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

Final Recommendations

The recommendations have been distilled and set into the form of algorithms for use by dermatologists and other physicians for the treatment of children and adults with vitiligo. The level of the recommendation and the level of the evidence are shown in parentheses. It is anticipated that phototherapy and surgical treatments will be available only to dermatologists (and their associates) but other approaches, e.g. topical treatments [with the exception of the use of p-(benzyloxy)phenol] and psychological support, may be widely available.

  1. Diagnosis of Vitiligo

    Where vitiligo is classical, as in the symmetrical types, the diagnosis is straightforward and can be made with confidence in primary care (D/4). In patients with an atypical presentation, diagnosis is more difficult and referral for expert assessment by a dermatologist is recommended (D/4). Assessment of skin type is useful in the initial examination, together with photographs to record the extent of the disease. Wood's light may be of benefit in the diagnosis of vitiligo and in the demonstration of the extent and activity of the disease in subjects with skin types I and II. Wood's light can be of use in monitoring response to therapy (D/4). A blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid disease in adults with vitiligo (D/3).

  2. Natural History

    A longitudinal epidemiological study is needed to define the natural history of vitiligo with time. This should use photographs combined with computerized image analysis, to quantify how the vitiligo changes with time (D/4). The response of vitiligo to treatment should be considered in the context of the natural history, recognizing that spontaneous repigmentation may occur but is uncommon (D/4).

  3. Psychological Impact

    Clinicians should make an assessment of the psychological and QoL effects of vitiligo on patients (C/2++). In therapeutic trials relating to vitiligo, researchers should make the patient's improvement in QoL the most important outcome measure (D/4).

  4. Assessment Tools

    In a research setting, the VASI and VETF assessment tools offer a more accurate measurement of disease extent than simple clinical photography alone (even when combined with computerized morphometry). The VETF gives further assessment of severity and spreading (D/2+). In clinical practice, serial photographs should be used to record progress (C/4).

  1. No Treatment Option

    In children with skin types I and II, in the consultation it is appropriate to consider, after discussion with the patient, whether the initial approach may be to use no active treatment other than consideration of the use of camouflage cosmetics and sunscreens (D/4).

  2. Topical Treatment

    • In all children with vitiligo who are under 18years, treatment with a potent or very potent topical steroid should be considered for a trial period of no more than 2months. Although benefits have been observed, skin atrophy has been a common side-effect (B/1+).

    • In children with vitiligo, topical pimecrolimus or tacrolimus should be considered as alternatives to the use of a highly potent topical steroid in view of their better short-term safety profile (B/1+).

  3. Phototherapy

    • NB-UVB phototherapy should be considered for treatment of vitiligo only in children who cannot be adequately managed with more conservative treatments (D/4), who have widespread vitiligo, or have localized vitiligo associated with a significant impact on patient's QoL. Ideally, this treatment should be reserved for patients with darker skin types and monitored with serial photographs every 2-3months (D/3).

    • If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should be used in preference to PUVA in view of evidence of greater efficacy, safety and lack of clinical trials of PUVA in children (A/1+).

    • Taking into account the published data for patients with psoriasis and in view of the greater susceptibility of vitiligo skin to sunburn and photodamage due to absence of melanin, it is advised that safety limits for the treatment of vitiligo are more stringent than those applied to psoriasis, with an arbitrary limit for NB-UVB of 200 treatments for skin types I-III. Evidence is lacking to define an upper limit for skin types IV-VI (D/3).

  4. Systemic Therapy

    The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects (B/2++).

  5. Surgical Treatment

    There are no studies of surgical treatment in children and it is not recommended.

  6. Psychological Treatments

    Psychological interventions should be offered as a way of improving coping mechanisms in children with vitiligo (D/4). Parents of children with vitiligo should be offered psychological counselling.

  1. No Treatment Option

    In adults with skin types I and II, in the consultation it is appropriate to consider, after discussion with the patient, whether the initial approach may be to use no active treatment other than consideration of the use of camouflage cosmetics and sunscreens (D/4).

  2. Topical Treatment

    • In adults with recent onset of vitiligo, treatment with a potent or very potent topical steroid should be considered for a trial period of no more than 2months. Although benefits have been observed, skin atrophy has been a common side-effect (B/1+).

    • In adults with symmetrical types of vitiligo, topical pimecrolimus should be considered as an alternative to the use of a topical steroid, based on one study. The side-effect profile of topical pimecrolimus is better than that of a highly potent topical steroid (C/2+).

    • Depigmentation with p-(benzyloxy)phenol (MBEH) should be reserved for patients severely affected by vitiligo (e.g. who have more than 50% depigmentation or who have extensive depigmentation on the face or hands) who cannot or choose not to seek repigmention and who can accept the permanence of never tanning (D/4).

  3. Phototherapy

    • NB-UVB phototherapy (or PUVA) should be considered for treatment of vitiligo only in patients who cannot be adequately managed with more conservative treatments (D/4), who have widespread vitiligo, or have localized vitiligo associated with a significant impact on patient's QoL. Ideally, this treatment should be reserved for patients with darker skin types and monitored with serial photographs every 2-3months (D/3).

    • If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should be used in preference to oral PUVA in view of evidence of greater efficacy (A/1+).

    • Taking into account the data published for patients with psoriasis and in view of the greater susceptibility of vitiliginous skin to sunburn and photodamage due to absence of melanin, it is advised that safety limits for the treatment of vitiligo are more stringent than those applied to psoriasis, with an arbitrary limit of 200 treatments with NB-UVB for patients with skin types I-III, and 150 treatments with PUVA for patients with skin types I-III. Evidence is lacking to define an upper limit for the number of treatments with NB-UVB or PUVA for patients with skin types IV-VI (D/3).

  4. Systemic Therapy

    The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects (B/2++).

  5. Surgical Treatments

    • Surgical treatments are best reserved for cosmetically sensitive sites in patients in whom there have been no new lesions, no Koebner phenomenon and no extension of the lesion in the previous 12months (A/1++).

    • Split-skin grafting gives better cosmetic and repigmentation results than minigraft procedures and utilizes surgical facilities that are relatively freely available (A/1+). Minigraft is not recommended due to a high incidence of side-effects and poor cosmetic results (A/1+).

    • Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA therapy is the optimal surgical transplantation procedure but requires special facilities (A/1+). Expanding the autologous cells in tissue culture prior to grafting is feasible and can treat larger areas successfully, without the need for additional phototherapy (D/3).

    • Transfer of suction blisters is an alternative transplantation method, which shows evidence of benefit over placebo but gives less good coverage than split-skin grafting or laser and cell suspension (B/1+).

  6. Psychological Treatments

    Psychological interventions should be offered as a way of improving coping mechanisms in patients with vitiligo (D/4).


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