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Vitiligo Treatment Protocol

The holy grail of vitiligo research is to find a medication that safely and effectively stops the progression of vitiligo. No such medication exists today. Research on identifying the genes causing vitiligo may lead to development of such a medication. If a molecule can be identified that inactivates the vitiligo genes, it will be possible to prevent vitiligo from spreading. Until that time, there are limits on the efficacy of therapies currently available.

Optimal therapy for vitiligo has been shown to be a combination of topical medications and one form of ultraviolet light. Vitiligo is caused by destruction of the melanocyte in the epidermis. To repigment a patch of skin, the melanocytes must be replaced from a reservoir. The reservoir is the hair follicle. Usually the melanocytes in the follicle are spared by vitiligo but not always. It is essential before beginning therapy to determine if the skin is able to repigment, i.e., there is a reservoir. Glabrous (hairless) skin such as that on the dorsum of the fingers, the ventral surface of the wrist, the genitalia, the ankles and feet cannot respond to medical treatments because this skin lacks a reservoir from which to stimulate melanocyte growth back into the white patch.

Hairy skin in which the hairs are white (not blond) also cannot repigment. Medical therapies are not helpful for treating such areas of skin. It should be recognized that at best 75% of those treated with get some or much of the color back. It is unusual to get total repigmentation. For those with bilateral vitiligo, it is possible that some or all of the repigmentation will be lost at a later date after therapy is stopped. Maintenance therapy usually is not recommended.

Tropical Therapies

A. Topical steroids: topical steroids can be very useful for treating vitiligo, especially in children. Steroids come in a wide variety of potencies. Generally for children, for the face or intertriginous areas medium to lower potency steroids are recommended. Higher potency steroids can be used with proper caution. Often time steroids are used in combination with immunomodulatory. One expert has the steroids applied once daily for the first half of each month. An immunomodulatory is applied once daily for the second half of the month. These alternating topical applications are done for 3 to 6 months or longer until no significant repigmentation is noted. It is optimal to combine topical treatments with a form of ultraviolet light.

B. Immunomodulatory: Tacrolimus or pimecrolimus have been used with topical steroids as described under paragraph A. Both have had a black box warning of cancer risk applied to them by the FDA. However the American Academy of Dermatology considers the potential benefit for these medications to out weigh their slight risks. Although there has been published data indicating both medications are successful in some patients with vitiligo, the FDA has not approved the use of either medication for treating vitiligo. Accordingly, treating vitiligo with them is an off label use.

C. Other Variations: Another way to use these medications is to apply the steroid every other night and the immunomodulatory on the alternative days.

D. Other Variations: There are many other variations on use of these medications, which can be equally effective. The dermatologist treating the patient might have special experience and advise a modification of the treatments suggested here.

E. Other Therapies: There are many therapies recommended on the Internet such as diets, Pseudocatalse, anti oxidants, etc. However none of these have been shown to be effective. The patient should be very cautious about buying medications for which there is no shown efficacy. At least they are often costly. The risk that they might be dangerous is unknown.

Ultraviolet Light

Ultraviolet light seems important for maximal success in treating vitiligo. Ultraviolet light stimulates melanocytes to proliferate within the hair follicle and to migrate into the surrounding white skin producing freckles. The freckles coalesce and the skin is repigmented. There are at least 4 sources of ultraviolet light that can be used in combination with topical treatments.

A. Natural sunlight: Natural sunlight has the entire spectrum of ultraviolet light and is very effective when used in combination with topical treatments described above. Exposure to sunlight for 30 minutes 3 times per week (avoiding sunburn) is sufficient. There are limitations with natural sunlight. These include seasonal variations in available sun, problems with exposing some parts of the body, work or school hours and similar logistical problems.

B. Narrow band ultraviolet light: Narrow band ultraviolet light has replaced PUVA. PUVA has been associated with a higher the expected incidence of skin cancers 25 years after therapy was given. It is not used as a primary treatment at this time. Narrow band ultraviolet light has replaced PUVA and has been shown to be equally effective. It is administered in the dermatologists office 2-3 times per week. Insurance coverage is limited and this form of ultraviolet can be moderately expensive.

C. Excimer lasers: The excimer laser is a form of narrow band ultraviolet light. It is effective and has the advantage if can be used to treat only the depigmented skin thereby avoiding the normal skin. Excimer lasers minimize the problem of the enhanced contrast of skin color associated with all other forms of ultraviolet light. It is much more expensive, takes longer time to administer and must be done in the physicians office.

D. Tanning parlors: Tanning parlors usually have long wave ultraviolet tanning beds. They have a bad reputation because many young people use them indiscriminately for cosmetic reasons thereby increasing their risk for skin cancers. When used as a medical therapy twice weekly for 20 minutes for 3-6 months, they are no more dangerous than treatments received in a physicians office. Their use should be limited to specific treatment times. They are inexpensive and provide ultraviolet light for those who do not have access to narrow band UV.