# Vitiligo

Confirm true depigmentation, define nonsegmental versus segmental distribution and activity, screen selectively for autoimmune disease, and match topical, phototherapy, systemic, or surgical treatment to extent, site, progression, and stability.

**Clinical question:** How should clinicians confirm, phenotype, investigate, treat, and monitor vitiligo according to distribution, activity, extent, and anatomic site?

Updated: 2026-09-15T23:55:00.413198+00:00

## What matters in practice
- Use natural-light and Wood lamp examination to document extent; vitiligo lesions show enhanced blue-white fluorescence, and Wood lamp may disclose subclinical depigmentation. [1][4]
- Classify distribution before treatment: bilateral symmetric disease favors nonsegmental vitiligo, whereas a unilateral pattern favors segmental vitiligo. [4]
- In suspected nonsegmental vitiligo, obtain thyroid function testing and antithyroid antibodies; broaden autoimmune testing only when history, family history, examination, or initial results indicate another disorder. [16]
- For limited disease, select topical corticosteroid therapy or a topical calcineurin inhibitor, particularly for face, neck, and folds; avoid chronic topical corticosteroid exposure because of skin atrophy risk. [11][15][19]
- Use NB-UVB as the principal light-based option for more extensive nonsegmental disease; follicular repigmentation generally becomes evident after 15 to 20 sessions, and treatment can continue when response persists. [12]
- Escalate rapidly progressive disease to dermatology for consideration of short systemic corticosteroid mini-pulses combined with NB-UVB; surgical grafting is reserved for stable disease. [14][3]

## Confirm depigmentation and classify the clinical pattern

The first management decision is whether the eruption is vitiligo and, if so, which distribution and activity pattern is present.

Diagnose typical vitiligo clinically when sharply demarcated, milky-white, non-scaly macules or patches are present. Examine all skin in natural light and with a Wood lamp before selecting therapy: lesions fluoresce blue-white, contrast is enhanced, and occult areas may become apparent. Record skin phototype, duration, body distribution, mucosal and hair involvement, and whether lesions are expanding; these features guide treatment selection and provide a baseline for response. [1][4]

Classify bilateral or symmetric patches as nonsegmental vitiligo unless another diagnosis explains the pattern. Classify a predominantly unilateral distribution as segmental vitiligo. This distinction matters because ruxolitinib cream efficacy and safety were established in nonsegmental vitiligo, and NB-UVB has less supporting evidence for segmental or unclassifiable disease. [1][4][12]

Use dermoscopy when clinical morphology or disease activity is uncertain, particularly when distinguishing vitiligo from other acquired hypopigmentary or depigmenting disorders. If the diagnosis remains uncertain after examination, biopsy a representative active edge rather than a fully depigmented center; vitiligo histology shows absent or near-absent epidermal melanocytes, while early lesions may show interface dermatitis with CD8-positive lymphocytes and lymphocytic infiltrates at the advancing border. [1]
- Document baseline extent with clinical photographs plus natural-light and Wood lamp examination before treatment; repeat the same method for longitudinal comparison. [1][4]
- Ask specifically about new lesions, enlargement of existing patches, trauma-associated lesions, hair depigmentation, mucosal involvement, prior treatment response, and personal or family autoimmune disease. [4][10][16]
- Assess psychosocial burden directly, including depression, anxiety, self-esteem, school or work disruption, and treatment feasibility; psychosocial impact can be substantial even with limited body surface area. [17][21]

*Clinical pattern and its immediate management implication. [1][4][12]*

| Pattern | Findings that support it | What changes next |
| --- | --- | --- |
| Nonsegmental vitiligo | Bilateral, often symmetric patches; generalized, acrofacial, or universal distribution may occur. [4] | Assess extent and activity; consider topical therapy for limited disease, NB-UVB for more extensive disease, and ruxolitinib cream only within its studied nonsegmental population. [1][12] |
| Segmental vitiligo | Usually unilateral distribution. [4] | Assess stability carefully; phototherapy evidence is less robust, and stable lesions may be candidates for surgical repigmentation approaches. [12][3] |
| Atypical or uncertain depigmentation | Morphology, scale, distribution, or Wood lamp findings do not support a confident clinical diagnosis. [1][24] | Use dermoscopy and consider biopsy of an active border to evaluate melanocyte loss and inflammatory pattern before immunomodulatory treatment. [1][22] |

## Screen for autoimmune thyroid disease and target further testing

Laboratory testing should identify clinically actionable autoimmune comorbidity without indiscriminate serologic panels.

