Management of vitiligo. Results of a questionnaire among dermatologists in The Netherlands

BACKGROUND: Several therapeutic options are available for the treatment of vitiligo. Concern exists that there is no uniform approach towards the management of vitiligo among Dutch dermatologists. METHODS: A written survey concerning the management of vitiligo was sent to 332 dermatologists in The Netherlands. RESULTS: The response rate was 86%. "Giving information and reassurance concerning the nature of disease" was regarded by most dermatologists (68%) as being the most important goal in the management of vitiligo. Only 16% of the dermatologists aimed for active treatment in vitiligo. The reported therapy choices in children resembled those of adults, except that slightly more dermatologists did not prescribe active therapy in children. Nine different therapeutic modalities were mentioned as first choice therapies. Topical corticosteroids were indicated by most dermatologists as first choice therapy (241 out of 266, i.e. 91%); however, only 2% indicated that 50% or more of the patients achieved a successful treatment; 66% found that less than 25% of the patients were successfully treated with topical corticosteroids. Only 15% of the respondents reported that 50% or more of the patients were treated successfully with narrow-band UVB. The observed response profile to broad-band UVB therapy was found to be comparable with that of narrow-band UVB. The classical therapy with oral psoralen plus UVA (PUVA) was prescribed as first choice therapy by only 12% (32 out of 266) of the dermatologists. Only 6% of these respondents observed that 50% or more of the patients achieved successful therapy using oral PUVA. The recommended maximum treatment duration for topical corticosteroids, oral PUVA, and UVB therapy was found to vary from 3 to 12 months. CONCLUSIONS: Most dermatologists in The Netherlands do not offer active treatment in vitiligo, probably because the estimated effectiveness of (nonsurgical) repigmentation therapy is low. In cases where treatment is prescribed, there appears to be no consensus on the choice of therapies and treatment strategies. The development of practice guidelines may be helpful in reducing inappropriate care and improving treatment outcome.     

Narrow-band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of vitiligo

Vitiligo is a common, idiopathic, acquired, depigmenting disease characterized by loss of normal melanin pigments in the skin. The most interesting treatment methods for extensive vitiligo involve psoralen plus ultraviolet A (PUVA) therapy and ultraviolet (UV)-B phototherapy, particularly narrow-band UV-B. In this randomized and comparative study, we investigated the safety and efficacy of narrow band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of generalized vitiligo. Of the 40 vitiligo patients enrolled in the study, 15 were treated with the calcipotriol plus narrow-band UV-B (NBUVB) and 25 with narrow band UV-B alone. The patients were randomized into two NBUVB treatment groups. The first group, consisting of 24 patients (all male), received only NBUVB treatment; the second group, consisting of 13 patients (all male) applied 0.05% topical calcipotriol ointments twice daily. Both groups were irradiated with NBUVB (311 nm). In the NBUVB group, the percentage of the body surface affected was reduced from 27.21 +/- 10.41% to 16.25 +/- 8.54% after a mean of 30 treatment sessions. The mean repigmentation percentage was 41.6 +/- 19.4%. In clinical evaluation (moderate and marked/complete response was accepted as an effective treatment), 19 patients (19/24; 79.17%) had clinically good results. In the NBUVB plus calcipotriol group, the percentage of the body surface affected was reduced from 23.35 +/- 6.5% to 13.23 +/- 7.05% after a mean of 30 treatment sessions. The mean repigmentation percentage was 45.01 +/- 19.15%. In clinical evaluation (moderate and marked/complete response was accepted as an effective treatment), 10 patients (10/13; 76.92%) had clinically good results. Statistically significant intragroup reductions from the baseline percentage of the body surface affected were seen at the endpoint of treatment for the two treatment groups (P < 0.001). However, there was no statistically significant difference between the two treatment groups at the end of therapy with respect to the reduction of repigmentation rates (P > 0.05). The present study reconfirmed the efficacy of NBUVB phototherapy in vitiligo. It can be a therapeutic option considered in the management of patients with vitiligo. However, addition of topical calcipotriol to NBUVB did not show any advantage.     

