Vitiligo
Vitiligo - Summary
Vitiligo is an acquired, chronic depigmentation disorder characterized by white patches on the skin. It is classified according to its distribution and extent.
Non-segmental vitiligo is the more common form, accounting for 85–90% of people with vitiligo. It has a non-dermatomal distribution and is usually generalised and symmetrical.
Segmental vitiligo is less common than non-segmental vitiligo, but has an earlier onset and affects 30% of children with vitiligo. It usually has a dermatomal distribution and is usually unilateral and limited to one segment.
Vitiligo is caused by the loss of functioning melanocytes (pigment cells) in the skin, resulting in patches of white skin or hair. Genetic and environmental factors are both thought to be important.
The prevalence of vitiligo in the worldwide population is approximately 0.5%, but this may be an underestimate. The mean age of onset is 20 years of age.
Complications include psychosocial problems (including low self-esteem and relationship difficulties) and hearing problems, which occur more commonly in people with vitiligo than the general population.
For most people with vitiligo, the prognosis for spontaneous repigmentation is poor.
Vitiligo is associated with an increased risk of other autoimmune diseases, which affect about a third of people with vitiligo.
Diagnosis is made on the basis of features in the history and clinical examination.
White (depigmented) patches are typical, with well-demarcated edges which may be smooth or irregular.
On palpation lesions are flat and non-scaly.
Lesions can be localized or generalized, and are often bilateral and symmetrical. They can appear anywhere, but particularly the fingers and wrists, axillae, groin and genitalia, and the skin around the mouth and eyes.
Individual lesions usually enlarge over time and patches may merge.
An alternative diagnosis should be suspected if there is scaling, hardness or swelling, significant inflammation, or scarring.
Common conditions that may be confused with vitiligo include pityriasis versicolor, post-inflammatory hypopigmentation, pityriasis alba, idiopathic guttate hypomelanosis, halo naevus, scarring, and lichen sclerosus and atrophicus.
When assessing someone with vitiligo it is necessary to determine:
Their skin type and ability to tan.
Whether vitiligo is segmental or non-segmental.
What previous treatments have been tried and their effectiveness.
The impact of the condition on quality of life.
The percentage of the body surface that is affected (for people with non-segmental vitiligo).
If vitiligo is non-segmental, a check for other autoimmune diseases should be carried out.
Advice should be offered on avoiding sunbeds and using sun protection.
Treatment depends on whether vitiligo is segmental or non-segmental and, in primary care, may involve:
Referral to a skin camouflage service.
Management of psychosocial complications.
Use of a topical corticosteroid.
Referral to a dermatologist.
Treatment options which may be available in secondary care include topical pimecrolimus or tacrolimus, narrow-band ultraviolet B phototherapy, surgical treatments, and topical depigmentation.
Have I got the right topic?
This CKS topic is based on a Cochrane systematic review of interventions for vitiligo [Whitton et al, 2010], and a guideline for the diagnosis and management of vitiligo by the British Association of Dermatologists [Gawkrodger et al, 2008].
This CKS topic covers the diagnosis and management of vitiligo in primary care.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
CKS gratefully acknowledges the contribution of the British Association of Dermatologists in the development of this topic.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
February to May 2010 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 March 2010.
HTAs (Health Technology Assessments)
No new HTAs since 1 March 2010.
Economic appraisals
No new economic appraisals relevant to England since 1 March 2010.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Chan, M.F., and Chua, T.L. (2012) The effectiveness of therapeutic interventions on quality of life for vitiligo patients: a systematic review. International Journal of Nursing Practice 18(4), 396-405. [Abstract]
Primary evidence
No new randomized controlled trials published in the major journals since 1 March 2010.
New policies
No new national policies or guidelines since 1 March 2010.
New safety alerts
No new safety alerts since 1 March 2010.
Changes in product availability
No changes in product availability since 1 March 2010.
Goals and outcome measures
Goals
To accurately diagnose vitiligo
To provide information and advice about vitiligo, and sources of support
To monitor for other autoimmune conditions (if appropriate)
To offer appropriate treatment of vitiligo in primary care
To offer referral to a skin camouflage service
To manage any psychosocial complications of vitiligo
To refer appropriately to secondary care
Background information
Definition
What is it?
Vitiligo is an acquired, chronic depigmentation disorder characterized by white patches on the skin. It is classified according to its distribution and extent.
Non-segmental vitiligo is the more common form, accounting for 85–90% of people with vitiligo.
It has a non-dermatomal distribution (that is, its distribution does not follow dermatomes, or unmarked areas of the skin supplied by cutaneous branches of a single spinal nerve).
It is usually generalized and symmetrical (when it is sometimes referred to as vitiligo vulgaris), although it can be localized (focal) or unilateral.
Segmental vitiligo is less common than non-segmental vitiligo, but has an earlier onset and affects 30% of children with vitiligo.
It usually has a dermatomal distribution, affecting part or all of a dermatome, but may affect areas delineated by Blaschko's lines (invisible lines representing the developmental growth pattern of the skin).
It is usually unilateral and limited to one segment. Rarely, it affects several segments, which may be on one or both sides of the body.
[Gawkrodger et al, 2007; Taϊeb et al, 2007; Gawkrodger et al, 2008; Taϊeb and Picardo, 2009]
Prevalence
How common is it?
The prevalence of vitiligo in the worldwide population is approximately 0.5%, but this may be an underestimate.
Higher prevalence has been reported in countries where there is considerable stigma associated with vitiligo.
Prevalence is evenly distributed between the two sexes, and there is no difference in frequency according to skin type or race. However, vitiligo is more commonly diagnosed in women and people with darker skin pigmentation.
The mean age of onset is 20 years of age.
[Gawkrodger et al, 2007; Gawkrodger et al, 2008; Taϊeb and Picardo, 2009; Whitton et al, 2010]
Causes
What causes it?
Vitiligo is caused by the loss of functioning melanocytes (pigment cells) in the skin, resulting in patches of white skin or hair. Genetic and environmental factors are both thought to be important.
In non-segmental vitiligo, the cause of melanocyte loss is thought to be autoimmune destruction — there are associations with other autoimmune diseases, and melanocyte-specific lymphocytes have been found both in the blood and at the margins of active vitiligo lesions.
In segmental vitiligo, the cause is thought to be neuronal — certain neurochemical mediators released from nerve endings in the epidermis become toxic to melanocytes.
[Gawkrodger et al, 2007; Gawkrodger, 2009; Taϊeb and Picardo, 2009]
Triggers
What are the triggers?
Proposed triggers for vitiligo include:
Stress, such as childbirth.
Skin trauma (Koebner phenomenon).
Exposure to certain chemicals (phenolic/catecholic derivatives), although this may reflect misclassification of chemical depigmentation as vitiligo.
Risk factors
What are the risk factors?
For non-segmental vitiligo:
Risk factors include:
Family history of vitiligo.
Family history of other autoimmune diseases.
Personal history of other autoimmune diseases.
Melanoma and cutaneous T-cell lymphoma (mycosis fungoides) — studies have reported vitiligo-like lesions occurring in people with melanoma and cutaneous T-cell lymphoma; such lesions may be a good prognostic factor.
Several specific genetic risk factors have been identified.
[Alkhateeb et al, 2003; Gawkrodger et al, 2007; Taϊeb and Picardo, 2009]
Prognosis
What is the prognosis?
For most people with vitiligo, the prognosis for spontaneous repigmentation is poor.
Vitiligo is a chronic, persistent condition.
Non-segmental vitiligo is characterized by periods of disease activity, when there may be rapid progression over weeks to months, and long periods of relative inactivity.
Rarely, spontaneous repigmentation occurs.
Loss of pigmentation often recurs after successful treatment.
[Gawkrodger et al, 2008; Gawkrodger, 2009; Taϊeb and Picardo, 2009; Whitton et al, 2010]
Complications
What are the complications?
Complications of vitiligo can include:
Psychosocial problems, including low self-esteem, embarrassment and difficulty in social and sexual relationships, social isolation, social anxiety, stigmatization (for example in marriage and the workplace), and depression. There is also considerable anxiety related to the unpredictability of the disease. These problems are more common in people with darker skin, but can also affect people with paler skin. These problems can have a significant impact on quality of life, similar to that seen with psoriasis.
Hearing problems (hypoacusis), which occur more commonly in people with vitiligo than in the general population.
The risks of non-melanoma skin cancers (NMSCs) in people with vitiligo have not been fully established, mainly because there is a lack of data from large, good-quality epidemiological studies.
Although there are reports of people developing non-melanoma skin cancers (NMSCs) on sun-exposed chronic vitiligo patches, other studies have not shown increased susceptibility to photo-damage or NMSCs.
[Kovacs, 1998; Grimes, 2005; Gawkrodger et al, 2007; Gawkrodger et al, 2008; Whitton et al, 2010]
Associations
What are the associations?
Vitiligo is associated with an increased risk of other autoimmune diseases, which affect about a third of people with vitiligo.
The most common group of autoimmune diseases associated with vitiligo is thyroid disease, in particular Hashimoto's thyroiditis.
Addison's disease, pernicious anaemia, systemic lupus erythematosus, diabetes mellitus, alopecia areata, rheumatoid arthritis, psoriasis, inflammatory bowel disease, and uveitis are also more common in people with vitiligo than in the general population.
[Grimes, 2005; Gawkrodger et al, 2007; Douglas and Whitton, 2008; Gawkrodger, 2009; Taϊeb and Picardo, 2009]
Diagnosis
Diagnosis of vitiligo
Diagnosis
How do I know my patient has it?
