Vitiligo: expert consensus for young patients

Half of cases of vitiligo occur during the first two decades of life. Although there are guidelines dedicated to the treatment of this disease, there is currently no text specific to children and adolescents, despite therapeutic advances made in recent years. American experts have written a consensus text on this issue, allowing both the use of clinical trial data and its adaptation to the characteristics of the population suffering from vitiligo.

Their recommendations were based on a review of the literature in pediatric, adolescent, and young adult populations, as well as expert opinions in areas where specific literature is scarce.

Some general recommendations

Experts indicate that topical corticosteroids, topical calcineurin inhibitors (CNIs), and UVB phototherapy constitute the standard treatment in young patients. A combination of phototherapy and topical treatment may improve repigmentation. Even if data in adults are encouraging, the risk of skin cancer associated with the use of phototherapy should nevertheless encourage long-term follow-up in children. Experts emphasize the need for early treatment of vitiligo to slow its progression and increase the likelihood of repigmentation.

Focus on three therapeutic classes

First-line topical CNIs are tacrolimus and pimecrolimus, which should be used twice daily for at least 3 months. Treatment can be continued for 6–12 months if repigmentation is observed. Otherwise, the use of another molecule or combination must be considered. Data in children under 2 years of age remains limited, and research suggests that effectiveness may be greater for the darkest phototypes. Its effectiveness is also greater in the head and neck, with the rest of the body reacting slightly less well, and the reaction in the arms and legs is usually weakest.

The choice of topical corticosteroid varies depending on the site of treatment and the expected duration of use. Its use is more common as a second-line treatment when treating areas with thin skin. Topical corticosteroids should be used for a limited period of time, and their concomitant use with CNIs is beneficial in reducing the risk of atrophy.

Finally, data regarding JAK inhibitors currently suggest the use of these molecules as first or second line in patients aged 12 years and older. Data on young children are currently too limited. The advantage of these molecules is that they can be applied to areas at risk of skin atrophy, such as the face or eyelids. To evaluate repigmentation here, a minimum of 3 months of treatment is also required.

Pathophysiological reminders

Vitiligo that appears before age 12 tends to be more extensive than in other people. It is also more often segmental, with rather rare evolution towards non-segmental forms.

The emergence of targeted treatments is associated with a better understanding of the pathophysiology of the disease: vitiligo results from an autoimmune process favored by various genetic and immunological factors. These pathogenic processes involve T cells targeting melanocytes. These cells then activate the production of interferon gamma, which, in particular, activates the JAK/STAT pathway.