What are the best treatments for Vitiligo?
What really upsets me about a lot of General Practitioners and Dermatologists is that the thing they often say about vitiligo to parents and children is that “there is no cure” triggering immediate anxiety and despair. That there is no cure is true about so many conditions in medicine, for example asthma, diabetes, eczema and high blood pressure to name but a few, but that doesn’t mean there is no treatment. There are in fact very good treatments for vitiligo that can achieve the three objectives of treatment:
- Reduce the stress on pigment cells (melanocytes)
- Regulate the over active immune response
- Stimulate pigment cell regeneration and skin repigmentation
It is also important for patients and families to realise that we have genuine excitement about new approaches to vitiligo treatment as well as potentially new and more successful treatments that are likely only years away. Scientists and Dermatologists are working hard every day to make better treatments both medical and surgical.
At The Vitiligo Centre Australia, we offer the best and most comprehensive treatment currently available for vitiligo. To do this we start with a thorough history of one’s vitiligo: when it started, where it started, whether it’s active or stable, and what treatments have been tried so far. We look for any possible associations such as vitiligo triggering chemicals or other autoimmune diseases and we test for deficiencies which may be important such as vitamin D, as well as checking for associated problems such as thyroid disease or diabetes. In addition, where necessary, our patients undertake additional screening to assess the psychological impact of their vitiligo on their life.
The examination of the skin assesses where the vitiligo is present and how much of the body is affected by vitiligo, but looks closely for signs that the vitiligo is either stable, improving or unstable and at risk of imminent further spreading. To do this we look for clues around the edges and within the vitiligo using special tools such as a magnification, Woods lamp, Dermatoscope and UV camera.
Based on collective findings on history taking, examination and blood tests we then work with the patient to develop a treatment plan. The treatment plan is not the same for everybody, because the disease extent, activity, and location for each patient is different. Patients also have different needs according to where they live, the resources available to them and how the vitiligo is affecting them emotionally
All our patients are given nutritional and lifestyle advice to reduce the stress (oxidative and physical) on their pigment cells (melanocytes) If a patient just has a few spots, we may use a potent topical steroid twice daily for 10-14 days followed by a break of up to a week before repeating treatment over a 2-4 month period. If there are concerns about topical steroid side effects such as thinning of the skin (such as on the face or skin creases or genital area) or steroid absorption through the skin we prefer high dose tacrolimus twice daily for 2-3 months. The topical treatments reduce the overactive immune system as a result of which pigment cells may be able to start functioning more normally again. Ideally in localised disease these topical treatments are combined with 308nm Excimer Pulsed Light which further reduces immune system over reactivity at the same time stimulating the pigment cells directly thereby increasing the speed and extend of repigmentation that can be achieved using topical treatment alone.
If there are too many spots for just topical treatments (usually more than 5% of the body surface covered), we strongly recommend introducing narrow band UVB (NBUVB) phototherapy, which is available at many dermatologists’ offices around the country. For those who have travelled to our clinic from a distance and therefore can’t get their treatment directly from us, we try to help them find a location that offers it closer to their home, and we’re often successful! This treatment requires 2-3 visits per week, each treatment duration only 1-5 minutes. Again, it takes 2-3 months to start seeing the improvement. However, the way that NBUVB treatment is given is very important – if not done correctly it may not work well, if at all. That’s ideally why we prefer to treat patients ourselves in our clinic, but if they live too far away, TVCA can provide a copy of our protocol for the therapy to undertaken elsewhere. Sometimes patients opt for purchasing a NBUVB device/unit for their home, and we help them do this. We recommend topical therapy be combined with phototherapy.
If patients have signs of unstable disease or rapidly expanding disease, it is vital that systemic (internal) treatment be discussed to stabilise vitiligo, maximise the chance of repigmentation and to minimise relapse. At TVCA we favour depending on the patients age and history either oral minipulse steroid (oral steroids only on Saturday and Sunday) or short term methotrexate therapy once per week. With close monitoring, we continue this until the disease has stabilised and another treatment has started working for them.
In the small group of patients with lot of disease (more than 80% of the body covered), unresponsive to the above treatments TVCA can discuss and offer topical monobenzone treatment, which “bleaches” or removes the rest of their colour so that they look even, without spots. This isn’t for everybody, since its permanent and before the decision is made a lot of thought and discussion is required.
In the near future, new treatments referred to as the JAK inhibitors, will likely revolutionise vitiligo treatment but for now these remain very expensive and still are not available in Australia under the Medicare system
Surgical treatment, where skin from a healthy part of the body is removed and the pigment cells extracted and then transplanted into vitiligo patches is a new and exciting treatment with excellent results provided the following criteria are met:
- The vitiligo has not spread nor new patches developed within 2 years of surgery
- The area of vitiligo to be treated is located around the face and neck
- The area to be treated is no larger than the size of an out stretched hand
As one can now appreciate, each patient needs a personalised approach starting with a lengthy conversation, baseline photographs, correct prescribing, and then close regular follow up