High-potency steroid use in children with vitiligo:

A retrospective study
Jennifer Kwinter, BA,a Janice Pelletier, MD, FAAP,b Amina Khambalia, MSc,c
and Elena Pope, MD, MSc, FRCPCc
Ottawa and Toronto, Ontario, Canada, and Boston, Massachusetts

Background: Data on efficacy and safety of treatments in children with vitiligo are limited.

Objective: We sought to describe the clinical outcomes and safety of children with vitiligo treated with
high-potency topical corticosteroids.

Methods: Clinical improvement and laboratory data were retrospectively analyzed in 101 children
(0-18 years) with vitiligo treated with moderate- to high-potency topical corticosteroids.

Results: Of patients, 64% (45 of 70) had repigmentation of the lesions, 24% (17 of 70) showed no change,
and 11% (8 of 70) were worse than at the initial presentation. Local steroid side effects were noted in 26%
of patients at 81.7 6 44 days of follow-up. Cortisol levels were abnormal in 29% of patients (21 of 73).
Two children with low cortisol levels were given the diagnosis of steroid-induced adrenal suppression.
Children with normal and abnormal cortisol levels were not significantly different by sex, age of onset,
potency of the corticosteroid use, or family history. However, children with head and/or neck affected
areas were 8.36 times more likely to have an abnormal cortisol level compared with children affected in
other body areas (RR 95% confidence interval: 1.19, 58.60, P = .003, n = 72). Of patients, 8% (6 of 74) had an
abnormal thyrotropin test result.

Limitations: The retrospective design of this study presents inherent limitations.

Conclusion: Moderate- to high-potency topical corticosteroids are efficacious in children with vitiligo,
but may be associated with systemic absorption. ( J Am Acad Dermatol 2007;56:236-41.)

V itiligo is an acquired disorder of depigmen- inflammatory factors affecting melanocyte structure

tation affecting 0.5% of the population.1 It
occurs in half of patients before the age of 20
years, and in a quarter before the age of 8 years.2,3
Current treatment modalities aim to stimulate
melanocyte proliferation or interfere with neural/
From the Faculty of Medicine, University of Ottawaa; Tufts
University School of Medicineb; and Section of Dermatology,
Division of Pediatric Medicine, The Hospital for Sick Children
and University of Toronto.c
Funding sources: None.
Conflicts of interest: None identified.
Accepted for publication August 3, 2006.
Reprint requests: Elena Pope, MD, MSc, FRCPC, Section of
Dermatology, Hospital for Sick Children, 555 University Ave,
Toronto, Ontario, Canada M5G 1X8. E-mail: elena.pope@
sickkids.ca.
Published online October 27, 2006.
0190-9622/$32.00
ª 2007 by the American Academy of Dermatology, Inc.
doi:10.1016/j.jaad.2006.08.017
or function; however, no single treatment method
has been found that is consistently effective with
relatively few side effects.4 The most common non-
surgical treatment options include topical cortico-
steroids, topical immunomodulators, phototherapy,
psoralen-UVA photochemotherapy, calcipotriol
(with or without psoralen-UVA), and camouflage
cosmetics.5-8
Topical corticosteroids are generally the first line
of therapy in both children and adults with vitiligo,
as this therapy is relatively inexpensive and easy to
use at home.5,6,9 Several studies have demonstrated
that high-potency topical corticosteroids are effica-
cious in producing moderate to excellent repigmen-
tation in adult patients with vitiligo.10-14 Data in
children are more limited. Two studies that included
predominantly or solely pediatric patients revealed
that more than 50% of repigmentation was achieved
in 34% and 68%, respectively.15,16 The concern with
the use of topical steroids are the local (atrophy,