Diagnose vitiligo on the basis of features in the history and clinical examination (see www.dermnet.com for images):
Colour
White (depigmented) patches (macules) are typical.
The patches may initially be pale (hypopigmented), before eventually becoming white (depigmented). Occasionally, they have a white centre with an intermediate, pale area around ('trichrome' vitiligo).
The patches may appear pink in more vascular areas.
Occasionally, inflammation (redness) or hyperpigmentation is seen at the edges of lesions.
Margins
Lesions are typically well-demarcated. The borders/margins may be smooth or irregular ('scalloped').
On palpation
Lesions are flat and non-scaly.
Extent and distribution
Lesions may be localized or generalized. Occasionally, 'confetti' vitiligo is seen, in which there are several tiny, discrete, hypopigmented macules.
Lesions are often bilateral and symmetrical. They may be unilateral in early non-segmental vitiligo, or in segmental vitiligo when they are confined to part or all of one or more dermatomes (unmarked segments of skin) or areas delineated by Blaschko's lines (invisible lines representing the developmental growth pattern of the skin).
Lesions can appear anywhere, but the sites most commonly affected are the fingers and wrists, axillae, groin and genitalia, and the skin around the mouth and eyes. Mucosal areas (including the mouth) can also be affected (and can be prominent in people with darker skin pigmentation).
Hair roots can be affected, resulting in white eyelashes and white hair (which may be patchy).
Progression
Without treatment, individual lesions usually enlarge over time and patches may merge to form extensive geographical patterns.
Rarely, vitiligo can spread to cover almost all of the skin.
Appearance under a Wood's lamp (if available)
Vitiligo lesions are accentuated.
Other features
Itch occasionally accompanies developing lesions.
Vitiligo may exhibit Koebner phenomenon, with depigmentation developing at the sites of trauma (for example cuts, burns, abrasions, or even sunburn).
The presence of risk factors and associations may support the diagnosis of non-segmental vitiligo. These include:
History of other autoimmune disease.
Family history of vitiligo or other autoimmune disease.
Suspect an alternative diagnosis if there is scaling, hardness or swelling, significant inflammation, or scarring.
Consider using a Wood's lamp, if available, to help distinguish vitiligo from other conditions.
If the diagnosis is uncertain, refer the person to a dermatologist.
Basis for recommendation
Basis for recommendation
Diagnosis is made clinically
This recommendation is based on expert opinion from narrative reviews [Mollet et al, 2007; Taϊeb and Picardo, 2009].
Colour
This information is derived from expert opinion in a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists (BAD) [Gawkrodger et al, 2008], narrative reviews [Mollet et al, 2007; Douglas and Whitton, 2008; Halder and Chappell, 2009], and a textbook [Cox and Coulson, 2004].
Margins
This information is derived from expert opinion in narrative reviews [Douglas and Whitton, 2008; Halder and Chappell, 2009].
On palpation
This information is derived from expert opinion in a textbook [Bleehen and Anstey, 2004].
Extent and distribution
This information is derived from expert opinion in the BAD guideline [Gawkrodger et al, 2008] and narrative reviews [Gawkrodger et al, 2007; Douglas and Whitton, 2008; Halder and Chappell, 2009; Taϊeb and Picardo, 2009].
Progression
This information is derived from expert opinion in the BAD guideline [Gawkrodger et al, 2008] and narrative reviews [Douglas and Whitton, 2008; Halder and Chappell, 2009].
Appearance under a Wood's lamp
The statement that vitiligo lesions are accentuated under a Wood's lamp is derived from expert opinion in a narrative review [Halder and Chappell, 2009].
Other features
This information is derived from expert opinion in narrative reviews [Mollet et al, 2007; Douglas and Whitton, 2008] and a textbook [Bleehen and Anstey, 2004].
The presence of risk factors and associations
This information is derived from expert opinion in a narrative review [Taϊeb and Picardo, 2009].
Suspect an alternative diagnosis if there is scaling, induration, significant inflammation, or scarring, or if lesions are not accentuated under a Wood's lamp.
This recommendation is based on expert opinion from a narrative review [Douglas and Whitton, 2008].
Consider using a Wood's lamp to distinguish vitiligo from other conditions.
This recommendation is based on expert opinion from narrative reviews [Douglas and Whitton, 2008; Halder and Chappell, 2009; Taϊeb and Picardo, 2009] and a textbook [Bleehen and Anstey, 2004; Cox and Coulson, 2004].
Refer to a dermatologist if the diagnosis is uncertain.
This recommendation is based on expert opinion from a narrative review [Gawkrodger, 2009].
Differential diagnosis
What else might it be?
More common conditions that may be confused with vitiligo include (see www.dermnet.com for images):
Pityriasis versicolor (or tinea versicolor) — a superficial yeast infection that can cause loss of pigment, particularly in people with darker skin. It presents as small (less than 1 cm in diameter), round, pale macules, which are dry and slightly scaly when scratched. They are usually found on the upper trunk and chest. If vitiligo cannot be easily distinguished from pityriasis versicolor, consider using a Wood's lamp (if available) or taking skin scrapings for microscopy. In pityriasis versicolor, hypopigmented areas may appear yellow under a Wood's lamp. For guidance on how to take skin scrapings, see the section on Investigations in the CKS topic on Fungal skin infection - body and groin.
Post-inflammatory hypopigmentation — a partial loss of pigment following any inflammatory skin condition. It can be distinguished from vitiligo by being hypopigmented rather than depigmented, and by hypopigmentation being less obvious under a Wood's lamp. Conditions which are known to cause it include: eczema, psoriasis, scleroderma/systemic sclerosis, lupus erythematosus, lichen sclerosus, sarcoidosis, leprosy, mycosis fungoides (cutaneous T-cell lymphoma), and syphilis and other treponemal infections.
Pityriasis alba — variously defined as either a form of eczema or a form of post-inflammatory hypopigmentation following mild eczema. It is relatively common in children with darker skin, in whom multiple, poorly defined, hypopigmented, slightly scaly patches are seen on the face. In people with paler skin, it may only be visible in the summer when the normal skin tans. Hypopigmentation is less obvious under a Wood's lamp.
Idiopathic guttate hypomelanosis — a common condition, where numerous small (1–5 mm) white macules are distributed symmetrically on the trunk, arms, and legs. Individual lesions have well-defined borders and normal skin markings within them. In common with vitiligo, hypopigmentation is more obvious under a Wood's lamp.
Halo naevus — a mole with a regular, symmetrical halo of depigmentation around it. It is caused by an immunological reaction against melanocytes and, eventually, the mole disappears. They are benign, common in children, and occur more often (compared with the general population) in people who also have vitiligo.
Solar elastosis — a yellowish discolouration of the skin, caused by chronic sun damage, that is most obvious in skin creases and follicular openings on the face and neck. Both open and closed comedones may be seen.
Scarring — common in older people, those taking systemic steroids, and people who self-harm. In common with vitiligo, hypopigmentation is more obvious under a Wood's lamp.
Morphoea — a localized thickening of the dermis due to excess collagen. It is most common in women 20–40 years of age. Apparent hypopigmentation is less obvious under a Wood's lamp.
Lichen sclerosis and atrophicus — characterized by itchy, white atrophic plaques in the perineum and, rarely, on the trunk and limbs. Apparent hypopigmentation is less obvious under a Wood's lamp.
Progressive macular hypomelanosis — a common disorder in people of African or Afro–Caribbean origin. It is characterized by ill-defined macules on the trunk, often confluent in and around the midline, and rarely extending to the proximal extremities, head, or neck.
Melasma (chloasma) — hyperpigmentation of the face, most commonly seen in women taking combined oral contraceptives and in those who are pregnant. It may be confused with vitiligo because normally pigmented skin can appear hypopigmented in comparison with hyperpigmented skin.
Post-traumatic leukoderma — may occur after deep burns or after toxic epidermal necrolysis.
Less common conditions that may be confused with vitiligo include (see www.dermnet.com for images):
Piebaldism — an autosomal dominant condition in which there is an absence of melanocytes in affected areas of the skin. It usually presents at birth with depigmented areas near the midline on the front, typically a forelock of white hair. The patches remain unchanged throughout life, have a flat surface, and otherwise appear identical to vitiligo. In common with vitiligo, hypopigmentation is more obvious under a Wood's lamp.
Naevus anaemicus — a white patch due to localized vasoconstriction. It can be congenital or acquired. It may be seen in close association with a port wine stain, and is also seen temporarily following injection of adrenaline into the skin. The pallor disappears under a Wood's lamp.
Melanoma-associated depigmentation — occasionally, a halo of depigmentation is seen around a malignant melanoma. It differs from that seen in a benign halo naevus by being irregular and asymmetrical.
Chemical/occupational depigmentation — for example caused by phenolic/catecholic derivatives. Sources include adhesives, de-emulsifiers used in oil fields, deodorants, disinfectants, duplicating paper, formaldehyde resins, germicidal detergents, insecticides, latex gloves, motor oil additives, paints, photographic chemicals, plasticizers, printing ink, rubber antioxidants, soap antioxidants, synthetic oils, varnish, and lacquer resins.
Drug-induced depigmentation — from steroid injections and systemic drugs (for example, chloroquine, fluphenazine, phyostigmine, imatinib, and imiquimod).
Tuberous sclerosis — an inherited disease, characterized by ash-leaf shaped, depigmented macules on the trunk. Although it usually presents in early childhood, it is occasionally detected in older teenagers and young adults. Other dermatological features include facial angio-fibromas or periungual fibromas. It is important that it is diagnosed because internal organs can be affected. In common with vitiligo, hypopigmentation is more obvious under a Wood's lamp.
