Guidelines for the Management of Vitiligo

The European Dermatology Forum Consensus

A. Taieb; A. Alomar; M. Böhm; M.L. Dell'Anna; A. De Pase; V. Eleftheriadou; K. Ezzedine; Y. Gauthier; D.J. Gawkrodger; T. Jouary; G. Leone; S. Moretti; L. Nieuweboer-Krobotova; M.J. Olsson; D. Parsad; T. Passeron; A. Tanew; W. van der Veen; N. van Geel; M. Whitton; A. Wolkerstorfer; M. Picardo

Disclosures

The British Journal of Dermatology. 2013;168(1):5-19. 

In This Article

Other Interventions

Camouflage

Considering the impact of the disease on the patient's self-body image, camouflage techniques are an important part of the global management of the disease.[100–104] Products developed to disguise aesthetic skin disfigurement, require specialized application techniques.[100,101] There is a wide choice of self-tanning agents, stains, dyes, whitening lotions, tinted cover creams, compact, liquid and stick foundations, fixing powders, fixing sprays, cleansers, semipermanent and permanent tattoos, and dyes for pigmenting facial and scalp white hairs.[103] Permanent camouflage, micropigmentation and tattoos should be considered with particular caution,[104] due to the unpredictable course of the vitiligo.

Depigmentation

In patients with extensive and refractory vitiligo, depigmenting the remaining islands through chemical or physical methods may be cosmetically acceptable. Monobenzone ethyl ester (MBEH) is a derivative of hydroquinone (HQ). Unlike HQ, MBEH almost always causes nearly irreversible depigmentation.[105,106]

The patients with the highest skin phototypes (V and VI), for which the contrast between dark pigmented and white skin is actually disfiguring, may be the best candidates. Patients with phototypes I and II may also obtain better cosmetic improvement using depigmenting agents rather than a repigmenting regimen on exposed areas. The patients must be extensively informed that most approaches lead to irreversible depigmentation.

MBEH is applied topically as a 20% cream. A thin layer of cream should be applied uniformly and rubbed into the pigmented area two to three times daily. Prolonged exposure to sunlight should be avoided during treatment, or a sunscreen should be used, as exposure to sunlight reduces the depigmenting effect. Depigmentation is usually obtained after 1–4 months of treatment. After 4 months of treatment without success, the drug should be discontinued. When the desired degree of depigmentation is obtained, monobenzone should be applied as often as needed to maintain depigmentation (usually only two times weekly).[106]

Mild transient skin irritation or sensitization causing eczema may occur. The treatment should be discontinued if irritation, burning sensation or dermatitis occurs. Ocular side-effects have been rarely reported. Sometimes areas of normal skin distant to the site of application have become depigmented. Monobenzone has been proposed in association with retinoic acid in order to overcome the resistance to treatment.[107]

The Q-switched 755 nm ruby laser has been proposed.[108] It can be used alone or in combination with methoxyphenol.[109,110] It destroys melanin and melanin-bearing cells. Cryotherapy has been reported as an inexpensive depigmentation therapy, but due to the risk of scarring, it should be used only by experienced dermatologists.[111–113] However, limited published information is available.[111]

Psychological Interventions

Depigmentation exerts a negative impact on the patient's appearance and self-esteem.[114] Most patients with vitiligo find their disfigurement moderately or severely intolerable, and suffer from poor body image, low self-esteem and social isolation in both personal and professional relationships. Levels of disability vary according to objective factors (extension and site of the disease, phototype, ethnicity and cultural background).[115,116] The prevalence of psychiatric morbidity ranges from 25% to 30% in Western Europe, with a predominance of fair-skinned subjects, and from 56% to 75% in India, with a predominance of dark-skinned patients.[117] Perceived severity of the disease is more influenced by the patient's personality than by objective traits of the vitiligo.[117] Additional discomforting aspects are the chronic, unpredictable nature of the disease and the lack of a universally effective treatment.[118]

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