236

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J AM ACAD DERMATOL
VOLUME 56, NUMBER 2
telangiectasia)15,17 and systemic side effects, the
most severe of which is the development of adrenal
suppression. Allenby et al18 reported adrenal sup-
pression in as many as 64% of adult patients (n = 39)
with lichen planus, dermatitis, and psoriasis when
using 50 g or more of potent topical corticosteroids
for greater than 2 weeks. In light of these findings,
authors have cautioned against the use of high-
potency corticosteroids in children.6,19,20 Despite
concerns regarding side effects, the high degree of
efficacy associated with potent corticosteroids and
the relative lack of other treatment options warrants
further investigation of this drug in the treatment
of children with vitiligo. A recent Cochrane review
examining interventions for vitiligo emphasized the
need for further data on the efficacy and short- and
long-term safety of topical corticosteroids, especially
among children where evidence-based data are
lacking.21
The objective of this study was to describe the
clinical outcomes and safety of high-potency topical
corticosteroids in the treatment of children with
vitiligo.
METHODS
The study was conducted in our dermatology
clinic between November 1, 2000, and November 1,
2002. Ethical approval for the study was obtained
from our research ethics board. The dermatology
clinic, serviced by 6 pediatric dermatologists, is
situated within a tertiary academic health sciences
center. The sample for this study included children
with a clinically confirmed diagnosis of vitiligo who
were seen in the clinic on more than one occasion
and who were solely treated with topical corticoste-
roids. Children with other causes of hypopigmenta-
tion were excluded. Data collected from medical
records included: patient characteristics (age, sex,
age of onset of vitiligo, disease location), medical
and family history, previous treatment modalities,
type of treatment prescribed, clinical outcomes (im-
provement, no change, and worse), and laboratory
indices (cortisol and thyroid hormone testing). Only
data from the first clinic visit to the first follow-up
visit were included to maximize the cohort size.
Descriptive statistics were performed using mean,
median, and proportions. Univariate analysis was
used to compare children with normal versus ab-
normal laboratory results. The chi-square test was
used for categorical variables (Fisher’s exact test was
used in cases with small cell sizes) and the Mann-
Whitney U test was used for nonnormally distributed
continuous data. A two-sided P value of .05 indi-
cated statistical significance. Statistical analyses were
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Kwinter et al 237
conducted using software (SAS, Version 9.1, SAS
Institute Inc, Cary, NC).
RESULTS
During the study period, 116 children were seen
with vitiligo. Of these patients, 101 (87%) met inclu-
sion criteria (were prescribed steroids as their single
therapy). Females represented 57% of patients (Table
I). The mean age at presentation to our clinic was 7.06
years (range 0.42-16.08 years). Age of onset of vitiligo
occurred before 2 years in 7 patients (7%), between
3 and 10 years in 78 patients (77%), from 11 to 18
years in 12 patients (12%), and was not specified
in 4 patients (4%). Topical corticosteroids alone
were used in 46% of patients, of which 26% were
high-potency corticosteroids. Other forms of therapy
were used in 9% of patients and included single or
combined therapy with topical tacrolimus, topical
steroids, light therapy, and naturopathic remedies.
Family history of autoimmune diseases was noted in
50% of patients (32 of 64), with 11 patients having
more than one autoimmune disease in the family
history. Vitiligo family history was noted in 22% of
patients (14 of 64), half of whom also had a history of
other autoimmune disorders.
At first clinic visit the most frequent location of
disease was the head and neck region (n = 68, 67%)
closely followed by extremities (upper and lower
extremities, genitourinary and buttock area involve-
ment) (n = 67, 66%). Trunk location was noted in 50
patients (49%). More than one area of involvement
was found in 59% of patients (n = 60). High-
potency steroids were prescribed in 83% of pa-
tients, whereas 17% of patients were treated with
moderate-potency corticosteroids. Of patients, 75%
(73 of 97) were prescribed topical steroids 3 times
a day, 11% (11 of 97) twice a day, 11% (11 of 97)
4 times a day, and 2% (2 of 97) daily. A continuous
daily regimen was used in 65% of patients (64/98)
and intermittently (3-8 weeks on and off regimen)
in 35% of patients. At their first follow-up visit
(mean: 81.7 6 44 days), 64% of patients (n = 45)
had repigmentation of their lesions, 11% (n = 8)
were worse than at the initial presentation, and 24%
(n = 17) had no change.
Results of a subgroup analysis indicated that there
were no statistically significant differences in clinical
outcome (improvement, no change, and worse)
between children treated with high- (n = 59) versus
moderate- (n = 11) potency corticosteroids (P = .31).
Local steroid side-effects were note in 25% (26 of 101)
of patients and consisted of striae (8 of 101), atrophy
(5 of 101), telangiectasia (5 of 101), and other skin
findings (14 of 101), which included bacterial, fungal
skin infections, nonspecific dermatitis, and acne.
238 Kwinter et al J AM ACAD DERMATOL
FEBRUARY 2007

