This is the current release of the guideline.

Definitions for the levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) and grades of recommendations (A-D) are presented at the end of the "Major Recommendations" field.

What Symptoms and Signs are Suggestive of Vitiligo?

1. Where vitiligo is classical, as in the symmetrical types, the diagnosis is straightforward and can be made with confidence in primary care. Grade of recommendation D, Level of evidence 4
2. In patients with an atypical presentation, diagnosis is more difficult and referral for expert assessment by a dermatologist is recommended. Grade of recommendation D, Level of evidence 4
3. In adults with vitiligo, a blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid disease in patients with vitiligo. Grade of recommendation D, Level of evidence 3

What is the Accuracy of Wood's light Compared with Naked Eye Examination in the Diagnosis of Vitiligo?

1. Wood's light may be of use in the diagnosis of vitiligo and in the demonstration of the extent and activity of the disease in subjects with skin types I and II. Wood's light can be of use in monitoring response to therapy. Grade of recommendation D, Level of evidence 4

What is the Natural History of Vitiligo?

1. The response to treatment of vitiligo should be considered in the context of the natural history, recognizing that spontaneous repigmentation may occur but is uncommon. Grade of recommendation D, Level of evidence 4

What is the Quality of Life in Patients with Vitiligo Compared with Other Skin Diseases?

1. Clinicians should make an assessment of the psychological and quality of life (QoL) effects of vitiligo on patients. Grade of recommendation C, Level of evidence 2+
2. In therapeutic trials relating to vitiligo, researchers should make the patient's improvement in QoL the most important outcome measure. Grade of recommendation D, Level of evidence 4

In All Patients with Vitiligo, What is the Accuracy of a Scoring Index in Showing the Outcome of Common Treatments Compared with Simple Photography?

1. The vitiligo area-scoring index (VASI) and Vitiligo European Task Force (VETF) tools offer a more accurate measure of disease extent than simple clinical photography alone (even when combined with computerized morphometry) and should be used in a research setting. Additionally, the VETF assesses severity and spreading. Grade of recommendation D, Level of evidence 2+
2. For routine clinical use, serial photographs should be used to monitor response to treatment in vitiligo. Grade of recommendation C, Level of evidence 4

In All patients with Vitiligo, What is the Efficacy of Applying Betamethasone, Clobetasol, Fluocinolone, Fluticasone or Mometasone vs. Placebo or Other Active Treatment in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. In children, and adults with recent onset of vitiligo, treatment with a potent or very potent topical steroid should be considered for a trial period of no more than 2 months. Although benefits have been observed, skin atrophy has been a common side-effect. Grade of recommendation B (by extrapolation), Level of evidence 1+
2. In patients with skin types I and II, in the consultation it is appropriate to consider, after discussion with the patient, whether the initial approach may be to use no active treatment other than consideration of the use of camouflage cosmetics, including fake tanning products and the use of sunscreens. Grade of recommendation D, Level of evidence 4

In All Patients with Vitiligo, What is the Efficacy of Applying Calcipotriol or Tacalcitol vs. Placebo or an Active Treatment in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. The use of topical calcipotriol as a monotherapy is not recommended. Grade of recommendation B, Level of evidence 2++

In All Patients with Vitiligo, What is the Efficacy of Applying Tacrolimus or Pimecrolimus vs. Placebo or an Active Treatment in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. In adults with symmetrical types of vitiligo, topical pimecrolimus should be considered as an alternative to the use of a topical steroid, based on evidence from one study. The side-effect profile of topical pimecrolimus is better than that of a highly potent topical steroid. Grade of recommendation C, Level of evidence 2+
2. In children with vitiligo, topical pimecrolimus or tacrolimus should be considered as alternatives to the use of a highly potent topical steroid in view of their better short-term safety profile. Grade of recommendation B, Level of evidence 1+

In All Patients with Vitiligo, What is the Efficacy of Applying P-(Benzyloxy)phenol (Monobenzyl Ether of Hydroquinone) vs. Placebo or an Active Treatment in Terms of Reducing Areas of Pigmentation?

1. Depigmentation with p-(benzyloxy)phenol (MBEH) or 4-methoxyphenol (4MP) should be reserved for adults severely affected by vitiligo (e.g., who have more than 50% depigmentation or who have extensive depigmentation on the face or hands) who cannot or choose not to seek repigmentation and who can accept the permanence of never tanning. Grade of recommendation D, Level of evidence 4

