Vitiligo: A Practical Review

The authors of this clinical practice article summarize the subtypes, natural history, and treatment of vitiligo, a common and disfiguring disease marked by loss of epidermal melanocytes. Vitiligo has a worldwide prevalence of 0.5%; half of all patients present before 20 years of age. Diagnosis is clinically based, with Wood’s lamp examination helpful in patients with lighter skin. Skin biopsy is rarely needed.

Nonsegmental vitiligo (NSV; aka generalized vitiligo) and segmental vitiligo (SV) differ clinically and in their responsiveness to treatment. SV is localized to a bandlike or segmental region (often on the face), has an earlier onset, and accounts for approximately 30% of childhood cases. SV has a rapid onset and stabilization and generally has a better prognosis than does NSV. Nevus depigmentosus (congenital nonprogressive hypopigmented macules) can be mistaken for SV. NSV accounts for up to 90% of all cases of vitiligo. This subtype can present in childhood, but later onset is more common. NSV is often chronic, progressive, and relapsing, and it is often associated with a personal or family history of autoimmunity. NSV commonly occurs symmetrically, at sites of pressure, friction, or trauma.

The treatment of choice for widespread NSV is narrow-band UVB (NB-UVB), which has proven to be more effective than photochemotherapy (psoralen and ultraviolet A radiation [PUVA]). Three months of twice-weekly NB-UVB treatment must be administered before the disease is determined to be unresponsive. The duration of vitiligo is inversely proportional to its response to NB-UVB. Facial vitiligo responds best to this treatment; hands and feet respond poorly. However, two thirds of cases relapse within 1 year. Topical therapies (corticosteroids and tacrolimus) are commonly used for localized vitiligo. Topical tacrolimus is valuable for facial vitiligo to avoid steroid-related atrophy, and topical and NB-UVB therapies may be combined. Surgical therapies, including autologous minigrafts, can be used for focal, stabilized lesions, but response is variable. Camouflage techniques are valuable; they include cosmetics, skin dyes, and sunless self-tanning lotions that contain dihydroxyacetone (DHA), which usually lasts 5 to 7 days from application. Chemical or laser depigmentation is reserved for carefully selected patients with extensive disfigurement, but, again, results vary.