Topical calcineurin inhibitors (TCIs) are considered the first choice for lesions of limited extent, especially on the face, neck, groin, and axillae. They should be applied once or twice daily for 6 months and may be extended to 12 months or longer in case of good response.

High- or very high-potency topical corticosteroids are also recommended, particularly for extrafacial areas with limited extent or as a second option for facial areas after TCIs. Application is suggested once daily for 3–6 months in adults and 2–4 months in children. These periods can be extended if an intermittent regimen (on a 2 weeks on/2 weeks off regimen) is chosen, which reduces local adverse effects and is the preferred option for facial areas.2

Ruxolitinib—a topical JAK inhibitor—is the first drug approved by the European Medicines Agency (EMA) and the Food and Drug Administration (FDA) for vitiligo repigmentation.2 In phase 3 clinical trials, 80.3–81.4%/56.8–60.8% of patients achieved F-VASI50/T-VASI50 (≥50% improvement in facial/total vitiligo area scoring index) at 52 weeks.3

For patients with extensive or rapidly progressive vitiligo, narrowband UVB phototherapy is ranked as the first-line therapy, which can be combined with topical therapy. A total of 3 weekly sessions are recommended, which should be discontinued after 3 months if no improvement has been reported or after 6 months with insufficient improvement.

In patients with rapidly progressive vitiligo resistant to other therapies, oral mini-pulses of dexamethasone (2.5–5mg) or betamethasone (5mg) for 2 non-consecutive days per week for a maximum of 3–6 months may be considered.2

The previously mentioned topical therapies, phototherapy, or a combination of both can be used. In cases resistant to these therapies and with no disease progression after 12 months, surgical treatment with grafts—tissue or cellular—may be considered.

If the goal is to prevent relapses, twice-weekly application of a TCI or topical corticosteroid is recommended.1

Finally, for resistant and extensive cases in visible areas, depigmentation of healthy skin may be considered using monobenzone (FDA-approved), other topical depigmenting agents, laser, or cryotherapy.1,2

Several therapies for this disease are under study. Recently, the results of a phase 2b clinical trial with ritlecitinib (an oral JAK3 and TEC kinase inhibitor) were published, showing favorable results regarding safety and efficacy.4 Other oral JAK inhibitors (upadacitinib, povorcitinib, baricitinib) have also begun phase 2 clinical trials.2 New therapeutic targets under investigation (IL-15, WNT signaling) aim to address not only immunomodulation but also repigmentation.2,5