Vitiligo Patches Research Articles

Depigmentation Patterns of Nonsegmental Vitiligo

Efforts have been recently made to investigate simple, objective, accurate, and reproducible methods of clinical/noninvasive assessment of nonsegmental vitiligo. However, studies have mostly considered quantitative or semiquantitative parameters, almost neglecting the purely qualitative appearance of vitiligo lesions at a given moment and over time. The objective of this study was to investigate the dynamics of macromorphologic alterations taking place within vitiligo patches. This was a prospective study of a vitiligo cohort. Consecutive patients affected by nonsegmental vitiligo. Enrolled patients affected by nonsegmental vitiligo underwent a dermatology visit once monthly for 12 months. Vitiligo lesions were photographed at each visit under both room light and Wood's light, and analyzed via a morphometric, digitalized software capable of detecting quantitative changes of white areas. Pictures depicting changing patches were evaluated in order to assess clinical morphology. Ninety patients were included for the final analysis and 360 lesions were evaluated, 102 of which (28.9 %) showed changes of white areas. Subjective evaluation highlighted two distinct depigmentation patterns, which were present either alone or in combination: (1) a sharply defined band of intermediate color between the depigmented center and the surrounding normal skin, which was defined as 'marginal hypopigmentation;' and (2) pinpoint hypopigmented/depigmented macules centered by a follicle, which we named 'perifollicular depigmentation.' On the other hand, only one repigmentation pattern was detected, the already known 'perifollicular repigmentation.' The depigmentation process in vitiligo seems to follow only two specific patterns. This preliminary study represents, in our opinion, a valuable background for future research aiming to investigate the dynamics of vitiligo pathogenesis or assess depigmentation/repigmentation patterns for monitoring treatment response.

Smashed skin grafting or smash grafting – a novel method of vitiligo surgery

Vitiligo is an acquired progressive disorder characterized by destruction of melanocytes in the lesion and the lesional hair follicles. A number of new therapeutic options for vitiligo have become available over the last decade or so both on the medical as well as surgical side. One among them is the smashed skin grafting or simply smash grafting, which is a modification of split-thickness grafting. In this method, the graft undergoes "smashing" before being applied to the recipient site. Though a simple and effective procedure, very few people are doing the procedure either due to lack of awareness or due to lack of published data. Smash skin grafting was performed in 26 patients with vitiligo in Mahatma Gandhi Institute of Medical Sciences, Sewagram, Maharashtra, India. Smashed skin grafting helped to achieve more than 90% repigmentation of the vitiligo patches in our patients. Smashed skin grafting is a simple procedure with fewer side effects, better outcome, and high patient satisfaction or, in simple words, it can be considered as an alternative to various conventional surgical modalities like punch grafting and melanocyte cell culture methods. This article deals with the steps of the procedure, results of the surgery in a small group of patients, and the necessity of increasing the awareness of smash grafting.

Digital image analysis vs. clinical assessment to evaluate repigmentation after punch grafting in vitiligo

Repigmentation as a treatment outcome in vitiligo is not assessed in a standard way, making results of clinical trials hard to compare. Different types of repigmentation assessments after punch grafting have not been compared so far. To compare assessments of repigmentation by a digital image analysis system (DIAS) with those of clinical observers and patients after punch grafting for vitiligo. One vitiligo patch was selected in each patient (n = 21). This patch was treated with the punch grafting technique. The grade of repigmentation (%) after 3 months was assessed by: (i) DIAS; (ii) 3 clinical observers ; and (iii) the patient, scoring the grade of repigmentation on photographs. Physicians and patients also evaluated the global result on a 7-point scale. There was an almost perfect agreement between the three clinical observers and the DIAS (ICC 0.83). As expected, variation was found between the clinical observers. Patients' scores showed a moderate agreement with the DIAS (ICC 0.49) and a poor agreement with the physicians (ICC 0.28). Overall, the patients were more satisfied with the results than the physicians. Whereas the results of the digital and clinical assessments were comparable, patients' ratings diverged. The DIAS can overcome the inevitable differences between observers, which are intrinsic to a visual grading method, and is advisable for clinical trials on vitiligo to objectively assess repigmentation in limited lesions.

