VITILIGO IN CHILDREN

The most effective treatment for vitiligo includes phototherapy and combination therapy.

Treatments:

  • Corticosteroids (topical, intralesional and systemic)
  • Calcineurin inhibitors: Tacrolimus and pimecrolimus
  • Surgery/ Transplantation
  • Discolouration of melanin
  • Phototherapy
  • PUVA
  • UVB (290-320 nm)
  • Narrow Band -UVB (311 nm)
  • VISIBLE LIGHT & wavelength at 633 nm
  • Excimer Laser phototherapy (308 nm)

Natural dermatologic phototherapy of vitiligo

Visible light (400-760nm), unlike solar ultraviolet UVC-UVB-UVA radiation (190-400 nm) that cause aging and skin cancer, is beneficial, rejuvenation and healing. It does not produce heat, unlike solar infrared radiation (760-3000 nm), which can cause skin dryness.

Visible light is the part of solar energy that allows existence of life on earth as well as normal human development.

Through the natural method of Photodynamic therapy visible and safe light that does not contain the harmful UVA & UVB irradiation and does not produce heat, activates melanocytes, which restore normal skin colour.

It is used together with a gel containing microspheres of a plant extract, which is capable of restoring normal levels of free radicals at the level of melanocytes and keratinocytes.

This is a totally new mechanism of action for the treatment of vitiligo, with no side effects.

Excimer Laser phototherapy (308 nm):

Advantages

  • Less erythema
  • Quicker improvement (with 6 sessions)
  • Faster recovery
  • UVB 308 nm targets Τ-cells
  • Infiltrating the epidermis and dermis
  • More effective than UVB 311 nm,
  • Penetrates as deep as PUVA

Indications

  • Clinical diagnosis of vitiligo
  • Lesions that are steady and firm for the last 6 months
  • Adults

Therapeutic Protocol

  • Target: erythema for 24-48 hours after treatment
  • Overlapping: 15%
  • MED multiple multilevel
  • Programme : 2 times a week

Friedman’s protocol

  • Erythema < 24 hours
  • Therapeutic energy should be increased by 50 mj
  • Erythema 24-48 hours
  • This is the ideal outcome
  • Therapeutic energy should be at the same level with previous treatments
  • Erythema 48-60 hours
  • Therapeutic energy should be reduced by 50 mj
  • Erythema 60-72 hours
  • Treatment should be postponed and in the next one energy should be reduced by 100mj

Guidelines for the management of vitiligo

Laurie Barclay, MD

August 7, 2012: The most effective management for vitiligo includes phototherapy and combination therapy, according to the most recent updated guidelines from the writing group of the Vitiligo European Task Force (VETF), which were published on August 3 in the British Journal of Dermatology.

The European Academy of Dermatology and Venereology and the Union Européenne des Médecins Spécialistes collaborated with the VETF in developing the new evidence- and expert-based guidelines for vitiligo.

According to A. Taïeb, MD, from Service de Dermatologie, CHU de Bordeaux, France, and colleagues “Vitiligo is a disease lacking definitive and completely effective therapies”. They also mention that “Phototherapy and combined treatments are the most effective treatments. Therapy should stop the progression of the lesions and provide complete or almost complete repigmentation to be satisfactory for the patient.”

Worldwide prevalence of vitiligo is 0.5%, without preference for specific age groups, races, or sex. The causes and pathophysiologic mechanisms underlying vitiligo are still poorly understood, which has hindered progress in diagnosis and management. To date, randomized controlled trials have been rare and affected by methodological issues and possible confounding factors.

Management Recommendations

In the review the following principles of management for segmental vitiligo or limited nonsegmental vitiligo (involving less than 2% – 3% of body surface) are recommended:

  • First-line treatment should be to avoid triggering factors and to use local agents such as corticosteroids or calcineurin inhibitors.
  • Second-line treatment should be localised narrow-band ultraviolet B (NB-UVB) radiation (311 nm), preferably with the excimer monochromatic lamp or laser.
  • Third-line treatment for patients left with cosmetically unsatisfactory repigmentation on visible areas after first- or second-line therapy is to consider use of surgical techniques.

In the review the following principles of management for nonsegmental vitiligo are recommended:

  • First-line management is to avoid triggering or aggravating factors and to stabilize the patient with NB-UVB therapy for at least 3 months. Patients who respond to NB-UVB should continue this treatment for 9 months or more. An additional consideration is to combine localized UVB therapy with systemic or topical therapies.
  • Second-line treatment for patients with rapidly progressive disease or lack of stabilization with NB-UVB is systemic corticosteroids, 3- to 4-month minipulse therapy, or immunosuppressants.
  • Third-line treatment is to graft areas failing to respond to previous treatment, particularly those areas with high cosmetic effect. The Koebner phenomenon, or new development of vitiligo in a previously unaffected area of skin undergoing traumatic injury, may limit graft persistence. Grafts are relatively contraindicated on the dorsum of the hands and similar areas.
  • Fourth-line treatment for widespread (covering more than 50% of body surface), refractory, or highly visible vitiligo is depigmentation using hydroquinone monobenzyl ether or 4-methoxyphenol alone or in combination with Q switch ruby laser.

Future Perspectives

As far as future developments for the management of vitiligo are concerned, the guidelines suggest more personalised strategies reflecting specific genetic and other clinical factors. Another general principle is the early initiation of treatment, before the development of premature graying of the hair.

Table: Proposed core outcomes in the trials on the treatment of vitiligo

Proposed outcomes Scale example Assessment methods Comments
Repigmentation % quartiles: 0-24%; 25-49%; 50- 74%; 75-100% Objective means such as planimetry, coloritmetry, digital photographs, UV photographs The method of assessment will depend upon its availability and appropriate training of personnel.
Cosmetically acceptable repigmentation Visual analogue scale (bad, fair, good, excellent) Patient This will take account of the colour match of the newly repigmented lesions to the surrounding normal skin including hyperpigmentation around the lesions if applicable
Global assessment of the disease Visual analogue scale: Complete improvement; very much improved; much improved; improved; minimal change; no change) Patient and doctor A unified combined scale should be used by both patients and clinicians, which would be quick and easy to use in both clinical setting and research environment.
Quality of life Skindex-29 (quality of life index regarding skin conditions) Patient Concerns have been recently reported regarding the use of DLQI in monitoring patients with mild to severe psoriasis and atopic dermatitis
Maintenance of gained repigmentation 2 years follow-up after completion of treatment Patient and doctor It is well known that repigmentation of vitiliginous lesions can take months and that depigmentation can recur; therefore it is important to assess maintenance of gained repigmentation when weighting the treatment benefits against the harms.
Cessation of spread of the disease Vitiligo Disease Activity (VIDA) score Patient and doctor Cessation of spreading of the disease is an important outcome due to the unpredictable nature of vitiligo, which can be devastating and distressing for patients. Stabilisation of the disease until repigmentation occurs was reported as a realistic measure of outcome
Side effects and harms Descriptive. Should also include convenience of the treatment from the patient’s perspective Patient and doctor Side effects and harms of an intervention should be clearly reported in the results section with relevant frequencies.

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