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Vitiligo: Management and prognosis

Author: Pearl E Grimes, MD

Section Editor: Hensin Tsao, MD, PhD
Deputy Editor: Rosamaria Corona, MD, DSc

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2018. | This topic last updated: May 05, 2017.

INTRODUCTION — Vitiligo is a relatively common acquired chronic disorder of pigmentation characterized by the

development of white macules on the skin due to loss of epidermal melanocytes [1,2]. The depigmented areas are
often symmetrical and usually increase in size with time. Given the contrast between the white patches and areas
of normal skin, the disease is most disfiguring in darker skin types and has a profound impact on the quality of life
of children and adults [3,4]. Patients with vitiligo often experience stigmatization, isolation, and low self-esteem [5-
8].

Although there is no cure for the disease, the available treatments may halt the progression of the disease and
induce varying degrees of repigmentation with acceptable cosmetic results in many cases. This topic review will
discuss the management of vitiligo. The pathogenesis, clinical features, and diagnosis of vitiligo are discussed
separately. Other pigmentation disorders are also discussed separately.

● (See "Vitiligo: Pathogenesis, clinical features, and diagnosis".)

● (See "Acquired hypopigmentation disorders other than vitiligo".)

● (See "Acquired hyperpigmentation disorders".)

● (See "Melasma".)

● (See "Postinflammatory hyperpigmentation".)

PATIENT EVALUATION

Assessment of severity — The evaluation of the patient with vitiligo involves a detailed history and a complete skin
examination to assess disease severity and individual prognostic factors. Factors that may influence the approach
to treatment include:

● Age at onset of lesions

● Type of vitiligo (segmental, nonsegmental)

● Mucosal involvement, Koebner phenomenon

● Rate of progression or spread of lesions

● Previous episodes of repigmentation

● Type and response to previous treatments

● Family history of vitiligo and/or autoimmune diseases

● Presence of concomitant diseases

● Current medications and supplements

 ● Occupation, exposure to chemicals

● Effects of disease on the quality of life

A full-body skin examination should be performed to assess the extent of the disease, with particular attention to
sites of vitiligo predilection, such as the lips and perioral area, periocular areas, dorsal surface of the hands, fingers,
flexor surface of the wrists, elbows, axillae, nipples, umbilicus, sacrum, groin, inguinal/anogenital regions, and
knees [9]. The percentage of the body area involved can be estimated by the so-called 1 percent rule or "palm
method." In both children and adults, the palm of the hand, including the fingers, is approximately 1 percent of the
total body surface area (TBSA), while the palm excluding the fingers is approximately 0.5 percent of the TBSA. An
alternative method is the "rule of nines":

● Each leg represents 18 percent of the TBSA.

● Each arm represents 9 percent of the TBSA.

● The anterior and posterior trunk each represent 18 percent of the TBSA.

● The head represents 9 percent of the TBSA.

Goals of treatment — The goals of treatment for vitiligo should be set with the individual patient or parents in the
case of children, based upon the patient's age and skin type, the extent, location, and degree of disease activity, and
the impact of the disease on the patient's quality of life. An open discussion with the patient about the limitations of
treatment may be helpful to create realistic expectations.

Nonsegmental vitiligo has an unpredictable course, and treatment is often challenging. However, multiple therapies,
including topical agents, light therapies, and autologous grafting procedures, have demonstrated efficacy for
repigmentation of vitiligo [10]. The response to treatments is generally slow and may be highly variable among
patients and among different body areas in the same patient. The best outcomes are often achieved in darker skin
types (Fitzpatrick IV to VI), although satisfactory results are often seen also in lighter skin types (Fitzpatrick II, III).
Facial and truncal lesions respond well to treatment, while acral areas are extremely difficult to treat.

Psychosocial aspects — The patient's psychologic profile and ability to cope with a lifelong disease should be
carefully evaluated at the time of treatment planning. Psychologic support should be offered to patients if needed.
(See 'Psychologic interventions' below.)

APPROACH — Our approach to the management of patients with vitiligo is generally consistent with published
guidelines [11,12]. Topical, systemic, and light-based therapies are available for the stabilization and repigmentation
of vitiligo (table 1) [13-17]. Treatment modalities are chosen in the individual patient on the basis of the disease
severity, patient preference (including cost and accessibility), and response evaluation. Combination therapies, such
as phototherapy plus topical or oral corticosteroids, are usually more effective than single therapies [18]. Despite
treatment, however, vitiligo has a highly unpredictable course, and the long-term persistence of repigmentation
cannot be predicted [18].

Stabilization of rapidly progressive disease — For patients who experience rapid progression of vitiligo, with
depigmented macules spreading over a few weeks or months, we suggest low-dose oral corticosteroids as first-line
therapy for the stabilization (cessation of spread) of the disease (table 1). Oral prednisone is given at the dose of 5
to 10 mg per day in children and 10 to 20 mg per day in adults for a maximum of two weeks. If needed, treatment
can be repeated in four to six weeks.

In adult patients, alternatives to oral prednisone include oral mini-pulse therapy with dexamethasone 2.5 mg on two
consecutive days weekly for an average of three months or intramuscular triamcinolone 40 mg in a single
administration. Treatment with triamcinolone can be repeated in four to six weeks for a maximum of three
injections. (See 'Systemic corticosteroids' below.)

Stabilization therapy can be given with or without concomitant narrowband ultraviolet B (NB-UVB) phototherapy.
However, for patients with active disseminated disease affecting multiple anatomic sites, we suggest that systemic
corticosteroids and NB-UVB phototherapy be initiated concomitantly. The disease is expected to stabilize in one to
three months.
In both adults and children in whom systemic corticosteroids are contraindicated, NB-UVB phototherapy alone may
be used to stabilize active vitiligo. NB-UVB is administered two to three times weekly. (See 'Narrowband ultraviolet B
phototherapy' below.)

