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Vitiligo treatment

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vitiligo treatment management therapies

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vitiligo phototherapy topical agents repigmentation

Harrison's Principles of Internal Medicine, Twenty First Edition

Page 1712

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vitiligo skin depigmentation clinical appearance

Harrison's Principles of Internal Medicine, Twenty First Edition

Harrison's Principles of Internal Medicine, Twenty First Edition

Page 1518

GradeResponse
GradeResponse
GradeResponse

Vitiligo Treatment

Vitiligo — characteristic sharply demarcated depigmented patches on the dorsal hands and wrists
Vitiligo: acral depigmented macules/patches on bilateral hands — Harrison's, p. 1518
Vitiligo is an autoimmune disorder causing loss of melanocytes, resulting in well-demarcated depigmented patches. Treatment aims to halt progression and achieve repigmentation.

Goals of Treatment

  1. Stop active disease progression
  2. Repigment affected skin
  3. Maintain achieved repigmentation

First-Line Therapies

Topical Agents

AgentDetails
Topical corticosteroids (TCS)High-potency (e.g., clobetasol) for trunk/extremities; moderate-potency for face. First-line for localized disease. Monitor for skin atrophy with prolonged use.
Topical calcineurin inhibitors (TCIs)Tacrolimus 0.1% or pimecrolimus 1%. Preferred for face and intertriginous areas (steroid-sparing). Safe for long-term use.
Ruxolitinib cream (JAK inhibitor)FDA-approved (2022) for non-segmental vitiligo in adults/adolescents ≥12 years. JAK1/2 inhibitor targeting the IFN-γ/CXCL10 pathway. Most effective repigmentation agent to date for facial lesions.

Phototherapy

Narrow-band UVB (NB-UVB) is the mainstay of phototherapy for vitiligo (Harrison's, p. 1712):
  • Fluorescent bulbs emitting ~311 nm radiation
  • Superior efficacy over broad-band UVB
  • Suitable for widespread disease or lesions resistant to topicals
  • 2–3 sessions/week for a minimum of 6–12 months
  • Can be combined with topical agents for enhanced effect
PUVA (Psoralen + UVA):
  • Oral or topical psoralen + UVA exposure
  • Effective but higher risk (nausea, phototoxicity, cataract risk with oral psoralen)
  • Less commonly used now that NB-UVB is available
Excimer laser (308 nm):
  • Targeted phototherapy for localized lesions
  • Allows high-dose UV delivery to affected patches while sparing normal skin
  • Faster response than whole-body NB-UVB

Surgical Options

Reserved for stable segmental or focal vitiligo (no new lesions for ≥12 months):
ProcedureDetails
Suction blister epidermal graftingMost widely used; good cosmetic outcomes
Split-thickness skin graftingFor larger areas
Punch graftingSmall, focal patches
Melanocyte-keratinocyte transplantation (MKTP)Cultured cells; can cover large areas

Systemic Therapies

  • Oral mini-pulse corticosteroids (e.g., betamethasone 5 mg on 2 consecutive days/week): used to halt rapidly progressive disease
  • Oral JAK inhibitors (ruxolitinib, baricitinib — investigational/emerging): promising phase II/III trial data for widespread disease
  • Afamelanotide (MC1R agonist implant): used in combination with NB-UVB, accelerates repigmentation

Camouflage / Depigmentation

  • Cosmetic camouflage (waterproof concealers, self-tanners) for psychosocial impact
  • Depigmentation with monobenzone (monobenzyl ether of hydroquinone): considered only when >50% BSA is affected and repigmentation has failed — permanently depigments remaining normal skin

Special Considerations

FactorGuidance
Segmental vitiligoLess responsive to medical treatment; surgical options preferred
Active/inflammatory vitiligoTreat inflammation first (TCIs, TCS, systemic steroids) before surgery
ChildrenPrefer TCIs and NB-UVB; avoid prolonged high-potency TCS
Face/eyelidsTCIs + NB-UVB or excimer laser; avoid TCS long-term
Koebner phenomenonMinimize trauma; treat wounds promptly

Monitoring

  • Assess repigmentation at 3–6 months
  • Wood's lamp examination to detect early lesions and assess progress
  • Screen for associated autoimmune conditions: thyroid disease (most common), type 1 diabetes, Addison's disease, alopecia areata
Key takeaway: Mild/localized disease → topical TCS or TCIs ± excimer. Moderate/widespread → NB-UVB ± topicals. Rapidly progressive → systemic mini-pulse steroids. Stable localized → surgical grafting. Ruxolitinib cream is a significant recent advance for facial non-segmental vitiligo.
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