What treatment options are available?
The treatments for vitiligo include a variety of topicals, light therapies, systemic steroids, surgery, and de-pigmentation techniques. Traditional therapies include Psoralen + Ultraviolet A Light (PUVA), and steroids. Modern therapies include Narrowband-Ultraviolet B Light (NB-UVB), topical immunomodulators (tacrolimus, pimecrolimus), analogues of vitamin D3, excimer laser, antioxidants, minocycline, oral corticosteroids, pseudocatalase, and surgery/transplantation.
How long does it take to treat vitiligo? When should I expect results?
The amount of repigmentation that you will experience depends on several things. First, consistent use of the prescribed treatment is the best predictor of success. Second, using the appropriate combination of treatments (often light therapy and a topical cream) improves the skin’s ability to repigment. Finally, the percentage of the body affected by vitiligo, distribution of the lesions and the length of time you have had the condition all play a part. Treatment results will vary by person and type of vitiligo. Some people will begin to see results within 3 to 6 months. Others may not see results for 8 months or more. Combination treatments will typically work faster than single (mono) therapy treatments. The rule of thumb is that you will need to allow at least 3 to 6 months before you begin to see results from ANY treatment. Additionally, you should expect to treat for up to two years or longer in order to see good results. It is vital to use any treatment consistently and correctly. If you don't use a treatment as directed by your physician, it can take much longer to work or it may not work at all.
What areas respond best to treatment?
Areas with hair follicles repigment fastest and with best results (e.g. face, upper arms, upper legs, chest, back, buttocks). The wrists, hands, and feet are the slowest to respond to treatment.
How long do I have to get treatment to get my pigment back?
You will generally start to see results with light therapy after 24-36 treatments. However, the best results may require 6 months or longer of continued treatment. Maximum improvement may require 1-2 years of treatment.
Does vitiligo come back when treatment is discontinued?
Treatment is not abruptly discontinued. The frequency of the light therapy treatments is usually tapered as the skin begins to reach maximum repigmentation until you are receiving 1 treatment every other week. At this point, if no new lesions occur, you may discontinue treatment. Vitiligo may return if the immune system is still active or later becomes active (e.g. triggered by stress, illness or trauma). At that time, you may need to resume treatment.
Should I avoid the sun if I have vitiligo?
Sunlight, while not the most effective therapy, can be used to treat vitiligo if a prescription light source is not available. You will need to follow your doctor’s instructions carefully when using sunlight therapy to avoid burning. Please note that Narrow Band-UVB, found in the doctor’s office, is safer for the skin than sunlight. Sunlight contains UVA and UVB rays. While UVA rays do not contribute significantly to sunburns, they do damage deeper layers of the skin and play an important role in causing premature aging and promoting the growth of skin cancers. In addition, by using Narrow Band-UVB, you can achieve a therapeutic level of treatment in just a few minutes as opposed to the longer times required by sunlight, reducing your overall exposure to these potentially damaging rays. Please note, if you are treating vitiligo with any type of light, it is a good idea to wear sunscreen when not actively treating the lesions so that the risk of sunburn and subsequent missed treatments is avoided.
What is the cost of treatment?
Topical therapy is usually not very expensive. Both topical creams and in-office light therapy are often covered by medical insurance but usually require a small co-pay amount. However, surgical procedures are not covered by insurance at this time.
Is it safe to use all treatments on the face and around the eyes?
Research has shown that NB-UVB eyelid phototherapy is a safe and effective treatment and does not penetrate the eyelid. For their patients old enough to understand the importance of keeping the eyes closed, many doctors permit removing the goggles for part of the time to expose depigmented areas around the eyes. Care must be taken however, not to over expose the eyelid, as the very thin skin will not tolerate a high exposure time. Eye protection is always required when using any type of psoralen and/or UVA light, such as with PUVA therapy.
