2010 vitiligo evidencias por diagnostico e manejamento

8/7/2019 2010 vitiligo evidencias por diagnostico e manejamento

1/7

Vitiligo: concise evidence based guidelineson diagnosis and management

David J Gawkrodger,1 Anthony D Ormerod,2 Lindsay Shaw,3 Inma Mauri-Sole,3

Maxine E Whitton,4 M Jane Watts,5 Alex V Anstey,6 Jane Ingham,7

Katharine Young

7

ABSTRACT

Vitiligo is a common disease that causes a great degreeof psychological distress. In its classical forms it is easilyrecognised and diagnosed. This review provides an

evidence based outline of the management of vitiligo,particularly with the non-specialist in mind. Treatmentsfor vitiligo are generally unsatisfactory. The initial

approach to a patient who is thought to have vitiligo is tomake a definite diagnosis, offer psychological support,and suggest supportive treatments such as the use ofcamouflage cosmetics and sunscreens, or in some cases

after discussion the option of no treatment. Activetherapies open to the non-specialist, after an explanationof potential side effects, include the topical use of potentor highly potent steroids or calcineurin inhibitors fora defined period of time (usually 2 months), followingwhich an assessment is made to establish whether ornot there has been a response. Patients whose conditionis difficult to diagnose, unresponsive to straightforwardtreatments, or is causing psychological distress, areusually referred to a dermatologist. Specialistdermatology units have at their disposal phototherapy,either narrow band ultraviolet B or in some casesphotochemotherapy, which is the most effectivetreatment presently available and can be considered for

symmetrical types of vitiligo. Depigmenting treatmentsand possibly surgical approaches may be appropriate forvitiligo in selected cases. There is no evidence thatpresently available systemic treatments are helpful andsafe in vitiligo. There is a need for further research intothe causes of vitiligo, and into discovering bettertreatments.

INTRODUCTIONVitiligo is a disease that results in depigmented skinwith loss of functioning melanocytes within the

epidermis. It usually begins after birth and,although it can develop in childhood, the averageage of onset is about 20 years.1 The treatment ofvitiligo is acknowledged as being difficult, especiallyfor the non-dermatologist. There is evidence tosuggest that in some patients vitiligo is an auto-immune disease and that it shows a familial trait inabout 18% of cases.2 The genetic basis for vitiligopostulates a contribution from multiple recessivealleles at unlinked autosomal loci.3 Vitiligo occursin all races and has an estimated prevalence of0.5e1%. In this paper our objective is to providea concise and evidence based review of the

management of vitiligo in a shorter form than thefull published guideline.4

The process of development of the full guidelineinvolved the guideline development group definingthe questions and interrogating the literature in anevidence based manner. Reference is made to therecently updated Cochrane review on the treat-ment of vitiligo.5 The guidance has been developedusing SIGN methodology (http://www.sign.ac.uk/methodology/index.html) and in accordance withAGREE principles (http://www.rcplondon.ac.uk),which allow a designation of the level of recom-mendation and of evidence.

Textbooks usually do not comment on thenatural history of vitiligo. Although some patientsreport spontaneous repigmentation, this is rare.More typically, vitiligo is a chronic persistentdisorder that progresses in a stepwise fashion withlong periods when the disease is static and rela-tively inactive, interspersed with shorter periodswhen areas of pigment loss extend.

A better understanding of the pathogenesis ofthe disease may lead to improved treatments. Thereis a paucity of effective treatments available anda lack of treatments specifically introduced forvitiligo itself. Almost all treatments have beenborrowed from therapies whose prime target is

another disease. Not even advances in the under-standing in the science underlying vitiligodforexample, evidence of autoimmune disease or ofoxidative stress in melanocytesdhas resulted inspecifically tailored treatments for vitiligo.

