Current and emerging treatments

for vitiligo
Michelle Rodrigues, MBBS(Hons), FACD,a,b Khaled Ezzedine, MD, PhD,c,d Iltefat Hamzavi, MD,e
Amit G. Pandya, MD,f and John E. Harris, MD, PhD,g on behalf of the Vitiligo Working Group
Victoria, Australia; Creteil, France; Detroit, Michigan; Dallas, Texas; and Worcester, Massachusetts

Learning objectives
After completing this learning activity, participants should be able to choose an optimal approach to management of all patients with vitiligo; list the risks associated with treatment for
vitiligo; and discuss emerging treatment options for vitiligo.

Disclosure
Editors
The editors involved with this CME activity and all content validation/peer reviewers of the journal-based CME activity have reported no relevant financial relationships with
commercial interest(s).
Authors
The authors involved with this journal-based CME activity other than Dr Harris have reported no relevant financial relationships with commercial interest(s). Dr Harrris has served on advisory
boards, as a consultant, or as principle investigator on research agreements with Pfizer, AbbVie, Genzyme/Sanofi, Concert Pharmaceuticals, Stiefel/GSK, Mitsubishi Tanabe Pharma, Novartis,
Aclaris Therapeutics, The Expert Institute, Celgene, Biologics MD, and Dermira. Dr Harris relevant relationship with Pfizer was resolved by nonconflicted reviewers and editors.

Planners
The planners involved with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s). The editorial and education staff involved
with this journal-based CME activity have reported no relevant financial relationships with commercial interest(s).

Clinicians should be aware that vitiligo is not merely a cosmetic disease and that there are safe and effective
treatments available for vitiligo. It is important to recognize common and uncommon presentations and
those with active disease, as well as their implications for clinical management; these were discussed in the
first article in this continuing medical education series. Existing treatments include topical and systemic
immunosuppressants, phototherapy, and surgical techniques, which together may serve to halt disease
progression, stabilize depigmented lesions, and encourage repigmentation. We discuss how to optimize the
currently available treatments and highlight emerging treatments that may improve treatment efficacy in the
future. ( J Am Acad Dermatol 2017;77:17-29.)

Key words: afamelanotide; biologics; corticosteroids; excimer lamp; excimer laser; grafting; leukoderma;
methotrexate; narrowband ultraviolet light; phototherapy; pigmentation; tacrolimus; treatment; vitiligo.

MEDICAL TREATMENTS d Topical tacrolimus 0.1% should be used

Key points twice daily for affected areas on the face
d Potent or ultrapotent topical corticosteroids and intertriginous areas
administered in a cyclical fashion avoids d Narrowband ultraviolet B light phototherapy
adverse effects appears to be safe and effective when [5-10%

From the Department of Dermatology,a St. Vincents Hospital, The Conflicts of interest: See above.
Skin and Cancer Foundation Inc, and The Royal Childrens Accepted for publication November 6, 2016.
Hospital,b Victoria, Australia; Department of Dermatology,c Reprints not available from the authors.
Henri Mondor Hospital, and EpiDermE,d Universite Paris-Est, Correspondence to: Michelle Rodrigues, MBBS(Hons), FACD,
Creteil, France; Department of Dermatology,e Henry Ford Department of Dermatology, 41 Victoria Parade, Fitzroy, VIC
Hospital, Detroit; Department of Dermatology,f University of 3065, Australia. E-mail: dr.rodrigues@gmail.com.
Texas Southwestern Medical Center, Dallas; and the 0190-9622/$36.00
Department of Dermatology,g University of Massachusetts 2016 by the American Academy of Dermatology, Inc. Published
Medical School, Worcester. by Elsevier Inc. All rights reserved.
Supported by the National Institute of Arthritis and Musculoskel- http://dx.doi.org/10.1016/j.jaad.2016.11.010
etal and Skin Diseases, part of the National Institutes of Health, Date of release: July 2017
under Award Numbers AR061437 and AR069114, and research Expiration date: July 2020
grants from the Kawaja Vitiligo Research Initiative, Vitiligo
Research Foundation, and Dermatology Foundation Stiefel
Scholar Award (to Dr Harris).

17
18 Rodrigues et al J AM ACAD DERMATOL
JULY 2017

body surface area is affected; focused Topical calcineurin inhibitors (level II

narrowband ultraviolet B light phototherapy, evidence)
such as hand and foot units or excimer laser, In recently published guidelines, the European
is useful in localized disease Dermatology Forum group proposed twice daily
d Topical tacrolimus 0.1% used twice per week topical calcineurin inhibitors for head and neck
may help prevent relapse after repigmenta- lesions as a first-line approach.5 This recommenda-
tion is achieved tion is based on a combination of its efficacy in these
sites and its favorable side effect profile.6,7 Warnings
Vitiligo is not a cosmetic disease,1 so treatment
have been placed on the long-term use of tacrolimus
can and should be offered to patients. The optimal because of a theoretical long-term risk of cancer,
treatment of vitiligo will first depend on the subtype
despite its repeatedly demonstrated safety.8 Other
of the disease, percent of body surface area (BSA)
than exposure to medically administered photo-
involved, effect on quality of life, and the perception
therapy or excimer laser, photoprotection should
of the patient concerning the risk to benefit ratio. For
be encouraged when using topical immunosuppres-
example, in the segmental variant of vitiligo, the
sion. When using a cyclical regimen for topical
disease follows a predictable course, with a phase of
steroids outlined above, calcineurin inhibitors may
rapid spreading and early hair follicle involvement
be used on the off days to provide consistent
restricted to the affected segment lasting 3 to treatment without increasing the risk of adverse
24 months. This is usually followed by complete
events.
stabilization. The segmental variant is therefore more
difficult to treat and requires early medical interven-
Phototherapy
tion or a surgical approach late in the disease course.
There are 2 main indications for the use of whole-
With all types of vitiligo, timing of treatment is an
body phototherapy in vitiligo: extensive disease
important predictor of success, with early disease
([5-10% of BSA) and rapidly spreading disease.
responding best.2
However, patients with smaller areas of involvement
In contrast to the segmental variant, most cases of
and less activity may also require phototherapy in
vitiligo follow an unpredictable course, with periods
some instances because of its superior efficacy.
of disease progression and quiescence. Early involve-
With all medical interventions, the physical and
ment of the hair follicle is uncommon.3 Spontaneous
psychological impact of the disease should be
repigmentation has been described, although this is
weighed against the risks of a particular treatment,
not the rule. At present, no medical treatment for
which typically requires physicians to customize
repigmenting vitiligo has been approved by the US
the management strategy for each patient. In
Food and Drug Administration (FDA), and therefore
general, patients should not apply any topical
treatments are used off-label. Topical treatments may
medications or sunscreen before ultraviolet (UV)
be applied alone when small areas are involved or
light therapy in order to avoid reduced transmission
when other treatment modalities are not readily
of UV light into the skin. Patients should also be
available. Phototherapy combined with topical
vigilant about sun protection to avoid additive effects
treatment is preferred when [5-10% of the BSA is
of sun exposure when receiving UV light therapy
affected or when focal areas are unresponsive to
treatment.
topical treatments alone.
Psoralen plus ultraviolet A light phototherapy
Topical corticosteroids (level II evidence) (level I evidence)
When selecting a topical steroid, the site of the Psoralen plus ultraviolet A light phototherapy
lesion and age of the patient should be considered. (PUVA) was the first phototherapy regimen used in
Lesions on the body may be treated with ultrapotent or patients with vitiligo. The results were reasonable,
potent corticosteroids; the face, neck, and intertrigi- but issues with compliance (eg, oculocutaneous
nous areas and lesions in children should be treated protection), side effects (eg, nausea), and an
with either midpotency topical corticosteroids or increased risk of skin cancer led to a decline in its
calcineurin inhibitors (see below). Possible regimens use. In a recent Cochrane review, PUVA was deemed
include daily or twice daily application in a cyclical inferior to narrowband ultraviolet B light therapy
fashion with days off (eg, 1 week on then 1 week off (NB-UVB) in achieving [75% repigmentation in the
for 6 months, or application for 5 consecutive days general population of vitiligo patients.6 Therefore,
followed by 2 days off).4 In practice, these regimens PUVA has been largely replaced by NB-UVB,
appear to minimize the risk of adverse effects, although although PUVA may still induce faster repigmenta-
evidence-based studies to support this are lacking. tion.9,10 PUVA may be considered in patients with
J AM ACAD DERMATOL Rodrigues et al 19
VOLUME 77, NUMBER 1