For suspected nonsegmental vitiligo, obtain thyroid function tests and antithyroid antibodies to identify patients at increased risk for autoimmune thyroid disease. Vitiligo is associated with Hashimoto thyroiditis and Graves disease, and thyroid testing is recommended in adults and children with vitiligo. [1][16]

Do not order broad autoimmune antibody panels solely because vitiligo is present. Add testing for another autoimmune condition only when symptoms, examination, family history, or initial testing creates a specific diagnostic suspicion. An abnormal thyroid result should trigger management according to the thyroid disorder rather than alter vitiligo treatment automatically. [16]

At each treatment review, reassess disease activity and quality-of-life effect rather than relying only on pigment change. Higher vitiligo activity and severity scores have been associated with greater quality-of-life impairment in patients with thyroid dysfunction, supporting closer follow-up when active disease and thyroid autoimmunity coexist. [10]
- Order thyroid function testing and antithyroid antibodies at initial evaluation of nonsegmental vitiligo. [16]
- Use personal and family autoimmune history to determine whether a targeted additional workup is warranted. [16]
- Document patient-reported treatment burden before prescribing office phototherapy, home-based treatment, or long-duration topical regimens. [17][21]

*Targeted investigation strategy in vitiligo. [1][16]*

| Clinical situation | Test or action | Interpretation and next step |
| --- | --- | --- |
| Suspected nonsegmental vitiligo | Thyroid function tests plus antithyroid antibodies. [16] | Identify autoimmune thyroid disease or risk for future thyroid disease; manage an identified thyroid disorder through the appropriate pathway. [1][16] |
| Symptoms, family history, examination, or prior results suggesting another autoimmune condition | Order condition-directed testing rather than a routine broad autoimmune screen. [16] | Pursue the specific suspected autoimmune diagnosis and coordinate care as indicated. [16] |
| Atypical lesions or diagnostic uncertainty | Dermoscopy; biopsy of a representative lesion when needed. [1][22] | Absent epidermal melanocytes supports vitiligo; an alternative histologic pattern redirects the differential and treatment. [1] |

## Choose site-directed therapy for localized vitiligo

For limited involvement, select treatment by anatomic site, patient age, progression, and tolerance for local adverse effects.

Topical corticosteroids are a first-line option for focal, segmental, and localized vitiligo. Use a time-limited course because prolonged exposure can cause skin thinning; reassess clinical response and local toxicity rather than continuing indefinitely. Older consensus practice used moderately potent to potent corticosteroids for facial disease and potent to very potent agents for body lesions, but long-term topical corticosteroid treatment is not advocated because of adverse effects. [11][19]

Prefer tacrolimus ointment or pimecrolimus cream when lesions involve the face, neck, or body folds, where avoiding corticosteroid atrophy is a priority. Topical calcineurin inhibitors can be used longer than topical corticosteroids and are especially useful for head and neck lesions; counsel that transient application-site burning, itch, or irritation can occur. In a meta-analysis, burning occurred in 9.8%, pruritus in 7.4%, and erythema in 2.4% of patients treated with topical calcineurin inhibitor monotherapy. [15][19][20]

Ruxolitinib 1.5% cream is a disease-directed topical option only for nonsegmental vitiligo, the population in which efficacy and safety were established. Confirm subtype before prescribing and reassess treatment response with standardized photography and Wood lamp examination; do not extrapolate the pivotal-population finding to segmental vitiligo as if equivalent evidence existed. [1]
- Use topical calcineurin inhibitors preferentially for face, neck, and intertriginous lesions when steroid-sparing treatment is needed. [15][19]
- Stop or modify topical corticosteroid therapy when cutaneous atrophy or other local adverse effects emerge; chronic uninterrupted use is not advised. [11][19]
- Consider combining a topical calcineurin inhibitor with NB-UVB when localized disease requires greater repigmentation response than topical treatment alone. [20]

*Topical treatment selection by clinical context. [1][11][15][19][20]*

| Clinical context | Preferred option | Key limitation or monitoring issue |
| --- | --- | --- |
| Localized nonfacial lesions | Time-limited topical corticosteroid therapy. [11][19] | Monitor for skin thinning; avoid long-term continuous use. [11][19] |
| Face, neck, or body folds | Tacrolimus ointment or pimecrolimus cream. [15][19] | Counsel regarding burning, pruritus, and local irritation. [19][20] |
| Nonsegmental vitiligo appropriate for topical JAK inhibition | Ruxolitinib 1.5% cream. [1] | Evidence base is for nonsegmental vitiligo; document subtype before treatment. [1] |
| Suboptimal response to topical calcineurin inhibitor alone | Add NB-UVB or excimer-based phototherapy where available. [20][9] | Response varies substantially; monitor repigmentation with consistent baseline and follow-up assessment. [9][20] |

## Use phototherapy for extensive disease and suppress rapidly progressive activity

Extent and active spread determine whether topical treatment alone is insufficient.

For nonsegmental vitiligo involving 10% to 40% body surface area, systemic NB-UVB is recommended as first-line therapy in adults and children older than 10 years. NB-UVB has largely replaced PUVA for lesions affecting at least 10% of skin surface area because it has no systemic toxicity and has favorable safety in children and adults. Expect perifollicular repigmentation after approximately 15 to 20 sessions; continue therapy when pigmentation is progressing, with courses extending beyond 9 to 12 months and, in selected responders, up to 24 months followed by gradual dose reduction. [12]

Choose targeted UVB or excimer laser/light for circumscribed lesions when whole-body NB-UVB is disproportionate to disease extent. Once-weekly targeted UVB may be as effective as twice-weekly therapy for lesions of the face, neck, torso, limbs, and scalp, but initial repigmentation may occur more slowly with the less frequent schedule. [9]

