10.5826/dpc.1304S2a316S
Vitiligo is a chronic depigmenting disorder characterized by characteristic, non-scaly, chalky-white skin macules and patches, due to the loss of skin pigment. Its exact pathogenesis is still not fully understood but it seems to be an autoimmune disease where the combination of genetic, environmental, and immune factors contributes to the destruction of melanocytes in the epidermis. Vitiligo is classified into different types based on its clinical characteristics and distribution patterns. The two main forms of vitiligo are non-segmental vitiligo (NSV) and segmental vitiligo (SV). NSV is the predominant form, characterized by symmetrical skin patches, that tend to evolve over time. In contrast, SV has unilateral or band-shaped lesions that progress rapidly but often stabilize early.Herein, current unmet needs in terms of psychosocial consequences and relative lack of valid therapeutic approaches are critically analyzed and put in perspective in the Italian prescribing scenario. Finally, available management guidelines are illustrated and briefly compared, to provide context for upcoming treatment options.
text/xml
2160-9381
4123
en
Claudio  Jommi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
clinical pathway
Vitiligo: Unmet Need, Management and Treatment Guidelines 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-12-19
2023-12-13
2023-12-19
2024-03-29
e2023316S
Dermatol Pract Concept
Vitiligo is a chronic depigmenting disorder characterized by characteristic, non-scaly, chalky-white skin macules and patches, due to the loss of skin pigment. Its exact pathogenesis is still not fully understood but it seems to be an autoimmune disease where the combination of genetic, environmental, and immune factors contributes to the destruction of melanocytes in the epidermis. Vitiligo is classified into different types based on its clinical characteristics and distribution patterns. The two main forms of vitiligo are non-segmental vitiligo (NSV) and segmental vitiligo (SV). NSV is the predominant form, characterized by symmetrical skin patches, that tend to evolve over time. In contrast, SV has unilateral or band-shaped lesions that progress rapidly but often stabilize early.Herein, current unmet needs in terms of psychosocial consequences and relative lack of valid therapeutic approaches are critically analyzed and put in perspective in the Italian prescribing scenario. Finally, available management guidelines are illustrated and briefly compared, to provide context for upcoming treatment options.
Claudio  Jommi
2023/12/19
10.5826/dpc.1304S2a316S
e2023316S
Department of Pharmaceutical Sciences, Università del Piemonte Orientale, Novara, Italy
2160-9381
clinical pathway
en
e2023316S
Tavoletti G, Avallone G, Conforti C, et al. Topical ruxolitinib: A new treatment for vitiligo. J Eur Acad Dermatol Venereol. 2023;37(11):2222-2230. doi:10.1111/jdv.19162
Vitiligo: Unmet Need, Management and Treatment Guidelines 
https://dpcj.org/index.php/dpc/article/download/4123/2439
                      Vitiligo: Unmet Need, Management
                            and Treatment Guidelines
          Angelo Valerio Marzano1,2, Silvia Alberti-Violetti1,2, Carlo Alberto Maronese1,2,
                            Gianluca Avallone1,2,3, Claudio Jommi4


1 Dermatology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
2 Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
3 Department of Medical Sciences, University of Turin, Dermatology Clinic, Turin, Italy
4 Department of Pharmaceutical Sciences, Università del Piemonte Orientale, Novara, Italy



Key words: vitiligo, unmet need, guidelines, clinical pathway
Citation: Marzano AV, Alberti-Violetti S, Maronese CA, Avallone G, Jommi C. Vitiligo: Unmet Need, Management
and Treatment Guidelines. Dermatol Pract Concept. 2023;13(4)S2:e2023316S. DOI: https://doi.org/10.5826/dpc.1304S2a316S
Accepted: December 11, 2023; Published: December 2023
Copyright: ©2023 Marzano et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: Angelo Valerio Marzano reports consultancy/advisory boards disease-relevant honoraria from AbbVie, Boehringer-
Ingelheim, Novartis, Pfizer, Sanofi, Incyte and UCB. The other authors report no conflicts of interest.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Angelo Valerio Marzano. Dermatology Unit - Via Pace, 9, 20122 Milan, Italy. Tel. +39 0255034717;
fax: +39 0255035236; e-mail: angelo.marzano@unimi.it




  ABSTRACT             Vitiligo is a chronic depigmenting disorder characterized by characteristic, non-scaly, chalky-white
                       skin macules and patches, due to the loss of skin pigment. Its exact pathogenesis is still not fully un-
                       derstood but it seems to be an autoimmune disease where the combination of genetic, environmental,
                       and immune factors contributes to the destruction of melanocytes in the epidermis. Vitiligo is classified
                       into different types based on its clinical characteristics and distribution patterns. The two main forms
                       of vitiligo are non-segmental vitiligo (NSV) and segmental vitiligo (SV). NSV is the predominant form,
                       characterized by symmetrical skin patches, that tend to evolve over time. In contrast, SV has unilateral
                       or band-shaped lesions that progress rapidly but often stabilize early. Herein, current unmet needs in
                       terms of psychosocial consequences and relative lack of valid therapeutic approaches are critically
                       analyzed and put in perspective in the Italian prescribing scenario. Finally, available management
                       guidelines are illustrated and briefly compared, to provide context for upcoming treatment options.




