, interspersed with shorter periods
when areas of pigment loss extend.
A better understanding of the pathogenesis of
the disease may lead to improved treatments. There
is a paucity of effective treatments available and
a lack of treatments specifically introduced for
vitiligo itself. Almost all treatments have been
borrowed from therapies whose prime target is
another disease. Not even advances in the under-
standing in the science underlying vitiligodfor
example, evidence of autoimmune disease or of
oxidative stress in melanocytesdhas resulted in
specifically tailored treatments for vitiligo.
INITIAL ASSESSMENT
In the first instance the diagnosis of vitiligo has to
be confirmed. Often this is regarded as being
straightforward, although it is not always so. Most
commonly, vitiligo produces symmetrical depig-
mented areas of skin that otherwise appear normal
(table 1). A less common type is the segmental
form in which unilateral depigmentation develops.
The aetiology of segmental vitiligo may be different
from the symmetrical types. In vitiligo the skin
texture is usually normal. Vitiligo can affect mela-
nocytes in the hair roots resulting in patches of
white hair. Depigmentation can affect mucosal
areas such as in the mouth or genitalia.
Three main diseases can be mistaken for vitiligo.
In tinea versicolor, a superficial yeast infection that
can cause loss of pigment on the upper trunk and
chest, darker skinned individuals show hypo-
pigmented patches with a fine dry surface scale. In
piebaldism, an autosomal dominant disease in
which there is absence of melanocytes from the
affected areas of the skin, a forelock of white hair is
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Table 1 Symptoms and signs

Non-segmental vitiligo (vulgaris/
symmetrical or acro-facial types)
Characterised by white patches that are usually symmetrical
and frequently increase in size with time
The most common sites affected are the fingers and wrists,
the axillae and groins and the body orifices such as the mouth,
eyes and genitalia
Corresponds with a substantial loss of functioning
epidermal and, sometimes, hair follicle melanocytes

Segmental vitiligo A variant of vitiligo confined to one or more unilateral segments

More commonly seen in childhood
Distribution may conform to one or more (adjacent) dermatomes
or to Blaschko’s lines

Patients’ permission for publication has been obtained.

usually evident and can be present at birth. In idiopathic guttate
hypomelanosis, multiple small, white macules are found, mostly
on the trunk or on sun exposed parts of the limbs.
At the initial consultation, the doctor should make a record of
the effect of vitiligo on the patient. The examination should
include observation of the disease distribution, extent, whether
depigmentation is total or partial, if there are symmetrical
lesions, and if there is involvement of mucous membranes.
The depigmentation on the face or hands is often visible to
others. A consequence is that vitiligo can be psychologically
devastating and have a significant impact on quality of life
(QoL) and self esteem.6 It may cause social isolation and
significant depression,7 create difficulties in sexual relationships,
stigmatisation and affect perceived suitability for marriage.8 9
(level of evidence: E-3). In people with a white skin colour,
vitiligo may cause less concern (E-3). One study comparing QoL
in vitiligo and psoriasis showed a higher dermatology life quality
index (DLQI) for psoriasis than vitiligo (mean 6.26 cf 4.95).10
The scoring pattern was different with vitiligo scoring lower on
the symptoms and treatment subscales and higher on the social,
clothing and leisure subscales. This suggests that QoL scales
with a weighting on the effect of symptoms and treatment
effects underestimate the effect of vitiligo on QoL. Some
assessment of the impact of vitiligo on the patient’s QoL should
be made (this could be done by using the DLQI, for example).
The doctor should discuss the disease and treatment options.
Patients with vitiligo can develop autoimmune thyroid disease
or other autoimmune diseases. A history of autoimmune disease
in a family member was obtained in 13 of 41 (32%) adults with
vitiligo.2 This compares to an overall general population preva-
lence of thyroid disease of 5%.11 Adults with vitiligo should have
their thyroid function checked.4
Patients should be given information about the Vitiligo
Society in the UK or other national patient help organisation.
SUPPORTIVE MEASURES
In many instances, the first line therapy involves topical medi-
caments. Most patients are offered advice about sunscreens and
cosmetic camouflage including fake tanning products. With
regard to topical therapy that might influence the state of the
disease, the use of topical steroids is the usual first line treatment
(figure 1). Recommended treatments for children differ slightly
from those for adults.
TOPICAL CORTICOSTEROIDS
Topical steroids are often viewed as the first active treatment to
consider. Clayton12 and Kandil13 showed that use of a highly
potent (clobetasol propionate) or potent (betamethasone
valerate) topical steroid can repigment vitiligo, but only in a small
proportion of cases. Clayton found 15e25% repigmentation in
10/23 subjects (ages not stated) and >75% in 2/23 (the other 11
showed no response), while Kandil found 90e100% repigmen-
tation in 6/23 subjects (ages not given for all, but one was aged
12 years) and 25e90% in three (with six showing ‘beginning’
repigmentation).12 13 Clayton found all steroid users had skin
atrophy with clobetasol propionate (used for 8 weeks), while
Kandil noted hypertrichosis in two subjects and acne in
three subjects, related to 4 months use of betamethasone
valerate.12 13
The experience of Westerhof et al,14 in probably the best
controlled study to date of a topical treatment, compared the
potent topical steroid fluticasone propionate alone or combined
with ultraviolet A (UVA) in 135 adults. They found that topical
fluticasone propionate used alone for 9 months induced mean
repigmentation of only 9% (compared to UVA alone of 8%)
whereas the combination of fluticasone propionate and UVA
induced mean repigmentation of 31%; no steroid atrophy was
noted in steroid users.