Narrowband ultraviolet B radiation therapy for recalcitrant vitiligo in Asians

BACKGROUND: Narrowband ultraviolet B (NBUVB) has recently been reported to be effective therapy for vitiligo. However, reports on its efficacy in recalcitrant vitiligo are lacking. OBJECTIVE: Our objective was to assess the efficacy of NBUVB in patients with vitiligo who did not respond to either topical therapy or oral psoralen plus ultraviolet A (PUVA). METHOD: This was a retrospective analysis of patients with vitiligo who were treated with NBUVB from February 1998 to January 2001. They received NBUVB treatment 2 times per week, with an initial dose of 100 mJ/cm(2). The dose was increased by 10% to 20% per treatment for 20 treatments. The dose was then increased by 2% to 5% per treatment until 50% repigmentation was observed or persistent erythema developed. The treatment was continued until maximum repigmentation was achieved. The treatment was terminated if the patient showed less than 25% improvement after 40 to 50 exposures. RESULTS: There were 60 patients: 22 men and 38 women, aged 11 to 61 years. The mean duration of vitiligo was 8.2 +/- 7.1 years. There were 53 cases of generalized and 7 cases of localized vitiligo. The lesions covered from less than 5% to 50% of body surface. Twenty-five patients were skin type III, 33 patients were skin type IV, and 2 patients were skin type V. Every case had been previously treated with topical steroid with or without topical psoralen with solar light exposure. Thirty-six patients (60%) had been treated with oral PUVA before NBUVB therapy. After NBUVB treatment, 25 of 60 patients (42%) achieved more than 50% repigmentation on face, trunk, arms, and legs. However, hand and foot lesions showed less than 25% repigmentation in all cases. There was no significant difference between the responders and nonresponders in age, sex, duration of diseases, and skin type. The response rate of patients who had not been previously treated with PUVA was significantly higher than that of patients who had been previously treated with PUVA (67% vs 36%, P =.003). CONCLUSION: This retrospective, open study demonstrated that NBUVB therapy was effective in 42% of Asian patients with recalcitrant vitiligo without serious side effect. The only clinical parameter that could differentiate nonresponders from responders was previous exposure to PUVA.     

Systemic PUVA vs. narrowband UVB in the treatment of vitiligo: a randomized controlled study

Vitiligo is an acquired depigmenting disorder having disfiguring consequences. Many treatments have been attempted with varying reports of success. A parallel‐group, assessor blinded, randomized, controlled trial was designed to compare the efficacy and adverse effects of narrowband UVB (NBUVB) with oral psoralen UVA (PUVA) therapy in the treatment of vitiligo. Patients aged 13–70 years with vitiliginous lesions involving more than 5% body surface area were eligible for the study. In total, 56 patients were randomized in a 1 : 1 ratio to oral PUVA or NBUVB phototherapy groups. Patients were assessed for the percentage of repigmentation over the depigmented areas as the primary outcome measure at each visit during the first three months and then monthly within the next three months. The incidence of adverse effects was also noted during the study period as the secondary outcome measure. The median repigmentation achieved at the end of the six‐month therapy course was 45% in the NBUVB group and 40% in the oral PUVA group. Focal vitiligo had the best response in both treatment groups. There were lesser adverse effects within the NBUVB (7.4%) than in the PUVA (57.2%) group. Two PUVA patients discontinued therapy due to severe dizziness. There was no significant difference in the mean degree of repigmentation; however, NBUVB carried a greater response rate and might be superior to oral PUVA with better tolerance and color match with the surrounding normal skin, as well as fewer side effects in the treatment of vitiligo.     

Psoralen and ultraviolet A and narrow-band ultraviolet B in inducing stability in vitiligo, assessed by vitiligo disease activity score: an open prospective comparative study