Review | Dermatol Pract Concept. 2023;13(4)S2:e2023316S                                                                               1
Introduction                                                      drugs used off-label on the grounds of less robust clinical
                                                                  evidence [4].
Vitiligo is a chronic depigmenting skin disorder characterized        It is thus clear that the dimension of the unmet need de-
by typical non-scaly, chalky-white patches, due to loss of skin   pends on the perspective used and inclusiveness of alterna-
pigment. The exact pathogenesis is still not fully understood     tives. The broader is the perspective and the narrower is the
but it seems to be an autoimmune disease where the combina-       definition of ‘validity’ of therapeutic alternatives (an alterna-
tion of genetic, environmental, and immune factors contributes    tive is valid if it has a therapeutic effect, a good safety profile
to induce the destruction of melanocytes in the epidermis [1].    and is acceptable to patients), the higher is the unmet need.
    Vitiligo is classified into different types based on its          In this perspective, vitiligo is a very interesting case-study.
clinical characteristics and distribution patterns. The two       The disease has not an impact on mortality. Guidelines high-
main forms of vitiligo are non-segmental vitiligo (NSV),          light the psychosocial distress due to vitiligo, and the im-
and segmental vitiligo (SV). NSV is the predominant form,         portance of providing psychological support if needed. The
­characterized by symmetrical skin patches, usually on the ex-    social impact of the disease could go beyond the psycholog-
tensor surfaces — such as the posterior aspect of the elbow       ical distress, leading to stigmatization or discrimination, and
— and the flexural zones, predisposed to mechanical trauma.       a decline in self-esteem [3,6]. A recent systematic review of
These lesions tend to evolve over time [2]. In contrast, SV has   the literature showed that more than half of patients with
unilateral or band-shaped lesions that often stabilize early.     vitiligo present depression, major depressive disorder, gen-
Distinguishing between these forms is essential for prognosis     eralized anxiety disorder, social phobia, feelings of stig-
and treatment guidance. Other variants include mixed vitil-       matization, adjustment disorders, sleep disorders, distress,
igo, where both NSV and SV coexist, and atypical forms such       emotional impairment, relational difficulties and cognitive
as focal, punctate, minor, and follicular vitiligo [3].           impairment [7]. Compared to the general population, a pa-
                                                                  tient with vitiligo is 5 times more likely to develop depres-
Unmet Need                                                        sion [8]. Approximately 90% of vitiligo patients suffer from
An unmet need refers in general to a need which is not ad-        light stigma (24% experienced nasty comments) [9]. 93.2%
equately satisfied by the existing therapeutic alternatives.      of adolescents are regularly victims of it (44.6% of nasty
The terms “need” and “unmet”, although linked one with            comments) and for 21.7% this leads to bullying [10]. A sys-
the other (satisfying a need decreases the entity of the need     tematic review of observational and interventional studies
itself), can be separated for a better understanding of the       on humanistic burden of vitiligo was recently published.
dimension of the unmet need [4].                                  The review highlighted that a majority of studies based on
    The term ‘need’ refers to the severity of the disease. The    dermatological-specific or vitiligo-specific instruments re-
                                                                  ­
severity of the disease depends on the perspective adopted in     vealed moderate to severe effects of vitiligo on the quality of
the assessment. From a clinical viewpoint, severity depends       life of patients, families and caregivers [11]. Notwithstanding
on mortality (and life expectancy) and health-related quality     health-related quality of life for vitiligo is still under-­reported
of life. Enlarging the perspective from a clinical to a soci-     and neither specific nor generic health-related quality of life
etal viewpoint, domains such as the societal impact of the        endpoints have been included into the pivotal studies of rux-
disease, including its impact on patients’ productivity losses    olitinib, the first medicine approved for vitiligo [12].
