Management of Childhood Vitiligo
Tuesday, December 06, 2005
Vitiligo, although not a life-threatening disease for the child,
can be a life-altering disease.1 Difficulties in coping
with impaired appearances are most pronounced during childhood and
are particularly important in children's future social and
psychological development. Children with vitiligo are affected
differently, depending on the location and extent of their disease,
their age, individual capacities, and social
Effects on Children and Parents
Children ages 3 to 6 are relatively unaffected by vitiligo
because they are still centered on family and self; however, when
children reach elementary school, they become sensitive to teasing
and unfriendliness.2 However, unlike adolescents, they
have not become preoccupied with appearance. In the pre-pubertal
years (ages 10 to 13), the anxieties that often come with the
increasing demands of normal adolescent development are accentuated
by the presence of vitiligo.2 For older teens, the
importance of appearance, although still significant, is offset or
compensated for by working on higher priorities, such as future
goals in life and acquisition of skills.2
There is no doubt that family support and guidance play an
important role in the child's ability to cope.2 Children
with more concerned parents tend to receive treatment earlier and
more consistently; therefore, they may do better.
The psychological effects on parents having a child with
vitiligo can also be devastating. Often, parents blame themselves
for the child's vitiligo. The effect of vitiligo can be more
devastating to parents than to the child, particularly if the child
is under the age of 5 or 6, when the child or the child's peers may
not notice the vitiligo. Many parents are insistent on treatment
for the disease from an early age.3
The modalities used for the treatment of vitiligo in children do
not differ significantly from those used in adults.3-8
However, some are age specific. Sunscreens may suffice in
light-complexioned children particularly in the summertime. This
will prevent the normally pigmented skin from becoming darker.
Regardless, the use of sunscreen is advocated for all children with
vitiligo to prevent the depigmented skin from burning while in the
The use of cosmetic camouflage is not ideal in children with
vitiligo. Most of the cosmetics that are well suited in terms of
color matching in adults (Dermablend, Prescriptives) are not
waterproof, and they can be easily removed during play. Those that
are semi-permanent and somewhat waterproof, such as
dihydroxyacetone dyes (Vitadye, Dyoderm) cannot be matched closely
to the normal skin color, particularly in darker skinned
Topical steroids have for many years been first-line therapy for
vitiligo in children. They are relatively inexpensive, can be
easily used at home, and can work well for areas of limited
involvement. Although a high-potency topical steroid works best for
vitiligo, these are not recommended in children.4
In children with vitiligo, a medium-potency steroid is suggested
for nonfacial areas. A low-potency steroid can be used for facial
areas. Topical steroids are applied twice a day to the affected
depigmented patches. It may take 3-4 months of continuous therapy
or longer to achieve acceptable results. Children, in particular,
should be monitored for side effects such as skin atrophy and
telangiectasiae. Topical steroids should be used with caution on
the eyelids because there have been reports of topical steroids
leading to increased intraocular pressure as well as complicating
congenital glaucoma in infants.10,11
It is sometimes difficult to maintain this rigorous daily
schedule in children; thus patients and their parents should be
well motivated. The response rate for topical steroids for vitiligo
in children is approximately 45%, with darker skinned individuals
such as blacks, Asians, and Hispanics responding
Recent alternatives to topical corticosteroids are the topical
immunomodulators, tacrolimus and pimecrolimus. The efficacy of
these agents for vitiligo in children are reported to be, at least,
equal to topical corticosteroids.13,14 In a documented
study, partial response was noted to tacrolimus ointment on the
head and neck in 89%, and on the trunk and extremities in 63% of
children with vitiligo and facial vitiligo of the segmental
type.13 The 0.03% concentration of tacrolimus ointment
works as well as the 0.1% concentration in children. Both topical
tacrolimus and pimecrolimus have advantages in children over
topical corticosteroids because of the potential for cutaneous
atrophy, telangiectasiae, and ocular complications associated with
corticosteroids in children.
Recent U.S. Food and Drug Administration (FDA) labeling gives
caution to prolonged use of topical tacrolimus and pimecrolimus in
the pediatric age group. However, short-term use of these agents in
localized areas in children with vitiligo is considered safe.
If topical corticosteroids or immunomodulators are unsuccessful,
then topical psoralen plus ultraviolet A light (PUVA) therapy can
be considered for children with less than 20% skin surface
involvement. This has been found to be a safe treatment in
children, if administered judiciously.5-7,15,16 Children
as young as 2 can be treated with this modality.1,2 The
1% stock solution of 8-methoxpsoralen (methoxalen) lotion is
diluted to a concentration of 0.1% in acid mantle cream or
hydrophilic ointment (i.e., Aquaphor®). It is applied
carefully within the margins of the vitiliginous lesion. The
specific protocol for UVA doses and frequency of administration for
topical PUVA therapy in children can be found in the
Using topical PUVA with natural sunlight is not recommended, nor
should topical methoxalen be dispensed to the patient. The main
hazard associated with topical PUVA is a severe phototoxic reaction
that occurs occasionally despite the best of care and caution in
controlling UVA exposure. It is very important that the child and
parents be warned in advance of this possibility. The response rate
for vitiligo for topical PUVA therapy in children is approximately
58%.3 The administration of topical PUVA must sometimes
be restricted during the summer months in this patient group.
