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Therapeutic Approach

Vitiligo is a common, chronic autoimmune disease of the skin characterized by depigmented lesions. Vitiligo is categorized based on clinical presentation as vitiligo (bilateral distribution, usually symmetric) and its segmental variant (localized, unilateral, asymmetric). Treatment strategy depends on disease activity (active vs stable), the extent of disease (body surface area involvement), location of disease (glabrous vs hair-bearing skin), and whether the patient has the segmental variant (Figure 65.1). The goal of treatment is to stop disease progression and repigment the skin.

Patients with active spreading of disease can be stabilized with systemic immunosuppression. This is primarily used as a bridge to more long-term therapy, typically nbUVB phototherapy, in order to prevent worsening of the disease until the phototherapy reaches a therapeutic dose. This can take 3 months, and so systemic treatments are typically used for this length of time.

If disease is localized to a small body surface area (<5% BSA), patients may be treated with topicals, localized phototherapy, or melanocyte-keratinocyte transplantation. More widespread disease (>5% BSA) indicates initiation of phototherapy, or potentially other systemic therapies as they become available in the future. Glabrous skin or skin where the hair has turned white does not repigment readily with most treatments, and patient expectations should be set accordingly. Those with lesions in these areas who have stable disease may benefit from surgical approaches.

The segmental variant of vitiligo progresses rapidly over ∼6 months and then typically stabilizes for the life of the individual. It also tends to involve hair follicles early during its progression, which decreases the likelihood of satisfactory repigmentation with most treatments. However, because of its stability, patients with segmental vitiligo are good candidates for surgical approaches, which requires a localized area of involvement and disease stability. Patients without the segmental variant who have stable disease (no worsening over 1-2 years) may also be candidates for this approach. See Table 65-1.

Table 65-1Vitiligo Treatment Table

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