and care-givers burden, and acceptability to patients of ex-          Apart from ruxolitinib, there are no approved treat-
isting treatments, should be considered. On the one hand,         ments for vitiligo and medicines used for vitiligo are only
mortality and health-related quality of life are for sure more    partially reimbursed and have important limitations. Topical
important than treatment acceptability. On the other side         corticosteroids are reimbursed in Italy for vitiligo through
the latter may have an impact on adherence, effectiveness of      Nota 88 [13] but they have a variable impact on repigmen-
treatment and, ultimately, on health. It has been suggested       tation; more importantly, they are not suitable for prolonged
that severity depends on prevalence too. However, preva-          use due to side effects and should not be used on areas that
lence is rarely considered when the level of unmet need is        highly absorb the product. In detail, Nota 88 mentions that
appraised [5].                                                    4-6 month courses may be effective in lesions of recent onset
    The term ‘unmet’ could refer to the (i) total absence of      and limited extent. Moreover, a regimen whereby the appli-
alternative treatments or (ii) their presence, but with limited   cation is stopped for one week every three weeks is proposed
therapeutic impact, or (iii) their availability with a certain    to limit potential side effects. However, it should be under-
therapeutic impact but a critical safety profile and/or low       scored that these instructions are based on the results of a
acceptability (barriers to access, critical route of adminis-     metanalysis published in 1998 [14]. Topical calcineurin in-
tration). Alternative treatments could include only medi-         hibitors are not reimbursed by the Italian National Health
cines approved and reimbursed for the same indication, or         Service and their costs may limit their use over time for



2                                                                          Review | Dermatol Pract Concept. 2023;13(4)S2:e2023316S
maintenance [6]. Phototherapy is recommended in patients            thyroid disease is significantly increased, with a reported
with vitiligo that do not respond or respond only partially         2 to 5-fold rise compared to those without the condition.
to topical treatments or in those that have extensive or pro-       Moreover, the risk of elevated thyroid antibodies in vitiligo
gressive involvement. However, more sessions are necessary          patients is over fivefold higher than in individuals without
to observe an improvement in the disease and the treatment          the disease [24]. Given these observations, it is crucial to
must be continued for several months with 2-3 sessions per          evaluate both personal and family histories for thyroid dys-
week. In Italy the reimbursement of phototherapy is limited         function and other autoimmune conditions. Consequently,
to a maximum of six sessions per prescription. Coverage of          it has been advised to consistently screen for antithyroid
extra sessions is decided by on a regional base.                    antibodies and assess thyroid function, including pediatric
   It is clear that if a narrow perspective is used - vitiligo is   patients [6]. These evaluations can identify individuals at an
not severe since it has not an impact on mortality and the          increased risk for developing autoimmune thyroid disorders,
effects on health-related quality of life are still questionable;   allowing for earlier intervention and potentially mitigating
alternative treatments are available - the unmet need is not        further complications.
important. If we adopt, on the contrary, a broader perspec-
tive - vitiligo has an important impact on the quality of life of   Management of NSV
patients, relatives and caregivers; alternative treatments are      Three management guidelines are currently available dealing
not approved for vitiligo, have critical safety profile and are     with the treatment of NSV, i.e., the 2021 edition of the Brit-
partially reimbursed by third payers – the unmet need would         ish Association of Dermatologists guidelines [6], the 2022 S1
be much higher.                                                     German guidelines3 and the 2012 European Dermatology
                                                                    Forum consensus [15], whose update has recently been pub-
Managing Patients with Vitiligo                                     lished [25,26].
Managing patients with vitiligo requires a meticulous col-             The 2012 European Dermatology Forum consensus [15]
lection of a comprehensive clinical history. Key documenta-         distinguishes between limited (< 2–3% of body surface area)
tion should include the classification of the lesions, disease      and more extensive NSV, with avoidance of triggering ⁄ ag-
extent, skin phototype, age at disease onset, and any poten-        gravating factors and camouflage being recommended in
tial triggering events. A critical evaluation to ascertain the      both. For limited extrafacial NSV, once daily potent topi-
stability or rapid progression of the disease is essential, as      cal corticosteroids (TCS) are advised for a period no lon-
this directly influences the choice of therapeutic modalities.      ger than 3 months, either continuous or intermittent. For
Utilizing medical photography (digital imaging) taken at the        the treatment of limited NSV involving the head and neck
onset of treatment and at regular intervals of approximately        region, twice daily topical calcineurin inhibitors (TCI) are
3–6 months can assist in both monitoring disease progres-           advised, initially for 6 months and then if effective for longer.