Albinism — a generalized loss of pigment that includes the eyes and is evident from birth. It is caused by defective manufacture of melanin.
Tuberculoid leprosy — can cause hypopigmented patches (usually one to five patches) with a raised red-copper coloured border. The patches can be distinguished from vitiligo in being anaesthetic, but there are usually other features to indicate the diagnosis (such as enlarged cutaneous nerves).
Incontentia pigmenti achromians of Ito (hypomelanosis of Ito) — characterized by depigmented whorls on the legs or trunk, usually in babies or small children. There may be associated disorders of the musculoskeletal system, eyes, teeth, and central nervous system. In common with vitiligo, hypopigmentation is more obvious under a Wood's lamp.
Basis for recommendation
Basis for recommendation
This list of conditions and descriptions is based on expert opinion from a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists [Gawkrodger et al, 2008], a European consensus report on the definition and assessment of vitiligo [Taϊeb et al, 2007], narrative reviews [Boissy and Manga, 2004; Gawkrodger et al, 2007; Douglas and Whitton, 2008; Gawkrodger, 2009; Halder and Chappell, 2009; Taϊeb and Picardo, 2009], and textbooks [Atherton and Moss, 2004; Bleehen and Anstey, 2004; Cox and Coulson, 2004; MacKie, 2004; Ashton and Leppard, 2005].
Management
Management
Scenario : Management: covers the management of vitiligo in primary care, and briefly outlines treatments that may be offered in secondary care.
Scenario : Management
Scenario : Management of vitiligo
Assessment
How should I assess a person with vitiligo?
Determine the person's skin type (that is, skin colour and ability to tan — see Table 1). Skin type may affect the person's choice of treatment (including no treatment).
Determine whether the person has non-segmental or segmental vitiligo.
Ask about any previous episodes of spontaneous repigmentation, previous treatments and their effectiveness, and any trauma preceding the skin changes (as in Koebner's phenomenon).
Assess the impact of the condition on the person's quality of life, including the presence and severity of any distress or psychosocial problems.
For people with non-segmental vitiligo:
Note whether the face is affected.
Estimate the percentage of the body surface area that is affected using the 'Rule of Nines' or the Lund and Browder chart (see Extent of body surface area involvement).
Ask about duration of lesions and whether they are active and progressing over weeks to months, stable (over the past 6 months), or regressing.
Skin type
Skin type
| Skin type | Typical features | Tanning ability |
|---|---|---|
| I | Pale white skin, blue/hazel eyes, blonde/red hair | Always burns, does not tan |
| II | Fair skin, blue eyes | Burns easily, tans poorly |
| III | Darker white skin | Tans after initial burn |
| IV | Lighter brown skin | Burns minimally, tans easily |
| V | Brown skin | Rarely burns, tans darkly easily |
| VI | Dark brown or black skin | Never burns, always tans darkly |
Extent of body surface area involvement
Extent of body surface area involvement
The extent of the person's body surface area that is affected by vitiligo can be estimated in the same way as for burns, using one of these two methods:
The 'Rule of Nines':
Arm — 9%
Head — 9%
Neck — 1%
Leg — 18%
Anterior trunk — 18%
Posterior trunk — 18%
The Lund and Browder chart — see www.bmj.com (pdf).
Basis for recommendation
Basis for recommendation
Determine skin type.
The recommendation to determine the person's skin type is based on expert opinion from a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists (BAD) [Gawkrodger et al, 2008] and a narrative review [Taϊeb and Picardo, 2009].
Determine whether the person has non-segmental or segmental vitiligo.
The need for distinguishing the type of vitiligo is because this affects management.
The classification and defining features are derived from the BAD guideline [Gawkrodger et al, 2008], a consensus report of the Vitiligo European Task Force on the definition and assessment of vitiligo [Taϊeb et al, 2007], and narrative reviews [Gawkrodger et al, 2007; Gawkrodger et al, 2008; Taϊeb and Picardo, 2009].
Ask about any previous episodes of spontaneous repigmentation, previous treatments and their effectiveness, and any trauma preceding the skin changes.
This recommendation is based on expert opinion from a narrative review [Taϊeb and Picardo, 2009]. These factors may affect management.
Assess the impact of the condition on the person's quality of life.
This recommendation is based on evidence from observational studies reported in a guideline [Gawkrodger et al, 2008], a Cochrane systematic review [Whitton et al, 2010], and several narrative reviews [Grimes, 2005; Gawkrodger et al, 2007; Douglas and Whitton, 2008; Gawkrodger, 2009; Taϊeb and Picardo, 2009] that vitiligo can cause psychosocial problems and has a significant impact on quality of life. The presence of psychosocial problems affects management.
Note whether the face is affected.
This recommendation is made because it affects management of people with non-segmental vitiligo.
Estimate the percentage of the body surface area affected.
This recommendation is made because it affects management of people with non-segmental vitiligo.
The information on methods for estimating surface area is derived from a textbook on burn care [Herndon, 1996] and a narrative review [Hettiaratchy and Papini, 2004].
Ask about the duration and progression of lesion.
This recommendation is derived form a narrative review [Taϊeb and Picardo, 2009]. It affects the management of people with non-segmental vitiligo.
Monitoring for other autoimmune conditions
What monitoring should I do for other autoimmune conditions?
For adults with non-segmental vitiligo, check for other autoimmune diseases. There is no need to do this in people who have segmental vitiligo or in children, unless there are other indications.
Enquire about symptoms of hyperthyroidism, hypothyroidism, diabetes mellitus, pernicious anaemia, and Addison's disease.
Take a blood sample to check thyroid function and for thyroid autoantibodies. Monitor thyroid function annually thereafter.
Advise the person to report any unusual symptoms (for example those of hyperthyroidism and hypothyroidism, diabetes mellitus, pernicious anaemia, and Addison's disease).
See the CKS topics on Hyperthyroidism and Hypothyroidism.
Basis for recommendation
Basis for recommendation
The recommendations to enquire about and advise reporting of symptoms of hyperthyroidism and hypothyroidism, diabetes mellitus, pernicious anaemia, and Addison's disease are based on evidence that people with non-segmental vitiligo are at increased risk of these autoimmune diseases compared with the general population [Grimes, 2005; Gawkrodger et al, 2007; Douglas and Whitton, 2008; Gawkrodger, 2009].
The recommendation to check thyroid function and for thyroid autoantibodies is derived from a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists [Gawkrodger et al, 2008] and a consensus report of the Vitiligo European Task Force on the definition and assessment of vitiligo [Taϊeb et al, 2007]. It is also based on evidence that adults with non-segmental vitiligo have a particularly high risk (30%) of autoimmune thyroid disease, most commonly Hashimoto's thyroiditis [Gawkrodger, 2009; Taϊeb and Picardo, 2009].
The recommendation to monitor thyroid function annually is based on expert opinion from a narrative review [Taϊeb and Picardo, 2009].
Treatment
What treatment can I offer for vitiligo in primary care?
Provide an explanation about the condition, including its causes and the prognosis without treatment (see Background information). Explain that there are a number of treatments available, but that none completely restore normal colour to the skin in all people, and none maintain the improvement or limit the spread of the condition. Most also have adverse effects.
Advise the person not to use sunbeds and to use appropriate protection from sunlight, such as a high-factor sunscreen (with protection against ultraviolet A and B). These can be prescribed, but the prescription must be endorsed ACBS (see Prescriptions).
Offer to refer the person to a skin camouflage service.
Be vigilant for psychosocial complications and, if necessary, offer treatment (for example by referring for cognitive behavioural therapy, if it is available).
For people who are not too distressed by the condition, offer the option of no treatment (apart from camouflage cosmetics and sunscreens). This may be acceptable to people with skin types I and II and localized vitiligo.
Consider whether to refer to a dermatologist or whether to offer treatment with a topical corticosteroid in primary care.
Inform the person about the Vitiligo Society, which offers support and information to people with vitiligo and their families.
Basis for recommendation
Basis for recommendation
Explanation
The recommendation to offer an explanation about the condition, including its causes and prognosis without treatment, is based on expert opinion from a narrative review [Douglas and Whitton, 2008].
The information about the effectiveness and adverse effects of treatments for vitiligo is derived from a Cochrane systematic review of interventions for vitiligo [Whitton et al, 2010] and from a narrative review [Gawkrodger, 2009].
Sunbeds and sunscreens
The recommendation to advise people with vitiligo to avoid sunbeds and use a sunscreen is based on expert opinion from a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists (BAD) [Gawkrodger et al, 2008] and narrative reviews [Gawkrodger et al, 2007; Douglas and Whitton, 2008; Halder and Chappell, 2009].
The purpose is threefold:
First of all, absence of melanin reduces the skin's natural protection against sunburn, skin ageing, and (possibly) skin cancer [Douglas and Whitton, 2008] (see Complications).
Secondly, these measures may prevent new lesions developing as a result of a Koebner response to sunburn [Halder and Chappell, 2009].
Thirdly, less tanning of the uninvolved skin will lessen the contrast with vitiligo lesions [Halder and Chappell, 2009].
Camouflage service
The recommendation to offer referral to a camouflage service is based on expert opinion from the BAD guideline [Gawkrodger et al, 2008] and narrative reviews [Gawkrodger et al, 2007; Douglas and Whitton, 2008]. There is only limited evidence on the effect of camouflage cosmetics on quality of life in people with vitiligo.
Be vigilant for psychosocial complications.