Fig 2. Vitiligo. Lesion on the lower leg before excimer

Fig 1. Vitiligo. Carnation pink color of vitiligo in a patient laser treatment.
being treated with narrowband ultraviolet B light
phototherapy.

darker Fitzpatrick skin phototypes or those with

treatment-resistant vitiligo.11-13

NB-UVB (level I evidence)

In addition to its immunosuppressive effects,
NB-UVB induces melanocyte differentiation and
melanin production.14 In the last decade, NB-UVB
has become the first-line therapy for extensive,
progressive vitiligo because of its superiority to
PUVA and its relative paucity of side effects. It can
also be used safely in children and those who
are pregnant or lactating. When used alone,
repigmentation rates ranging from 40% to 100%
have been reported, depending on the location of
the lesions.15-19 Patients should be treated with an Fig 3. Vitiligo. Lesion on the lower leg (with pigmented
optimized, aggressive approach, starting at a safe, hairs, which portend a favorable prognosis) after 7 months
low dose (ie, 200 mJ) 2 to 3 times per week with 10% of excimer laser therapy.
to 20% dose increments. When asymptomatic, light typically fails to stabilize vitiligo because clinically
pink erythema (Fig 1) lasting \24 hours is achieved, unaffected skin is not treated. In the segmental
the optimal dose has been reached and treatment variant, excimer laser seems to be the most beneficial
should continue at this dose until erythema treatment when used early in the disease course.21 In
disappears. The dose should then be increased again a recent retrospective study, 59 patients with the
until it returns.20 The maximum dose of NB-UVB segmental variant, which is typically refractory to
varies depending on Fitzpatrick skin phototype and treatment, responded well to excimer laser, topical
photosensitivity. There are no established guidelines tacrolimus, and short-term systemic corticosteroids
for maximum dosing for vitiligo, and we therefore for 3 months; almost 50% of patients achieved [75%
recommend increasing the dose until light pink repigmentation.22
erythema is achieved or until side effects (such as
skin burning, sensitivity, peeling, or thickening)
Oral immunosuppression (level III-2 evidence)
develop. A lack of response after 6 months suggests
Oral steroids may help stabilize rapidly
a nonresponsive patient, and discontinuation of
progressive disease. Oral minipulse therapy (OMP)
treatment should be considered.11
refers to the discontinuous administration of
suprapharmacologic doses of steroids. Randomized
Targeted UVB phototherapy (level II) controlled trials investigating their efficacy are still
Targeted phototherapy (excimer lasers and lacking, although numerous retrospective studies
excimer lamps) can be considered when \10% of support their use in progressive disease. The
BSA is affected.2 This therapy is attractive for patients regimen consists of low-dose betamethasone or
who wish to avoid skin darkening caused by dexamethasone for 3 to 6 months on 2 consecutive
NB-UVB (Figs 2 and 3). Although effective in the days. It is usually administered in combination with
repigmentation of stable lesions, this focal therapy other therapies, including phototherapy.23 In initial
20 Rodrigues et al J AM ACAD DERMATOL
JULY 2017

reports, 5 mg betamethasone/dexamethasone was significant. Facial lesions responded best, with most
used on 2 consecutive days per week.24,25 This was patients tolerating treatment well. While small, this
increased to 7.5 mg/day in nonresponders study provides evidence of efficacy for the treatment
and decreased back to 5 mg/day when disease of vitiligo with tacrolimus (level of evidence I, strength
progression was arrested. The results showed that of recommendation A).
89% of patients were stabilized within 1 to 3 months. Another study evaluated 100 children with vitiligo
In another study, dexamethasone 10 mg twice treated with tacrolimus, clobetasol, or placebo
weekly for #24 weeks halted disease progression ointment.39 The clobetasol-treated group received
in 88% of patients after 18.2 weeks.26 However, 69% intermittent therapy and others continuous therapy;
experienced side effects, including weight gain, the clobetasol-treated group received clobetasol
insomnia, acne, agitation, menstrual irregularities, ointment for 2 months, petroleum jelly for the next
and hypertrichosis. 2 months, and clobetasol again for the remaining
2 months. The tacrolimus-treated group received
Other immunosuppressants and biologics 0.1% ointment for 6 months, and the placebo-treated
Limited data are available for the use of other group received petroleum jelly continuously for
immunosuppressant drugs in vitiligo. In a recent 6 months. There was no statistically significant
randomized comparative study, low-dose oral difference between the tacrolimus and clobetasol
methotrexate was reported to be comparable to OMP, groups, although facial lesions responded better
and suggested when OMP is contraindicated, although than nonfacial lesions overall. Both treatments
responses were marginal with small study sizes.27 were superior to placebo (level of evidence I,
Antietumor necrosis factor-a drugs have been strength of recommendation A).
suggested for the treatment of vitiligo28,29 despite A small study of 10 patients with bilaterally
reports of no benefit and even initiation and symmetrical generalized vitiligo treated with
worsening with their administration.30-34 Twice clobetasol cream on one side of the body and
daily oral cyclophosphamide (50 mg) has also pimecrolimus cream on the other showed a
demonstrated repigmentation in 29 patients, comparable degree of repigmentation, although
including those with difficult to treat acral sites, small numbers make noninferiority trials like this
although significant side effects were reported.35 difficult to interpret.40 (level of evidence II-I, strength
Although spontaneous remissions are uncommon of recommendation B).
in patients with vitiligo, treatment recommendations NB-UVB versus PUVA. NB-UVB therapy has
based on uncontrolled studies should be weighed become the predominant form of phototherapy for
against that possibility. vitiligo because of its efficacy, relative lack of side
effects, and convenience. A study comparing
Other treatments 12 months of twice weekly NB-UVB to twice weekly
Vitamin D analogs (level III-I evidence). Most oral 8-methoxypsoralen PUVA demonstrated
studies have evaluated calcipotriene in combination superior repigmentation, color matching, and fewer
with other therapies, particularly phototherapy. side effects in the NB-UVBetreated group.11 Overall,
Calcipotriene may shorten the time to achieve 64% of the NB-UVB group had [50% improvement
repigmentation and reduce overall cumulative in BSA affected versus 36% in the PUVA group. The
exposure during phototherapy, but it has not superiority of NB-UVB was maintained 12 months
demonstrated appreciable repigmentation when after treatment ended (level of evidence I, strength of
used alone.36,37 recommendation A).
Other treatments for vitiligo appeared to be Another investigator-blinded trial of NB-UVB
promising in pilot trials but failed to demonstrate versus PUVA 3 times per week for 6 months was
significant efficacy in later controlled trials. Examples conducted in 56 patients.41 Median repigmentation
include Polypodium leucotomas, ginkgo biloba, was similar between the 2 groups but adverse effects,
antioxidants, and pseudocatalase cream.38 particularly pruritus, were much lower in the
Comparative efficacy studies. Topical steroids NB-UVB group (7.4% vs 57.2%). The face, neck,
versus calcineurin inhibitors. There have been a few and trunk demonstrated the best response in
studies comparing different treatments for vitiligo. In 1 both groups (level of evidence I, strength of
study, tacrolimus ointment 0.1% was compared recommendation A).
with clobetasol cream 0.05% in children.7 This Combination therapies. Although antioxidants have
randomized, double-blind, comparative trial revealed been promoted for various skin diseases, including
49% repigmentation with clobetasol and 41% with vitiligo, few controlled studies have attempted
tacrolimus, but the difference was not statistically to determine their true efficacy. In 1 randomized,
J AM ACAD DERMATOL Rodrigues et al 21
VOLUME 77, NUMBER 1

