Pigmentology Group of the Professional Committee of the Chinese Academy of Integrative Medicine This guideline is based on the consensus on vitiligo treatment (2009 version) developed by the Pigmentology Group of the Professional Committee of the Chinese Academy of Integrative Medicine, discussed and formulated by some experts from the Pigmentology Group, the Vitiligo Research Center of the Chinese Medical Association Branch and relevant experts in China. The purpose of vitiligo treatment is to control the development of the lesions and promote the re-coloring of the white spots.
I. The main considerations when choosing a treatment method.
(a) stage of disease: divided into progressive and stable stage. The progressive stage is determined with reference to vitiligo disease activity score (VIDA) points, isomorphic reaction, Wood lamp.
1, VIDA points: new lesions or original lesions enlarged in the last 6 weeks (+4 points), new lesions or original lesions enlarged in the last 3 months (+3 points), new lesions or original lesions enlarged in the last 6 months (+2 points); new lesions or original lesions enlarged in the last 1 year (+1 points); stable for at least 1 year (0 points); stable for at least 1 year with spontaneous pigment regeneration (a 1 points). A total score > 1 is the progressive stage, ≥ 4 is the rapid progressive stage.
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, therapeutic (radiation therapy, phototherapy). White spots occurring on sites of constant pressure or friction, or chronic friction of clothing/accessories, with a specific shape, apparently induced by injury.
3.Wood 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. Any one of the above 3 items can be considered as progressive.
4. The image changes of laser confocal scanning microscopy (referred to as skin CT) and dermoscopy can be referred to simultaneously to supplement the diagnosis.
(ii) White spot area (palm area is about 1% of body surface area): Grade 1 is mild, <1%; Grade 2 is moderate, 1%-5%; Grade 3 is moderate to severe, 6%-50%; Grade 4 is severe, >50%. The area of vitiligo can also be determined by vitiligo area scoring index (VASI). vasi=∑(number of units of body parts in the palm) × percentage of pigment loss in the area, VASI value is 0~100.
(iii) 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.
1, segmental vitiligo: distribution along a certain dermal nerve segment (completely or partially matching skin segments), unilateral asymmetric vitiligo. Few can be distributed bilaterally in multiple segments.
2, non-segmental vitiligo: including disseminated type, pancytopenia, facial extremity type and mucosal type. The sporadic type refers to the white spot ≥ 2 pieces, the area is 1 to 3; the pancystic type is the white spot area 4 (>50%); the facial extremity type refers to the white spot is mainly limited to the head and face, 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 2 and more mucous membrane parts, can develop into the sporadic type, pancystic type.
3, mixed type vitiligo: segmental and non-segmental type coexist; ④ undetermined type vitiligo: refers to single lesion with non-segmental distribution and area of 1 level.
4, efficacy: good efficacy of re-coloring on face, poor efficacy of re-coloring on mouth, lips, hands and feet parts. The shorter the duration of the disease, the better the efficacy. The efficacy of children is better than that of adults.
Second, the principle of treatment
(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 < 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 the 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 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-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 patients). 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, 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 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, small doses of oral prednisone 0.3 mg can be taken for 1 to 3 months and discontinued when it is not effective. After the effect, every 2 to 4 weeks decreasing 5mg to 5mg every other day, maintain 3 to 6 months. Or compound betamethasone injection lml, intramuscular injection, once every 20-30d, 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, according to different parts of the selection of different initial treatment dose, or before treatment to determine the minimum erythema amount (MED), the starting dose is 70% of the minimum erythema amount. The next irradiation dose depends on the erythema reaction after the previous irradiation: if erythema does not appear or erythema lasts <24h, the treatment dose is increased by 10%-20% until the single irradiation dose reaches 3.0J/cm2 (type III, 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 erythema persists for 24-72 h, the original dose of treatment should be maintained. 308 nm single-frequency excimer light, 308 nm excimer laser: 2-3 times a week, the starting dose of treatment 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 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 of treatments, frequency, amount of erythema and cumulative dose are related to the emergence of phototolerance (plateau period).
(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 with the minimum amount of erythema.
(2) Stop treatment after 3 months of treatment without effect.
(3) Phototherapy may be continued as long as there is sustained repigmentation.
(4) Maintenance phototherapy is not recommended.
(5) In the rapidly progressive phase, combined with systemic hormone therapy, phototherapy-induced anisocoria can be avoided with a starting dose of <70% of the minimum erythema volume. Short duration, non-segmental type efficacy is better than long duration, segmental type; face and neck, trunk efficacy is better than extremities.
3, the combination of phototherapy: phototherapy combined therapy efficacy is better than monotherapy. Combination therapy mainly has.
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: Since their efficacy is not better than NB-UVB and there are many adverse reactions, they have been replaced by NB-UVB.
(C) transplantation therapy.
It is suitable for patients with stable vitiligo (stable for more than 6 months), especially for patients with undetermined type and segmental vitiligo in stable stage, 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, progressive vitiligo and keloid patients are contraindications to transplantation. The commonly used 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 duration of treatment is applied continuously for 3-6 months, intermittent application can be longer. The best sites for recoloration 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 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 application of carbotriol ointment or tacalcitol ointment can enhance the efficacy of NB-UVB treatment for vitiligo.
(F) Traditional Chinese 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. 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 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. 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% methoxyphenol cream (hydroquinone monomethyl ether). Start with 10% concentration of decolorizer, and gradually increase the concentration every 1 to 2 months thereafter. 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 depigmenting agent, the body is prohibited from contacting the skin of others for 2 to 3 hours after applying the drug.
2, laser treatment: optional Q755 nm, Q694 nm, Q532 nm laser.
(H) Covering therapy.
For exposed parts of the skin lesions, use cosmetics containing dyes to apply white spots, so that the color is close to the surrounding normal skin color.
(ix) Vitiligo in children.
Limited leukoplakia: Children <2 years old can be treated with topical medium-acting hormones, and 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; 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) 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.