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2010 Vitiligo Evidencias Por Diagnostico e Manejamento
2010 Vitiligo Evidencias Por Diagnostico e Manejamento
2010 Vitiligo Evidencias Por Diagnostico e Manejamento
com
Review
Review
usually evident and can be present at birth. In idiopathic guttate SUPPORTIVE MEASURES
hypomelanosis, multiple small, white macules are found, mostly In many instances, the first line therapy involves topical medi-
on the trunk or on sun exposed parts of the limbs. caments. Most patients are offered advice about sunscreens and
At the initial consultation, the doctor should make a record of cosmetic camouflage including fake tanning products. With
the effect of vitiligo on the patient. The examination should regard to topical therapy that might influence the state of the
include observation of the disease distribution, extent, whether disease, the use of topical steroids is the usual first line treatment
depigmentation is total or partial, if there are symmetrical (figure 1). Recommended treatments for children differ slightly
lesions, and if there is involvement of mucous membranes. from those for adults.
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 TOPICAL CORTICOSTEROIDS
(QoL) and self esteem.6 It may cause social isolation and Topical steroids are often viewed as the first active treatment to
significant depression,7 create difficulties in sexual relationships, consider. Clayton12 and Kandil13 showed that use of a highly
stigmatisation and affect perceived suitability for marriage.8 9 potent (clobetasol propionate) or potent (betamethasone
(level of evidence: E-3). In people with a white skin colour, valerate) topical steroid can repigment vitiligo, but only in a small
vitiligo may cause less concern (E-3). One study comparing QoL proportion of cases. Clayton found 15e25% repigmentation in
in vitiligo and psoriasis showed a higher dermatology life quality 10/23 subjects (ages not stated) and >75% in 2/23 (the other 11
index (DLQI) for psoriasis than vitiligo (mean 6.26 cf 4.95).10 showed no response), while Kandil found 90e100% repigmen-
The scoring pattern was different with vitiligo scoring lower on tation in 6/23 subjects (ages not given for all, but one was aged
the symptoms and treatment subscales and higher on the social, 12 years) and 25e90% in three (with six showing ‘beginning’
clothing and leisure subscales. This suggests that QoL scales repigmentation).12 13 Clayton found all steroid users had skin
with a weighting on the effect of symptoms and treatment atrophy with clobetasol propionate (used for 8 weeks), while
effects underestimate the effect of vitiligo on QoL. Some Kandil noted hypertrichosis in two subjects and acne in
assessment of the impact of vitiligo on the patient’s QoL should three subjects, related to 4 months use of betamethasone
be made (this could be done by using the DLQI, for example). valerate.12 13
The doctor should discuss the disease and treatment options. The experience of Westerhof et al,14 in probably the best
Patients with vitiligo can develop autoimmune thyroid disease controlled study to date of a topical treatment, compared the
or other autoimmune diseases. A history of autoimmune disease potent topical steroid fluticasone propionate alone or combined
in a family member was obtained in 13 of 41 (32%) adults with with ultraviolet A (UVA) in 135 adults. They found that topical
vitiligo.2 This compares to an overall general population preva- fluticasone propionate used alone for 9 months induced mean
lence of thyroid disease of 5%.11 Adults with vitiligo should have repigmentation of only 9% (compared to UVA alone of 8%)
their thyroid function checked.4 whereas the combination of fluticasone propionate and UVA
Patients should be given information about the Vitiligo induced mean repigmentation of 31%; no steroid atrophy was
Society in the UK or other national patient help organisation. noted in steroid users.
Review
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 compared to an equivalent degree of repigmentation in 7/10
(betamethasone valerate) topical steroid can repigment vitiligo, cases treated with clobetasol propionate. No skin atrophy was
but only in a small proportion of cases; even then, skin atrophy is noted, but burning was a side effect with pimecrolimus.
a common complication after only 2 months’ treatment.5 In an open proof of concept study of 26 children aged over
6 years and adults with generalised symmetrical forms of viti-
TOPICAL CALCINEURIN INHIBITORS ligo, treated for head and neck lesions with topical 1% pime-
Calcineurin inhibitors have an advantage over steroids in that crolimus twice daily, total repigmentation of a target lesion was
they do not thin the skin, which is a concern to many patients. found in 50% of cases after 6 months of therapy.16 Twenty
Coskun and colleagues,15 in a left versus right comparison over children treated over 8 weeks with either topical clobetasol or
an 8 week period in 10 adults, compared topical pimecrolimus tacrolimus were shown to have repigmentation that amounted
with topical clobetasol propionate. They found topical pime- to 41% with clobetasol and 49% with tacrolimus.17 Lesions on
crolimus resulted in 50e100% repigmentation in 8/10 cases the face and thorax responded better than those on the abdomen
most noticeable for lesions on the trunk or extremities, or legs, while lesions on the hands did not respond.
