承鴻醫師的皮膚科手札

From Medscape Education Clinical Briefs

Task Force Issues Guidelines for management of Vitiligo
      白斑的治療指引

     白斑是一種慢性皮膚疾病,約佔總人數的0.5%. 白斑的影響是不分
年齡,種族與性別的. 白斑的定義是皮膚色素脫失,且通常是對稱和隨時
間增加.
     白斑的治療對於皮膚科醫師一直都是一個挑戰,本篇文章是來自於
VETF (Vitiligo European Task Force)所提出關於白斑治療在臨床
上較佳的治療指引.

治療建議:
分節型白斑或小於2~3%的非分節型白斑的治療原則:
1. 第一線治療是避免誘發因子和使用局部製劑,如類固醇或免疫抑制劑類
2. 第二線治療是照光治療: NBUVB 窄波紫外光 311nm, 或 低能量雷射
3. 第三線治療是針對經過第一,第二線治療後,對外表美觀仍不滿意者,可
    考慮使用外科手術治療.

Management Recommendations

The reviewers recommend the following principles of management for segmental vitiligo or limited nonsegmental vitiligo (involving less than 2% - 3% of body surface):

• First-line treatment should be to avoid triggering factors and to use local agents such as corticosteroids or calcineurin inhibitors.
• Second-line treatment should be localized narrow-band ultraviolet B (NB-UVB) radiation (311 nm), preferably with the excimer monochromatic lamp or laser.
• Third-line treatment for patients left with cosmetically unsatisfactory repigmentation on visible areas after first- or second-line therapy is to consider use of surgical techniques.

非分節型白斑的治療原則:
1. 第一線治療仍是避免誘發或加重因子,且建議使用最少3個月的
    光照治療來穩定病情. 若治療反應良好,建議持續治療9個月以上.
    可以考慮是照光治療合併全身或局部治療.
2. 第二線治療是針對病患有快速發展的病情或對於照光治療
    後仍無法穩定時,建議使用類固醇的脈衝治療或免疫抑制治療.
3. 第三線治療是針對前述治療無效的白斑處進行皮膚移植.
    對於手背或其它相似區域則是移植治療的相對禁忌區域
4. 第四線治療則是針對廣泛型 (>50% BSA),頑固型或明
   顯區域的白斑病患,將改成去色素的治療,不論是外用藥
   或使用雷射去針對正常膚色的部份進行治療.　

 The reviewers recommend the following principles of management for nonsegmental vitiligo:

• First-line management is to avoid triggering or aggravating factors and to stabilize the patient with NB-UVB therapy for at least 3 months. Patients who respond to NB-UVB should continue this treatment for 9 months or more. An additional consideration is to combine localized UVB therapy with systemic or topical therapies.
• Second-line treatment for patients with rapidly progressive disease or lack of stabilization with NB-UVB is systemic corticosteroids, 3- to 4-month minipulse therapy, or immunosuppressants.
• Third-line treatment is to graft areas failing to respond to previous treatment, particularly those areas with high cosmetic effect. The Koebner phenomenon, or new development of vitiligo in a previously unaffected area of skin undergoing traumatic injury, may limit graft persistence. Grafts are relatively contraindicated on the dorsum of the hands and similar areas.
• Fourth-line treatment for widespread (covering more than 50% of body surface), refractory, or highly visible vitiligo is depigmentation using hydroquinone monobenzyl ether or 4-methoxyphenol alone or in combination with Q switch ruby laser.

在看過這份新的治療指引後,對於一般的白斑患者而言, 
可以治療還是放在照光治療與外用藥兩部份;其中的照
光治療在最近除了最常用的紫外光外,也開始有文獻提到
低能量雷射的功效,所以若是因為紫外光會造成皮膚曬黑
與癌化疑慮的患者,建議可以嘗試"低能量雷射",只是目前
低能量雷射的缺點還是在於治療面積受限,只適用於局部
或面部白斑病患.下次會再針對"低能量雷射"對於白斑部份
進行療效分享.

                   李承鴻 感恩合十 2012.8.25