INITIAL ASSESSMENTIn the first instance the diagnosis of vitiligo has tobe confirmed. Often this is regarded as beingstraightforward, although it is not always so. Mostcommonly, vitiligo produces symmetrical depig-mented areas of skin that otherwise appear normal(table 1). A less common type is the segmental

form in which unilateral depigmentation develops.The aetiology of segmental vitiligo may be differentfrom the symmetrical types. In vitiligo the skintexture is usually normal. Vitiligo can affect mela-nocytes in the hair roots resulting in patches ofwhite hair. Depigmentation can affect mucosalareas such as in the mouth or genitalia.

Three main diseases can be mistaken for vitiligo.In tinea versicolor, a superficial yeast infection thatcan cause loss of pigment on the upper trunk andchest, darker skinned individuals show hypo-pigmented patches with a fine dry surface scale. Inpiebaldism, an autosomal dominant disease in

which there is absence of melanocytes from theaffected areas of the skin, a forelock of white hair is

1British Association ofDermatologists, London, UK2Therapy, Guidelines and Auditsubcommittee of the BritishAssociation of Dermatologists,London, UK3Departments of Dermatologyand Paediatric Dermatology,Bristol Royal Infirmary, Bristol,UK4The Vitiligo Society, London,UK5Department of Dermatology,Whipps Cross Hospital, London,

UK6British PhotodermatologyGroup, British Association ofDermatologists, UK7Clinical Standards Department,Royal College of Physicians ofLondon, London, UK

Correspondence toProfessor David J Gawkrodger,Department of Dermatology,Royal Hallamshire Hospital,Sheffield S10 2JF, UK; [email protected]

Received 27 October 2009

Accepted 7 April 2010

466 Postgrad Med J 2010;86:466e471. doi:10.1136/pgmj.2009.093278

Review

group.bmj.comon March 20, 2011 - Published bypmj.bmj.comDownloaded from
http://group.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://pmj.bmj.com/http://group.bmj.com/http://pmj.bmj.com/


2/7

usually evident and can be present at birth. In idiopathic guttatehypomelanosis, multiple small, white macules are found, mostlyon the trunk or on sun exposed parts of the limbs.

At the initial consultation, the doctor should make a record ofthe effect of vitiligo on the patient. The examination should

include observation of the disease distribution, extent, whetherdepigmentation is total or partial, if there are symmetricallesions, and if there is involvement of mucous membranes.

The depigmentation on the face or hands is often visible toothers. A consequence is that vitiligo can be psychologicallydevastating and have a significant impact on quality of life(QoL) and self esteem.6 It may cause social isolation andsignificant depression,7 create difficulties in sexual relationships,stigmatisation and affect perceived suitability for marriage.8 9

(level of evidence: E-3). In people with a white skin colour,vitiligo may cause less concern (E-3). One study comparing QoLin vitiligo and psoriasis showed a higher dermatology life qualityindex (DLQI) for psoriasis than vitiligo (mean 6.26 cf 4.95).10

The scoring pattern was different with vitiligo scoring lower on

the symptoms and treatment subscales and higher on the social,clothing and leisure subscales. This suggests that QoL scaleswith a weighting on the effect of symptoms and treatmenteffects underestimate the effect of vitiligo on QoL. Someassessment of the impact of vitiligo on the patient s QoL shouldbe made (this could be done by using the DLQI, for example).The doctor should discuss the disease and treatment options.

Patients with vitiligo can develop autoimmune thyroid diseaseor other autoimmune diseases. A history of autoimmune diseasein a family member was obtained in 13 of 41 (32%) adults withvitiligo.2 This compares to an overall general population preva-lence of thyroid disease of 5%.11 Adults with vitiligo should havetheir thyroid function checked.4

Patients should be given information about the VitiligoSociety in the UK or other national patient help organisation.

SUPPORTIVE MEASURESIn many instances, the first line therapy involves topical medi-caments. Most patients are offered advice about sunscreens andcosmetic camouflage including fake tanning products. Withregard to topical therapy that might influence the state of the

disease, the use of topical steroids is the usualfi

rst line treatment(figure 1). Recommended treatments for children differ slightlyfrom those for adults.

