Expert recommendations published in JAMA Dermatology support the use of topical calcineurin inhibitors (TCIs), topical corticosteroids (TCSs), and topical Janus kinase (JAK) inhibitors for vitiligo management among children, adolescents, and young adult patients.
Vitiligo that onsets before the age of 12 years results in more extensive disease and requires early, effective, and sustained disease treatment.
The most recent United States guidelines regarding vitiligo treatment was released in 1996 and there have been no specific guideline updates about vitiligo treatment for pediatric patients since.
An expert panel formulated 4 statements on general definitions and diagnosis of vitiligo, 4 on general recommendations, 10 on the use of TCIs, 8 on the use of TCSs, and 7 on the use of topical JAK inhibitor treatment strategies.
Effective therapy requires a focus on long-term therapeutic interventions to maximize the local gain and retention of pigmentation with a trial period of twice-weekly application.
Vitiligo was defined as a progressive, chronic, relapsing, autoimmune condition that presents as patches of depigmented skin and mucous membranes associated with melanocyte loss of function. Cases are subdivided into nonsegmental, segmental, and mixed vitiligo. It is caused by genetic and environmental factors, in which epidermal melanocytes are targeted by T-cell autoantigens.
Diagnosis Recommendations
To diagnose pediatric vitiligo, wood lamp examination is useful for assessing the extent of disease, particularly in the case of patients with lighter skin tones. In uncertain cases, a biopsy may be used to confirm diagnosis and to rule out potassium hydroxide for tinea versicolor or T-cell gene rearrangements for mycosis fungoides. Clinicians should assess patients for halo nevi (A1, level 3), trichrome coloration, confetti-like depigmentation, Koebner phenomenon, nonhair-bearing anatomical site involvement, and young age with diffuse nonsegmental disease, as these are markers for high disease progression risk.
Vitiligo Treatment Recommendations
The current mainstay treatment options for vitiligo include TCIs, TCSs, topical JAK inhibitors, and phototherapy (ultraviolet- [UV] B).
Topical Calcineurin Inhibitors
The experts recommend TCI use in the first-line setting, including topical tacrolimus and/or topical pimecrolimus in children and adolescents (age, 2-18 years), and young adults (≥18 years). The standard TCI protocol for pediatric patients is twice-daily application for 3 months. At 3 months, if repigmentation has not occurred, another treatment strategy should be considered. Trial results support continued use of TCIs for 6 to 12 months when repigmentation is achieved. Patients should be counseled about risks of burning, stinging, or itching within the first month of use. Discontinuation is recommended in the event of visible irritation or inflammation.
Topical Corticosteroids
The statement authors noted that TCSs may be used as a first-line therapy, in which case the choice of TCS class should depend on the site and planned treatment duration. However, TCSs should be a second-line option for lesions of the face, groin, and intertriginous areas. The potential risks of TCSs include atrophy and glaucoma, in the case of eyelid skin lesions.
Topical JAK Inhibitors
Use of topical JAK inhibitors should be restricted to patients aged 12 years and older, and may be considered in the first-line setting. These therapeutics may also be effective among younger patients; however, there is limited evidence to support its use in this manner. Clinicians should be aware that initial repigmentation may not appear until 3 months of treatment and maximal repigmentation may not occur before 1 year. These agents may be used on the face, eyelids, and groin.
UV Therapy and Phototherapy
Combination therapy of UV-B light (narrowband UV-B or 308 nm laser) plus topical therapeutics (such as TCSs and TCIs) may enhance initial repigmentation response. Additionally, short outdoor UV exposure (range, 10-15 minutes) may enhance response to topical therapies among pediatric patients. Although unconfirmed in pediatric patients, combination therapy of topical JAK inhibitors and phototherapy (natural sunlight or narrowband UV-B) may be synergistic among adults.
The statement authors concluded, “Effective therapy requires a focus on long-term therapeutic interventions to maximize the local gain and retention of pigmentation with a trial period of twice-weekly application. Counseling should include discussion of the chronicity of vitiligo and the need for long-term care.”
References:
Renert-Yuval Y, Ezzedine K, Grimes P, et al. Expert recommendations on use of topical therapeutics for vitiligo in pediatric, adolescent, and young adult patients. JAMA Dermatol. Published online March 13, 2024. doi:10.1001/jamadermatol.2024.0021
