Key Takeaways
- Backbone therapy for generalized/nonsegmental vitiligo; best responses on face/neck, slower on acral sites.
- Start low, escalate by 10–20% as tolerated; manage erythema with hold/reduce rules.
- Combine with tacrolimus 0.1% (face/folds) and excimer 308 nm for rims or focal gaps.
- Expect perifollicular islands on face by weeks 4–8; trunk later; acral requires patience and add-ons.
Standard Dosing Protocol
- Frequency: 2–3×/week on non-consecutive days.
- Starting dose: per device/phototype (e.g., 200–300 mJ/cm²) or MED-based if available.
- Escalation: +10–20% per session if no erythema >24 h; cap per clinic/device policy.
- Shielding: eyes with goggles; cover uninvolved skin where feasible.
- Course length: initial 24–48 sessions; extend if improving; taper for maintenance.
Erythema & Safety Rules
- No erythema → escalate as planned.
- Transient <24 h erythema → repeat dose or small step-up.
- Erythema >24 h / tenderness → hold or step down 10–20%, moisturize, reassess.
- Document reactions; adjust increments for sensitive zones (face/folds).
Timelines & Response by Site
| Site | Early signs | Repigmentation velocity | Notes |
|---|---|---|---|
| Face/neck | Islands by 4–8 wks | Fast | High F-VASI change with tacrolimus |
| Trunk/limbs | 8–12 wks | Moderate | Requires sustained sessions |
| Acral | 12+ wks | Slow | Add excimer; manage expectations |
Combinations with Topicals/Excimer
- Tacrolimus 0.1% on off-light days for face/folds; reduces steroid need.
- Mid-potency steroids pulsed off-face for resistant plaques.
- Excimer 308 nm for rims, periorificial islands, acral borders.
- Separate topical application and light by ≥8–12 h when feasible.
Pediatric Adaptations
- Start lower; escalate cautiously; enforce goggles and shielding.
- Use adherence tools (charts, reminders); combine with child-friendly topicals.
Clinic Workflow
- Baseline photos + Wood’s lamp; record F-/T-VASI.
- Set site-specific goals (face vs acral) and schedule 2–3×/week slots.
- Track dose, reactions, and islands; adjust increments accordingly.
- At session 24–36: evaluate VASI and QoL; continue, modify, or taper.
- Plan maintenance if good fill-in achieved.
Tables (framework)
| Session | Dose (mJ/cm²) | Site | Reaction | Next step |
|---|---|---|---|---|
| 1 | — | Whole-body | — | +10–20% |