For highly progressive vitiligo, refer promptly to dermatology for systemic disease-stabilizing treatment rather than escalating topical therapy alone. A described regimen is methylprednisolone 16 mg or dexamethasone 5 mg on two consecutive days weekly for 3 to 6 months, combined with NB-UVB two to three times weekly for 6 months. This approach is reported to block relapse in more than 80% of cases, but systemic corticosteroid exposure requires individualized risk assessment and pediatric review after 3 months in growing children. [14]

Do not equate stabilization with durable remission. After treatment cessation, approximately 40% of patients have some pigment loss within one year. For patients who repigment, plan maintenance topical therapy several times weekly when appropriate and continue objective surveillance for recurrent activity. [19]
- Use whole-body NB-UVB when nonsegmental disease involves at least 10% body surface area or when lesion burden exceeds practical topical treatment. [12]
- Assess for an early follicular repigmentation signal after 15 to 20 NB-UVB sessions; lack of objective change should prompt reassessment of adherence, diagnosis, disease activity, and modality selection. [12]
- Reserve systemic corticosteroid mini-pulses for rapidly progressive disease under dermatologic supervision, preferably alongside NB-UVB. [14]

*Escalation by vitiligo extent and activity. [9][12][14][19]*

| Disease state | Treatment approach | Timing and reassessment |
| --- | --- | --- |
| Nonsegmental vitiligo involving 10% to 40% body surface area | Whole-body NB-UVB. [12] | Look for follicular repigmentation after 15 to 20 sessions; continue responsive treatment beyond 9 to 12 months when benefit persists. [12] |
| Circumscribed lesions needing light treatment | Targeted UVB or excimer laser/light. [9] | Once-weekly treatment may delay initial visible restoration compared with twice-weekly treatment. [9] |
| Highly progressive disease | Systemic corticosteroid mini-pulse plus NB-UVB two to three times weekly. [14] | Systemic mini-pulses are described for 3 to 6 months; obtain pediatric input after 3 months in growing children. [14] |
| Repigmented disease after treatment withdrawal | Topical maintenance medication several times weekly when appropriate. [19] | Monitor for recurrence because about 40% experience some color loss within one year after treatment ends. [19] |

## Refer stable, treatment-refractory lesions for surgical repigmentation assessment

Surgery is a lesion-directed option after stability, not a rescue strategy for ongoing inflammatory spread.

Consider surgical repigmentation procedures for stable vitiligo that remains cosmetically significant despite medical treatment, particularly segmental disease or focal stable lesions. Available approaches include tissue grafting and cellular grafting techniques; a systematic review and meta-analysis evaluated treatment response across surgical modalities, supporting surgery as a distinct management pathway rather than an extension of topical therapy. [3]

Before surgical referral, reconfirm lesion stability with serial clinical and Wood lamp photographs and exclude active expansion. Persistent inflammatory activity, new lesions, or trauma-associated spread should redirect management toward disease stabilization, typically phototherapy with or without systemic therapy for highly progressive disease, rather than grafting into an active disease field. [1][10][14]

Use dermoscopy and Wood lamp examination as adjuncts when monitoring postoperative repigmentation. Evaluate both pigment gain and recurrence at lesion edges; repeat grafting decisions should be based on durable stability and objective repigmentation rather than a single follow-up appearance. [5]
- Refer for surgical assessment only after demonstrating clinical stability; active disease should be medically stabilized first. [3][14]
- Use serial standardized photographs and Wood lamp examination before and after intervention to distinguish true repigmentation from variation in ambient lighting or tanning. [1][4][5]
- Maintain psychosocial screening during refractory-disease management because treatment duration and visible disease can impair self-esteem and daily function. [17][21]

*When to change from medical to procedural management. [3][5][14]*

| Finding | Management decision | Reason |
| --- | --- | --- |
| New or enlarging lesions, or other evidence of highly progressive disease | Do not proceed directly to surgery; prioritize stabilization with dermatology-directed systemic mini-pulse therapy and NB-UVB when indicated. [14] | Surgical repigmentation is best considered in stable disease rather than an actively spreading disease field. [3][14] |
| Stable focal or segmental lesions with inadequate medical response | Refer for consideration of tissue or cellular grafting techniques. [3] | Surgical modalities are established options for selected stable vitiligo. [3] |
| Postoperative pigment assessment | Use dermoscopy as an adjunct to Wood lamp examination. [5] | These tools support objective assessment of repigmentation. [5] |

## References
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15. Scenario: Management of vitiligo - CKS - NICE — cks.nice.org.uk — https://cks.nice.org.uk/topics/vitiligo/management/management
16. [PDF] National Institute for Health and Care Excellence - NICE — www.nice.org.uk — https://www.nice.org.uk/guidance/ta1140/documents/scope-consultation-comments-and-responses
17. 3 Committee discussion | Ruxolitinib cream for treating non-segmental vitiligo in people 12 years and over | Guidance | NICE — www.nice.org.uk — https://www.nice.org.uk/guidance/TA1140/chapter/3-committee-discussion
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## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.