No single therapy for vitiligo produces predictably good results in all patients; the response to therapy is highly variable. In patients with segmental vitiligo, the presence of antinuclear antibody and onset at age younger than 14 years are significant risk factors and may be associated with more refractory disease.  Treatment must be individualized, and patients should be made aware of the risks associated with therapy. During medical therapy, pigment cells arise and proliferate from the following 3 sources:
The pilosebaceous unit, which provides the highest number of cells, migrating from the external root sheath toward the epidermis
Spared epidermal melanocytes not affected during depigmentation 
The border of lesions, migrating up to 2-4 mm from the edge
Systemic phototherapy induces cosmetically satisfactory repigmentation in up to 70% of patients with early or localized disease. 
Narrow-band UV-B phototherapy is widely used and produces good clinical results. Narrow-band fluorescent tubes (Philips TL-01/100W) with an emission spectrum of 310-315 nm and a maximum wavelength of 311 nm are used. Treatment frequency is 2-3 times weekly, but never on consecutive days. This treatment can be safely used in children, pregnant women, and lactating women. Short-term adverse effects include pruritus and xerosis. Several studies have demonstrated the effectiveness of narrow-band UV-B therapy as monotherapy. A 2009 study concluded that oral vitamin E may represent a valuable adjuvant therapy, preventing lipid peroxidation in the cellular membrane of melanocytes and increasing the effectiveness of narrow-band UV-B therapy. 
UV-B narrow-band microphototherapy  is therapy targeting the specific small lesions. Selective narrow-band UV-B (311 nm) is used with a fiber optic system to direct radiation to specific areas of skin. Narrow-band UV-B has become the first choice of therapy for adults and children with generalized vitiligo.
Psoralen photochemotherapy involves the use of psoralens combined with UV-A light. Treatment with 8-methoxypsoralen, 5-methoxypsoralen, and trimethylpsoralen plus UV-A (PUVA) has often been the most practical choice for treatment, especially in patients with skin types IV-VI who have widespread vitiligo. Psoralens can be applied either topically or orally, followed by exposure to artificial UV light or natural sunlight. Vitiligo on the back of the hands and feet is highly resistant to therapy.
The best results from PUVA can be obtained on the face, trunk, and proximal parts of the extremities. However, 2-3 treatments per week for many months are required before repigmentation from perifollicular openings merges to produce confluent repigmentation. The total number of PUVA treatments required is 50-300. Repigmentation occurs in a perifollicular pattern.
The advantages of narrow-band UV-B over PUVA include shorter treatment times, no drug costs, no adverse GI effects (eg, nausea), and no need for subsequent photoprotection.
It has also been used with orally administered glycyrrhizin. 
Another innovation is therapy with an excimer laser, which produces monochromatic rays at 308 nm to treat limited, stable patches of vitiligo. This new treatment is an efficacious, safe, and well-tolerated treatment for vitiligo when limited to less than 30% of the body surface. However, therapy is expensive. Localized lesions of vitiligo are treated twice weekly for an average of 24-48 sessions.
According to studies from 2004 and 2007, combination treatment with 0.1% tacrolimus ointment plus the 308-nm excimer laser is superior to 308-nm excimer laser monotherapy for the treatment of UV-resistant vitiliginous lesions. [34, 35] Excimer laser has been combined with both topical tacrolimus and short-term systemic corticosteroids in the setting of segmental vitiligo. 
A retrospective chart and photographic review of 80 patients concluded that segmental vitiligo has a better repigmentation response with excimer laser treatment used at earlier stages of the disease.  The study also concluded that long-term use and high cumulative UV energy of the excimer laser had better response.
Systemic steroids (prednisone) have been used, although prolonged use and their toxicity are undesirable.  Steroids have been reported anecdotally to achieve success when given in pulse doses or low doses to minimize adverse effects. The benefits versus the toxicity of this therapy must be weighed carefully. More research is necessary to establish the safety and effectiveness of this therapy for vitiligo.
A topical steroid preparation is often chosen first to treat localized vitiligo because it is easy and convenient for both doctors and patients to maintain the treatment. The results of therapy have been reported as moderately successful, particularly in patients with localized vitiligo and/or an inflammatory component to their vitiligo, even if the inflammation is subclinical.
In general, intralesional corticosteroids should be avoided because of the pain associated with injection and the risk of cutaneous atrophy.
Topical tacrolimus ointment (0.03% or 0.1%) is an effective alternative therapy for vitiligo, particularly when the disease involves the head and neck. Combination treatment with topical tacrolimus 0.1% plus the 308-nm excimer laser is superior to monotherapy with the 308-nm excimer laser monotherapy for UV-resistant vitiliginous lesions. On the face, narrow-band UV-B works better if combined with pimecrolimus 1% cream rather than used alone. [38, 39]
A 2009 study out of Kerman Medical University in Iran showed that a combination of pimecrolimus 1% cream and microdermabrasion enhanced response time and repigmentation rates in children with vitiligo. 
Vitamin D analogs, particularly calcipotriol and tacalcitol, have been used as topical therapeutic agents in vitiligo. They target the local immune response and act on specific T-cell activation. They do this by inhibition of the transition of T cells (early to late G1 phase) and inhibition of the expression of various proinflammatory cytokines that encode tumor necrosis factor-alpha and interferon gamma. These vitamin D3 compounds influence melanocyte maturation and differentiation, in addition to up-regulating melanogenesis through pathways that are activated by specific ligand receptors (eg, endothelin receptor and c-kit).  The combination of topical calcipotriene and narrow-band UV-B or PUVA results in improvement appreciably better than that achieved with monotherapy.
