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Vitiligo AHM Vitiligo AHM Clinical indication Any one of the following established methods for the treatment of Vitiligo is considered medically necessary : o Excimer laser (e.g., XTRAC, PhotoMedex, Radnor, PA; EX-308, Ra Medical Systems, Inc., Carlsbad, CA) o Narrow-band ultraviolet B (UVB) o Topical and oral psoralen photochemotherapy (PUVA) Note: Continued PUVA or narrow-band UVB therapy is not medically necessary unless there is significant follicular pigmentation after 6 months of therapy (8 to 10 treatments per month) o Topical and systemic corticosteroids Indications considered Not Medically Necessary Treatments for vitiligo are considered cosmetic if they do not affect the underlying condition and do not result in improved protection against skin cancer; specifically micropigmentation (tattooing) and depigmentation (with monobenzylether of hydroquinone/monobenzone) are considered cosmetic. The following treatments for the condition vitiligo are considered not medically necessary as there is a lack of evidence regarding the safety and effectiveness have not been established o Home phototherapy o Melanocyte transplantation/cultured and non-cultured cellular melanocyte keratinocyte transfer for the treatment of vitiligo o Vitamin D analogs (e.g., calcitriol and paricalcitol) o Tumor necrosis factor-alpha agents (e.g., adalimumab, etanercept, and infliximab) o Alpha-melanocyte stimulating hormone (e.g., afamelanotide) o Chimeric monoclonal antibody to CD20 (e.g., rituximab) o Autologous mini-punching grafting, blister roof grafting (suction epidermal blister grafting) and split thickness skin grafting AC-AEVITI082014 Page 1 of 5 Copyright 2016 No part of this document may be reproduced without permission ActiveHealth Management Medical Management Guidelines References: 1. Grimes PE. Diseases of hypopigmentation. In: Principles and Practice of Dermatology. WM Sams Jr, PJ Lynch, eds. 2nd ed. New York, NY: Churchill Livingstone; 1996:843- 859. 2. Lorton DA. Pigmentary disorders. In: Conn's Current Therapy. RE Rakel, ed. Philadelphia, PA: W.B. Saunders Co.; 1999:875-876. 3. Goroll AH. Primary Care Medicine. 3rd ed. Philadelphia, PA: Lippincott-Raven; 1995:894-895. 4. Habif TB. Clinical Dermatology. St. Louis, MO: Mosby-Year Book, Inc.; 1996:616-621. 5. Kim SM, Lee HS, Hann SK. The efficacy of low-dose oral corticosteroids in the treatment of vitiligo patients. Int J Dermatol. 1999;38(7):546-550. 6. Jimbow K. Vitiligo. Therapeutic advances. Dermatol Clin. 1998;16(2):399-407. 7. Grimes PE. Vitiligo. An overview of therapeutic approaches. Dermatol Clin. 1993;11(2):325-338. 8. National Institutes of Health (NIH), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Questions and answers about vitiligo. Health Topics. NIH Publication No. 01-4909. Bethesda, MD: NIH; updated May 2001. Available at: http://www.niams.nih.gov/hi/topics/vitiligo/vitiligo.htm. Accessed June 29, 2005. 9. National Vitiligo Foundation (NVF) [website]. Tyler, TX: NVF; 2001. Available at: http://www.vitiligofoundation.org. Accessed July 31, 2001. 10. Arnold HL, Odom RB, James WD. Andrews' Diseases of the Skin: Clinical Dermatology. 8th Ed. Philadelphia, PA: W.B. Saunders Co.; 1990. 11. Njoo MD, Spuls PI, Bos JD, et al. Nonsurgical repigmentation therapies in vitiligo: Meta- analysis of the literature. Arch Dermatol. 1998;134(12):1532-1540. 12. Njoo MD, Westerhof W, Bos JD, et al. The development of guidelines for the treatment of vitiligo. Arch Dermatol. 1999;135:1514-1521. 13. Halder RM. New and emerging therapies for vitiligo. Dermatol Clin. 2000;18(1):79-89, ix. 14. Scherschun L, Kim JJ, Lim HW. Narrow-band ultraviolet B is a useful and well-tolerated treatment for vitiligo. J Am Acad Dermatol. 2001;44(6):999-1003. 15. Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo in children with narrow-band (TL-01) UVB radiation therapy. J Am Acad Dermatol; 2000;42(2 Pt 1):245- 253. 16. Njoo MD, Westerhof W, Bos JD, Bossuyt PM. The development of guidelines for the treatment of vitiligo. Clinical Epidemiology Unit of the Istituto Dermopatico dell'Immacolata-Istituto di Recovero e Cura a Carattere Scientifico (IDI-IRCCS) and the Archives of Dermatology. Arch Dermatol. 1999;135(12):1514-1521. 17. Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs topical psoralen plus UV-A. Arch Dermatol. 1997;133(12):1525-1528. 18. Chen YF, Chang JS, Yang PY, et al. Transplant of cultured autologous pure melanocytes after laser-abrasion for the treatment of segmental vitiligo. J Dermatol. 2000;27(7):434- 439. AC-AEVITI082014 Page 2 of 5 Copyright 2016 No part of this document may be reproduced without permission ActiveHealth Management Medical Management Guidelines 19. Phillips J, Gawkrodger DJ, Caddy CM, et al. Keratinocytes suppress TRP-1 expression and reduce cell number of co-cultured melanocytes - implications for grafting of patients with vitiligo. Pigment Cell Res. 2001;14(2):116-125. 