Table I. Baseline characteristics for children 0 to 18 years treated with topical steroids for vitiligo (n = 101)
All patients Cortisol test No cortisol test
Characteristics N = 101 N = 73 (72%) N = 28 (28%) P value*
Sex
Female, n (%) 58/101 (57) 41/73 (56) 17/28 (61) .68
Age, y
Median, range (0-100) [n] 7.06 (0.42, 16.08) [99] 7.47 (0.42, 16.08) [71] 6.81 (2.28, 14.54) [28] .81
Age of onset, y
\2 7/97 (7) 4/70 (6) 3/27 (11)
2-10 78/97 (80) 59/70 (84) 19/27 (70)
[10 12/97 (12) 7/70 (10) 5/27 (19) .31
Prior treatment
Topical steroids 46/101 (46) 32/73 (44) 14/28 (50)
Othery 9/101 (9) 7/73 (10) 2/28 (7) .64
None 28/101 (28) 19/73 (26) 9/28 (32)
Uncertain history 18/101 (18) 15/73 (21) 3/28 (11)
Potency of prior steroids
High 11/42 (26) 8/29 (28) 3/13 (23)
Moderate 31/42 (74) 21/29 (72) 10/13 (77) 1.00
Potency of current steroids
High 83/100 (83) 58/72 (81) 25/28 (89)
Moderate/low 17/100 (17) 14/72 (19) 3/28 (11) .38
Family history
Vitiligo only 7/32 (22) 6/27 (22) 1/5 (20)
Other autoimmune disorders 18/32 (56) 15/27 (56) 3/5 (60)
Vitiligo and other 7/32 (22) 6/27 (22) 1/5 (20) 1.0
autoimmune disorders
Location of vitiligo
Head/neck
Yes 68/101 (67) 50/73 (68) 18/28 (64)
No 33/101 (33) 23/73 (32) 10/28 (36) .64
Trunk
Yes 50/101 (49) 39/73 (53) 11/28 (39)
No 51/101 (51) 34/73 (47) 17/28 (61) .27
Extremitiesz
Yes 67/101 (66) 52/73 (71) 15/28 (53)
No 33/101 (34) 20/73 (29) 13/28 (47) .1

*Univariate analyses were conducted using t tests for continuous variables and chi-square tests for categorical variables. Fisher’s exact test
was performed for categorical data with small cell sizes.
y
For those with a cortisol test includes steroid, protopic, and tar (n = 1); steroids and vitamins (n = 2); steroids, light, and tar (n = 1);
antiyeast/fungal preparation (n = 1); oxsoralen and sunlight (n = 1); and psoralen and steroids (n = 1). For those without a cortisol test
includes steroid, protopic, and tar (n = 1); and steroids and antifungal (n = 1).
z
Includes upper and lower extremities, genitourinary area, and buttocks.