Fig 4. Vitiligo. Lesion on the upper aspect of the back

before narrowband ultraviolet B light phototherapy.
Fig 5. Vitiligo. Lesion on the upper aspect of the back
after 5 months of narrowband ultraviolet B light
phototherapy.
double-blind, placebo-controlled study,42 patients
received a combination of a-lipoic acid, vitamin C,
vitamin E, and polyunsaturated fatty acids or placebo Maintenance therapy. Given that the risk of
for 2 months. They were then treated with NB-UVB for relapse in the first year after ceasing therapy is
6 months. Forty-seven percent of those treated with 44%,45 it may be important to transition patients
antioxidants before NB-UVB demonstrated [75% to maintenance therapy once repigmentation is
repigmentation versus 18% in the placebo plus achieved. In 1 study, all patients achieving [75%
NB-UVB group. Although this is a single study, this repigmentation from any modality were treated with
controlled trial supports the use of antioxidants in either tacrolimus ointment 0.1% or placebo ointment
patients undergoing phototherapy (level of evidence twice weekly. Thirty-five patients were enrolled in
I, strength of recommendation A). this 24-week trial.46 Lesions on the hands and feet
Evidence for treatment regimens. There is little were excluded. Ninety-six percent of those treated
evidence to guide clinicians on selecting the optimal with tacrolimus on the head and neck maintained the
frequency, dosing, and duration of treatment for repigmented areas without relapse, while only 60%
vitiligo. No comparative studies have been on placebo were maintained. Success of the
performed on one topical dosing frequency versus maintenance therapy was independent of initial
another, 2 times weekly versus 3 times weekly treatment modality. Topical tacrolimus ointment
phototherapy, or on different doses of oral 0.1% twice weekly can therefore be recommended
corticosteroids for active vitiligo. Two have studied for maintenance therapy (level of evidence II; Figs 6
differences in efficacy between 2 and 3 times weekly and 7). Some have suggested a similar approach with
treatments with the excimer laser for vitiligo.43,44 NB-UVB to prevent relapse, but no studies have
Both concluded that there was no difference in tested the efficacy of this approach.
the final degree of repigmentation between the 2
dosing frequencies; however, repigmentation was
SURGICAL TECHNIQUES
dependent on the total number of treatment
Key points
sessions, with earlier onset of pigmentation noted d Surgical techniques are most successful in
with 3 times weekly dosing. This is likely to be the
late-stage segmental vitiligo
case for NB-UVB also. d Surgery can be considered in those with
Regarding duration of therapy, a previous study
nonresponsive, stable vitiligo
reported a mean 25% improvement after 3 months, d Noncultured epidermal melanocyte cell
50% after 6 months, and 75% after 9 months of
grafting demonstrates superior extent and
NB-UVB therapy11 (Figs 4 and 5). The slow but
quality of pigmentation compared with
steady improvement when undergoing therapy for
other surgical techniques
vitiligo requires patience and motivation on the part
of the patient and clinician. Monitoring improvement Surgical treatments offer some of the best results
requires baseline and serial images at each visit. As for stable vitiligo. Repigmentation can improve by
long as the patient is improving and side effects are $68% in certain types of vitiligo with only 1
tolerable, treatment can be continued until no further treatment session.47 When repigmentation is
improvement occurs, after which maintenance obtained in these patients, relapse is uncommon.48,49
treatment can be initiated. Several surgical options exist, which can be classified
22 Rodrigues et al J AM ACAD DERMATOL
JULY 2017

Fig 6. Vitiligo. Depigmented patch on buttock and

scrotum of baby boy that repigmented with topical
therapy.
Fig 8. Vitiligo. Lesion on left upper eyelid before treatment.

Fig 7. Vitiligo. After 13 months of maintenance therapy

with twice weekly tacrolimus, pigmentation has been Fig 9. Vitiligo. Lesion on left upper eyelid 9 months after
maintained on the buttock and scrotum. punch grafting. The hyperpigmentation and cobblestone
appearance of the punch grafts usually subside with time.