Diphencyprone Induced Vitiligo: A Case Report

Diphencyprone (DCP) is a contact sensitizer which is used to treat dermatological disorders with an immunological origin, such as extensive alopecia areata (AA). Vitiligo is a rare but known side effect of DPCP therapy which is formed in the treatment site or remote areas. In this paper a 37-year-old man developed alopecia totalis with loss of eyebrows and eyelashes who presented some vitiligo patches on his scalp and arm distant from the location of DPCP application and a 42-year-old woman with 25 years history of hair loss and 3 months DPCP application who revealed some vitiligo patches on the scalp with distant to the site of application at the 6th week are reported. Considering the absence of personal and family history of Vitiligo in our two cases, the hypothesis of latent Vitiligo is not proved. The positive patch test in left arm of one of the patients also suggests the direct role of DPCP as the cause of Vitiligo occurrence. As the development of vitiligo by DCP is unpredictable and the depigmentation may persist indefinitely, it is important to inform all patients about this potential adverse effect before starting the treatment.

Excimer light photototherapy of segmental and non‐segmental vitiligo: experience in Taiwan

To determine the efficacy of excimer light in the treatment vitiligo and to assess parameters affecting therapeutic results. This retrospective study analyzed 227 patches of vitiligo in 142 patients. Treatment was performed twice weekly and treatment efficacy was assessed by two independent dermatologists. Patients who received less than 24 treatment sessions were excluded from the analysis of predictive factors for response. Sixty-eight (30.0%) patches achieved more than 50% repigmentation, and 42 (18.5%) achieved more than 75% repigmentation. The mean treatment numbers to achieve any repigmentation and more than 50% repigmentation were 19.41 and 34.93, respectively. Fewer treatment sessions number, segmental lesions and absence of melasma were significant predictors for poor treatment response in multivariate analysis. Lesions on the hands/feet needed the highest dose and scalp lesions needed the highest number of treatment sessions to produce initial repigmentation. Excimer light is a valuable treatment modality for both segmental and non-segmental vitiligo even in patients who have failed previous treatments. The number of treatment sessions needed to produce initial pigmentation may be higher than 30 for scalp lesions. There is a need to find other combination methods, both medical and surgical, to enhance its therapeutic efficacy.

Vitiligo Treatment with Monochromatic Excimer Light and Tacrolimus: Results of an Open Randomized Controlled Study

Narrow band ultraviolet B (UVB) is an effective and safe option for the treatment of vitiligo. However, a complete and long-lasting repigmention of vitiligo patches is difficult to achieve. Combined treatments with novel sources of phototherapy and topical agents represent possible new strategies. The purpose of this study was to compare the efficacy of combined tacrolimus and 308-nm excimer light (MEL) vs 308-nm MEL monotherapy in treating vitiligo in a controlled study. Fifty-three patients affected by vitiligo were enrolled in this open prospective study. Patients were divided into three groups: Group I included 20 patients treated with MEL 308 nm twice weekly and oral vitamin E; Group II included 20 patients treated with MEL 308 nm twice weekly combined with 0.1% tacrolimus once a day and oral vitamin E; and Group III included 13 patients treated only with oral vitamin E. Efficacy was assessed at the end of 12 weeks based on the percentage of repigmentation. Fifty-two patients completed 12 weeks of treatment. Group I (MEL + vitamin E) showed a moderate repigmentation in 35% of patients, good repigmentation in 30%, excellent repigmentation in 25%, and poor repigmentation in 10%; Group II (MEL + tacrolimus 0.1%+ vitamin E) presented moderate repigmentation in 25% of patients, good repigmentation in 40%, excellent repigmentation in 30%, and poor repigmentation in 5%; Group III (vitamin E) showed moderate repigmentation in 16% and 84% did not show signs of repigmentation. Our results demonstrate that the combination treatment of 0.1% tacrolimus ointment plus 308-nm MEL and 308-nm MEL monotherapy are effective, safe, and well tolerated for the treatment of vitiligo compared to treatment with vitamin E. Furthermore, this study suggests that an association with topical immunomodulators could enhance the clinical response in vitiligo, especially in more resistant anatomical sites.

