Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

segmental vitiligo or limited vitiligo

1st line – topical therapy

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ONGOING
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segmental vitiligo or limited vitiligo
1st line – 

topical therapy

In segmental or nonextensive/limited vitiligo (i.e., lesions that cover <2% to 3% of the body surface), topical therapies (i.e., corticosteroids and calcineurin inhibitors) are recommended as a first-line treatment.[39]

One Cochrane review found that topical corticosteroids are the most effective and safest treatments for localized vitiligo.[44] They work by suppressing the immune response against melanocytes, and can be used in adults and children. Topical corticosteroids have the best response on sun-exposed areas, in dark skin, and in recent lesions.[39]

Potent corticosteroids (e.g., clobetasol, mometasone) should be tested for 3 months to evaluate the response.[39] In some areas - particularly the face, genitals, axillae, and breasts - prolonged treatment with a topical corticosteroid may result in corticosteroid-induced atrophy and hypertrichosis. Therefore, patients should be evaluated regularly for adverse effects such as skin thinning, purpura, and striae distensae.[45]

Therapy can be used on a discontinuous basis to provide benefit and potentially avoid adverse effects.[39] One useful approach is to use topical corticosteroids twice daily for 1 week, and then no treatment for 1 week.

One systematic review and meta-analysis concluded that topical calcineurin inhibitor monotherapy is effective, particularly in children and on lesions on the face and neck.[46] Topical tacrolimus can be used as an alternative to topical corticosteroid (particularly in patients with facial vitiligo), thereby avoiding corticosteroid-related adverse effects, or during the off-week when using corticosteroids discontinuously.[42][47]

Primary options

clobetasol topical: (0.05%) apply to the affected area(s) twice daily, maximum 50 g/week

OR

mometasone topical: (0.1%) apply to the affected area(s) once daily

OR

tacrolimus topical: (0.1%) apply to the affected area(s) twice daily

Plus – supportive therapies

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ONGOING
|
segmental vitiligo or limited vitiligo
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

Cosmetic coverage may be an adequate choice of treatment in some patients. The strong contrast between affected and unaffected skin in people with darker pigmentation makes the disease more visible, for which make-up products can be customized to match the patient's skin tone.

Over-the-counter self-tanning products containing dihydroxyacetone may help to camouflage affected skin in patients with Fitzpatrick type I-IV skin.[43]

2nd line – phototherapy

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ONGOING
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segmental vitiligo or limited vitiligo
2nd line – 

phototherapy

Phototherapy devices that deliver light in the narrowband UV-B range (peak at 308 nm) can be considered as second-line treatment in patients who do not respond to topical therapies.[39][42][48][49]

Treatments are given 2 to 3 times weekly for several months. This avoids unnecessary adverse effects due to total body irradiation.

Plus – supportive therapies

Back
ONGOING
|
segmental vitiligo or limited vitiligo
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

Over-the-counter self-tanning products containing dihydroxyacetone may help to camouflage affected skin in patients with Fitzpatrick type I-IV skin.[43]

3rd line – surgery

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ONGOING
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segmental vitiligo or limited vitiligo
3rd line – 

surgery

Surgical options may be considered in areas that do not respond, especially those areas with a high cosmetic impact, if segmental vitiligo is stable.[39][42] 

UK guidelines recommend that the disease be inactive for at least 12 months prior to surgery.[42] 

In meta-regression analyses, successful surgical outcome (>90% repigmentation) was associated with stable segmental disease and younger patient age.[50] 

Surgery is relatively contraindicated in areas such as dorsum of hands.[39] 

Plus – supportive therapies

Back
ONGOING
|
segmental vitiligo or limited vitiligo
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

widespread vitiligo (more than 3% body surface area)

1st line – phototherapy

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ONGOING
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widespread vitiligo (more than 3% body surface area)
1st line – 

phototherapy

Narrowband UV-B therapy is a safe and effective treatment for widespread vitiligo and is recommended as a first-line treatment option in these patients.[42] It should be continued for at least 3 months, and for up to 12 months if tolerated, to achieve maximal response.[39][42]

Plus – supportive therapies

Back
ONGOING
|
widespread vitiligo (more than 3% body surface area)
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

Cosmetic coverage may be an adequate choice of treatment in some patients. The strong contrast between affected and unaffected skin in people with darker pigmentation makes the disease more visible, for which make-up products can be customized to match the patient's skin tone.

