Managing vitiligo in primary care

Vitiligo is a chronic skin condition characterised by depigmentation due to the loss of melanocytes. Although it is not life-threatening, vitiligo often has a significant psychological and social impact due to its effect on the patient’s physical appearance. Primary care physicians play a crucial role in the early identification, patient education, and management of vitiligo. This article is a an overview of how to manage this condition effectively in a primary care setting.

Vitiligo affects approximately one to two percent of the population worldwide. The exact causes are unknown. Researchers believe that multiple factors lead to the development of the disease. These may include autoimmune, genetic, and environmental factors as well as oxidative stress.

Vitiligo patients in primary care typically present with symmetrical white patches on the skin. Usually, these patches are located on the face, hands, elbows, knees, and genitalia. The condition can also affect mucous membranes, hair, and retina.

How to diagnose vitiligo in primary care

The first step towards diagnosing the condition is to gather information about the onset and progression of depigmented patches, and discuss with the patient the family history of vitiligo or other autoimmune diseases.

Next, it is important to recognise the potential triggers, such as stress, sunburn, or trauma (Koebner phenomenon).

Physical examination should aim at identifying distinct, well-demarcated, white macules and patches. Wood’s lamp can help examine and enhance depigmented areas.

All of this will allow a primary care doctor to set up a proper diagnosis, and dismiss other potential causes with similar symptoms, such as:

• Post-inflammatory hypopigmentation,
• Tinea versicolor,
• Pityriasis alba, and
• Albinism

Managing vitiligo in primary care

There are limited tools available for the primary care management of vitiligo. Although, physicians with additional education in general dermatology can offer a wider array of treatments (e.g. phototherapy). The basis of successful treatment is educating the patient about the condition and its chronic nature. The other vitiligo management options include topical therapies and photoprotection.

Topical therapies

Topical therapies for vitiligo involve the use of corticosteroids and calcineurin inhibitors.

Topical corticosteroids are the first-line treatment for localised vitiligo. Sensitive areas, like the face, require the use of low-to-mid potency steroids.

Calcineurin Inhibitors, such as tacrolimus, pimecrolimus are better for long-term use, particularly for the face and intertriginous areas.

Photoprotection

Patients should use sunscreens (SPF 30 or higher) to prevent sunburn and minimise contrast between depigmented and normal skin.

The cases unresponsive to initial treatment or those requiring phototherapy (narrowband UVB) or systemic immunosuppressants usually require referral to a dermatologist.

Other indications for referral include:

• Rapid progression or extensive vitiligo (more than ten per cent of body surface area affected).
• Children with vitiligo for specialised pediatric management.
• Presence of comorbid autoimmune diseases (e.g. thyroid disorders).
• Psychological distress requiring specialised intervention.

The treatment progress and efficacy requires regular review every six to twelve weeks. A primary care physician should also monitor for side effects of topical therapies, such as skin atrophy from steroids.

Although vitiligo requires specialised care in some cases, primary care physicians still play a pivotal role in its early management and support. With appropriate education, treatment, and timely referrals, they can help patients manage the condition and improve their quality of life.

– Dr Rosmy De Barros

For further information on this topic, you may be interested to learn more about the HealthCert online Professional Diploma program in General Dermatology.

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References

• Bergqvist, C., & Ezzedine, K. (2020). Vitiligo: a review. Dermatology, 236(6), 571-592.
• Gawkrodger, D. J., Ormerod, A. D., Shaw, L., Mauri‐Sole, I., Whitton, M. E., Watts, M. J., ... & Young, K. (2008). Guideline for the diagnosis and management of vitiligo. British Journal of Dermatology, 159(5), 1051-1076.
• Lee, J. H., Kwon, H. S., Jung, H. M., Lee, H., Kim, G. M., Yim, H. W., & Bae, J. M. (2019). Treatment outcomes of topical calcineurin inhibitor therapy for patients with vitiligo: a systematic review and meta-analysis. JAMA dermatology, 155(8), 929-938.
• El‐Khateeb, E. A., Ragab, N. F., & Mohamed, S. A. (2011). Epidermal photoprotection: comparative study of narrowband ultraviolet B minimal erythema doses with and without stratum corneum stripping in normal and vitiligo skin. Clinical and experimental dermatology, 36(4), 393-398.