20. Sachdev M, Shankar DS. Dermatologic surgery: Pulsed erbium:YAG laser-assisted autologous epidermal punch grafting in vitiligo. Int J Dermatol. 2000;39(11):868-871. 21. Kim HY, Kang KY. Epidermal grafts for treatment of stable and progressive vitiligo. J Am Acad Dermatol. 1999;40(3):412-417. 22. Olsson MJ, Juhlin L. Epidermal sheet grafts for repigmentation of vitiligo and piebaldism, with a review of surgical techniques. Acta Derm Venereol. 1997;77(6):463- 466. 23. Roelandts R. Photo(chemo) therapy for vitiligo. Photodermatol Photoimmunol Photomed. 2003;19(1):1-4. 24. Hadi SM, Spencer JM, Lebwohl M. The use of the 308-nm excimer laser for the treatment of vitiligo. Dermatol Surg. 2004;30(7):983-986. 25. Choi KH, Park JH, Ro YS. Treatment of vitiligo with 308-nm xenon-chloride excimer laser: Therapeutic efficacy of different initial doses according to treatment areas. J Dermatol. 2004;31(4):284-292. 26. Esposito M, Soda R, Costanzo A, Chimenti S. Treatment of vitiligo with the 308 nm excimer laser. Clin Exp Dermatol. 2004;29(2):133-137. 27. Kawalek AZ, Spencer JM, Phelps RG. Combined excimer laser and topical tacrolimus for the treatment of vitiligo: A pilot study. Dermatol Surg. 2004;30(2 Pt 1):130-135. 28. Taneja A, Trehan M, Taylor CR. 308-nm excimer laser for the treatment of localized vitiligo. Int J Dermatol. 2003;42(8):658-662. 29. Spencer JM, Nossa R, Ajmeri J. Treatment of vitiligo with the 308-nm excimer laser: A pilot study. J Am Acad Dermatol. 2002;46(5):727-731. 30. Baltás E, Nagy P, Bónis B, et al. Repigmentation of localized vitiligo with the xenon chloride laser. Br J Dermatol. 2001;144:1266-1267. 31. Kostovic K, Nola I, Bucan Z, Situm M. Treatment of vitiligo: Current methods and new approaches. Acta Dermatovenerol Croat. 2003;11(3):163-170. 32. Hartmann A, Brocker EB, Becker JC. Hypopigmentary skin disorders: Current treatment options and future directions. Drugs. 2004;64(1):89-107. 33. Sarkany RP, Anstey A, Diffey BL, et al. Home phototherapy: Report on a workshop of the British Photodermatology Group, December 1996. Br J Dermatol. 1999;140(2):145- 149. 34. Passeron T, Ostovari N, Zakaria W, et al. Topical tacrolimus and the 308-nm excimer laser: A synergistic combination for the treatment of vitiligo. Arch Dermatol. 2004 Sep;140(9):1065-1069. 35. Ada S, Sahin S, Boztepe G, et al. No additional effect of topical calcipotriol on narrow- band UVB phototherapy in patients with generalized vitiligo. Photodermatol Photoimmunol Photomed. 2005;21(2):79-83. 36. Grimes PE. New insights and new therapies in vitiligo. JAMA. 2005;293(6):730-735. 37. Hartmann A, Lurz C, Hamm H, et al. Narrow-band UVB311 nm vs. broad-band UVB therapy in combination with topical calcipotriol vs. placebo in vitiligo. Int J Dermatol. 2005;44(9):736-742. AC-AEVITI082014 Page 3 of 5 Copyright 2016 No part of this document may be reproduced without permission ActiveHealth Management Medical Management Guidelines 38. Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol. 2006;45(4):411-417. 39. van Geel N, Ongenae K, Vander Haeghen Y, et al. Subjective and objective evaluation of noncultured epidermal cellular grafting for repigmenting vitiligo. Dermatology. 2006;213(1):23-29. 40. Yones SS, Palmer RA, Garibaldinos TM, Hawk JL. Randomized double-blind trial of treatment of vitiligo: Efficacy of psoralen–UV-A therapy vs narrowband–UV-B therapy. Arch Dermatol 2007;143(5):578-584. 41. Casacci M, Thomas P, Pacifico A, et al. Comparison between 308-nm monochromatic excimer light and narrowband UVB phototherapy (311-313 nm) in the treatment of vitiligo -- a multicentre controlled study. J Eur Acad Dermatol Venereol. 2007;21(7):956- 963. 42. Mulekar SV, Ghwish B, Al Issa A, Al Eisa A. Treatment of vitiligo lesions by ReCell vs. conventional melanocyte-keratinocyte transplantation: A pilot study. Br J Dermatol. 2008;158(1):45-49. 43. Szczurko O, Boon HS. A systematic review of natural health product treatment for vitiligo. BMC Dermatol. 2008;8:2. 44. Gawkrodger DJ, Ormerod AD, Shaw L, et al; Therapy Guidelines and Audit Subcommittee, British Association of Dermatologists; Clinical Standards Department, Royal College of Physicians of London; Cochrane Skin Group; Vitiligo Society. Guideline for the diagnosis and management of vitiligo. Br J Dermatol. 2008;159(5):1051-1076. 45. Rodríguez-Martín M, García Bustínduy M, Sáez Rodríguez M, Noda Cabrera A. Randomized, double-blind clinical trial to evaluate the efficacy of topical tacalcitol and sunlight exposure in the treatment of adult nonsegmental vitiligo. Br J Dermatol. 2009;160(2):409-414. 46. Matin R. Vitiligo in adults and children. In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; March 2010. 47. Birlea SA, Costin GE, Norris DA. New insights on therapy with vitamin D analogs targeting the intracellular pathways that control repigmentation in human vitiligo. Med Res Rev. 2009;29(3):514-546.
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