Review
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 Expert opinion concludes that patients with a dark skin type
(HYDROQUINONE MONOBENZYL ETHER)) selected for depigmentation treatments must understand the
Extensive vitiligo in a patient with a dark skin tone, especially cultural effects the depigmentation may have.4 It is usual to
on a cosmetically sensitive area such as the hands or face, can consider depigmentation only for subjects in whom the area of
produce a severe social disability. In this instance it is worth- skin involved by vitiligo is extensivedthat is, involving >50% of
while considering whether complete depigmentation of the the skin surface area.4 If there is extensive involvement of the
affected areas might be beneficial. The profound effect that this cosmetically sensitive areas of the face and hands, and covering
may have culturally needs to be taken into account. cosmetics are ineffective, depigmentation can be considered
In an open study, 18 patients ‘severely’ affected by vitiligo although it is usual to only treat the exposed sites.
(type of vitiligo not stated) were treated with the topical
application of 20% p-(benzyloxy)phenol (monobenzyl ether of SYSTEMIC TREATMENT
hydroquinone (MBEH)18: eight achieved complete depigmen- Since vitiligo is viewed as an autoimmune disease, it is natural to
tation after 10 months and three had ‘dramatic’ depigmenta- wonder whether systemic treatment might have something to
tion, but in three there was no effect at all (after 4 months of offer. However, there are few studies in the literature. A well
use). conducted open study of 25 European adults with active
Review
Review
topical steroid. In children, topical pimecrolimus or tacrolimus 4. Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for the diagnosis and
should be considered as alternatives to the use of a highly management of vitiligo. Br J Dermatol 2008;159:1051e76.
5. Whitton ME, Pinart M, Batchelor J, et al. Interventions for vitiligo. Cochrane
potent topical steroid in view of their better safety profile. Database of Systematic Reviews 2010, issue 1.
Depigmentation should be reserved for adults severely affected 6. Firooz A, Bouzari N, Fallah N, et al. What patients with vitiligo believe about their
by vitiligo and should be undertaken only by a specialist condition. Int J Dermatol 2004;43:811e14.
7. Mattoo SK, Handa S, Kaur L, et al. Psychiatric morbidity in vitiligo: prevalence and
dermatology unit. correlates in India. J Eur Acad Dermatol Venerol 2002;16:573e8.
Phototherapy and surgical treatments can be considered in 8. Ongenae K, Dierckxsens L, Brochez L, et al. Quality of life and stigmatization profile
specialist units. Phototherapy is appropriate for extensive viti- in a cohort of vitiligo patients and effect of the use of camouflage, Dermatology
2005;210:279e85.
ligo, especially if it is active. Surgical treatment, if available, is 9. Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of vitiligo:
appropriate for cosmetically sensitive sitesdfor example, the a preliminary investigation into the effects of cognitive-behavioural therapy. Br J Med
face or back of the handsdbut only when the vitiligo is inactive Psychol 1999;72(Pt 3):385e96.
(no progression for 6e12 months). Surgical treatments are not 10. Stangier U, Gieler U, Ehlers A. Measuring adjustment to chronic skin
disorders: validation of a self-report measure. Psychological Assessment
recommended in children. 2003;15:532e49.
Clinicians should make an assessment of the psychological 11. Bjoro T, Holmen J, Krüger O, et al. Prevalence of thyroid disease, thyroid dysfunction
and QoL effects of vitiligo on adults and children. Psychological and thyroid peroxidase antibodies in a large, unselected population. The Health Study
of Nord-Trondelag (HUNT). Eur J Endocrinol 2000;143:639e47.
interventions should be offered as a way of improving coping 12. Clayton R. A double-blind trial of 0-05% clobetasol proprionate in the treatment of
mechanisms. vitiligo. Br J Dermatol 1977;96:71e3.