RNA released from necrotic keratinocytes upregulates intercellular adhesion molecule-1 expression in melanocytes

Intercellular adhesion molecule-1 (ICAM-1) expression has been detected in melanocytes around active vitiligo patches as well as in surgically transplanted melanocytes. However, it is unclear whether and how skin injury induces the inappropriate expression of ICAM-1 and other proinflammatory genes in melanocytes. We previously reported that human melanocytes expressed TLR3. We hypothesized that the TLR3 expressed in melanocytes may recognize skin injury by binding to the endogenous ligands secreted by the damaged keratinocytes. Here we showed that RNA released from necrotic keratinocytes induced the upregulation of ICAM-1 protein and mRNA, as shown by FACS and real-time RT-PCR. Use of NF-κB inhibitor prevents upregulation of ICAM-1 in melanocytes indicating a direct role of NF-κB in necrotic keratinocyte-mediated upregulation of ICAM-1. Using a shRNA-expressing lentivirus, we demonstrated that in human melanocytes, TLR3 seems to be necessary for the upregulation of ICAM-1. Using oligonucleotide microarray, we demonstrated a dramatic increase in proinflammatory cytokine and chemokine transcripts (CXCL10, CXCL11, TNFSF10, CCL5, CCL4, CCL2, IFNB1, CCL20, IL-8, and CCL11). These observations suggested that RNA released from necrotic keratinocytes might act as an endogenous TLR3 ligand for the stimulation of ICAM-1 and other proinflammatory gene expression in human melanocytes, which might be involved in the pathogenesis of vitiligo following skin physical trauma.

Combination of Microdermabrasion and 5-Fluorouracil to Induce Repigmentation in Vitiligo: An Observational Study

Treatment of resistant vitiligo is challenging. A few well-researched studies have shown variable results with surgical and other therapeutic strategies. To evaluate the usefulness of a less-painful method of repigmentation of vitiligo patches. Forty vitiligo patches in 22 consecutive patients with resistant vitiligo presenting at a vitiligo clinic of a university teaching medical school in New Delhi, India, were treated with microdermabrasion followed by topical 5% 5-fluorouracil (5-FU). One-third of the patches showed more than 50% repigmentation, and one-fourth showed more than 75% repigmentation. Gratifying results were obtained in seven patches after a single session. Microdermabrasion is adjunctive with topical 5% 5-FU in the treatment of resistant vitiligo patches. Further well-controlled randomized trials are required to validate the observations of the study. The authors have indicated no significant interest with commercial supporters.

A randomized comparison of excimer laser versus narrow‐band ultraviolet B phototherapy after punch grafting in stable vitiligo patients

Background Ultraviolet radiation following punch grafting may stimulate the migration of melanocytes from the grafts into the vitiliginous skin, thereby increasing the rate of repigmentation. We compared the effects of the 308-nm xenon chloride excimer laser (EL) vs. narrow-band ultraviolet B (NB-UVB) after punch grafting in patients with vitiligo. Objectives The aims of this study were to evaluate (i) repigmentation (%); (ii) treatment satisfaction; and (iii) patient preferences for EL vs. NB-UVB therapy after punch grafting in vitiligo. Methods Fourteen patients were treated with the punch-grafting technique on two symmetrical vitiligo patches. Starting 1 week after the punch grafting, the vitiligo patches were treated twice a week during 3 months, with EL on one side and with NB-UVB on the other side. Repigmentation (%) was measured by a digital image analysis system. Patients' satisfaction and preference for treatment were also assessed. Results Whereas both treatment modalities induced repigmentation, no statistically significant difference was found in grade of repigmentation after 3 months. With EL, 71.4% lower cumulative dose was reached. Patients were significantly more satisfied with NB-UVB and preferred it over EL. Conclusions The choice between EL and NB-UVB cannot solely be based on repigmentation, but rather on other factors, such as patients' preferences. However, given the lower UV dose of EL, we recommend its use in vulnerable populations, such as in small children and patients with sun-damaged skin with a history of long-term UVB treatment.

Non‐cultured melanocyte‐keratinocyte transplantation for the treatment of vitiligo: a clinical trial in an Iranian population

Non-cultured cellular grafting as a surgical procedure is indicated to treat stable vitiligo, refractory to medical treatment, and is gaining wider acceptance among dermatologists. The aim of this study was to assess the efficacy of non-cultured melanocyte-keratinocyte transplantation (MKT) for the treatment of generalized vitiligo in Iranian patients. In this clinical trial, a total of 14 vitiligo patches in eight patients were treated; eight patches with non-cultured MKT and six patches dermabraded alone without application of keratinocyte-melanocyte suspension. Repigmentation was compared at about 4 months post-transplantation. Of the eight lesions treated with non-cultured MKT, four lesions showed 96-100% repigmentation, one lesion 65-95% and three lesions 0-25%. Of the patients who showed excellent results, only one showed a post-inflammatory hyperpigmentation in recipient and control areas. Of the six control lesions, five showed failed repigmentation and one showed post-inflammatory hyperpigmentation. Non-cultured MKT is an effective method to treat stable vitiligo. Studies on larger series of vitiligo patients are required to confirm its efficacy.

