by Thomas B. Fitzpatrick, MD , Ph.D
Myths About Vitiligo Treatment
Three myths about the treatment of vitiligo prevail in the medical profession.
The first myth is that treatment of vitiligo is "impossible." This is clearly not true and the majority of patients can achieve good results.
The second myth is that oral psoralens, which form the basis for some vitiligo treatments are "toxic to the liver." Oral psoralens are not toxic to the liver.
The third myth is that psoralen + UVA (PUVA) treatments for vitiligo "cause cancer of the skin." When used to treat vitiligo, PUVA therapy requires only a limited number of treatments-approximately 150 in number that has not been shown to cause skin cancer. By comparison, PUVA treatments for psoriasis can be as many as double the number for vitiligo. It has been shown that a small percentage of patients who receive more than 250 PUVA treatments can develop treatable squamous cell cancers of the skin.
Vitiligo Treatment Options
Four options are currently available for the treatment of vitiligo: sunscreens; cover-up; restoration of normal skin color; and bleaching of normal skin with topical creams to remove normal skin pigment to make an even color.
The two goals of sunscreen treatments are: to protect unpigmented involved skin from sunburn reaction and to limit the tanning of normal pigmented skin. The sun protection factor (SPF) of sunscreens should be no less than SPF 30, as this grade blocks not only erythema, but also the affects of sunlight on the DNA of the skin cells. Sunscreen treatment skin phototypes 1, 2, and sometimes 3 (those who burn, then tan to some degree).
The goal of cover-up with dyes or make-up is to hide the white macules so that the vitiligo is less visible. Self-tanning lotions and camouflage are quite helpful for some patients.
Restoring Normal Skin Color
Restoration of normal skin color can take the form of spot treatments or whole body treatment.
Spot Treatment: Topical Corticosteroid Creams
Initial treatment with certain topical corticosteroid creams is practical, simple, and safe. If there is no response in 2 months, it is unlikely to be effective. Physician monitoring every 2 months for signs of early steroid atrophy (thinning of the skin) is required.
Spot Treatment: Topical Oxsoralen
Much more complicated is the use of topical Oxsoralen (8-MOP). Oxsoralen is highly phototoxic (likely to cause a sunburn), and the phototoxicity lasts for 3 days or more. This should be performed only as an office procedure, only for small spots, and only by experienced physicians on well-informed patients. As with oral psoralens, 15 or more treatments may be required to initiate a response, and 100 or more to finish.
Spot Treatment: Mini Grafting
Mini grafting, which involves transplanting the patient's normal skin to vitiligo affected areas, may be a useful technique for refractory segmental vitiligo macules. PUVA may be required following the procedure to unify the color between the graft sites. The demonstrated occurrence of Koebnerization in donor sites in generalized vitiligo restricts this procedure to patients who have limited skin areas at risk for vitiligo. "Pebbling" of grafted site may occur.
Whole Body Treatment: PUVA Photochemotherapy (Oral Psoralens + UVA Irradiation)
For more widespread vitiligo, treatment with oral psoralen + UVA (PUVA) is practical. This may be done with sunlight and trimethylpsoralen (Trisoralen) or with artificial UVA (in the doctor's office or at an approved phototherapy facility) and Trisoralen or Oxsoralen-Ultra.
| Copyright 2005
American Vitiligo Research Foundation Inc.
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