TOPICAL CORTICOSTEROIDSTopical steroids are often viewed as the first active treatment toconsider. Clayton12 and Kandil13 showed that use of a highlypotent (clobetasol propionate) or potent (betamethasonevalerate) topical steroid can repigment vitiligo, but only in a smallproportion of cases. Clayton found 15e25% repigmentation in10/23 subjects (ages not stated) and >75% in 2/23 (the other 11showed no response), while Kandil found 90e100% repigmen-tation in 6/23 subjects (ages not given for all, but one was aged

12 years) and 25e

90% in three (with six showing beginningrepigmentation).1 2 1 3 Clayton found all steroid users had skinatrophy with clobetasol propionate (used for 8 weeks), whileKandil noted hypertrichosis in two subjects and acne inthree subjects, related to 4 months use of betamethasonevalerate.12 13

The experience of Westerhof et al,14 in probably the bestcontrolled study to date of a topical treatment, compared thepotent topical steroid fluticasone propionate alone or combinedwith ultraviolet A (UVA) in 135 adults. They found that topicalfluticasone propionate used alone for 9 months induced meanrepigmentation of only 9% (compared to UVA alone of 8%)whereas the combination of fluticasone propionate and UVAinduced mean repigmentation of 31%; no steroid atrophy wasnoted in steroid users.

Table 1 Symptoms and signs

Non-segmental vitiligo (vulgaris/symmetrical or acro-facial types)

Characterised by white patches that are usually symmetricaland frequently increase in size with timeThe most common sites affected are the fingers and wrists,the axillae and groins and the body orifices such as the mouth,eyes and genitaliaCorresponds with a substantial loss of functioningepidermal and, sometimes, hair follicle melanocytes

Segmental vitil igo A variant of vitil igo confined to one or more unilateral segmentsMore commonly seen in childhoodDistribution may conform to one or more (adjacent) dermatomesor to Blaschkos lines

Patients permission for publication has been obtained.

Postgrad Med J 2010;86:466e471. doi:10.1136/pgmj.2009.093278 467

Review



3/7

Hence, use of a highly potent (clobetasol propionate) or potent(betamethasone valerate) topical steroid can repigment vitiligo,but only in a small proportion of cases; even then, skin atrophy isa common complication after only 2 months treatment.5

TOPICAL CALCINEURIN INHIBITORSCalcineurin inhibitors have an advantage over steroids in thatthey do not thin the skin, which is a concern to many patients.Coskun and colleagues,15 in a left versus right comparison overan 8 week period in 10 adults, compared topical pimecrolimuswith topical clobetasol propionate. They found topical pime-

crolimus resulted in 50e

100% repigmentation in 8/10 casesmost noticeable for lesions on the trunk or extremities,

compared to an equivalent degree of repigmentation in 7/10cases treated with clobetasol propionate. No skin atrophy wasnoted, but burning was a side effect with pimecrolimus.

In an open proof of concept study of 26 children aged over6 years and adults with generalised symmetrical forms of viti-ligo, treated for head and neck lesions with topical 1% pime-crolimus twice daily, total repigmentation of a target lesion wasfound in 50% of cases after 6 months of therapy.16 Twentychildren treated over 8 weeks with either topical clobetasol ortacrolimus were shown to have repigmentation that amountedto 41% with clobetasol and 49% with tacrolimus.17 Lesions on

the face and thorax responded better than those on the abdomenor legs, while lesions on the hands did not respond.

Figure 1 Algorithm for themanagement of vitiligo in adults andchildren by non-specialists.

Diagnosis

No treatment option Topical Treatment Psychological treatments

When vitiligo is classical the diagnosis is straightforward

and can be made in primary care (D/4) but atypical

presentations may require expert assessment by a

dermatologist (D/4). In adults a blood test to check thyroid

function should be considered in view of the high

prevalence of autoimmune thyroid disease in patients

with vitiligo (D/3).

