The main goal of treating vitiligo is to improve the appearance of the skin. However, to date, no universally effective and safe therapy exists. Many treatment options have been developed but challenges persist, as not all patients respond to available therapies and relapse is common. Their effect varies greatly and complete repigmentation is rarely accomplished. Factors such as the extent, distribution and rate of progression of the depigmentation dictate the choice of treatment. Self care, phototherapy, surgery and topical treatments may be used alone or in combination.

Self care

There are effective ways for patients to protect their skin and improve the appearance of vitiligo without medical intervention:

• Solar protection - minimising sun exposure and ensuring that protective clothing and sunscreen are worn whilst in the sun to protect against UV radiation.
• Camouflage - the use of cosmetics, such as make-up and tanning lotions, to cover up the patches of depigmented skin.

Topical treatments

Many of the medical therapies available are applied topically and can reduce the appearance of vitiligo:

• Corticosteroids – topical steroid creams, such as Mometasone furoate, may aid in the repigmentation of patches of depigmented skin in vitiligo patients. They act by suppressing the immune system to prevent the destruction of melanocytes, slowing the progression of vitiligo and allowing for repigmentation. Corticosteroids are most effective on small areas of the face and repigmentation by this method is more successful in dark-skinned individuals. The steroids may take several months to take effect, this can exceed the safe period for exposure to these medications. Therefore, side-effects can arise, including; atrophy of the skin, telangiectasias (dilated blood vessels) and hypertrichosis (abnormal hair growth).
• Depigmentation therapy – in cases where vitiligo is extensive (greater than 80%), some opt to undergo depigmentation to lighten the remaining pigmented areas of skin to match their depigmented skin. This treatment is quite extreme and involves the use of topical monobenzyl ether of hydroquinone (Benoquin). The entire process usually takes somewhere between 6 months and two years to complete. Patients can suffer irritant dermatitis from the Benoquin and must also practice strict photoprotection afterwards. A more recently developed method involves the use of lasers and topical 4-methoxyphenol (4-MP) to remove pigment.
• Immunomodulators – creams containing agents such as tacrolimus and pimecrolimus can be used to reduce the immune response against melanocytes. These drugs down regulate the expression of certain genes involved in inflammation and immune response (interleukins and TNF-α), allowing for repigmentation to occur.
• Calcium modulators – research shows that calcium transport in the melanocytes of vitiligo patients is often defective. Since vitamin D₃ aids in calcium transport, it’s  analogues (calcipotriol and tacalcitol) have been trialed as a vitiligo treatment with varying success. Vitamin D₃ has also been shown to activate melanin synthesis.

Surgical intervention

Surgical therapies are only recommended for patients with stable vitiligo. That is, patients whose patches have not grown or spread for at least 6 months. Surgery is usually very costly and can leave scarring, hence, it is only considered after other therapies have proven ineffective.

• Skin grafts – surgeons remove healthy skin from the patients’ own body, or from a donor, and transplant it to the affected area.
• Tattooing (micropigmentation) – manual tattooing of depigmented areas is a cheaper alternative, however is it difficult to find an exact match for skin colour. In addition, the tattooed skin may not remain the same colour as the surrounding skin as it will not naturally change tone in response to environmental influences.
• Melanocyte transplantation – a promising treatment still in experimental trials, melanocyte transplantation involves culturing normal melanocytes from a skin sample and transferring the new cells into the depigmented patches.

Phototherapy

Ultraviolet (UV) radiation can be used as a therapy to restore pigment to the skin. Multiple sessions over several months may be required before the patient sees results. The extent of the response to phototherapy is highly variable and it is possible for relapse to occur. In the case of successful treatment, vitiligo patches may stabalise or further extend in the future.

• Psolaren plus ultraviolet A radiation (PUVA) – Oral and topical medications called psolarens (photosensitisers) are combined with UVA radiation to repigment areas of skin. PUVA is a moderately effective treatment with a high relapse rate and potential side effects, including: nausea, sunburn, blistering, scaling, abnormally dark repigmentation and rarely, skin malignancies.
• Narrowband ultraviolet B (NB-UVB) radiation – Light therapy using a narrow range of UVB radiation (wavelength of 311 nm), has been shown to be an effective treatment of vitiligo and produces minimal adverse effects. The repigmentation achieved by NB-UVB is generally very acceptable cosmetically, matching well with the surrounding skin. Children and individuals with a darker complexion tend to see better results from this type of phototherapy. Targeted phototherapy using an excimer laser is another source of NB-UVB. Useful for specifically targeting depigmented areas, this form of treatment can be expensive. Excimer laser treatment shows best results on the face, with the hands and feet being less responsive.

Used with permission from Clinuvel, original text online here.