Aggressive Treatment of Vitiligo Advocated
By: DAMIAN McNAMARA
SAN FRANCISCO — Because children generally respond better to vitiligo interventions than adults, early recognition and treatment are crucial, Dr. Pearl E. Grimes said.
“These patients need you. I strongly encourage you to be a little more aggressive when children with vitiligo come into your practice,” Dr. Grimes said at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).
“This is one of the tragedies of not treating kids; if I compare every therapy—grafting, steroids, [psoralen plus ultraviolet A]—children for some reason give you an enhanced clinical response and are able to maintain pigmentation for a long time,” Dr. Grimes said.
Stabilization, repigmentation, psychological well-being, and improved quality of life are among the goals of childhood vitiligo treatment.
“I work very hard in my patients to attain stabilization, which is just as important as repigmentation,” Dr. Grimes said. She also evaluates the child with vitiligo for associated diseases. For example, it is important to check for chronic autoimmune disorders, especially Hashimoto thyroiditis, she said.
“Often we as dermatologists are the ones who establish this diagnosis,” said Dr. Grimes, director of the Vitiligo and Pigmentation Institute of Southern California in Los Angeles.
Hyperthyroidism, hypothyroidism, diabetes, rheumatoid arthritis, and alopecia areata also occur with vitiligo. She recommended thyroid-stimulating hormone and thyroid peroxidase antibody testing at a minimum, as well as regular testing for thyroid microsomal and antinuclear antibodies.
Dr. Grimes emphasized the importance of psychological counseling for children with vitiligo. “Some of these kids really do need to be referred … to help them cope with the burden of this disease,” she said. Without proper counseling, “they become ‘fossilized’ in the pain of the disease and carry it to their adult lives,” added Dr. Grimes, also of the dermatology department at the University of California, Los Angeles.
There are multiple subtypes of vitiligo. Children have an increased prevalence of segmental vitiligo, compared with adults “and that can be a good thing,” Dr. Grimes said. This subtype typically becomes quiescent in 95% of children within 6–12 months.
More good news is that autologous skin grafting can be very effective for segmental vitiligo. “I really believe this is the only type of vitiligo where I have the potential to cure it,” Dr. Grimes said.
Corticosteroids, topical immunomodulators, narrow-band UVB phototherapy, targeted light and laser therapy, phototherapy, and surgery are other options. Topical steroid therapy is “the absolute mainstay” for a child with limited body surface involvement, she said.
Calcineurin inhibitors are moving to the forefront of therapy for vitiligo. Current data suggest that tacrolimus and pimecrolimus are appropriate for patients with limited involvement, Dr. Grimes said. She has performed clinical trials of Protopic (tacrolimus) for Astellas.
In general, the calcineurin inhibitors are well tolerated, Dr. Grimes said. However, “I am very cautious. I do not use [them] in combination with narrow-band UVB.” Prescription of these agents also requires more counseling time with parents to review the black box warning.
SDEF and this news organization are owned by Elsevier.
For more on antioxidants, nutrition, and other aspects of childhood vitiligo, see a video interview with Dr. Grimes at www.youtube.com/SkinAndAllergyNews