Vitiligo involving <10 percent of the TBSA

Localized disease — In patients with nonsegmental stable vitiligo (no increase in size of existing lesions and
absence of new lesions in the previous three to six months) that involves <10 percent of the total body surface area
(TBSA) and is limited to the face, neck (picture 1), trunk, or extremities, mid- to high-potency topical corticosteroids
(groups two to four (table 2)) are the first-line therapy [12,19]. High-potency and mid-potency topical corticosteroids
are applied to the involved skin once and twice daily, respectively. Agents with negligible systemic or local side
effects, such as mometasone furoate, are preferred [12]. (See 'Topical corticosteroids' below.)

There are no studies evaluating the optimal duration of treatment with topical corticosteroids. In the author's
experience, topical corticosteroids can be used safely for two to three months, interrupted for one month, and then
resumed for an additional two or three months. Others suggest a discontinuous scheme (eg, once-daily application
for 15 days per month for six months) [11,12,20].

Patients must be monitored closely for adverse effects of topical corticosteroids, which include skin atrophy,
telangiectasias, hypertrichosis, and acneiform eruptions. Limited quantities should be prescribed.

Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are the preferred first-line therapy in patients with
limited disease involving the face or areas at high risk for skin atrophy. Topical calcineurin inhibitors are generally
applied twice daily. They can also be used in combination with a topical corticosteroid for the first month or two,
applying each one once daily. (See 'Topical calcineurin inhibitors' below.)

For patients with limited disease who do not respond to topical corticosteroids or topical calcineurin inhibitors,
targeted phototherapy administered twice weekly is an option (picture 2). (See 'Targeted phototherapy' below.)

Disseminated disease — For patients with disseminated areas of depigmentation affecting multiple anatomic
sites but overall involvement of less than 10 percent of the TBSA, we suggest NB-UVB phototherapy as first-line
therapy. NB-UVB phototherapy is administered two to three times weekly. In the author's experience, less than 50
treatments are usually sufficient to achieve optimal outcomes. (See 'Narrowband ultraviolet B phototherapy' below.)

Segmental vitiligo — Topical corticosteroids, calcineurin inhibitors, or targeted phototherapy are the first-line
therapy for segmental vitiligo. (See 'Topical corticosteroids' below and 'Topical calcineurin inhibitors' below and
'Targeted phototherapy' below.)

NB-UVB phototherapy can be used for more extensive disease affecting multiple dermatomes. For patients who do
not respond to topical or light therapies, autologous grafting is a second-line option [21]. Given the stable nature of
segmental vitiligo, long-term repigmentation can be achieved with autologous melanocyte transplantation [22]. (See
'Narrowband ultraviolet B phototherapy' below and 'Surgical therapies' below.)

Localized recalcitrant vitiligo — Surgical procedures are a therapeutic option for patients with localized stable
vitiligo that does not respond to topical agents or NB-UVB phototherapy. Autologous grafting techniques include 1-
mm punch grafts, suction blister grafts, or cellular suspensions. While all these techniques have proven success,
most are technically challenging and expensive. One-millimeter punch grafts, however, can be performed with ease
and without the need of special devices or equipment. (See 'Surgical therapies' below.)

Vitiligo involving 10 to 40 percent of the TBSA — For adults and children with stable nonsegmental vitiligo
involving 10 to 40 percent of the TBSA, we suggest NB-UVB as first-line therapy (picture 3). (See 'Narrowband
ultraviolet B phototherapy' below.)

NB-UVB is administered two to three times per week for an average of 9 to 12 months. Follicular areas of
repigmentation usually begin to appear after 15 to 20 NB-UVB treatments (picture 4). If patients are responding well
with continued repigmentation, treatment can be maintained beyond 9 to 12 months and up to 24 months or 200
sessions and then tapered off. Mid-potency topical corticosteroids or topical calcineurin inhibitors are often
intermittently used in combination with phototherapy.
Home NB-UVB phototherapy is an option for patients unable to travel to the clinician's office for weekly treatments
[23]. Whole-body or portable, handheld units are available on the market (sample brand names include Daavlin,
National Biological Solarc Systems). Patients should be provided with detailed instructions on the use of the home
phototherapy units and return for in-office clinician follow-up on a regular basis.

Vitiligo involving >40 percent of the TBSA — NB-UVB is the first-line therapy for patients with extensive vitiligo
involving greater than 40 percent of the TBSA. The suggested regimen and duration of treatment are similar to that
discussed above for patients with more limited disease. (See 'Vitiligo involving 10 to 40 percent of the TBSA'
above.)

However, for patients with extensive recalcitrant vitiligo that does not respond to repigmentation regimens and for
patients with extensive vitiligo who do not desire undergoing repigmentation treatments, depigmentation of
residual normally pigmented areas utilizing topical monobenzyl ether of hydroquinone (monobenzone) may be an
option. Depigmentation therapy is usually initiated with monobenzone 10% cream for one month and then
continued with monobenzone 20% cream. Monobenzone is applied on the areas of residual pigmentation once or
twice daily; we typically treat exposed areas first. These sites include the face, neck, upper extremities, chest, and
lower legs. Depigmentation usually begins at distant sites (where the drug has not been applied) after three to six
months of continued use. Depigmentation therapy may require one to three years to achieve optimal outcomes.
(See 'Depigmentation' below.)

Side effects of monobenzone are dose-dependent and include irritant contact dermatitis and severe xerosis.
Monobenzone should never be used as a lightening agent in cases other than vitiligo. It will induce vitiligo in normal
individuals.

Response assessment — Initial response to treatment is in most cases indicated by the appearance of perifollicular
areas of repigmentation in the vitiliginous patch, which usually begins 8 to 12 weeks after the initiation of treatment
or after 15 to 20 NB-UVB sessions (picture 4). Some patients may show a diffuse repigmentation pattern or a
combination of diffuse and perifollicular [24,25]. Photographs should be taken before starting treatment and at
each follow-up visit to evaluate the degree of repigmentation.