into tissue and cellular grafts. Tissue grafts usually Koebnerization, confetti-like lesions, inflammatory
transfer solid tissue from donor to recipient site in a vitiligo, and trichrome vitiligo are also indicators of
1:1 ratio. Cellular grafts cover larger surface areas and unstable disease and are discussed in detail in the
are composed of suspensions of keratinocytes and first article in this continuing medical education
melanocytes in a donor to recipient ratio up to 1:10. series.52,53
Recipient site is another variable that should
Patient selection be considered. In general, the head and neck
Patient selection is key to success with surgical demonstrate a superior response.55,56 Acrofacial
treatment for vitiligo. Those with stable disease have disease and areas over joints respond poorly, possibly
a superior response to surgical intervention. Patients because of repeated motion or friction and injury at
with segmental disease have better results than those these locations.55,56 Patients must be screened for a
with focal disease who, in turn, fare better than history of keloids, coagulation abnormalities,
patients with generalized, unstable vitiligo.50-53 bloodborne infections, and other contraindications
Disease stability must be evaluated before surgery to surgery, such as severe heart disease.
and is defined by the absence of new or expanding
lesions over 6 months to 2 years. Several methods
can be used to assess stability, such as patient report, Tissue grafts
serial photography, and validated scoring systems. Minipunch grafts are performed by placing 1- to
These include changes in the Vitiligo Area Scoring 1.5-mm punch biopsy specimens from a donor site
Index, Vitiligo European Task Force assessment, and into a preprepared recipient site (Figs 8 and 9). This
Vitiligo Disease Activity Score. In cases where technically simple, inexpensive technique does not
stability or treatment outcome is uncertain, require specialized equipment but is difficult to
performing a test procedure with a single punch perform on large areas, can lead to pigment and
graft in the center of a stable, depigmented lesion to textural variations such as cobblestoning, and carries
assess the degree of repigmentation is useful.53,54 a risk of scarring and keloids.57-60
J AM ACAD DERMATOL Rodrigues et al 23
VOLUME 77, NUMBER 1

Fig 10. Vitiligo. Harvesting of suction blister grafts. Fig 11. Vitiligo. Segmental variant of vitiligo on the left
upper forehead at baseline.
Suction blister epidermal grafting involves the
creation and transfer of blister roofs from normal
skin (Fig 10) to abraded depigmented skin.
Advantages include low cost, use of simple
equipment, uniform color match, low rates of
scarring, and good efficacy. The time required to
create blisters and risk of hemorrhagic blisters are
disadvantages.57-59,61-63

Cellular grafts
Cellular grafts can be cultured or noncultured and
involve creating a cellular suspension from a thin to
ultrathin skin graft. Noncultured options, although
complex, do not require a full cell culture laboratory. Fig 12. Vitiligo. Segmental variant of vitiligo on the left
Therefore, noncultured epidermal suspension upper forehead 9 months after noncultured epidermal
suspension grafting.
(NCES) grafting, also known as a melanocyte
keratinocyte transplant procedure, is performed Comparative efficacy
more frequently than cultured melanocyte grafting. NCES has shown superior extent and quality of
It is now considered the criterion standard for vitiligo repigmentation compared with blister grafting.67
grafting worldwide. However, blister grafting and punch grafting are
NCES is performed by harvesting an ultrathin skin much easier techniques to master and require fewer
graft from a donor site, which is then incubated in support staff.
trypsin. After removal of the epidermis from the
dermis, the epidermis is manually disrupted and then
Camouflage techniques
centrifuged to obtain the cellular pellet, which is
Camouflage may be an important part of overall
resuspended in Ringers lactate, applied to the
patient management given the aesthetic impact of
abraded recipient site, and dressed. Movement
the disease in many patients. Self-tanning agents
should be restricted postoperatively to avoid
provide waterproof protection for 3 to 5 days; highly
dressing displacement, but bed rest is not required.
pigmented cover creams require daily application
Dressings are removed between days 4 and 7. This
but are lightweight and waterproof. While dermal
procedure yields good cosmetic results and color
pigmentation can be achieved with techniques like
match (Figs 11 and 12). Disadvantages include the
cosmetic tattooing, potential risks should be
cost, need for specialized equipment and a skilled
carefully considered. These risks include the
team, and limitations of sites that can be successfully
potential for infection, risk of koebnerizing vitiligo,
treated.47,51 A new method using epidermal suction
lack of legislation on tattoo pigments, poor color
blisters for donor skin has also been described.64 Of
match, bleeding of color over time, and potential for
note, battery-operated cell harvesting devices have
spread of the lesion beyond the tattoo border.68
also been developed, offering a self-contained
system for cell separation without the need for
additional equipment. Head to head comparison TREATMENT ALGORITHM
studies to standard NCES tissue processing Treatment for vitiligo should be started as early as
techniques have not yet been performed.65,66 possible to maximize efficacy. The type of vitiligo,
24 Rodrigues et al J AM ACAD DERMATOL
JULY 2017

Topical therapies
Reported side effects of inappropriate or
unsupervised topical steroids include cutaneous
atrophy, telangiectasias, hypertrichosis, acne, and
striae. However, its side effect profile has been
deemed favorable when used as prescribed by
dermatologists for atopic dermatitis, in which there
is epidermal barrier dysfunction and a greater
likelihood of systemic absorption.69 To minimize
the risk of side effects, a sequential discontinuous
scheme may be used.
Topical tacrolimus lacks the side effect profile of
topical steroids and appears to be much safer,
particularly on sensitive areas like the face, genitals,
and intertriginous sites. When topical tacrolimus first
became available for use, concerns were raised
about the risk of malignancies that had been
observed in those taking large oral doses to prevent
transplant organ rejection. However, a recent
systematic review and metaanalysis reporting on
Fig 13. Treatment algorithm for the segmental variant of the risk of lymphoma in those with atopic dermatitis
vitiligo. NB-UVB, Narrowband ultraviolet light phototherapy; concluded that it does not appear to significantly
TCS, topical corticosteroids; TIM, topical immunomodulators. contribute to the overall risk of lymphoma in this
subgroup of patients.70 Nevertheless, this black box
extent and duration of disease, effect on quality of warning remains and it is still not approved by the
life, and previous treatments should determine FDA, Therapeutic Goods Administration (Australia),
the initial treatment approach. The segmental or the European Medicines Agency for use in vitiligo.
variant, when treated early in the disease course If burning after application of tacrolimus is noted, the
(#12 months), can be initially treated with concentration may be decreased. While skin flushing
skin-directed medical therapy. In nonresponsive or may occur immediately after alcohol ingestion and is
longstanding stable disease, surgical therapies not always limited to the area of application, it
should be considered (Fig 13). resolves quickly.71
The extent of involvement also determines the
treatment approach in vitiligo. Localized disease Phototherapy
(#5-10% of BSA) is best treated with topical therapy While an absence of melanin in lesional skin and
and targeted phototherapy, while a combination of NB- prolonged administration of phototherapy may give
UVB and topical therapy is used to treat more extensive rise to concern about the development of skin cancer
disease ([5-10% of BSA). OMP can be added for those in this population, recent evidence suggests that the
with clinical signs of aggressive, progressive disease genetic and autoimmune profile of vitiligo patients
(Fig 14). Efficacy can be assessed at approximately confers a degree of protection against melanoma and
6 months based on twice-weekly NB-UVB. nonmelanoma skin cancers (NMSCs).72-78 While
prolonged PUVA for psoriasis increases the risk of
TREATMENT SAFETY cutaneous malignancies in white patients, the same
Key points has not been noted with NB-UVB.79,80 Even studies
d Topical corticosteroids, when used as of PUVA for vitiligo do not appear to be associated
directed and with dermatologic supervision, with the development of NMSCs.81,82
appear to be safe and are usually efficacious While Hexsel et al83 reported a higher annual
for vitiligo incidence of NMSC in those with vitiligo compared
d Despite evidence that tacrolimus does not with the rest of the population, 5 other studies reveal
appear to increase the risk of malignancy, its lower rates of melanoma and NMSC in this
black box warning remains population.84-88 In addition, a 2005 review of the
d Long-term administration of NB-UVB does not literature suggested that chronic use of ultraviolet
appear to increase incidence of melanoma or B light does not seem to increase the risk of
nonmelanoma skin cancers in those with skin cancer.89 Limitations exist for all of these
vitiligo studies, highlighting the need for well-constructed
J AM ACAD DERMATOL Rodrigues et al 25
VOLUME 77, NUMBER 1

