A minimum of two sessions per week. In accordance with literature guidelines, the optimal dosing is three times per week, namely every alternate day. Two sessions is the minimum.

Each session takes between one to seven minutes to perform. If you are having this done at Cutis Medical, you can park your car in the shopping centre 10 meters from the Clinic. Cutis is also open on Saturday mornings.

The optimal combination of creams will depend on the extent & location of vitiligo. As

A guide, I use the following combinations-

• Corticosteroid- both creams & ointments, in various strengths.
• Calcineurin inhibitors- Tacrolimus over pimecrolimus.
• Vitamin D analogues- are useful if I need to cover large areas of vitiligo.
• PGE analogues- best combined with micro needling.

Some creams are covered under the PBS in Australia and cost only a few dollars, other topicals are more expensive as they require special compounding.

The internet is trying to sell you everything in order to treat vitiligo. A cost-effective & evidence based approach is to supplement the 20 week challenge with-

• Ginkgo biloba.
• Ascorbic acid orally not topically.
• Vitamin B12.
• Vitamin E or tocopherol.
• Vitamin D tablets. It is advisable to see the advice of a professional before taking high strength vitamin D supplements. The dose needs to be balanced to avoid vitamin D toxicity. Too much vitamin D can lead to a build-up of calcium in the blood. As a guide, 150% of the RDI is fine.

There are some studies that suggest dietary changes & supplements could have a positive impact on the course of vitiligo. As a guide plant-based diet rich in antioxidants, low in inflammatory foods may have a beneficial effect on vitiligo. I will divide this into three main food groups.

Antioxidants. A diet high in antioxidants can reduce oxidative stress. Vegetables, fruits, nuts, seeds and spices are all high in antioxidants. A good rule of thumb for eating enough antioxidants is to eat as many different coloured fruits and vegetables. Foods high in omega-3 such as fish, nuts & seeds, green tea are good sources of antioxidants. Plant-based diet has been shown to be very high in antioxidants

Gluten free. This diet is harmless & in extremely rare cases, it can be beneficial. Gluten is thought to be pro inflammatory.

Low acidic diet. Acidic Inflammatory foods make it harder for your gut to work and remain healthy. Fibre, probiotic and prebiotic foods, such as sauerkraut, can help improve gut health. Examples of pro-inflammatory foods include- sugar drinks, white pasta, bread, gluten foods, processed foods. Generally, it is in a packet, it is bad for you.

My approach to vitiligo is evidence based and scientific. My aim is to get you better in the safest, most effective, & cost-effective way possible. If your vitiligo does not respond, I will go up the treatment ladder. A simplified approach is outlined below.

Stage 1: Phototherapy & Topical as described (CS & calcineurin inhibitors)

Stage 2. Phototherapy & stage 1 +PGE analogies + diet + supplements

Stage 3. Phototherapy & stage 2 + vitamin D creams

Stage 4. Phototherapy & stage 3, option for fractional devices + 5FU

Stage 5. Phototherapy & consideration of surgery if indicated.

Phototherapy forms the cornerstone of management as it suppresses immune attack & at the same time stimulates pigment production.

Photos, photos, photos. Take pictures using your camera phone. This will give you an unbiased opinion on how things are going. This is how vitiligo re-pigments-

Firstly, you will notice tiny dark dots. This represents hair follicles that have pigment cells. These cells escaped (hopefully) the immune system attack. Phototherapy awakens the sleeping cells to migrate from the base of your follicle to the skin. Over time these dots get bigger & touch each other.

Secondly you will notice the sides of vitiligo closing in. This is due to migration of melanocytes from normal skin. Coupled with perifollicular re-pigmentation, this results in re-pigmentation of your vitiligo patches.

I normally review your progress from week 15 to week 20. This is because it takes time for you to re-pigment white patches. As to what to expect in this timeframe-

• Facial vitiligo, has at least 80-90% chance of improvement.
• Neck & chest, has 70+% chances of improvement.
• Body & upper limbs, approximately 50+% respond
• Hands & feet, only 10-20% respond.
• White hair to pigment hair- will be exceptional if it responds.

Apart from supplementation, & possibly dietary supplements, there’s not much else to do. I don’t usually start you on micro needling in the early stages of treatment. The main reason is that I need to understand what works for you.

By eating healthy, limiting stress & excessive alcohol you will give your immune system a break, ensuring the best possible chances of re-pigmentation.