Key Takeaways
- Backbone: NB-UVB 311 nm for generalized disease; excimer 308 nm for focal patches, rims, and acral borders.
- Face/folds: tacrolimus (± pimecrolimus) is first-line; avoid chronic steroid use here.
- Off-face: mid-potency steroids in short pulses can “jump-start” with NB-UVB, then switch to tacrolimus maintenance.
- Label-eligible topical JAK may accelerate facial/periorificial fill-in; space applications from light sessions.
- Separate modalities: apply topicals on non-light days or ≥8–12 h apart from phototherapy.
Zone-Specific Pathways
Face / Neck
- Start: NB-UVB 2–3×/wk or excimer for small focal/periorificial sites.
- Topical: tacrolimus 0.1% nightly (or pimecrolimus 1% if sensitive); consider label-eligible topical JAK once daily if access allows.
- Escalate: add excimer to persistent rims; keep tacrolimus between light days.
Trunk / Proximal Limbs
- Start: NB-UVB 2–3×/wk.
- Topical: mid-potency steroid pulse (1–2 weeks) → switch to tacrolimus nightly.
- Focal gaps: excimer on slow rims while NB-UVB continues.
Acral (Hands/Feet)
- Start: excimer 2–3×/wk to borders ± NB-UVB if more extensive.
- Topical: tacrolimus nightly; avoid friction; protective gear/footwear mods.
- Expectations: slow; aim for islands first; consider surgery if stable and refractory.
Folds / Eyelids / Lips
- Topical backbone: tacrolimus/pimecrolimus only.
- Light: excimer preferred for small targets; carefully shield mucosa.
Sequencing & Spacing Rules
- Light days: perform NB-UVB/excimer first; moisturize after; no immediate tacrolimus/JAK right before light.
- Off-light days: tacrolimus or label-eligible topical JAK once nightly.
- Steroid pulses (off-face): short, time-limited; then transition to calcineurin inhibitor.
- Minimum spacing: keep ≥8–12 h between potent topicals and light exposure.
Timelines & Response Checks
- 4–8 weeks: look for facial perifollicular islands; continue if present.
- 8–12 weeks: trunk response; add excimer to slow rims.
- 12+ weeks: acral changes; discuss realistic milestones and adherence.
- Track with standardized photos and F-/T-VASI; add patient-reported outcomes (see QoL article).
Algorithm Tables
| Phase | Light | Topical | Checkpoints | If suboptimal |
|---|---|---|---|---|
| Initiation (0–4 wks) | NB-UVB 2–3×/wk or excimer | Tacrolimus qHS | Early islands | Add excimer to rims |
| Consolidation (4–12 wks) | Continue | Tacrolimus qHS ± JAK (label-eligible) | F-VASI↓ | Increase excimer focus; review spacing |
| Maintenance | Taper NB-UVB; excimer PRN | Tacrolimus 2–3 nights/wk | Stable fill-in | Rescue mini-cycles |
| Phase | Light | Topical | Checkpoints | If suboptimal |
|---|---|---|---|---|
| Initiation | NB-UVB 2–3×/wk | Steroid pulse 1–2 wks → tacrolimus | Islands @ 8–12 wks | Add excimer to rims |
| Consolidation | Continue NB-UVB | Tacrolimus nightly | T-VASI↓ | Second pulse or switch focal areas to excimer |
| Maintenance | Taper to weekly → q2wk | Tacrolimus 2–3 nights/wk | Stable color | Rescue cycles |
| Phase | Light | Topical | Adjuncts | Notes |
|---|---|---|---|---|
| Initiation | Excimer 2–3×/wk | Tacrolimus qHS | Friction control | Slow trajectory; set expectations |
| Consolidation | Continue excimer ± NB-UVB | Tacrolimus | Protective footwear/gloves | Consider surgery if stable and refractory |
Maintenance & Relapse Prevention
- After fill-in, taper NB-UVB (weekly → q2wk → stop) and keep tacrolimus 2–3 nights/week on relapse-prone sites.
- Use excimer mini-cycles for border “sparkle” during seasonal flares.
- Provide a written rescue plan for early flecks/confetti.
Topical JAK Inhibitor (Ruxolitinib) for Vitiligo — Proof-of-Concept (JAAD, 2017)
Open-label, 20-week study of ruxolitinib 1.5% cream (BID). Overall mean VASI improved
23% at week 20; in patients with notable facial involvement, facial VASI improved
~76%. Minimal response on acral sites. Useful as evidence for topical JAKs in combination algorithms.
- Design: Open-label, 20 weeks
- Regimen: Ruxolitinib 1.5% cream BID
- Participants: n=11 (9 completed)
- Endpoints: VASI (overall and facial)