The 308‐nm excimer laser: a promising device for the treatment of childhood vitiligo

Numerous modalities have been used to treat vitiligo in children. Up to now, phototherapy and topical corticosteroids are the most commonly used treatments for adult vitiligo but studies evaluating the efficacy of these treatments in the pediatric population remain insufficient. This study was a retrospective review to evaluate the efficacy and safety of 308-nm excimer laser treatment in 30 childhood vitiligo patients. Thirty vitiligo patients with 40 vitiligo patches were evaluated after the cessation of 308-nm excimer laser treatment. Seventeen patients (56.7%) with 20 patches (50%) achieved an acceptable degree (>50%) of repigmentation at the end of the treatment, with five patches (12.5%) showing >75% of repigmentation. The treatment response showed anatomical preferences, favoring the face, neck and trunk. However, the treatment response did not correlate to the cumulative dose or duration of treatment. Side effects occurred in nine patients, but were transient and minimal. The results of this study shows that the 308-nm excimer laser can be an effective and promising device for the treatment of various vitiligo types, other than generalized, in childhood.

Single-hair follicular unit transplant for stable vitiligo

Follicular unit transplant (FUT) is one of the surgical procedures which has been recently used to repigment a stable vitiligo patch. Single-hair FUT was done for a 30-year-old male with stable vitiligo patch on the upper lip. Repigmentation was noted in 4 weeks and complete pigmentation seen at 8 weeks. No recurrence was noted at the end of 6-month follow-up with excellent colour match. This case is presented to highlight the effectiveness of FUT in focal vitligo patch with leukotrichia.

Treatment of vitiligo with khellin liposomes, ultraviolet light and blister roof transplantation

Various surgical and non-surgical methods are available to treat vitiligo. Surgical techniques such as epidermal blister graft transplantation may be effective for the re-pigmentation of stable, but refractory vitiligo areas. Khellin has phototherapeutic properties that are similar to those of the psoralens, but with substantially lower phototoxic effects and DNA mutation effects. Its penetration into the hair follicles is enhanced by encapsulating it into liposomes. Subsequent activation of the khellin with UV light stimulates the melanocytes in the hair follicles. The first objective was to evaluate the additional value of combining blister roof transplantation (BRT) with khellin in liposomes and ultraviolet light (KLUV) in the treatment of recalcitrant vitiligo patches. The second objective was to assess patients' satisfaction. Nineteen patients with vitiligo lesions which did not respond to KLUV treatment for at least a year were treated with BRT followed by KLUV. The transplantation was performed by creating blisters with a suction device, preparing the target site with Erbium laser ablation and the actual transplantation. Locations where randomly assigned. A blinded observer established the results. Seventy-five percent of the patients were satisfied with the cosmetic result. All of the patients would recommend the treatment to other vitiligo patients. More than 75% re-pigmentation of the vitiligo areas was noted in 47% of the patients according to the blinded evaluation of photographs taken before and after the treatment.

Clinical efficacy of a 308 nm excimer laser in the treatment of vitiligo

To investigate the clinical efficacy and safety of the treatment of vitiligo using a 308 nm excimer laser. Thirty-six patients with 44 vitiligo patches were treated using a 308 nm excimer laser, which was performed twice a week, for a total of 30 treatments. The therapeutic efficacy and safety were then evaluated. After 30 treatments: (1) 27/44 patches (61.4%) achieved more than 75% repigmentation, 4/44 lesions (9.1%) showed 51-75% repigmentation, 10/44 (22.7%) showed 26-50% repigmentation and 3/44 (6.8%) showed 1-25% repigmentation. (2) Of the 44 patches of vitiligo, 20/27 (74.1%) lesions on the face/neck, 9/9 (100%) on the trunk and 2/8 (25.0%) on the extremities showed >or=50% repigmentation. The repigmentation (>or=50%) in face/neck and trunk were much higher than that in the extremities (P<0.05). (3) The repigmentation (>or=50%) in disease duration of <or=2 years and >2 years were 100.0% and 46.2% (P<0.05). (4) The average cumulative doses in the face/neck, trunk and extremities were 7.92+/-5.26, 9.93+/-7.36 and 22.13+/-8.15 J/cm(2). The doses in the face/neck and trunk were much lower than those in the extremities. (P<0.05). Side effects were limited mainly to symptomatic erythema. The clinical data indicate that the treatment of vitiligo using a 308 nm excimer laser is safe and effective. However, lesion location and disease duration may be the key factors affecting the clinical outcome.