In patients who respond well to treatment and achieve optimal repigmentation, therapies can be gradually tapered
and then discontinued. However, some patients may require maintenance treatment. Intermittent use of topical
corticosteroids or topical calcineurin inhibitors (eg, twice weekly) and phototherapy every other week may be used
as long-term maintenance treatments. For patients who relapse after stopping treatment or during the maintenance
phase, another cycle of phototherapy can be administered.

TREATMENT MODALITIES

Topical therapies

Topical corticosteroids — Mid- to super-high-potency topical corticosteroids are commonly used as a first-line

therapy for the treatment of limited vitiligo. Their efficacy is attributed to modulation of the immune response.

The efficacy of topical corticosteroids as monotherapy for the treatment of vitiligo is supported by a few small
randomized trials [16]. A systematic review of 17 randomized trials examined the effect of topical corticosteroids in
combination with other therapies (eg, narrowband ultraviolet B [NB-UVB], psoralen plus ultraviolet A with sunlight
[PUVAsol], excimer laser) [26]. The combination of potent or super-potent topical corticosteroids (eg,
betamethasone dipropionate, mometasone furoate, clobetasol propionate) with light therapies is more effective
than light therapies alone in inducing repigmentation [27-29]. However, the quality of studies was generally poor,
and the study results could not be pooled because of considerable heterogeneity in study design and outcome
measure.

Adverse effects related to a prolonged use of topical corticosteroids, including folliculitis, mild atrophy,
telangiectasia, and hypertrichosis, have been reported, generally in a small number of patients, in nearly all studies.
Systemic absorption resulting in adrenal suppression is a concern when large areas of skin and areas with thin skin
are treated for a prolonged time with potent steroids, especially in children [19].
 Topical calcineurin inhibitors — Tacrolimus and pimecrolimus are topical immunomodulatory agents that affect
the T-cell and mast-cell function and inhibit the synthesis and release of multiple proinflammatory cytokines,
including interferon-gamma, tumor necrosis factor-alpha, interleukin (IL)-4, IL-5, and IL-10 [30-32]. In contrast with
topical corticosteroids, topical calcineurin inhibitors do not induce skin atrophy, striae, or telangiectasias and are
increasingly used for the treatment of facial vitiligo.

The efficacy of tacrolimus and pimecrolimus alone or in combination with other therapies for the treatment of
nonsegmental vitiligo has been evaluated in several randomized trials including either adults or children with vitiligo
[26].

● In a randomized trial, 100 children (55 children with facial vitiligo; 45 with nonfacial vitiligo) were treated with
topical corticosteroid (clobetasol propionate 0.05%), tacrolimus 0.1%, or placebo for six months [33]. Among
children with facial vitiligo, the success rate (defined as repigmentation >50 percent) was the same in the
topical corticosteroid and tacrolimus groups (58 percent); however, among children with nonfacial vitiligo, the
success rate was higher in the topical corticosteroid group compared with the tacrolimus groups (39 versus 23
percent). The success rate in the placebo group was 7 percent.

● Another randomized trial including 44 adult patients with stable vitiligo compared 0.1% tacrolimus ointment
twice daily, 1% pimecrolimus cream twice daily, and NB-UVB phototherapy three times a week for 24 weeks
[34]. At the end of the study, there was no significant difference among treatments in the repigmentation for
any anatomical site.

● In a 12-week open, randomized study, 53 patients with vitiligo were treated with 308 nm monochromatic
excimer light (MEL) twice weekly plus 0.1% tacrolimus and oral vitamin E daily, 308 nm MEL twice weekly plus
daily oral vitamin E, or daily oral vitamin E alone [35]. At the end of the study, good to excellent repigmentation
was achieved in 70 percent of patients in the MEL plus tacrolimus and vitamin E group, 55 percent of those in
the MEL plus vitamin E group, and in none of the patients in the vitamin E group.

● In an open trial, 40 children with nonsegmental, focal, or segmental vitiligo were treated with 0.1%
mometasone furoate cream once daily or 1% pimecrolimus cream twice daily for three months [36]. Moderate
or marked responses were seen in 11 patients (55 percent) in the mometasone furoate group and in 7 (35
percent) in the pimecrolimus group, but the difference was not statistically significant.

Although the increased risk of skin cancer among transplant patients treated with systemic calcineurin inhibitors is
well recognized, the use of topical calcineurin inhibitors does not seem to be associated with an increased risk for
skin or systemic malignancies [37-39]. However, based upon animal studies documenting an increased risk of
lymphoma and skin cancers associated with topical or systemic exposure to calcineurin inhibitors and to reports of
cancer cases in children who used topical pimecrolimus or tacrolimus for atopic dermatitis, in 2006 the US Food
and Drug Administration placed a boxed warning on the prescribing information for these medications. Labeling
also recommends that these agents should not be used in combination with ultraviolet (UV) light therapy.

Unproven topical therapies — The benefit of topical vitamin D3 analogues in the treatment of vitiligo is
controversial. A few small randomized trials evaluated the role of calcipotriol and tacalcitol in combination with
psoralen plus ultraviolet A (PUVA), narrowband ultraviolet (NB-UV), or natural sunlight for the treatment of
nonsegmental vitiligo with conflicting results [40-42].

● In a prospective right-left 24-week comparative study including 24 patients with vitiligo, there were no
statistically significant differences between the sides treated with NB-UVB monotherapy and the sides treated
with NB-UVB plus calcipotriol [41].