sion and the response to treatment [3,6,15]. A Wood’s lamp          Localized narrowband Ultraviolet B (nbUVB) therapy and,
examination can represent a supporting tool in confirming           especially, excimer monochromatic lamp or laser are rec-
both the diagnosis and the extent of the disease in individu-       ommended as a second line in limited disease, with surgical
als with fair skin. Conversely, histopathologic examination is      techniques representing a third line in case of cosmetically
only occasionally required for diagnostic confirmation [16].        unsatisfactory repigmentation on visible areas (preferably in
The psychosocial implications, especially the impact on the         patients with a negative Koebner phenomenon). For gener-
patient’s quality of life and the psychological distress due to     alized NSV, nbUVB therapy for a maximum of 1-2 years is
vitiligo, require a thorough assessment. Notably, individuals       indicated as a first line, with oral Psoralen plus Ultraviolet
with vitiligo often face stigmatization, discrimination, and        A therapy (PUVA) still being listed as a second line. NbUVB
a decline in self-esteem, highlighting the importance of rig-       discontinuation is advised in cases failing to respond within
orously tracking the psychosocial burden of the disease [6].        3 months. According to the 2012 consensus [15], photother-
Comprehensive assessment tools like the Patient Health              apy may be combined with potent TCS and TCI. For rap-
Questionnaire-4 [17], Patient Health Questionnaire-9 [18],          idly progressing disease, weekend oral minipulse therapy
Generalized Anxiety Disorder [19], and Dermatology                  with dexamethasone for 3-6 months is advised, starting with
Life Quality Index [20] can be used. For a more targeted            2.5 mg daily. The consensus does not specify whether to
approach, the Vitiligo Impact Patient Scale [21] and the            combine the oral minipulse with phototherapy. Grafting in
vitiligo-specific quality-of-life tool [22] are recommended.        nonresponding areas - especially with high cosmetic impact -
An additional consideration is the established link between         is suggested as a third line in patients with stable disease,
vitiligo and several autoimmune diseases, such as thyroid           no repigmentation, and a negative Koebner phenomenon.
disorders, pernicious anemia, and Addison’s disease [23].           The consensus also covers combinations between different
The likelihood of vitiligo patients developing autoimmune           treatment modalities. For example, phototherapy is advised



Review | Dermatol Pract Concept. 2023;13(4)S2:e2023316S                                                                            3
for 3 or 4 weeks after surgical procedures to enhance re-          A specific regimen is recommended consisting of oral beta-
pigmentation. Depigmentation techniques (hydroquinone              methasone 0.1 mg/kg twice weekly on two consecutive days
monobenzyl ether or 4-methoxyphenol alone or associated            for 3 months followed by tapering of the dose by 1 mg per
with Q-switched ruby laser) are listed as a fourth line in non-    month for a further 3 months. As third-line options, exci-
responding widespread (> 50%) or highly visible recalcitrant       mer laser or light plus TCI is advised for localized disease
facial ⁄ hands vitiligo with a positive Koebner phenomenon.        while CO2 laser (once a month for 5 months) in combina-
    Together with psychological referral, camouflage op-           tion with 5-fluorouracil (once daily for 7 days per month
tions, including self-tanning agents, highly pigmented cover       for 5 months) is advised exclusively in adults with NSV on
creams, and dermal pigmentation/cosmetic tattoos (espe-            the hands and feet where other treatments have proved inef-
cially in black people, for depigmented nipples and lips) are      fective. Surgical treatment, e.g., cellular grafting, is reserved
also discussed [15].                                               for stable vitiligo unresponsive to other treatments in case
    The update of the EDF/EADV guidelines [25,26] em-              of subjective distress, irrespective of non-segmental or seg-
phasizes a shared decision-making process with three pos-          mental type. Finally, depigmentation therapies are advised
sible treatment goals, i.e., stabilization, repigmentation, and    in people with extensive vitiligo on visible sites, in case of
depigmentation.                                                    subjective distress [25,26].
