I. Main considerations when choosing treatment measures
1, the disease stage: divided into progressive and stable stage. The progressive stage is determined by reference to the VIDA score: new lesions or enlargement of the original lesions within the last 6 weeks (+4 points); new lesions or enlargement of the original lesions within the last 3 months (+3 points); new lesions or enlargement of the original lesions within the last 6 months (+2 points); new lesions or enlargement of the original lesions within the last 1 year (+1 points); stable for at least 1 year (0 points); stable for at least 1 year with pigment regeneration (-1 score). The total score >1 point is the progressive stage, >4 points is the rapid progressive stage.
2, white spot area (accounting for the body surface area): Grade 1 is mild, <1%; Grade 2 is moderate, 1% to 5%; Grade 3 is moderately severe, 6% to 50%; Grade 4 is severe, >50% (palm area is 1% of the body surface area).
3, type: divided into common type and segmental type. Unusual type is further divided into limited type: area of grade 1, confined to an anatomical area; disseminated type: area of grade 2~3, multiple anatomical areas; generalized type: area of grade 4 (or >50%); extremity type.
4.Site: good re-coloring effect on the face, poor re-coloring effect on the mouth, lips, hands and feet.
5, age: divided into adults and children vitiligo. The efficacy of children is better than adults.
6, early efficacy is good, long course of treatment effect is relatively poor.
Second, the principle of treatment
(a) progressive vitiligo
1, common type.
①limited type: can be topical glucocorticoid (referred to as hormone) or calcium-regulated neurophosphatase inhibitors (tacrolimus, pimecrolimus), etc., can also be topical low concentration of photosensitizing drugs, such as concentration <0.1% of 8-methoxazole; local phototherapy optional narrow-spectrum medium-wave ultraviolet light, 308nm excimer laser and excimer light, high-energy ultraviolet light.
②Disseminated, pancytopenia and extremity type: TCM, immunomodulators, VIDA score > 3 points consider systemic glucocorticoids. Phototherapy and local topical medication refer to the progressive limited type.
2, segmental type: refer to the treatment of progressive limited type.
(II) Stable vitiligo.
1, common type.
①limited type: topical photosensitizers (such as furanocoumarins 8-MOP, etc.), hormones, nitrogen mustard, calcium-regulated neurophosphatase inhibitors, vitamin D3 derivatives, etc.; autologous epidermal transplantation and melanocyte transplantation; local phototherapy refer to progressive limited type or photochemotherapy.
②Disseminated, pancytopenic and limbic types: phototherapy or photochemotherapy, e.g., PUVA, etc.; Chinese herbal medicine; autologous epidermal transplantation or melanocyte transplantation (exposed sites or sites requested by patients). Topical topical drug treatment refer to the stable stage limited type.
2. Segmental type.
Autologous epidermal transplantation or melanocyte transplantation, including autologous epidermal slice transplantation, microdermal slice transplantation, bladed thick skin slice transplantation, autologous non-cultured epidermal cell suspension transplantation, autologous cultured melanocyte transplantation. Others refer to the stable stage limited treatment.
III. Treatment details
(I) Hormone therapy.
1. Topical topical hormone: suitable for progressive lesions with white spots involving <10% of the area. Super- or strong-acting hormones can be used continuously for 1-3 months or under the guidance of a specialist, or alternately with strong- or weak- or weak-medium-acting hormones. Weak-acting hormones are relatively less effective, while strong-acting hormones are relatively more effective. For adults, topical strong hormones are recommended. If there is no recurrence of color in 3~4 months of continuous topical hormone treatment, it indicates poor efficacy of hormone treatment and needs to be replaced by other treatment methods.
2. Systemic hormone: It is mainly applied to patients with pancytopenia progressive vitiligo. The actual hormone can be taken orally or intramuscularly to stabilize the progressive vitiligo as soon as possible. The actual fact is that you can get a lot more than just a few of the most effective and most effective products and services. After the effect, every 2~4 weeks decreasing 5mg to 5mg every other day, maintain for 3~6 months. Or compound betamethasone 1ml, intramuscular injection, once every 20~30 days, available 1~4 times.
(B) Phototherapy and photochemotherapy.
1. Local phototherapy.
Treatment 2~3 times a week, according to the instructions to select different initial treatment doses according to different sites, or determine the minimum erythema amount (MED) before treatment, the starting dose is 70% of the minimum erythema amount. The next irradiation dose depends on the appearance of erythema reaction after the previous irradiation: if erythema does not appear or erythema lasts <24 hours, the treatment dose is increased by 10%~20% until the single irradiation dose reaches 3.0J/cm2 (type III, type IV skin).
