Treating vitiligo: Expanding list of options advances therapy for wide range of patients

November 1, 2008

Vitiligo in patients with skin of color can have devastating psychosocial consequences. A variety of newer therapeutic options are improving management for patients with disease manifestation ranging across the spectrum, from localized to general.

Key Points

Dr. Grimes is a leading vitiligo researcher who has conducted multiple studies to elucidate disease pathogenesis and the efficacy, safety and mechanism of action of new therapeutic modalities.

"Vitiligo is an equal-opportunity disorder that occurs with a similar prevalence regardless of skin type. However, it is the most psychologically devastating of all common skin disorders in darker-skin patients," she says.

Treatment selection for vitiligo depends on the body surface area of involvement. For patients with limited disease (less than 15 percent body surface area), several topical therapy options exist, including corticosteroids, calcipotriol and topical immunomodulators.

"In 2002, our seminal work documented the efficacy and safety of topical calcineurin inhibitors for the treatment of vitiligo, and the value of these agents for achieving repigmentation has been subsequently confirmed in other studies," Dr. Grimes tells Dermatology Times.

Topical immunomodulators are an integral part of Dr. Grimes' therapeutic armamentarium, and available research suggests the greatest benefit is achieved when using these agents on the face and neck.

Dr. Grimes says vitiligo patients are very savvy and well informed, and they are concerned about long-term safety issues.

"Discuss the 'black box' warning with patients. Although there is no evidence from clinical or epidemiological studies that the risks of cancer are increased after exposure to topical calcineurin inhibitors, it is important to educate your patients," Dr. Grimes says.

Targeted phototherapy

Targeted phototherapy is another important option for treating limited areas of skin involvement, and multiple laser and light units are available for this purpose, including 308 nm excimer laser units, high-intensity filtered UVB (290 nm to 320 nm) sources, and devices that have both UVA and UVB modes.

Dr. Grimes says the combination unit is a workhorse in her center, where she uses it for topical PUVA using oxsoralen in a dilute concentration of 0.001 percent or 0.01 percent.

"The results achieved are very nice and sometimes substantially better than with the excimer laser alone," she says.

When vitiligo affects more than 15 to 20 percent of body surface area, narrowband UVB (311 nm to 313 nm) has moved to the forefront as the treatment of choice.

"Now, I limit my use of PUVA to patients whose disease is resistant to narrowband UVB. PUVA is certainly effective, but narrowband UVB is a much easier treatment, with fewer side effects," Dr. Grimes says.

Combination therapies

Several recent studies have examined use of narrowband UVB in combination with topical treatments. One controlled trial showed no benefit for adding topical tacrolimus compared with narrowband UVB alone, whereas two open-label studies reported a response when adding pimecrolimus or tacrolimus.

However, Dr. Grimes warns of the potential increased risk of skin cancer when combining these treatments. She does not personally use this dual regimen.

However, narrowband UVB combined with oral polypodium leucotomos extract A appears to be useful, based on results of a randomized study comparing the combination approach versus narrowband UVB alone.

In that trial, only the group receiving narrowband UVB with polypodium leucotomos extract A achieved significant repigmentation.

Other therapies

There also appears to be benefit from antioxidant supplementation in combination with narrowband UVB, based on evidence that oxidative stress is involved in the pathogenesis of vitiligo.

Based on positive clinical trial data, Dr. Grimes says she has been treating vitiligo patients with vitamins E and C, coenzyme Q10, folic acid, vitamin B12, a high-potency multivitamin and alpha lipoic acid.

Surgical therapy is considered for patients with focal and/or segmental vitiligo that is stable and unresponsive to medical therapies.

Dr. Grimes says she favors autologous punch grafts, using a 1 mm punch. However, a new technique - not yet available in the United States - is expected to make grafting easier. Known as ReCell, it involves harvesting of autologous cells via a split-thickness skin graft, immediate tissue processing to create an expanded cell population and placement onto dermabraded skin.

Depigmentation may be considered if the patient is refractory to all other options or has extensive disease and no desire for repigmentation.

However, because monobenzyl ether of hydroquinone is no longer on the market, a 20 percent formulation must be obtained through a compounding pharmacy.

Disclosure: Dr. Grimes has no financial relationships with commercial interests.