Most topical treatments prescribed for vitiligo can be used on the face; however, care must be taken to prevent them from getting into the eye. Due to their many potential side effects, potent topical steroids are generally not prescribed for use on the face, except for very short periods of time while under careful supervision of the prescribing physician. Monobenzone for depigmentation is generally not used on the face due to the potential for a rash forming.
How are topical steroids used for vitiligo?
Generally, use of topical steroids in widespread vitiligo is considered impractical because of the greater risk of associated adverse side effects due to the significant amount of skin that would be treated. However, research has shown that very potent or potent (class 1 and class 2) topical corticosteroids can be used either intermittently or on a short-term basis to re-pigment vitiligo-affected skin in adults. Most physicians prescribe less potent topical steroids for use by children.
What are Protopic and Elidel?
Protopic (tacrolimus), and Elidel (pimecrolimus) are both classified as immunomodulators, and are prescribed in their topical form for vitiligo. An immunomodulator is not the same as a steroid; it works by modulating (reducing) the immune response (where applied), allowing the melanocytes to once again grow and flourish.
What is V-Tar?
V- Tar is a prescription coal tar product used for treating vitiligo. V-Tar is applied once weekly and is one of the few treatments for vitiligo that does not need some form of light therapy to work. However, because of its photo-sensitizing properties, patients using V-tar are advised to avoid direct sunlight, or use a sunscreen, on the treated areas for 3 days post application. It is only available from the one compounding pharmacy that developed it.
What is Pseudocatalase?
Pseudocatalase is an antioxidant that is prescribed in its topical form for the treatment of vitiligo. It is usually combined with light therapy and is occasionally combined with salt water bathing in The Dead Sea. Studies have shown varying responses to this form of treatment, with greatest reports of success when the original formulation of activated pseudocatalase was used.
What is PUVA?
PUVA stands for Psoralen plus UltraViolet A light, and is a form of phototherapy using long wave UVA light in combination with either a photosensitizing (making more sensitive to the effects of light) pill or a topical solution known as a psoralen. When using the pill form, the psoralen sensitizes the skin and eyes for up to 24 hours. To prevent the risk of cataracts, patients must wear approved wraparound sunglasses, indoors and out, for up to 24 hours after taking the tablets. PUVA is generally considered a less effective therapy, with more side effects, than NB-UVB.
What is PUVA-SOL?
For patients who cannot go to a facility with a UVA light box, the doctor may prescribe psoralen to be used with natural sunlight exposure. The doctor will give the patient careful instructions on carrying out treatment at home and monitor the patient during scheduled checkups.
What is Narrowband UVB (NB-UVB)?
NB-UVB, now considered the gold standard of treatment for vitiligo, is a more recent vitiligo treatment than PUVA, and uses the portion of the UVB spectrum from 311-313 nm. This light spectrum has been determined to help stimulate the melanocytes (pigment making cells) in less time than it takes to burn the skin. NB-UVB is sometimes used in combination with other topical treatments, but is effective for many on its own. NB-UVB can be used on children old enough to stand still and keep goggles on.
What is an excimer laser?
The excimer laser is a targeted NB machine typically using the 308 nm portion of the UVB spectrum. Laser can be very effective for smaller areas of stable vitiligo. As it treats a small area, it is inefficient for larger areas or percentages. Results from laser treatments frequently occur more quickly than with other treatments. Because laser treatments are expensive, it is typically only used on stable vitiligo, because when the vitiligo is active there is a greater chance of pigment being lost afterwards. Hands and feet are often not treated with laser because it is less effective there. Treatments are generally 2-3 times per week.
How are oral steroids used for vitiligo?
Oral steroids are used to help stabilize active vitiligo, meaning that they help stop new spots of vitiligo from developing. These can be prescribed as pulse dosing, where they are only taken on a few days of the week, or with daily dosing. Oral steroids are typically tapered when they need to be stopped, meaning that the dosage and frequency is gradually reduced to prevent side effects. When taken by mouth, steroids can cause many side effects such as increasing blood sugar, increasing blood pressure, and weakening the bones. As such, monitoring is required when taking this medication. Oral steroids are usually combined with other treatments, such as light therapy.
