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Vitiligo: A Practical Review

Summary and Comment |
January 7, 2009

Vitiligo: A Practical Review

  1. Mary Wu Chang, MD

This review of the most common depigmenting disease differentiates between vitiligo types and discusses the best approaches to treatment.

  1. Mary Wu Chang, MD

The authors of this clinical practice article summarize the subtypes, natural history, and treatment of vitiligo, a common and disfiguring disease marked by loss of epidermal melanocytes. Vitiligo has a worldwide prevalence of 0.5%; half of all patients present before 20 years of age. Diagnosis is clinically based, with Wood’s lamp examination helpful in patients with lighter skin. Skin biopsy is rarely needed.

Nonsegmental vitiligo (NSV; aka generalized vitiligo) and segmental vitiligo (SV) differ clinically and in their responsiveness to treatment. SV is localized to a bandlike or segmental region (often on the face), has an earlier onset, and accounts for approximately 30% of childhood cases. SV has a rapid onset and stabilization and generally has a better prognosis than does NSV. Nevus depigmentosus (congenital nonprogressive hypopigmented macules) can be mistaken for SV. NSV accounts for up to 90% of all cases of vitiligo. This subtype can present in childhood, but later onset is more common. NSV is often chronic, progressive, and relapsing, and it is often associated with a personal or family history of autoimmunity. NSV commonly occurs symmetrically, at sites of pressure, friction, or trauma.

The treatment of choice for widespread NSV is narrow-band UVB (NB-UVB), which has proven to be more effective than photochemotherapy (psoralen and ultraviolet A radiation [PUVA]). Three months of twice-weekly NB-UVB treatment must be administered before the disease is determined to be unresponsive. The duration of vitiligo is inversely proportional to its response to NB-UVB. Facial vitiligo responds best to this treatment; hands and feet respond poorly. However, two thirds of cases relapse within 1 year. Topical therapies (corticosteroids and tacrolimus) are commonly used for localized vitiligo. Topical tacrolimus is valuable for facial vitiligo to avoid steroid-related atrophy, and topical and NB-UVB therapies may be combined. Surgical therapies, including autologous minigrafts, can be used for focal, stabilized lesions, but response is variable. Camouflage techniques are valuable; they include cosmetics, skin dyes, and sunless self-tanning lotions that contain dihydroxyacetone (DHA), which usually lasts 5 to 7 days from application. Chemical or laser depigmentation is reserved for carefully selected patients with extensive disfigurement, but, again, results vary.

Comment

There is no “cure” for vitiligo. Research data are limited, and therapy does not change the natural history of the disease. Fair-skinned individuals often do best with year-round use of sun block on normal skin. Natural sunlight therapy can be considered if phototherapy is not available. Poliosis (loss of hair color) can be hidden with hair dye. One should always offer camouflage therapies.

Citation(s):

Reader Comments (1)

Karen Russell

Help! I cannot find a dermatologist in my area who uses the NB-UVB technology for treatment of my daughter's facial segmental vitiligo. I am simply told there is no cure. Do the dermatologists in my area not read the journals, such as this one? I even called one of the doctors listed on the Vitiligo Foundation site, but she doesn't have the technology either. I am very frustrated with the lack of treatment options in my area of Virginia!

Competing interests: None declared

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