In adults and children with skin

types I and II (type I- always

burns, does not tan; type II-

burns easily tans poorly) in

the consultation it may be

appropriate to consider,

after discussion, whether the

initial approach may be to

use no Active treatment other

than use of camouflage

cosmetics and

sunscreens (D/4).

In adults with recent onset of

vitiligo and in children, treat-

ment with a potent or very

potent topical steroid should

be considered for a trial

period of no more than 2

months. Skin atrophy has

been a common side effect

(B/1+).

In adults, topical pimecrolimusshould be considered as an

alternative to a topical steroid,

based on one study. The side

effect profile of topical

pimecrolimus is better than

that of a highly potent topical

steroid (C/2+). In children,

topical pimecrolimus or

tacrolimus should be considered

as alternatives to the use of a

highly potent topical steroid in

view of their better safety profile

(B/1+).

Depigmentation should be

reserved for adults severely

affected by vitiligo and should

be undertaken only by a

specialist dermatology unit.

Clinicians should make an

assessment of the psycho-

logical and QoL effects of

vitiligo on adults and children

(C/2++). Psychological inter-

ventions should be offered

as a way of improving coping

mechanisms (D/4). Parents

of children with vitiligo

should be offered psycho-logical counselling.

These treatments should be

considered only in specialist

units. Surgical treatments

are not recommended in

children.

Phototherapy, systemic

therapy and surgical

treatments


Review



4/7

DEPIGMENTATION TREATMENT (P-(BENZYLOXY)PHENOL(HYDROQUINONE MONOBENZYL ETHER))Extensive vitiligo in a patient with a dark skin tone, especiallyon a cosmetically sensitive area such as the hands or face, canproduce a severe social disability. In this instance it is worth-while considering whether complete depigmentation of theaffected areas might be beneficial. The profound effect that thismay have culturally needs to be taken into account.

In an open study, 18 patients severely affected by vitiligo(type of vitiligo not stated) were treated with the topicalapplication of 20% p-(benzyloxy)phenol (monobenzyl ether ofhydroquinone (MBEH)18: eight achieved complete depigmen-tation after 10 months and three had dramatic depigmenta-

tion, but in three there was no effect at all (after 4 months ofuse).

Expert opinion concludes that patients with a dark skin typeselected for depigmentation treatments must understand thecultural effects the depigmentation may have.4 It is usual toconsider depigmentation only for subjects in whom the area ofskin involved by vitiligo is extensivedthat is, involving >50% ofthe skin surface area.4 If there is extensive involvement of thecosmetically sensitive areas of the face and hands, and coveringcosmetics are ineffective, depigmentation can be consideredalthough it is usual to only treat the exposed sites.

SYSTEMIC TREATMENTSince vitiligo is viewed as an autoimmune disease, it is natural towonder whether systemic treatment might have something to

offer. However, there are few studies in the literature. A wellconducted open study of 25 European adults with active

Main messages (with indicated levels of recommendation and of evidence)

DIAGNOSISWhere vitiligo is classical, as in the symmetrical types, the diagnosis is straightforward and can be made with confidence in primary care(grade of recommendation R-D, level of evidence E-4).

In patients with an atypical presentation, diagnosis is more difficult and referral for expert assessment by a dermatologist is recommended(R-D, E-4).

In adults with vitiligo, a blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroiddisease in patients with vitiligo (R-D, E-3).

NATURAL HISTORYThe response of vitiligo to treatment should be considered in the context of the natural history, recognising that spontaneous repigmentationmay occur but is uncommon (R-D, E-4).A longitudinal epidemiological study is needed to define the natural history of vitiligo over time (R-D, E-4).

Psychological assessment and quality of lifeClinicians should make an assessment of the psychological and QoL effects of vitiligo on patients (R-C, E-2++).

