Consensus on Vitiligo Treatment (2014 Edition) Jiao Jian, Department of Dermatology, Qilu Hospital, Shandong University
Pigmentary Diseases Group of the Specialized Committee of Dermatologic Venereal Diseases of the Chinese Society of Integrative Medicine
This guideline is based on the Vitiligo Treatment Consensus (2009 edition) developed by the Pigmentology Group of the Specialized Committee of Dermatological Venereal Diseases of the Chinese Society of Integrative Medicine, and was discussed and developed by some experts from the Pigmentology Group, the Vitiligo Research Center of the Dermatology Branch of the Chinese Medical Association and related experts in China.
The purpose of vitiligo treatment is to control the development of lesions and promote the re-coloration of white spots.
A. The main considerations when choosing a treatment method: 1.
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①VIDA score: new lesions or enlargement of original lesions in the last 6 weeks (+4 points), new lesions or enlargement of original lesions in the last 3 months (+3 points), new lesions or enlargement of original lesions in the last 6 months (+2 points); new lesions or enlargement of original lesions in the last 1 year (+1 point); stable for at least 1 year (0 points); stable for at least 1 year with spontaneous pigment regeneration (-1 point).
A total score >1 is considered progressive, and ≥4 is considered rapidly progressive.
② Isomorphic reaction: localized white spots appear within 1 year of skin injury. Injuries include physical (trauma, cuts, scratches), mechanical friction, chemical/thermal burns, allergic (contact dermatitis) or irritant reactions (vaccinations, tattoos, etc.), chronic stress, inflammatory skin diseases, and therapeutic (radiation therapy, phototherapy). White spots occur in areas of constant pressure or friction, or in chronic friction areas of clothing, ornaments, with a specific shape, obviously induced by injury.
③wood light: the color of the lesions is grayish white, the border is less clear, and the area of the lesions under the wood light is larger than the visual area, suggesting a progressive stage. The color of the lesion is white, the border is clear, and the area of the lesion under the wood lamp is ≤ the visual area, suggesting that it is the stable stage.
Progressive stage can be considered if any of the above 3 conditions are met.
④The diagnosis can be supplemented by referring to the image changes of laser confocal scanning microscopy (referred to as skin CT) and dermoscopy at the same time.
2. White spot area (palm area is about 1% of body surface area).
Grade 1 is mild.
3. Combination therapy of phototherapy: Combination therapy of phototherapy is more effective than monotherapy. Combination therapy mainly includes.
Phototherapy + hormones orally or topically.
phototherapy + topical application of calcium-regulated neurophosphatase inhibitors.
phototherapy + oral herbal preparations.
phototherapy + topical vitamin D3 derivatives.
phototherapy + topical application of photosensitizers.
phototherapy + transplantation therapy.
phototherapy + oral antioxidants.
Phototherapy + fractional laser treatment.
Phototherapy + dermabrasion, etc.
(4) Topical photochemotherapy and oral photochemotherapy: as their efficacy is not better than NB-UVB and there are many adverse reactions, they have been replaced by NB-UVB.
(C) transplantation: it is suitable for patients with stable vitiligo (stable for more than 6 months), especially for patients with undetermined type and segmental vitiligo in the stable stage, and exposed lesions of other types of vitiligo can also be used. The choice of transplantation method needs to consider the site and area of the white spots, progressive vitiligo and keloid patients are contraindications to transplantation. The common transplantation methods include: autologous epidermal slice transplantation, micro skin slice transplantation, edge thick skin slice transplantation, autologous non-cultured epidermal cell suspension transplantation, autologous cultured melanocyte transplantation, and single follicle transplantation. The combination of transplantation treatment and phototherapy can improve the efficacy.
(iv) Calcium-regulated neurophosphatase inhibitors: including tacrolimus ointment and pimecrolimus cream. The treatment duration is applied continuously for 3-6 months, intermittent application can be longer. The best sites for recoloring are the face and neck. Special areas such as periorbital area can be preferred for application, mucous membrane areas and genital areas can also be used without adverse reactions caused by hormones, but it should be noted that it can cause local infections such as folliculitis and the appearance or aggravation of acne.
