WORKUP	Section 5 of 10
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Lab Studies:

• Although the diagnosis of vitiligo generally is made clinically, biopsy is occasionally helpful in differentiating vitiligo from other hypopigmentary disorders.

• Vitiligo may be associated with other autoimmune diseases, especially thyroid disease and diabetes mellitus. Other associated autoimmune diseases include pernicious anemia, Addison disease, and alopecia areata.

• Patients should be made aware of signs and symptoms that suggest onset of hypothyroidism, diabetes, or other autoimmune disease. If signs or symptoms occur, appropriate tests should be performed.

• Thyroid-stimulating hormone (TSH) test is the most cost-effective screening test for thyroid disease.

• Screening for diabetes can be accomplished with a fasting blood sugar or glycosylated hemoglobin.

Other Tests:

• Vitiligo is diagnosed by means of inspection with a Wood lamp.

	TREATMENT	Section 6 of 10
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Medical Care:

• No single therapy for vitiligo produces predictably good results in all patients; the response to therapy is highly variable.

• Treatment must be individualized, and patients should be made aware of the risks associated with therapy.

• Systemic phototherapy induces cosmetically satisfactory repigmentation in up to 70% of early or localized cases.

• PUVA treatment (8-methoxypsoralen, 5-methoxypsoralen, trimethylpsoralen plus UVA) was often the most practical choice for treatment, especially in widespread vitiligo in patients with skin types IV-VI. However, 2 or 3 treatments per week for many months are required before repigmentation from perifollicular openings merges to produce confluent repigmentation.
  • The best results can be obtained on the face and on the proximal parts of extremities.

  • Vitiligo on the back of hands and feet is very resistant to therapy.

• Narrowband UV-B phototherapy was recently developed and widely being used with good clinical results. Narrowband fluorescent tubes (Philips TL-01/100W) with an emission spectrum of 310-315 nm and a maximum wavelength of 311nm are used. Treatment frequency is twice weekly and never on consecutive days. This treatment can be safely used in children, as well as pregnant and lactating women.

• UV-B narrowband microphototherapy is targeting the specific small lesions. Selective narrowband UV-B (311 nm) is used with a fiber optic system to direct radiation to specific areas of skin.
  • Another recent innovation is therapy with an Excimer laser that produces monochromatic rays at 308-nm to treat limited, stable patches of vitiligo.

  • These new treatments are efficacious, safe, and well-tolerated treatment for vitiligo when limited to less than 30% of the body surface. However, they are expensive.

• Systemic steroids (prednisone) have been used, though their prolonged use and toxicity are undesirable.
  • Steroids have been given with anecdotal success in pulse doses or low doses to minimize adverse effects.

  • Benefits and toxicity of this therapy must be weighed carefully.

  • More research is necessary to establish safety and effectiveness of this therapy for vitiligo.

  • A topical steroid preparation is often chosen first to treat localized vitiligo because it is easy and convenient for both doctors and patients to maintain the treatment.

  • Results of therapy have been reported as moderately successful, particularly in patients with localized vitiligo and/or an inflammatory component to their vitiligo, even if inflammation is subclinical.

• Topical tacrolimus ointment (0.03% or 0.1%) is an effective alternative therapy for vitiligo, particularly when the disease involves the head and neck. Combination treatment with topical tacrolimus 0.1% plus the 308-nm Excimer laser is superior to monotherapy with the 308-nm Excimer laser monotherapy for UV-resistant vitiliginous lesions.

• The combination of topical calcipotriene and narrowband UV-B or PUVA results in improvement appreciably better than achieve with monotherapy.

• If vitiligo is widespread and attempts at repigmentation do not produce satisfactory results, depigmentation may be attempted in selected patients.
  • Long-term social and emotional consequences of depigmentation must be considered.

  • Depigmentation should not be attempted unless the patient fully understands that the procedure generally results in permanent depigmentation.

  • Some authorities have recommended consultation with a mental health professional to discuss potential social consequences of depigmentation.

  • A 20% cream of monobenzylether of hydroquinone is applied twice daily for 3-12 months. Burning or itching may occur. Allergic contact dermatitis may be seen.

  • Topical PUVA is of benefit in some patients with localized lesions. Cream and solution of 8-methoxypsoralen (0.1-0.3% concentration) are available for this treatment.
    • It is applied 30 minutes prior to UV-A radiation (usually 0.1-0.3 J/cm² UV-A). It should be applied once or twice a week.

    • Physicians who prescribe PUVA therapy should be thoroughly familiar with the risks associated with the treatment.

    • Additional UV-A exposure should be avoided while skin is sensitized.

    • Severe burns may occur if patients receive additional UV-A exposure.

    • Sunscreens should be given to all patients with vitiligo to minimize risk of sunburn or repeated solar damage to depigmented skin.

    • Patients must understand that most sunblocks have a limited ability to screen UV-A light.

  • Tanning of surrounding normal skin exaggerates the appearance of vitiligo, and this is prevented by sun protection. Sunscreens with a sun protection factor (SPF) of 15 or higher are best.

Surgical Care: Patients who have small areas of vitiligo with stable activity are candidates for surgical transplants.

• Punch grafts

• Punch biopsy specimens from a pigmented donor site are transplanted into depigmented sites.

• Repigmentation and spread of color begin about 4-6 weeks after grafting.

• The major problem is a residual, pebbled, pigmentary pattern.

• Minigrafts

• Small donor grafts are inserted into the incision of recipient sites and held in place by a pressure dressing.

• The graft heals readily and begins to show repigmentation within 4-6 weeks.

• Some pebbling persists but is minimal, and the cosmetic result is excellent.

• Suction blister
  • Epidermal grafts can be obtained by vacuum suction usually with 150 mm Hg.

  • The recipient site can be prepared by suction, freezing, or dermabrasion of the sites, 24 hours before grafting.

  • The depigmented blister roof is discarded, and the epidermal donor graft is placed on the vitiliginous areas.

• Autologous cultures and autologous melanocytes grafts: These 2 techniques are expensive and currently impractical.

• Micropigmentation
  • Tattooing can be used to repigment depigmented skin in dark-skinned individuals.

  • Color matching is difficult, and the color tends to fade. Skin can be dyed with dihydroxyacetone preparations, though the color match is often poor.

	MEDICATION	Section 7 of 10
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The goals of pharmacotherapy are to reduce morbidity and to prevent complications.