Treatment Options for Vitiligo

I. Repigmentation Therapy

A. Topical Corticosteroid
Corticosteroid creams or ointments of varying strengths may be prescribed for the treatment of vitiligo. The strength of the cream or ointment is determined by the age of the patient as well as the location of the lesion(s). For example, lower strength corticosteroids are used in children whereas higher strength corticosteroids are prescribed in adults. In addition, when ultra-potent corticosteroids such as Temovate are prescribed, limited areas of involvement are treated. Chronic use of potent topical corticosteroids may result in atrophy (thinning) of the skin. This is manifested by telangiectasias (broken blood vessels) and a transparent appearance to the skin. Therefore, both the patient and the physician must check areas of application for hese signs. If irritation is noted following the use of any of these creams, they should be discontinued and you should notify our office.

B. Topical PUVA
An ointment containing 8-methoxypsoralen (a light sensitizing agent) is plied to areas of vitiligo 30 minutes prior to ultraviolet A exposure. The ointments applied at the light treatment center by a nurse. We do not allow patients to apply this ointment on their own at home. Topical PUA is used primarily in children or individuals with limited areas of involvement.
We cover the normal surrounding skin with a sunscreen so as to minimize the development of increased pigmentation in this area. Topical psoralen can be rather phototoxic and for that reason, we start at very low doses of ultraviolet A. Compared to oral PUVA, patients treated with topical PUVA have an increased risk of developing erythema and occasionally blisters in the area of treatment. The treatment period may vary from 6-18 months, and we check for evidence of repigmentation, either at the edge of the lesion or around air follicles within the lesion. This type of response is usually seen by 24 treatments. Following the topical use of psoralen at the light treatment center one must wash the area with soap and water and then apply sunscreen to the vitiligo. Sun exposure is avoided for the next 24 hours. Please note that it is recommended that all areas of vitiligo exposed to the sun be covered with sunscreen at all times, not just following light treatments.

C. Oral PUVA
In oral PUVA, one takes a light sensitizing oral medication Oxsoralen-Ultra, and occasionally Trisoralen). Approximately 1 and _ hours following the ingestion of the medication, the patient undergoes exposure to ultraviolet A light. The exposure to ultraviolet light is done in a light treatment center and we recommend that treatment be done twice a week. Treatment time varies from 6-18 months. Small lesions (the size of a nickel) may repigment within 6 months, but larger lesions require longer periods of time. If a light pink color develops in the areas of vitiligo following PUVA treatment, we would like to see evidence of repigmentation by 24 treatments. Repigmentation manifests itself as small round dots of normal skin color around hair follicles within the lesion as well as a contraction in
the size of the lesion. The latter is due to melanocytes (pigment cells) igrating from normal surrounding skin while the dots are due to the migration of melanocytes from hair follicles into previously involved skin. One should be aware that areas such as lips, fingers and toes respond poorly to this treatment. The face and neck have the best response rate while the trunk and extremities have intermediate response rates. Before PUVA is administered, several blood tests must be obtained including liver function tests, renal function tests, complete blood count and antinuclear antibody. For 24 hours following a PUVA reatment, one must wear wrap-around sunglasses that protect against UVA while outside or sitting close to a window. In addition, run bathing is contraindicated for this 24-hour period, and while outside, one should apply a broad-spectrum sunscreen with an SPF f 15. Side effects of PUVA therapy include nausea, headaches, premature aging of the skin and an increased risk of skin cancer. The latter two have been found primarily in patients with psoriasis who receive higher doses of UVA for longer periods of time. While PUVA treatments are being given, the patient may apply cover-ups or selftanning creams. Cover-ups must be removed prior to UVA exposure. In addition, it should be noted that self-tanning creams provide no protection against the sun. They are simply a stain on the dead layerof skin and are not a sunscreen. Patients who have light complexion must be aware that of the fact that their normal skin will hyperpigment (get darker) and therefore, the contrast between normal skin and vitiligo skin will initially be more noticeable than before the treatment.

D. Narrowband UVB
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II. Cosmetics

A. Corrective Make-up
Cover-ups such as Dermablend and Covermark are used to mask theareas of vitiligo by matching the normal color of the skin. These creams are usually used on the face and occasionally on the arms. Use of such cover-ups can be taught to a patient by one of our nurses. Please let us know if you would like to arrange such a session. The one problem with these cover-ups is that with sweating they may run; therefore, it is sometimes difficult to use these creams on the hands.comewhat easier to use and longer lasting are the self-tanning creams such as those made by Estee Lauder and Prescriptives. These creams contain dihydroxyacetone and simply stain the outer or dead layer of the skin. As the dead layer desquamates (peels off), the stain goes with it. Therefore, it mus be reapplied every 5-7 days. It should be noted that these creams provide no sun protection and are simply a camouflage. However, they do not run or come off with sweating and they must be combined with daily sunscreen use. Multiple applications may be required to match skin color.

B. Tattooing
At Howard University in Washington, D.C., Dr. Rebat Halder, (202) 865-6725, offers tattooing of the distal fingertips and lips. A color reprint of his work is available in our department. Please ask if you would like to see it. This treatment will probably require 3-4 visits to Washington, D.C., where more details can be obtained.
III. Depigmentation Theory This is the treatment of choice for patients who have failed PUVA therapy or who have greater than 50% of the body surface area involved with vitiligo. This treatment involves the application of 20% monobenzylether of hydroquinone cream (Benoquin; MBEH) to uninvolved areas of the skin. Application of MGEH results in permanent loss of pigment and can lead to distant sites of depigmentation, i.e., loss of pigment in areas where cream has not been applied. The major side affect of MBEH is local irritation of the skin, which primarily affects uninvolved skin. This manifests itself as redness or itchiness. Because of the possibility of irritation, we initially begin with a test site on one forearm. The medication is applied to a limited area on the forearm once a day. If no irritation occurs after two weeks, the cream is applied twice a day. If no irritation is seen after another two-week period, then the cream can be applied to any area of involvement. IF irritation occurs, please contact us and we will decrease the concentration of the MGEH, usually to 5%. The 5% cream will be tested in the manner as previously described, and if no irritation occurs after several weeks of use, ten we can slowly increase the concentration to find the highest concentration that produces no irritation. An occasional patient will require a concentration greater than 20%. Depigmentation therapy usually requires at least one year of treatment.
Because MBEH is a potent depigmenting agent, it is important that other members of the household not be exposed to the agent. For this reason, we recommend that patients put the cream on at least _ hour before going to bed and wear pajamas, which cover the areas of application. The cream should be applied after sexual relations. Once depigmentation is complete, small areas of repigmentation may occur in chronically sun-exposed areas of the body, especially extensor forearms (tops of the lower arm) and cheeks. This can be reduced by daily application of sunscreen and limiting exposure to the sun. Should this occur, MBEH can be reapplied to these areas. It is important to know that once depigmentation has been achieved, the patient has no protection against the sun and we recommend that sunscreen be worn daily to those areas that are exposed to the sun. The decision to undergo depigmentation therapy is one that should be well thought out by the patient. We can offer counseling with a social worker should a person wish to discuss the implications of having skin of a different color. Patients who choose depigmentation have decided that being one color is preferable to being colors.