Vitiligo Management Guidelines Released

August 7, 2012 — The most effective management for vitiligo includes phototherapy and combination therapy, according to updated guidelines from the writing group of the Vitiligo European Task Force (VETF), which were accepted for publication andpublished online August 3 in the British Journal of Dermatology.

The European Academy of Dermatology and Venereology and the Union Européenne des Médecins Spécialistes collaborated with the VETF in developing the new evidence- and expert-based guidelines for vitiligo.

"Vitiligo is a disease lacking definitive and completely effective therapies," write A. Taïeb, MD, from Service de Dermatologie, CHU de Bordeaux, France, and colleagues. "Phototherapy and combined treatments are the most effective treatments. Therapy should stop the progression of the lesions and provide complete or almost complete repigmentation to be satisfactory for the patient."

Worldwide prevalence of vitiligo is 0.5%, without preference for specific age groups, races, or sex. The causes and pathophysiologic mechanisms underlying vitiligo are still poorly understood, which has hindered progress in diagnosis and management. To date, randomized controlled trials have been rare and affected by methodological issues and possible confounding factors.

Management Recommendations

The reviewers recommend the following principles of management for segmental vitiligo or limited nonsegmental vitiligo (involving less than 2% - 3% of body surface):

• First-line treatment should be to avoid triggering factors and to use local agents such as corticosteroids or calcineurin inhibitors.
• Second-line treatment should be localized narrow-band ultraviolet B (NB-UVB) radiation (311 nm), preferably with the excimer monochromatic lamp or laser.
• Third-line treatment for patients left with cosmetically unsatisfactory repigmentation on visible areas after first- or second-line therapy is to consider use of surgical techniques.

The reviewers recommend the following principles of management for nonsegmental vitiligo:

• First-line management is to avoid triggering or aggravating factors and to stabilize the patient with NB-UVB therapy for at least 3 months. Patients who respond to NB-UVB should continue this treatment for 9 months or more. An additional consideration is to combine localized UVB therapy with systemic or topical therapies.
• Second-line treatment for patients with rapidly progressive disease or lack of stabilization with NB-UVB is systemic corticosteroids, 3- to 4-month minipulse therapy, or immunosuppressants.
• Third-line treatment is to graft areas failing to respond to previous treatment, particularly those areas with high cosmetic effect. The Koebner phenomenon, or new development of vitiligo in a previously unaffected area of skin undergoing traumatic injury, may limit graft persistence. Grafts are relatively contraindicated on the dorsum of the hands and similar areas.
• Fourth-line treatment for widespread (covering more than 50% of body surface), refractory, or highly visible vitiligo is depigmentation using hydroquinone monobenzyl ether or 4-methoxyphenol alone or in combination with Q switch ruby laser.

Future Perspectives

Regarding future developments for vitiligo management, the guidelines suggest more personalized strategies reflecting specific genetic and other clinical factors. Another general principle is to treat early before premature graying of the hair develops.

Because skin inflammation may be a common mechanism underlying vitiligo, use of methotrexate or other aggressive anti-inflammatory therapy may be useful.

Future strategies addressing impaired melanocyte survival mechanisms may include growth factor supplementation with melanocyte-stimulating hormones, antioxidant therapy targeting the epidermis, or gene transfer. Emerging repigmenting therapies include Helium-Neon lasers and prostaglandin E2.

"Recent development[s] in the field of melanocyte precursors are promising," the authors conclude. "If we can better stimulate the migration of those cells towards the epidermis and understand why they usually stop migrating when becoming pigmented, a major step would be achieved. Newer technologies derived from progenitors or reprogrammed skin cells will probably further increase possibility of surgical intervention."

The authors have disclosed no relevant financial relationships.