Guideline for the Diagnosis and Management of Vitiligo

Summary and Key Recommendations

Summary

This detailed and user-friendly guideline for the diagnosis and management of vitiligo in children and adults aims to give high quality clinical advice, based on the best available evidence and expert consensus, taking into account patient choice and clinical expertise.

The guideline was devised by a structured process and is intended for use by dermatologists and as a resource for interested parties including patients. Recommendations and levels of evidence have been graded according to the method developed by the Scottish Inter-Collegiate Guidelines Network. Where evidence was lacking, research recommendations were made.

The types of vitiligo, process of diagnosis in primary and secondary care, and investigation of vitiligo were assessed. Treatments considered include offering no treatment other than camouflage cosmetics and sunscreens, the use of topical potent or highly potent corticosteroids, of vitamin D analogues, and of topical calcineurin inhibitors, and depigmentation with p-(benzyloxy)phenol. The use of systemic treatment, e.g. corticosteroids, ciclosporin and other immunosuppressive agents was analyzed.

Phototherapy was considered, including narrowband ultraviolet B (UVB), psoralen with ultraviolet A (UVA), and khellin with UVA or UVB, along with combinations of topical preparations and various forms of UV. Surgical treatments that were assessed include full-thickness and split skin grafting, mini (punch) grafts, autologous epidermal cell suspensions, and autologous skin equivalents. The effectiveness of cognitive therapy and psychological treatments was considered.

Therapeutic algorithms using grades of recommendation and levels of evidence have been produced for children and for adults with vitiligo.

Key Recommendations

Grades of recommendation/levels of evidence are given (see Table 1 and Table 2 ).

Therapeutic Algorithm in Children

1. Diagnosis
   
   Where vitiligo is classical, the diagnosis is straightforward and can be made in primary care (D/4) but atypical presentations may require expert assessment by a dermatologist (D/4).

2. No Treatment Option
   
   In children with skin types I and II, in the consultation it is appropriate to consider, after discussion, whether the initial approach may be to use no active treatment other than use of camouflage cosmetics and sunscreens (D/4).

3. Topical Treatment

   • Treatment with a potent or very potent topical steroid should be considered for a trial period of no more than 2months. Skin atrophy has been a common side-effect (B/1+).

   • Topical pimecrolimus or tacrolimus should be considered as alternatives to the use of a highly potent topical steroid in view of their better short-term safety profile (B/1+).

    

4. Phototherapy
   
   Narrowband (NB) ultraviolet (UV) B phototherapy should be considered only in children who cannot be adequately managed with more conservative treatments (D/4), who have widespread vitiligo, or have localized vitiligo associated with a significant impact on patient's quality of life (QoL). Ideally, this treatment should be reserved for patients with darker skin types and monitored with serial photographs every 2-3months (D/3). NB-UVB should be used in preference to PUVA in view of evidence of greater efficacy, safety and lack of clinical trials of PUVA in children (A/1+).

5. Systemic and Surgical Treatments
   
   The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects (B/2++). There are no studies of surgical treatments in children.

6. Psychological Treatments
   
   Clinicians should make an assessment of the psychological and QoL effects of vitiligo on children (C/2++). Psychological interventions should be offered as a way of improving coping mechanisms (D/4). Parents of children with vitiligo should be offered psychological counselling.

Therapeutic Algorithm in Adults

1. Diagnosis
   
   Where vitiligo is classical, the diagnosis is straightforward and can be made in primary care (D/4) but atypical presentations may require expert assessment by a dermatologist (D/4). A blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid disease in patients with vitiligo (D/3).

2. No Treatment Option
   
   In adults with skin types I and II, in the consultation it is appropriate to consider, after discussion, whether the initial approach may be to use no active treatment other than use of camouflage cosmetics and sunscreens (D/4).

3. Topical Treatment

   • In adults with recent onset of vitiligo, treatment with a potent or very potent topical steroid should be considered for a trial period of no more than 2months. Skin atrophy has been a common side-effect (B/1+).

   • Topical pimecrolimus should be considered as an alternative to a topical steroid, based on one study. The side-effect profile of topical pimecrolimus is better than that of a highly potent topical steroid (C/2+).

   • Depigmentation with p-(benzyloxy)phenol (monobenzyl ether of hydroquinone) should be reserved for adults severely affected by vitiligo (e.g. more than 50% depigmentation or extensive depigmentation on the face or hands) who cannot or choose not to seek repigmention and who can accept permanently not tanning (D/4).

    

4. Phototherapy
   
   NB-UVB phototherapy (or PUVA) should be considered for treatment of vitiligo only in adults who cannot be adequately managed with more conservative treatments (D/4), who have widespread vitiligo, or have localized vitiligo with a significant impact on QoL. Ideally, this treatment should be reserved for patients with darker skin types and monitored with serial photographs every 2-3months (D/3). NB-UVB should be used in preference to oral PUVA in view of evidence of greater efficacy (A/1+).

5. Systemic Therapy
   
   The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects (B/2++).

6. Surgical Treatments

   • Surgical treatments are reserved for cosmetically sensitive sites where there have been no new lesions, no Koebner phenomenon and no extension of the lesion in the previous 12months (A/1++).

   • Split-skin grafting gives better cosmetic and repigmentation results than minigraft procedures and utilizes surgical facilities that are relatively freely available (A/1+). Minigraft is not recommended due to a high incidence of side-effects and poor cosmetic results (A/1+). Other surgical treatments are generally not available.

    

7. Psychological Treatments
   
   Clinicians should make an assessment of the psychological and QoL effects of vitiligo on patients (C/2++). Psychological interventions should be offered as a way of improving coping mechanisms in adults with vitiligo (D/4).

The British Journal of Dermatology. 2008;159(5):1051-1076. © 2008  Blackwell Publishing

Cite this: Guideline for the Diagnosis and Management of Vitiligo - Medscape - Nov 01, 2008.