Vitiligo: Diagnosis and treatment

How do dermatologists diagnose vitiligo?

If your dermatologist suspects that you have vitiligo, your dermatologist will:

• Review your medical history, and may ask specific questions, such as whether anyone in your family has vitiligo

• Perform a physical exam, looking carefully at the affected skin

You also may need a blood test to check the health of your thyroid gland. People who have vitiligo often have thyroid disease. A blood test will tell whether your thyroid is healthy. If you have thyroid disease, treatment can successfully control it.

How do dermatologists treat vitiligo?

If you have vitiligo and want to treat it, you should discuss treatment options with a dermatologist. There are many treatment options. The goal of most treatments is to restore lost skin color.

Here are some key facts about treatment options to help you start a conversation with a dermatologist. The type of treatment that is best for you will depend on your preference, overall health, age, and where the vitiligo appears on your body. Some people choose not to treat vitiligo.

1. No medical treatment (use cosmetics to camouflage lost color)

   • Cosmetic options include makeup, self-tanners, and skin dyes.
   • Offers safe way to make vitiligo less noticeable.
   • Often recommended for children because it avoids possible side effects from medicine.
   • Must be repeatedly applied, can be time-consuming, takes practice to get a natural-looking result.

2. Medicine applied to the skin

   • Several different topical (applied to the skin) medicines can add color to your skin.
   • Prescribed for small areas.
   • The most commonly prescribed medicine is a potent or super-potent corticosteroid that you apply to your skin. About half, 45%, of patients regain at least some skin color after 4 to 6 months.
   • A corticosteroid that you apply to your skin may be combined with another medicine to improve results.
   • This option works best in people with darkly pigmented skin.
   • These medicines are most effective on certain areas of the body, such as the face. They are least effective on the hands and feet.
   • Some of these medicines should not be used on the face because of possible side effects.
   • These medicines have possible side effects, so patients must be carefully monitored. A possible serious side effect of using of a topical corticosteroid for a year or longer is skin atrophy. This means the skin becomes paper thin, very dry, and fragile.

3. Light treatment

   • Uses light to restore lost color to the skin.
   • Patient may sit in a light box or receive excimer laser treatments.
   • Light boxes are used to treat widespread vitiligo; lasers are used to treat a small area.
   • Works best on the face; least effective on hands and feet.
   • Effective for many patients; about 70% see results with an excimer laser.
   • Results can disappear. About half, 44%, see results disappear within 1 year of stopping treatment. After 4 years, about 86% lose some color restored by treatment.
   • May cause patients with darkly pigmented skin to see areas of darker skin after treatment, but treated skin usually matches untreated skin within a few months.
   • Requires a time commitment. Patients need 2 to 3 treatments per week for several weeks.
   • May be combined with another treatment such as a corticosteroid that you apply to your skin.

4. PUVA light therapy

   • Uses UVA light and a medicine called psoralen to restore skin color.
   • Psoralen may be applied to the skin or taken as a pill.
   • Can treat widespread vitiligo.
   • About 50% to 75% effective in restoring pigment to the face, trunk, upper arms, and upper legs.
   • Not very effective for the hands or feet.
   • Time-consuming, requiring treatment at a hospital or PUVA center twice a week for about 1 year.
   • Psoralen can affect the eyes, so this treatment requires an eye exam before and after finishing treatment.
   • To help prevent serious side effects, patients are carefully monitored.

5. Surgery

   • May be an option when light therapy and medicines applied to the skin do not work.
   • For adults whose vitiligo has been stable (not changed) for at least 6 months.
   • Not for children.
   • Not for people who scar easily or develop keloids (scars that rise above the skin).
   • Different surgical procedures are available. Most involve removing skin with your natural color or skin cells and placing these where you need color.
   • Can be effective for 90% to 95% of patients.
   • Possible side effects include failure to work, cobblestone-like skin, and infection.

