"It is essential to get good baseline images that can be shown to patients at their regular follow-up visits. Only by providing documentation that they are really improving will you be able to motivate some of these individuals to keep going," commented Dr. Pandya, professor of dermatology, University of Texas Southwestern Medical Center, Dallas.

Narrowband UVB phototherapy continues to be the workhorse for the management of vitiligo, and the excimer laser can also play a role. Additional treatment may be needed to address the difficult areas on the hands and feet, and patients with darker skin types appear to respond best.

Results of a randomized controlled study conducted by Dr. Pandya and colleagues showed no benefit of using a topical calcineurin inhibitor together with narrowband UVB compared with the light therapy alone. These findings conflict with a previous report suggesting a benefit of the topical calcineurin inhibitor, although Dr. Pandya noted the latter was an open-label study.

"My preference for topical therapy is a Class I corticosteroid administered in a pulse regimen with one week on and one week off," Dr. Pandya said.

Clinical trial evidence supports a benefit of using a topical corticosteroid combined with light therapy versus either alone. In addition, results from a randomized, double-blind, placebo-controlled study conducted by Italian investigators provide the first evidence that treatment with antioxidant vitamins may be beneficial.

In that trial, patients with vitiligo received vitamin C, vitamin E, polyunsaturated fatty acids, and alpha lipoic acid 2 months before narrowband UVB and continued for 6 months. Compared with placebo-treated controls, the percentage of patients achieving greater than 75 percent repigmentation was about 2.5 times higher among patients receiving the combination of antioxidants.

"I am now putting all of my vitiligo patients on these oral supplements," Dr. Pandya said.

He reminded attendees that punch grafting does work and does not require any sophisticated equipment. However, it is not always effective, and "cobblestoning" of the punch grafts can occur. Therefore, for surgical intervention, Dr. Pandya says he now prefers blister grafting, raising lesions on the back side of the hand.

"The grafts created with this technique are much larger and the donor site heals up nicely with no scarring," commented Dr. Pandya. DT