TREATMENT

Camouflage cosmeticsIn patients with skin types I (always burn, never tan) and II (always burn, sometimes tan) it is appropriate to consider after discussionwhether the initial approach may be to use no active treatment other than consideration of camouflage cosmetics (including fake tanningproducts) and sunscreens (R-D, E-4).

Topical steroidsIn children, and adults with the recent onset of vitiligo, treatment with a potent or very potent topical steroid should be considered for

a trial period of no more than 2 months. Although benefits have been observed, skin atrophy is a common side effect (R-B by extrapolation;E-1+).

Calcineurin inhibitorsIn adults with symmetrical types of vitiligo, topical pimecrolimus is an alternative to a topical steroid, based on evidence from one study.The side effect profile of topical pimecrolimus is better than that of a highly potent topical steroid, although stinging may occur in somecases (R-C, E-2++).In children with vitiligo, topical pimecrolimus or tacrolimus should be considered as alternatives to a highly potent topical steroid in view oftheir better short term safety profiles (R-B, E-1+).

Depigmentation treatmentsDepigmentation treatments should be considered only in specialist dermatology units.

Phototherapy treatments

Phototherapy treatments should be considered only in specialist dermatology units.Systemic treatmentsThe use of oral dexamethasone to arrest progression of vitiligo cannot be recommended due to an unacceptable risk of side effects (R-B;E-2++).

Surgical treatmentsSurgical treatments should be considered only in specialist dermatology or plastic surgery units.

Cognitive therapy and psychological supportPsychological interventions should be offered as a way of improving coping mechanisms in patients with vitiligo (R-D; E-4).

Implications for implementationTreatments suggested in this guideline for non-specialists, with the exception of psychological therapies (which are generally not available),are inexpensive and unlikely to have a major financial impact on the National Health Service.


Review



5/7

generalised vitiligo (and four with stable disease) examined theeffect of oral dexamethasone (10 mg twice a week for 24 weeks),evaluating pigment change using photographs.19 The authorsshowed that disease progression was arrested in 22 of the 25subjects with active vitiligo, after an average of 18 (65) weeks.Marked repigmentation (51e75%) occurred in two subjects(7%) and moderate or slight repigmentation (26e50%; 75%repigmentation of surface area was seen in 24% in the PUVAgroup (although this group was not completely blinded) and36% in the NB-UVB group (in whom the quality of repigmen-tation was better than that seen with PUVA).21

Westerhof et al compared PUVA and NB-UVB in 28 vitiligopatients, reporting 46% repigmentation for the PUVA group.22

The risk of skin cancer in PUVA treated vitiligo patients iscurrently unclear. There is no long term follow-up study of thetype which established the clear cancer risk for PUVA in psori-

asis patients.The Excimer light source is an NB-UVB source for treating

localised areas such as the face and neck. Pseudocatalase treat-ment is a combination of a topical pseudocatalase preparationwith brief exposure to UV irradiation; results of trials areinconclusive.23 24 Home based NB-UVB is a possibility providedit is adequately supervised.

SURGICAL TREATMENTSSurgical treatment of vitiligo can be an attractive option, butonly if the disease has been inactive for 6e12 months. Njoo et alperformed a systematic review which evaluated 39 studiesassessing split thickness graft, minigraft using punch biopsies,

epidermal suction blisters as preparation, and donor and trans-plantation of non-cultured cell suspension or cultured melano-cytes.25 The highest mean success rates were achieved with splitskin grafting (87%, 95% confidence interval (CI) 82% to 91%)and epidermal blister grafting (87%, 95% CI 83% to 90%). Themean success rate of five culturing techniques varied from13e53%.

COGNITIVE THERAPY AND PSYCHOLOGICAL SUPPORTVitiligo is a disease with profound psychological effects, andpsychological approaches need to be assessed to see if they helpsufferers. QoL and coping mechanisms may improve over timein patients with vitiligo.26 Cognitive behavioural therapy strat-

egies rather than avoidance or concealment may be associatedwith better coping.27

DECIDING ON APPROPRIATE TREATMENTFor adults and children with skin types I and II (type Idalwaysburns, does not tan; type IIdburns easily, tans poorly) it may beappropriate to consider, after consultation, whether the initialapproach may be to use no active treatment other than use ofcamouflage cosmetics and sunscreens.