2. Whole-body phototherapy.
Treatment 2~3 times a week, the initial dose and the next treatment dose adjustment is similar to local. More convenient than PUVA treatment, the eyes do not need to be protected from light after treatment, less phototoxic reactions. Patients who are ineffective in treatment can be switched to PUVA therapy. There is no definitive data on the maximum safe cumulative dose. The longest treatment duration in the literature for white people is 15 months, the number of treatments is 133, and the cumulative dose is 246 J/cm2. One treatment guideline suggests a minimum of 6 months of treatment, with up to 2 years of treatment if the results are satisfactory. However, after the first year of treatment, patients should rest for 3 months before treatment.
3.Local photochemotherapy.
For limited vitiligo, local topical application of furanocoumarins (8-MOP, tincture of psoralen, etc.) + sunlight is a curative and practical treatment option that can be used for adults and children over 5 years old. Patients with white spots involving <10% of the body surface area: apply furanocoumarins to the white spots daily and sunbathe after 30 minutes, and sunbathe the white spots for 15 to 20 minutes daily from 10 am to 4 pm.
For people with fairer complexion, the sun exposure time should be increased to 35~45 minutes per day after 2 weeks if there is no local erythema. Patients with white spots involving <20% of the body surface area: apply furanocoumarins to the white spot area every day and irradiate locally with UVA for 30 minutes after the application of the drug. Treatment is given twice a week. After the appearance of light erythema, the dose is no longer increased to maintain the amount of erythema.
4.Oral photochemotherapy.
Suitable for patients with white spots involving >20% of body surface area, patients resistant to and topical PUVA treatment, and patients aged >12 years. Treatment method: 8-MOP 0.3~0.4mg/kg orally 1.5 hours before UVA irradiation, UVA starting dose 1~2J/cm2, then increase 0.25~0.5J/cm2 each time until the appearance of pale erythema. the dose of UVA should always be maintained at the minimum erythema appearance amount. Treatment should be given twice a week and not on 2 consecutive days. After taking 8-MOP orally, you should wear anti-UVA glasses indoors and outdoors for 18~24 hours, and use sunscreen outside to avoid sun exposure.
5.Photosensitizing drugs.
①Topical psoralen, coal tar preparations, etc.
② Chinese medicine photosensitizing drugs: bone marrow, dahurica, figs, etc.
Prohibited: women during pregnancy, lactation, diabetes, abnormal liver and kidney function, cataract, photosensitive, skin cancer, vulvar area, allergic or intolerant to psoralen.
(iii) Transplantation therapy.
It is suitable for patients with stable vitiligo, especially for patients with limited and segmental vitiligo, and other types of vitiligo with exposed skin lesions can also be used. The treatment needs to take into account the location and size 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. Autologous epidermal transplantation is simple and feasible, and has good efficacy. The combination of transplantation treatment and phototherapy can improve the clinical efficacy.
(iv) Immunosuppressants.
Topical calcium-regulated neurophosphatase inhibitors include tacrolimus ointment and pimecrolimus cream. The duration of treatment is 3-6 months, and the sites with the best re-coloring effect are the face and neck. Mucous membrane areas and genital areas can also be used. No side effects caused by hormones, especially strong hormones, but be aware of increased local infections such as folliculitis.
(v) Vitamin D3 derivatives.
Topical carbotriol and tacalcitol can be used for the treatment of vitiligo and applied topically twice daily. Vitamin D3 derivatives can be combined with narrow-spectrum UVB, 308nm excimer laser, PUVA, etc. It can also be combined with topical hormones and calcium-regulated neurophosphatase inhibitors. Topical topical application of carbofurantrin or tacalcitol can enhance the efficacy of narrow-spectrum UVB treatment for vitiligo. The therapeutic effect of carbofurantrin or tacalcitol combined with psoralen + sun exposure is superior to that of carbofurantrin or tacalcitol alone. Combined with PUVA, especially in hand and foot lesions where PUVA alone is ineffective.
(vi) Traditional Chinese medicine.
Identification of disease combined with identification of evidence: divided into 2 stages: progressive stage and stable stage, forming the four main types of evidence corresponding to them (rheumatism-depression-heat evidence, liver-depression-qi stagnation, liver-kidney deficiency evidence, blood stasis-blocking evidence). The progressive stage is characterized by wind-dampness and heat and liver-depression and qi stagnation, while the stable stage is characterized by liver-kidney deficiency and blood stasis and obstruction. Children often present with weakness of the spleen and stomach. In the stable stage, the main treatment is to nourish the liver and kidney, invigorate blood circulation and remove blood stasis, and select the corresponding meridian inducing drugs according to the location.
(VII) Depigmentation treatment.
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. Commonly used depigmentation agents: 20% monobenzone (hydroquinone monophenyl ether), twice daily for 3-6 weeks; also available 20% 4-methoxyphenol cream (hydroquinone monomethyl ether). Start with a 10% concentration of decolorizer, and gradually increase the concentration every 1~2 months. Twice a day, first decolorize the exposed area and then the non-exposed area, and clinical results will appear in 1~3 months. Pay attention to reduce skin absorption of decolorant, and prohibit contact with other people’s skin 2~3 hours after body rubbing.