Medical Care

No single therapy for vitiligo produces predictably good results in all patients; the response to
therapy is highly variable. Treatment must be individualized, and patients should be made
aware of the risks associated with therapy. During medical therapy, pigment cells arise and
proliferate from the following 3 sources
The pilosebaceous unit, which provides the highest number of cells, migrating from
the e!ternal root sheath toward the epidermis
"pared epidermal melanocytes not affected during depigmentation
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The border of lesions, migrating up to $'( mm from the edge
Systemic phototherapy
"ystemic phototherapy induces cosmetically satisfactory repigmentation in up to )*+ of
patients with early or localized disease.
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Narrow'band -.'/ phototherapy is widely used and produces good clinical results. Narrow'
band fluorescent tubes 01hilips T2'*343**56 with an emission spectrum of 33*'33, nm and
a ma!imum wavelength of 333 nm are used. Treatment fre7uency is $'3 times weekly, but
never on consecutive days. This treatment can be safely used in children, pregnant women,
and lactating women. "hort'term adverse effects include pruritus and !erosis. "everal studies
have demonstrated the effectiveness of narrow'band -.'/ therapy as monotherapy. 8 $**9
study concluded that oral vitamin : may represent a valuable ad;uvant therapy, preventing
lipid pero!idation in the cellular membrane of melanocytes and increasing the effectiveness
of narrow'band -.'/ therapy.
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-.'/ narrow'band microphototherapy
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is therapy targeting the specific small lesions.
"elective narrow'band -.'/ 0333 nm6 is used with a fiber optic system to direct radiation to
specific areas of skin. Narrow'band -.'/ has become the first choice of therapy for adults
and children with generalized vitiligo.
1soralen photochemotherapy involves the use of psoralens combined with -.'8 light.
Treatment with %'metho!ypsoralen, ,'metho!ypsoralen, and trimethylpsoralen plus -.'8
01-.86 has often been the most practical choice for treatment, especially in patients with
skin types <.'.< who have widespread vitiligo. 1soralens can be applied either topically or
orally, followed by e!posure to artificial -. light or natural sunlight. .itiligo on the back of
the hands and feet is highly resistant to therapy.
The best results from 1-.8 can be obtained on the face, trunk, and pro!imal parts of the
e!tremities. =owever, $'3 treatments per week for many months are re7uired before
repigmentation from perifollicular openings merges to produce confluent repigmentation. The
total number of 1-.8 treatments re7uired is ,*'3**. >epigmentation occurs in a
perifollicular pattern.
The advantages of narrow'band -.'/ over 1-.8 include shorter treatment times, no drug
costs, no adverse ?< effects 0eg, nausea6, and no need for subse7uent photoprotection.
Laser therapy
8nother innovation is therapy with an e!cimer laser, which produces monochromatic rays at
3*% nm to treat limited, stable patches of vitiligo. This new treatment is an efficacious, safe,
and well'tolerated treatment for vitiligo when limited to less than 3*+ of the body surface.
=owever, therapy is e!pensive. 2ocalized lesions of vitiligo are treated twice weekly for an
average of $('(% sessions.
8ccording to studies from $**( and $**), combination treatment with *.3+ tacrolimus
ointment plus the 3*%'nm e!cimer laser is superior to 3*%'nm e!cimer laser monotherapy for
the treatment of -.'resistant vitiliginous lesions.
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8 retrospective chart and photographic review of %* patients concluded that segmental
vitiligo has a better repigmentation response with e!cimer laser treatment used at earlier
stages of the disease.
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The study also concluded that long'term use and high cumulative -.
energy of the e!cimer laser had better response.
Steroid therapy
"ystemic steroids 0prednisone6 have been used, although prolonged use and their to!icity are
undesirable.
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"teroids have been reported anecdotally to achieve success when given in pulse
doses or low doses to minimize adverse effects. The benefits versus the to!icity of this
therapy must be weighed carefully. Aore research is necessary to establish the safety and
effectiveness of this therapy for vitiligo.