BACKGROUND: Vitiligo is a common pigmentary disorder with great cosmetic and psychological morbidity and an unpredictable course. No treatment available is a definitive cure. Systemic psoralen and ultraviolet A (PUVA) has been the mainstay of treatment. Narrow-band UVB (NBUVB) was later introduced. In this study, we have compared the phototherapy modalities PUVA and NBUVB in inducing stability in vitiligo, assessed by using vitiligo disease activity score (VIDA), for the first time. AIMS: To investigate the position of NBUVB vis-à-vis PUVA in terms of stability achieved during therapy as indicated by the VIDA scores. SUBJECTS AND METHODS: It was an open, prospective study of 50 patients divided equally in PUVA and NBUVB groups. The study period was from January 2004 to June 2005. This study was done as a part of a larger project to compare the efficacy of mentioned modalities in degree of repigmentation. RESULTS: In the NBUVB group, disease activity was present in 40% patients before commencement of therapy, which was reduced to 16% at the end of therapy (statistically significant, P = 0.049). In the PUVA group, similar figures were 20% and 16%, respectively. In the NBUVB group, 50% of patients whose disease was active prior to commencement of therapy had less than 50% repigmentation, whereas an equal number of patients had repigmentation of more than 50%. Almost an equal number of stable patients had less than and more than 50% repigmentation. In the PUVA group, 4 of the 5 (80%) patients who had active disease had less than 50% repigmentation, whereas only 1 patient (20%) with active disease obtained more than 50% repigmentation. The time to attain stability was 3.6 +/- 2.1 months in the NBUVB group and 3.22 +/- 3.1 months in the PUVA group. Eight of the 10 (80%) patients with unstable disease in the NBUVB group achieved stability, whereas 2 of the 5 (40%) patients of similar pre-treatment status in the PUVA group achieved stability. CONCLUSION: NBUVB was in a more statistically advantageous position vis-à-vis PUVA, in respect to stability achieved and efficacy in both active and stable disease in a comparable time period.     

Treatment policy for psoriasis and eczema: a survey among dermatologists in the Netherlands and Belgian Flanders

Today, many therapies are available for the treatment of psoriasis and eczema. One of the oldest topical therapies is coal tar. Coal tar has been used for decades, but over the past years, the use of coal tar has decreased for several reasons, including the supposed carcinogenicity of coal tar.We investigated the current and past treatment policies for psoriasis and eczema with special emphasis on the use of tar products; a postal survey was conducted among all dermatologists in two European countries: the Netherlands (n = 360) and the Flemish speaking part of Belgium (Flanders) (n = 328). This study was conducted as part of the ongoing LATER-study ("Late effects of coal tar treatment in eczema and psoriasis; the Radboud study").All practising dermatologists received a questionnaire. Dermatologists were asked to describe their treatment policies in mild/moderate psoriasis, severe psoriasis, mild/moderate eczema and severe eczema.The response rate to the questionnaire was 62.5% for the Dutch dermatologists and 45.7% for the Flemish dermatologists. Almost all dermatologists prescribe topical corticosteroids. In eczema, most of the dermatologists prescribe the recently introduced calcineurin inhibitors (95%). Coal tar is a second choice topical therapy. Dutch dermatologists mainly use tar in the treatment of eczema (72% vs. 48% in Flanders), whereas in Flanders, tar is mainly prescribed in psoriasis (60% vs. 41% in Holland). Flemish dermatologists very frequently prescribe PUVA in psoriasis (93% vs. 63%).Topical treatment, especially topical corticosteroids, is the mainstay in psoriasis and eczema. Coal tar still is an important (second choice) therapy for the topical treatment of psoriasis and eczema, but its use varies from country to country. Despite the carcinogenicity of PUVA, this photochemotherapy is frequently prescribed by dermatologists, mainly in Flanders.     

Psoralen–ultraviolet A vs. narrow-band ultraviolet B phototherapy for the treatment of vitiligo

BACKGROUND: Although many treatment modalities have been tried for the treatment of vitiligo, none is uniformly effective. Psoralen phototherapy (psoralen ultraviolet A (PUVA)) is established as efficacious treatment for vitiligo. Recently, narrow-band UVB (NBUVB) has been reported to be an effective and safe therapeutic option in patients with vitiligo. OBJECTIVE: To compare the efficacy of PUVA and NBUVB in the treatment of vitiligo. DESIGN AND SETTING: Retrospective analysis of 69 patients with vitiligo who were treated either with PUVA or NBUVB at the pigmentary clinic of the Dermatology Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, India. OUTCOME MEASURES: The following variables were compared between the two groups of patients: repigmentation status, number of treatments for marked to complete repigmentation in existing lesions, appearance of new lesions or increase in size of existing lesions, adverse effect of therapy, stability of repigmentation and colour match. RESULTS: In PUVA-treated group, 9 patients showed marked to complete repigmentation (23.6%) and 14 patients showed moderate improvement (36.8%), whereas in NBUVB-treated group, 13 patients showed marked to complete repigmentation (41.9%) and 10 patients showed moderate improvement (32.2%). A statistically significantly better stability and colour match of repigmentation with surrounding skin was seen in NBUVB-treated patients. CONCLUSION: We showed that NBUVB is more effective than PUVA and repigmentation induced with NBUVB is statistically significantly more stable.     

