Tacrolimus 0.1% for Vitiligo: Efficacy by Zone (Face/Neck vs Trunk vs Acral)

Key Takeaways

Face/neck respond fastest: perifollicular islands in 4–8 weeks, meaningful F-VASI drops by 8–12 weeks—best as nightly monotherapy or with excimer 308 nm.
Trunk/proximal limbs: slower curve; add NB-UVB 311 nm 2–3×/wk and keep tacrolimus on off-light days for synergy.
Acral (hands/feet): lowest yield with monotherapy; prioritize excimer to rims + tacrolimus; consider surgery when stable focal plaques persist.
Safety: no atrophy risk on face/folds; manage transient stinging with emollient-first technique; long-term maintenance 2–3 nights/week helps prevent relapse (see TRM maintenance).

Why Calcineurin Inhibitors in Vitiligo

Tacrolimus down-modulates T-cell–driven melanocyte damage at the rim and supports repigmentation from follicular reservoirs. On face/folds it replaces chronic steroids to avoid atrophy and telangiectasia.

Efficacy by Zone

Table 1. Expected response with tacrolimus 0.1% by site.

Zone	Time to first islands	12-week expectation	24-week expectation	Pearls
Face/Neck	4–8 wks	Visible fill-in; F-VASI ↓	Confluence in periorificial/hairy areas	Nightly use; add excimer for rims
Trunk/Proximal Limbs	8–12 wks	Islands; T-VASI modest ↓	Consolidation with NB-UVB	Short steroid pulse → switch to tacrolimus
Acral (Hands/Feet)	12+ wks (variable)	Limited without light	Better with excimer focus	Friction control; consider surgery if stable
Folds/Lips/Eyelids	4–8 wks	Good cosmetic gain	Maintain 2–3 nights/week	Preferred over steroids long-term

Combining with Light

NB-UVB 311 nm: keep tacrolimus on non-light days; recheck at 8–12 weeks (photos + VASI).
Excimer 308 nm: ideal for face rims, periorificial sites, and acral borders; space tacrolimus by ≥8–12 h from sessions.
See combination algorithms for zone-specific flows.

Dosing, Spacing & Maintenance

Initiation: tacrolimus 0.1% thin layer nightly (face/folds; off-face if steroid-sparing needed).
Spacing with light: avoid immediate pre-light application; use on off-light days or after ≥8–12 h.
Maintenance: after fill-in, continue 2–3 nights/week on relapse-prone sites to offset TRM-driven flares (see maintenance).

Safety & Counseling

Local AEs: transient burning/stinging; minimize by emollient 15–30 min before and starting alternate nights.
No skin atrophy risk—advantage over chronic facial steroids.
Sun habits: standard photoprotection; continue light therapy as prescribed.

Quick Tables

Table 2. When to escalate beyond tacrolimus monotherapy.

Scenario	Action	Notes
Face islands absent at 8–10 wks	Add excimer 2–3×/wk	Ensure adherence and spacing
Trunk plateau at 12 wks	Start NB-UVB 2–3×/wk	Short steroid pulse then tacrolimus
Acral non-response	Excimer to rims; friction control	Consider surgery if stable focal
Frequent relapses post-fill-in	Maintenance 2–3 nights/week	Pair with tapered NB-UVB