Treatment of vitiligo can be viewed in two phases: thefi

rst isto halt the progression of the disease; and the second is to inducerepigmentation. Some treatments can be considered to achieveboth. In adults with recent onset of vitiligo and in children,treatment with a potent or very potent topical steroid should beconsidered for a trial period of no more than 2 months. Skinatrophy has been a common side effect. In adults, topicalpimecrolimus should be considered as an alternative to atopical steroid, based on one study. The side effect profile oftopical pimecrolimus is better than that of a highly potent

Key references

< Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for thediagnosis and management of vitiligo. Br J Dermatol

2008;159:1051e76.< Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo

with UV-B radiation vs topical Psoralen plus UVA. ArchDermatol 1997;133:1525e8.

< Njoo MD, Westerhoff W, Bos JD, et al. A systematic reviewof autologous transplantation methods in vitiligo. ArchDermatol 1998;134:1543e9.

< Birlea SA, Gowan K, Fain PR, et al. Genome-wide associationstudy of generalized vitiligo in an isolated European founderpopulation identifies SMOC2, in close proximity to IDDM8.

J Invest Dermatol 2010;130:798e

803.

Current research questions

Pertinent research questions include the following:< More scientific research into the causes of vitiligo.< A longitudinal epidemiological study to define the natural

history of vitiligo, to quantify how the disease changes withtime.

< Development of more appropriate quality of life tools forvitiligo that should always be used as outcome measures onstudies in the disease.

< The establishment of simple and reproducible methods ofmonitoring the response of vitiligo to treatment both in theclinic and in clinical trials.

< A head-to-head study of tacrolimus versus pimecrolimus inadults and children with vitiligo is suggested.

< Assessment of the long term risk of skin cancer with extendedcourses of narrow band UVB or PUVA in patients with vitiligo.

< Development of criteria for use of surgical treatments (eg,definition of disease inactivity).

< Evaluation of different treatments for different types and

phases of the disease.< There are current studies into the scientific aspects of vitiligoincluding the genetics of vitiligo and autoimmune changes.28 29

However, there are no known studies on the other issuesmentioned above at present.


Review



6/7

topical steroid. In children, topical pimecrolimus or tacrolimusshould be considered as alternatives to the use of a highlypotent topical steroid in view of their better safety profile.Depigmentation should be reserved for adults severely affectedby vitiligo and should be undertaken only by a specialistdermatology unit.

Phototherapy and surgical treatments can be considered inspecialist units. Phototherapy is appropriate for extensive viti-

ligo, especially if it is active. Surgical treatment, if available, isappropriate for cosmetically sensitive sitesdfor example, theface or back of the handsdbut only when the vitiligo is inactive(no progression for 6e12 months). Surgical treatments are notrecommended in children.

Clinicians should make an assessment of the psychologicaland QoL effects of vitiligo on adults and children. Psychologicalinterventions should be offered as a way of improving copingmechanisms.

CONCLUSIONAfter making an assessment and suggesting supportive measure(ie, covering cosmetics and sunscreens), the first line treatmentfor vitiligo should be the use of a topical calcineurin inhibitor(eg, pimecrolimus or tacrolimus). The psychological impact ofthe disease can easily be overlooked but needs special attentionduring a consultation. The specialist dermatologist can usephototherapy (or possibly a surgical approach in patientswith stable disease). However, the paucity of the advice hereunderlines the desperate need for more effective treatments invitiligo.

MULTIPLE CHOICE QUESTIONS (TRUE (T)/FALSE (F); ANSWERS

AFTER THE REFERENCES)1. Segmental vitiligo is more common in children.2. The prevalence of thyroid disease in patients with vitiligo is

10%.

