A 27-Year-Old Woman With White Spots on Her Face

Miriam Kinai, MB ChB


September 14, 2018

Medical management of vitiligo is the preferred first-line intervention, and the available options include the following:

  • Topical corticosteroids

  • Topical calcineurin inhibitors

  • Vitamin D analogues

  • Narrow-band ultraviolet B (UV-B) light therapy

  • Topical psoralen ointment with ultraviolet A light therapy (PUVA)

  • Oral psoralen with ultraviolet A light therapy (PUVA) or systemic psoralen photochemotherapy

  • Laser therapy with a 308 nm excimer laser

  • In very select cases, depigmentation of normal surrounding skin with monobenzyl ether of hydroquinone (MBEH)

Topical PUVA, corticosteroids, and calcineurin inhibitors are used to treat patients with a few localized patches of vitiligo. Oral PUVA is usually reserved for patients with vitiligo affecting more than 20% of their skin surface area, laser therapy is used when less than 30% of the skin is involved, and monobenzyl ether of hydroquinone is used to treat selected patients with extensive vitiligo affecting more than 50% of their skin, as it will depigment normal, unaffected skin. The safest and most effective of the medical therapies for vitiligo are class 3 topical corticosteroids and ultraviolet B (UV-B) therapy.[2] Narrow band ultraviolet B (UV-B) therapy is superior even to oral PUVA in treating nonsegmental vitiligo.[5]

Surgical interventions can be applied in patients who fail or have an inadequate response to medical treatment. Furthermore, they should only be considered in patients with localized stable vitiligo that does not Koebnerize and is in a cosmetically sensitive area.[4] The available options include split skin grafts, skin grafts using blisters, minigrafting, cultured or noncultured autologous epidermal suspensions, and micropigmentation or tattooing to repigment skin. The Erbium:YAG laser can be used for disepithelialization of large vitiliginous patches prior to graft application.[7] Split skin grafting is the best surgical option, whereas minigrafting has the most adverse effects (which include a cobblestone appearance in over 25% of patients).[4]

Adjunctive therapies are useful in most patients as they address the physiologic as well as the psychologic effect that result from having vitiligo. Several adjunctive treatment options are available. Broad-spectrum sunscreens that offer protection from ultraviolet A (UV-A) and ultraviolet B (UV-B) light and have a sun protection factor (SPF) of 30 or higher should be used because the depigmented lesions are at increased risk for sunburn and subsequent skin cancers. Patients should also be advised to wear protective clothing and minimize sun exposure. Camouflage cosmetics, which include makeup, dyes and self-tanning lotions, are also beneficial. Psychological treatments, including cognitive therapy and counseling, are important because they improve the coping mechanisms of patients with vitiligo. Patient support groups are useful for enhancing emotional well-being. The parents of children with vitiligo should also receive counseling.

The patient in the case above was started on topical fluticasone propionate cream. She was also advised to use sunscreen with a sun protection factor (SPF) of at least 30.


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