The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. These drugs are used to stop spread of vitiligo and accomplish repigmentation. Data supporting the efficacy of such treatment is largely anecdotal. More study is needed to establish the safety and efficacy of systemic agents.
Triamcinolone topical is a medium potency topical steroid used to treat inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Hydrocortisone topical is an adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. It has mineralocorticoid and glucocorticoid effects resulting in relief of pruritus.
Clobetasol propionate is a class I superpotent topical steroid; it suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. It decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation.
These agents are used with UV-A exposure for the treatment of localized or generalized vitiligo.
Methoxsalen inhibits mitosis by covalently binding to pyrimidine bases in DNA when photoactivated by UV-A. It is effective in treating hyperkeratosis.
Immunomodulators suppress the activity of the immune system.
The mechanism of action of tacrolimus in atopic dermatitis is not known. It reduces itching and inflammation by suppressing the release of cytokines from T cells. It also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in the early stages of T-cell activation. Additionally, it may inhibit the release of preformed mediators from skin mast cells and basophils and down-regulate the expression of FCeRI on Langerhans cells. Tacrolimus can be used in patients as young as 2 years. Drugs of this class are more expensive than topical corticosteroids. It is available as an ointment in concentrations of 0.03 and 0.1%.
Vitamin D analogs may regulate skin cell production and differentiation.
Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It inhibits epidermal proliferation, promotes keratinocyte differentiation, and has immunosuppressive effects on lymphoid cells. Calcipotriene is used in the treatment of moderate plaque psoriasis. Use 0.005% cream, ointment, or solution.
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