A large scale analytical study on efficacy of different photo(chemo)therapeutic modalities in the treatment of psoriasis,vitiligo and mycosis fungoides

Psoriasis, vitiligo, and mycosis fungoides (MF) are among the most frequently treated dermatological diseases by photo(chemo)therapy. The objectives are to determine which photo (chemo) therapeutic modality could achieve the best response in the treatment of psoriasis, vitiligo, and MF. The design used in this study is retrospective analytical study. The study included 745 patients' records; 293 with psoriasis, 309 with vitiligo, and 143 with early MF, treated in the Phototherapy Unit, Dermatology Department, Kasr El‐Aini Hospital, Cairo University by either psoralen and ultraviolet A (PUVA), narrow band ultraviolet B (NB‐UVB), psoralen and narrow band UVB (P‐NBUVB), broad band UVB (BB‐UVB), or broad band UVA (ΒΒ‐UVA). Data were retrieved from the computer database of the unit and statistically analyzed. In psoriasis, oral and topical PUVA and NB‐UVB were found to be equally effective, whereas oral PUVA had significantly better results than both UVA and BB‐UVB at the end of therapy. In generalized vitiligo, PUVA and P‐NBUVB had significantly better results than NB‐UVB alone. In early MF, there was no statistically significant difference between the response to oral PUVA and NB‐UVB. PUVA and NB‐UVB are good choices in patients with psoriasis and early stage MF, whereas PUVA appears the best choice in the treatment of vitiligo.     

Topical immunomodulators are effective for treatment of vitiligo

Vitiligo is a common, acquired, depigmenting disease of the skin. Although the pathogenesis of vitiligo is still unclear, it is postulated that topical immunomodulators exert therapeutic effects on treatment of vitiligo. We reviewed the treatment of vitiligo with topical immunomodulators and topical steroids to evaluate the efficacy of immunomodulators in treatment of vitiligo. We reviewed 52 patients treated with topical immunomodulators and 27 patients with topical steroids. To evaluate the efficacy, repigmentation of vitiligo was reviewed. Between the two treatments, the duration from the start of treatment to onset of repigmentation was significantly shorter in the topical immunomodulator group (P = 0.002). However, no statistically significant differences were found in sex, age, mean disease duration, sites of vitiligo lesion and ratio of patients who showed response. We may suggest topical immunomodulator as an alternative to topical steroids for treatment of vitiligo.     

Efficacy and safety of tarcrolimus cream 0.1% in the treatment of vitiligo

Background  Vitiligo is an acquired, pigmentary skin disorder which is disfiguring and difficult to treat. Phototherapy and application of topical corticosteroids are most commonly prescribed. However, these therapies are often not effective and use of corticosteroids on the face may lead to cutaneous atrophy, telangiectasia, and ocular complications.
Objective  We sought to assess the efficacy of topical tacrolimus ointment in the treatment of vitiligo.
Methods  A prospective pilot study was performed of 30 patients with vitiligo. Patients were treated with tacrolimus ointment for at least 4 months. Clinical responses were documented during clinic visits, and by pretacrolimus and post-tacrolimus photography.
Results  Twenty-five (83.3%) patients showed some repigmentation at the end of 4 months. Patients with vitiligo for more than 5 years also responded well to tacrolimus ointment. Repigmentation in active vitiligo was superior to that in stable vitiligo. 80% of patients with segmental vitiligo of the head and neck showed some response to tacrolimus, but there was no statistical significance between segmental and vulgaris vitiligo. The mean percentage of repigmentation on the head and neck was greater than that on the trunk and extremities. Four patients initially experienced burning on application.
Conclusions  Topical tacrolimus ointment is an effective and well-tolerated alternative therapy for vitiligo especially involving the head and neck.     

