Vitiligo

Guideline for the Diagnosis and Management of Vitiligo
D.J. Gawkrodger; A.D. Ormerod; L. Shaw; I. Mauri-Sole; M.E. Whitton; M.J. Watts; A.V. Anstey; J. Ingham; K. Young
Authors and Disclosures
Posted: 12/23/2008; The British Journal of Dermatology. 2008;159(5):1051-1076. © 2008 Blackwell Publishing
Summary and Key Recommendations
Summary
This detailed and user-friendly guideline for thediagnosis and management of vitiligo in children and adults aims to give high quality clinical advice, based on the best available evidence and expert consensus, taking into account patient choice and clinical expertise.

The guideline was devised by a structured process and is intended for use by dermatologists and as a resource for interested parties including patients. Recommendations andlevels of evidence have been graded according to the method developed by the Scottish Inter-Collegiate Guidelines Network. Where evidence was lacking, research recommendations were made.

The types of vitiligo, process of diagnosis in primary and secondary care, and investigation of vitiligo were assessed. Treatments considered include offering no treatment other than camouflage cosmetics andsunscreens, the use of topical potent or highly potent corticosteroids, of vitamin D analogues, and of topical calcineurin inhibitors, and depigmentation with p-(benzyloxy)phenol. The use of systemic treatment, e.g. corticosteroids, ciclosporin and other immunosuppressive agents was analyzed.

Phototherapy was considered, including narrowband ultraviolet B (UVB), psoralen with ultraviolet A (UVA), andkhellin with UVA or UVB, along with combinations of topical preparations and various forms of UV. Surgical treatments that were assessed include full-thickness and split skin grafting, mini (punch) grafts, autologous epidermal cell suspensions, and autologous skin equivalents. The effectiveness of cognitive therapy and psychological treatments was considered.

Therapeutic algorithms using gradesof recommendation and levels of evidence have been produced for children and for adults with vitiligo.
Key Recommendations
Grades of recommendation/levels of evidence are given (see Table 1 and Table 2 ).
Therapeutic Algorithm in Children
1. Diagnosis

Where vitiligo is classical, the diagnosis is straightforward and can be made in primary care (D/4) but atypical presentations may requireexpert assessment by a dermatologist (D/4).
2. No Treatment Option

In children with skin types I and II, in the consultation it is appropriate to consider, after discussion, whether the initial approach may be to use no active treatment other than use of camouflage cosmetics and sunscreens (D/4).
3. Topical Treatment
o Treatment with a potent or very potent topical steroid should beconsidered for a trial period of no more than 2months. Skin atrophy has been a common side-effect (B/1+).
o Topical pimecrolimus or tacrolimus should be considered as alternatives to the use of a highly potent topical steroid in view of their better short-term safety profile (B/1+).

4. Phototherapy

Narrowband (NB) ultraviolet (UV) B phototherapy should be considered only in children whocannot be adequately managed with more conservative treatments (D/4), who have widespread vitiligo, or have localized vitiligo associated with a significant impact on patient's quality of life (QoL). Ideally, this treatment should be reserved for patients with darker skin types and monitored with serial photographs every 2-3months (D/3). NB-UVB should be used in preference to PUVA in view of evidenceof greater efficacy, safety and lack of clinical trials of PUVA in children (A/1+).
5. Systemic and Surgical Treatments

The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects (B/2++). There are no studies of surgical treatments in children.
6. Psychological Treatments

Clinicians should make an assessment of the...