Vitiligo

5-10% BSA >5-10% BSA

TCS; TIM + targeted Aggressive/rapidly Nonaggressive/not

NBUVB progressive rapidly progressive

No response (lack of Response (stable at 3

stability at 3 months, months, OMP + NBUVB +
TMI
T MI NBUVB+TCS/TIM
no repigmentation at 6 repigmentation at 6 TCS/TMI
months) months

Continue treatment No response at 6

stable 1 year or more and review at 3 month Response at 6 months
months
intervals No response at 6
Response at 3 months
months

Continue treatment
and review at 3 month
Surgical therapy intervals
Cosmetic camou lage
Stop OMP and continue
NBUVB + TCS/TMI with
3 month intervals

Depigment (if
extensive - >70%BSA)

Fig 14. Treatment algorithm for vitiligo.

prospective randomized controlled trials that span of 48.64% and 33.26% at day 168, respectively. Side
decades. effects included hyperpigmentation, itch, and
nausea.90 Additional studies with this promising
Surgical treatments treatment are warranted.
Complications are rare with most surgical
procedures but include pain, hypopigmentation, Targeted immunotherapy
koebnerization, scarring, and infection.47,60 In the first article in this series, we outlined recent
translational research that has provided insight
EMERGING TREATMENT MODALITIES into possible targets for targeted therapies
Key points for vitiligo. In particular, interfering with the
d Afamelanotide enhances the efficacy of interferon (IFN)-g-CXCL10 chemokine axis may be
NB-UVB in patients with vitiligo an effective strategy to develop novel, targeted
d Targeted immunotherapy has been safe immunotherapies.91 Significant repigmentation of 2
and effective for psoriasis, and a similar patients after the oral administration of tofacitinib92
treatment strategy may be equally beneficial (a paneJanus kinase inhibitor [JAK 1/3)]) and
for vitiligo patients ruxolitinib93 (JAK 1/2 inhibitor), which directly
d The interferon-g-CXCL10 chemokine axis inhibit IFN-g signaling, supports this concept.
appears to be an important target for the However, repigmentation regressed when the
development of new treatments for vitiligo patient discontinued ruxolitinib, suggesting that
continuous treatment is required. Importantly, the
a-Melanocyte-stimulating hormone analogues patients serum CXCL10 level was reduced during
Afamelanotide is a potent synthetic analogue of treatment with ruxolitinib, suggesting that JAK
the naturally occurring a-melanocyte-stimulating inhibition works by targeting the IFN-g-CXCL10
hormone. It was investigated as an adjunct to axis, and that it may serve as a biomarker for disease
NB-UVB in a double blind, multicenter study. activity and treatment response. A recent case series
Patients treated with NB-UVB plus afamelanotide reported efficacy of topical ruxolitinib in patients
versus NB-UVB alone achieved repigmentation rates with vitiligo, particularly on the face.94 While these
26 Rodrigues et al J AM ACAD DERMATOL
JULY 2017

advances are promising for vitiligo sufferers and autoimmune destruction of melanocytes along
dermatologists alike, larger, controlled studies are with stimulation of melanocyte regeneration is
required to assess the safety and efficacy of targeted likely to produce the best results. Lack of previous
therapies for vitiligo. success is often the reason for a pessimistic outlook
regarding treatment on the part of both the treating
Depigmentation physician and the patient; however, education and
For patients with recalcitrant and widespread establishing realistic expectations, a comprehensive
([50% of BSA) vitiligo, depigmentation of the treatment plan, and photography at each visit can
remaining islands of pigment may provide cosmetic result in a successful outcome. Recent advances in
improvement that may enhance quality of life. determining the pathogenesis of the disease have
Following its discovery in rubber gloves95 opened exciting new treatment avenues that may
more than 50 years ago, monobenzylether of herald a revolution in the future treatment of
hydroquinone (MBEH) has become the most vitiligo.
commonly used depigmentation therapy for vitiligo
and is currently the only drug approved by the FDA REFERENCES
for the treatment of vitiligo in the United States. 1. Ezzedine K, Sheth V, Rodrigues M, et al. Vitiligo is not a
Depigmentation should only be considered after cosmetic disease. J Am Acad Dermatol. 2015;73:883-885.
2. Ezzedine K, Eleftheriadou V, Whitton M, van Geel N. Vitiligo.
psychological screening and informed consent Lancet. 2015;386:74-84.
about the irreversible nature of the treatment. 3. Gan EY, Cario-Andre M, Pain C, et al. Follicular vitiligo: a
Patients should be aware that depigmentation report of 8 cases. J Am Acad Dermatol. 2016;74:1178-1184.
cannot be targeted to a single location, but local 4. Stinco G, Trevisan G, Buligan C, et al. Narrow band-ultraviolet
application frequently depigments the entire skin. B versus clobetasol propionate foam in the treatment of
vitiligo: a retrospective study. Dermatol Ther. 2013;3:95-105.
MBEH is applied in a 20% concentration twice daily 5. Taieb A, Alomar A, Bohm M, et al. Guidelines for the
to pigmented skin, and care should be taken to avoid management of vitiligo: the European Dermatology Forum
excessive sun exposure, which can result in consensus. Br J Dermatol. 2013;168:5-19.
perifollicular repigmentation. The most common 6. Whitton ME, Pinart M, Batchelor J, et al. Interventions for
side effect is irritant contact dermatitis, which vitiligo. Cochrane Database Syst Rev. 2015;2:CD003263.
7. Lepe V, Moncada B, Castanedo-Cazares JP, Torres-Alvarez MB,
may be treatment-limiting,96 and rarely ocular side Ortiz CA, Torres-Rubalcava AB. A double-blind randomized
effects have been reported, such as conjunctival trial of 0.1% tacrolimus vs 0.05% clobetasol for the treatment
melanosis.97 of childhood vitiligo. Arch Dermatol. 2003;139:581-585.
Complete depigmentation may require 4 to 8. Mehrabi D, Pandya AG. A randomized, placebo-controlled,
12 months of therapy with potentially longer double-blind trial comparing narrowband UV-B Plus 0.1%
tacrolimus ointment with narrowband UV-B plus placebo in
durations required in patients with skin of color. the treatment of generalized vitiligo. Arch Dermatol. 2006;
The concentration can be increased to 30% if 142:927-929.
responses are not noted after 4 months of treatment, 9. Rath N, Kar HK, Sabhnani S. An open labeled, comparative
but treatment should be discontinued if no response clinical study on efficacy and tolerability of oral minipulse of
is seen at 6 months. Once depigmentation is steroid (OMP) alone, OMP with PUVA and broad/narrowband
UVB phototherapy in progressive vitiligo. Indian J Dermatol
achieved, MBEH can be used a few times per week Venereol Leprol. 2008;74:357-360.
as maintenance if required. 10. Bhatnagar A, Kanwar AJ, Parsad D, De D. Psoralen and
Recalcitrant areas of pigmentation postdepigmen- ultraviolet A and narrow-band ultraviolet B in inducing
tation therapy may be treated with quality-switched stability in vitiligo, assessed by vitiligo disease activity score:
694-nm laser98 alone or in combination with an open prospective comparative study. J Eur Acad Dermatol
Venereol. 2007;21:1381-1385.
methoxyphenol.99 Mequinol is a phenol derivative 11. Yones SS, Palmer RA, Garibaldinos TM, Hawk JL. Randomized
thought to produce similar results to MBEH but with double-blind trial of treatment of vitiligo: efficacy of
a slower onset of depigmentation. Laser and psoralen-UV-A therapy vs narrowband-UV-B therapy. Arch
cryotherapy100 have also been tested in Europe, Dermatol. 2007;143:578-584.
where the use of MBEH has been restricted. 12. Bhatnagar A, Kanwar AJ, Parsad D, De D. Comparison of
systemic PUVA and NB-UVB in the treatment of vitiligo: an
open prospective study. J Eur Acad Dermatol Venereol. 2007;
SUMMARY 21:638-642.
Although it is usually slow to respond and 13. Pathak MA, Mosher DB, Fitzpatrick TB. Safety and therapeutic
repigmentation may not always occur despite effectiveness of 8-methoxypsoralen, 4,59,8-trimethylpsoralen,
and psoralen in vitiligo. Natl Cancer Inst Monogr. 1984;66:165-173.
intensive treatment, the variety of management
14. De Francesco V, Stinco G, Laspina S, Parlangeli ME, Mariuzzi L,
options should be presented to patients who Patrone P. Immunohistochemical study before and after
seek treatment. A 2-pronged approach combining narrow band (311 nm) UVB treatment in vitiligo. Eur J
stabilization of the disease by reducing the Dermatol. 2008;18:292-296.
J AM ACAD DERMATOL Rodrigues et al 27
VOLUME 77, NUMBER 1

