I want to know what are the best vitiligo treatments? Can someone help me figure it out?
Which Vitiligo Treatments Work?
Doctor Answers (2)
Treatments For Vitiligo
Vitiligo is caused by the loss of melanocytes, the pigment-making cells, of the skin. It consists of well-defined white patches in normal skin. Usually there are a few, large, irregularly- shaped areas rather than many small patches. Vitiligo is slowly progressively, although it may remain static or even show areas of repigmentation. It is obviously more noticeable in patients with dark skin types for whom it can be a major cosmetic problem. Most authorities now feel it is auto-immune, ie the body is producing antibodies which are wiping out the melanocytes. For this reason it is associated with other auto-immune disorders such as pernicious anemia, Addison's Disease, Hashimoto's thyroiditis, etc.
Vitiligo has been one of the more difficult conditions for us dermatologists to treat. A number of newer therapies have augmented the traditional therapies of the past.
Vitiligo, when it is diagnosed early and treated, can be reversed about fifty per cent of the time. The commanding word here is if. In its early stages this can be difficult to diagnose. My feeling is that, if there is any suspicion that we are dealing with vitiligo, topical therapy should be initiated.
Topical therapy would include a mid to even potent steroid cream (not if the vitiligo is on the face.) The calcineurin inhibitors Protopic or Elidel can also be used either in a regimen with steroids or by themselves. In fact in recent years a number of studies have shown these to effective and safe and they have advanced to become first-line treatment for limited vitiligo.
These agents have an advantage over steroid creams in that they do not thin the skin and can be used readily on the face and groin. Unfortunately, a few years ago the FDA slapped a black box warning on them, so they should not be used for too long a stretch or in children under 2.
Vitamin D, which we covered in one of our recent radio shows, has increasingly been shown to have antioxidant and photoprotective effects. It also stimulates the maturation of melanocytes and increases the tyrosinase enzyme, which we try to block with Hydroquinone and Arbutin.
However, when Vitamin D analogues are used alone the results are disappointing. Combined with sunlight, phototherapy, or steroids, we have a whole other thing. They can work. Thus, Taclonex, a combo drug is quite effect for vitiligo. It is too early to see whether Vectical, a recently released Vitamin D analogue (like Vitamin D), may work. Hopefully, Galderma, its maker, will sponsor such a study.
As far as light sources: narrow band UVB is enjoying success as a treatment for this curious entity. An article in last month's. Indian Journal of Dermatology, demonstrated marked success with this treatment. A good response can be achieved even in patients with extensive involvement. This is a very well tolerated procedure. Narrow Band UVB seems to be even more effective than that mainstay of vitiligo treatment PUVA ( psoralen, a pill, and UVA light).
Speaking of light, targeted light therapy is another effective option for treating vitiligo. The Excimer laser targets the affected skin with a high-intensity light but avoids exposure to normal skin. Rapid therapeutic responses are seen; cumulative UV exposure is limited. It is best to use this therapy with one of the previously described topical treatments. IPL using the UVB device works similarly and in my hands has been as effective and far cheaper. This is important since insurance companies (except one) do not cover this treatment.
That fascinating fern, Polypodium Leucotomos, from which we get the photoprotective drug, Heliocare, is enjoying a resurgence of interest. It developed a following in the 1980's for the same purpose. This plant has anti-tumor and anti-inflammatory properties. A recent study showed that combining this fern with PUVA, worked better than PUVA alone.
Gleevac, Imatinib Mesylate, a drug used to treat leukemia has had a number of interesting side effects. It can turn gray hair brown but ironically can depigment the skin. One of its derivatives may see use as a depigmenting agent. Depigmenting agents are used by dermatologists when the skin is so marred by hypo-pigmentation it looks better to make the patient all white rather than speckled.
Finally, there have been advances in the surgical treatment of vitiligo. This is used for stable disease or disease that has not responded to the above measures. Available procedures include suction blister grafts (suctions pull the top layer of skin off and this is grafted onto the vitiligo areas), melanocyte transfer, punch grafts, and sheet grafts In another technique melanocytes are taken from the patient, cultured out and then transplanted onto the vitiligo site.
Recently, surgeons have been using something called the ReCell. This is a single -use battery-operated, cell harvesting system. The cell suspension is then sprayed onto the affected areas of skin much like the spraying in a self-tanning booth.
I hope this explains some of the options available for treating this vexing condition.
Treatments for vitiligo
Treamt of vitiligo is often a challenge and can require patience and persistence. Not all treatments work for every patient and some vitiligo can be very difficult to treat. It is important to consult with a board-certified dermatologist to diagnose and treat vitiligo.
Vitiligo that has been present for many years is often more difficult to treat than newer areas. Some areas of the body (like the hands and feet) are more difficult to treat, while other areas (like the face or eyelids) may respond better to treatment.
Initial therapy is often with topical creams like steroids or immune modulators (Protopic or Elidel). These usually require at least several months of use to see benefit and need to be monitored since they can have side effects.
More aggressive therapies include ultraviolet treatment (PUVA or narrow-band UVB) or excimer laser done at the dermatologist's office. These are often more effective than creams alone but still do not work for everyone and generally require at least 50 treatments (usually treatments are 3 times per week) to see if they are going to work.
Specialized centers may offer more uncommon or aggressive treatments like punch grafts.