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Clinical Updates

Rebat M. Halder, MD

Management of Childhood Vitiligo

Rebat Halder

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 environment.2

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

Treating Vitiligo

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 sun.

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 patients.3,9

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 better.4,12

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 literature.4,15,16

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 phototherapy.

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.

References

  1. 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. 1996:153-60.
  2. Hill-Beuf A, Porter JD. Children coping with impaired appearance: Social and psychologic influences. Gen Hosp Psychiatry. 1984;6(4):294-301.
  3. Halder RM. Childhood vitiligo. Clin Dermatol. 1997;15(6):899-906.
  4. Halder RM, Grimes PE, Cowan CA, et al. Childhood vitiligo. J Am Acad Dermatol. 1987;16(5):948-54.
  5. Grimes PE, Kelly AP, Cline DJ. Management of vitiligo in children. Symposium. Pediatr Dermatol. 1986;3(6):498-510.
  6. Nordlund JJ, Halder RM, Grimes PE. Management of vitiligo. Dermatol Clin. 1993;11(1):27-33.
  7. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for vitiligo. American Academy of Dermatology. J Am Acad Dermatol. 1996;35(4):620-6.
  8. Janniger CK. Childhood vitiligo. Cutis. 1993 Jan; 51(1):25-8.
  9. Goldstein E, Haberman HF, Menon IA, et al. Non-psoralen treatment of vitiligo. Part I. Cosmetics, Systemic coloring agents, and corticosteroids. Int J Dermatol. 1992;31(4):229-36.
  10. Morman MR. Possible side effects of topical steroids. Am Fam Physician. 1981;23(2):171-4.
  11. Spiers F. A case of irreversible steroid-induced rise in intraocular pressure. Acta Opthalmol (Copenh). 1965;43:419-22.
  12. Kumari J. Vitiligo treated with topical clobetasol propionate. Arch Dermatol. 1984;120(5):631-5.
  13. 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.
  14. Kanwar AJ, Dogra S, Prasad D. Topical tacrolimus for treatment of childhood vitiligo in Asians. Clin Exp Dermatol. 2004 Nov;29(6):589-92.
  15. Grimes PE, Minus HR, Chakrabarti SG, et al. Determination of optimal topical photochemotherapy for vitiligo. J Am Acad Dermatol. 1982;7(6):771-8.
  16. Halder RM. Topical PUVA therapy for vitiligo. Dermatol Nurs. 1991;3(3):178-80.
  17. 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.
  18. 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.
  19. Kanwar AJ, Dogra S. Narrow-band UVB for the treatment of generalized vitiligo in children. Clin Exp Dermatol. 2005;30(4):332-6.
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