Many different methods are available for the treatment of vitiligo. Treatment is usually preferred to safe and effective methods that are also less invasive and less costly.
Targeted UVB (308 or 311 nm) alone or in combination with topical hormones/topical calcium phosphatase inhibitors is the safest and most effective approach if the area of skin involved is less than 15%.
Second, third and fourth line treatments must be discussed by the dermatologist and the vitiligo patient in an open and constructive manner, keeping in mind that less invasive and less costly treatments are always preferred; if first line treatment options do not achieve your satisfaction, do not get frustrated, discuss other options with your dermatologist and follow the new treatment plan.
Stay positive: you have many opportunities to find the right treatment option for vitiligo!
Choosing a treatment option for vitiligo can be difficult and in some cases tremendously difficult. In general, first-line treatment options are safe, effective, less invasive and less expensive. More complex, invasive and time-consuming treatment options are usually applied to patients with stubborn disease. Because pigment recovery is quite slow, each treatment modality should be used for a long enough period of time that effective treatment should continue until the lesions improve or completely regain color.
Regardless of which recommended treatment regimen is applied, consistent data on maintenance regimens or long-term maintenance of pigmentation are currently lacking.
How is vitiligo treated?
First-line treatment There are many topical and oral medications that are inexpensive, easy to use, and effective in slowing disease progression and inducing repigmentation. Corticosteroids (CSs) are the most effective topical agents, followed by calcium phosphatase inhibitors (Cis ). Given the side effects of topical hormones, regular intermittent application of medications is recommended.
In our experience, focusedmicro-phototherapy (with 308nm or 311nm emitters) is the recommended treatment, either alone or in combination with topical therapy. For patients who cannot tolerate topical hormones, calcium phosphatase inhibitors alone are also effective.
For recalcitrant lesions on the extremities, once-a-night encapsulation therapy is also effective. The available data do not support the use of topical vitamin D3 derivatives alone. However, vitamin D3 may increase the effectiveness of topical steroids, including in patients who have not previously been sensitive to steroids. Topical L-phenylalanine, antioxidants and mitochondrial stimulating cream, combined with natural light and oral khellin, have been suggested as alternative first-line treatment options given their therapeutic efficacy.
For most patients in the active phase, short-term oral or intravenous administration of hormones can stop vitiligo progression and induce repigmentation. However, the most appropriate dose that is most effective and has the lowest incidence of side effects remains unclear.
Second-line treatment Second-line regimens are considered when first-line treatment fails. Considering the time and money spent by patients and physicians, as well as the increased incidence of side effects, phototherapy is recommended as a second-line treatment option after failure of conservative first-line therapy. Focused microlight therapy (308 or 311 nm) may be chosen when the affected skin area is less than 15%. Narrow-wave UVB phototherapy (NBUVB) produces the best clinical efficacy relative to other types of phototherapy and is more effective in combination with topical medications than either treatment alone.
Narrow-wave UVB (NBUVB) in combination with Cls topicals produced the best clinical results compared to other topicals. Whether the addition of vitamin D3 derivatives increases the effect of NBUVB phototherapy is not certain. UVA and broad-spectrum UVB phototherapy in combination with various other adjuvant treatments is clinically inferior to narrow-wave UVB (NBUVB) phototherapy, but it is equally effective as a second-line treatment option.
Third-line treatment 308 nm single-frequency excimer laser (MEL) targeted phototherapy is effective as a single treatment and is superior to NBUVB phototherapy. MEL is most effective when combined with topical CSs or CIs.
Fourth-line treatment When lesions persist despite prolonged and reasonable treatment, surgical treatment should be considered. There are many different surgical techniques available, but the choice of technique depends on the individual characteristics of the patient and the clinical practice of the expert surgeon. For limited lesions that are resistant to other treatments, excellent cosmetic results can be achieved.
Special Populations We have studied both patients with segmental vitiligo (SV) and non-segmental vitiligo, but the applicability of the findings to this population is unclear. Segmental vitiligo (SV) tends to be more stable and does not respond well to treatment; the He-Ne laser is more effective in this population. Pancytopenic and generalized vitiligo may also require modified regimens of treatment.
In some patients, the lesions are so extensive that it is difficult to achieve a satisfactory re-coloring of the appearance. In these patients, the application of depigmentation agents should be considered, but the consideration of their irreversible effects needs to be explored.
Regardless of the stage of treatment, the important thing to remember is that vitiligo is a disease that can be lifelong, which may commonly be psychosocially devastating to the patient. Being aware of its latent impact on quality of life and providing support to cope with it can greatly enhance the doctor-patient relationship and have a positive impact. Cover-up approaches can provide temporary cosmetic improvements and should provide psychotherapy to help patients cope with the psychological burden.
Treatment of vitiligo (progressive approach): We have divided the treatment into first, second, third and fourth line options. Treatment levels are determined by the level of evidence in the literature. Treatment options for special cases are also included.