Clinical Pearls for the Management of Vitiligo

Amit G. Pandya, MD, FAAD: The most important messages I would give to health care providers who are seeing patients with vitiligo is, No. 1, to listen to the patient. Find out what they want to achieve with the treatment of their vitiligo, and express to them that it takes a while to see that improvement. I ask the patient to commit to about 9 months of treatment to see a difference. I highly suggest taking baseline photographs, and then seeing the patient every 2 to 3 months and taking photographs at every visit, so that you can see the 10% or 20% improvement in the lesions. If you don’t do that, it’ll be difficult for you to determine if there’s been 10% or 20% improvement, and certainly for the patient to determine that, which often causes pessimism and then abandoning treatment. When you see that improvement in the photographs, you will be motivated with future patients and will understand how vitiligo can be repigmented if you have patience and the right outlook in terms of expectations for treatment.

I also recommend that health care providers look for signs of activity such as confetti-like lesions, trichrome lesions, and the Koebner phenomenon, because patients who have those lesions must be treated aggressively. Perhaps they need oral mini-pulse dexamethasone, phototherapy, and topicals, all combined to stop it from spreading, because those patients are in danger of rapidly worsening vitiligo. Finally, I recommend that health care providers give support to patients and talk to them about the psychological effects of vitiligo. If you find that the patient appears to be depressed or having significant psychological issues, perhaps recommend counseling, or referring them to a psychiatrist to help them deal with this condition while they’re undergoing treatment.

Often, patients ask me if they’ll be on phototherapy forever, or if they must be on this pill or these creams forever. I tell them that their vitiligo will improve, but at some point, they will hit a plateau. In other words, they will come in one day and they will not be any better than their last visit. At that point, I move into maintenance therapy. If they’re on phototherapy 3 times a week, I drop them to twice a week for a month, then once a week for a month, and then once every other week for 2 months, and see if the vitiligo returns. If it doesn’t, I stop phototherapy. If it does come back, I put them on a maintenance therapy perhaps once a week, so that the vitiligo can be stable.

This is the same with topical therapy. Once they have reached maximum repigmentation, I drop the topical therapy. For example, topical steroids, especially the strong ones, I typically give them once a day, 5 days per week, Monday through Friday, when I’m trying to repigment. For maintenance therapy, I drop down to twice a week, and that includes topical steroids. For topical immunomodulators, such as tacrolimus and pimecrolimus, I usually use twice a day. But once again, for maintenance therapy, I’ll drop to twice a week in the areas where they have vitiligo, and the areas where they used to have vitiligo, so it doesn’t return. This maintenance therapy is very important.

I also give all my patients information about great web resources where they can get more information, good information, about vitiligo. There are many sites on the web with confusing messages about vitiligo. I send them to good locations such as the Global Vitiligo Foundation website, where they can get accurate, up to date, scientifically based information about vitiligo to guide their treatment.

Transcript Edited for Clarity