- Best Results6-12 months
- Treatment Recovery0 days
- Procedure TimeVariable
- Skin SpecialistDr Davin Lim
- Duration of ResultsVariable
- Back to WorkImmediately
- Cost$0 (Medicare)
Vitiligo on the Face
Though distressing facial vitiligo carries a good prognosis with over 85% of patients re-pigmenting within weeks of therapy. I use the international guides for vitiligo management, namely combining topicals with phototherapy. The majority of vitiligo treatments are covered by Medicare.
FactsFacts on facial vitiligo
- White patches on the face can be due to vitiligo, eczema of other inflammatory skin conditions
- Each condition will have an optimal treatment algorithm
- Facial vitiligo carries a good prognosis
- The vast majority of patients will show evidence of re-pigmentation within week
- Topicals & phototherapy form the mainstay of treatment
- Camouflage creams from Dermblend, Covermark, Dermacolor can be useful
What are the chances of getting pigmentation back?
There’s good news & bad news. The bad news is that vitiligo is on your face, & that’s why you are reading this page.
The good news is that if you do have face involvement, the chances of getting pigment back is very high, in the order of 85% or more (excluding pure mucosal vitiligo). If you have tiny areas of follicular pigment in areas of vitiligo, I have a good chance of helping you.
If you have white hairs (for example in your brows), I still have a good chance of helping you, but treatments are more involved. Refer to the section on FUE eyebrows to understand.
If you have loss of pigment on your lips, it is hard to get pigment back. Failing topicals & phototherapy, you can attempt cosmetic tattooing.
What is a basic but effective treatment protocol for facial vitiligo?
A basic treatment goes something like this-
- Creams, CS & CS sparing topical (see below)
- Narrow Band 311 nm UVB phototherapy 2-3 times a week (see below)
- Diet & supplements are optional (see below)
What topical creams are prescribed for treating vitiligo?
Topicals, coupled with narrowband phototherapy, is the mainstay for the management of facial vitiligo. The ideal combination depends on the site. Eyelid skin is thinner than skin on the nose or cheeks, hence formulations & concentrations will differ according to facial sites. As a guide-
- Corticosteroid creams & ointments.
- Calcineurin inhibitors.
- Prostaglandin analogues.
- Vitamin D derivatives
The above-mentioned accounts for the vast majority of topicals I employ for vitiligo. Occasionally I may use 5 Fluorouracil for recalcitrant vitiligo involving the hands. Given the availability of phototherapy, I do not use methoxy psoralen creams much. Pseudo catalase, popular in the 1990s is outdated
What side effects are there with creams?
If I monitor you & if you follow the instructions I have written on your prescription, side effects are extremely rare. The most common side effect is perioral dermatitis. This is usually secondary to the CS ointment or cream, usually the calcineurin inhibitory cancels out this effect. If needed it can be treated with doxycycline 50 mg bd for 3-6 weeks. (You may get sun sensitivity with this, but the action spectrum is in the UVA, & not UVB).
Why phototherapy for facial vitiligo & how does it work?
Narrowband phototherapy is a special form of delivering clinically prescribed light. It forms the foundation of vitiligo management in Australia & overseas. Phototherapy works by –
- Halting the immune attack on pigment cells.
- Stimulation of remaining melanocytes (pigment cells) to migrate to areas of vitiligo & to produce pigment.
Phototherapy is conducted at Clinic Cutis. It takes several minutes to perform & is bulk billed on Medicare with no out of pocket expenses to patients. This treatment is best combined with topical creams as part of the 20 week vitiligo challenge.
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How soon will I see an improvement in my vitiligo?
About 8 weeks but it could take 6-12 months before you get full re-pigmentation, maybe even longer. Pigment doesn’t magically appear. Melanin can only come from 3 ways.
Firstly, pigment cells (if there are any left), must awaken. They usually hide in the hair follicle. Hence one of the first signs you see is perifollicular pigmentation, those dots in the middle of your vitiligo patches. Melanin then fills up the gaps.
Secondly, pigment can come from the sides. This occurs when melanocytes migrate. It is a slow process. Tacrolimus helps them move faster.
Thirdly, I take pigment from one area then place it in the vitiligo patches. I use various surgical techniques including punch, split & blister grafting. I also use autologous melanocyte transfer (spray on skin).
How much are treatments?
Australia is one of the only countries that subsidizes vitiligo therapy. Treatments are bulk billed if you have a Medicare card. As a guide-
- Phototherapy – no charge as this is Bulk Billed.
- Topical creams- approximately $1.90 per day.
- Supplements- approximately $1.20 per day.
- Camouflage creams- prices vary depending on the brand. Some insurance companies will provide subsidies. Medicare does not, NHS might.
What can diet, vitamins and supplements do for vitiligo?