8 topical steroid preparation is often chosen first to treat localized vitiligo because it is easy
and convenient for both doctors and patients to maintain the treatment. The results of therapy
have been reported as moderately successful, particularly in patients with localized vitiligo
and4or an inflammatory component to their vitiligo, even if the inflammation is subclinical.
<n general, intralesional corticosteroids should be avoided because of the pain associated with
in;ection and the risk of cutaneous atrophy.
Topical therapies
Topical tacrolimus ointment 0*.*3+ or *.3+6 is an effective alternative therapy for vitiligo,
particularly when the disease involves the head and neck. Bombination treatment with topical
tacrolimus *.3+ plus the 3*%'nm e!cimer laser is superior to monotherapy with the 3*%'nm
e!cimer laser monotherapy for -.'resistant vitiliginous lesions. Cn the face, narrow'band
-.'/ works better if combined with pimecrolimus 3+ cream rather than used alone.
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8 $**9 study out of Derman Aedical -niversity in <ran showed that a combination of
pimecrolimus 3+ cream and microdermabrasion enhanced response time and repigmentation
rates in children with vitiligo.
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.itamin D analogs, particularly calcipotriol and tacalcitol, have been used as topical
therapeutic agents in vitiligo. They target the local immune response and act on specific T'
cell activation. They do this by inhibition of the transition of T cells 0early to late ?3 phase6
and inhibition of the e!pression of various proinflammatory cytokines that encode tumor
necrosis factor'alpha and interferon gamma. These vitamin D3 compounds influence
melanocyte maturation and differentiation, in addition to up'regulating melanogenesis
through pathways that are activated by specific ligand receptors 0eg, endothelin receptor and
c'kit6.
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The combination of topical calcipotriene and narrow'band -.'/ or 1-.8 results in
improvement appreciably better than that achieved with monotherapy.
-se of khellin (+ ointment and monochromatic e!cimer light 0A:26 3*% nm has been
investigated. Eorty'eight patients with vitiligo were randomized to 3 groups. ?roup < included
3@ patients treated with A:2 3*% nm once weekly and oral vitamin :; group << included 3@
patients treated with A:2 3*% nm once weekly combined with khellin (+ ointment 0A:2'
D6 and oral vitamin :; group <<< 0control group6 included 3@ patients treated only with oral
vitamin :. :fficacy was assessed at the end of 3$ weeks based on the percentage of
repigmentation. The clinical response achieved in groups < and << was higher compared with
group <<< 0control group6, without showing significant differences. -se of khellin (+ may me
a valid therapeutic option worthy of consideration in the treatment of vitiligo.
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Depigmentation therapy
<f vitiligo is widespread and attempts at repigmentation do not produce satisfactory results,
depigmentation may be attempted in selected patients.
The long'term social and emotional conse7uences of depigmentation must be considered.
Depigmentation should not be attempted unless the patient fully understands that the
procedure generally results in permanent depigmentation. "ome authorities have
recommended consultation with a mental health professional to discuss potential social
conse7uences of depigmentation.
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8 $*+ cream of monobenzylether of hydro7uinone is applied twice daily for 3'3$ months.
/urning or itching may occur. 8llergic contact dermatitis may be seen.
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Topical 1-.8 is of benefit in some patients with localized lesions. Bream and solution of %'
metho!ypsoralen 0*.3'*.3+ concentration6 are available for this treatment.
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<t is applied 3*
minutes prior to -.'8 radiation 0usually *.3'*.3 F4cm
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-.'86 e!posure. <t should be applied
once or twice a week. 1hysicians who prescribe 1-.8 therapy should be thoroughly familiar
with the risks associated with the treatment. 8dditional -.'8 e!posure should be avoided
while skin is sensitized because severe burns may occur if patients receive additional -.'8
e!posure. "unscreens should be given to all patients with vitiligo to minimize risk of sunburn
or repeated solar damage to depigmented skin. 1atients must understand that most sunblocks
have a limited ability to screen -.'8 light.
