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Vitiligo Task Force Issues Consensus Recommendations on Diagnosis, Management

ReachMD Healthcare Image
12/18/2023
dermatologyadvisor.com

The international Vitiligo Task Force has issued up-to-date evidence-based recommendations for the diagnosis and management of patients with vitiligo. Part 2 of the position statement, which outlines specific current and emerging treatment modalities, was published in the Journal of the European Academy of Dermatology & Venereology.

In the position statement, the Task Force presented treatment recommendations based on the most recent evidence for the use of topical therapies, including steroids, topical calcineurin inhibitors (TCIs), and Janus kinase (JAK) inhibitors, as well as systemic therapies, such as steroids and other systemic immunomodulating and antioxidant agents. Phototherapy modalities, including narrow-band ultraviolet-B (NB-UVB) therapy, photochemotherapy, excimer devices, and home phototherapy, were assessed. Interventional approaches and depigmentation strategies for specific indications were also discussed, as was the status of innovative and targeted therapies in development.

The consensus recommendations were made by a consortium of 42 international experts and 4 patient representatives. The recommendations were discussed and finalized at 2 meetings in April and September 2022. In introducing their recommendations, the task force cautioned, “It should be noted that many vitiligo therapies are not licensed and can only be prescribed ‘off label.'”

Topical Corticosteroids

Topical corticosteroids (TCSs) are recommended for patients with vitiligo, especially in those with extrafacial locations and limited treatment areas. TCSs are generally regarded as more effective for stabilizing vitiligo vs repigmentation, although there is no clear evidence, the task force noted.

Although strategies that provide complete clearance will warrant further research, this should not discourage dermatologists and patients from treating vitiligo, as disease stabilization is within reach in most cases.

Once-daily application of potent TCSs is recommended for adults and children who have limited skin involvement. Local side effects, such as skin atrophy, telangiectasia, hypertrichosis, acneiform eruptions, and striae can be reduced with an intermittent treatment approach (incorporating treatment breaks) and will allow for longer treatment periods. TCSs are considered safe for children if they are used continuously for no longer than 2 to 4 months. Long-term treatment may be needed for maintaining repigmentation.

Topical Immunomodulators

TCIs are considered to be the first-line treatment option for adults and children with limited involvement, particularly for lesions in the face, neck, and body folds with thin skin. While no differences in efficacy were found in patients treated with TCIs vs TCSs, use of TCIs may be less effective for the management of extrafacial lesions. TCIs have a more favorable topical safety profile than potent TCSs, especially in terms of the risk for skin atrophy.

TCIs are effective when longer use of potent TCSs is contraindicated, and a twice-daily application can be used. TCIs are recommended initially for 6 months, and when they are effective, patients can receive treatment for 12 months or longer. Combination therapy with TCIs plus ultraviolet (UV) light can be considered for optimal repigmentation. To date, researchers conducting clinical vitiligo trials have found that TCIs are not associated with significant systemic immunosuppression; skin infections; or increased risk for skin cancer and other malignancies, including lymphoma.

Topical JAK Inhibitors

Ruxolitinib, a topical JAK inhibitor, is the first treatment approved for repigmentation in patients with vitiligo. In 2 randomized, double-blind phase 3 studies, researchers found improved response rates in ruxolitinib-treated patients compared with placebo, although adverse events such as application-site acne and pruritus occurred.

NB-UVB Phototherapy

Phototherapy is an essential component of effective treatment for vitiligo; however, patient awareness and compliance are key for optimal results.

NB-UVB is recommended as first-line therapy for widespread or rapidly progressive disease and for total body UV treatment. Excimer lamp or laser 308-nm UV sources are recommended for patients with limited vitiligo. Early initiation of NB-UVB is also recommended.

Phototherapy has been used in those as young as 3 years of age when assisted by a parent or nurse. To limit cumulative exposure risks in children and adults, it is recommended that phototherapy be discontinued if no improvement is observed after 3 months or if results after 6 months of treatment are unsatisfactory. Erythema and xerosis have been the most frequently reported acute adverse effects of NB-UVB therapy; however, there appears to be no significant association between NB-UVB therapy and basal cell carcinoma, squamous cell carcinoma, or melanoma.

Photochemotherapy

In photochemotherapy, oral psoralen plus ultraviolet A therapy (PUVA) is not recommended. Topical PUVA or topical PUVA of solar origin (PUVA SOL) therapy can be used to treat localized lesions; these approaches avoid certain systemic complications associated with oral psoralen, such as gastralgia and nausea. Erythema and skin phototoxicity are the most common side effects associated with the use of topical PUVA or topical PUVA SOL therapy. The possible association of these techniques with an increased risk for skin cancer warrants further investigation.