Over-the-counter self-tanning products containing dihydroxyacetone may help to camouflage affected skin in patients with Fitzpatrick type I-IV skin.[43]

Consider – topical therapy or oral corticosteroid

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ONGOING
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widespread vitiligo (more than 3% body surface area)
Consider – 

topical therapy or oral corticosteroid

Treatment recommended for SOME patients in selected patient group

Narrowband UV-B therapy can be combined with topical therapies (i.e., corticosteroids or tacrolimus) or systemic therapies (i.e., corticosteroids) as necessary, which may result in improved efficacy.

Systemic corticosteroids are recommended to stabilize disease if the condition is progressing rapidly, or progresses despite therapy.[39][42] 

Minipulse therapy (i.e., the intermittent administration of larger doses) or alternate-day dosing has been advocated when using systemic corticosteroids.[39][51] 

Primary options

clobetasol topical: (0.05%) apply to the affected area(s) twice daily, maximum 50 g/week

OR

mometasone topical: (0.1%) apply to the affected area(s) once daily

OR

tacrolimus topical: (0.1%) apply to the affected area(s) twice daily

Secondary options

dexamethasone: consult specialist for guidance on oral dose

OR

prednisone: consult specialist for guidance on oral dose

2nd line – oral corticosteroid

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ONGOING
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widespread vitiligo (more than 3% body surface area)
2nd line – 

oral corticosteroid

Systemic corticosteroids are recommended to stabilize disease if the condition is progressing rapidly or progresses despite therapy.[39][42]

Minipulse therapy (i.e., the intermittent administration of larger doses) or alternate-day dosing has been advocated when using systemic corticosteroids.[39][51]

Primary options

dexamethasone: consult specialist for guidance on oral dose

OR

prednisone: consult specialist for guidance on oral dose

Plus – supportive therapies

Back
ONGOING
|
widespread vitiligo (more than 3% body surface area)
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

Over-the-counter self-tanning products containing dihydroxyacetone may help to camouflage affected skin in patients with Fitzpatrick type I-IV skin.[43]

3rd line – surgery

Back
ONGOING
|
widespread vitiligo (more than 3% body surface area)
3rd line – 

surgery

Surgical options may be considered in areas that do not respond, especially those areas with a high cosmetic impact, if widespread (nonsegmental) vitiligo is stable.[39][42]

Guidelines recommend that the disease be inactive for at least 12 months prior to surgery, and that patients with widespread vitiligo should not have a history of Koebner phenomenon.[6][39][42]

In meta-regression analyses, successful surgical outcome (>90% repigmentation) was associated with stable segmental disease and younger patient age.[50] 

Surgery is relatively contraindicated in areas such as dorsum of hands.[39] 

Plus – supportive therapies

Back
ONGOING
|
widespread vitiligo (more than 3% body surface area)
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

4th line – depigmentation therapies

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ONGOING
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widespread vitiligo (more than 3% body surface area)
4th line – 

depigmentation therapies

Depigmentation techniques could be considered as a last option in patients with unresponsive, widespread (i.e., >50%), or highly visible recalcitrant vitiligo of face or hands.[39] 

Monobenzone (the monobenzyl ether of hydroquinone) has been used to permanently depigment unaffected skin in patients with vitiligo.

Treatment induces depigmentation that usually starts at the application site, but eventually affects remote areas of the body. This may take up to 1 year and is not always permanent, although retreatment is possible if repigmentation occurs. Depigmentation is associated with permanent photosensitivity.

Assessment of depigmentation success should be measured using percentage of repigmentation quartiles (0% to 25%, 26% to 50%, 51% to 79%, 80% to 100%) and the Vitiligo Noticeability Scale.[52]  

Laser-assisted melanocyte removal may be considered for areas that do not respond to chemical depigmentation, or for small pigmented islands. The Q-switched ruby laser is well suited for this approach, and works much faster than chemical depigmentation.[53][54]

Primary options

monobenzone topical: (20%) apply to the affected area(s) twice to three times daily

More

Plus – supportive therapies

Back
ONGOING
|
widespread vitiligo (more than 3% body surface area)
Plus – 

supportive therapies

Treatment recommended for ALL patients in selected patient group

Patients should be advised to practice sun protection (with high factor sunscreen offering UV-A and UV-B protection) and avoid cutaneous trauma where possible (e.g., physical trauma, surgical incisions, friction).[39]

Psychological or psychiatric support should be considered in all patients.[42]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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