Considerations for Different Vitiligo Treatment Strategies

David Rosemary, MD: There are different types of light therapy. The most common type is narrowband UVB [ultraviolet B], which is a light box that patients will step into, where they will be highlighted anywhere from seconds to minutes. They build the time they spend there. It turns out that it’s not the frequency of phototherapy visits that determines how patients function; is the total number of visits. Patients can go to the phototherapy booths twice a week and have a similar response to patients who get it 3 times a week. However, it will take longer to achieve their goal. But we usually don’t like to do this less than twice a week, and we maximize the time patients spend in the photo booth, depending on their skin type. People with darker skin will stay there longer. People with lighter skin will stay there for a shorter period.

This is one of our first line treatments for Vitiligo patients, especially if it is widespread and if it is very widespread in the body. We often protect their eyes and sometimes their genitals if they are not involved. It does not work well in areas with hair, if the patient is wrapping it over the scalp or in other hair areas, because it is difficult for light to penetrate those spots.

Another treatment, which is very similar to narrowband UVB but more localized, is the excimer laser. This is also a specific wavelength similar to what we offer in narrowband UVB but above the laser, so we can only process one spot or a few points. This is especially good for topical diseases, where patients may not want to expose the light to their entire body, but we prefer to do this over stable plaques. If patients are getting new places elsewhere, we want to treat those with a full-body phototherapy cabin. The third most common type of light therapy is PUVA [psoralen with ultraviolet A], where patients take a photosensitizer and then get UVA light that activates that photosensitizer for treatment. Since there are more adverse effects, this treatment has not been done as often as it has been in years. But these are the three main types of light therapy: narrowband UVB, excimer laser, and PUFA.

What are our common repigmentation treatments? Most often, we start patients with a combination of corticosteroids plus topical calcineurin inhibitors. Corticosteroids have been shown to work on some patients, but we have to be careful how we use them. Because vitiligo re-pigmentation takes so long, steroids are not ideal as they have adverse effects when used long term, such as skin thinning, skin atrophy, skin lightening, stretch marks, and telangiectasias. This is especially true if we use it on areas where there is thinner skin, such as the face, where we have to limit the strength of the corticosteroid and the length of time we use it. This is true around the eyes, because the eyelid skin is very thin and corticosteroids around the eyes can lead to cataracts or glaucoma.

Although corticosteroids are our first line of treatments and are certainly good for the body, calcineurin inhibitors are also commonly used, especially for sensitive areas of the skin, such as the face and eyelids. Although the calcineurin inhibitors in our studies can work well for re-pigmentation of facial vitiligo, they certainly do not work for everyone. Because they are so bulky, they also don’t penetrate into areas where there is thicker skin, such as the body, trunk, and arm. It is very good for sensitive areas, such as the genitals, face and armpits, but not so good for those areas with thicker skin, which often have vitiligo. So we need to use a combination.

Text has been edited for clarity.