Cf general concern, tanning of surrounding normal skin e!aggerates the appearance of
vitiligo, and this is prevented by sun protection. "unscreens with a sun protection factor of 3,
or higher are best.
8 clinical guideline summary from the /ritish 8ssociation of Dermatologists, ?uideline for
the diagnosis and management of vitiligo, may be of interest.
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Surgical Care
"urgical alternatives e!ist for the treatment of vitiligo; however, because of the time'
consuming nature of surgical therapies, these treatment regimens are limited to segmental or
localized vitiligo. -nilateral 0segmental6 vitiligo has been shown as the most stable form,
responding well to surgical interventions in numerous studies. "uch areas as dorsal fingers,
ankles, forehead, and hairline tend to not repigment well. 1atients who have small areas of
vitiligo with stable activity are candidates for surgical transplants. The most important factors
indicating stability are as follows
No progression of lesions for at least $ years
"pontaneous repigmentation indicates vitiligo inactivity
8 positive minigrafting test disclosing repigmentation at (', minigrafts, which, to
date, is the most accurate evidence of vitiligo stability
8bsence of new koebnerization, including the donor site for the minigrafting test
-nilateral vitiligo most stable form of vitiligo
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Eive basic methods for repigmentation surgery have been described, as follows
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Noncultured epidermal suspensions 8fter the achromic epidermis is removed, an
epidermal suspension with melanocytes and keratinocytes previously prepared by
trypsinization of normally pigmented donor skin is spread onto the denuded area and
immediately covered with nonadherent dressings. -sing noncultured epidermal
cellular grafts, )3+ of patients in one study achieved more than ),+ repigmentation,
especially in segmental vitiligo, piebaldism, and halo nevi.
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Bolor mismatches were
common, and generalized vitiligo did not repigment 7uite as well.
Thin dermoepidermal grafts The depigmented epidermis is removed by superficial
dermabrasion, including the papillary dermis, and very thin dermoepidermal sheets
harvested with dermatome are grafted onto the denuded skin.
"uction epidermal grafting :pidermal grafts can be obtained by vacuum suction,
usually with 3,* mm =g. The recipient site can be prepared by suction, freezing, or
dermabrasion of the sites $( hours before grafting. The depigmented blister roof is
discarded, and the epidermal donor graft is placed on the vitiliginous areas.
1unch minigrafting "mall donor grafts are inserted into the incision of recipient sites
and held in place by a pressure dressing. The graft heals readily and begins to show
repigmentation within ('@ weeks. "ome pebbling persists but is minimal, and the
cosmetic result is e!cellent.
Bultured epidermis with melanocytes or cultured melanocyte suspensions
Depigmented skin is removed using li7uid nitrogen, superficial dermabrasion,
thermosurgery, or carbon dio!ide lasers; very thin sheets of cultured epidermis are
grafted or suspensions are spread onto the denuded surface.
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Aicropigmentation
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is another option. Tattooing can be used to repigment depigmented skin
in dark'skinned individuals. Bolor matching is difficult, and the color tends to fade. "kin can
be dyed with dihydro!yacetone preparations, although the color match is often poor.
2ong'term results of $'mm punch grafts in patients with generalized vitiligo and segmental
vitiligo were assessed. <n patients with generalized vitiligo 0@3 lesions6, $%+ had e!cellent
repigmentation, $3+ had good repigmentation, $3+ had fair repigmentation, and $@+ had
poor repigmentation. <n patients with segmental vitiligo 09 lesions6, )%+ had e!cellent
repigmentation. Twenty'seven percent of the )* patients had a cobblestonelike effect. The
authors suggested that to prevent a cobblestonelike event, use of smaller grafts may be
helpful.
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Consultations
Bonsultation with an ophthalmologist is warranted. 8dditionally, psychological needs must
be addressed on a continual basis with appropriate referrals to mental health specialists.
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1roceed to Aedication

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