Use of khellin 4% ointment and monochromatic excimer light (MEL) 308 nm has been investigated. Forty-eight patients with vitiligo were randomized to 3 groups. Group I included 16 patients treated with MEL 308 nm once weekly and oral vitamin E; group II included 16 patients treated with MEL 308 nm once weekly combined with khellin 4% ointment (MEL-K) and oral vitamin E; group III (control group) included 16 patients treated only with oral vitamin E. Efficacy was assessed at the end of 12 weeks based on the percentage of repigmentation. The clinical response achieved in groups I and II was higher compared with group III (control group), without showing significant differences. Use of khellin 4% may me a valid therapeutic option worthy of consideration in the treatment of vitiligo. 
If vitiligo is widespread and attempts at repigmentation do not produce satisfactory results, depigmentation may be attempted in selected patients.
The long-term social and emotional consequences of depigmentation must be considered. Depigmentation should not be attempted unless the patient fully understands that the procedure generally results in permanent depigmentation. Some authorities have recommended consultation with a mental health professional to discuss potential social consequences of depigmentation. 
A 20% cream of monobenzylether of hydroquinone is applied twice daily for 3-12 months. Burning or itching may occur. Allergic contact dermatitis may be seen. 
Topical PUVA is of benefit in some patients with localized lesions. Cream and solution of 8-methoxypsoralen (0.1-0.3% concentration) are available for this treatment.  It is applied 30 minutes prior to UV-A radiation (usually 0.1-0.3 J/cm2 UV-A) exposure. It should be applied once or twice a week. Physicians who prescribe PUVA therapy should be thoroughly familiar with the risks associated with the treatment. Additional UV-A exposure should be avoided while skin is sensitized because severe burns may occur if patients receive additional UV-A exposure. Sunscreens should be given to all patients with vitiligo to minimize risk of sunburn or repeated solar damage to depigmented skin. Patients must understand that most sunblocks have a limited ability to screen UV-A light.
Of general concern, tanning of surrounding normal skin exaggerates the appearance of vitiligo, and this is prevented by sun protection. Sunscreens with a sun protection factor of 15 or higher are best.
Surgical alternatives exist for the treatment of vitiligo; however, because of the time-consuming nature of surgical therapies, these treatment regimens are limited to segmental or localized vitiligo. Unilateral (segmental) vitiligo has been shown as the most stable form, responding well to surgical interventions in numerous studies. Such areas as dorsal fingers, ankles, forehead, and hairline tend to not repigment well. Patients who have small areas of vitiligo with stable activity are candidates for surgical transplants. The most important factors indicating stability are as follows:
No progression of lesions for at least 2 years
Spontaneous repigmentation indicates vitiligo inactivity
A positive minigrafting test disclosing repigmentation at 4-5 minigrafts, which, to date, is the most accurate evidence of vitiligo stability
Absence of new koebnerization, including the donor site for the minigrafting test
Unilateral vitiligo most stable form of vitiligo 
Noncultured epidermal suspensions: After the achromic epidermis is removed, an epidermal suspension with melanocytes and keratinocytes previously prepared by trypsinization of normally pigmented donor skin is spread onto the denuded area and immediately covered with nonadherent dressings. Using noncultured epidermal cellular grafts, 71% of patients in one study achieved more than 75% repigmentation, especially in segmental vitiligo, piebaldism, and halo nevi.  Color mismatches were common, and generalized vitiligo did not repigment quite as well.
Thin dermoepidermal grafts: The depigmented epidermis is removed by superficial dermabrasion, including the papillary dermis, and very thin dermoepidermal sheets harvested with dermatome are grafted onto the denuded skin.
Suction epidermal grafting: Epidermal grafts can be obtained by vacuum suction, usually with 150 mm Hg. The recipient site can be prepared by suction, freezing, or dermabrasion of the sites 24 hours before grafting. The depigmented blister roof is discarded, and the epidermal donor graft is placed on the vitiliginous areas. 
Punch minigrafting: Small donor grafts are inserted into the incision of recipient sites and held in place by a pressure dressing. The graft heals readily and begins to show repigmentation within 4-6 weeks. Some pebbling persists but is minimal, and the cosmetic result is excellent.
Cultured epidermis with melanocytes or cultured melanocyte suspensions: Depigmented skin is removed using liquid nitrogen, superficial dermabrasion, thermosurgery, or carbon dioxide lasers; very thin sheets of cultured epidermis are grafted or suspensions are spread onto the denuded surface. 
Micropigmentation  is another option. Tattooing can be used to repigment depigmented skin in dark-skinned individuals. Color matching is difficult, and the color tends to fade. Skin can be dyed with dihydroxyacetone preparations, although the color match is often poor.
Long-term results of 2-mm punch grafts in patients with generalized vitiligo and segmental vitiligo were assessed. In patients with generalized vitiligo (61 lesions), 28% had excellent repigmentation, 23% had good repigmentation, 23% had fair repigmentation, and 26% had poor repigmentation. In patients with segmental vitiligo (9 lesions), 78% had excellent repigmentation. Twenty-seven percent of the 70 patients had a cobblestonelike effect. The authors suggested that to prevent a cobblestonelike event, use of smaller grafts may be helpful. 
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