Pediatric Vitiligo: Therapy, Safety, and Phototherapy Protocols

Key Takeaways

Face/neck first-line: topical calcineurin inhibitors (tacrolimus 0.03–0.1%) are preferred to avoid steroid atrophy.
Generalized disease: NB-UVB 311 nm 2–3×/wk with pediatric dose moderation; use excimer 308 nm for focal rims or small patches.
Safety: goggles, shielding, incremental dosing, and emollients reduce AEs; steroid pulses off-face with breaks.
Family workflow: brief visits, photo checklists, and simple home routines improve adherence and outcomes.

Confirm with Wood’s lamp (chalk/blue-white accentuation) and dermoscopy (perifollicular islands).
Common mimickers: pityriasis alba, post-inflammatory hypopigmentation, tinea versicolor—check for fine scale and consider KOH if needed.
Baseline photos + F-/T-VASI; consider simple QoL screen for the child/parents.

Table 1. Pediatric-friendly topical plan.

Site	Preferred agent	Frequency	Notes
Face/neck & folds	Tacrolimus 0.03–0.1%	Once nightly (up to BID)	Start low to reduce stinging; emollient first if sensitive
Trunk/limbs (small areas)	Tacrolimus or mild steroid	Nightly; steroid in pulses	Alternate with tacrolimus to minimize atrophy
Acral patches	Tacrolimus	Nightly	Combine with excimer for rims

Frequency: 2–3×/wk on non-consecutive days.
Start dose: lower end of device/phototype tables; escalate by 10% if no erythema >24 h.
Protection: child-sized goggles; cover uninvolved skin; moisturize after sessions.
Course: 24–36 sessions then reassess; continue if responding; taper to weekly → q2wk for maintenance.
Spacing with topicals: apply tacrolimus on off-light days or ≥8–12 h apart.

Ideal for periorificial face, small focal macules, and rims that lag on NB-UVB.
Schedule 2–3×/wk mini-cycles (e.g., 6–12 weeks) with quick reviews to keep children engaged.
Pair with tacrolimus between light days.

For short pulses on trunk/limbs if plateauing: low-to-mid potency 1–2×/day for 1–2 weeks, then break.
Avoid chronic daily use; monitor for atrophy and striae; prefer tacrolimus for long-term control.

Create a simple weekly plan (stickers/check boxes). Celebrate milestones (first islands!).
Provide a short script for parents/teachers to reduce stigma and explain treatment days.
Consider child-appropriate QoL tools and camouflage options for events/photos if desired.

Review at 8–12 weeks for early response; optimize regimen and friction/sun care.
After fill-in, transition to proactive tacrolimus 2–3 nights/week on face/neck; taper NB-UVB.
Plan early “rescue” slots for rims with excimer 308 nm to avoid relapse spread.