I. Main considerations when choosing a treatment method
1, disease stage: divided into progressive and stable stage. The progressive stage is determined with reference to vitiligo disease activity score (VIDA) points [1], isomorphic reaction, Wood lamp. ①VIDA score: new lesions or enlargement of original lesions within the last 6 weeks (+4 points), new lesions or enlargement of original lesions within the last 3 months (+3 points), new lesions or enlargement of original lesions within the last 6 months (+2 points); new lesions or enlargement of original lesions within 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, ≥ 4 is rapid progressive; ② isomorphic reaction: localized white spots appearing 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 disease, therapeutic (radiation therapy, phototherapy). White spots occur in areas of constant pressure or friction, or chronic friction of clothing/accessories, with a specific shape, clearly induced by injury; ③Wood light: the color of the lesions is grayish white with poorly defined borders, and the area of the lesions under 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 Wood’s lamp is ≤ the visual area, suggesting that it is the stable stage. Progression can be considered if any of the above three conditions are met; ④ The diagnosis can be supplemented by referring to the image changes of laser confocal scanning microscopy (referred to as skin CT) [2] and dermatoscopy at the same time.
2. White spot area (palm area is about 1% of body surface area): Grade 1 is mild, < 1%; Grade 2 is moderate, l% to 5%; Grade 3 is moderate to severe, 6% to 50%; Grade 4 is severe, > 50%. The area of vitiligo can also be determined by vitiligo area scoring index (VASI), VASI = ∑ (the number of units of each body part in the palm of the hand) × the percentage of pigment loss in the area, VASI value is 0 ~ 100 [3].
3, Type: According to the 2012 Vitiligo Global Issues Consensus Conference (VGICC) and expert discussion, it was divided into segmental, non-segmental, mixed and undefined types of vitiligo. ① Segmental vitiligo: asymmetric vitiligo distributed along a certain dermal nerve segment (completely or partially matching skin segments), unilaterally. A few can have bilateral multi-segmental distribution; ② Non-segmental vitiligo: including disseminated type, pancystic type, facial extremity type and mucosal type. The sporadic type refers to the white spots ≥ 2, the area is 1 ~ 3; the pancystic type refers to the white spot area 4 (> 50%); the facial extremity type refers to the white spot is mainly limited to the head, hands and feet, especially in the distal end of the fingers and toes and around the facial cavity, can develop into the sporadic type, pancystic type; the mucous membrane type refers to the white spot distribution in two or more mucous membrane parts, can develop into the sporadic type, pancystic type; ③ mixed vitiligo: segmental and non-segmental coexist; ④Undetermined type vitiligo: refers to non-segmental distribution of single lesion with area of 1 level.
4, efficacy: facial re-coloring efficacy is good, mouth and lips, hands and feet parts re-coloring efficacy is poor. The shorter the duration of the disease, the better the efficacy. The efficacy of children is better than that of adults.
The first is that the person who is in the process of the process is the person who is in the process of the process.
A progressive vitiligo.
1, undetermined type (formerly known as limited type): can be used externally glucocorticoids (referred to as hormones) or calcium-regulated neurophosphatase inhibitors (tacrolimus ointment, pimecrolimus cream), etc., can also be used externally low concentration of photosensitizing drugs, such as concentration < 0.1% of 8-methoxazole (8-MOP); vitamin D3 derivatives; local phototherapy optional narrow-spectrum medium wave ultraviolet (NB-UVB), 308 nm excimer laser and excimer light. For rapidly progressive stage, hormones can be used systematically.
2, non-segmental and mixed type: VIDA score > 3 points consider systemic hormone, Chinese herbal medicine, NB-UVB, 308 nm excimer light and excimer laser. Rapidly progressive stage using phototherapy can be combined with systemic hormones or antioxidants to avoid the oxidative stress caused by phototherapy that leads to lesion expansion. Topical topical drug treatment is used in reference to the progressive undefined type.
3. Segmental type: refer to progressive undetermined type of treatment.
Two stable stage vitiligo.
1, undetermined type (formerly called limited 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 the progressive undetermined type.
2. Non-segmental and mixed types: phototherapy (such as NB-UVB, 308 nm excimer light and excimer laser, etc.), Chinese herbal medicine, autologous epidermal transplantation or melanocyte transplantation (exposed site or site requested by the patient). Topical topical medications refer to the stable stage undetermined type.
3.Segmental type: autologous epidermal transplantation or melanocyte transplantation (stable for more than 6 months), including autologous epidermal slice transplantation, micro skin slice transplantation, edged thick skin slice transplantation, autologous non-cultured epidermal cell suspension transplantation, autologous cultured melanocyte transplantation etc. Refer to the unspecified type of treatment in the stable stage.
III. Treatment details
I. Hormone therapy.
1.Topical topical hormone: Applicable to progressive lesions with white spots involving < 2% ~ 3% of body surface area. Super- or strong-acting hormones can be used continuously for 1 to 3 months or under the guidance of a dermatologist, or alternately with strong- or weak- or medium-acting hormones. For adults, topical strong hormones are recommended. If there is no recoloration after 3 to 4 months of continuous topical hormone treatment, it indicates that the hormone is ineffective and needs to be replaced by other treatment methods.
2. Systemic hormone: It is suitable for vitiligo patients with VIDA > 3 points. The hormone can be taken orally or intramuscularly to stabilize the progressive vitiligo as soon as possible. For adults with progressive vitiligo, a small oral dose of prednisone 0.3 mg?kg-1?d-1 can be taken for 1 to 3 months, and then discontinued. After the effect, the dose can be reduced by 5 mg every 2-4 weeks to 5 mg every other day for 3-6 months. Or compound betamethasone injection 1 ml, intramuscular injection, once every 20 ~ 30 d, available 1 ~ 4 times or at the discretion of the doctor.
