In All Patients With Vitiligo, What is the Efficacy of Systemic (i.e. Orally and Parenterally Administered) Treatments, Including Corticosteroids, Ciclosporin and Other Immunosuppressive Agents, in Terms of Condition Progression, Area Reduction and Quality of Life Score?
There is evidence that in many cases autoimmune mechanisms are involved in causing vitiligo. It is not surprising that systemic immunosuppressive treatments have been used in patients with vitiligo.
There is only one satisfactory RCT of any systemic treatment for vitiligo, a double-blind placebo-controlled trial of Gingko biloba extract. This product is said to have antioxidant and immunomodulatory properties. The study looked at cessation of progression in spreading generalized and focal types of vitiligo and at repigmentation.
Numerous open studies lacking any comparator arm have suggested a beneficial effect for systemic treatments, often of oral corticosteroids, on patients (often with Asian skin types) with usually generalized (symmetrical) forms of vitiligo.[90,91,92,93,94,95,96] These have been excluded from consideration here. The paper of Pasricha and Khera has been excluded as the effects of treatment are unclear - the trial design is suboptimal. The study of Orecchia etal. regarding the use of phenylalanine was excluded as it had fewer than 20 subjects in comparator groups.
Some other studies, usually also lacking a comparator, were of mixed treatment modalities, e.g. including some sort of phototherapy, and are excluded from consideration here although they may be considered elsewhere.[99,100,101,102,103,104,105,106,107]
A double-blind placebo-controlled trial looked at the effect of G. biloba extract for 6months, in adults with spreading generalized and focal types of vitiligo, and also on repigmentation, in 47 subjects divided into two groups. The authors showed that the G. biloba extract induced cessation of activity of the vitiligo in all subjects with acrofacial type (placebo induced cessation in one of six), in a third of those with symmetrical type called here 'vulgaris' (placebo one of six) and in a quarter with focal type (placebo seven of 10). The G. biloba extract was associated with some degree of repigmentation in four of nine with focal, two of nine with vulgaris and four of seven with acrofacial type, whereas only two subjects with focal type who had placebo experienced any repigmentation. The conclusion seems to be that G. biloba extract can arrest active vitiligo of the acrofacial type. This is the only study on G. biloba extract, and it is therefore unwise to place too much reliance on this result without confirmation of a beneficial effect.
Azathioprine has not been tried as a monotherapy in vitiligo but, at a dose of 0·75mg kg−1 daily, has been combined with PUVA in adults with symmetrical types of vitiligo. Earlier (after five treatments compared with six) and a greater degree of repigmentation (58% compared with 25%) was noted in the group that received azathioprine and PUVA (compared with PUVA alone), without any serious side-effects. No recommendation can be made based on this single study.
A well-conducted but open study of 25 European adults with active generalized types of vitiligo (and four with stable disease) examined the effect of oral dexamethasone 10mg twice a week for 24weeks, evaluating pigment change using photographs. The authors showed that disease progression was arrested in 22 of the 25 subjects with active vitiligo, after a mean treatment of 18±5weeks. 'Marked' repigmentation (51-75%) occurred in two subjects (7%) and 'moderate' or 'slight' repigmentation (26-50%; <25%) was noted in three (10%), with no response being found in 21 (72%). Side-effects were common, being seen in 20 of 29 subjects, and included weight gain, acne, menstrual irregularity and hypertrichosis.
One study of intralesional triamcinolone in 35 patients with one (12 subjects) or more (23 subjects) areas of vitiligo is worthy of mention. The 25 patients were randomly allocated to receive weekly injections of triamcinolone (0·1mL of 10mg mL−1 strength) for 8weeks, vs. 10 who received distilled water. Seventeen of the treatment group (69%) vs. six in the control group (60%) had a 'fair-to-excellent' response, indicating that the intralesional triamcinolone was no better than placebo.
In adult patients with active generalized (symmetrical) types of vitiligo, oral dexamethasone 10mg twice weekly can arrest the progression of the disease after a mean of 18weeks, but there is poor objective evidence for repigmentation and side-effects are common. The use of oral G. biloba extract in active generalized vitiligo cannot be recommended unless further studies confirm the effect of the one reported study.
There is no convincing evidence at present that any systemic treatment (apart from PUVA) has a role in the treatment of vitiligo.
The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects.
Grade of recommendation B Level of evidence 2++
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.