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PEARLS IN DERMATOLOGY
Hossani-Madani A. R., Halder R. M.
Howard University College of Medicine, Washington, DC, USA
Topical coticosteroids perform better than placebo and topical PUVAsol in repigmenting vitiliginous skin. Topical corticosteroids compare in efficacy to topical calcineurin inhibitors, but produce greater adverse events. Calcineurin inhibitors are more effective in twice daily dosing and may be used on facial areas and in children. Vitamin D analogues are not as effective as topical corticosteroids as monotherapy, but can increase effectiveness of topical steroids in combination therapy. There are no randomized trials examining pseudocatalase monotherapy. With the advent of NB-UVB, oral PUVA is less used in the treatment of generalized vitiligo. Topical PUVA may be effectively used for the treatment of localized vitiligo. NB-UVB has less side effects and can be used in children. Excimer is also as effective as NB-UVB and may be used in the treatment of localized vitiligo. NB-UVB and excimer combination therapies show some greater effectiveness in repigmentation in vitiligo. All patient undergoing surgical repigmentation therapies, including split-thickness skin grafting, autologous epidermal non-cultured grafts, suction blistering and punch grafting require careful patient selection. Those that have localized, stable vitiligo refractory to other treatments are good surgical candidates. Split thickness skin grafting has the best cosmetic results, with the least side effects. However, scarring of donor and recipient sites is common to split thickness skin grafting. Depigmenting treatments include MBEH, 4-MP, and the Q-switched ruby laser. MBEH and 4-MP may have similar efficacy, but MBEH has a greater side effect profile than 4-MP. Also, visible depigmentation occurs sooner with MBEH as compared with 4-MP, despite both of them requiring long treatment periods. Relapse with both treatments may occur. The Q-switched ruby laser does seem to have the advantage of inducing depigmentation more quickly, but with more discomfort.