3. PUVA is more effective than NB-UVB for symmetrical typesof vitiligo.

4. Topical calcineurin inhibitors are preferred to topical cortico-steroids for the treatment of facial vitiligo in children.

5. Skin grafting is ineffective for vitiligo on the backs of thehands.

Acknowledgements The Guideline Development Group (GDG) would like to thankand acknowledge the support received from the British Association ofDermatologists, Cochrane Skin Group and the Vitiligo Society.

Competing interests None.

Patient consent Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES1. Nordlund JJ, Majumder PP. Recent investigations on vitiligo vulgaris. Dermatologic

Clinics 1997;15:69e78.2. Mason CP, Gawkrodger DJ. Vitiligo presentation in adults. Clin Exper Dermatol

2005;30:344e5.3. Nath SK, Majumder PP, Nordland JJ. Genetic epidemiology of vitiligo: Multilocus

recessivity cross-validated. Am J Hum Genet 1994;55:981e90.

4. Gawkrodger DJ, Ormerod AD, Shaw L, et al. Guideline for the diagnosis andmanagement of vitiligo. Br J Dermatol 2008;159:1051e76.

5. Whitton ME, Pinart M, Batchelor J, et al. Interventions for vitiligo. CochraneDatabase of Systematic Reviews 2010, issue 1.

6. Firooz A, Bouzari N, Fallah N, et al. What patients with vitiligo believe about theircondition. Int J Dermatol 2004;43:811e14.

7. Mattoo SK, Handa S, Kaur L, et al. Psychiatric morbidity in vitiligo: prevalence andcorrelates in India. J Eur Acad Dermatol Venerol 2002;16:573e8.

8. Ongenae K, Dierckxsens L, Brochez L, et al. Quality of life and stigmatization profilein a cohort of vitiligo patients and effect of the use of camouflage, Dermatology2005;210:279e85.

9. Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of vitiligo:a preliminary investigation into the effects of cognitive-behavioural therapy. Br J MedPsychol1999;72(Pt 3):385e96.

10. Stangier U, Gieler U, Ehlers A. Measuring adjustment to chronic skindisorders: validation of a self-report measure. Psychological Assessment2003;15:532e49.

11. Bjoro T, Holmen J, Kruger O, et al. Prevalence of thyroid disease, thyroid dysfunctionand thyroid peroxidase antibodies in a large, unselected population. The Health Studyof Nord-Trondelag (HUNT). Eur J Endocrinol 2000;143:639e47.

12. Clayton R. A double-blind trial of 0-05% clobetasol proprionate in the treatment ofvitiligo. Br J Dermatol 1977;96:71e3.

13. Kandil-E. Treatment of vitiligo with 0-1 per cent betamethasone 17-valerate inisopropyl alcoholea double-blind trial. Br J Dermatol 1974;91:457e60.

14. Westerhof W, Nieuweboer-Krobotova L, Mulder PGH, et al. Left-right comparisonstudy of the combination of fluticasone propionate and UV-A vs either fluticasonepropionate or UV-A alone for the long-term treatment of vitiligo. Arch Dermatol1999;135:1061e6.

15. Coskun B, Saral Y, Turgut D. Topical 0.05% clobetasol propionate versus 1%pimecrolimus ointment in vitiligo. Eur J Dermatol 2005;15:88e91.

16. Boone B, Ongenae K, Van Geel N, et al. Topical pimecrolimus in the treatment ofvitiligo. Eur J Dermatol 2007;17:55e61. Epub 2007 Feb 27.

17. Lepe V, Moncada B, Castanedo-Cazares JP, et al. A double-blind randomized trial of0.1% tacrolimus vs 0.05% clobetasol for the treatment of childhood vitiligo.[comment]. Arch Dermatol 2003;139:581e5.

18. Mosher DB, Parrish JA, Fitzpatrick TB. Monobenzylether of hydroquinone.A retrospective study of treatment of 18 vitiligo patients and a review of theliterature. Br J Dermatol 1977;97:669e79.

