Updates in the Treatment of Vitiligo - Episode 4

Considerations for Various Vitiligo Treatment Strategies

Dr Rosmarin explores several treatment approaches for vitiligo, including specific options for oral repigmentation treatments.

David Rosmarin, MD: There are different types of phototherapy. The most common type is narrowband UVB [ultraviolet B], which is a light box that patients will step into, where they will get the light shined on them for anywhere from seconds to minutes. They build up the time that they’re in there for. It turns out that it isn’t the frequency of phototherapy visits that determines how patients do; it’s the number of total visits. Patients can go into phototherapy booths twice a week and have a similar response to patients who get it 3 times a week. However, it will take longer for them to achieve their goal. But usually we don’t like to do it less than twice a week, and we ramp up the time that patients are in the photo booth up to a maximum, depending on their skin type. People who have darker skin will be in there for a longer time. People who have lighter skin will be in there for a shorter time.

That’s one of our first-line treatments for patients with vitiligo, particularly if it’s spreading and if it’s pretty extensive on the body. We’ll often shield their eyes and sometimes the genitals if they aren’t involved. It doesn’t work well for areas that have hair, if patients have it over the scalp or in other hairy areas, because it’s hard for the light to penetrate those spots.

Another treatment, which is very similar to narrowband UVB but more localized, is the excimer laser. This is also a particular wavelength similar to what we deliver in narrowband UVB but over a laser, so we can treat just a single spot or a few spots. That’s particularly good for localized disease, where patients may not want the light to be exposed to their whole body, but we prefer to do that on stable plaques. If patients are getting new spots elsewhere, we want to treat those with the whole-body phototherapy booth. The third most common type of phototherapy treatment is PUVA [psoralen with ultraviolet A], in which patients take a photosensitizer and then have UVA light activate that photosensitizer for treatment. Because there are more adverse effects, that treatment isn’t done nearly as much as it was years ago. But those are the 3 main types of phototherapy: narrowband UVB, excimer laser, and PUVA.

What are our common treatments for repigmentation? Most often, we’re starting patients with a combination of corticosteroids as well as topical calcineurin inhibitors. Corticosteroids have been shown to work on some patients, but we have to be careful with how we use them. Because repigmentation of vitiligo takes a long time, steroids are far from ideal because they have adverse effects when used in the long term, such as thinning of the skin, or atrophy, lightening of the skin, stretch marks, and telangiectasias. This is particularly true if we use it on areas where there’s thin skin, such as the face, where we have to limit the strength of our corticosteroid and the length of time we’re using it. This is most true around the eyes, because the eyelid skin is very thin and corticosteroids around the eye can lead to cataracts or glaucoma.

Although corticosteroids are our first-line treatments and they’re certainly good for the body, calcineurin inhibitors are also commonly used, particularly for sensitive areas of the skin, such as the face and eyelids. Although calcineurin inhibitors in our studies can work well for repigmenting facial vitiligo, they certainly don’t work in everybody. Because they’re a large size, they don’t penetrate as well for areas where there’s thicker skin, such as the body, trunk, and arm. They’re very good for sensitive areas, such as genitals, face, and armpits, but not as good for those areas that have thicker skin, which is often also involved with vitiligo. So we need to use a combination.

Transcript edited for clarity.