A young woman with large depigmented patches on her face and dorsum of hands asks if something can be done for her "white spots." Her sister has a few lesions.
Cosmetics: The use of the following covering or staining preparations is recommended: pancake-type cosmetics, such as Covermark, by Lydia O'Leary; Vitadye (Elder); dihydroxyacetone containing self-tanning creams, gels, and foams; walnut-juice stain; or potassium permanganate solution in appropriate dilution. Many patients with vitiligo become quite proficient in the application of these agents.
Corticosteroid cream therapy: This is effective for early mild cases of vitiligo, especially when one is mainly concerned with face and hand lesions. Betamethasone valerate cream 0.1% (Valisone cream) can be prescribed for use on the hands for 4 months or so and for use on the face for only 3 months. It should not be used on the eyelids or as full-body therapy.
Sun avoidance: Suntanning should be avoided because this accentuates the normal pigmentation and makes the nonpigmented vitiligo more noticeable. The white areas of vitiligo are more susceptible to sunburn.
If the patient desires a more specific treatment, the following can be suggested, with certain reservations:
Psoralen derivatives: For many years, Egyptians along the Nile River chewed certain plants to cause the disappearance of the white spots of vitiligo. Extraction of the chemicals from these plants revealed the psoralen derivatives to be the active agents, and one of these, 8-methoxypsoralen (8-MOP), was found to be the most effective. This chemical is available as Oxsoralen in 10-mg capsules and also as a topical liquid form. The oral form is to be ingested 2 hours before exposure to measured sun radiation. The package insert should be consulted. Our results with this long-term therapy have been very disappointing.
Trisoralen is a synthetic psoralen in 5-mg tablets. The recommended dosage is 2 tablets taken 2 hours before measured sun exposure for a long-term course. Detailed instructions accompany the package. Some dermatologists believe this therapy to be more effective than Oxsoralen.
A short 2-week course of Oxsoralen capsules (20 mg/day) has been advocated for the purpose of acquiring a better and quicker suntan. The value of such a course has been questioned. The sun exposure must be gradual. Oral psoralens plus self-administered UVA or UVB in "tanning booths" can produce severe burns, which may be fatal.
PUVA therapy: The combination of topical or oral psoralen therapy with UVA radiation has been somewhat successful in repigmenting vitiligo. The psoralen can be given orally, topically, or as a bath. Precautions concerning photoaging and skin cancer apply.
Depigmentation therapy: In the hands of experts, monobenzyl ether of hydroquinone (Benoquin) can be used to remove skin pigment to even out the patient's skin color.
Skin grafting: Autologous minigrafting and other similar surgical procedures have been used with success by some.
Surgical therapy: Various grafting procedures are valuable in recalcitrant disease. Epidermal or full thickness autographs have been advocated by some authors. Classification of Pigmentary Disorders
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