Topical and Procedural Treatments for Vitiligo: A Clinical Reference

Topical Therapies

Agent	Class	Dosing	Key Points
Tacrolimus 0.03–0.1%	Calcineurin inhibitor (TCI)	BID	Face/neck, intertriginous, thin skin; avoids steroid atrophy; burning transient
Pimecrolimus 1%	TCI	BID	Similar to tacrolimus; less burning; less potent for thick skin
Clobetasol propionate 0.05%	Superpotent steroid	BID → taper	Body only; max 4–8 wks; monitor atrophy, striae, telangiectasia
Betamethasone dipropionate 0.05%	Potent steroid	BID	Alternative for body; pulse therapy (weekends) reduces side effects
Calcipotriene 0.005%	Vitamin D analog	BID	Synergistic with steroids/UVB; avoid face (irritation); max 100 g/week

Phototherapy

• Narrowband UVB (311 nm): Gold standard; 2–3×/week; home units available. Repigmentation in 60–70% at 6–12 months.
• PUVA (psoralen + UVA): Oral/topical psoralen + UVA; 2–3×/week. Higher efficacy but more side effects (phototoxic, cataract, skin cancer risk). Now second-line.
• Excimer laser (308 nm): Targeted; 2×/week. Best for localized, stable vitiligo (<10% BSA). Faster repigmentation than NB-UVB.

Systemic Therapy (for rapidly progressive / extensive disease)

• Oral mini-pulse dexamethasone (0.5 mg/kg 2 consecutive days/week) or prednisone 0.3 mg/kg/day × 1–3 months.
• JAK inhibitors (tofacitinib, ruxolitinib cream 1.5% BID – FDA approved for non-segmental vitiligo ≥12 yrs).

Surgical (Stable Disease Only: no new lesions × 1 yr, no Koebner)

• Suction blister grafting, split-thickness skin grafts, melanocyte-keratinocyte transplantation (MKTP).
• Requires expertise; risk of cobblestoning, Koebner at donor/recipient sites.

Depigmentation (for >50% BSA involvement)

Monobenzone 20% cream BID → permanent depigmentation. Strict sun protection lifelong. Irreversible.

Cosmetic Camouflage

• Dermablend, Covermark, Microskin – waterproof, high-coverage.
• Self-tanners (DHA) – temporary, requires reapplication.