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The main goal of treating vitiligo is to improve appearance.
Therapy for vitiligo takes a long time—it usually must be continued for 6 to
18 months. The choice of therapy depends on the number of white patches; their
location, sizes, and how widespread they are; and what you prefer in terms of
treatment. Each patient responds differently to therapy, and a particular
treatment may not work for everyone. Current treatment options for vitiligo
include medical, surgical, and adjunctive therapies (therapies that can be
used along with surgical or medical treatments).
Medical Therapies
A number of medical therapies, most of which are applied
topically, can reduce the appearance of white patches with vitiligo. These are
some of the most commonly used ones:
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Topical steroid therapy—steroid creams may be
helpful in repigmenting (returning the color to) white patches,
particularly if they are applied in the initial stages of the disease.
Corticosteroids are a group of drugs similar to hormones such as
cortisone, which are produced by the adrenal glands. Doctors often
prescribe a mild topical corticosteroid cream for children under 10 years
old and a stronger one for adults. You must apply the cream to the white
patches on the skin for at least 3 months before seeing any results.
Corticosteriod creams are the simplest and safest treatment for vitiligo,
but are not as effective as psoralen photochemotherapy (see below). Yet,
like any medication, these creams can cause side effects. For this reason,
the doctor will monitor you closely for skin shrinkage and skin striae
(streaks or lines on the skin). These side effects are more likely to
occur in areas where the skin is thin, such as on the face and armpits, or
in the genital region. They can be minimized by using weaker formulations
of steroid creams in these areas.
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Psoralen photochemotherapy—also known as psoralen
and ultraviolet A therapy, or PUVA therapy, this is probably the most
effective treatment for vitiligo available in the United States. The goal
of PUVA therapy is to repigment the white patches. However, it is
time-consuming, and care must be taken to avoid side effects, which can
sometimes be severe. Psoralen is a drug that contains chemicals that react
with ultraviolet light to cause darkening of the skin. The treatment
involves taking psoralen by mouth (orally) or applying it to the skin
(topically). This is followed by carefully timed exposure to sunlight or
to ultraviolet A (UVA) light that comes from a special lamp. Typically,
you will receive treatments in your doctor’s office so you can be
carefully watched for any side effects. You must minimize exposure to
sunlight at other times. Both oral and topical psoralen photochemotherapy
are described below.
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Topical psoralen photochemotherapy—often used for people with a
small number of depigmented patches affecting a limited part of the
body, it is also used for children 2 years old and older who have
localized patches of vitiligo. Treatments are done in a doctor’s
office under artificial UVA light once or twice a week. The doctor or
nurse applies a thin coat of psoralen to your depigmented patches
about 30 minutes before exposing you to enough UVA light to turn the
affected area pink. The doctor usually increases the dose of UVA light
slowly over many weeks. Eventually, the pink areas fade and a more
normal skin color appears. After each treatment, you wash your skin
with soap and water and apply a sunscreen before leaving the
doctor’s office.
There are two major potential side effects of topical PUVA therapy:
(1) severe sunburn and blistering and (2) too much repigmentation or
darkening (hyperpigmentation) of the treated patches or the normal
skin surrounding the vitiligo. You can minimize your chances of
sunburn if you avoid exposure to direct sunlight after each treatment.
Usually, hyperpigmentation is a temporary problem that eventually
disappears when treatment is stopped.
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Oral psoralen photochemotherapy—used for people with extensive
vitiligo (affecting more than 20 percent of the body) or for people
who do not respond to topical PUVA therapy, oral psoralen is not
recommended for children under 10 years of age because it increases
the risk of damage to the eyes caused by conditions such as cataracts.
For oral PUVA therapy, you take a prescribed dose of psoralen by mouth
about 2 hours before exposure to artificial UVA light or sunlight. If
artificial light is used, the doctor adjusts the dose of light until
the skin in the areas being treated becomes pink. Treatments are
usually given 2 or 3 times a week, but never 2 days in a row.
For patients who cannot go to a facility to receive PUVA therapy,
the doctor may prescribe psoralen that can be used with natural
sunlight exposure. The doctor will give you careful instructions on
carrying out treatment at home and monitor you during scheduled
checkups.
Known side effects of oral psoralen include sunburn, nausea and
vomiting, itching, abnormal hair growth, and hyperpigmentation. Oral
psoralen photochemotherapy may also increase the risk of skin cancer,
although the risk is minimal at doses used for vitiligo. If you are
undergoing oral PUVA therapy, you should apply sunscreen and avoid
direct sunlight for 24 to 48 hours after each treatment to avoid
sunburn and reduce the risk of skin cancer. To avoid eye damage,
particularly cataracts, you should also wear protective UVA sunglasses
for 18 to 24 hours after each treatment.