15. Arca E, Tastan HB, Erbil AH, Sezer E, Koc E, Kurumlu Z. 34. Rigopoulos D, Gregoriou S, Larios G, Moustou E,
Narrow-band ultraviolet B as monotherapy and in combina- Belayeva-Karatza E, Kalogeromitros D. Etanercept in the
tion with topical calcipotriol in the treatment of vitiligo. J treatment of vitiligo. Dermatology. 2007;215:84-85.
Dermatol. 2006;33:338-343. 35. Gokhale BB. Cyclophosphamide and vitiligo. Int J Dermatol.
16. Welsh O, Herz-Ruelas ME, Gomez M, Ocampo-Candiani J. 1979;18:92.
Therapeutic evaluation of UVB-targeted phototherapy in 36. Goktas EO, Aydin F, Senturk N, Canturk MT, Turanli AY.
vitiligo that affects less than 10% of the body surface area. Combination of narrow band UVB and topical calcipotriol for
Int J Dermatol. 2009;48:529-534. the treatment of vitiligo. J Eur Acad Dermatol Venereol. 2006;
17. Kanwar AJ, Dogra S. Narrow-band UVB for the treatment of 20:553-557.
generalized vitiligo in children. Clin Exp Dermatol. 2005;30: 37. Ermis O, Alpsoy E, Cetin L, Yilmaz E. Is the efficacy of psoralen
332-336. plus ultraviolet A therapy for vitiligo enhanced by concurrent
18. Kanwar AJ, Dogra S, Parsad D, Kumar B. Narrow-band UVB for topical calcipotriol? A placebo-controlled double-blind study.
the treatment of vitiligo: an emerging effective and Br J Dermatol. 2001;145:472-475.
well-tolerated therapy. Int J Dermatol. 2005;44:57-60. 38. Cohen BE, Elbuluk N, Mu EW, Orlow SJ. Alternative systemic
19. Njoo MD, Bos JD, Westerhof W. Treatment of generalized treatments for vitiligo: a review. Am J Clin Dermatol. 2015;16:
vitiligo in children with narrow-band (TL-01) UVB radiation 463-474.
therapy. J Am Acad Dermatol. 2000;42:245-253. 39. Ho N, Pope E, Weinstein M, Greenberg S, Webster C, Krafchik BR.
20. Mohammad TF, Al-Jamal M, Hamzavi IH, et al. The vitiligo A double-blind, randomized, placebo-controlled trial of topical
working group recommendations for narrowband ultraviolet tacrolimus 0.1% vs. clobetasol propionate 0.05% in childhood
B light phototherapy treatment of vitiligo. J Am Acad vitiligo. Br J Dermatol. 2011;165:626-632.
Dermatol. 2017;76:879-888. 40. Coskun B, Saral Y, Turgut D. Topical 0.05% clobetasol
21. Do JE, Shin JY, Kim DY, Hann SK, Oh SH. The effect of 308nm propionate versus 1% pimecrolimus ointment in vitiligo.
excimer laser on segmental vitiligo: a retrospective study Eur J Dermatol. 2005;15:88-91.
of 80 patients with segmental vitiligo. Photodermatol 41. Sapam R, Agrawal S, Dhali TK. Systemic PUVA vs. narrowband
Photoimmunol Photomed. 2011;27:147-151. UVB in the treatment of vitiligo: a randomized controlled
22. Bae JM, Yoo HJ, Kim H, Lee JH, Kim GM. Combination therapy study. Int J Dermatol. 2012;51:1107-1115.
with 308-nm excimer laser, topical tacrolimus, and short-term 42. DellAnna ML, Mastrofrancesco A, Sala R, et al. Antioxidants
systemic corticosteroids for segmental vitiligo: a retrospective and narrow band-UVB in the treatment of vitiligo: a
study of 159 patients. J Am Acad Dermatol. 2015;73:76-82. double-blind placebo controlled trial. Clin Exp Dermatol.
23. Kanwar AJ, Mahajan R, Parsad D. Low-dose oral mini-pulse 2007;32:631-636.
dexamethasone therapy in progressive unstable vitiligo. 43. Hofer A, Hassan AS, Legat FJ, Kerl H, Wolf P. Optimal weekly
J Cutan Med Surg. 2013;17:259-268. frequency of 308-nm excimer laser treatment in vitiligo
24. Pasricha JS, Khaitan BK. Oral mini-pulse therapy with patients. Br J Dermatol. 2005;152:981-985.
betamethasone in vitiligo patients having extensive or 44. Shen Z, Gao TW, Chen L, et al. Optimal frequency of
fast-spreading disease. Int J Dermatol. 1993;32:753-757. treatment with the 308-nm excimer laser for vitiligo on the
25. Pasricha JS, Seetharam KA, Dashore A. Evaluation of five face and neck. Photomed Laser Surg. 2007;25:418-427.
different regimes for the treatment of vitiligo. Indian J Dermatol 45. Nicolaidou E, Antoniou C, Stratigos AJ, Stefanaki C,
Venereol Leprol. 1989;55:18-21. Katsambas AD. Efficacy, predictors of response, and
26. Radakovic-Fijan S, Furnsinn-Friedl AM, Honigsmann H, long-term follow-up in patients with vitiligo treated with
Tanew A. Oral dexamethasone pulse treatment for vitiligo. narrowband UVB phototherapy. J Am Acad Dermatol. 2007;
J Am Acad Dermatol. 2001;44:814-817. 56:274-278.
27. Singh H, Kumaran MS, Bains A, Parsad D. A randomized 46. Cavalie M, Ezzedine K, Fontas E, et al. Maintenance therapy of
comparative study of oral corticosteroid minipulse and adult vitiligo with 0.1% tacrolimus ointment: a randomized,
low-dose oral methotrexate in the treatment of unstable double blind, placebo-controlled study. J Invest Dermatol.
vitiligo. Dermatology. 2015;231:286-290. 2015;135:970-974.
28. Kim NH, Torchia D, Rouhani P, Roberts B, Romanelli P. Tumor 47. Huggins RH, Henderson MD, Mulekar SV, et al. Melanocyte-
necrosis factor-alpha in vitiligo: direct correlation between keratinocyte transplantation procedure in the treatment of
tissue levels and clinical parameters. Cutan Ocul Toxicol. 2011; vitiligo: the experience of an academic medical center in the
30:225-227. United States. J Am Acad Dermatol. 2012;66:785-793.
29. Webb KC, Tung R, Winterfield LS, et al. Tumour necrosis 48. Gan EY, Kong YL, Tan WD, Thng ST, Goh BK. Twelve-month
factor-alpha inhibition can stabilize disease in progressive and sixty-month outcomes of noncultured cellular grafting
vitiligo. Br J Dermatol. 2015;173:641-650. for vitiligo. J Am Acad Dermatol. 2016;75:564-571.
30. Alghamdi KM, Khurrum H, Taieb A, Ezzedine K. Treatment of 49. van Geel N, Wallaeys E, Goh BK, De Mil M, Lambert J.
generalized vitiligo with anti-TNF-alpha agents. J Drugs Long-term results of noncultured epidermal cellular grafting
Dermatol. 2012;11:534-539. in vitiligo, halo naevi, piebaldism and naevus depigmento-
31. Maruthappu T, Leandro M, Morris SD. Deterioration of sus. Br J Dermatol. 2010;163:1186-1193.
vitiligo and new onset of halo naevi observed in two 50. Khunger N, Kathuria SD, Ramesh V. Tissue grafts in vitiligo
patients receiving adalimumab. Dermatol Ther. 2013;26: surgery - past, present, and future. Indian J Dermatol. 2009;
370-372. 54:150-158.
32. Alghamdi KM, Khurrum H, Rikabi A. Worsening of vitiligo and 51. Mulekar SV. Melanocyte-keratinocyte cell transplantation for
onset of new psoriasiform dermatitis following treatment stable vitiligo. Int J Dermatol. 2003;42:132-136.
with infliximab. J Cutan Med Surg. 2011;15:280-284. 52. Njoo MD, Das PK, Bos JD, Westerhof W. Association of the
33. Speeckaert R, Speeckaert MM, van Geel N. Why treatments Kobner phenomenon with disease activity and therapeutic
do(nt) work in vitiligo: an autoinflammatory perspective. responsiveness in vitiligo vulgaris. Arch Dermatol. 1999;135:
Autoimmun Rev. 2015;14:332-340. 407-413.
28 Rodrigues et al J AM ACAD DERMATOL
JULY 2017