6. Unconventional treatment

   • Some vitamins, minerals, amino acids, and enzymes have been reported to restore skin color in people who have vitiligo.
   • Most have not been studied, so there is no evidence to support these treatments and no knowledge of possible side effects.
   • Ginkgo biloba, an herb, has been studied in a clinical trial. Results from this trial indicate that the herb may restore skin color and stop vitiligo from worsening.
   • In the ginkgo biloba trial, 10 patients given ginkgo biloba had noticeable or complete return of skin color. Two patients taking the placebo (contains no active ingredient) also had noticeable or complete return of skin color.
   • Because some patients taking the placebo regained their skin color, more study is needed.

7. Depigmentation

   • This treatment removes the remaining pigment from the skin.
   • Very few patients opt for this treatment.
   • Removing the rest of the pigment leaves a person with completely white skin.
   • It may be an option for an adult who has little pigment left and other treatment has not worked. Removing the remaining pigment can be an effective way to even out the skin color, giving the person white skin.
   • To remove the remaining color, you'd apply a cream once or twice a day. This cream gradually removes the remaining color from your skin.
   • Depigmentation can take 1 to 4 years.
   • Once treatment is finished, some people see spots of pigment on their skin from being out in the sun. To get rid of these spots, you can use the cream to remove this color.

Outcome

It is not possible to predict how a patient will respond to treatment. It is important to keep in mind that no one treatment works for everyone. Results can vary from one part of the body to another. Combining two or more treatments often gives the best results.

Treatment Q&A

Q: Can a child with vitiligo be treated? A: Yes, but some treatments are not appropriate for children. The following may be an option for a child:

• Medicine applied to the skin.

• PUVA that uses psoralen applied to the skin. PUVA therapy that uses the psoralen pill is usually not recommended until after 12 years of age. Even then, the risk and benefits of this treatment must be carefully weighed.

• For children with extensive vitiligo, a dermatologist may recommend narrowband UVB light treatments.

Q: Are researchers looking for more effective treatment? A: Yes. They are studying the genes involved in vitiligo. Researchers believe that by identifying all of the genes involved in vitiligo, they will learn what destroys the cells that give skin its color. With this knowledge, it should be possible to develop better treatments. One of the key goals of this research is to develop a treatment that will permanently stop the skin from losing color.

Related AAD resources

• Is vitiligo a medical condition?

• Vitiligo discomfort stops with sunscreen use

References
Gawkrodger DJ, Ormerod AD, Shaw L et al. “Guideline for the diagnosis and management of vitiligo.” Br J Dermatol 2008; 159: 1051-76.

Grimes PE, “Vitiligo.” In: Kelly AP and Taylor SC, editors. Dermatology for Skin of Color, China, McGraw-Hill; 2009. p. 317-23.

Halder RM, Taliaferro SJ. “Vitiligo.” In: Wolff K, Goldsmith LA, Katz SI, et al. editors. Fitzpatrick’s Dermatology in General Medicine, 7th ed. United States of America, McGraw Hill Medical; 2008. p.616-21.

Linthorst Homan MW, Spuls PI, de Korte J et al. “The burden of vitiligo: patient characteristics associated with quality of life.” J Am Acad Dermatol 2009; 61: 411-20.

Nicolaidou E, Antoniou C, Stratigos A et al. “Narrowband ultraviolet B phototherapy and 308-nm excimer laser in the treatment of vitiligo: a review.” J Am Acad Dermatol 2009; 60: 470-7.

Ortonne JP, “Vitiligo and other disorders of hypopigmentation.” In: Bolognia JL, Jorizzo JL, Rapini RP, et al. editors. Dermatology, 2nd ed. Spain, Mosby Elsevier; 2008. p. 913-20.

Whitton ME, Ashcroft DM, Gonzalez U. “Therapeutic interventions for vitiligo.” J Am Acad Dermatol 2008; 59: 713-7.