II. Phototherapy.
1, local phototherapy: NB-UVB treatment 2 ~ 3 times a week, according to different parts of the selection of different initial treatment dose, or before treatment to determine the minimum erythema (MED), the starting dose is 70% of the minimum erythema. The next dose depends on the erythema response after the previous irradiation: if no erythema appears or the duration of erythema is < 24 h, the treatment dose is increased by 10% to 20% until the single dose reaches 3.0 J/cm2 (type III and type IV skin). If the erythema exceeds 72 h or blisters appear, the treatment time should be postponed until the symptoms disappear, and the next treatment dose should be reduced by 10%-20%. If the erythema persists for 24 to 72 h, the original dose should be maintained. 308 nm single-frequency excimer light, 308 nm excimer laser: 2 ~ 3 times per week, the starting dose and the next treatment dose refer to NB-UVB.
2, whole body NB-UVB treatment: applicable to non-segmental or mixed vitiligo with disseminated or generalized lesions. The initial dose and the next treatment dose adjustment are the same as local NB-UVB. The number, frequency, erythema and cumulative dose of phototherapy treatment are not the more the better, the cumulative dose is easy to form skin dryness, itching, photoaging and other adverse reactions. The number, frequency, erythema and cumulative dose of treatment are related to the emergence of phototolerance (plateau). ①If plateau phase occurs (no pigment recovery after 20 ~ 30 consecutive irradiations), treatment should be stopped and rested for 3 ~ 6 months, starting dose with minimum erythema amount; ②Stop treatment after 3 months of treatment without effect; ③As long as there is continuous recoloration, phototherapy can be continued; ④Maintenance phototherapy is not recommended; ⑤Rapidly progressive phase, combined with systemic hormone therapy, can avoid phototherapy-induced isomorphic reaction, starting dose < 70% of the minimum erythema volume. Short duration, non-segmental type is more effective than long duration, segmental type; face and neck, trunk is more effective than extremities.
3, the combination of phototherapy: phototherapy combination therapy efficacy is better than monotherapy. Combination therapy mainly includes: phototherapy + hormone oral or topical; phototherapy + calcium-regulated neurophosphatase inhibitor topical; phototherapy + oral Chinese medicine preparation; phototherapy + vitamin D3 derivatives topical; phototherapy + photosensitizer topical; phototherapy + transplantation therapy; phototherapy + oral antioxidant; phototherapy + fractional laser therapy; phototherapy + dermabrasion, etc.
4. Topical photochemotherapy and oral photochemotherapy: Since their efficacy is not better than NB-UVB and there are many adverse reactions, they have been replaced by NB-UVB.
Third, transplantation therapy.
It is suitable for patients with stable vitiligo (stable for more than 6 months), especially for patients with undetermined type of stable vitiligo and segmental vitiligo, and exposed area 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, and patients with progressive vitiligo and keloid 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 time is 3 ~ 6 months, intermittent application can be longer, the best re-coloring effect is the face and neck. Special areas such as the periorbital area can be preferred for application, and mucosal areas and genital areas can also be used [4] without hormone-induced adverse effects, but it should be noted that it can cause local infections such as folliculitis and the appearance or aggravation of acne.
V. Vitamin D3 derivatives.
Topical carbotriol ointment and tacalcitol ointment can be used to treat vitiligo and 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 topical carbotriol ointment or tacalcitol ointment can enhance the efficacy of NB-UVB treatment for vitiligo.
Six, Chinese herbal medicine.
It is 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-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. Treatment of the progressive stage is based on expelling evil, draining wind and clearing heat and dampness, and draining liver and relieving 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 treatment.
It is mainly applied to patients with white spots involving > 95% of the area. Resistant to various methods of repigmentation therapy, skin depigmentation can be accepted 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, topical application twice daily for 3 ~ 6 weeks; also available 20% 4-methoxyphenol cream (hydroquinone monomethyl ether). Start with 10% concentration of decolorizer, and gradually increase the concentration every 1 ~ 2 months. Apply topically twice daily, decolorizing exposed areas first and then non-exposed areas, with clinical efficacy appearing in 1 ~ 3 months. Pay attention to reduce the absorption of the decolorant by the skin, and prohibit contact with other people’s skin for 2 ~ 3 hours after the body is coated with the drug.
2, laser treatment: optional Q755 nm, Q694 nm, Q532 nm laser.
VIII. Covering therapy.
For the exposed parts of the skin lesions, using cosmetics containing dyes to apply white spots, so that the color is close to the surrounding normal skin color.
Nine, children vitiligo.
Limited leukoplakia: 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 oral hormones; oral prednisone 5 ~ 10 mg/d for 2 ~ 3 weeks is recommended. If necessary, the treatment can be repeated again after 4 ~ 6 weeks.
X. Adjuvant therapy.
Predisposing 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
(i) This guideline does not guarantee satisfactory outcome for all patients.
②This guideline does not include all treatments for vitiligo.
③The treatment of vitiligo should strive for early treatment after diagnosis, and the treatment should be personalized and comprehensive. Treatment should be adhered to over a long period of time, with a course of treatment lasting at least 3 months.
(iv) Certain drugs (such as tacrolimus ointment, pimecrolimus cream, carbotriol ointment, etc.) are not included in the drug instructions for vitiligo, but it has been documented that these drugs are effective for vitiligo.
⑤ Regarding the treatment of children with rapidly progressive vitiligo using small oral doses of hormones, reference was made to the consensus on vitiligo treatment published by Pear E. Grimes at the 63rd annual meeting of the American Academy of Dermatology in 2005, which was formed by combining expert clinical experience.