Vitiligo
Evidence-based treatment (Part 2)
Three goals, in order: stop the spread, restore pigment, prevent relapse. Most treatment plans combine two or more approaches, because combinations consistently outperform single agents.
Summary table
| Treatment | Best suited to | Evidence | Time to visible response |
| Sun protection & camouflage | All patients | Strong (protective), high patient satisfaction | Immediate (camouflage) |
| Topical corticosteroids | Limited disease, body sites | Well established | 2–3 months |
| Topical calcineurin inhibitors | Face, neck, folds; children; maintenance | Strong; first line for facial disease | 2–4 months |
| Topical JAK inhibitor cream | Non-segmental vitiligo with facial involvement, age 12+ | Randomised controlled trial evidence; registered in HK | 3–6 months, continuing to 12 months |
| Narrowband UVB | Widespread or progressive disease | Strongest evidence for extensive disease | 3 months minimum; treat 6–12 months |
| 308nm excimer | Localised disease, under ~10% body surface | Strong for localised disease; faster than whole-body UVB | 1–3 months |
| Oral mini-pulse steroids | Rapidly spreading disease | Moderate; used to arrest progression | 1–3 months to halt spread |
| Oral JAK inhibitors | Extensive disease unresponsive to the above | Phase 3 data; under regulatory review, currently off-label | 6–12 months |
| Surgical grafting | Stable segmental or focal disease, stable ≥12 months | Strong in correctly selected patients | 2–6 months |
| Adjunctive (fractional laser, PRP, oral antioxidants) | Resistant sites, as an add-on only | Low to moderate quality | Variable |
Systemic treatment
Oral mini-pulse corticosteroids. Used specifically when disease is spreading rapidly. A low steroid dose is given on two consecutive days each week, which arrests progression in a majority of patients while limiting the side effects of daily steroids. This is a stabilising treatment, not a repigmenting one, and is given for a defined period with monitoring.
Oral JAK inhibitors. The most significant development in vitiligo therapeutics. Phase 3 Viti-Up studies demonstrated that upadacitinib achieved the co-primary endpoints of at least 50% improvement in total body re-pigmentation (T-VASI 50) and at least 75% improvement in facial re-pigmentation (F-VASI 75) from baseline at week 48. If approved, upadacitinib would represent a first-in-class systemic option for vitiligo.
To be clear about current status: the use of upadacitinib in non-segmental vitiligo is not approved, and its safety and efficacy have not been evaluated by regulatory authorities. Regulatory applications were submitted to the FDA and the EMA in February 2026. Any use for vitiligo today is off-label, requires informed discussion of risks including infection, blood count and lipid changes, and thrombotic and cardiovascular considerations, and requires baseline and ongoing blood monitoring. It is reserved for extensive disease that has not responded to established treatment.
Surgical treatment
For stable vitiligo only — no new or enlarging patches for at least 12 months, and no Koebner phenomenon. This is the treatment of choice for segmental vitiligo, which responds poorly to medical therapy but very well to grafting.
Mini-punch grafting — small pigmented grafts transferred into the depigmented area, from which pigment spreads outward.
Suction blister epidermal grafting — a thin epidermal roof is raised by suction from donor skin and transferred, giving excellent colour match and minimal donor scarring.
In appropriately selected stable patients, success rates of 60–90% are reported. Patient selection is the entire game: performing surgery on active disease risks Koebnerisation at the donor site. A test graft is often sensible before committing to a larger procedure.
Adjunctive treatments
Presented honestly: these are add-ons with lower-quality evidence than the treatments above, and none should replace them.
Fractional CO₂ laser — used before topical treatment or phototherapy to improve penetration in resistant areas, particularly hands, feet and bony prominences. Small controlled studies show improved response when combined; evidence is limited but the rationale is sound.
Platelet-rich plasma (PRP) — as an adjuvant to phototherapy or fractional laser, small studies report improved repigmentation, likely via growth-factor–mediated melanocyte stimulation. Evidence quality is low and PRP should be presented as adjunctive, not primary.
Polypodium leucotomos extract — an oral fern extract with antioxidant and photoprotective properties. Small randomised trials suggest improved head and neck repigmentation when combined with narrowband UVB. Well tolerated, modest benefit, best regarded as supportive.
Other oral antioxidants — vitamin E, alpha-lipoic acid and ginkgo biloba have limited supporting evidence, mostly small studies.
Preventing relapse
The most under-appreciated part of treatment. After successful repigmentation, roughly 40% of patients relapse within a year if nothing further is done. Applying a topical calcineurin inhibitor twice weekly to previously affected areas reduces relapse substantially — in one randomised trial, from around 40% to under 10%. Maintenance therapy should be planned from the outset, not improvised after relapse.
Psychological support
Should be part of management, not an afterthought. Screening for low mood and anxiety, addressing school or workplace difficulties, and referral for psychological support where indicated all form part of proper care. Patient support organisations help considerably.
Reference:
- Ezzedine K, et al. Revised classification/nomenclature of vitiligo. Pigment Cell Melanoma Res. 2012 — VGICC consensus, basis of the classification section.
- Eleftheriadou V, et al. British Association of Dermatologists guidelines for the management of people with vitiligo. Br J Dermatol. 2022.
- Seneschal J, Taïeb A, et al. European Dermatology Forum / EADV vitiligo guideline (most recent update).
- Rosmarin D, et al. Two Phase 3, Randomized, Controlled Trials of Ruxolitinib Cream for Vitiligo. N Engl J Med. 2022 — TRuE-V1 and TRuE-V2.
- Passeron T, Prajapati V, Sivamani R, et al. Efficacy and safety of upadacitinib in adolescents and adults for treatment of non-segmental vitiligo: results of two phase 3 studies (Viti-Up). Presented at the 2026 American Academy of Dermatology Annual Meeting, March 27–31, 2026, Denver, CO.
- China Medical System Holdings. New Drug Application of ruxolitinib phosphate cream for vitiligo approved by the Pharmacy & Poisons Board of Hong Kong, 4 November 2024.
- Cavalié M, et al. Maintenance therapy of adult vitiligo with 0.1% tacrolimus ointment: a randomized, double-blind, placebo-controlled study. J Invest Dermatol. 2015.
- Bae JM, et al. Phototherapy for vitiligo: a systematic review and meta-analysis. JAMA Dermatol. 2017.
- Middelkamp-Hup MA, et al. Treatment of vitiligo vulgaris with narrow-band UVB and oral Polypodium leucotomos extract: a randomized double-blind placebo-controlled study. J Eur Acad Dermatol Venereol. 2007.
- Hong Kong Drug Office, Department of Health — search the local registration status of any medicine mentioned.