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Review

Figure 1 Algorithm for the

management of vitiligo in adults and Diagnosis
children by non-specialists. When vitiligo is classical the diagnosis is straightforward
and can be made in primary care (D/4) but atypical
presentations may require expert assessment by a
dermatologist (D/4). In adults a blood test to check thyroid
function should be considered in view of the high
prevalence of autoimmune thyroid disease in patients
with vitiligo (D/3).

No treatment option Topical Treatment Psychological treatments

In adults and children with skin
types I and II (type I- always
burns, does not tan; type II-
burns easily tans poorly) in
the consultation it may be
appropriate to consider,
after discussion, whether the
initial approach may be to
use no Active treatment other
than use of camouflage
cosmetics and
sunscreens (D/4).
In adults with recent onset of
vitiligo and in children, treat- Clinicians should make an
ment with a potent or very assessment of the psycho-
potent topical steroid should logical and QoL effects of
be considered for a trial vitiligo on adults and children
period of no more than 2 (C/2++). Psychological inter-
months. Skin atrophy has ventions should be offered
been a common side effect as a way of improving coping
(B/1+). mechanisms (D/4). Parents
In adults, topical pimecrolimus of children with vitiligo
should be considered as an should be offered psycho-
alternative to a topical steroid, logical counselling.
based on one study. The side
effect profile of topical
pimecrolimus is better than
that of a highly potent topical
steroid (C/2+). In children,
topical pimecrolimus or
tacrolimus should be considered
as alternatives to the use of a
highly potent topical steroid in
view of their better safety profile
(B/1+).
Depigmentation should be
reserved for adults severely
affected by vitiligo and should
be undertaken only by a
specialist dermatology unit.

Phototherapy, systemic
therapy and surgical
treatments
These treatments should be
considered only in specialist
units. Surgical treatments
are not recommended in
children.

Hence, use of a highly potent (clobetasol propionate) or potent
(betamethasone valerate) topical steroid can repigment vitiligo,
but only in a small proportion of cases; even then, skin atrophy is
a common complication after only 2 months’ treatment.5
TOPICAL CALCINEURIN INHIBITORS
Calcineurin inhibitors have an advantage over steroids in that
they do not thin the skin, which is a concern to many patients.
Coskun and colleagues,15 in a left versus right comparison over
an 8 week period in 10 adults, compared topical pimecrolimus
with topical clobetasol propionate. They found topical pime-
crolimus resulted in 50e100% repigmentation in 8/10 cases
most noticeable for lesions on the trunk or extremities,
compared to an equivalent degree of repigmentation in 7/10
cases treated with clobetasol propionate. No skin atrophy was
noted, but burning was a side effect with pimecrolimus.
In an open proof of concept study of 26 children aged over
6 years and adults with generalised symmetrical forms of viti-
ligo, treated for head and neck lesions with topical 1% pime-
crolimus twice daily, total repigmentation of a target lesion was
found in 50% of cases after 6 months of therapy.16 Twenty
children treated over 8 weeks with either topical clobetasol or
tacrolimus were shown to have repigmentation that amounted
to 41% with clobetasol and 49% with tacrolimus.17 Lesions on
the face and thorax responded better than those on the abdomen
or legs, while lesions on the hands did not respond.