The recommendation to be vigilant for psychosocial complications and, if necessary, offer treatment is based on expert opinion from the BAD guideline [Gawkrodger et al, 2008] and narrative reviews [Douglas and Whitton, 2008; Gawkrodger, 2009]. There is a lack of evidence on the effectiveness of psychosocial interventions; cognitive behavioural therapy is recommended in one narrative review [Douglas and Whitton, 2008].
Offer the option of no treatment.
The recommendation to offer the option of no treatment (apart from camouflage cosmetics and sunscreens) to people who are not too distressed by the condition (and that this may be acceptable to people with skin types I and II and localized vitiligo) is based on expert opinion from the BAD guideline [Gawkrodger et al, 2008] and a narrative review [Douglas and Whitton, 2008].
Inform the person about the Vitiligo Society.
The recommendation to inform the person about the Vitiligo Society is based on the BAD guideline [Gawkrodger et al, 2008]; the guideline development group included members of the society.
Referral
Who should I refer a person with vitiligo to a dermatologist?
Refer the person to a dermatologist if any of the following apply:
The diagnosis is uncertain.
The person has segmental vitiligo and the option of no treatment is unacceptable.
A child requires treatment.
A woman who is pregnant requires treatment.
Large areas of the body are affected (more than 10% of body surface area).
The person (or their parent or guardian) is particularly distressed by the condition.
The person's face is affected and the option of no treatment is unacceptable.
The potential adverse effects of topical corticosteroids are not acceptable.
The initial treatment strategy has failed.
Consider whether to offer treatment whilst awaiting dermatology referral.
Basis for recommendation
Basis for recommendation
Refer the person to a dermatologist if the diagnosis is uncertain.
This recommendation is based on expert opinion from a narrative review [Gawkrodger, 2009].
Refer the person to a dermatologist if they have segmental vitiligo and the option of no treatment is unacceptable.
There is a lack of evidence on interventions for segmental vitiligo, but segmental vitiligo is not thought to respond to conventional treatments such as topical corticosteroids [Whitton et al, 2010]. A Cochrane systematic review of interventions for vitiligo found no studies that included only participants with segmental vitiligo; subgroup analysis for segmental vitiligo was not possible for the few studies that included people with vitiligo of any type [Whitton et al, 2010]. The systematic review cited two uncontrolled studies suggesting that segmental vitiligo may respond to helium neon laser and autologous grafting. Although these treatments are not routinely available in the UK, referral to a dermatologist is clearly indicated to access the full range of available treatments.
Refer children who require treatment to a dermatologist.
This recommendation is based on concerns of the adverse effects of prolonged use of potent topical corticosteroids in children. No alternative interventions are feasible for use in primary care (see Secondary care treatments).
Weak-to-moderate evidence from one Cochrane systematic review of six small randomized controlled trials (n = 363) suggests that potent or very potent topical corticosteroids are efficacious in people with non-segmental vitiligo when applied for 2–9 months [Whitton et al, 2010].
One retrospective study of children with vitiligo, treated with a moderate-to-high potency topical corticosteroid (intermittently or continuously), reported that 21 of 73 children (29%) had abnormal cortisol levels, and two children were diagnosed with steroid-induced adrenal suppression [Kwinter et al, 2007].
One evidence-based narrative review of topical steroids for atopic dermatitis in primary care states that children are potentially at a higher risk of systemic effects of topical corticosteroids than adults, because of their greater ratio of body surface area to weight [DTB, 2003]. The authors recommend that 'children who need frequent or prolonged courses of potent topical corticosteroids should be referred to a dermatologist, so that alternative treatments may be considered, and growth, development and pituitary function monitored'. This recommendation has been extrapolated to children with vitiligo.
The safety of topical fluticasone propionate (a potent corticosteroid with evidence of benefit in vitiligo) has only been established in children for use up to 4 weeks for treatment of atopic dermatitis [Friedlander et al, 2002].
Refer women who are pregnant and require treatment to a dermatologist.
This recommendation is based on a consensus of opinion from CKS expert reviewers. A recent Cochrane systematic review suggests there is uncertainty regarding the safety of long-term potent topical corticosteroids in pregnancy [Chi et al, 2009].
Refer to a dermatologist if large areas of the body are affected (more than 10% of body surface area).
This recommendation is based on expert opinion from a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists [Gawkrodger et al, 2008] and narrative reviews [Falabella and Barona, 2009; Halder and Chappell, 2009] that topical treatments should only be used on limited or localized areas. The threshold of 10% of body surface area is extrapolated from evidence on the safety of potent topical steroids in adults with atopic eczema (see the section on Adverse effects DELETE. Linked to corticosteroids topic in the CKS topic on Eczema - atopic) and from a narrative review [Falabella and Barona, 2009].
Refer to a dermatologist if the person (or their parent or guardian) is particularly distressed by the condition.
This recommendation is based on expert opinion from a narrative review [Gawkrodger, 2009].
Refer to a dermatologist if the face is affected and the option of no treatment is unacceptable.
Although there is some expert opinion that potent topical corticosteroids can be used on the face [Douglas and Whitton, 2008] and that responses are good in this area [Khalid et al, 1995; Sassi et al, 2008], adverse effects (including skin atrophy) are common [Whitton et al, 2010]. Given the high risk of adverse effects, the assumed cosmetic importance of the face, and the fact that topical corticosteroids are not licensed for the treatment of vitiligo [BNF 58, 2009], CKS recommends that people with vitiligo affecting the face for whom the option of no treatment is unacceptable are referred to a dermatologist.
Refer to a dermatologist if the potential adverse effects of topical corticosteroids are not acceptable.
This recommendation is based on the lack of feasibility, in primary care, of treatments for vitiligo besides topical corticosteroids (see Secondary care treatments).
Refer to a dermatologist if the response to topical corticosteroids is unacceptable.
This recommendation is based on the lack of feasibility, in primary care, of treatments for vitiligo besides topical corticosteroids (see Secondary care treatments).
Treatment whilst awaiting referral
What treatment can I offer for vitiligo whilst the person is awaiting dermatology referral?
For people with segmental vitiligo, do not offer any treatment whilst awaiting dermatology referral.
For children with non-segmental vitiligo, if the lesions are of recent onset, localized, and not on the face, and the child will be seen by a dermatologist within 4 weeks, consider offering treatment with a potent topical corticosteroid whilst awaiting referral. If there is likely to be a delay in the child being seen of more than 4 weeks or if lesions are on the face, do not start a topical corticosteroid without seeking specialist advice (for example by telephone).
For adults with non-segmental vitiligo:
If large areas of the body are affected (more than 10% of body surface area), consider offering treatment of localized areas (particularly for lesions that are new or rapidly progressing) with a potent topical corticosteroid whilst the person is awaiting dermatology referral.
If the face is affected, seek urgent specialist advice (for example by telephone) on the appropriateness of treating with a potent topical corticosteroid whilst the person is awaiting dermatology referral. This may be appropriate if the lesions are new or rapidly progressing.
If a potent topical corticosteroid is indicated, see Topical corticosteroids.
Basis for recommendation
Basis for recommendation
For people with segmental vitiligo, do not offer any treatment whilst awaiting dermatology referral.
There is a lack of evidence on interventions for segmental vitiligo. A Cochrane systematic review of interventions for vitiligo found no studies that included only participants with segmental vitiligo; subgroup analysis for segmental vitiligo was not possible for the few studies that included people with vitiligo of any type [Whitton et al, 2010]. The systematic review cited two uncontrolled studies suggesting that segmental vitiligo may respond to helium neon laser and autologous grafting. Although these treatments are not routinely available in the UK, referral to a dermatologist is clearly indicated to access the full range of available treatments.
Children with non-segmental vitiligo
The recommendations to consider offering treatment with a topical corticosteroid whilst the child is waiting for their appointment if the lesions are of recent onset, localized, and not on the face, and the child will be seen within 4 weeks, and not to start a topical corticosteroid without seeking specialist advice by telephone if there is likely to be a delay in the child being seen of more than 4 weeks are based on the following:
Limited expert opinion suggests that, compared with longstanding lesions, lesions of recent onset are more likely to clear with treatment [Douglas and Whitton, 2008]. This may indicate a window of opportunity when topical corticosteroids might be more effective. This opinion was supported by most CKS expert reviewers.
The threshold of 4 weeks was chosen because the safety of potent topical corticosteroids for this period of time is established [Friedlander et al, 2002]. Their use over longer periods may increase the risk of adverse effects.
Adults with large areas of non-segmental vitiligo
The recommendation to consider offering treatment of localized areas with a topical corticosteroid whilst the person is waiting for their appointment, particularly if the lesions are new or rapidly progressing, is based on limited expert opinion that (compared with longstanding lesions) lesions of recent onset are more likely to clear with treatment [Douglas and Whitton, 2008]. This may indicate a window of opportunity when topical corticosteroids might be more effective; this opinion was supported by most CKS expert reviewers.
Adults with non-segmental vitiligo affecting the face
The recommendation to seek urgent specialist advice on the appropriateness of treating with a topical corticosteroid whilst the person is waiting for their appointment (particularly lesions that are new or rapidly progressing) is based on limited expert opinion that (compared with longstanding lesions) lesions of recent onset lesions are more likely to clear with treatment [Douglas and Whitton, 2008]. This may indicate a window of opportunity when topical corticosteroids might be more effective.
Topical corticosteroids
When and how should I treat a person with vitiligo with a topical corticosteroid in primary care?
Offer treatment with a potent topical corticosteroid (without seeking specialist advice) to adults who meet all of the following criteria:
They have non-segmental vitiligo that is localized or limited (affecting less than 10% of the body surface area).
The option of no treatment is not acceptable.
Treatment is not planned for the face.
For women, they are not pregnant.