Excimer Devices

Excimer laser and lamp therapy have similar efficacy, may be superior to NB-UVB, and have a shorter treatment duration. Excimer devices can be used in cases of localized disease, but the treatment process may be time-consuming for patients and clinicians when they are used to treat large areas. The safety and tolerability of excimer laser therapy are comparable to those of NB-UVB, although the cost is often greater. Acute adverse effects include erythema and blistering; the risk for such events is most likely operator-dependent.

Home Phototherapy

Home phototherapy is advantageous because patients can avoid having to make multiple visits to phototherapy centers. However, limitations include the shortage of home phototherapy units, high initial cost, the device’s low energy output over time, lack of mechanical servicing, and patients’ unfamiliarity with the method. Home phototherapy is associated with improved compliance, similar repigmentation outcomes, similar frequency of adverse effects, and lower time investment, but patient satisfaction with this treatment is significantly less compared with in-office treatment.

Systemic Treatments

Systemic treatments for vitiligo include oral steroids and immunosuppressants such as biologics. Oral mini-pulses (OMP) of moderate doses of betamethasone 5 mg or dexamethasone 2.5 mg to 5 mg twice weekly on 2 consecutive days per week are recommended for the management of rapidly progressive vitiligo after careful consideration of the risks and benefits. Treatment is recommended for up to 3 months, with a maximum of 6 months to avoid the risk for adverse effects. While OMP therapy combined with UV exposure may result in a greater degree of repigmentation, safety issues must be considered and discussed with patients. Potential side effects include weight gain, insomnia, agitation, acne, menstrual disturbances, hypertrichosis, growth retardation in children, and immunosuppression; these can be minimized with intermittent, low-dose therapy.

Current & Emerging Systemic Interventions

Although other immunomodulating agents such as methotrexate, cyclosporine, azathioprine, and minocycline may be used in cases of progressive vitiligo, strong evidence is lacking regarding their efficiency and safety. No biologics (such as anti-TNF-α and anti-interleukin-17) are currently recommended for vitiligo.

Antioxidants such as vitamin E, vitamin C, resveratrol, ubiquinone, alpha lipoic acid, panthotenic acid, catalase/superoxide dismutase combination, and Ginkgo biloba have been used alone or in combination with phototherapy in an effort to achieve stabilization and repigmentation of vitiligo lesions, but there is little or no consensus for their use in vitiligo.

Among emerging therapies, systemic JAK inhibitors have shown promise. Several oral JAK inhibitors are in phase 2 trials, and ritlecitinib has been investigated at different doses in a phase 2 trial.

Surgical Interventions and Depigmentation Therapies

Surgery may be an option in patients with segmental vitiligo and other localized and stabilized forms after other medical interventions have failed. Punch grafting, suction blister grafting, noncultured epidermal cellular grafting, and cultured epidermal cellular grafting are available techniques, each of which has its risks and benefits

Among patients with darker skin types in particular, potential sociocultural issues associated with depigmentation therapies should be evaluated before initiating therapy. Topical depigmenting treatments include monobenzyl ether of hydroquinone (MBEH), 4-methoxyphenol, and phenol. MBEH (p-benzyloxy-phenol, monobenzone) is the only topical depigmenting agent approved by the US Food and Drug Administration for treatment of vitiligo.

Cryotherapy and pigment lasers are options for physical depigmentation treatment. The Q-switched ruby laser is more appropriate for patients with lighter skin types, and the Q-switched alexandrite laser has a faster pulse frequency vs the QSR, which may allow for better tissue penetration. The neodymium-doped yttrium aluminium garnet (Nd:YAG) laser can be used at a wavelength of 532 nm for epidermal pigment and to induce knoeberization of vitiliginous lesions.

The Vitiligo Task Force concluded, “Although strategies that provide complete clearance will warrant further research, this should not discourage dermatologists and patients from treating vitiligo, as disease stabilization is within reach in most cases.” They added, “To date, the odds of repigmentation remain primarily dependent on the involved body areas and grade of disease activity; therefore, early treatment is recommended. Options such as JAK inhibitors and research into other drugs that affect adaptive and innate immunity are exciting developments that continue to pave a promising way forward.” Preventing the development of vitiligo, they emphasized, is an important area of future research.

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

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Schedule27 May 2024