Key Takeaways
- Why relapse? Persistent tissue-resident memory T cells (TRM) linger in previously affected skin and can reignite depigmentation after stopping therapy.
- Who relapses? Higher risk in NSV, face/hands involvement, recent activity (confetti/Koebner), and rapid stop of light therapy.
- What helps? Proactive tacrolimus on relapse-prone sites, NB-UVB taper (not abrupt stop), and excimer boosters for rim “sparkle.”
- Plan ahead: give patients a Rescue Plan (how to respond within 2–4 weeks of new flecks) and define follow-up intervals.
TRM Biology & Clinical Signals
- TRM persistence: even after clinical fill-in, CD8⁺ TRM may remain around follicles and adnexa, primed to re-activate.
- Clinical correlates: confetti depigmentation at borders, quick reappearance at old sites, and Koebner phenomena after friction or procedures.
- Implication: maintain a small, steady immunomodulatory “pressure” rather than on/off cycles.
Risk Stratification
| Tier | Features | Examples |
|---|---|---|
| Low | SV post-surgery stable; no activity 12+ mo; non-acral | Stable segmental cheek patch after SBEG |
| Moderate | NSV with face/neck response; no confetti ×6 mo | Facial NSV controlled on NB-UVB + tacrolimus |
| High | Recent confetti/Koebner; acral sites; abrupt therapy stop | Hands/feet; frequent manual work/friction |
Maintenance Schedules (Proactive Care)
| Modality | Schedule | Use Case | Pearls |
|---|---|---|---|
| Tacrolimus 0.1% (face/folds) | 2–3 nights/week (long-term) | Post-fill-in on face/neck | Apply on non-light days; thin layer |
| NB-UVB 311 nm taper | Weekly ×4–6 → q2wk ×8–12 → stop | NSV after good response | Avoid abrupt stop; track erythema |
| Excimer 308 nm boosters | Mini-cycles 1–2×/wk for 3–6 wks PRN | Rim “sparkle”, periorificial areas | Focus on borders; separate from topicals by ≥8–12 h |
| Steroid pulses (off-face) | 1–2×/day for 1–2 wks, then break | Trunk/limbs prone to flare | Alternate with tacrolimus to limit atrophy |
Rescue Algorithms (Early Relapse)
- Detect: patient spots new flecks/confetti → contact clinic within 2–4 weeks.
- Restart/step-up:
- Face/neck: nightly tacrolimus 0.1% + excimer 2–3×/wk mini-cycle.
- Trunk/limbs: NB-UVB back to 2–3×/wk for 4–8 weeks ± short steroid pulse.
- Acral: excimer to rims + friction control (gloves, footwear mods).
- Reassess @ 8–12 wks: photos + F-/T-VASI; if controlled, resume maintenance tier; if not, escalate or consider surgery if stable focal plaque.
Friction, Seasons & Counseling
- Friction/pressure: watch tools, straps, tight shoes; add padding, rotate contact points.
- Seasons: plan maintenance before high-UV or dry/cold seasons; moisturizers, barrier repair.
- Cosmetics & QoL: offer camouflage options and set realistic timelines to reduce stress-triggered flares.
Follow-Up & Documentation
- Schedule: 3–4 months after stopping active therapy; then q6–12 months (high-risk: q3–6 months).
- Tools: standardized photos, Wood’s lamp for rims, and PROMs from QoL article.
- Discharge plan: written maintenance + rescue steps; direct line for early flare reporting.