They accept the risks of adverse effects.
For people who do not meet these criteria (including children with vitiligo), see Referral and Treatment whilst awaiting referral.
If a topical corticosteroid is indicated:
Advise the person that topical corticosteroids are not licensed for the treatment of vitiligo and are commonly associated with adverse effects (including skin atrophy, telangiectasia, striae, and hypertrichosis [excess hair growth]).
Treat for up to 2 months with a potent topical corticosteroid applied once daily.
Available potent topical corticosteroids include fluticasone propionate, betamethasone valerate 0.1%, hydrocortisone butyrate, betamethasone dipropionate, mometasone furoate, fluocinolone acetonide 0.025%, fluocinonide, or diflucortolone valerate 0.1%.
Prescribe an ointment or a cream, depending on the person's preference and the site of lesions (for example, use a cream in the flexures).
Advise the person to use a digital camera (if they have one available) to monitor their response to treatment.
Review after 1 month to assess response and detect any adverse effects (including telangiectasia, skin atrophy, hypertrichosis, or striae). If there are any adverse effects or the response to treatment is already acceptable, consider discontinuing treatment.
After 2 months of corticosteroid treatment:
If there is no response, discontinue treatment and refer the person to a dermatologist.
If there is a partial response, continue treatment (possibly with an immediate break of 2 weeks, and further breaks after every 3 weeks of treatment) and refer the person to a dermatologist. Monitor for adverse effects monthly whilst awaiting referral.
If there is a complete response, stop the treatment.
Basis for recommendation
Basis for recommendation
Who to offer potent topical corticosteroids
The basis of the recommendation on who to offer treatment with a topical corticosteroid in primary care is covered in the Basis for recommendation for Referral.
Advice that topical corticosteroids are not licensed for the treatment of vitiligo and are commonly associated with adverse effects
These recommendations are based on the British National Formulary [BNF 58, 2009] and evidence from a Cochrane systematic review of six small, randomized controlled trials (n = 363) [Whitton et al, 2010].
Treatment with a potent corticosteroid
Weak-to-moderate evidence from one Cochrane systematic review of six small randomized controlled trials (with 363 participants) suggests that potent or very potent topical corticosteroids are efficacious in people with non-segmental vitiligo [Whitton et al, 2010].
In the primary studies, topical corticosteroids were applied once daily in some trials, and twice daily in others; evidence was insufficient to compare the efficacy and safety of these dosages. A guideline for the diagnosis and management of vitiligo by the British Association of Dermatologists (BAD) makes no recommendation on dosage [Gawkrodger et al, 2008], and there appears to be no consensus in the literature [Gawkrodger et al, 2007; Douglas and Whitton, 2008]. However, most CKS expert reviewers recommended once-daily application.
The recommendation on the duration of use is derived from the BAD guideline [Gawkrodger et al, 2008]. In the studies included in the Cochrane systematic review, topical corticosteroids were applied for 2–9 months [Whitton et al, 2010].
The recommendation on the prescribing of ointments or creams according the person's preference and the site of lesions is based on the opinion of CKS expert reviewers.
In spite of the limited evidence of efficacy, potent or very potent topical corticosteroids are almost universally recommended as first-line treatment for people with localized or limited non-segmental vitiligo; including the BAD guideline [Gawkrodger et al, 2008] and several narrative reviews [Forschner et al, 2007; Gawkrodger et al, 2007; Douglas and Whitton, 2008; Halder and Chappell, 2009]. The guideline included evidence from non-randomized controlled trials and other lower quality studies [Kandil, 1974; Clayton, 1977; Coskun et al, 2005] which were not included in the Cochrane systematic review.
In the absence of any direct comparisons between potent and very potent topical corticosteroids, CKS recommends the use of a potent topical corticosteroid (as it is less likely to cause adverse effects) [BNF 58, 2009]. The list of potent topical corticosteroids is derived from the British National Formulary [BNF 58, 2009].
Use of a digital camera to monitor treatment response
This recommendation is based on the BAD guideline [Gawkrodger et al, 2008], although it is likely that the guideline was referring to medical photography within the hospital setting. CKS expert reviewers suggest that digital photography is also useful and feasible for people with vitiligo using their own digital camera or camera phone.
Review after 1 month
The recommendation to review after 1 month is based on a narrative review by the Vitiligo Society [Gawkrodger et al, 2007]. This recommends treatment with a potent or very potent topical corticosteroid for 4 weeks, and discontinuation of treatment at the first sign of skin thinning (as demonstrated by telangiectasia).
The recommendation to discontinue treatment after 1 month if the response is already acceptable is based on what CKS considers to be good clinical practice (to avoid unnecessary adverse effects).
No response after 2 months
The recommendation to discontinue treatment and to refer the person to a dermatologist if there is no response after 2 months of treatment is based on the BAD guideline [Gawkrodger et al, 2008], which recommends no more than 2 months' treatment. This action will prevent unnecessary adverse effects and allow the person to access secondary care treatments.
Partial response after 2 months
CKS found no published evidence or opinion on how to manage people with a partial response after 2 months of treatment, and there was no consensus amongst CKS expert reviewers. The recommendations are therefore based on what CKS considers to be safe clinical practice which does not prevent effective ongoing treatment. The suggestion for intermittent corticosteroid use is derived from one of the trials in a Cochrane systematic review [Whitton et al, 2010].
Complete response after 2 months
This recommendation is based on what CKS considers to be good clinical practice.
Referral for skin camouflage
How do I refer a person with vitiligo for skin camouflage?
Offer referral to a local British Red Cross skin camouflage service.
The British Red Cross provides education by trained volunteers on the use of cosmetic camouflage creams. Education is needed for the correct use of cosmetic camouflage creams.
Referrals are accepted from GPs, dermatologists, dermatology nurse specialists, psychiatrists, and social workers, as well as people with vitiligo themselves.
Details of the nearest British Red Cross skin camouflage service can be found at www.redcross.org.uk/skincamouflage.
Cosmetic camouflage creams can be used on any part of the body. The aim is to provide natural-looking cover. They are waterproof, and may remain on the body for up to 4 days, and on the face for 12–18 hours.
Following assessment, the service produces a letter to the person's general practitioner detailing which camouflage products to prescribe.
Four brands of camouflage product, in a range of shades, are available to prescribe on an NHS prescription via the borderline substances list. The prescription must be endorsed 'ACBS'.
Covermark classic foundation (10 shades) and Covermark finishing powder.
Dermacolor camouflage cream (100 shades) and Dermacolor fixing powder.
Keromask masking cream (9 shades) and Keromask finishing powder.
Veil cover cream (40 shades) and Veil finishing powder.
The British Red Cross does not charge for this service, but donations are welcomed.
Basis for recommendation
Basis for recommendation
This information is mainly derived from a section about the British Red Cross skin camouflage service in Information for medical professionals, published by the Vitiligo Society [Gawkrodger et al, 2007].
There is limited evidence on the effect of camouflage cosmetics on quality of life in people with vitiligo. There is no evidence from controlled trials, but small observational studies and case reports suggest a benefit from camouflage cosmetics.
The recommendation that education in the use of camouflage cosmetics is required is based on expert opinion [Tanioka and Miyachi, 2009].
Information on who can make referrals, and that self-referrals are accepted, is derived from a CKS reviewer from the British Red Cross.
The brands of camouflage products prescribable on the NHS are derived from the Drug tariff [Prescription Pricing Division, 2010].
Secondary care treatments
What secondary care treatments may be available for vitiligo?
In a guideline for the diagnosis and management of vitiligo by the British Association of Dermatologists:
For children
Topical pimecrolimus or tacrolimus are recommended as alternatives to highly potent topical corticosteroids 'in view of their better short-term safety profile'.
Narrow-band ultraviolet B (NB-UVB) phototherapy is recommended for children who cannot be managed with topical treatments, have widespread vitiligo, or have localized vitiligo associated with a significant impact on their quality of life.
For adults
Topical pimecrolimus is recommended as an alternative to topical corticosteroids.
NB–UVB phototherapy is recommended only for adults who cannot be managed with topical treatments, have widespread vitiligo, or have localized vitiligo associated with a significant impact on their quality of life.
Surgical treatments are only recommended for cosmetically-sensitive sites where there have been no new lesions, no extension of the lesion in the previous 12 months, and no Koebner phenomenon. Split-skin grafting is recommended over minigraft procedures. However, surgical treatments are not widely available in the UK.
Depigmentation (using topical p-benzyloxyphenol [monobenzyl ether of hydoquinone] or 4-methoxyphenol) is recommended only for adults with severe vitiligo (that is, more than 50% depigmentation or extensive depigmentation on the face or hands) who cannot (or choose not to) seek repigmentation and who can accept a permanent inability to tan.
Basis for recommendation
Basis for recommendation
This information is derived from a guideline on the diagnosis and management of vitiligo by the British Association of Dermatologists [Gawkrodger et al, 2008].
Topical calcineurin inhibitors (pimecrolimus and tacrolimus) are not recommended for routine initiation in primary care, because:
The National Institute for Health and Clinical Excellence guideline technology appraisal of tacrolimus and pimecrolimus for atopic eczema recommends that treatment with tacrolimus or pimecrolimus should only be initiated by physicians (including general practitioners) with a special interest in, and experience of, dermatology [NICE, 2004].
There is an unknown risk of infection and cutaneous malignancy with long-term use [NICE, 2004].
The evidence of their efficacy in vitiligo is very limited [Gawkrodger et al, 2008; Whitton et al, 2010].
They are not licensed for the treatment of vitiligo [BNF 58, 2009].