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Main messages (with indicated levels of recommendation and of evidence)

DIAGNOSIS
Where vitiligo is classical, as in the symmetrical types, the diagnosis is straightforward and can be made with confidence in primary care
(grade of recommendation R-D, level of evidence E-4).
In patients with an atypical presentation, diagnosis is more difficult and referral for expert assessment by a dermatologist is recommended
(R-D, E-4).
In adults with vitiligo, a blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid
disease in patients with vitiligo (R-D, E-3).
NATURAL HISTORY
The response of vitiligo to treatment should be considered in the context of the natural history, recognising that spontaneous repigmentation
may occur but is uncommon (R-D, E-4).
A longitudinal epidemiological study is needed to define the natural history of vitiligo over time (R-D, E-4).
Psychological assessment and quality of life
Clinicians should make an assessment of the psychological and QoL effects of vitiligo on patients (R-C, E-2++).
TREATMENT
Camouflage cosmetics
In patients with skin types I (always burn, never tan) and II (always burn, sometimes tan) it is appropriate to consider after discussion
whether the initial approach may be to use no active treatment other than consideration of camouflage cosmetics (including fake tanning
products) and sunscreens (R-D, E-4).
Topical steroids
In children, and adults with the recent onset of vitiligo, treatment with a potent or very potent topical steroid should be considered for
a trial period of no more than 2 months. Although benefits have been observed, skin atrophy is a common side effect (R-B by extrapolation;
E-1+).
Calcineurin inhibitors
In adults with symmetrical types of vitiligo, topical pimecrolimus is an alternative to a topical steroid, based on evidence from one study.
The side effect profile of topical pimecrolimus is better than that of a highly potent topical steroid, although stinging may occur in some
cases (R-C, E-2++).
In children with vitiligo, topical pimecrolimus or tacrolimus should be considered as alternatives to a highly potent topical steroid in view of
their better short term safety profiles (R-B, E-1+).
Depigmentation treatments
Depigmentation treatments should be considered only in specialist dermatology units.
Phototherapy treatments
Phototherapy treatments should be considered only in specialist dermatology units.
Systemic treatments
The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side effects (R-B;
E-2++).
Surgical treatments
Surgical treatments should be considered only in specialist dermatology or plastic surgery units.
Cognitive therapy and psychological support
Psychological interventions should be offered as a way of improving coping mechanisms in patients with vitiligo (R-D; E-4).
Implications for implementation
Treatments suggested in this guideline for non-specialists, with the exception of psychological therapies (which are generally not available),
are inexpensive and unlikely to have a major financial impact on the National Health Service.

DEPIGMENTATION TREATMENT (P-(BENZYLOXY)PHENOL
(HYDROQUINONE MONOBENZYL ETHER))
Extensive vitiligo in a patient with a dark skin tone, especially
on a cosmetically sensitive area such as the hands or face, can
produce a severe social disability. In this instance it is worth-
while considering whether complete depigmentation of the
affected areas might be beneficial. The profound effect that this
may have culturally needs to be taken into account.
In an open study, 18 patients ‘severely’ affected by vitiligo
(type of vitiligo not stated) were treated with the topical
application of 20% p-(benzyloxy)phenol (monobenzyl ether of
hydroquinone (MBEH)18: eight achieved complete depigmen-
tation after 10 months and three had ‘dramatic’ depigmenta-
tion, but in three there was no effect at all (after 4 months of
use).
Expert opinion concludes that patients with a dark skin type
selected for depigmentation treatments must understand the
cultural effects the depigmentation may have.4 It is usual to
consider depigmentation only for subjects in whom the area of
skin involved by vitiligo is extensivedthat is, involving >50% of
the skin surface area.4 If there is extensive involvement of the
cosmetically sensitive areas of the face and hands, and covering
cosmetics are ineffective, depigmentation can be considered
although it is usual to only treat the exposed sites.
SYSTEMIC TREATMENT
Since vitiligo is viewed as an autoimmune disease, it is natural to
wonder whether systemic treatment might have something to
offer. However, there are few studies in the literature. A well
conducted open study of 25 European adults with active