● In another right-left comparative study, 35 patients with generalized vitiligo applied calcipotriol 0.05 mg/g
cream or placebo to the reference lesions one hour before PUVA treatment twice weekly [40]. Lesions on the
side treated with calcipotriol plus PUVA had a fourfold increase in the likelihood of achieving greater than 75
percent repigmentation sooner than the side treated with placebo plus PUVA (mean number of PUVA sessions
9 and 12, respectively).

Phototherapy
 Narrowband ultraviolet B phototherapy — NB-UVB involves the use of UV lamps with a peak emission of
approximately 311 nm [43]. These shorter wavelengths provide higher-energy fluences and induce less cutaneous
erythema. NB-UVB induces local immunosuppression and apoptosis; stimulates the production of melanocyte-
stimulating hormones, basic fibroblasts, growth factor, and endothelin I; and increases melanocyte proliferation and
melanogenesis [43-45]. (See "UVB therapy (broadband and narrowband)".)

Due to its lack of systemic toxicity and its good safety profile in both children and adults, NB-UVB phototherapy has
emerged as the initial treatment of choice for patients with vitiligo involving >10 percent of the body surface area
(BSA). NB-UVB can be used for both stabilization and repigmentation of vitiligo (picture 3).

A meta-analysis of three randomized trials comparing oral PUVA with NB-UVB found a 60 percent higher proportion
of participants achieving >75 percent repigmentation in the NB-UVB group compared with the oral PUVA group [26].
The additive effect of tacrolimus ointment (0.1%) applied once daily combined with NB-UVB in the treatment of
vitiligo has been evaluated in one randomized trial [46]. In this study, 40 patients with stable, symmetrical vitiligo
were treated with tacrolimus ointment 0.1% on one side of their body and a placebo ointment on the other side plus
whole-body NB-UVB two or three times weekly for at least three months. In 27 of 40 patients, a greater reduction in
the target lesion area was seen in the side treated with tacrolimus compared with the side treated with NB-UVB
alone (42 versus 29 percent). However, a possible increase in the risk of skin cancer with this combination therapy
cannot be excluded.

A 2017 meta-analysis of 35 randomized and nonrandomized studies including 1428 patients compared the
repigmentation rates of NB-UVB and PUVA by treatment duration [47]. For NB-UVB, a ≥75 percent repigmentation
was achieved by 13, 19, and 36 percent of patients at 3, 6, and 12 months of treatment, respectively. For PUVA, ≥75
percent repigmentation was achieved by 9 percent of patients at 6 months and 14 percent at 12 months. The
results of this meta-analysis confirm the superiority of NB-UVB over PUVA and suggest that phototherapy should be
continued for at least 12 months to achieve a maximal response.

Only a few small observational studies have evaluated the duration of repigmentation in patients with vitiligo
treated with phototherapy. In a small observational study of 11 patients followed up for two years after treatment
with NB-UVB phototherapy, five maintained areas of repigmentation and six experienced complete or partial relapse
of vitiligo at previously repigmented sites [48]. In another study including 15 children treated with NB-UVB
phototherapy and followed up for a mean of 12 months after completing treatment, six showed stable
repigmentation, four further improvement, and three complete or partial regression of the pigmentation achieved
with treatment [49].

PUVA photochemotherapy — Historically, photochemotherapy with topical or systemic PUVA radiation was the
"gold standard" treatment for the repigmentation of vitiligo but has been largely replaced by NB-UVB phototherapy.
PUVA is associated with substantial adverse effects, including phototoxicity and gastrointestinal discomfort, and
requires patients to use ocular protection for 12 to 24 hours following treatment. In addition, the long-term risk of
skin cancer is well established for PUVA [50]. (See "Psoralen plus ultraviolet A (PUVA) photochemotherapy".)

Targeted phototherapy — Targeted phototherapy using 308 nm monochromatic excimer lamps or lasers has
demonstrated efficacy for the treatment of localized vitiligo (picture 2) [51]. These devices deliver high-intensity
light only to the affected areas while avoiding exposure of the healthy skin and lowering the cumulative ultraviolet B
(UVB) dose. (See "Targeted phototherapy".)

A systematic review of six randomized trials (411 patients with 764 lesions) found that excimer lamps and excimer
lasers were equally effective in inducing ≥50 percent and ≥75 percent repigmentation [52]. Although the
repigmentation may occur more rapidly with more frequent weekly treatments, the final result appears to be related
to the overall number of treatment sessions rather than their frequency [53].

As with NB-UVB, targeted phototherapy can work synergistically with topical therapies, including tacrolimus
ointment and topical corticosteroids [12,54].

● In a study of eight patients with vitiligo, 24 symmetric vitiliginous areas were treated with the excimer laser
three times per week for a total of 24 treatments [55]. Topical tacrolimus ointment or placebo was applied to
randomized affected areas twice daily throughout the length of the trial. Fifty percent of the areas treated with
 the combination excimer laser and topical tacrolimus achieved ≥75 percent repigmentation compared with 20
percent of the areas treated with placebo.

● In a 12-week open randomized study, 53 patients with vitiligo were treated with 308 nm MEL twice weekly plus
0.1% tacrolimus and oral vitamin E daily, 308 nm MEL twice weekly plus daily oral vitamin E, or daily oral
vitamin E alone [35]. At the end of the study, good to excellent repigmentation was achieved in 70 percent of
patients in the MEL plus tacrolimus and vitamin E group, 55 percent of those in the MEL plus vitamin E group,
and in none of the patients in the vitamin E group.

Systemic therapies

Systemic corticosteroids — Low-dose oral corticosteroids are generally utilized for the stabilization of rapidly
progressive vitiligo, often in combination with NB-UVB phototherapy. Evidence for their efficacy in halting the spread
of vitiligo is limited to a few uncontrolled studies [56-58].

● In one study, 81 patients were treated with prednisolone 0.3 mg/kg per day for two months, and then the dose
was progressively reduced in the subsequent three months [56]. Control of disease progression was achieved
in approximately 90 percent of patients and repigmentation in 74 percent.

