The British Association of Dermatologists guidelines provides the latest updates in managing people with vitiligo. This article covers the key recommendations from the 2021 guidelines.

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General recommendations

People with suspected vitiligo should be referred to a healthcare professional experienced in managing the condition if the condition is progressing rapidly, there is diagnostic uncertainty, the condition has a significant psychosocial impact, or the condition is not responding to topical treatment.

Screening for thyroid dysfunction is necessary to assess the risk of developing autoimmune thyroid disease. A complete history is recommended for people with vitiligo. The history should include:

• The site and type of vitiligo (segmental, nonsegmental)
• Disease extent (affected body surface area)
• Disease stability
• Speed of onset, trigger factors
• Quality of life, psychological and psychosocial impact
• Personal and family history of associated thyroid dysfunction or other autoimmune diseases

Tools for psychological screening

Discussing the psychosocial aspect of living with vitiligo, while focussing on the relationship between the skin and the mind, is suggested. The quality of life and level of psychological distress should be evaluated using tools such as:

• Patient Health Questionnaire-4 (PHQ-4)
• Patient Health Questionnaire-9 (PHQ-9)
• Generalised Anxiety Disorder 7 (GAD7)
• Dermatology Life Quality Index (DLQI)
• Vitiligo Impact Patient Scale (VIPs)
• Vitiligo-specific quality-of-life instrument (VitiQoL)

General practices should include:

1. Serum vitamin D levels should be measured in people with vitiligo who avoid sun exposure. For cases with vitamin D deficiency, vitamin D3 supplements (10-25 micrograms per day) should be advised. Vitamin D rich food such as oily fish, eggs, meat, fortified margarine and cereals is also recommended.
2. Sunscreen with a 4-star or 5-star UVA rating and sun protection factor 50 is advised for people with vitiligo. This should be applied to the affected patches and adjacent skin before going out in the sun.
3. Treatment response and disease progression should be monitored using medical photography (digital imaging). Medical photography is recommended at the start of treatment and at intervals of around 3-6 months.
4. Apart from medical photography, body surface area (BSA) and areas affected by vitiligo should be documented. Patients can use personal devices to take photographs if medical photography is not available or is not practical.
5. Topical corticosteroid is recommended as the first-line treatment in primary or secondary care. In people with rapidly progressive vitiligo, oral betamethasone is recommended.

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Topical therapy alternatives

Topical corticosteroids

1. Once daily potent or very potent topical corticosteroid is recommended as the first-line treatment in primary or secondary care. The periocular area should be avoided.
2. When using topical corticosteroids, the amount, site of application and safe use of the topical steroid should be discussed with the patient.

Topical tacrolimus

1. As an alternative to potent or very potent topical corticosteroids, topical tacrolimus 0·1% ointment is recommended twice daily in people with facial vitiligo.
2. As an alternative to potent or very potent topical corticosteroids, topical tacrolimus 0·1% ointment twice daily can be considered in people with nonfacial vitiligo, only under occlusion on photo exposed areas.

Topical corticosteroids with or without topical calcineurin inhibitors

An intermittent regimen of once-daily application of potent or very potent topical corticosteroids with or without topical calcineurin inhibitors can be considered in people with vitiligo after considering the risks and benefits. The following are some examples of intermittent regimens:

• One week of potent or very potent corticosteroids and at least 1 week off or
• One week of potent or very potent topical corticosteroids alternating with ≥ 1 week of topical calcineurin inhibitor

Intermittent regimens are recommended in areas with thin skin such as the skin flexures, genital area and periocular region. The use of topical corticosteroids in the intermittent regimen can be extended to more than 1 week after consideration of the risks and benefits.

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Depigmentation therapies

Depigmentation therapies can be used in cases with extensive vitiligo on visible sites, especially in people suffering from a profound negative psychological impact. Adequate psychological assessment and/or intervention should be carried out before depigmentation therapies.

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Systemic therapies

Oral betamethasone

1. In people with rapidly progressive vitiligo, the recommended regimen for oral betamethasone is 0·1 mg kg−1 twice weekly on two consecutive days for 3 months.
2. The dose should be tapered by 1 mg per month for a further 3 months in combination with NB-UVB.

Oral corticosteroids

In people with rapidly progressive vitiligo, an equivalent dose of oral corticosteroids can be used as an alternative if betamethasone is not available.

• Azathioprine- Azathioprine in combination with PUVA (or NB-UVB) is not recommended in people with vitiligo considering the risk of malignancy
• Minocycline, methotrexate or tofacitinib- Minocycline, methotrexate or tofacitinib are not recommended for people with vitiligo

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Light and laser monotherapy and combination therapies

NB-UVB (whole body or localised, e.g. home-based handheld)

1. NB-UVB is recommended as first-line phototherapy in people with extensive or progressive disease and who have an inadequate response to topical therapy.
2. For localised sites, NB-UVB may be combined with topical calcineurin inhibitor or potent topical corticosteroid.
3. Patients should be educated regarding the significant risk of loss of response upon stopping treatment.

PUVA or PUVAsol- If treatment with NB-UVB is unavailable or has been ineffective, PUVA or PUVAsol can be considered in adults with vitiligo.

Excimer laser or light

1. Excimer laser or light in combination with topical calcineurin inhibitors can be considered in people with localised vitiligo.
2. Patients should be informed regarding the increased risk of skin cancer with this treatment combination.

CO2 laser

If other treatment options are ineffective, CO2 laser in combination with 5-fluorouracil can be considered in adults with nonsegmental vitiligo on the hands and feet.

• 5-fluorouracil once daily for 7 days per month for 5 months
• CO2 laser treatments once a month for 5 months

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Surgical therapies

Cellular grafting such as blister grafting or cell suspension can be considered in:

• People with stable, segmental or nonsegmental vitiligo unresponsive to other treatments
• People who remain distressed by the condition

Mini-punch grafting is not recommended in people with vitiligo.

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Psychological therapies

People with mild psychological distress should be guided with self-help information using websites, apps, leaflets and books. In people with moderate-to-severe psychological distress, cognitive behavioural therapy (CBT) can be considered.

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.