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generalised vitiligo (and four with stable disease) examined the
effect of oral dexamethasone (10 mg twice a week for 24 weeks),
evaluating pigment change using photographs.19 The authors
showed that disease progression was arrested in 22 of the 25
subjects with active vitiligo, after an average of 18 (65) weeks.
‘Marked’ repigmentation (51e75%) occurred in two subjects
(7%) and ‘moderate’ or ‘slight’ repigmentation (26e50%; <25%)
was noted in three (10%), with no response being seen in
21 (72%). Side effects were common, occurring in 20 of 29
subjects, and included weight gain, acne, menstrual irregularity
and hypertrichosis. Azathioprine has not been tried as a mono-
therapy in vitiligo but, combined with PUVA in adults with
symmetrical types of vitiligo produced earlier and greater
repigmentation.20 No conclusion can be drawn on the basis of
this one study.
PHOTOTHERAPY
Phototherapy has been a mainstay of treatment for vitiligo for
several years. There is evidence that some vitiligo patients
respond well to phototherapy with narrow band ultraviolet
B (NB-UVB). A single randomised double blind trial comparing
oral PUVA (psoralen in combination with UVA) with NB-UVB
demonstrated the superiority of NB-UVB over PUVA. Twelve
month follow-up showed that some patients relapsed and ended
up with worse vitiligo than they had before PUVA (28%) or
NB-UVB (12%) was started. However, maintenance of >75%
repigmentation of surface area was seen in 24% in the PUVA
group (although this group was not completely blinded) and
36% in the NB-UVB group (in whom the quality of repigmen-
tation was better than that seen with PUVA).21
Westerhof et al compared PUVA and NB-UVB in 28 vitiligo
patients, reporting 46% repigmentation for the PUVA group.22
The risk of skin cancer in PUVA treated vitiligo patients is
currently unclear. There is no long term follow-up study of the
type which established the clear cancer risk for PUVA in psori-
asis patients.
The Excimer light source is an NB-UVB source for treating
localised areas such as the face and neck. Pseudocatalase treat-
ment is a combination of a topical pseudocatalase preparation
with brief exposure to UV irradiation; results of trials are
inconclusive.23 24 Home based NB-UVB is a possibility provided
it is adequately supervised.
SURGICAL TREATMENTS
Surgical treatment of vitiligo can be an attractive option, but
only if the disease has been inactive for 6e12 months. Njoo et al
performed a systematic review which evaluated 39 studies
assessing split thickness graft, minigraft using punch biopsies,
epidermal suction blisters as preparation, and donor and trans-
plantation of non-cultured cell suspension or cultured melano-
cytes.25 The highest mean success rates were achieved with split
skin grafting (87%, 95% confidence interval (CI) 82% to 91%)
and epidermal blister grafting (87%, 95% CI 83% to 90%). The
mean success rate of five culturing techniques varied from
13e53%.
COGNITIVE THERAPY AND PSYCHOLOGICAL SUPPORT
Vitiligo is a disease with profound psychological effects, and
psychological approaches need to be assessed to see if they help
sufferers. QoL and coping mechanisms may improve over time
in patients with vitiligo.26 Cognitive behavioural therapy strat-
egies rather than avoidance or concealment may be associated
with better coping.27
470
Current research questions
Pertinent research questions include the following:
< More scientific research into the causes of vitiligo.
< A longitudinal epidemiological study to define the natural
history of vitiligo, to quantify how the disease changes with
time.
< Development of more appropriate quality of life tools for
vitiligo that should always be used as outcome measures on
studies in the disease.
< The establishment of simple and reproducible methods of
monitoring the response of vitiligo to treatment both in the
clinic and in clinical trials.
< A head-to-head study of tacrolimus versus pimecrolimus in
adults and children with vitiligo is suggested.
< Assessment of the long term risk of skin cancer with extended
courses of narrow band UVB or PUVA in patients with vitiligo.
< Development of criteria for use of surgical treatments (eg,
definition of disease inactivity).
< Evaluation of different treatments for different types and
phases of the disease.
< There are current studies into the scientific aspects of vitiligo
including the genetics of vitiligo and autoimmune changes.28 29
