Vitiligo: A comprehensive overview Part II: Treatment options and approach to treatment Lesley M. Felsten, MD,a AliAlikhan,MD,a and Vesna Petronic-Rosic, MD, MScb Berwyn and Chicago, Illinois CME INSTRUCTIONS The following is a journal-based CME activity presented by the American Disclosures Academy of Dermatology and is made up of four phases: Editors 1. Reading of the CME Information (delineated below) The editors involved with this CME activity and all content validation/ 2. Reading of the Source Article peer reviewers of this journal-based CME activity have reported no 3. Achievement of a 70% or higher on the online Case-based Post Test relevant financial relationships with commercial interest(s). 4. Completion of the Journal CME Evaluation Authors CME INFORMATION AND DISCLOSURES The authors of this journal-based CME activity have reported no relevant Statement of Need: financial relationships with commercial interest(s). The American Academy of Dermatology bases its CME activities on the Planners Academy’s core curriculum, identified professional practice gaps, the The planners involved with this journal-based CME activity have educational needs which underlie these gaps, and emerging clinical reported no relevant financial relationships with commercial interest(s). research findings. Learners should reflect upon clinical and scientific The editorial and education staff involved with this journal-based CME information presented in the article and determine the need for further activity have reported no relevant financial relationships with commer- study. cial interest(s). Target Audience: Resolution of Conflicts of Interest Dermatologists and others involved in the delivery of dermatologic care. In accordance with the ACCME Standards for Commercial Support of Accreditation CME, the American Academy of Dermatology has implemented mech- The American Academy of Dermatology is accredited by the anisms, prior to the planning and implementation of this Journal-based Accreditation Council for Continuing Medical Education to provide CME activity, to identify and mitigate conflicts of interest for all individ- continuing medical education for physicians. uals in a position to control the content of this Journal-based CME activity. AMA PRA Credit Designation Learning Objectives The American Academy of Dermatology designates this journal-based After completing this learning activity, participants should be able to list CME activity for a maximum of 1 AMA PRA Category 1 CreditsÔ. the available treatments for vitiligo and restate the indications and Physicians should claim only the credit commensurate with the extent of contraindications for their use and their safety, efficacy, and side effect their participation in the activity. profiles; develop an appropriate treatment plan for patients who present AAD Recognized Credit with a diagnosis of vitiligo; compare and contrast the efficacy and This journal-based CME activity is recognized by the American Academy adverse effects of conventional medical and surgical options as well as of Dermatology for 1 AAD Recognized Category 1 CME Credits and may the role of alternative and new therapies; identify adverse effects of be used toward the American Academy of Dermatology’s Continuing treatment and delineate the appropriate response to such an event; Medical Education Award. describe the effect vitiligo has on the patient’s quality of life; and counsel patients regarding their options in the event of disease recalcitrant to Disclaimer: both medical and surgical therapy. The American Academy of Dermatology is not responsible for statements made by the author(s). Statements or opinions expressed in this activity reflect the views of the author(s) and do not reflect Date of release: August 2011 the official policy of the American Academy of Dermatology. The information provided in this CME Expiration date: August 2012 activity is for continuing education purposes only and is not meant to substitute for the independent Ó medical judgment of a healthcare provider relative to the diagnostic, management and treatment 2010 by the American Academy of Dermatology, Inc. options of a specific patient’s medical condition. doi:10.1016/j.jaad.2010.10.043 Vitiligo is a common skin disorder that results in depigmentation. With the appropriate management, many patients can minimize disease progression, attain repigmentation, and achieve cosmetically pleasing results. There are numerous medical and surgical treatments aimed at repigmentation; therapies for depigmentation are available for patients with recalcitrant or advanced disease. The use of cosmetics at all stages of treatment may be vital to the patient’s quality of life. Understanding all the available options helps choose the appropriate treatment plan and tailor it to your patient. Part II of this two-part series on vitiligo discusses the indications for, evidence behind, and adverse effects associated with many of the therapies used for vitiligo. Both conventional medical and surgical options are discussed in addition to several alternative and promising new therapies. ( J Am Acad Dermatol 2011;65:493-514.) 