There is limited-to-moderate evidence of the efficacy of various types and regimens of light therapy (ultraviolet A and ultraviolet B), used alone or in combination with other treatments.
The statement that surgical treatments are not widely available in the UK is based on a comment from a CKS expert reviewer.
Complementary therapies
What is the role of complementary therapies for vitiligo?
There is insufficient evidence to recommend any complementary therapies for the treatment of vitiligo.
Limited evidence from a single, low-quality trial suggests that Ginkgo biloba may be effective for non-segmental vitiligo, but further trials are needed before a recommendation can be made on it use.
Basis for recommendation
Basis for recommendation
There is a lack of evidence on complementary and alternative medicines for vitiligo.
Limited evidence from one small, low-quality, double-blind, randomized, placebo-controlled trial suggests that Ginkgo biloba is efficacious in the treatment of less severe vitiligo. Adverse effects include nausea and gastrointestinal complaints.
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Topical corticosteroids
Topical corticosteroids
Adverse effects
What are the adverse effects of topical corticosteroids and how can I minimize them?
The likelihood of adverse effects occurring with topical corticosteroids is directly related to the potency, the amount used, and the duration of treatment (longer than 4 weeks).
Local adverse effects are commonly reported following treatment for vitiligo because topical corticosteroids are generally used for several months on areas of thinner skin (such as the face and skin folds). Local adverse effects include:
Skin atrophy, telangiectasia, stretch marks, acne, folliculitis, purpura, contact dermatitis.
Exacerbation of pre-existing or coexistent dermatoses (such as rosacea, perioral dermatitis, and tinea infection).
Systemic adverse effects are rare, but include adrenal suppression, Cushing's syndrome, and, in children, growth retardation. They are more likely to occur when potent or very potent topical corticosteroids are used over a large surface area, for a prolonged period, or when they are used under occlusion.
Advise the person to use finger tip units to avoid over-application of topical corticosteroids.
The weekly prescribing limit for topical corticosteroids thought to avoid systemic adverse effects is listed in Table 1. This is based on expert opinion, not on data from controlled trials, and local adverse effects may occur at lower doses.
Check for signs of adverse effects at review, such as areas of thin skin or striae. In children who are using large amounts of topical corticosteroid, monitor their height.
If there are any adverse effects or the response to treatment is already acceptable, consider discontinuing treatment.
Table 1. Weekly dose of topical corticosteroids unlikely to cause systemic adverse effects in adults.| Treatment period | Potent (grams) | Very potent (grams) |
|---|---|---|
| < 2 months | 50 | 30 |
| 2–6 months | 30 | 15 |
| 6–12 months | 15 | 7.5 |
Basis for recommendation
These recommendations are based on expert opinion [Coulson, 1996] and the manufacturers' Summary of Product Characteristics [ABPI Medicines Compendium, 2007a; ABPI Medicines Compendium, 2007b].
One Cochrane systematic review of interventions for vitiligo identified 10 randomized, controlled trials on topical corticosteroids that met its inclusion criteria [Whitton et al, 2010]. The trials were generally small and of poor methodological quality. However, longer-term treatment with topical corticosteroids was used (in general between 3 weeks and 3 months, but up to 9 months in one study).
Adverse effects (including atrophy, telangiectasia, hypertrichosis [excess hair growth], and acne) were very common (up to around 40%) in people receiving clobetasol (very potent).
Adverse effects (including atrophy, soreness, and hypertrichosis) were common in people receiving betamethasone (potent).
In one study of fluticasone propionate, there was no evidence of skin atrophy on skin biopsy in any of the people treated with fluticasone propionate (potent) on lesions on the arms, legs, or trunk for 9 months.
Systemic adverse effects caused by topical corticosteroids are rare. The Summary of Product Characteristics for Betnovate® (betamethasone valerate) states that both Cushing's syndrome and skin atrophy are 'very rare', meaning they affect less than one in 10,000 people (based on case reports rather than controlled trials) [ABPI Medicines Compendium, 2007a].
Pregnancy and breastfeeding
Can topical corticosteroids be used during pregnancy and breastfeeding?
Pregnancy
It is not known whether there is any risk to the fetus if women who are pregnant use a potent topical corticosteroid long term.
Pregnant women who require treatment for vitiligo should be referred to a dermatologist.
Breastfeeding
Potent topical corticosteroids are thought to be suitable for use whilst breastfeeding.
Basis for recommendation
Pregnancy
This recommendation is based on a consensus of opinion from CKS expert reviewers.
A recent Cochrane systematic review identified two cohort studies and five case-controlled studies (with 659,675 participants) of women who used topical corticosteroids during pregnancy [Chi et al, 2009]. These studies had a number of methodological weaknesses making the results difficult to interpret.
The available data do not suggest any association between topical corticosteroids and congenital abnormality, preterm delivery, or stillbirth; however, an association between very potent topical corticosteroids and low birthweight was found.
However, data on duration of use (short-term or long-term use) were not available from these studies.
Breastfeeding
This recommendation is based on expert opinion in a World Health Organization report on the safety of medications during breastfeeding and pregnancy [WHO, 2002].
Advice for patients
What advice should I give about topical corticosteroids?
It is important to provide education on the correct use of topical corticosteroids. Advise the person to apply the product sparingly to all the affected areas. Most products are supplied with an information leaflet specifying the number of finger-tip units (FTUs) needed to treat specific body areas.
One FTU is equivalent to about 500 mg; this is sufficient to treat a skin area about twice that of the flat of the hand with the fingers together. The approximate amount that should be applied for each area of the body is listed in Table 1.
Table 1. Amount of topical preparation needed cover a given adult body surface.| Body area* | Number of finger-tip units (FTUs) |
|---|---|
| Face and neck | 2.5 |
| One hand (front and back including fingers) | 1 |
| One arm (including entire hand) | 4 |
| Genitalia | 0.5 |
Basis for recommendation
This information is based on expert opinion [MeReC, 1999].
Evidence
Evidence
Supporting evidence
This section summarizes the evidence on treatments for vitiligo that can feasibly be given in primary care. It also briefly summarizes the evidence on more commonly used secondary care treatments to inform recommendations on the appropriateness of primary care treatment or referral to secondary care.
Skin camouflage
Evidence on skin camouflage cosmetics for adults and children with vitiligo
There is limited evidence on the effect of camouflage cosmetics on quality of life in people with vitiligo. There is no evidence from controlled trials, but small observational studies and case reports suggest a benefit from camouflage cosmetics.
A Cochrane systematic review identified no studies of camouflage cosmetics in people with vitiligo that met its inclusion criteria [Whitton et al, 2010].
One observational study compared quality of life before and after the use of camouflage for at least 1 month in people with vitiligo [Ongenae et al, 2005].
Initial response rates to requests for participation were high (90%). Of the 78 people who were initially recruited and assessed by questionnaire, 62 people used camouflage and returned a second questionnaire.
Among the 62 people completing the study protocol, quality of life improved significantly with the use of camouflage (p = 0.006). Items that showed particular improvement were 'feelings of embarrassment and self-consciousness' and 'choice of clothing'.
The main concern about the validity of this study is the lack of a control group.
One observational study invited 135 people, 24 of whom had vitiligo, to self-assess perceived quality of life before and 1 month after their first visit to a cosmetic camouflage clinic [Holme et al, 2002].
The response rate was low at 68%.
Quality of life was assessed using the Dermatology Life Quality Index.
There was a statistically significant improvement in quality of life scores (p = 0.0001). However, the lack of a control group is an important validity issue.
One small, observational study of 32 people with skin blemishes (mostly vitiligo) reported statistically significant increases in confidence (p < 0.001) and decreases in avoidance (p < 0.01) in social situations 4 months after an appointment with a British Red Cross skin camouflage service [Kent, 2002].
One small, observational study of 20 women with skin diseases affecting the face (including only one woman with vitiligo) reported a significant improvement in quality of life following instruction from a 'cosmetician' on how to use decorative cosmetics, and their daily use for 2 weeks [Boehncke et al, 2002].
Various case reports and expert opinion suggest that camouflage cosmetics are acceptable and beneficial [Tanioka and Miyachi, 2008; Tanioka and Miyachi, 2009].
Topical corticosteroids
Evidence on topical corticosteroids for adults and children with vitiligo
Weak evidence from one Cochrane systematic review of six small randomized controlled trials (RCTs, n = 363) suggests that potent or very potent topical corticosteroids used for 2–9 months are efficacious for non-segmental vitiligo. However, the review found no RCTs that compared topical corticosteroids with placebo. Adverse effects such as skin atrophy, telangiectasia, and hypertrichosis (excess hair growth) were common, although one study reported that fluticasone propionate used for 9 months did not result in skin atrophy.
One Cochrane systematic review of interventions for vitiligo identified ten randomized, controlled trials (RCTs) on topical corticosteroids that met its inclusion criteria [Whitton et al, 2010]. Two studies did not report any outcomes of interest apart from adverse effects, and only six studies reported quality of life and repigmentation of more than 75%. None of the studies compared topical corticosteroids alone with placebo, and none included people with segmental vitiligo; all of the people participating had non-segmental vitiligo.
Quality of the included studies
Overall, the quality of the studies was poor. In most of the studies, participants and clinicians were not blinded and, in only a few was the assessor blinded. In several studies, the method of allocation concealment was unclear. Sample size was generally small (20–135 people).
Efficacy — quality of life
One parallel-group study of 84 adults with symmetrical (non-segmental) vitiligo affecting the face and/or neck found no statistically significant difference between topical hydrocortisone-17 butyrate (applied twice daily for three periods of 3 weeks) plus laser (for 12 weeks) and laser alone (for 12 weeks).
