Current treatment options in vitiligo

Dr Evanthia Frangos explores various treatments for this chronic and psychologically distressing skin condition.

Vitiligo is a common, acquired, idiopathic cutaneous disorder characterised by circumscribed white macules, due to loss of functioning melanocytes and melanin from the epidermis.

Mucous membranes, eyes and hair are occasionally involved.

Vitiligo is estimated to affect up to 2 per cent of the world's population. It can present at any age, but is very rarely reported to be present at birth. Peak incidence is between 10 and 30 years. Once it appears, vitiligo follows a chronic course.

Even though it is asymptomatic, it can be distressing.

Vitiligo affects around two per cent of the population

Management
A multidisciplinary approach is needed to assess and manage patients. The choice of therapy should be individualised; however it is not curative and patients should be aware of this.

In addition, the patient needs to protect against trigger factors like skin injury and sunburn, as they may induce the progression of depigmentation.

Topical corticosteroids
Topical corticosteroids are mainly used to stabilise the rapidly progressive early stage of the disease, but also encourage some repigmentation.

The reported rates of repigmentation vary significantly, with mean success rate of 56-95 per cent.1

To be effective, potent/very potent (clobetasol propionate) ointments need to be started early. Mild/moderately potent steroids (e.g. fluticasone propionate or betamethasone valerate) are often sufficient for facial/genital skin or on children.

Care should be taken with the use of strong topical steroids on eyelids because of the risk of glaucoma.

Treatment should last for at least three months (with a treatment-free interval of several weeks every six weeks) and can be continued for a total of six to nine months provided there are signs of repigmentation and no potential adverse effects.

Calcineurin inhibitors
Although tacrolimus and pimecrolimus are not licensed for vitiligo treatment, research has shown they are almost as effective as 0.05% clobetasol in adults as well as children after three months treatment but with a better safety profile.2,3

However, recent observations suggest that tacrolimus monotherapy in the absence of UV has little repigmentation potential.4 More studies are needed to establish it as a viable, cost-effective alternative.

Phototherapy
Being one of the most effective treatments of vitiligo, phototherapy is usually used in extensive segmental disease or after poor response to topical treatments.

Psolaren photochemotherapy with UVA (PUVA) is the topical/oral administration of a psolaren, a chemically synthesised drug that reacts with UV light to cause skin darkening.

Most commonly reported long-term side-effects are lichenification, desquamation, telangiectasia, premature photoaging, actinic keratoses and skin malignancies. Because of the possible side-effects, annual pre-treatment liver/renal function tests and ophthalmological examination are advised.

The dose of the artificial light is gradually increased until minimal asymptomatic erythema of the involved skin occurs (optimal dose). Treatments are usually given two to three times a week, but never on two consecutive days. It is usually given for a minimum of three months, before assessment is made.

Patients should wear protective UVA sunglasses for 18-24 hours after psoralen tablet ingestion to prevent theoretical ocular damage, with further photoprotection measures to prevent skin cancers.

If any progress is seen, therapy continues until the patches have resolved completely or there is no further improvement, or the patient can no longer attend.

Studies looking into the therapy outcome have shown approximately half to two-thirds of patients repigment significantly (60-70 per cent success rate) with 60 per cent of patients relapsing two to three years after completing a PUVA course.

The lifetime maximum number of PUVA sessions is 150-200 to minimise the risk of skin cancer.

A safer and more effective form of unsensitised phototherapy is narrowband UVB, with a mean success rate of 75 per cent in 60 per cent of patients. The advantages include shorter treatment times, no oral drugs required, fewer burning incidents, no hyperkeratosis, and it does not require post-treatment photoprotection.

Depigmentation
Skin bleaching is a last resort in people with widespread vitiligo on more than 50 per cent of body surface area or on vitiligo universalis. Depigmentation therapy requires careful counselling as it is permanent, irreversible and results in photosensitivity.

Twice daily application of monobenzyl ether of hydroquinone (MBEH) or 4-methoxyphenol (4-MP) to the remaining pigmented skin for one to two years until the skin is completely white prevents repigmentation following sun exposure.

The success rate is about 75 per cent.5 It is contraindicated during pregnancy or lactation.

Surgical interventions
Surgical interventions form an ultimate option in recalcitrant non-progressive vitiligo.

Surgical therapies such as transplantation of autologous melanocytes can be considered as a second or third line therapeutic approach. Repigmentation of a vitiligo patch is possible using skin grafts under local/topical anaesthetic from hidden sites (usually gluteal region) of the same patient.

The surgeon's expertise and careful patient selection are also essential for high success. The procedure is only available in specialised centres and is quite time consuming and costly.

For incomplete or unsuccessful repigmentation, transplantation methods can be used in combination with medical and/or irradiation therapies.

Adjuvant therapies
Sunscreen and cosmetic camouflage may also be considered as adjuvant therapies.

Vitiligo can have a profound psychological and social impact on the patient. Recent work has suggested that counselling and CBT could enhance the well-being of the patient and may also improve the disease.

Social support groups (see Resources) are a way of educating, giving support and a sense of belonging to patients.

  • Dr Frangos is a GPSI in dermatology in London

Topical corticosteroids

The therapeutic effect is dependent upon several parameters:

  • Skin type: higher response rate in dark-skinned patients (type IV-VI).
  • Location of vitiligo: facial lesions respond most favourably and acral sites, joints, lips, eyelids, genitalia and areas with no hair respond the least.
  • Disease duration: active disease has better results if treated early.
  • Patient's age: children respond better than adults.
  • Type of vitiligo.
  • Presence of achromotrichia: a poor prognostic factor.

 

Resources

References

1. Matin R. Vitiligo. BMJ Clinical Evidence, Nov 2006.

2. Whitton M E, Ashcroft D M, Barrett C W, Gonzalez U. Interventions for vitiligo. Cochrane Database Syst Review 2009 Issue 2: CD003263.

3. Lepe V, Moncada B, Castanedo-Cazares JP et al. A double-blind randomized trial of 0.1% tacrolimus vs 0.05% clobetasol for the treatment of childhood vitiligo. Arch Dermatol 2003; 139: 581-5.

4. Lotti T, Prignano F, Buggiani G. New and experimental treatments of vitiligo and other hypomelanoses. Dermatol Clin 2007; 25(3): 393-400.

5. Guidelines for the treatment of patients with vitiligo. National Vitiligo Foundation, 2007. www.nvfi.org.

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