Clinical study of repigmentation patterns with different treatment modalities and their correlation with speed and stability of repigmentation in 352 vitiliginous patches

Because the etiopathogenesis of depigmentation in vitiligo is still obscure, the source of pigmentation in the repigmentating lesion and its stability is also not fully known. Several authors have shown on histopathology and electron microscopy predominantly a perifollicular spread of pigment. The aim of this study was to clinically assess the types of repigmentation patterns obtained with different treatment modalities and their correlation with speed and stability of repigmentation. A total of 125 patients with vitiligo on treatment with psoralens (topical and systemic psoralen-UVA [PUVA]), steroids (both topical and systemic), and topical calcipotriol, alone or in combination were enrolled. Representative lesions of vitiligo excluding mucosal sites were selected in each patient and photographed at baseline. Repigmentation was assessed and labeled as marginal, perifollicular, diffuse, or combined. The preselected patches were evaluated at 3 months to assess the speed of repigmentation. Retention of pigment (stability) was noted at 6 months, after the stoppage of active treatment. Of the 352 vitiligo patches selected, 194 (55%) showed predominant perifollicular repigmentation, of which a majority (127; 65.5%) were on systemic PUVA and 35 (18%) were on topical PUVA. Diffuse pigmentation was observed in 98 patches (27.8%) of which 66 (67.3%) were on topical steroids. Marginal repigmentation was seen in 15, of which the majority (80%) were on systemic PUVA and topical calcipotriol. Of the 28 total lesions showing marked repigmentation at 3 months, 22 lesions pigmented in a diffuse manner, 2 in a perifollicular pattern, and 4 showed a combined type of repigmentation. On follow-up, marginal repigmentation was the most stable (93.3%), followed by perifollicular (91.7%) and combined type (84.4%). Diffuse repigmentation was the least stable (78.5%). Psoralens predominantly exhibit a perifollicular pattern of repigmentation and steroids (topical/systemic), a diffuse type. The speed of repigmentation is much faster when initial repigmentation is of the diffuse type as compared with follicular repigmentation. The marginal and perifollicular repigmentation is more stable than the diffuse type of repigmentation.     

Vitiligo is more than skin deep: a survey of members of the Vitiligo Society

Background. Vitiligo is a common, largely acquired skin disease of unknown aetiology, which causes a variable amount of skin and hair depigmentation in affected people. It affects over half a million people in the UK alone, and a massive 50 million people worldwide. Aim. To quantify the psychosocial burden of vitiligo in the UK, by estimating its effect on daily life. Methods. All members (n = 1790) of the Vitiligo Society, a UK national patient support group, were sent a questionnaire. Survey questions included demographics, disease‐related characteristics, effect of vitiligo on daily life, and psychosocial support measures for patients with vitiligo. Results. In total, 520 (29% of members) responded, of which 354 (68%) were women. Vitiligo affected the hands in 414 (80%) and the face in 394 (76%) of the respondents. Over half (56.6%) of respondents indicated that vitiligo moderately or severely affects their quality of life (QOL). Finding a cure or effective lasting treatment was the main priority for most affected respondents. Most respondents obtain information about their disease from nonmedical sources: 431 (83%) from the Vitiligo Society and 129 (25%) from the internet, compared with 61 (12.5%) from dermatologists. Conclusion. Vitiligo is a skin condition that moderately or severely affects the QOL of most patients. Although most patients look for a cure or long‐lasting treatment, only 12.5% of respondents to our survey had obtained information from a dermatologist. Vitiligo is a common condition that affects more than the skin, and has profound psychosocial implications for affected patients.     