53. Falabella R. The minigrafting test for vitiligo: validation of a 73. Bishop DT, Demenais F, Iles MM, et al. Genome-wide
predicting tool. J Am Acad Dermatol. 2004;51:672-673. association study identifies three loci associated with
54. Falabella R, Arrunategui A, Barona MI, Alzate A. The melanoma risk. Nat Genet. 2009;41:920-925.
minigrafting test for vitiligo: detection of stable lesions for 74. Liu JB, Li M, Chen H, et al. Association of vitiligo with HLA-A2:
melanocyte transplantation. J Am Acad Dermatol. 1995;32: a meta-analysis. J Eur Acad Dermatol Venereol. 2007;21:
228-232. 205-213.
55. Mulekar SV, Isedeh P. Surgical interventions for vitiligo: an 75. Alonso-Castro L, Rios-Buceta L, Vano-Galvan S, Moreno C,
evidence-based review. Br J Dermatol. 2013;169(suppl 3):57-66. Soria-Rivas A, Jaen P. Vitiligo in 2 patients receiving
56. Gupta S. Surgical Management of Vitiligo. Malden (MA): vemurafenib for metastatic melanoma. J Am Acad Dermatol.
Blackwell Publishers; 2007. 2013;69:e28-e29.
57. Feetham HJ, Chan JL, Pandya AG. Characterization of clinical 76. Mochel MC, Ming ME, Imadojemu S, et al. Cutaneous
response in patients with vitiligo undergoing autologous autoimmune effects in the setting of therapeutic immune
epidermal punch grafting. Dermatol Surg. 2012;38:14-19. checkpoint inhibition for metastatic melanoma. J Cutan
58. Gupta S, Ajith C, Kanwar AJ, Kumar B. Surgical pearl: Pathol. 2016;43:787-791.
standardized suction syringe for epidermal grafting. J Am 77. Hua C, Boussemart L, Mateus C, et al. Association of vitiligo
Acad Dermatol. 2005;52:348-350. with tumor response in patients with metastatic melanoma
59. Gupta S, Chandrashekar BS, Reddy R, Jagadish P, Asati D. treated with pembrolizumab. JAMA Dermatol. 2016;152:
Rapid induction of suction blisters by intra-cavity positive 45-51.
pressure enhancement. Dermatol Surg. 2011;37:843-845. 78. Rodrigues M. Skin cancer risk (nonmelanoma skin cancer-
60. Al-Hadidi N, Griffith JL, Al-Jamal MS, Hamzavi I. Role of s/melanoma) in vitiligo patients. Dermatol Clin. 2017;35:
recipient-site preparation techniques and post-operative 129-134.
wound dressing in the surgical management of vitiligo. 79. Hearn RM, Kerr AC, Rahim KF, Ferguson J, Dawe RS.
J Cutan Aesthet Surg. 2015;8:79-87. Incidence of skin cancers in 3867 patients treated with
61. Agrawal K, Agrawal A. Vitiligo: repigmentation with narrow-band ultraviolet B phototherapy. Br J Dermatol.
dermabrasion and thin split-thickness skin graft. Dermatol 2008;159:931-935.
Surg. 1995;21:295-300. 80. Weischer M, Blum A, Eberhard F, Rocken M, Berneburg M. No
62. Malakar S, Malakar RS. Surgical pearl: composite film and evidence for increased skin cancer risk in psoriasis patients
graft unit for the recipient area dressing after split-thickness treated with broadband or narrowband UVB phototherapy: a
skin grafting in vitiligo. J Am Acad Dermatol. 2001;44:856-858. first retrospective study. Acta Derm Venereol. 2004;84:
63. Krishnan A, Kar S. Smashed skin grafting or smash grafting - a 370-374.
novel method of vitiligo surgery. Int J Dermatol. 2012;51: 81. Wildfang IL, Jacobsen FK, Thestrup-Pedersen K. PUVA
1242-1247. treatment of vitiligo: a retrospective study of 59 patients.
64. Jeong HS, Vandergriff T, Pandya AG. Use of suction blisters Acta Derm Venereol. 1992;72:305-306.
for noncultured epidermal suspension grafting in patients 82. Halder RM, Battle EF, Smith EM. Cutaneous malignancies in
with vitiligo. Dermatol Surg. 2016;42:688-691. patients treated with psoralen photochemotherapy (PUVA)
65. Mulekar SV, Ghwish B, Al Issa A, Al Eisa A. Treatment of for vitiligo. Arch Dermatol. 1995;131:734-735.
vitiligo lesions by ReCell vs. conventional melanocyte- 83. Hexsel CL, Eide MJ, Johnson CC, et al. Incidence of
keratinocyte transplantation: a pilot study. Br J Dermatol. nonmelanoma skin cancer in a cohort of patients with
2008;158:45-49. vitiligo. J Am Acad Dermatol. 2009;60:929-933.
66. Komen L, Vrijman C, Tjin EP, et al. Autologous cell suspension 84. Lindelof B, Hedblad MA, Sigurgeirsson B. On the association
transplantation using a cell extraction device in segmental between vitiligo and malignant melanoma. Acta Derm
vitiligo and piebaldism patients: a randomized controlled Venereol. 1998;78:483-484.
pilot study. J Am Acad Dermatol. 2015;73:170-172. 85. Schallreuter KU, Tobin DJ, Panske A. Decreased
67. Budania A, Parsad D, Kanwar AJ, Dogra S. Comparison photodamage and low incidence of non-melanoma skin
between autologous noncultured epidermal cell cancer in 136 sun-exposed caucasian patients with vitiligo.
suspension and suction blister epidermal grafting in stable Dermatology. 2002;204:194-201.
vitiligo: a randomized study. Br J Dermatol. 2012;167: 86. Teulings HE, Overkamp M, Ceylan E, et al. Decreased risk of
1295-1301. melanoma and nonmelanoma skin cancer in patients with
68. De Cuyper C. Permanent makeup: indications and vitiligo: a survey among 1307 patients and their partners. Br J
complications. Clin Dermatol. 2008;26:30-34. Dermatol. 2013;168:162-171.
69. Mooney E, Rademaker M, Dailey R, et al. Adverse 87. Park KK, Murase JE, Koo J. Long-term prognosis of vitiligo
effects of topical corticosteroids in paediatric eczema: patients on narrowband UVB phototherapy. J Am Acad
Australasian consensus statement. Australas J Dermatol. Dermatol. 2012;66:326-327.
2015;56:241-251. 88. Paradisi A, Tabolli S, Didona B, Sobrino L, Russo N, Abeni D.
70. Legendre L, Barnetche T, Mazereeuw-Hautier J, Meyer N, Markedly reduced incidence of melanoma and
Murrell D, Paul C. Risk of lymphoma in patients with nonmelanoma skin cancer in a nonconcurrent cohort of
atopic dermatitis and the role of topical treatment: a systematic 10,040 patients with vitiligo. J Am Acad Dermatol. 2014;71:
review and meta-analysis. J Am Acad Dermatol. 2015;72: 1110-1116.
992-1002. 89. Lee E, Koo J, Berger T. UVB phototherapy and skin cancer
71. Milingou M, Antille C, Sorg O, Saurat JH, Lubbe J. Alcohol risk: a review of the literature. Int J Dermatol. 2005;44:
intolerance and facial flushing in patients treated with topical 355-360.
tacrolimus. Arch Dermatol. 2004;140:1542-1544. 90. Lim HW, Grimes PE, Agbai O, et al. Afamelanotide
72. Jin Y, Birlea SA, Fain PR, et al. Variant of TYR and and narrowband UV-B phototherapy for the treatment of
autoimmunity susceptibility loci in generalized vitiligo. N vitiligo: a randomized multicenter trial. JAMA Dermatol. 2015;
Engl J Med. 2010;362:1686-1697. 151:42-50.
J AM ACAD DERMATOL Rodrigues et al 29
VOLUME 77, NUMBER 1