There was no statistically significant difference in the
occurrence of the local side effects in the high versus
moderate corticosteroids groups (P = .3).
Cortisol and thyroid hormone testing were re-
quested at the first visit in 78 patients (77%), 40%
(n = 31) of whom had an abnormal blood test result.
Laboratory tests were performed at a median of
14 days (range: 1-100, n = 48) after the start of the
treatment. An abnormal cortisol level (normal: 170-
700 nmol/L) was found in 29% of patients (21 of 73),
of whom 48% represented an early morning sample.
Thirteen patients with an initial abnormal cortisol
test result had repeated investigations. A persistent
low cortisol level was detected in 9 of the 11 children
with repeated cortisol testing. Corticotropin (ACTH)
stimulation testing was performed in 5 patients
with persistent undetectable levels of cortisol (\25
nmol/L). One patient had hypercortisolemia and
two showed a normal response (a peak cortisol level
of [500 nmol/L at 60 minutes postinjection of 250
g of synthetic ACTH). Two children with small
areas of disease involvement (\1% body surface
area) using corticosteroids sparingly for 2 and 4
weeks, respectively, did not respond to the ACTH
stimulation test and had their topical steroids
discontinued. They consequently recovered from

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J AM ACAD DERMATOL Kwinter et al 239
VOLUME 56, NUMBER 2

Table II. Patient and clinical characteristics for pediatric patients with vitiligo treated with topical steroids
(n = 73) by cortisol test result
Cortisol result
Characteristics Normal N = 52 (51%) Abnormal N = 21 (21%) P value*
Sex
Female, n/N (%) 30/52 (57) 11/21 (52) .68
Age, y
Median, range (0-100) [n] 7.53 (0.42, 16.08) [51] 6.48 (4.05, 15.10) [20] .79
Age of onset, y
\2, n/N (%) 3/50 (6) 1/20 (5)
2-10, n/N (%) 42/50 (84) 17/20 (85) .97
[10, n/N (%) 5/50 (10) 2/20 (10)
Steroid potency
High, n/N (%) 44/52 (85) 14/20 (70) .16
Moderate, n/N (%) 8/52 (15) 6/20 (30)
Steroid regimen
Intermittent, n/N (%) 17/51 (33) 4/21 (19) .27
Continuous, n/N (%) 34/51 (67) 17/21 (81)
Vitiligo location
Head/neck
Yes, n/N (%) 31/52 (60) 19/21 (90) .003
No, n/N (%) 21/52 (40) 2/21 (10)
Trunk
Yes, n/N (%) 30/52 (58) 9/21 (43) .43
N, n/N (%) 22/52 (42) 11/21 (57)
Extremitiesy
Yes, n/N (%) 40/52 (77) 12/21 (57) .24
No, n/N (%) 12/52 (23) 9/21 (43)

*Univariate analyses were conducted using t tests for continuous variables and chi-square tests for categorical variables. Fisher’s exact test
was performed for categorical data with small cell sizes.
y
Includes upper and lower extremities, genitourinary area, and buttocks.

steroid-induced adrenal suppression indicated by
repeated ACTH stimulation testing 1 month later
with normal cortisol responses. Children with nor-
mal and abnormal cortisol levels were not signifi-
cantly different by sex, age of onset, potency and
regimen of the corticosteroid use, and family history.
Children with head and neck involvement were 8.26
times more likely to have an abnormal cortisol level
(\170 and [700 nmol/L) compared with children
with other affected areas (95% confidence interval:
1.19, 58.60, n = 72, P = .003) (Table II). An abnormal
thyrotropin was found in 8% of the tested patients
(6 of 74). Three patients also showed evidence of
thyroid autoantibodies.
DISCUSSION
Results of this descriptive study suggest that
high-potency topical corticosteroids were efficacious
in repigmentation of vitiligo lesions in 64% of chil-
dren. Although 24% of patients showed no change
in presentation of disease, only 11% were worse at
follow-up compared with their original clinical visit.
The potency of steroids did not affect the clinical
outcome in our patients, a finding that is likely
explained by the small sample of patients who
received moderate-potency steroids. Of the 78 chil-
dren with laboratory measurements, 40% had an
abnormal result. An abnormal cortisol level was
found in 29% of the patients with this testing, of
which 48% represented an early morning sample.
Two patients had evidence of steroid-induced adre-
nal suppression that resolved after steroid discontin-
uation. Of the potential risk factors examined, the
only factor that was significantly different between
children with normal versus abnormal cortisol levels
was evidence of a head and neck affected area as
compared with other affected body areas (90% vs
10%, P = .003). This could be explained by increased
absorption of medication through the thin skin of
the head and neck, increased patient motivation and
adherence with the treatment as a result of the visible
location of the disease, or both. Of patients, 25% had
evidence of local steroid side effects, the most
common being striae, atrophy, and telangiectasia.
Of the patients, 8% had evidence of comorbid