    In NSV that has been active in the previous 6 months,             The recently published S1 German guidelines [3] rec-
topical treatments with intermittent, prolonged potent once        ommend a combination of supportive care (UV protection,
daily TCS and/or twice daily TCI, as well as phototherapy          dermatocosmetics, camouflage, psychotherapy, self-help
(targeted if needed), are recommended for both stabilization       groups) as well as a series of treatments including TCS/TCI,
and repigmentation, with optional systemic treatment for           systemic CS, and phototherapy according to the extent of
rapidly progressive disease (for a maximum of 6 months).           the involvement. In greater detail, for NSV affecting less than
When effective, prolonged treatment (e.g., up to 12 months         3% of BSA, potent TCS and/or TCI or targeted light therapy
or more) with TCI can be proposed. For NSV that has been           are recommended, either alone or in combination. Intermit-
stable in the previous 6 months, either clinical follow-up or      tent regimens are mentioned as a possibility, but no clear rec-
maintenance treatment with TCS/TCI at least twice a week           ommendation is given. In case of successful repigmentation,
for 6 months is advised for stabilization. The latter represents   proactive therapy with TCI twice a week as maintenance is
a novelty compared with the 2012 version. To pursue repig-         recommended.
mentation in stable NSV, important temporal cut-offs are              Concerning light-based therapies, the German guidelines
introduced, so that TCS/TCI and phototherapy (targeted if          advocate in favor of 308-nm excimer laser or lamp as the
needed) are recommended for cases with stable disease in the       first choice in NSV or SV of limited extent, due to the lower
previous 6 months, whereas surgical techniques are recom-          dose as compared with nbUVB to achieve the same result.
mended as an option only for cases that had been stable for           For NSV involving more than 3% of BSA, the therapeu-
at least 12 months and were resistant to treatment [25,26].        tic algorithm differentiates chronic from acute, rapid, and
    The 2021 edition of the British Association of Derma-          progressive forms. The formers are treated by means of
tologists guidelines [5] for the management of people with         nbUVB and potent TCS and/or TCI, while the latter may
vitiligo recommends three lines of treatment, irrespective         also benefit from a course with systemic CS. Systemic CS
of non-segmental or segmental type of vitiligo, in addition        should not be administered as monotherapy and consists of
to UV protection, camouflage, psychotherapy, and self-help         an oral mini-pulse therapy of 3-6 months with betametha-
groups. Specifically, potent or very potent TCS once daily are     sone, dexamethasone (e.g., for both, 5 mg on two consec-
offered as a first line, avoiding the periocular area. Tacroli-    utive days per week with a potential increase to 7.5 mg in
mus 0.1% twice daily is offered as an alternative for facial       case of non-response), prednisone or methylprednisolone.
involvement or under occlusion on photoexposed areas for           Periodic reassessment of the effectiveness of nbUVB is rec-
non-facial vitiligo. Intermittent regimens with potent or very     ommended every 3 months, with nbUVB discontinuation af-
potent TCS with or without TCI are advised for areas with          ter 6 months in case of non-response. Overall, no more than
thinner skin. The effectiveness of this first-line, topical ap-    12–24 months should be administered.
proach is periodically reassessed every 3-6 months. As a sec-         Surgical options are recommended in case of unrespon-
ond line, nbUVB with or without potent or very potent TCS          sive and stable disease, with no specific indication of the
or TCI is offered. However, it is underscored that nbUVB           optimal technique. Depigmentation is recommended only in
is recommended as a first line in case of extensive or pro-        extremely rare cases of subtotal vitiligo and after exploita-
gressive disease. No details are provided concerning nbUVB         tion of all options [3].
duration. Systemic corticosteroids (CS) are offered only in           After the Food and Drug Administration (FDA) and
rapidly progressive disease, in combination with nbUVB.            ­European Medicine Agency (EMA) approval, respectively in



4                                                                          Review | Dermatol Pract Concept. 2023;13(4)S2:e2023316S
July 2022 and February 2023, topical ruxolitinib (TR) has            to topical treatment and/or phototherapy and in which the
opened up options for treatment of NSV. Based on the results         goal of repigmentation is pursued, surgical techniques are
of the phase III registrational trial of the twice-daily applica-    advised [25,26].