In All Patients with Vitiligo, What is the Efficacy of a Course of Narrowband Ultraviolet B (UVB) Including High-Intensity Light Sources Compared with Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. Narrow band ultraviolet B (NB-UVB) phototherapy should be considered for treatment of vitiligo only in children or adults who cannot be adequately managed with more conservative treatments. Grade of recommendation D, Level of evidence 4
2. A trial of NB-UVB therapy should be considered for children or adults with widespread vitiligo, or localized vitiligo associated with a significant impact on patient's QoL. Ideally, this treatment should be reserved for patients with darker skin types. Grade of recommendation D, Level of evidence 3
3. Before starting treatment, children, their parents and carers, and adults should be made aware that there is no evidence that NB-UVB phototherapy alters the natural history of vitiligo. They should also be made aware that not all patients respond to this treatment, and that some body sites, such as the hands and feet, respond poorly in all patients. They should also be informed of the limit to the number of treatments due to possible side-effects. Grade of recommendation D, Level of evidence 3
4. If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should be used in preference to oral psoralen with ultraviolet A (PUVA). Grade of recommendation A, Level of evidence 1+
5. Evidence is lacking to define an upper limit for the number of treatments with NB-UVB for patients with vitiligo. Taking into account the published data for patients with psoriasis (see below) and in view of the greater susceptibility of vitiliginous skin to sunburn and possible photodamage (due to absence of melanin), it is advised that safety limits for NB-UVB for the treatment of vitiligo are more stringent than those applied to psoriasis, with an arbitrary limit of 200 treatments for skin types I–III. This could be higher for skin types IV–VI at the discretion of the clinician and with the consent of the patient. Grade of recommendation D, Level of evidence 3
6. It is recommended that physicians prescribing NB-UVB for vitiligo monitor response closely with the assistance of serial clinical photographs (every 2–3 months), more easily to identify patients who fail to respond adequately or in whom the disease progresses during treatment. Grade of recommendation D, Level of evidence 3

In All patients With Vitiligo, What is the Efficacy of a Course of PUVA or PUVA-sol Compared with Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. PUVA therapy should be considered for treatment of vitiligo only in adults who cannot be adequately managed with more conservative treatments. PUVA is not recommended in children. Grade of recommendation D, Level of evidence 4
2. If phototherapy is to be used for treating nonsegmental vitiligo, NB-UVB should usually be used in preference to oral PUVA. Grade of recommendation A, Level of evidence 1+
3. A trial of PUVA therapy should be considered only for adults with widespread vitiligo, or localized vitiligo associated with a significant impact on patient's QoL. Ideally, this treatment should be reserved for patients with darker skin types. Grade of recommendation D, Level of evidence 3
4. Before starting PUVA treatment patients should be made aware that there is no evidence that this treatment alters the natural history of vitiligo. They should also be made aware that not all patients respond, and that some body sites, such as the hands and feet, respond poorly in all patients. They should also be informed of the limit to the number of treatments due to possible side-effects. Grade of recommendation D, Level of evidence 3
5. Evidence is lacking to define an upper limit for the number of treatments with PUVA for patients with vitiligo. Taking into account the published data for patients with psoriasis (see below) and in view of the greater susceptibility of vitiligo skin to psoralen-induced burning and possible photodamage (due to absence of melanin), it is advised that safety limits for PUVA in the treatment of vitiligo are more stringent than those for psoriasis, with an arbitrary limit of 150 treatments for patients with skin types I–III. This could be higher for skin types IV–VI at the discretion of the clinician and with the consent of the patient. Grade of recommendation D, Level of evidence 3
6. It is recommended that physicians prescribing PUVA for vitiligo monitor response closely using serial clinical photographs (every 2–3 months) to identify patients who fail to respond adequately or in whom the disease progresses during treatment. Grade of recommendation D, Level of evidence 3

In All patients with Vitiligo, What is the Efficacy of a Course of Khellin with Sunlight Ultraviolet A (UVA) or UVB Compared with PUVA or PUVA-sol in Terms of Progression, Area Reduction and Quality of Life Score?

1. There is currently insufficient evidence to recommend khellin with UV in the treatment of vitiligo. Grade of recommendation D, Level of evidence 3

Late Complications of PUVA or Narrowband UVB Therapy in Patients with Vitiligo: are Patients Who Have Received Large Doses of PUVA (More than 150 Treatment Sessions) or Narrowband UVB (More than 150 treatment Sessions) at Increased Risk of Developing Premalignant or Malignant Skin Changes?

1. In view of uncertainty regarding the cancer risk, clinicians prescribing NB-UVB or PUVA should be cautious in prescribing these treatments in vitiligo. A clear explanation of the risks and benefits of treatment must be given before treatment, with a Patient Information Leaflet written in lay terms. Grade of recommendation D, Level of evidence 3
2. Patients treated with PUVA or UVB should have their treatment closely supervised by a consultant dermatologist and the treatment regimen for patients with skin types I–III should not exceed 200 treatments for NB-UVB and 150 treatments for PUVA. This recommendation is based on published evidence for patients with psoriasis. Evidence is lacking to define an upper limit for patients with skin types IV–VI for NB-UVB or PUVA. Grade of recommendation D, Level of evidence 4
3. In most patients, NB-UVB should be used in preference to PUVA. Grade of recommendation A, Level of evidence 1+