19. Radakovic FS, Furnsinn FA, Honigsmann H, et al. Oral dexamethasone pulsetreatment for vitiligo. J Am Acad Dermatol 2001;44:814e17.

20. Radmanesh M, Saedi K. The efficacy of combined PUVA and low-dose azathioprinefor early and enhanced repigmentation in vitiligo patients. J Dermatol Treat2006;17:151e3.

21. Yones SS, Palmer RA, Garibaldinos TM, et al. Randomised double-blind trial oftreatment of vitiligo. Efficacy of Psoralen-UVA vs. narrowband-UVB therapy. ArchDermatol2007;143:578e84.

22. Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vstopical Psoralen plus UVA. Arch Dermatol 1997;133:1525e8.

23. Njoo MD, Westerhoff W, Bos JD, et al. A systematic review of autologoustransplantation methods in vitiligo Arch Dermatol 1998;134:1543e9.

24. Schallreuter KU, Wood JM, Lemke KR, et al. Treatment of vitiligo with a topicalapplication of pseudocatalase and calcium in combination with short-term UVBexposure: a case study on 33 patients. Dermatology1995;190:223e9.

25. Bakis-Petsoglou S, Le Guay JL, Wittal R. A randomized, double-blinded, placebo-controlled trial of pseudocatalase cream and narrowband ultraviolet B in thetreatment of vitiligo. Br J Dermatol 2009;161:910e17. Epub 2009 Jun 11.

26. Papadopoulos L, Bor R, Legg C. Psychological factors in cutaneous disease; anoverview of research. Psychol Health Med 1999;4:107e26.

27. Thomson AR, Kent G, Smith JA. Living with vitiligo: dealing with difference.Br J Health Psychol 2002;7:213e25.

28. Birlea SA, Gowan K, Fain PR, et al. Genome-wide association study of generalizedvitiligo in an isolated European founder population identifies SMOC2, in closeproximity to IDDM8. J Invest Dermatol 2010;130:798e803. Epub 2009 Nov 5.

29. Waterman EA, Gawkrodger DJ, Watson PF, et al. Autoantigens in vitiligo identifiedby the serological selection of a phage-displayed melanocyte cDNA expressionlibrary. J Invest Dermatol 2010;130:230e40.

ANSWERS

1 (T); 2 (F); 3 (F); 4 (T); 5 (F)


Review



7/7

doi: 10.1136/pgmj.2009.0932782010 86: 466-471Postgrad Med J

David J Gawkrodger, Anthony D Ormerod, Lindsay Shaw, et al.on diagnosis and managementVitiligo: concise evidence based guidelines

http://pmj.bmj.com/content/86/1018/466.full.htmlUpdated information and services can be found at:

These include:

Referenceshttp://pmj.bmj.com/content/86/1018/466.full.html#ref-list-1

This article cites 28 articles, 6 of which can be accessed free at:

serviceEmail alerting

the box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

http://pmj.bmj.com/content/86/1018/466.full.htmlhttp://pmj.bmj.com/content/86/1018/466.full.html#ref-list-1http://pmj.bmj.com/content/86/1018/466.full.html#ref-list-1http://group.bmj.com/group/rights-licensing/permissionshttp://group.bmj.com/group/rights-licensing/permissionshttp://journals.bmj.com/cgi/reprintformhttp://journals.bmj.com/cgi/reprintformhttp://group.bmj.com/subscribe/http://group.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://pmj.bmj.com/http://group.bmj.com/http://pmj.bmj.com/http://group.bmj.com/subscribe/http://journals.bmj.com/cgi/reprintformhttp://group.bmj.com/group/rights-licensing/permissionshttp://pmj.bmj.com/content/86/1018/466.full.html#ref-list-1http://pmj.bmj.com/content/86/1018/466.full.html

2010 vitiligo evidencias por diagnostico e manejamento

Documents

Transcript of 2010 vitiligo evidencias por diagnostico e manejamento