tion, especially for lesions on the face (more than 75% im-             As stated, the 2021 British Association of Dermatolo-
provement in facial VASI at 24 weeks compared to controls            gists guidelines propose a similar outline for the manage-
with limited side effects), TR seems to have the best use in         ment of NSV and SV. In detail, potent or very potent TCS
localized NSV no longer responding to conventional topical           once daily are offered as a first line, avoiding the periocular
agents or to reduce risk of greater adverse effects. The asso-       area. ­Tacrolimus 0.1% twice daily is offered as an alternative
ciation of TR with phototherapy has been investigated with           for facial involvement or under occlusion on photoexposed
good results but larger studies are needed to confirm these          areas for non-facial vitiligo. Intermittent regimens with po-
findings [12,27].                                                    tent or very potent TCS with or without TCI are advised for
                                                                     areas with thinner skin. As a second line, nbUVB with or
Management of SV                                                     without potent or very potent TCS or TCI is offered. Sys-
The same four guidelines also provide guidance for the man-          temic CS are offered in rapidly progressive disease in com-
agement of SV [3,6,15,25,26].                                        bination with nbUVB. The same regimen is recommended
   As SV progresses but also reaches stabilization rapidly, a        consisting of oral betamethasone 0.1 mg/kg twice weekly on
slightly different approach is required.                             two consecutive days for 3 months followed by tapering of
   Like in limited NSV, the 2012 European Dermatology                the dose by 1 mg per month for a further 3 months. Exci-
Forum consensus [4] recommends: avoidance of triggering              mer laser or light plus TCI are listed as third-line options,
factors and camouflage; once daily potent TCS for a period           mainly due to limited availability. Surgical treatment, e.g.,
no longer than 3 months, either continuous or intermittent;          cellular grafting, is reserved for stable vitiligo unresponsive
and twice daily TCI for the head and neck region, initially          to other treatments, in case of subjective distress. According
for 6 months and then if effective for longer. While oral mini-      to the guidelines, depigmentation is to be considered only in
pulse therapy with systemic CS is listed as an option for rap-       case of extensive disease, irrespective of non-segmental or
idly progressing disease, irrespective of non-segmental or           segmental type [6].
segmental type, it is not reported in the suggested algorithm           The S1 German guidelines [3] distinguish between acute
for the management of SV. Localized nbUVB therapy and,               and chronic forms of SV. For chronic SV, potent TCS and/or
especially, excimer monochromatic lamp or laser are listed           TCI or targeted light therapy are recommended, either alone
as the second line in case of progression under topical treat-       or, preferably, in combination. For acute SV, a regimen con-
ment. If stabilization without repigmentation is achieved,           sisting of systemic CS (see above for details) plus potent TCS
surgical techniques are advised as an option in patients with        and/or TCI plus targeted light therapy is advised. Finally, in
a negative Koebner phenomenon. For those with a positive             case of stable and unresponsive disease, surgical therapy is
Koebner phenomenon, camouflage is recommended. Depig-                recommended. Depigmentation is recommended only in ex-
mentation is not explicitly listed as an option for SV but, as       tremely rare cases of subtotal vitiligo after the exploitation
for NSV, it may be considered in nonresponding widespread            of all options and is not specifically mentioned for SV. Sim-
(> 50%) or highly visible recalcitrant facial ⁄ hands vitiligo       ilarly to NSV, supportive care (UV protection, dermatocos-
with a positive Koebner phenomenon [15].                             metics, camouflage, psychotherapy, self-help groups) is also
   The recently published update of the EDF/EADV guide-              recommended [3].
lines [25,26] maintains the two possible treatment goals,
stabilization and repigmentation, but different temporal
                                                                     Conclusions
cut-offs are adopted relative to NSV. In SV that has been
active in the previous 12 months, topical treatments with            As new therapeutic options are being approved for vitiligo
intermittent, prolonged TCS and/or twice daily TCIs as well          and many more are currently under investigations, patients
as phototherapy (targeted if needed) are recommended for             still experience a substantial unmet need in terms of psycho-
both stabilization and repigmentation. Maintenance with              logical distress and lack of effective and available therapeu-
TCS and or TCI is not listed/needed in SV. While systemic CS         tic approaches. The review examined the disconnect between
are listed as an option for rapidly progressing disease, irre-       the current prescription/reimbursement scenario in Italy and
spective of non-segmental or segmental type, they are not re-        recommendations from the most recent guidelines. Nego-
ported in the suggested algorithm for the management of SV.          tiation of reimbursement of new and selective treatment
For SV that has been stable in the previous 12 months, only          options will soon define their use in Italy, with important
clinical follow-up is advised if the goal of stabilization is pur-   implications for the management of this often under-treated
sued. Conversely, for stable cases that have proven resistant        but potentially dramatic dermatological disease.



Review | Dermatol Pract Concept. 2023;13(4)S2:e2023316S                                                                           5
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