Efficacy — more than 75% repigmentation
Meta-analysis was not performed because of differences between the studies in the interventions under evaluation.
One parallel-group study of 84 adults with symmetrical (non-segmental) vitiligo affecting the face and/or neck found a statistically significant difference in favour of topical hydrocortisone-17 butyrate (applied twice daily for three periods of 3 weeks) plus laser (for 12 weeks) compared with laser alone (for 12 weeks) (relative risk [RR] 2.57; 95% CI 1.20 to 5.50).
One parallel-group study, of 49 people, compared topical betamethasone dipropionate (applied twice daily) alone, topical calcipotriol alone, or a combination of the two, for 3 months. None of the groups achieved more than 75% repigmentation.
One study of 25 people acting as their own control (comparing left with right) compared topical clobetasol propionate (applied once daily) plus narrow-band ultraviolet B light (NB–UVB) with placebo plus NB–UVB, for 6 months. There was no statistically significant difference between the groups.
One parallel-group, left/right comparison study of 135 adults with vitiligo on the arms, legs, or trunk compared topical fluticasone propionate 0.05% (applied once daily), ultraviolet A light (UVA), or a combination of the two, for 9 months. There was no statistically significant difference between the combination treatment and topical fluticasone propionate alone, or between the combination treatment and UVA alone. Topical fluticasone propionate either alone or in combination with UVA was superior to UVA alone (RR 3.94; 95% CI 1.16 to 13.43), but this analysis does not appear to have been originally planned [Westerhof et al, 1999] and the data should therefore be treated with caution. There was a left/right comparison (within each participant) of the combination versus UVA alone, and the combination versus fluticasone propionate alone; however, there was no such comparison of UVA alone and fluticasone propionate alone.
One study of 20 children acting as their own control (comparing left with right) compared topical clobetasol propionate with tacrolimus 0.1% (both applied twice daily), for 2 months. No statistically significant difference was found between the groups.
One parallel-group study of 50 children with non-segmental vitiligo (affecting any area) found a statistically significant difference in favour of topical clobetasol propionate (applied twice daily) compared with topical psoralen plus sunlight, for 6 months (RR 4.70; 95% CI 1.14 to 19.39). Every 6 weeks, treatment was interrupted for 2 weeks for children taking clobetasol.
Safety
Adverse effects (including atrophy, telangiectasia, hypertrichosis, and acne) were very common (up to around 40%) in people receiving clobetasol.
Adverse effects (including atrophy, soreness, and hypertrichosis) were common in people receiving betamethasone.
In one study of fluticasone propionate, there was no evidence of skin atrophy on skin biopsy in any of the people treated with fluticasone propionate on lesions on the arms, legs, or trunk for 9 months.
Similar adverse effects were seen in people taking topical corticosteroids in combination with other treatments, but it is not clear which intervention caused them.
Authors' conclusions
The authors concluded that there is moderate evidence for the use of topical corticosteroids, although long-term use is likely to lead to adverse effects. This conclusion would only seem to be appropriate for people with non-segmental vitiligo.
Complementary and alternative treatments
Evidence on complementary and alternative treatments for adults and children with vitiligo
There are no good quality published trials that have assessed the efficacy of complementary or alternative treatments for vitiligo. Two systematic reviews identified one small, double-blind, randomized, placebo-controlled trial which suggested that Ginkgo biloba is efficacious, but this trial had a number of methodological weakness.
One Cochrane systematic review of interventions for vitiligo found no studies of complementary therapies that met its inclusion criteria [Whitton et al, 2010]. However, one randomized, controlled trial (RCT) comparing oral Ginkgo biloba with placebo was identified (this treatment was listed under 'oral therapies' as opposed to complementary therapies).
The study was conducted in 52 people with gradually progressive, symmetrical (non-segmental) vitiligo.
The intervention group took Ginkgo biloba 40 mg, three times per day.
Participants were blinded to their treatment group, but the methods of random sequence generation and allocation concealment were unclear, and the outcome assessor was unblinded.
Compared with placebo, Ginkgo biloba showed a statistically significant improvement in the likelihood of more than 75% repigmentation, but the confidence interval was wide (relative risk 4.40; 95% CI 1.08 to 17.95).
Adverse effects included nausea (two participants).
One systematic review of natural health products for vitiligo concluded that the quality of evidence was poor, but that L-phenylalanine (used with phototherapy), and oral Ginkgo biloba (monotherapy) show promise and warrant further investigation [Szczurko and Boon, 2008].
Fifteen controlled trials were identified. Four studies investigated L-phenylalanine (with or without phototherapy), three trials evaluated traditional Chinese medicine products, six trials evaluated the use of plants (including one of Ginkgo biloba), and two trials investigated vitamins as adjuvants to phototherapy. Only interventions that could feasibly be recommended by primary care professionals are discussed here (excluding studies of L-phenylalanine, vitamins, and photosensitizing plants combined with phototherapy; phototherapy cannot be delivered in primary care).
The three trials of traditional Chinese medicine products each showed positive effects. However, the products were not adequately described and the quality of the trials was very poor.
One small double-blind RCT compared oral Ginkgo biloba 40 mg three times daily with placebo, for 6 months, in 52 people with less severe vitiligo. This is the same trial included in the above Cochrane systematic review [Whitton et al, 2010].
The likelihood of marked to complete repigmentation (75–100%) was 40% in the group taking Ginkgo biloba and 9% in the placebo group. The statistical significance was not reported and the quality of the study was poor.
Adverse effects of treatment included nausea and gastrointestinal complaints.
One small trial compared topical extract of Cucumis melo with placebo cream on the contralateral side in 30 people with less severe vitiligo. The difference between the intervention and placebo groups was not statistically significant.
Psychosocial interventions
Evidence on psychosocial interventions for adults with vitiligo
There is a lack of evidence on psychosocial interventions for adults with vitiligo.
One Cochrane systematic review of interventions for vitiligo identified one randomized, controlled trial of psychological interventions that met its inclusion criteria [Whitton et al, 2010].
The trial participants were 44 adults who had been affected with vitiligo for at least 1 year. They were not taking any form of psychotropic medication; they were not receiving counselling and had not previously received counselling to help them cope with their condition. Participants received either cognitive behavioural therapy (CBT), person-centred therapy, or no psychological therapy. However, the study did not assess any outcomes of interest. Furthermore, whilst it reported changes within each of the three groups, it did not report any differences between groups.
One systematic review of psychosocial interventions for adults with 'visible differences' identified 12 studies that met its inclusion criteria [Bessell and Moss, 2007]. Two of those studies (by the same author) were exclusively in adults with vitiligo. The review concluded that none of the studies demonstrated adequately the clinical effectiveness of the interventions and further research, in particular randomized controlled trials, was needed.
One non-randomized, controlled trial in 16 people with vitiligo recruited from UK dermatology outpatient clinics compared eight, 1-hour, weekly sessions of CBT-based individual counselling with no medical treatment.
Despite the small study size, the review reports that a sample size calculation was done. The statistical analyses and outcome measures were reported to be suitable and objective. The groups were comparable at baseline for demographic variables, and were followed up for 5 months. However, the study was deemed to have limited validity.
There were no large differences between data obtained before and after treatment, and this presumably applied to both intervention and control groups.
One non-randomized, controlled trial of 47 people with less severe vitiligo recruited through UK dermatology outpatient departments compared three interventions. The first consisted of eight, 1.5-hour, weekly sessions of person-centred group counselling; the second of eight, 1.5-hour, weekly sessions of CBT-based group counselling; and the third comprised no medical treatment. This is the same trial as is reported in the Cochrane systematic review [Whitton et al, 2010].
The trial was unblinded, and the sample size was inadequate. The outcome measures were objective and appropriate, but baseline outcome measures were not reported in detail. The groups were comparable at baseline for demographic characteristics. Statistical analyses were not suitable. Follow up was for 12 months. The study was deemed to have poor validity.
There were no large differences between data obtained before and after treatment, and this presumably applied to both intervention and control groups.
Secondary care treatments
Evidence on secondary care treatments for vitiligo
Topical calcineurin inhibitors
Evidence on topical calcineurin inhibitors (tacrolimus and pimecrolimus) for vitiligo
Very limited evidence suggests calcineurin inhibitors may be effective for vitiligo. Evidence is lacking regarding their efficacy as monotherapy.
One Cochrane systematic review of interventions for vitiligo identified six randomized, controlled trials on topical calcineurin inhibitors that met its inclusion criteria [Whitton et al, 2010]. None of the studies assessed quality of life as an outcome. Only four studies assessed the other primary outcome: greater than 75% repigmentation. Only one study evaluated monotherapy, whilst the remaining five studies examined the effect of topical calcineurin inhibitors in combination with other interventions.
One study in 20 children acting as their own controls (comparing left with right) compared topical tacrolimus 0.1% with topical clobetasol propionate (both applied twice daily), for 2 months. No statistically significant difference between the groups was found.
Two studies in which participants acted as their own controls (comparing left with right), one including eight people (20 evaluations) and one including 14 people, compared topical tacrolimus plus laser with placebo plus laser, for 8–12 weeks. In a meta-analysis, combined treatment was significantly more likely than laser alone to achieve more than 75% repigmentation (relative risk 3.15; 95% CI 1.46 to 6.76). As the participants acted as their own controls in both studies, the 95% confidence intervals may be falsely narrow.
One parallel-group study, including 68 people (50 evaluations), compared topical pimecrolimus plus narrow-band ultraviolet B light (NB-UVB) with placebo plus NB-UVB, for 12 weeks. There was no statistically significant difference between the groups in rates of more than 75% repigmentation.