In the best case they can marginally help. In the worst-case scenario, they will not make your vitiligo worse, but will markedly reduce the chances of a heart attack, stroke, & will reduce your body fat & cholesterol. On this basis, I highly recommend supplementation.
Dietary supplements can be useful adjunctive treatments. Vitamin B, C, E, D & ginkgo biloba can be purchased from pharmacies & health food stores. See the dedicated section on diet & supplements for more information.
The vitiligo diet is easy to follow, consuming lots of greens, fish, nuts, & seeds can help increase your antioxidant intake. If it has a low pH, such as citrus, limes, tomatoes, etc., give it a miss.
- Antioxidants. A diet high in antioxidants can reduce oxidative stress. Green leafy vegetables, fruits, nuts, seeds and spices are all high in antioxidants. Foods high in omega-3 such as fish, nuts & seeds, and green tea are good sources of antioxidants.
- Gluten free diet. This diet is harmless & in extremely rare cases, it can be beneficial. Gluten is thought to be pro- inflammatory. This diet is hard to follow, ask any coeliac disease sufferer (or dermatitis herpetiformis). With coeliac disease your body gives you feedback when you stuff up. With vitiligo it does not. See a dietician. It is the only way you are going to get it right.
- 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.
Can lasers treat vitiligo?
Yes. I do love the physics of lasers as Cutis has over 30 different types. I do think that lasers should be used as last line therapy. Simple procedures including phototherapy are both more effective & more cost effective. If you fail to respond to phototherapy, I may consider microneedling & 5FU.
I do use fractional lasers including erbium, CO2 & thulium often in conjunction with phototherapy. I did use excimer 308 lasers in the past, however they are not cost effective ($200 per session, 20-25 sessions required).
Is sunscreen important when treating vitiligo?
The use of sunscreen is debatable. Here is my opinion.
If you are undertaking phototherapy sessions & have built up a tolerance over weeks to months (over 2 minutes 30 seconds in the UVB booth) & if you are sensible about sun exposure, sunscreen is not vital (I am talking about the chances of burning in the areas of vitiligo & not skin cancer or anti-aging). You should not burn with everyday exposure. Additionally, camouflage creams will give an SPF of around 2-4, depending on the particle size & chemicals.
Now, if the debate shifts to skin cancer & photoaging, yes, sunscreen is advisable. This applies to all skin types, including darker – ethnic patients.
Are all white patches on the face vitiligo?
No. White patches can be due to many skin conditions. The most common cause of white patches on the face in children is a condition called pityriasis alba. This is a self-limiting form of eczema.
Other conditions that can produce white patches include post inflammatory hypopigmentation secondary to yeast infections, fungi, dermatitis, eczema, & other inflammatory conditions. These all have different treatment algorithms. A dermatologist can tell the difference.
When do I consider surgical modalities for vitiligo?
If you have stable vitiligo & exhibit poliosis, & if you fail phototherapy, medical therapy, microneedling or if you have stable segmental vitiligo, I may consider surgical methods.
You will also need to have a relatively small surface area & understand the risk benefit ratio of surgery. Surgical treatments are not covered under Medicare, unlike phototherapy.
I use various transfer techniques including micrografting, suction grafts & tiny follicular unit extraction grafts. After surgery, phototherapy is required for 6 to 12 months.
What is the best way to hide vitiligo?
Cosmetic camouflage is the best & quickest way to cover up vitiligo patches. They can be divided into the following categories.
Firstly, fake tan or dihydroxyacetone. This is best for lighter skin types 1 & 2. Colour matching darker skin types, namely 3 and above is not possible with DHA. This product is easy to apply, & can last up to 6 days. It is waterproof.
Secondly, heavy pigment cover-up creams. These are lightweight, easy to apply & they are waterproof. A fixing spray can help maintain the characteristics for the whole day. Bands include Dermablend, Covermark, Dermacolor, & Veil. Try before you buy, you will need to get an accurate colour match. Photos online are difficult to judge. In some cases you can blend two colours together to get the product of choice.
Cosmetic tattoos are best for lips, & small patches, especially in darker skin types. They last 12-18 months before top-up application. The talent of the cosmetic tattooist will ensure a good colour match.
How do I get an appointment?
Firstly, you require a referral to see me as I am a specialist. If you are uncertain about how to get a referral, my administration team can assist.
A referral will allow you to claim all of your phototherapy sessions on Medicare, saving approximately $600 per month.
Davin’s Viewpoint on Facial Vitiligo
The good news is that the vast majority of patients with this pattern of vitiligo do well with treatment. My go to regiment is topicals coupled with narrowband phototherapy. We should expect to see changes within 4- 8 weeks of commencement, though it can take up to 6 to 12 months for full repigmentation.
Having a well-balanced diet, with supplements can help mentally more than physically. The prognosis for facial vitiligo is excellent.
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