Segmental and nonsegmental childhood vitiligo has distinct clinical characteristics: A prospective observational study

Vitiligo often starts in childhood. It is traditionally divided into segmental vitiligo and nonsegmental vitiligo. There are limited data regarding the clinical characteristics of both forms and no comparative study has been performed. To compare the clinical features of nonsegmental and segmental vitiligo in children. We performed a prospective observational study. Consecutive children with vitiligo seen between October 2005 and December 2007 in the 11 French Departments of Pediatric Dermatology were included. A standardized evaluation was completed after total body clinical examination. A second examination was performed 1 year after inclusion. The clinical characteristics of segmental vitiligo and nonsegmental vitiligo were compared. A total of 114 children with vitiligo were included. Compared with segmental vitiligo, nonsegmental vitiligo was associated with a higher number of lesions (more than 5 patches in 65.17% vs 20% of patients, P < .0001) and a larger body surface area of involvement (9.8% +/- 2.51% vs 3.48% +/- 1.6%, P +/- .01). A higher incidence of the Koebner phenomenon (47.19% vs 24%, P = .03), and more frequent progression of the disease (23.29% vs 5.56%, P = .043) were found in nonsegmental vitiligo. Hyperpigmented rims surrounding patches of vitiligo were only seen in nonsegmental vitiligo (8.99% vs 0% (P = .007). Sixty-four children (56%) had laboratory investigations performed; thyroid abnormalities were found only in nonsegmental vitiligo (11.23% vs 0%, P = .0001). Not all patients underwent laboratory investigations. Segmental and nonsegmental types of vitiligo have distinguishing clinical characteristics.

Cosmetic camouflage in vitiligo

Vitiligo is not a life–threatening nor a contagious disease. But the disfigurement of vitiligo can be devastating to its sufferers, especially dark-skinned individuals. Available treatment options are disappointing and sufferers often use various forms of camouflage. Remedial cosmetic cover creams help conceal the blemish of vitiligo at least temporarily. A high concentration of pigment is incorporated into water–free or anhydrous foundations to give a color that matches the patient’s skin, thereby concealing vitiligo patches. The article highlights the content and technique of application of these creams.

Agminated acquired melanocytic naevus modified by vitiligo vulgaris arising in the elderly

Conflict of interest: none declared. A healthy 74‐year‐old Japanese woman, who had a history of vitiligo vulgaris on her neck for several years, visited our dermatology clinic with a 6‐month history of slowly growing pigmented macules on her right breast (Fig. 1a). On physical examination, she had a cluster of approximately 15 melanocytic macules, 15 × 10 mm in size. The cluster was surrounded by vitiligo (Fig. 1b). The vitiligo patch on her right breast had not been seen before the appearance of pigmented macules, which suggested that the vitiligo and pigmented macules had appeared simultaneously. Dermatoscopic analysis revealed patchy reticular networks for all macules within the cluster, some of which had irregular pigment networks. Bluish‐white veils were also seen in the centre of the cluster (Fig. 1c). The number of naevi over the entire body was > 10. Because malignant melanoma (MM) was suspected on clinical observation, the lesion was excised.

Evaluation of safety and efficacy of topical prostaglandin E2in treatment of vitiligo

Prostaglandin E2 (PGE2) has stimulant and immunomodulatory effects on melanocytes and regulates their proliferation. To study the efficacy and safety of topical PGE2 in treating stable vitiligo patches involving <5% body surface area. Fifty-six consecutive patients with clinically diagnosed stable vitiligo of types vulgaris, focal, segmental, lip and genital applied a translucent PGE2 (0.25 mg g(-1)) gel twice daily for 6 months. Evaluation was fortnightly for 3 months and monthly thereafter up to 6 months. Assessment was based on degree of repigmentation in treated patches ranging from 0% (no change) to 100% (complete repigmentation). Overall response was graded as: poor, 1-25% repigmentation; moderate, 26-50%; good, 51-75%; excellent, >75%. Vitiligo vulgaris was the most common type (n=22; 39%), followed by focal and lip vitiligo, with lesions being mostly on the face (25%) and lips. Repigmentation was seen in 40 of 56 patients (71%), with mean onset at 2 months. Patients with disease duration of 6 months or less repigmented best, with face and scalp responding earliest (1-1.5 months). Complete clearance occurred in eight of 40 patients, six of the eight having face lesions. Excellent response was seen in 22 of 40 patients. All neck, scalp and trunk lesions, 33% genital, 29% lip vitiligo, 100% segmental and 63% focal patches showed moderate to excellent response. Incidence of side-effects was 18%, mainly a transient burning sensation especially on the lips. The efficacy and safety of topical PGE2 make it a promising therapy for localized stable vitiligo.