Light and laser therapies
Evidence on light and laser therapies for vitiligo
There is limited-to-moderate evidence of the efficacy of various types and regimens of light therapy (ultraviolet A [UVA], ultraviolet B [UVB]) and of excimer laser, used alone or in combination with other treatments.
One Cochrane systematic review concluded that there is limited-to-moderate evidence of the efficacy of various types and regimens of light therapy (UVA and UVB) used alone or in combination with psoralens, topical steroids, vitamin D analogues, 5-fluorouracil, azathioprine, or oral prednisolone [Whitton et al, 2010]. The authors also concluded that there is some evidence that excimer laser is more effective in combination with topical interventions (such as hydrocortisone 17-butyrate, tacrolimus, and tacalcitol).
Although the review authors stated that 42 studies evaluated light therapies either as monotherapy or in combination with other treatments, fewer studies actually evaluated the effects of the light therapy. In several studies, both intervention groups received the light therapy. For example, in one study, one group received calcipotriol plus UVA whereas the other group received placebo plus psoralen and UVA (PUVA). Such a study does not evaluate UVA or PUVA, but compares the efficacy of calcipotriol with that of psoralen, both in combination with UVA.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of Vitiligo, with additional searches in the following areas:
Incidence of skin cancer
Use of cosmetics/camouflage
Comorbid autoimmune disease
Search dates
Medline and Embase
January 1980 – February 2010
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Vitiligo/, vitiligo.tw.
exp Administration, Topical/, exp Clobetasol/, exp Betamethasone/, corticosteroids.tw
exp Skin Neoplasms/, skin cancer.tw
exp Autoimmune Diseases/
exp Sunscreening Agents/, exp Cosmetics/
exp Stress, Psychological/
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Topic specific literature search sources
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
References
ABPI Medicines Compendium (2007a) Summary of product characteristics for Betnovate ointment. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
ABPI Medicines Compendium (2007b) Summary of product characteristics for Dermovate ointment. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
Alkhateeb, A., Fain, P.R., Thody, A. et al. (2003) Epidemiology of vitiligo and associated autoimmune diseases in Caucasian probands and their families. Pigment Cell Research 16(3), 208-214. [Abstract]
Ashton, R. and Leppard, B. (2005) Differential diagnosis in dermatology. 3rd edn. Abingdon: Radcliffe.
Atherton, D.J. and Moss, C. (2004)
Bessell, A. and Moss, T.P. (2007) Evaluating the effectiveness of psychosocial interventions for individuals with visible differences: a systematic review of the empirical literature. Body Image 4(3), 227-238. [Abstract]
Bleehen, S.S. and Anstey, A.V. (2004)
BNF 58 (2009) British National Formulary. 58th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Boehncke, W.H., Ochsendorf, F., Paeslack, I. et al. (2002) Decorative cosmetics improve the quality of life in patients with disfiguring skin diseases. European Journal of Dermatology 12(6), 577-580. [Abstract] [Free Full-text]
Boissy, R.E. and Manga, P. (2004) On the etiology of contact/occupational vitiligo. Pigment Cell Research 17(3), 208-214. [Abstract] [Free Full-text]
Chi, C.C., Lee, C.W., Wojnarowska, F. and Kirtschig, G. (2009) Safety of topical corticosteroids in pregnancy (Cochrane Review). The Cochrane Library.Issue 3.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
Clayton, R. (1977) A double-blind trial of 0-05% clobetasol proprionate in the treatment of vitiligo. British Journal of Dermatology 96(1), 71-73. [Abstract]
Coskun, B., Saral, Y. and Turgut, D. (2005) Topical 0.05% clobetasol propionate versus 1% pimecrolimus ointment in vitiligo. European Journal of Dermatology 15(2), 88-91. [Abstract] [Free Full-text]
Coulson, I. (1996) Topical steroids for skin disease. Dermatology in Practice 4(2), 5-9.
Cox, N.H. and Coulson, I.H. (2004)
Douglas, W.S and Whitton, M.E. (2008) What's new in vitiligo? ..The Vitiligo Society.www.vitiligosociety.org.uk
DTB (2003) Topical steroids for atopic dermatitis in primary care. Drug & Therapeutics Bulletin 41(1), 5-8. [Abstract]
Falabella, R. and Barona, M.I. (2009) Update on skin repigmentation therapies in vitiligo. Pigment Cell & Melanoma Research 22(1), 42-65. [Abstract]
Forschner, T., Buchholtz, S. and Stockfleth, E. (2007) Current state of vitiligo therapy–evidence-based analysis of the literature. Journal of The German Society of Dermatology 5(6), 467-475. [Abstract]
Friedlander, S.F., Hebert, A.A., Allen, D.B. and Fluticasone Pediatrics Safety Study Group (2002) Safety of fluticasone propionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. Journal of the American Academy of Dermatology 46(3), 387-393. [Abstract]
Gawkrodger, D.J. (2009) Vitiligo: what general physicians need to know. Clinical Medicine 9(5), 408-409.
Gawkrodger, D., Fain, P., Bennett, D.C. et al. (2007) Vitiligo: its aetiology, diagnosis and treatment. ..The Vitiligo Society.www.vitiligosociety.org.uk
Gawkrodger, D.J., Ormerod, A.D., Shaw, L. et al. (2008) Guideline for the diagnosis and management of vitiligo. British Journal of Dermatology 159(5), 1051-1076. [Abstract] [Free Full-text]
Grimes, P.E. (2005) New insights and new therapies in vitiligo. Journal of The American Medical Association 293(6), 730-735.
Halder, R.M. and Chappell, J.L. (2009) Vitiligo update. Seminars in Cutaneous Medicine and Surgery 28(2), 86-92. [Abstract]
Herndon, D.N. (Ed.) (1996) Total burn care. London: W.B. Saunders.
Hettiaratchy, S. and Papini, R. (2004) ABC of burns. Initial management of a major burn: II–assessment and resuscitation. British Medical Journal 329(7457), 101-103. [Free Full-text]
Holme, S.A., Beattie, P.E. and Fleming, C.J. (2002) Cosmetic camouflage advice improves quality of life. British Journal of Dermatology 147(5), 946-949. [Abstract]
Kandil, E. (1974) Treatment of vitiligo with 0-1 per cent betamethasone 17-valerate in isopropyl alcohol-a double-blind trial. British Journal of Dermatology 91(4), 457-460.
Kent, G. (2002) Testing a model of disfigurement: effects of a skin camouflage service on well-bieng and appearance anxiety. Psychology and Health 17(3), 377-386.
Khalid, M., Mujtaba, G. and Haroon, T.S. (1995) Comparison of 0.05% clobetasol propionate cream and topical Puvasol in childhood vitiligo. International Journal of Dermatology 34(3), 203-205.
Kovacs, S.O. (1998) Vitiligo. Journal of the American Academy of Dermatology 38(5 Pt 1), 647-666. [Abstract]
Kwinter, J., Pelletier, J., Khambalia, A. and Pope, E. (2007) High-potency steroid use in children with vitiligo: a retrospective study. Journal of the American Academy of Dermatology 56(2), 236-241. [Abstract]
MacKie, R.M. (2004)
MeReC (1999) Using topical corticosteroids in general practice. MeReC Bulletin 10(6), 21-24. [Free Full-text]
Mollet, I., Ongenae, K. and Naeyaert, J.M. (2007) Origin, clinical presentation, and diagnosis of hypomelanotic skin disorders. Dermatologic Clinics 25(3), 363-371. [Abstract]
NICE (2004) Tacrolimus and pimecrolimus for atopic eczema (NICE technology appraisal 82). ..National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Ongenae, K., Dierckxsens, L., Brochez, L. et al. (2005) Quality of life and stigmatization profile in a cohort of vitiligo patients and effect of the use of camouflage. Dermatology 210(4), 279-285. [Abstract]
Prescription Pricing Division, Business Services Authority (Ed.) (2010) NHS drug tariff. February 2010 edn. London: The Stationery Office.
Sassi, F., Cazzaniga, S., Tessari, G. et al. (2008) Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligo of the face and neck. British Journal of Dermatology 159(5), 1186-1191. [Abstract]
Szczurko, O. and Boon, H.S. (2008) A systematic review of natural health product treatment for vitiligo. BMC Dermatology 8, 2. [Abstract] [Free Full-text]
Taϊeb, A. and Picardo, M. (2009) Clinical practice. Vitiligo. New England Journal of Medicine 360(2), 160-169.
Taϊeb, A., Picardo, M. and VETF Members (2007) The definition and assessment of vitiligo: a consensus report of the Vitiligo European Task Force. Pigment Cell Research 20(1), 27-35. [Abstract]
Tanioka, M. and Miyachi, Y. (2008) Camouflaging vitiligo of the fingers. Archives of Dermatology 144(6), 809-810.
Tanioka, M. and Miyachi, Y. (2009) Camouflage for vitiligo. Dermatologic Therapy 22(1), 90-93. [Abstract]
Westerhof, W., Nieuweboer-Krobotova, L., Mulder PG and Glazenburg, E.J. (1999) Left-right comparison study of the combination of fluticasone propionate and UV-A vs either fluticasone propionate or UV-A alone for the long-term treatment of vitiligo. Archives of Dermatology 135(9), 1061-1066. [Abstract] [Free Full-text]
Whitton, M.E., Pinart, M., Batchelor, J. et al. (2010) Interventions for vitiligo (Cochrane Review). The Cochrane Library.Issue 1.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
WHO (2002) Breastfeeding and maternal medication. ..World Health Organization.www.who.int [Free Full-text]