Guideline for the Diagnosis and Management of Vitiligo

D.J. Gawkrodger; A.D. Ormerod; L. Shaw; I. Mauri-Sole; M.E. Whitton; M.J. Watts; A.V. Anstey; J. Ingham; K. Young

Disclosures

The British Journal of Dermatology. 2008;159(5):1051-1076. 

In This Article

In All Patients With Vitiligo, What is the Efficacy of a Course of PUVA or PUVA-sol Compared With Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score?

Introduction

Psoralen derived from plants applied to the skin followed by exposure to sunlight has been used as treatment for vitiligo since biblical times. El Mofty in 1948 first published on this treatment in a contemporary journal.[63] Since then, there have been many publications on the efficacy of PUVA in vitiligo.

Methods

Fifteen papers were identified by the computer-assisted search strategy, but only five of these were relevant to the question.

Evidence Statements

Two studies used an RCT study design.[57,64] The study by Pathak had a poor assessment method and lacked statistical analysis but included 366 patients and a placebo group.[64] This study confirmed that PUVA is an effective treatment for vitiligo compared with placebo, yet failed to address the issue of disease progression and impact on QoL. Yones etal. compared the efficacy of NB-UVB with oral PUVA in nonsegmental vitiligo in a well-conducted study that showed that both treatments were effective.[57] However, PUVA was less effective at inducing repigmentation and the colour match of the repigmented skin was not as good as for NB-UVB. At 12months follow-up >25% of PUVA-treated patients had vitiligo that was worse than at baseline. However, a similar proportion of patients had maintained more than 75% improvement in body surface area repigmented at 12months.

Khalid etal. reported on 50 children less than 12years old with vitiligo, using photographs to compare PUVA-sol with topical clobetasone.[38] They reported a good response to PUVA-sol but used no formal statistical analysis. In a study of 89 patients with vitiligo, Sehgal found three different psoralen products to be efficacious in inducing repigmentation compared with baseline but used no control group and no statistical analysis.[65]

Two studies have compared efficacy of PUVA compared with NB-UVB. Westerhof and Nieuweboer-Krobotova compared PUVA and NB-UVB in 28 patients with vitiligo, reporting 46% repigmentation for the PUVA group.[59] Another (open) study of NB-UVB and PUVA using systemic trimethylpsoralen showed a better response to NB-UVB in 50 subjects.[66]

Evidence to Recommendations

Both PUVA and PUVA-sol are efficacious in the treatment of some patients with vitiligo. However, most studies fail adequately to address the degree of this response, its durability or its effect on QoL. PUVA has now been demonstrated to be less effective than NB-UVB in the treatment of vitiligo, and sustained improvement at 12months following treatment end is seen in <25% of patients. No study has looked at long-term dangers of PUVA in vitiligo.

Recommendations

  1. PUVA therapy should be considered for treatment of vitiligo only in adults who cannot be adequately managed with more conservative treatments. PUVA is not recommended in children.

    Grade of recommendation D
    Level of evidence 4

     

  2. If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should usually be used in preference to oral PUVA.

    Grade of recommendation A
    Level of evidence 1+

     

  3. A trial of PUVA therapy should be considered only for adults with widespread vitiligo, or localized vitiligo associated with a significant impact on patient's QoL. Ideally, this treatment should be reserved for patients with darker skin types.

    Grade of recommendation D
    Level of evidence 3

     

  4. Before starting PUVA treatment patients should be made aware that there is no evidence that this treatment alters the natural history of vitiligo. They should also be made aware that not all patients respond, and that some body sites, such as the hands and feet, respond poorly in all patients. They should also be informed of the limit to the number of treatments due to possible side-effects.

    Grade of recommendation D
    Level of evidence 3

     

  5. Evidence is lacking to define an upper limit for the number of treatments with PUVA for patients with vitiligo. Taking into account the published data for patients with psoriasis (see below) and in view of the greater susceptibility of vitiligo skin to psoralen-induced burning and possible photodamage (due to absence of melanin), it is advised that safety limits for PUVA in the treatment of vitiligo are more stringent than those for psoriasis, with an arbitrary limit of 150 treatments for patients with skin types I-III. This could be higher for skin types IV-VI at the discretion of the clinician and with the consent of the patient.

    Grade of recommendation D
    Level of evidence 3

     

  6. It is recommended that physicians prescribing PUVA for vitiligo monitor response closely using serial clinical photographs (every 2-3months) to identify patients who fail to respond adequately or in whom the disease progresses during treatment.

    Grade of recommendation D
    Level of evidence 3

     

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