Key Takeaways
- First-line on face/neck: calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as steroid-sparing agents.
- Backbone for generalized disease: NB-UVB 311 nm (2–3×/week) with pediatric dose escalation and eye protection.
- Focal lesions/edges: Excimer 308 nm accelerates facial fill-in and rim control.
- Safety: avoid chronic potent steroids on face/folds; monitor erythema from light; counsel on sun/trauma (Koebner) avoidance.
Diagnosis Nuances in Children
- Use Wood’s lamp & dermoscopy to confirm depigmentation and map early islands.
- Differential: pityriasis alba, tinea versicolor, post-inflammatory hypopigmentation—check scale/KOH if unclear.
- Record baseline photos and simple F-VASI/T-VASI for follow-up.
Topicals: Choices & Dosing
| Agent | Sites | Dose/Timing | Notes |
|---|---|---|---|
| Tacrolimus 0.1% | Face/neck, folds | BID thin layer | Stinging early; no atrophy |
| Pimecrolimus 1% | Face/neck, sensitive areas | BID | Steroid-sparing alternative |
| Topical corticosteroids | Body (non-facial) | Intermittent/pulsed | Avoid long-term on face/folds |
Phototherapy Protocols
- NB-UVB 311 nm: 2–3×/week; start low (e.g., 200–300 mJ/cm²) and increase 10–20% as tolerated.
- Monitoring: hold/reduce after erythema >24 h; moisturize; use goggles and shield uninvolved areas.
- Course: 24–48 sessions initial; extend if responding; taper for maintenance.
Focal Disease & Excimer 308 nm
- 2–3×/week to active rims and facial macules; expect islands by weeks 4–8 on face.
- Combine with tacrolimus 0.1% on off-days to deepen response.
Adherence, Family Education & QoL
- Teach fingertip-unit dosing; use reminder charts and photo diaries for motivation.
- Address school/peer concerns; consider vitiligo-specific QoL scales.
- Friction control (backpacks, sports gear) and sun safety reduce relapses.
Safety & Monitoring
| Issue | Risk | Action |
|---|---|---|
| Steroid overuse (face/folds) | Atrophy/telangiectasia | Prefer CNI; pulse steroids off-face |
| Light-induced erythema | Burn/discomfort | Hold/reduce dose; emollients |
| Eye safety | UV exposure | Goggles; shield eyes rigorously |
Treatment Tables (framework)
| Outcome | Topicals | NB-UVB | Excimer |
|---|---|---|---|
| F-VASI % change (12–24 wks) | — | — | — |
| F-VASI50/75 | — | — | — |
| Relapse at 6–12 mo | — | — | — |