Management of vitiligo patients and attitude of dermatologists towards vitiligo

As vitiligo does not cause any physical impairment, it is often considered unimportant by physicians. Vitiligo patients repeatedly experience disinterest from the medical world regarding their skin problem. A questionnaire survey was used to assess the management of vitiligo patients and the attitude of dermatologists towards vitiligo in Belgium. Vitiligo patients (n = 244) visiting an academic affiliated dermatology department were included and 454 out of 558 Belgian dermatologists returned a mailed questionnaire. Vitiligo patients do not often visit a doctor concerning their disease and do not often treat their disease. Disease severity as reported by the patient is correlated with the number of doctor visits (p = 0.001) but not to treatment of the disease. Information about the treatment and physician's encouragement to treat seem important in motivating patients to treat their vitiligo, but 50% of the patients were not adequately informed about their disease and its treatment during their first doctor visit. Today, nearly all the dermatologists report widely informing their patients, but only 36% of them encourage their patients to treat their disease, being pessimistic concerning expected treatment results. Interestingly, two thirds of the patients who ever treated their disease find it worthwhile.     

Therapeutic options and hot topics in vitiligo with special focus on pediatrics' vitiligo: A comprehensive review study

Vitiligo is a common skin disorder with an estimated worldwide prevalence to 2.28% which is connected with selective melanocytes loss which leads to depigmentation and chalky‐white macules. Vitiligo may be dismissed as a cosmetic problem and may have psychologic impacts on patients. It is occurring in both children and adults and is considered as the most common depigmenting skin disorder in the world. There are still many unknown topics about this disease regarding to its treatment in pediatrics, curable drugs and manifestations. Therefore, we decided to evaluate the recent studies about its therapeutic strategies in pediatrics. Topical therapies should be considered as first line treatment in children, but phototherapy especially NBUVB may be used after topical treatment modalities failure or in extensive or rapidly progressive disease. Our suggestion for the treatment of this disease in children is to use combine treatment modalities with observing safety according to the patient's age.     

Current state of vitiligo therapy – evidence-based analysis of the literature

Vitiligo is a skin disease with a worldwide prevalence ranging from 0.5% to 4%. Conservative therapies include photochemotherapy, phototherapy with UVB radiation (broadband UVB 290–320 nm, narrow band UVB 311 nm), systemic steroids and pseudocatalase. Modern therapeutic options include treatment with topical immunomodulators (tacrolimus, pimecrolimus), analogues of vitamin D3, excimer laser and surgery/transplantation. Our analysis compares these therapies for vitiligo and the evidence levels supporting their effectiveness. Conclusions: The face and neck respond best to all therapeutic approaches, while the acral areas are least responsive. For generalized vitiligo, phototherapy with UVB radiation is most effective with the fewest side effects; PUVA is the second best choice.Topical corticosteroids are the preferred drugs for localized vitiligo. They may be replaced by topical immunomodulators which display comparable effectiveness and fewer side effects.The effectiveness of vitamin D analogues is controversial with limited data. Surgical therapy can be very successful, but requires an experienced surgeon and is very demanding of time and facilities, thus limiting its widespread use. L-phenylalanine therapy appears effective on the face but enjoys neither widespread use nor extensive data support. No single therapy for vitiligo can be regarded as the most effective as the success of each treatment modality depends on the type and location of vitiligo.     

308-nm excimer laser for the treatment of localized vitiligo

BACKGROUND AND OBJECTIVE: Vitiligo is commonly treated with PUVA, and more recently, narrow-band UVB (NBUVB) phototherapy. Given the proximity of the wavelengths of NBUVB (311 nm) and the excimer laser (308 nm), we undertook a clinical trial to test the efficacy of this device. METHODS: Twice-weekly 308-nm UV-B radiation was given to selected vitiligo lesions for a maximum of 60 treatments. These lesions had been unsuccessfully treated previously with at least one other method of treatment. Initial doses were 100 mJ/cm2 with increments of 10-25%. Improvement was assessed on a visual scale via serial photographs. RESULTS: Subjects tolerated the treatment well. Improvement varied with body site. After 60 treatments, lesions on the hands and feet showed grade 2 improvement in 2/10 subjects and grade 1 in 8/10. For the axillae, there was grade 4 improvement in 1/3 subjects and grade 2 improvement in 2/3 by treatment 60. The face demonstrated the most rapid repigmentation with grade 4 repigmentation seen in 3/5 subjects by 40 treatments and grade 3 in 2/5 by 30 treatments. There were no adverse effects. CONCLUSIONS: The user-friendly 308-nm excimer laser allows targeted treatments of localized vitiligo.     