493 494 Felsten, Alikhan, and Petronic-Rosic JAM ACAD DERMATOL SEPTEMBER 2011 Key words: antioxidants; autoimmune; autologous melanocyte suspension graft; biologic agents; camou- flage; corticosteroids; chemophototherapy; depigmentation; depigmented; hypopigmentation; hypopig- mented; laser; leukoderma; macule; melanocyte; melanosome; phototherapy; psychotherapy; punch graft; split thickness skin graft; suction blister graft; topical calcineurin inhibitors; vitamin D3 analogs; vitiligo. Key points vitiligo are associated d Many different modali- CAPSULE SUMMARY with disease progres- ties—both conventional sion in patients not re- and alternative and non- d Numerous treatment options exist for ceiving therapy surgical and surgical— vitiligo, but there is no cure. d Younger patients, those are used to treat vitiligo with recent onset of dis- d Nonsurgical treatments include topical, d For patients with exten- systemic, phototherapy, ease, darker skin types, sive or recalcitrant dis- photochemotherapy, and laser therapy. and lesions of the face, ease, treatments are neck, and trunk tend to aimed at depigmenta- d Surgical options include skin grafting respond best to therapy tion and/or camouflage and melanocyte suspension transplantation. Counseling patients on Vitiligo can be socially and therapeutic options should d Alternative therapies, camouflage, psychologically devastating. create realistic expectations. psychotherapy, and depigmentation can Because there is currently no Understanding the factors be beneficial to patients with vitiligo. known cure, treatment is that may affect a patient’s aimed at halting disease pro- d Treatment efficacy varies with duration prognosis and response to gression, inducing repigmen- and distribution of disease, type of treatment is essential for suc- tation, and achieving an vitiligo, and use in combination with cess. In general, patients with acceptable cosmetic result. other modalities. a family history of vitiligo, This paper reviews treatment mucosal involvement, a pos- the modalities currently available for patients with itive Koebner response, and the nonsegmental sub- vitiligo and evaluates their efficacy in comparison to type of vitiligo (NSV) tend to have progression of one another through a comprehensive literature re- their condition in the absence of therapy.1 The best view. Conventional nonsurgical and surgical therapies response to treatment is seen in younger patients, are discussed along with alternative and promising disease of recent onset, darker skin types, and in new treatments. Despite treatment, many patients will lesions on the face, neck, and trunk. Distal extrem- continue to suffer with vitiligo throughout their entire ities tend to be extremely refractory to nonsurgical lives. For this reason, methods for coping with lifelong modalities.2-7 disease are addressed as an adjunct for those with recalcitrant disease. CORTICOSTEROIDS Key points d Topical corticosteroids are common first- INDIVIDUAL PROGNOSTIC FACTORS line and adjunctive therapies Key points d Topical corticosteroids are the most effective d Mucosal involvement, a family history of monotherapy and produce the best clinical vitiligo, koebnerization, and nonsegmental outcomes when combined with light therapy d Systemic corticosteroids effectively halt dis- From the Department of Medical Education,a MacNeal Hospital, ease progression and induce repigmenta- Berwyn, and the Section of Dermatology,b The University of tion; however, safety profiles and optimal Chicago, Chicago, Illinois. dosing parameters are lacking Drs Felsten and Alikhan contributed equally to this manuscript. d Side effects of corticosteroids limit treatment; Funding sources: None. regular steroid holidays are recommended Reprints not available from the authors. Correspondence to: Vesna Petronic-Rosic, MD, MSc, Associate Background Professor and Clinic Director, The University of Chicago Section of Dermatology, 5841 S Maryland Ave, MC 5067, Chicago, IL Corticosteroids (CSs) are commonly used as a 60637. E-mail: [email protected]. first-line and adjunctive therapy for the treatment of 0190-9622/$36.00 vitiligo. Their efficacy is attributed to modulation of JAM ACAD DERMATOL Felsten, Alikhan, and Petronic-Rosic 495 VOLUME 65, NUMBER 3 the immune response. Studies have shown an abundance of inflammatory cells in vitiligo, with a predominance of macrophages