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 Applying Betamethasone, Clobetasol, Fluocinolone, Fluticasone or Mometasone vs. Placebo or Other Active Treatment in Terms Of Condition Progression, Area Reduction and Quality of Life Score?

Introduction

In the management of vitiligo, the physician typically makes an initial assessment of the patient and discusses the disease and treatment options. In many instances, the first-line therapy involves topical medicaments. In most cases, patients are offered advice about use of sunscreens and cosmetic camouflage including fake tanning products. There is evidence from one study that use of cosmetic camouflage can produce an improvement in QoL (DLQI 7·3 to 5·9).[15] With regard to topical therapy that might influence the state of the disease, the use of topical steroids is the usual first-line treatment.

Methods

Seven papers met the criteria for inclusion, underlining the paucity of good quality clinical studies of topical treatments in vitiligo. Only studies in which there were 20 or more evaluations were included. In all trials, only patients with generalized (symmetrical) types of vitiligo were included. In some studies, the researchers had excluded patients with vitiligo on the hands, presumably as they assumed the lesions would not respond to treatment. A left-vs.-right treatment methodology has been used in some studies and this presents potential problems. Studies on children have been separated from those on adults.

Evidence Statements

The studies of Clayton[33] and Kandil,[34] although easily criticized, show that the use of a highly potent (clobetasol) or potent (betamethasone) topical steroid can repigment vitiligo but only in a small proportion of cases. Clayton found 15-25% repigmentation in 10 of 23 subjects (ages not stated) and >75% in two of 23 (the other 11 showed no response), while Kandil found 90-100% repigmentation in six of 23 subjects (ages not given for all but one was aged 12years) and 25-90% in three (with six showing 'beginning' repigmentation).[33,34] Clayton found that all steroid users had skin atrophy with clobetasol, a highly potent topical steroid (used for 8weeks), while Kandil noted hypertrichosis in two subjects and acne in three subjects, related to 4months use of the potent topical steroid, betamethasone.[33,34]

Westerhof and colleagues,[35] in probably the best controlled study to date of a topical treatment, compared topical fluticasone alone or combined with UVA in 135 adults. They found that the potent topical steroid fluticasone used alone for 9months induced mean repigmentation of only 9% (compared with UVA alone of 8%) whereas the combination of fluticasone and UVA induced mean repigmentation of 31%: no steroid atrophy was noted in steroid users.

Comparison of a potent or highly potent topical steroid with another topical agent has been made but the studies are not robust. In a left-vs.-right comparison over an 8-week period in 10 adults, topical pimecrolimus was found to give 50-100% repigmentation in eight of 10 patients compared with an equivalent degree of repigmentation in seven of 10 patients treated with clobetasol.[36] A study of topical betamethasone vs. calcipotriol vs. a combination of the two over 5-10weeks in 15, 16 and 18 adults, respectively, showed >50% repigmentation in two, one and four, respectively, each out of 15 evaluable cases, with a conclusion that the results favoured the combination of topical betamethasone and calcipotriol.[37]

In children, Khalid etal. noted that topical use of the highly potent steroid clobetasol induced better repigmentation than PUVA-sol alone, finding >50% repigmentation in 15 of 22 (vs. four of 23 for PUVA-sol) following use for 6months, but six steroid users developed skin atrophy.[38] Another study in 20 children (aged less than 18years of age) over an 8-week period compared topical clobetasol and tacrolimus and described '41%' repigmentation for clobetasol vs. '49%' repigmentation for tacrolimus.[32]

Evidence to Recommendations

There is evidence that very potent or potent topical corticosteroids can repigment vitiligo in adults but the studies that support this statement have often been poorly conducted and side-effects are common if treatment lasts for more than a few weeks. For generalized symmetrical types of vitiligo, topical clobetasol used over 2-6months repigments vitiligo to some degree. There is weak evidence for clinically meaningful repigmentation with topical betamethasone, used over a period of 4months, and for topical fluticasone used over 9months. There are significant potential side-effects, mainly of skin atrophy and hypertrichosis, especially for clobetasol and betamethasone, less so with fluticasone. For generalized symmetrical types of vitiligo, the combination of topical betamethasone with calcipotriol was better than betamethasone alone over a 5-10-week period. The combination of topical fluticasone with UVA used over 9months was much more effective than fluticasone used alone. In children, topical clobetasol induced repigmentation but skin atrophy was a side-effect.

Recommendations

  1. In children, and 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.

    Grade of recommendation B
    Level of evidence 1+

     

  2. In patients 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 including fake tanning products and the use of sunscreens.

    Grade of recommendation D
    Level of evidence 4

     

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