In All Patients with Vitiligo, What is the Efficacy of a Course of Narrowband UVB with a Vitamin D Analogue Compared with Narrowband UVB with Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. Topical vitamin D analogues in combination with NB-UVB therapy should not be used in the treatment of vitiligo. Grade of recommendation C, Level of evidence 3

In All Patients with Vitiligo, What is the Efficacy of a Course of PUVA with a Vitamin D Analogue Compared with PUVA with Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. Topical vitamin D analogues in combination with PUVA therapy should not be used in the treatment of vitiligo. Grade of recommendation C, Level of evidence 3

In All patients with Vitiligo, What is the Efficacy of Systemic (i.e., Orally and Parenterally Administered) Treatments, Including Corticosteroids, Ciclosporin and Other Immunosuppressive Agents, in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. The use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side-effects. Grade of recommendation B, Level of evidence 2++

In Patients with Vitiligo, What is the Efficacy of a Skin Graft and of Various Forms of Placebo in Terms of Condition Progression, Area Reduction and Quality of Life Score? This May Include Punch Grafts, Full-Thickness Skin Graft, Split-Thickness Skin Graft, Autologous Epidermal Cell Suspension, and Autologous Skin Equivalent (Commercial Skin Equivalent)

1. Surgical treatments in vitiligo should be used only for cosmetically sensitive sites where there have been no new lesions, no Koebner phenomenon and no extension of the lesion in the previous 12 months. Grade of recommendation A, Level of evidence 1++
2. Split-skin grafting is the best option when a surgical treatment is required. Grade of recommendation A, Level of evidence 1+
3. Minigraft is not recommended due to a high incidence of side-effects and poor cosmetic results including cobblestone appearance and polka dot appearance. Grade of recommendation A, Level of evidence 1+
4. Autologous epidermal suspension applied to laser-abraded lesions followed by NB-UVB or PUVA therapy is the optimal surgical transplantation procedure but does require special facilities. Grade of recommendation A, Level of evidence 1+
5. Expanding the autologous cells in tissue culture prior to grafting is feasible and treats larger areas successfully, without the need for additional phototherapy. However, the culturing introduces growth factors leading to uncertain risks and cultures can fail, reducing the value of the procedure. Grade of recommendation D, Level of evidence 3
6. Transfer of suction blisters is an alternative transplantation method, which shows evidence of benefit over placebo but gives less good coverage than split-skin grafting or laser and cell suspension. Grade of recommendation B, Level of evidence 1+

In All Patients with Vitiligo, What is the Efficacy of Cognitive Therapy vs. Psychological Support or No Treatment in Terms of Condition Progression, Area Reduction and Quality of Life Score?

1. Psychological interventions should be offered as a way of improving coping mechanisms in patients with vitiligo. Parents of affected children should be offered psychological counselling. Grade of recommendation D, Level of evidence 4

Definitions:

Levels of Evidence

Grades of Recommendation

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

Where no evidence was available, consensus statements were drawn up.

Not applicable: The guideline was not adapted from another source.

2008 Nov

British Association of Dermatologists - Medical Specialty Society

British Association of Dermatologists

Not stated

Primary Authors: D.J. Gawkrodger, British Association of Dermatologists, 4 Fitzroy Square, London W1T 5HQ, U.K.; A.D. Ormerod, British Association of Dermatologists, 4 Fitzroy Square, London W1T 5HQ, U.K.; L. Shaw, British Association of Dermatologists, 4 Fitzroy Square, London W1T 5HQ, U.K.; I. Mauri-Sole, British Association of Dermatologists, 4 Fitzroy Square, London W1T 5HQ, U.K.; M.E. Whitton, Vitiligo Society, 125 Kennington Road, London SE11 6SF, U.K., Cochrane Skin Group, Centre of Evidence Based Dermatology, King's Meadow Campus, University of Nottingham NG7 2NR, U.K.; M.J. Watts, British Association of Dermatologists, 4 Fitzroy Square, London W1T 5HQ, U.K.; A.V. Anstey, British Association of Dermatologists, 4 Fitzroy Square, London W1T 5HQ, U.K.; J. Ingham, Royal College of Physicians, St Andrew's Place, Regent's Park, London NW1 4LE, U.K.; K. Young, Royal College of Physicians, St Andrew's Place, Regent's Park, London NW1 4LE, U.K.

No member of the Guideline Development Group has declared any interest in companies whose products are named in the guideline, or has had any sponsorship or consultancy from or with companies whose products are named in the guideline, or has had any editorial fees related to commissioned articles for publications named in the guideline, or has a patent pending or existing related to products named in the guideline. D.J.G. has been chairman of the Vitiligo Society's Medical Advisory Board, and M.E.W. is a patron of the Vitiligo Society.

D.J.G., A.D.O., L.S., I.M.-S., M.E.W., M.J.W. and A.V.A. are members of the Guideline Development Group, and technical support was provided by J.I. and K.Y.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on June 4, 2009. The information was verified by the guideline developer on June 18, 2009.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.