● In another study, 40 patients with extensive or rapidly spreading vitiligo were treated with oral mini-pulses of
betamethasone or dexamethasone (5 mg in single dose) on two consecutive days per week for several
months. After one to three months, vitiligo progression was arrested in 32 of 36 patients with active disease
[57].

Oral corticosteroids are not effective as a repigmenting therapy for stable vitiligo. In a small open-label trial, 86
patients with progressive nonsegmental vitiligo were treated with oral mini-pulses of betamethasone (0.1 mg/kg
twice weekly on two consecutive days for three months followed by 1 mg every month for the following three
months) alone or in combination with PUVA, NB-UVB, or broadband UVB [59]. At six months, marked or moderate
improvement was achieved in 15 percent of patients treated with corticosteroids alone versus 85 percent of
patients treated with corticosteroids plus PUVA, 81 percent of those treated with corticosteroids plus NB-UVB, and
33 percent of those treated with corticosteroids plus broadband-UVB.

Complementary and alternative therapies — Oral supplementation with antioxidants and vitamins is often used
as an adjunctive treatment for vitiligo, usually in combination with phototherapy. However, there is limited evidence
from high-quality studies to support their use.

● Vitamins – A few small uncontrolled studies have reported stabilization and repigmentation in vitiligo patients
treated with UVB phototherapy and high-dose vitamin supplementation, vitamin C, vitamin B12, and folic acid
[60,61].

● Alpha-lipoic acid – Alpha-lipoic acid is an organosulfur compound derived from octanoic acid. It is widely
available as an over-the-counter nutritional supplement and has been marketed as an antioxidant. The efficacy
of alpha-lipoic acid in vitiligo was demonstrated in one randomized trial including 35 patients with
nonsegmental vitiligo [62]. In this study, twice-daily oral supplementation with alpha-lipoic acid, vitamin E,
polyunsaturated fatty acids, and cysteine monohydrate combined with NB-UVB twice weekly for six months
resulted in significantly more patients (47 versus 18 percent) achieving >75 percent repigmentation compared
with phototherapy alone. In addition, repigmentation occurred earlier with lower cumulative UVB dose.
Biochemical evaluations at two and six months showed increased catalase activity, decreased intracellular
reactive oxygen species production, and reduced membrane peroxidation in the combination-treatment group.
Despite these promising results, further studies are needed to confirm the benefit of alpha-lipoic acid
supplementation in the management of vitiligo.

● Ginkgo biloba – Extracts from the Ginkgo biloba leaf have long been used in traditional Chinese medicine to
treat various conditions, including cutaneous, neurologic, and vascular disorders. The two main groups of
active constituents responsible for G. biloba's medicinal effects are terpene lactones (ginkgolides and
bilobalides) and ginkgo flavone glycosides, which are present in varying concentrations in the leaf of the
ginkgo tree. (See "Clinical use of ginkgo biloba".)
 Only a few investigations have evaluated ginkgo's use in the management of vitiligo.

• A small randomized trial reported that the spread of vitiligo was arrested in 20 of 25 subjects receiving 40
mg of G. biloba extract three times daily for six months but in none of 22 subjects in the placebo group
[63]. In addition, 10 patients in the active treatment group but only two in the placebo group showed >75
percent repigmentation.

• Another pilot study found significant improvements in total Vitiligo Area Scoring Index and Vitiligo
European Task Force assessment in 12 participants following 12 weeks of supplementation with twice-
daily G. biloba extract [64]. In addition to repigmentation, active depigmentation ceased in all patients with
acrofacial vitiligo.

● Polypodium leucotomos – In one randomized trial, NB-UVB in combination with oral extracts of Polypodium
leucotomos, a tropical fern with antioxidant and immunomodulator properties, was more effective than NB-UVB
alone in inducing repigmentation of vitiligo in the head and neck area (50 versus 19 percent) after 25 weeks
[65]. No difference was noted in other body areas.

Surgical therapies — Surgical therapies have been used for vitiligo for the past 25 years and remain viable options
for patients with localized depigmented areas that have been unresponsive to medical intervention [66-69]. They
include:

● Autologous suction blister grafts [70,71]

● Minigrafts or punch grafts [72-74]

● Split-thickness grafts [75,76]

● Autologous melanocyte cultures

● Cultured epidermal suspensions [77,78]

● Autologous noncultured epidermal cell suspension [79]

● Hair follicle transplantation [80-82]

The scope of transplantation procedures is the transfer of a reservoir of healthy melanocytes to vitiliginous skin for
proliferation and migration into areas of depigmentation. Transplantation procedures are contraindicated for
patients with a history of hypertrophic scars or keloids.

A systematic review of randomized trials and observational studies of autologous transplantation methods for
vitiligo concluded that maximal repigmentation occurred in patients treated with split-thickness grafting and
epidermal blister grafting [66]. Both treatment groups achieved success rates of 90 percent repigmentation.

Other studies have reported the benefits of transplantation of autologous melanocyte cultures and epidermal
suspensions containing both melanocytes and keratinocytes [67,77,79]. In one randomized trial comparing
autologous noncultured epidermal cell suspension with suction blister grafts in 41 patients, a repigmentation ≥75
percent was achieved in over 85 percent of lesions in both treatment groups [79]. However, more lesions in the
noncultured epidermal cell suspension group achieved a 90 to 100 percent repigmentation compared with those in
the suction blister group (70 versus 27 percent).

Adverse effects of surgical therapies include cobblestoning, scarring, graft depigmentation, and graft displacement.
Suction blister grafts and split skin grafts may be associated with the Koebner phenomenon at the donor site, a
complication of major clinical importance since it results in the development of new vitiligo lesions [26]. Other
adverse effects include hypopigmentation, hyperpigmentation, scarring, and infection at both donor and recipient
sites. Punch grafting or minigrafting adverse effects include lack of color blending and matching with the
surrounding normal skin, cobblestoning, and "polka dot" appearance [83].