For extensive disease in children, narrow-band UVB phototherapy
is recommended. Several reports indicate that it is effective with
response rates of 50-75% of patients averaging more than 75%
overall repigmentation and stabilization of disease occurring in
80% of patients.17,18,19 A major advantage of
narrow-band UVB phototherapy in children, in my experience, is the
lack of need for eye protection following therapy, unlike oral PUVA
therapy. Also, phototoxic reactions are less with narrow-band UVB
phototherapy. I treat children as young as 6 with narrow-band UVB
Currently, I do not use oral PUVA therapy for vitiligo in
children; however, it can be a treatment option for extensive
disease if narrow-band UVB phototherapy is not available, though it
is not recommended under the age of 12. Eye protection during and
for 24 hours following treatment is of utmost importance in
children on oral PUVA therapy.
For all forms of therapy, children with vitiligo respond better
than adults.3,4 The reasons for this have not been
delineated. However, melanocytes in children may be easier to
stimulate to migrate and to synthesize melanin because they have
not undergone senescence as have adult melanocytes. In light of the
enhanced repigmentation responses in children with vitiligo, early
therapeutic intervention is indicated.
There are other forms of treatment for vitiligo that are used
when standard medical therapies fail. These include depigmentation
and surgical modalities, such as grafting and melanocyte
transplantation.6,7 Depigmentation with monobenzyl ether
of hydroquinone is not recommended in a child because the child
would face a lifetime of sun avoidance from an early
age.3 Likewise, surgical treatments for vitiligo are not
indicated in children; however, both can be considered later in
adolescence.3 Parents and children should be directed to
support groups, such as the National Vitiligo Foundation, for
information regarding new research in vitiligo and to help them
deal with the disease.
- Halder RM, Pham HN, Crawford LM. Vitiligo: A Life-Altering
Disease. In: Walther RR, Beachman A, Ginsburg IH, eds.
Dermatology and Person-Threatening Illness: The Patient, the
Family, the Staff. New York, NY: Haworth Press.
- Hill-Beuf A, Porter JD. Children coping with impaired
appearance: Social and psychologic influences. Gen Hosp
- Halder RM. Childhood vitiligo. Clin Dermatol.
- Halder RM, Grimes PE, Cowan CA, et al. Childhood vitiligo.
J Am Acad Dermatol. 1987;16(5):948-54.
- Grimes PE, Kelly AP, Cline DJ. Management of vitiligo in
children. Symposium. Pediatr Dermatol.
- Nordlund JJ, Halder RM, Grimes PE. Management of vitiligo.
Dermatol Clin. 1993;11(1):27-33.
- Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for
vitiligo. American Academy of Dermatology. J Am Acad
- Janniger CK. Childhood vitiligo. Cutis. 1993 Jan;
- Goldstein E, Haberman HF, Menon IA, et al. Non-psoralen
treatment of vitiligo. Part I. Cosmetics, Systemic coloring agents,
and corticosteroids. Int J Dermatol.
- Morman MR. Possible side effects of topical steroids. Am
Fam Physician. 1981;23(2):171-4.
- Spiers F. A case of irreversible steroid-induced rise in
intraocular pressure. Acta Opthalmol (Copenh).
- Kumari J. Vitiligo treated with topical clobetasol propionate.
Arch Dermatol. 1984;120(5):631-5.
- Silverberg NB, Lin P, Travis L, et al. Tacrolimus ointment
promotes repigmentation of vitiligo in children: a review of 57
cases. J Am Acad Dermatol. 2004;51(5):760-6.
- Kanwar AJ, Dogra S, Prasad D. Topical tacrolimus for treatment
of childhood vitiligo in Asians. Clin Exp Dermatol. 2004
- Grimes PE, Minus HR, Chakrabarti SG, et al. Determination of
optimal topical photochemotherapy for vitiligo. J Am Acad
- Halder RM. Topical PUVA therapy for vitiligo. Dermatol
- Njoo MD, Bos JD, Westerhof W. Treatment of generalized vitiligo
in children with narrow-band (TL-01) UVB radiation therapy. J
Am Acad Dermatol. 2000 Feb;42(2Pt1):245-53.
- Brazzelli V, Prestinari F, Castello M, et al. Useful treatment
of vitiligo in 10 children with UV-B narrowband (311 nm).
Pediatr Dermatol. 2005;22(3):257-61.
- Kanwar AJ, Dogra S. Narrow-band UVB for the treatment of
generalized vitiligo in children. Clin Exp Dermatol.