Abstract Body

Vitiligo is an acquired chronic pigmentary disorder affecting the melanocytes, mainly in the skin and mucosae. It occurs due to the dynamic interaction between genetic and environmental factors leading to autoimmune destruction of melanocytes. Defects in melanocyte adhesion and increased oxidative stress further augment the immune response in vitiligo. It is a cosmetically disfiguring condition with a substantial psychological burden. Its autoimmune nature with resultant chronicity, variable responses to therapeutic modalities, and frequent recurrences have further diminished the quality of life. Hence, treatment should aim to provide more extended remission periods, prevent recurrences, provide good cosmetic outcomes and ensure patient satisfaction. These treatment goals seem plausible with the recent progress in our understanding of the complex pathogenic mechanisms underlying vitiligo. Inhibiting cytokine signaling through targeted immunotherapy with corticosteroids and other immunosuppressants and facilitating melanogenesis are the main strategies to achieve the above goals to a great extent. Immunosuppressants are mainly used to halt the disease progression, and they also induce repigmentation perhaps by allowing the existing melanocytes to work better in the milieu of reduced autoimmunity. These include-(a) systemic corticosteroids and (b) other immunosuppressants. Corticosteroids are recommended in patients with rapidly progressive vitiligo to halt disease progression. In the management of vitiligo, daily corticosteroids have mainly been replaced by the relatively safer oral corticosteroid mini pulse (OMP) therapy. OMP has been used in combination with other modalities like phototherapy, photochemotherapy, and other immunosuppressants particularly azathioprine and cyclophosphamide. Azathioprine alone is efficaceous, though having slower response and therefore used in patients where corticosteroids are contraindicated. Several other agents like methotrexate, mycophenolate mofetil are also useful, though results are variable. OMP has been safely used with NBUVB and PUVA; its combination with NBUVB results in better and earlier repigmentation than PUVA.

These can be further supplemented with surgical treatment as per the need of the individual patient. A treatment approach targeting multiple pathogenic pathways with a combination of drugs may offer even better results