Factors influencing the outcome of transplantation techniques include age, site of lesion, and type of vitiligo. In a
series of 117 patients, the best results were achieved for patients younger than age 20 and patients with segmental
vitiligo, whereas the grafting site did not significantly affect the outcome [68].
Depigmentation — Since the 1950s, monobenzyl ether of hydroquinone (monobenzone) has been used as a
depigmenting agent for patients with extensive vitiligo [84,85]. Monobenzone causes permanent destruction of
melanocytes and induces depigmentation locally and remotely from the sites of application. Thus, the use of
monobenzone for other disorders of pigmentation is contraindicated. The major side effects of monobenzone
therapy are irritant contact dermatitis and pruritus, which usually respond to topical and systemic steroids. Other
side effects include severe xerosis, alopecia, and premature graying.

Experimental therapies

● Afamelanotide – Afamelanotide, a potent and longer-lasting synthetic analog of naturally occurring alpha-
melanocyte-stimulating hormone (MSH), is a novel intervention for vitiligo [86,87]. Its use is based upon the
demonstration of defects in the melanocortin system in patients with vitiligo, including decreased circulating
and lesional skin levels of alpha-MSH [88]. Afamelanotide is delivered as a subcutaneous, bioresorbable
implant that promotes melanocyte proliferation and melanogenesis.

The safety and efficacy of afamelanotide implants combined with NB-UVB were assessed in an observational
study of four patients with generalized vitiligo [86]. Patients were treated three times weekly with NB-UVB for
one month and then administered a series of four monthly implants containing 16 mg of afamelanotide.
Follicular and confluent areas of repigmentation were evident within two days to four weeks after the initial
implant. Afamelanotide induced fast and deep repigmentation as well as diffuse hyperpigmentation in all
cases. In a subsequent randomized trial including 55 patients with skin type III to VI and vitiligo involving 15 to
50 percent of the BSA, patients in the NB-UVB plus afamelanotide group achieved a greater repigmentation
than patients in the NB-UVB monotherapy group at five months (49 versus 33 percent) [87].

● Prostaglandin E2 – Prostaglandin E2 (PGE2) is a potentially beneficial treatment for localized stable vitiligo.
PGE2 controls the proliferation of melanocytes by means of stimulant and immunomodulatory effects. In a
consecutive series of patients with stable vitiligo, repigmentation occurred in 40 of 56 patients treated with
PGE2 0.25 mg/g gel twice daily for six months [89]. The response was excellent in 22 of 40 patients, with
complete repigmentation observed in eight patients.

● Bimatoprost – Bimatoprost, a synthetic analog of prostaglandin F2-alpha approved for the topical treatment of
glaucoma and hypotrichosis of the eyelashes, is associated with hyperpigmentation of periocular skin caused
by increased melanogenesis [90]. The efficacy of bimatoprost in the treatment of vitiligo was initially evaluated
in a preliminary study of 10 patients with localized vitiligo treated with bimatoprost 0.03% ophthalmic solution
twice daily for four months [91]. Of the 10 patients, three had 100 percent repigmentation, three had 75 to 99
percent repigmentation, and one patient had 50 to 75 percent repigmentation. The best responses were
observed on the face.

A subsequent proof-of-concept randomized trial compared the efficacy of bimatoprost 0.03% ophthalmic
solution alone and in combination with a topical steroid (mometasone) with mometasone alone in 32 patients
with nonsegmental, nonfacial stable vitiligo involving <5 percent of the body surface area [92]. At 20 weeks,
none of the patients achieved the prespecified end point of 50 to 75 percent repigmentation. However, in a
post-hoc analysis using a less stringent definition of response (25 to 50 percent repigmentation), patients
treated with bimatoprost, either alone or with mometasone, achieved a greater repigmentation in the neck and
trunk than patients treated with mometasone alone.

● Topical ruxolitinib – Ruxolitinib is a Janus kinase 1 and 2 inhibitor approved for the treatment of intermediate-
or high-risk myelofibrosis and polycythemia vera. In a phase 2, proof-of-concept trial, topical ruxolitinib 1.5%
cream was administered twice daily to 11 adult patients with vitiligo involving at least 1 percent of the body
surface area for 20 weeks [93]. Eight of 11 patients had some response to treatment, with a mean
improvement of the Vitiligo Area Scoring Index of 23 percent. The best response was observed in patients with
facial vitiligo. The main adverse effect was erythema over the treated lesion.

PSYCHOLOGIC INTERVENTIONS — There is a scarcity of high-quality studies evaluating the efficacy of psychologic

interventions in the management of patients with vitiligo. One small randomized trial found that cognitive-
behavioral therapy in addition to conventional therapies was effective in improving the quality of life, self-esteem,
and perceived body image in adult patients with vitiligo and even influenced the course of the disease itself [94].
CAMOUFLAGE — Cosmetic camouflage can be beneficial for patients with vitiligo affecting exposed areas such as
the face, neck, and hands. Camouflage products include foundation-based cosmetics and self-tanning products
containing dihydroxyacetone (DHA). DHA-based products are most popular because they provide lasting color for
up to several days and are not immediately rubbed off onto clothing. Tattooing or micropigmentation should be
avoided, given the risk of koebnerization and oxidation of tattoo pigment causing further dyschromia. (See "Vitiligo:
Pathogenesis, clinical features, and diagnosis", section on 'Koebner phenomenon'.)

PROGNOSIS — Vitiligo is a chronic disease with a highly unpredictable course. Early-onset vitiligo appears to be
associated with involvement of a greater body surface area involvement and increased rate of disease progression
[95]. Despite treatment, most patients experience alternating periods of pigment loss and disease stability for their
entire life. Occasionally, patients may experience spontaneous repigmentation.