Calcipotriene and corticosteroid combination therapy for vitiligo

Corticosteroids and photochemotherapy, using a combination of psoralen and ultraviolet A (PUVA) exposure, are the most widely prescribed therapies for vitiligo. These treatments are not uniformly effective and many patients have inadequate responses. Calcipotriene has been shown to be effective in adults and children with psoriasis when used as monotherapy and in combination with corticosteroids and phototherapy. We hypothesized that since the mechanisms of action for calcipotriene and corticosteroids are different, patients may develop more repigmentation with a combination of the two agents, while decreasing the side effects from both agents. Twelve patients with vitiligo (average age 13.1 years) were advised to use topical corticosteroids in the morning and topical calcipotriene in the evening. Of the 12 patients, 83% responded to therapy, with an average of 95% repigmentation by body surface area. Four of the patients who responded had previously failed trials of topical corticosteroids alone. All of the patients in this group had repigmentation. Eyelid and facial skin responded best to this therapy. None of the patients had adverse reactions to the treatment. Our results show that topical calcipotriene in combination with corticosteroids can repigment vitiligo, even in those patients who were previous topical corticosteroid failures.     

Two therapeutic challenges: periocular and genital vitiligo in children successfully treated with pimecrolimus cream

Vitiligo is characterized by the selective destruction of melanocytes resulting in patches of skin depigmentation. Vitiligo is a therapeutic challenge. Eyebrows, eyelids and genital vitiligo are a therapeutic dilemma, especially in children. The possible side effects of topical corticosteroids and the difficulties for choosing any other adequate treatment option are a major concern. We present two children, one with vitiligo of the eyelids and the other with genital vitiligo, both treated with pimecrolimus 1% cream with almost full repigmentation of the lesions, showing pimecrolimus could be an adequate option for the treatment of vitiligo for these special vitiligo areas in children.     

Topical methotrexate 1% gel for treatment of vitiligo: A case report and review of the literature

Vitiligo is quite a common hypopigmentary disorder, which may affect both children and adults with important psychological effects due to the well‐known leopard skin‐like appearance. Even if asymptomatic and not life threatening, vitiligo has to be increasingly studied and treated. Hitherto, the efficacy of topical methotrexate in treatment of vitiligo has not been reported. We herein reporting our preliminary observation on the promising efficacy of topical methotrexate in one patient with stable vitiligo. The patient applied topical methotrexate 1% gel twice daily for 12 weeks. Significant improvement of the lesion with no local or systemic side effects were noted during the course of therapy. We propose that this well‐tolerated drug can be used for vitiligo therapy; however, further investigations should be performed to ascertain the exact topically effective dose.     

Effects of autologous micrografts on stable bilateral vitiligo: A focus on hand lesions

Vitiligo is an autoimmune skin disorder characterized by depigmented patches of the skin associated with, among several factors, dysregulation and death of melanocytes. Currently, the treatment of vitiligo is based both on the arrest of the progression of active disease and on the stimulation of the skin repigmentation. The aim of this study was to assess the effects of autologous micrografts and narrowband ultraviolet B (NBUVB) phototherapy for skin repigmentation of patients with bilateral stable vitiligo. Autologous micrografts are derived from mechanical disaggregation of small pieces of the patient’s own skin, while phototherapy is a strategy treatment already used. Twenty patients with stable bilateral vitiligo were treated, showing a mean percentage rate of 59.1% at baseline. Combined treatment by autologous micrografts and NBUVB was performed only on the lesions of the hands, and the clinical follow up was performed after 3 and 6 months by photographs taken under Wood’s light. After 6 months, we classed 100% of patients as responders. We also reported a mean of repigmentation rate of 36.7% after 3 months and 64.6% after 6 months of treatment. In particular, six of the 20 patients reached a marked repigmentation rate (75–100%), four moderate (51–75%) and 10 mild (26–50%). No adverse effects were observed and no drugs were administrated as co-adjuvant therapy. These results are suggestive of a potential wide use of autologous micrografts associated with NBUVB phototherapy for the treatment of stable vitiligo.