How is minocycline used for vitiligo?
Minocycline is an antibiotic that is used to treat many skin conditions. In vitiligo, it has been shown to stabilize active disease when taken daily. Side effects include abnormal pigmentation, increase in liver enzymes, abdominal discomfort, and increased sensitivity to light. Oral minocycline is usually combined with other treatments, such as light therapy.
How are oral antioxidants used for vitiligo?
There are multiple oral antioxidants that have been used to help stabilize active vitiligo. In vitiligo, melanocytes are more easily damaged by oxidative stress. Antioxidants can help prevent this. Side effects are dependent on the type of antioxidant, but are generally mild. Oral antioxidants are typically used with other forms of treatment, such as light therapy or topical medications.
What is surgical therapy for vitiligo?
Vitiligo surgery has the goal of transplanting functional melanocytes (pigment cells) to the depigmented area to cause repigmentation. This transplantation can be done through one of several methods, each of which harvests the melanocytes in a different way.
When is surgical therapy an option?
Although medical therapy has improved considerably in the last years, some people fail to sufficiently re-pigment through medical treatment. Surgical therapy can provide higher re-pigmentation rates for difficult-to-treat localized areas in selected patients, and can be used to treat generalized disease as well. Those considered the best candidates and most likely to experience a high rate of repigmentation from surgical therapies are those with stable, segmental, or localized vitiligo.
Where is vitiligo surgery performed?
Several major institutions that perform vitiligo surgery are listed below. However, this is not a comprehensive list.
If your institution regularly performs vitiligo surgery and you would like to add your institution to this list, please contact our site administrator at firstname.lastname@example.org.
Henry Ford New Center One
3031 W. Grand Blvd
Detroit, MI, USA 48202
University of Texas Southwestern Medical Center
5939 Harry Hines Blvd #300
Dallas, TX, USA 75390
University of Massachusetts Medical School
281 Lincoln St
Worcester, MA, USA 01605
The National Center for Vitiligo and Psoriasis
PO Box 300320,
Riyadh 11372, Saudi Arabia
Mulekar Vitiligo Clinic
Unit 142, Laxmi Plaza, Laxmi Industrial Estate, Sab Tv Lane, Link Road
Postgraduate Institute of Medical Education & Research, Chandigarh
Kairon Block, Sector 12,
Chandigarh, 160012, India
What is depigmentation?
While some people totally depigment through the natural progression of their vitiligo, others make the choice to depigment. For patients considering this option, doctors may request they begin with a psychological screening to determine that this decision is one they fully understand and are emotionally prepared for. It is generally only used in cases of advanced vitiligo, where there is more than 50% loss of pigment, though some physicians may allow its use with a lower percentage when a great deal of the vitiligo is located in the more visible areas.
If a physician determines that a patient is a candidate for this treatment, they begin the fairly simple process by using a topical prescription called monobenzyl ether of hydroquinone (MBEH). It is important to understand that this is a systemic treatment, meaning that once the cream is applied to the skin, it will cause depigmentation in remote areas away from the site of application.
This prescription is a compounded cream for use only by those with extensive vitiligo and is available in strengths of 10%, 20% (most often) or 30% or 40%. This cream has been around for at least 30 years, and was formerly manufactured with the trade name of “Benoquin," but is now most commonly known by its generic name “monobenzone.”
The patient will apply the cream twice daily, perhaps increasing the strength of the active ingredients and/or the coverage area, over a period of a year or more, until the normally pigmented skin has faded to match the vitiligo spots, creating an overall pale appearance. The skin of those who have depigmented looks quite normal, just fair. The paleness is not a stark white, as many fear, but rather a slightly pink tone. Protection from the sun is important after depigmentation is completed in order to prevent sunburns and return of pigmentation from hair follicles.