Pigmentology Group of the Chinese Society of Integrative Medicine and Dermatology
This guideline is based on the Vitiligo Treatment Consensus (2009 version) developed by the Pigmentology Group of the Chinese Society of Integrative Medicine and Dermatology, and discussed and formulated 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-coloring 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,
Grade 3 is moderately severe, 6% to 50%.
Grade 4 is severe, >50%.
The area of vitiligo can also be determined by the vitiligo areascoring index (VASI), VASI=∑(number of units of the body parts in the palm of the hand)×the percentage of pigment loss in the area, VASI value is 0-100.
3. Type: According to the 2012 Vitiligo Global Issues Consensus Conference (VGICC) and expert discussion, it is divided into segmental, non-segmental, mixed and undefined types of vitiligo.
①Segmental vitiligo: asymmetric vitiligo distributed along a certain dermal nerve segment (completely or partially matching skin segments), unilateral. A few can be distributed bilaterally in multiple segments.
② Non-segmental vitiligo: including disseminated type, pancytopenia, facial extremity type and mucosal type. (a) Sporadic type refers to white patches ≥ 2 with an area of grade 1 to 3.
(b) Pancytopenia refers to leukoplakia with an area of grade 4 (>50%).
Facial-extremity type means that the white spots are mainly confined to the head and face, hands and feet, especially around the distal ends of the fingers and toes and facial cavities, and can develop into disseminated and pancreatic type.
The mucous membrane type refers to the distribution of white spots in two or more mucous membrane parts, can develop into epidemic type, pancystic type.
③Mixed type vitiligo: segmental and non-segmental types coexist.
④Undetermined type of vitiligo: refers to a single lesion with non-segmental distribution and an area of 1 level.
4. efficacy: good efficacy of repigmentation on the face and poor efficacy of repigmentation on the mouth, lips, hands and feet. The shorter the duration of the disease, the better the efficacy. The efficacy of children is better than that of adults.
II. Treatment principles
(A) the progressive stage of vitiligo.
1, undetermined type (formerly known as limited type): can be used externally glucocorticoid (referred to as hormone) or calcium-regulated neurophosphatase inhibitor (tacrolimus ointment, pimecrolimus cream), etc., can also be used externally low concentration of photosensitizing drugs, such as concentration <0.1% of 8 a methoxazole (8 a 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, TCM, NB-UVB, 308 nm excimer light and excimer laser. Phototherapy can be used in combination with systemic hormones or antioxidants during the rapid progressive phase to avoid the oxidative stress caused by phototherapy that leads to lesion expansion. Topical topical medication is used in reference to the progressive undefined type.
3. Segmental type: refer to the treatment of undetermined type of progressive stage.
(II) Stable stage vitiligo.
1. undetermined type (formerly called limited type): topical photosensitizers (such as furanocoumarins 8 a 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 sites or sites 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, microdermal slice transplantation, bladed thick skin slice transplantation, autologous non-cultured epidermal cell suspension transplantation, autologous cultured melanocyte transplantation. 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% to 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 weak-medium-acting hormones. Topical strong hormones are recommended for adults. If there is no recoloration after 3-4 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 score. Oral or intramuscular injection of hormone can make the progressive vitiligo stabilize as soon as possible. For adults with progressive vitiligo, a small oral dose of prednisone 0.3 mg/kg?d can be taken for 1 to 3 months and discontinued if it is not effective. After the effect of 5 mg every 2 to 4 weeks to 5 mg every other day, maintain 3 to 6 months. Or compound betamethasone injection lml, intramuscular injection, 1 time every 20-30 d, available 1-4 times or at the discretion of the doctor.
(II) Phototherapy.
1. Local phototherapy: NB-UVB treatment 2 to 3 times a week, different initial treatment doses are selected according to different sites, or the minimum erythema amount (MED) is measured before treatment, and the starting dose is 70% of the minimum erythema amount. The next irradiation dose depends on the erythema response after the previous irradiation: if erythema does not appear or erythema lasts <24 h, the treatment dose is increased by 10%-20% until the single irradiation 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 24-72 h, the original dose should be maintained. 308 nm single-frequency excimer light, 308 nm excimer laser: 2-3 times a week, the starting dose and the next treatment dose refer to NB-UVB. 2.
2. Systemic NB-UVB treatment: It is suitable for 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 of phototherapy treatments, frequency, erythema amount and cumulative dose are not the more the better, the cumulative dose is easy to form skin dryness, pruritus, photoaging and other adverse reactions large. The number, frequency, erythema and cumulative dose of treatment are related to the emergence of phototolerance (plateau). ① If the plateau period (no pigment recovery after 20-30 consecutive irradiations) occurs, treatment should be stopped and rested for 3-6 months, with the starting dose starting at the minimum erythema amount; ② Stop treatment after 3 months of treatment with no effect; ③ As long as there is continuous recoloration, phototherapy can be continued; ④ Maintenance phototherapy is not recommended; ⑤ Rapidly progressive phase, combined with systematic treatment with hormones, can avoid phototherapy-induced isomorphic reactions with a starting dose < 70% of the minimum erythema volume. Short duration, non-segmental type has better efficacy than long duration, segmental type; face and neck, trunk has better efficacy than extremities.
3. Combined therapy of phototherapy: combined therapy of phototherapy is more effective than single therapy. Combination therapy mainly includes.
Phototherapy + hormone oral or topical.
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.