91. Rashighi M, Harris JE. Interfering with the IFN-gamma/ 96. Nordlund JJ, Forget B, Kirkwood J, Lerner AB. Dermatitis
CXCL10 pathway to develop new targeted treatments for produced by applications of monobenzone in patients with
vitiligo. Ann Transl Med. 2015;3:343. active vitiligo. Arch Dermatol. 1985;121:1141-1144.
92. King BA, Craiglow BG. Tofacitinib citrate for the treatment of 97. Hedges TR 3rd, Kenyon KR, Hanninen LA, Mosher DB. Corneal
vitiligo: A pathogenesis-directed therapy. JAMA Dermatol. and conjunctival effects of monobenzone in patients with
2015;151(10):1110-1112. vitiligo. Arch Ophthalmol. 1983;101:64-68.
93. Harris JE, Rashighi M, Nguyen N, et al. Rapid skin 98. Kim YJ, Chung BS, Choi KC. Depigmentation therapy with
repigmentation on oral ruxolitinib in a patient with Q-switched ruby laser after tanning in vitiligo universalis.
coexistent vitiligo and alopecia areata (AA). J Am Acad Dermatol Surg. 2001;27:969-970.
Dermatol. 2016;74:370-371. 99. Solano F, Briganti S, Picardo M, Ghanem G. Hypopigmenting
94. Rothstein B, Joshipura D, Saraiya A, et al. Treatment of vitiligo agents: an updated review on biological, chemical and
with the topical Janus kinase inhibtor ruxolitinib. J Am Acad clinical aspects. Pigment Cell Res. 2006;19:550-571.
Dermatol. 2017;76:1054-1060. 100. AlGhamdi KM, Kumar A. Depigmentation therapies for
95. Oliver EA, Schwartz L, Warren LH. Occupational leukoderma. normal skin in vitiligo universalis. J Eur Acad Dermatol
Arch Dermatol. 1940;42:993-1014. Venereol. 2011;25:749-757.

Answers to CME examination

Identification No. JB0717
July 2017 issue of the Journal of the American Academy of Dermatology.

Rodrigues M, Ezzedine K, Hamzavi I, Pandya AG, Harris JE, Vitiligo Working Group. J Am Acad Dermatol 2017;77:17-29.

1. c 4. e
2. a 5. a
3. a 6. d