However, there are no known studies on the other issues
mentioned above at present.
DECIDING ON APPROPRIATE TREATMENT
For adults and children with skin types I and II (type Idalways
burns, does not tan; type IIdburns easily, tans poorly) it may be
appropriate to consider, after consultation, whether the initial
approach may be to use no active treatment other than use of
camouflage cosmetics and sunscreens.
Treatment of vitiligo can be viewed in two phases: the first is
to halt the progression of the disease; and the second is to induce
repigmentation. Some treatments can be considered to achieve
both. In adults with recent onset of vitiligo and in children,
treatment with a potent or very potent topical steroid should be
considered for a trial period of no more than 2 months. Skin
atrophy has been a common side effect. In adults, topical
pimecrolimus should be considered as an alternative to a
topical steroid, based on one study. The side effect profile of
topical pimecrolimus is better than that of a highly potent
Key references
< Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for the
diagnosis and management of vitiligo. Br J Dermatol
2008;159:1051e76.
< Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo
with UV-B radiation vs topical Psoralen plus UVA. Arch
Dermatol 1997;133:1525e8.
< Njoo MD, Westerhoff W, Bos JD, et al. A systematic review
of autologous transplantation methods in vitiligo. Arch
Dermatol 1998;134:1543e9.
< Birlea SA, Gowan K, Fain PR, et al. Genome-wide association
study of generalized vitiligo in an isolated European founder
population identifies SMOC2, in close proximity to IDDM8.
J Invest Dermatol 2010;130:798e803.
Postgrad Med J 2010;86:466e471. doi:10.1136/pgmj.2009.093278
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topical steroid. In children, topical pimecrolimus or tacrolimus
should be considered as alternatives to the use of a highly
potent topical steroid in view of their better safety profile.
Depigmentation should be reserved for adults severely affected
by vitiligo and should be undertaken only by a specialist
dermatology unit.
Phototherapy and surgical treatments can be considered in
specialist units. Phototherapy is appropriate for extensive viti-
ligo, especially if it is active. Surgical treatment, if available, is
appropriate for cosmetically sensitive sitesdfor example, the
face or back of the handsdbut only when the vitiligo is inactive
(no progression for 6e12 months). Surgical treatments are not
recommended in children.
Clinicians should make an assessment of the psychological
and QoL effects of vitiligo on adults and children. Psychological
interventions should be offered as a way of improving coping
mechanisms.
CONCLUSION
After making an assessment and suggesting supportive measure
(ie, covering cosmetics and sunscreens), the first line treatment
for vitiligo should be the use of a topical calcineurin inhibitor
(eg, pimecrolimus or tacrolimus). The psychological impact of
the disease can easily be overlooked but needs special attention
during a consultation. The specialist dermatologist can use
phototherapy (or possibly a surgical approach in patients
with stable disease). However, the paucity of the advice here
underlines the desperate need for more effective treatments in
vitiligo.
MULTIPLE CHOICE QUESTIONS (TRUE (T)/FALSE (F); ANSWERS
AFTER THE REFERENCES)
1. Segmental vitiligo is more common in children.
2. The prevalence of thyroid disease in patients with vitiligo is
10%.
3. PUVA is more effective than NB-UVB for symmetrical types
of vitiligo.
4. Topical calcineurin inhibitors are preferred to topical cortico-
steroids for the treatment of facial vitiligo in children.
5. Skin grafting is ineffective for vitiligo on the backs of the
hands.
Acknowledgements The Guideline Development Group (GDG) would like to thank
and acknowledge the support received from the British Association of
Dermatologists, Cochrane Skin Group and the Vitiligo Society.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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ANSWERS
1 (T); 2 (F); 3 (F); 4 (T); 5 (F)
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Vitiligo: concise evidence based guidelines

on diagnosis and management
David J Gawkrodger, Anthony D Ormerod, Lindsay Shaw, et al.

Postgrad Med J 2010 86: 466-471

doi: 10.1136/pgmj.2009.093278

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