Patients who have organ-specific autoantibodies have an increased risk of developing subclinical or overt
autoimmune disease [96]. (See "Vitiligo: Pathogenesis, clinical features, and diagnosis", section on 'Associated
disorders'.)

SUMMARY AND RECOMMENDATIONS

● Vitiligo is a chronic, relapsing disease. The goals of treatment include the stabilization of active disease and
the repigmentation of depigmented patches. However, the response to treatments is slow and may be highly
variable among patients and among different body areas in the same patient. (See 'Patient evaluation' above
and 'Assessment of severity' above and 'Goals of treatment' above.)

● In patients with rapidly progressive vitiligo (ie, depigmented macules spreading over a few weeks or months),
we suggest systemic corticosteroids as adjunct therapy to narrowband ultraviolet B (NB-UVB) phototherapy for
stabilization (Grade 2C). (See 'Stabilization of rapidly progressive disease' above.)

● For patients with vitiligo involving <10 percent of the total body surface area (TBSA), we suggest topical
corticosteroids as initial therapy (Grade 2C). Topical corticosteroids are applied once daily for two to three
months and then interrupted for one month. Topical calcineurin inhibitors are preferred to topical
corticosteroids for body areas at increased risk of atrophy. Targeted phototherapy is an option for patients with
limited vitiligo who do not respond to topical therapies. (See 'Vitiligo involving <10 percent of the TBSA' above.)

● For patients with vitiligo involving 10 to 40 percent of the TBSA, we suggest phototherapy with NB-UVB (Grade
2B). Phototherapy is administered two to three times per week for 9 to 12 months or up to 200 treatments.
Topical corticosteroids or topical calcineurin inhibitors may be intermittently used in combination with NB-UVB
phototherapy. (See 'Vitiligo involving 10 to 40 percent of the TBSA' above.)

● Surgical therapies involving the autologous transplantation of healthy melanocytes in depigmented areas are
an option for patients with localized, recalcitrant vitiligo and for patients with segmental vitiligo. (See 'Localized
recalcitrant vitiligo' above and 'Segmental vitiligo' above.)

● Depigmentation of residual pigmented areas with monobenzyl ether of hydroquinone (monobenzone) can be
considered for patients with extensive recalcitrant vitiligo that does not respond to repigmentation regimens
and for those with extensive vitiligo who do not desire undergoing repigmentation treatments. (See 'Vitiligo
involving >40 percent of the TBSA' above.)

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Topic 106619 Version 5.0

GRAPHICS

Therapies for stabilization and repigmentation of vitiligo

Stabilization Repigmentation

Oral corticosteroids Topical corticosteroids

NB-UVB phototherapy Calcineurin inhibitors

Minocycline Vitamin D analogues

Methotrexate NB-UVB phototherapy

Vitamin supplementation Psoralen photochemotherapy

  Targeted phototherapy

  Experimental agents
Afamelanotide
Prostaglandin F2-alpha analogues

NB-UVB: narrowband ultraviolet B.

Graphic 107691 Version 4.0

Localized vitiligo with depigmented patches of the neck

Localized vitiligo, depigmented patches of the neck, sparing other body parts.

Courtesy of Pearl E Grimes, MD.

Graphic 107625 Version 1.0

Comparison of representative topical corticosteroid preparations (classified according to the US system)

Available
Trade names
Potency group* Corticosteroid Vehicle type/form strength(s), percent
(United States)
(except as noted)

Super-high potency Betamethasone Ointment, optimized Diprolene 0.05

(group 1) dipropionate, augmented
Lotion Diprolene 0.05

Gel Diprolene 0.05

Clobetasol propionate Ointment Temovate 0.05

Cream Temovate 0.05

Cream, emollient base Temovate E 0.05

Gel Temovate 0.05

Lotion Clobex 0.05

Foam aerosol Olux-E 0.05

Foam aerosol (scalp) Olux 0.05

Shampoo Clobex 0.05

Solution (scalp) Temovate, Cormax 0.05

Spray aerosol Clobex 0.05

Diflucortolone valerate Ointment, oily cream Nerisone Forte (United 0.3

(not available in United Kingdom, others)
States)

Fluocinonide Cream Vanos 0.1

Flurandrenolide Tape (roll) Cordran 4 mcg/cm 2

Halobetasol propionate Ointment Ultravate 0.05

Cream Ultravate 0.05

Lotion Ultravate 0.05

High potency Amcinonide Ointment Cyclocort ¶, Amcort ¶ 0.1

(group 2)
Betamethasone Ointment Diprosone 0.05
dipropionate
Cream, augmented Diprolene AF 0.05
formulation (AF)

Clobetasol propionate Cream Impoyz 0.025

Desoximetasone Ointment Topicort 0.25

Cream Topicort 0.25

Spray Topicort 0.25

Gel Topicort 0.05

Diflorasone diacetate Ointment ApexiCon ¶, Florone ¶ 0.05

Cream, emollient ApexiCon E 0.05

Fluocinonide Ointment Lidex ¶ 0.05

Gel Lidex ¶ 0.05

Cream anhydrous Lidex ¶ 0.05

Solution Lidex ¶ 0.05

Halcinonide Ointment Halog 0.1

Cream Halog 0.1

High potency Amcinonide Cream Cyclocort ¶, Amcort ¶ 0.1

(group 3)
Lotion Amcort ¶ 0.1

Betamethasone Cream, hydrophilic Diprosone 0.05

dipropionate emollient

Betamethasone valerate Ointment Valisone ¶ 0.1

Foam Luxiq 0.12

 Desoximetasone Cream Topicort LP 0.05

Diflorasone diacetate Cream Florone ¶ 0.05

Diflucortolone valerate Cream, oily cream, Nerisone (Canada, United 0.1

(not available in United ointment Kingdom, others)
States)

