Vitiligo is an acquired autoimmune disease — loss of epidermal melanocyte function results in sharply demarcated depigmented patches.Not contagious, but with familial predisposition (about 20–30% of patients have a family history). Often co-occurs with thyroid disease and other autoimmune conditions; active screening is recommended.
What is Vitiligo?
Vitiligo is a chronic autoimmune disease in which the immune system attacks melanocytes (pigment cells), producing sharply demarcated white patches. Lifetime prevalence ~0.5-2%; can occur at any age but most commonly age 10-30. ~25% have a family history of vitiligo or other autoimmunity.
Types
| Type | Features | Course |
|---|---|---|
| Non-segmental (NSV) — most common | Symmetric, bilateral; trunk, hands, face, joints, around orifices | Chronic, can spread |
| Segmental (SV) | Unilateral, follows dermatome; common in children | Stabilizes within 1-2 years; treatment-responsive when stable |
| Universal vitiligo | > 80% body surface depigmented | Severe, often paired with autoimmune comorbidity |
| Mucosal / acrofacial | Lips, areolae, glans, hands, feet | Difficult to treat (limited follicular reservoir) |
Diagnosis
- Clinical exam: porcelain-white, sharply demarcated patches; symmetric (NSV) or unilateral (SV)
- Wood's lamp (UV-A 365 nm): vitiligo glows bright white-blue, far more visible than under regular light — useful for fair skin and early disease
- Skin biopsy rarely needed; helpful if confused with pityriasis alba, tinea versicolor, post-inflammatory hypopigmentation
- Screen autoimmune comorbidities: thyroid (TSH, anti-TPO), DM, pernicious anemia, Addison's disease
Treatment Strategy
Non-segmental vitiligo
| Severity | 1st-line | 2nd-line / advanced |
|---|---|---|
| Limited (BSA < 3%) | Potent / very potent topical corticosteroid OD (BAD R10, ↑↑); face → tacrolimus 0.1% BID (BAD R12, ↑); reassess at 3–6 months Eleftheriadou 2021, BJD | + NB-UVB / 308 nm excimer; topical Ruxolitinib 1.5% (Opzelura, post-BAD addition: FDA 2022 / EMA 2023) |
| Moderate (BSA 3-10%) | NB-UVB phototherapy 2-3×/wk, may continue up to 1 year (BAD R20, ↑↑); response order face/trunk > limbs > acral Eleftheriadou 2021, BJD | + topical agents; for rapidly progressive disease BAD recommends oral betamethasone 0.1 mg/kg twice weekly + NB-UVB (R17, ↑) |
| Extensive / refractory | NB-UVB + topical/oral therapy | Surgical: cellular grafting (blister grafting / cell suspension) for stable SV/NSV (BAD R25, ↑); mini-punch grafting NOT recommended due to insufficient evidence (BAD Θ); depigmentation in extensive refractory cases (R16) |
JAK inhibitor era (2022 breakthrough)
Topical Ruxolitinib 1.5% cream (Opzelura) is FDA-approved for non-segmental vitiligo aged ≥ 12. TRuE-V1 / V2 phase-3 trials (Rosmarin et al., NEJM 2022): T-VASI50 (50% improvement in target lesion) at week 24 ~ 50%; F-VASI75 (face) ~ 30%. Apply BID, expect first response at 8-12 weeks. Out-of-pocket in Taiwan.
Segmental vitiligo
Standard treatment plus consider surgical melanocyte / mini-punch grafting once stable (≥ 1 year stable). Excellent response in young patients with stable SV.
Prognosis
- Spontaneous repigmentation rare (< 5%) without treatment
- Earlier treatment = better response — start within 6 months of onset for best outcomes
- Face / neck / trunk respond best; hands / feet / lips most resistant (limited follicular reservoir)
- Long-term maintenance often required — vitiligo can relapse
Daily Care
- Sunscreen: BAD 2021 R9 (↑↑) — apply sunscreen with UVA 4–5 star + SPF 50 to affected and surrounding skin before sun exposure Eleftheriadou 2021, BJD. Avoid sunburn (Koebner phenomenon — new vitiligo at trauma sites)
- Camouflage: medical-grade cover makeup (Vichy Dermablend, Covermark) for psychosocial support; BAD R28 supports skin camouflage consultation (↑)
- Vitamin D: BAD R7 (GPP) — for patients avoiding all sun exposure, consider checking serum vitamin D and supplementing D3 10–25 μg/day if low Eleftheriadou 2021, BJD. Topical vitamin D analogues have insufficient evidence (Θ)
- Mental health: vitiligo significantly impacts QoL; consider counseling support
Summary
Vitiligo is treatable but requires patience — repigmentation takes months to years. The 2022 introduction of topical Ruxolitinib has changed the treatment landscape significantly. Early intervention, sun protection, and combined topical-phototherapy are the cornerstones. For stable segmental disease, surgical options offer excellent results.