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Depigmentation—this treatment involves fading the
rest of the skin on the body to match the areas that are already white.
For people who have vitiligo on more than 50 percent of their bodies,
depigmentation may be the best treatment option. Patients apply the drug
monobenzylether of hydroquinone (monobenzone or Benoquin)
twice a day to pigmented areas until they match the already-depigmented
areas. You must avoid direct skin-to-skin contact with other people for at
least 2 hours after applying the drug, as transfer of the drug may cause
depigmentation of the other person’s skin. The major side effect of
depigmentation therapy is inflammation (redness and swelling) of the skin.
You may experience itching or dry skin. Depigmentation tends to be
permanent and is not easily reversed. In addition, a person who undergoes
depigmentation will always be unusually sensitive to sunlight.
Surgical Therapies
All surgical therapies must be considered only after proper
medical therapy is provided. Surgical techniques are time-consuming and
expensive and usually not paid for by insurance carriers. They are appropriate
only for carefully selected patients who have vitiligo that has been stable
for at least 3 years:
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Autologous skin grafts—the doctor removes skin from
one area of your body and attaches it to another area. This type of skin
grafting is sometimes used for patients with small patches of vitiligo.
The doctor removes sections of the normal, pigmented skin (donor sites)
and places them on the depigmented areas (recipient sites). There are
several possible complications of autologous skin grafting. Infections may
occur at the donor or recipient sites. The recipient and donor sites may
develop scarring, a cobblestone appearance, or a spotty pigmentation, or
may fail to repigment at all. Treatment with grafting takes time and is
costly, and many people find it neither acceptable nor affordable.
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Skin grafts using blisters—in this procedure, the
doctor creates blisters on your pigmented skin by using heat, suction, or
freezing cold. The tops of the blisters are then cut out and transplanted
to a depigmented skin area. The risks of blister grafting include scarring
and lack of repigmentation. However, there is less risk of scarring with
this procedure than with other types of grafting.
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Micropigmentation (tattooing)—this procedure
involves implanting pigment into the skin with a special surgical
instrument. This procedure works best for the lip area, particularly in
people with dark skin. However, it is difficult for the doctor to match
perfectly the color of the skin of the surrounding area.
The tattooed area will not change in color when exposed to sun, while
the surrounding normal skin will. So even if the tattooed area matches the
surrounding skin perfectly at first, it may not later on. Tattooing tends
to fade over time. In addition, tattooing of the lips may lead to episodes
of blister outbreaks caused by the herpes simplex virus.
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Autologous melanocyte transplants—in this procedure,
the doctor takes a sample of your normal pigmented skin and places it in a
laboratory dish containing a special cell-culture solution to grow
melanocytes. When the melanocytes in the culture solution have multiplied,
the doctor transplants them to your depigmented skin patches. This
procedure is currently experimental and is impractical for the routine
care of people with vitiligo. It is also very expensive, and its side
effects are not known.
Additional Therapies
In addition to medical and surgical therapies, there are many
things you can do on your own to protect your skin, minimize the appearance of
white patches, and cope with the emotional aspects of vitiligo:
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Sunscreens—people who have vitiligo, particularly
those with fair skin, should minimize sun exposure and use a sunscreen
that provides protection from both the UVA and UVB forms of ultraviolet
light. Sunscreen helps protect the skin from sunburn and long-term damage.
Sunscreen also minimizes tanning, which makes the contrast between normal
and depigmented skin less noticeable.
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Cosmetics—some patients with vitiligo cover
depigmented patches with stains, makeup, or self-tanning lotions. These
cosmetic products can be particularly effective for people whose vitiligo
is limited to exposed areas of the body. Dermablend, Lydia O’Leary,
Clinique, Fashion Flair, Vitadye, and Chromelin offer makeup or dyes that
you may find helpful for covering up depigmented patches. Selftanning
lotions have an advantage over makeup in that the color will last for
several days and will not come off with washing.
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Counseling and support groups—many people with
vitiligo find it helpful to get counseling from a mental health
professional. People often find they can talk to their counselor about
issues that are difficult to discuss with anyone else. A mental health
counselor can also offer support and help in coping with vitiligo. In
addition, it may be helpful to attend a vitiligo support group.
Reference:
National Institute of Arthritis and
Musculoskeletal and Skin Diseases, USA.
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