Fluocinonide Cream aqueous emollient Lidex-E ¶ 0.05

Fluticasone propionate Ointment Cutivate 0.005

Mometasone furoate Ointment Elocon 0.1

Triamcinolone acetonide Ointment Kenalog ¶ 0.5

Cream Triderm, Aristocort HP ¶ 0.5

Medium potency Betamethasone Spray Sernivo 0.05

(group 4) dipropionate

Clocortolone pivalate Cream Cloderm 0.1

Fluocinolone acetonide Ointment Synalar ¶ 0.025

Flurandrenolide Ointment Cordran 0.05

Hydrocortisone valerate Ointment Westcort 0.2

Mometasone furoate Cream Elocon 0.1

Lotion Elocon 0.1

Solution Elocon ¶ 0.1

Triamcinolone acetonide Cream Kenalog ¶ 0.1

Ointment Kenalog ¶ 0.1

Aerosol spray Kenalog 0.2 mg per 2 second

spray

Lower-mid potency Betamethasone Lotion Diprosone 0.05

(group 5) dipropionate

Betamethasone valerate Cream Beta-Val, Valisone ¶ 0.1

Desonide Ointment DesOwen, Tridesilon ¶ 0.05

Gel Desonate 0.05

Fluocinolone acetonide Cream Synalar ¶ 0.025

Flurandrenolide Cream Cordran 0.05

Lotion Cordran 0.05

Fluticasone propionate Cream Cutivate 0.05

Lotion Cutivate 0.05

Hydrocortisone butyrate Ointment Locoid 0.1

Cream Locoid, Locoid 0.1

Lipocream

Lotion, spray Cortizone 10 maximum 0.1

Lotion Locoid 0.1

Solution Locoid 0.1

Hydrocortisone probutate Cream Pandel 0.1

Hydrocortisone valerate Cream Westcort ¶ 0.2

Prednicarbate Cream, emollient Dermatop 0.1

Ointment Dermatop 0.1

Triamcinolone acetonide Lotion Kenalog ¶ 0.1

Ointment Kenalog ¶ 0.025

Low potency Alclometasone Ointment Aclovate 0.05

(group 6) dipropionate
Cream Aclovate 0.05

Betamethasone valerate Lotion Beta-Val, Valisone ¶ 0.1

Desonide Cream DesOwen, Tridesilon ¶ 0.05

 Lotion DesOwen, LoKara 0.05

Foam Verdeso 0.05

Fluocinolone acetonide Cream Synalar ¶ 0.01

Solution Synalar ¶ 0.01

Shampoo Capex 0.01

Oil (scalp) Δ Derma-Smoothe/FS 0.01

Scalp

Oil (body) Δ Derma-Smoothe/FS Body 0.01

Triamcinolone acetonide Cream Kenalog ¶, Aristocort ¶ 0.025

Lotion Kenalog ¶ 0.025

Least potent Hydrocortisone (base, Ointment Hytone 2.5

(group 7) ≥2%)
Cream Hytone, Nutracort ¶ 2.5

Lotion Hytone, Ala Scalp, 2.5 or 2

Scalacort

Solution Texacort 2.5

Hydrocortisone (base, Ointment Cortaid, Hytone, 1

<2%) Nutracort

Cream Cortaid, Hytone, Synacort 1

Lotion Aquanil HC, Sarnol-HC, 1

Cortizone 10

Spray Cortaid 1

Solution Cortaid, Noble, Scalp 1

relief

Ointment Cortaid 0.5

Cream Cortaid 0.5

Hydrocortisone acetate Ointment Pramosone 1 or 2.5

with pramoxine 1%
Cream Pramosone, Analpram- 1 or 2.5
combination
HC

Lotion Pramosone, Analpram- 1 or 2.5

HC

Aerosol foam Epifoam 1

US: United States.

* Listed by potency according to the US classification system: group 1 is the most potent, group 7 is the least potent. Other countries use a different
classification system with only four or five groups.
¶ Inactive United States trade name for specific product; brand may be available outside United States.
Δ 48% refined peanut oil.

Data from:
1. Lexicomp Online. Copyright © 1978-2018 Lexicomp, Inc. All Rights Reserved.
2. Tadicherla S, Ross K, Shenefelt D. Topical corticosteroids in dermatology. Journal of Drugs in Dermatology 2009; 12:1093.
3. U.S. Food & Drug Administration Approved Drug Products with Therapeutic Equivalence (Orange Book). Available at:
https://www.accessdata.fda.gov/scripts/cder/ob/default.cfm (Accessed on June 18, 2017).

Graphic 62402 Version 46.0

Repigmentation of localized vitiligo with excimer laser phototherapy

(A) Before and (B) after excimer laser phototherapy.

Courtesy of Pearl E Grimes, MD.

Graphic 107629 Version 1.0

Repigmentation of vitiligo with narrowband UVB phototherapy

(A and B) Before and (C and D) after narrowband UVB phototherapy, 68 treatments.

UVB: ultraviolet B.

Courtesy of Pearl E Grimes, MD.

Graphic 107628 Version 2.0

Vitiligo repigmentation

Follicular areas of repigmentation are early signs of response to narrowband UVB phototherapy.

UVB: ultraviolet B.

Courtesy of Pearl E Grimes, MD.

Graphic 107627 Version 2.0

Contributor Disclosures
Pearl E Grimes, MD Nothing to disclose Hensin Tsao, MD, PhD Grant/Research/Clinical Trial Support: Relay
Therapeutics [Melanoma]. Consultant/Advisory Boards: Epiphany Dermatology [Basal cell carcinoma, melanoma,
nevi, skin cancer screening]; World Care Clinical [Melanoma (Imaging services)]. Rosamaria Corona, MD,
DSc Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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standards of evidence.

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