13. Kandil-E. Treatment of vitiligo with 0-1 per cent betamethasone 17-valerate in
CONCLUSION isopropyl alcoholea double-blind trial. Br J Dermatol 1974;91:457e60.
14. Westerhof W, Nieuweboer-Krobotova L, Mulder PGH, et al. Left-right comparison
After making an assessment and suggesting supportive measure study of the combination of fluticasone propionate and UV-A vs either fluticasone
(ie, covering cosmetics and sunscreens), the first line treatment propionate or UV-A alone for the long-term treatment of vitiligo. Arch Dermatol
for vitiligo should be the use of a topical calcineurin inhibitor 1999;135:1061e6.
15. Coskun B, Saral Y, Turgut D. Topical 0.05% clobetasol propionate versus 1%
(eg, pimecrolimus or tacrolimus). The psychological impact of pimecrolimus ointment in vitiligo. Eur J Dermatol 2005;15:88e91.
the disease can easily be overlooked but needs special attention 16. Boone B, Ongenae K, Van Geel N, et al. Topical pimecrolimus in the treatment of
during a consultation. The specialist dermatologist can use vitiligo. Eur J Dermatol 2007;17:55e61. Epub 2007 Feb 27.
17. Lepe V, Moncada B, Castanedo-Cazares JP, et al. A double-blind randomized trial of
phototherapy (or possibly a surgical approach in patients 0.1% tacrolimus vs 0.05% clobetasol for the treatment of childhood vitiligo.
with stable disease). However, the paucity of the advice here [comment]. Arch Dermatol 2003;139:581e5.
underlines the desperate need for more effective treatments in 18. Mosher DB, Parrish JA, Fitzpatrick TB. Monobenzylether of hydroquinone.
vitiligo. A retrospective study of treatment of 18 vitiligo patients and a review of the
literature. Br J Dermatol 1977;97:669e79.
19. Radakovic FS, Furnsinn FA, Honigsmann H, et al. Oral dexamethasone pulse
MULTIPLE CHOICE QUESTIONS (TRUE (T)/FALSE (F); ANSWERS treatment for vitiligo. J Am Acad Dermatol 2001;44:814e17.
20. Radmanesh M, Saedi K. The efficacy of combined PUVA and low-dose azathioprine
AFTER THE REFERENCES) for early and enhanced repigmentation in vitiligo patients. J Dermatol Treat
1. Segmental vitiligo is more common in children. 2006;17:151e3.
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treatment of vitiligo. Efficacy of Psoralen-UVA vs. narrowband-UVB therapy. Arch
10%. Dermatol 2007;143:578e84.
3. PUVA is more effective than NB-UVB for symmetrical types 22. Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs
of vitiligo. topical Psoralen plus UVA. Arch Dermatol 1997;133:1525e8.
23. Njoo MD, Westerhoff W, Bos JD, et al. A systematic review of autologous
4. Topical calcineurin inhibitors are preferred to topical cortico- transplantation methods in vitiligo Arch Dermatol 1998;134:1543e9.
steroids for the treatment of facial vitiligo in children. 24. Schallreuter KU, Wood JM, Lemke KR, et al. Treatment of vitiligo with a topical
5. Skin grafting is ineffective for vitiligo on the backs of the application of pseudocatalase and calcium in combination with short-term UVB
hands. exposure: a case study on 33 patients. Dermatology 1995;190:223e9.
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Acknowledgements The Guideline Development Group (GDG) would like to thank treatment of vitiligo. Br J Dermatol 2009;161:910e17. Epub 2009 Jun 11.
and acknowledge the support received from the British Association of 26. Papadopoulos L, Bor R, Legg C. Psychological factors in cutaneous disease; an
Dermatologists, Cochrane Skin Group and the Vitiligo Society. overview of research. Psychol Health Med 1999;4:107e26.
27. Thomson AR, Kent G, Smith JA. Living with vitiligo: dealing with difference.
Competing interests None. Br J Health Psychol 2002;7:213e25.
Patient consent Obtained. 28. 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
Provenance and peer review Not commissioned; externally peer reviewed. proximity to IDDM8. J Invest Dermatol 2010;130:798e803. Epub 2009 Nov 5.
29. Waterman EA, Gawkrodger DJ, Watson PF, et al. Autoantigens in vitiligo identified
by the serological selection of a phage-displayed melanocyte cDNA expression
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These include:
References This article cites 28 articles, 6 of which can be accessed free at:
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Notes