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240 Kwinter et al
association with thyroid disease evidenced by abnor-
mal thryroid function testing.
Study limitations, inherent of retrospective
chart reviews, include the inability to collect data
on potentially important confounders and avoid
missing data. Data on clinical outcome could be
presented only in qualitative terms (improved, no
change, or worse). There was also variability in the
frequency and potency of administered corticoste-
roids, in the frequency and consistency (time of the
day) of laboratory investigations, and in the duration
of corticosteroid treatments before their presenta-
tion. Despite these limitations our study supports
results from previous trials in adults/children indi-
cating that potent topical corticosteroids are one of
the most effective options available for the treatment
of vitiligo. Randomized control trials comparing
calcipotriol and clobetasol ointments13 and tacroli-
mus and clobetasol17 both found clobetasol to be
more effective (18%, 65%, and 41%, 49% marked
repigmentation, respectively).
In addition, our study highlights possible adverse
events resulting from high-potency corticosteroids in
pediatric population. The possibility of adverse side
effects18,22 and the lack of an evidence-based proto-
col has caused many physician to be wary and
uncomfortable prescribing high-potency topical
corticosteroids in children.
Studies of adults with psoriasis, eczema, dermati-
tis, lichen planus, and intertrigo using high-potency
topical corticosteroids have shown an abnormal
morning cortisol level in 18% (n = 188)23 to 64%
(n = 39)18 of patients. Adrenal suppression has been
observed with use of as low as 7.5 g/wk with ele-
vated risk with increasing dosage and one reported
death in an infant using more than 200 g/wk.22,24
However, all of the previous literature has focused
on skin conditions in which the epithelium is disru-
pted leading to increased absorption of topical medi-
cations and, therefore, increased risk of systemic
effects. Although rare, there is possibility of adrenal
suppression with the use of high-potency topical cor-
ticosteroids in patients with an intact epithelium,25
such as vitiligo. In our subgroup analysis, there did
not appear to be any increased risk of an abnormal
cortisol level in the group treated with high- versus
moderate-potency corticosteroids. As the study sam-
ple was modest and laboratory measurements were
not available for all patients, further research into this
area is needed.
Although the association between vitiligo and
autoimmune disease, particularly autoimmune thy-
roiditis,26,27 is well established in adults, thyroid
anomalies, reported in 0.14% (n = 58)28 to 13% (n =
121)29 of children with vitiligo, have only recently
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J AM ACAD DERMATOL
FEBRUARY 2007
been described in a small number of reports. This
study supports the findings of previous literature that
autoimmune comorbidities are present in children
with vitiligo, thus, warranting routine monitoring
and standardized screening guidelines.
High-potency steroids are an efficacious treat-
ment modality for pediatric vitiligo. However, the
potential for systemic absorption should be kept
in mind and regularly monitored, particularly in
patients with head and/or neck locations of disease.
An intermittent regimen (on-and-off every 4-6
weeks) may be useful in decreasing the potential
for local and systemic side effects. In addition,
routine screening with an early morning plasma
cortisol level at baseline and at 4 weeks posttreat-
ment is recommended. All abnormal cortisol levels
should be repeated and a referral to an endocrinol-
ogist for an ACTH stimulation test is required for
persistent low cortisol levels to differentiate between
Addison’s disease and steroid-induced suppression.
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