Pimecrolimus & tacrolimus are calcineurin inhibitors. The former is available in Australia, the latter is not. As per usual the TGA in Australia is about two decades behind the rest of the world. Regardless, dermatologists worldwide have been prescribing these topical medications as first line treatment for vitiligo.  They work via two pathways, firstly by decreasing T cell mediated inflammation. Secondly, they encourage migration of melanocytes. Melanocytes are cells that produce pigment.

My usual prescription practice is to alternate a calcineurin inhibitor with a CS preparation. The most common cycle I use is one week on one, followed by one week on another. The concentration depends on the area of vitiligo. The instructions are written on your prescription. 

Yes. I am well aware of the black box warning in the United States. The international consensus suggests that tacrolimus & pirmocrilums are safe in the context of vitiligo management. This applies to combination therapy with narrowband phototherapy. 

There is no increased risk of skin cancer with this combination. For children under the age of 12, tacrolimus at one third adult concentration has been proposed.

The international consensus has voted that light therapy or narrowband UVB should be used in all patients who do not have contraindications.

Topicals such as tacrolimus reduce inflammation & promote pigment. Phototherapy further amplifies pigment production. Corticosteroids reduce inflammation & can promote hair growth as a side effect (hypertrichosis). This increased hair growth can add more pigment cells in patches of vitiligo. Coupled with pigment stimulation light, re-pigmentation can be accelerated.

Phototherapy is bulk billed in Australia. If you have Medicare, this treatment is rebated with not out of pocket expense to the patient.

This is a brilliant hack by dermatologists in the Middle-East & India. This is a prescription of psoralen cream that the patient applies at home & self exposes to UVA several times a week. This essentially is a substitute for narrowband phototherapy for patients who cannot afford or have access to a light source. It can work. I do not use it because phototherapy in Australia is free (on Medicare). Additionally, there are safety issues with psoralen & UVA, though the risks are lower for darker skin types.

Ruxolitinib cream is a novel treatment undergoing phase 3 (shortly) trials in the United States. To date it has shown promise of being both safe and effective during long-term treatment period and resulted in substantial re-pigmentation of vitiligo lesions on the face. The study has reached beyond the 2-year mark.

Ruxolitinib, like other creams, do not cure vitiligo. Whether it induces longer remission than calcineurin inhibitors & CS is yet unknown. When will it reach Australia? If tacrolimus is the goal post, it may take two to three decades before the TGA investigates it.

Bimatoprost or Latiesse is topical prostaglandin E. This medication can increase the length of eyelashes (Latiesse). It can re-pigment small patches of vitiligo by increasing the migration of pigment cells. Facial vitiligo responds best to topicals.

This is my third line topical, after CS & calcineurin inhibitors. Bimatoprost should ideally be combined with phototherapy. 

Pseudocatalase is a synthetic topical used in the treatment of vitiligo. It is thought that one of the contributing factors for vitiligo is the excessive accumulation of hydrogen peroxide in the skin. This causes depigmentation or loss of skin color in patches. In normal conditions, hydrogen peroxide is broken down into water and oxygen. In patients with vitiligo, the levels of catalase enzymes are reduced. This can lead to an accumulation of hydrogen peroxide.

Pseudocatalase therapy involves application of a cream containing pseudocatalase and calcium among other ingredients which are followed by exposure to narrowband phototherapy. This treatment acts similar to natural catalase and breaks down the hydrogen peroxide thus causing repigmentation.

You are welcome to try pseudocatalase. The literature does not support this as monotherapy; however it can be safely combined with phototherapy & medically prescribed creams.  Pseudocatalase can be purchased online- be resourceful & search.

• Apply twice a day to the white patches of vitiligo
• Small amounts are needed to cover the area; increasing the frequency and/or amount will not necessarily bring about better results.
• Allow the Pseudocatalase cream to vanish into the skin and completely dry before applying any other topical agents.
• Expose the affected skin to narrowband phototherapy

If there is no response after 3 months, the therapy should be stopped, and other options evaluated. Treatment may be stopped if regimentation occurs. This cream can be used to repigment the skin on hands, lips, ears, neck and genitals.

Treatment with pseudocatalase is considered to be safe with no known systemic side effects. Your dermatologist will have their own protocols. I personally do not prescribe this topical as there are many more effective creams.

Not a good idea to try. Various plants including lime, lemon, citrus fruits, bergamot contain furanocoumarins. These are essentially psoralens that react with sunlight to produce a phototoxic reaction. Post-inflammatory hyperpigmentation is a wanted side effect in the context of vitiligo. If you are so inclined to try natural stuff, review the section on this website. You are far safer with supplements like vitamin B, C, D, E & a tablet or two of ginkgo biloba. 

Psoralea corylifolia (used in India) & Ammi majus Linnaeus are plants that have been used in ancient times to treat vitiligo. They do have value in countries like India & Africa where narrowband phototherapy is limited (or super expensive). I know they can work; I have no experience in herbal or natural remedies. Discuss this with your village physician.

*Warning: If you have vitiligo, do not put vitamin C on the affected areas. Vitamin C is a potent antioxidant; however it is also a potent inhibitor of tyrosinase, the enzyme that produces pigment.

In most cases, results can be seen within 10 to 12 weeks. In some cases, creams are designed to halt the progression of vitiligo on areas such as the hands & feet. In other cases, topicals are designed to accelerate re-pigmentation, most often on the face & neck.

It is important to follow instructions as topicals can have side effects. My favoured prescription patterns pulses two different topicals on a rotational basis. The strengths will vary depending on the location of vitiligo. Creams are adjunctive to phototherapy. 

Unfortunately, 50% of patients can relapse after 1-2 years. The flipside is that 50% do not. If relapse is seen, you can continue back on the course of narrowband phototherapy & topicals.

My usual protocol is to first re-pigment as much as I can in a finite amount of time (usually 6 to 12 months). I then stop your CS but continue your tacrolimus. I then reduce your phototherapy sessions, & finally stop your calcineurin inhibitor. If you relapse, restart your phototherapy & topicals.

Early onset vitiligo involving the face & neck respond best to creams, most often in combination with phototherapy. If you have pigmented hairs within white patches, the combination of topicals with narrowband light will give you an 80-90% chance of re-pigmentation.

If you have no pigmentation in the white patches (namely white hairs), your chances of re-pigmentation drops to 20%, even with narrowband phototherapy.

In Australia, some creams are covered under the PBS & cost between $10 to $34 per tube. Compounded topical creams are slightly more expensive, ranging from $50 to $98. On average you should not be spending more than $1.30 to $2 per day on topicals. Peseudocatalyase is not sold in Australia, you can source this on Amazon, if you must.

If you have a Medicare card, phototherapy is bulk billed, as it is covered. Visit my clinic to book in.

Creams should be adjunctive to phototherapy. Phototherapy remains as one of the most effective methods to treat vitiligo & re-pigment skin. This treatment uses narrowband UVB that suppresses skin inflammation & promotes migration of skin pigment cells.

Phototherapy involves exposure to prescribed light sources at Cutis Medical. This treatment takes between 1-7 minutes to perform. If you have Medicare, there is no out of pocket fee as it is bulk billed. This treatment is successful in re-pigmenting up to 90% of vitiligo cases.