(E) vitamin D3 derivatives: topical carboplatinol ointment and tacalcitol ointment can be used to treat vitiligo, applied topically twice daily. Vitamin D3 derivatives can be combined with NB-UVB, 308 nm excimer laser, etc. It can also be combined with topical hormones and calcium-regulated neurophosphatase inhibitors. Topical application of carbotriol ointment or tacalcitol ointment can enhance the efficacy of NB-UVB treatment for vitiligo.
(F) Chinese medicine: divided into 2 stages: progressive stage and stable stage, forming 4 main types of evidence corresponding to them (wind-damp and heat evidence, liver-depression and qi stagnation evidence, liver and kidney deficiency evidence, blood stasis and blockage evidence). The progressive stage is characterized by wind-damp-heat and liver-depression-qi stagnation, while the stable stage is characterized by liver-kidney deficiency and blood stasis. Children often present with weakness of the spleen and stomach. The treatment of the progressive stage is based on expelling evil, clearing wind and heat, relieving dampness, and relieving liver and depression; the stable stage is based on nourishing liver and kidney, activating blood circulation and resolving blood stasis, and selecting the corresponding herbs according to the site.
(vii) Depigmentation therapy: It is mainly applied to patients whose white spots involve >95% of the area. Resistance to various methods of repigmentation therapy has been proven, and skin depigmentation is acceptable at the patient’s request. Strict sun protection is required after depigmentation to avoid sun damage and repigmentation.
1. Depigmentation agent treatment: 20% hydroquinone monophenyl ether, applied topically twice daily for 3-6 weeks; 20% 4-methoxyphenol cream (hydroquinone monomethyl ether) is also available. Start with 10% concentration of decolorizer, and gradually increase the concentration every 1 to 2 months. Apply topically twice a day, decolorize exposed areas first and then decolorize non-exposed areas, and clinical results will appear in 1 to 3 months. Pay attention to reduce the absorption of the skin to the decolorant, the body 2 ~ 3 hours after the application of drugs prohibited contact with the skin of others.
2. Laser treatment: optional Q755 nm, Q694 nm, Q532 nm laser.
(H) Covering therapy: used for exposed parts of the skin lesions, with cosmetics containing dyes applied to the white spots, so that the color is close to the surrounding normal skin color.
(ix) Children vitiligo: limited white spots: children <2 years old can be treated with topical medium-acting hormones, intermittent topical therapy is safer; children >2 years old can be treated with topical medium- or strong-acting hormones. Tacrolimus ointment and pimecrolimus cream can be used for the treatment of limited childhood vitiligo. Rapidly progressive vitiligo lesions in children can be treated with small doses of hormones orally, and oral prednisone 5-10 mg/d for 2-3 weeks is recommended. If necessary, the treatment can be repeated once more after 4-6 weeks.
(X) Adjunctive treatment: Triggering factors such as trauma, sun exposure and mental stress should be avoided, especially in the progressive phase. Treatment of concomitant diseases. Psychological counseling to relieve concerns, build confidence and adhere to treatment.
Note: ① this guideline cannot guarantee satisfactory results for all patients; ② this guideline does not include all treatments for vitiligo; ③ vitiligo treatment should strive for early treatment after diagnosis, and treatment should be personalized and comprehensive. The treatment should be adhered to for a long time, and a course of treatment should be at least 3 months; ④Some drugs (such as tacrolimus ointment, pimecrolimus cream, carbotriol ointment, etc.) are not included in the drug instructions for vitiligo, but it has been proven in the literature that these drugs are effective for vitiligo; ⑤For the treatment of children with rapidly progressive vitiligo using small doses of hormones orally, refer to the 63rd American Academy of Dermatology 2005 The treatment of vitiligo in children with rapidly progressive vitiligo is based on the consensus on the treatment of vitiligo presented by Pear E. Grimes at the 63rd Annual Meeting of the American Academy of Dermatology in 2005, combined with expert clinical experience.