Chinese Cupping

BACKGROUND The introduction of surgical techniques provided a major development in the management of resistant vitiligo and replaced other conventional unsuccessful therapies. Most of these procedures require special devices and experience that prevent many dermatologists from utilizing them. OBJECTIVES The aim of this work is to evaluate the introduction of a new simple technique that can be used in epithelial grafting for recalcitrant patches of vitiligo. METHODS Twenty vitiligo patients, nonresponding to classic phototherapy, were candidates in this study. A simple Chinese cupping device was used to induce blisters on the inner aspect of the thighs of the patients and the resulting blister roofs were used for grafting on dermabraded vitiliginous patches. The patients were followed up for 1 year. RESULTS Blister roofs induced by Chinese cupping were able to repigment vitiliginous patches in 80% of the patients with admirable coloring match, and the donor areas did not show any cosmetic disfigurement at the end of the study. CONCLUSION In conclusion, Chinese cupping is a simple and easy-to-use method to obtain epithelial grafts for vitiligo management.

Targeted and combination treatments for vitiligo Comparative evaluation of different current modalities in 458 subjects

The current treatment of vitiligo is not satisfactory according to the opinions of both the patient population and the dermatologists. Recently, combination therapies have been introduced, which are both systemic and targeted (microphototherapy). To evaluate the effects of topical treatments given alone or in combination with 311-nm narrow-band microphototherapy. We evaluated the efficacy and safety of: (1) 311-nm narrow-band microphototherapy;(2) tacrolimus 0.1% ointment twice a day; (3) pimecrolimus 1% cream twice a day; (4) betamethasone dipropionate 0.05% cream twice a day; (5) calcipotriol ointment 50 microg/g twice a day; and (6) 10%l-phenylalanine cream twice a day, for the treatment of exclusively vitiligo patches. A 311-nm narrow-band microphototherapy (Bioskin) was given alone or in combination with the above-mentioned popular local treatments. Four hundred and seventy patients suffering from vitiligo that affected less than 10% of the skin surface were evaluated. The patients were divided into 11 groups according to the selected treatment modalities. Four hundred and fifty-eight patients completed the study period of 6 months. Excellent repigmentation (> 75%) was achieved by 72% of the patients in group 1, 76.5% in group 2, 76.1% in group 3, 90.2% in group 4, 75.6% in group 5, 74.8% in group 6, 61% in group 7, 54.6% in group 8, 71.2% in group 9, 59.1% in group 10, and 29.3% in group 11. Marked repigmentation (50-75%) was evident in 19.8% of the patients in group 1, 18.2% in group 2, 20.1% in group 3, 6.7% in group 4, 14.1% in group 5, 11.3% in group 6, 16.1% in group 7, 18.4% in group 8, 25% in group 9, 10.6% in group 10, and 8.1% in group 11. Moderate results (25-50% repigmentation) were seen in 4.6% of the patients in group 1, 3.3% in group 2, 2.7% in group 3, 2.2% in group 4, 7.4% in group 5, 10.1% in group 6, 18.4% in group 7, 21.7% in group 8, 2.1% in group 9, 27.1% in group 10, and 55% in group 11. Finally, minimal (< 25%) or no response was achieved in 3.6% of the patients in group 1, 2% in group 2, 1.1% in group 3, 0.9% in group 4, 2.9% in group 5, 3.8% in group 6, 4.5% in group 7, 5.3% in group 8, 1.75% in group 9, 3.2% in group 10, and 7.6% in group 11. Side effects were skin atrophy (76% in group 4 and 81% in group 9), stinging and burning (groups 2, 3, 7, and 8). Targeted combination therapies in vitiligo are remarkably more effective than single treatments. When single treatments are considered alone, 311-nm narrow-band UVB microfocused phototherapy and 0.05% betamethasone dipropionate cream are the most effective treatments in our study. When combined therapies are chosen, 0.05% betamethasone dipropionate cream plus 311-nm narrow-band UVB microfocused phototherapy apparently give the highest repigmentation rate. In the short term, the only side-effects registered have been cutaneous atrophy with corticosteroid cream, and stinging and burning with 0.1% tacrolimus ointment and, less frequently, with 1% pimecrolimus cream.