Half of cases of vitiligo appear during the first two decades of life. Although there are recommendations dedicated to the management of the disease, no text dedicated to children and adolescents currently exists, despite the therapeutic progress made in recent years. American experts have drafted a consensus text on the subject, making it possible both to use data from clinical evidence and to adapt them to the specificities of the population suffering from vitiligo.
Their recommendations were based on a review of the literature devoted to the pediatric, adolescent and young adult population, as well as on expert opinions in areas where specific literature is insufficient.
Some general recommendations
Experts specify that topical corticosteroids, topical calcineurin inhibitors (CNIs) and UVB phototherapy constitute the standard treatments in young patients. The combination of phototherapy and topical treatment could improve repigmentation. Even if the data in adults are reassuring, the risk of skin cancer linked to the use of phototherapy must nevertheless encourage long-term monitoring of children. Experts emphasize the need for early treatment of vitiligo in order to reduce its progression and improve the chances of repigmentation.
Focus on the three therapeutic classes
First-line topical CNIs are tacrolimus and pimecrolimus, which should be applied twice daily for a minimum of 3 months. Treatment can be continued for 6 to 12 months if repigmentation is observed. Otherwise, the use of another molecule or a combination must be considered. Data in children under 2 years old remain limited and studies suggest effectiveness which could be greater on the darkest phototypes. Its effectiveness is also greater in lesions of the head and neck, the rest of the body responding a little less well, and the response in the hands and feet generally being the weakest.
The choice of topical corticosteroid varies depending on the site to be treated and the expected duration of use. Its use is more readily reserved as a second line when the treatment is in areas where the skin is thin. Topical corticosteroids should be used for limited durations and their overlap with CNIs is useful to reduce the risk of atrophy.
Finally, the data relating to JAK inhibitors currently suggest using these molecules in first or second line in subjects aged 12 and over. Data for younger children are currently too scarce. These molecules have the advantage of being able to be applied to areas at risk of skin atrophy, such as the face or eyelids. The evaluation of repigmentation here also requires at least 3 months of treatment.
Pathophysiological reminders
Vitiligo that appears before the age of 12 tends to be more extensive than in other subjects. It is also more often segmental, with a rather rare evolution towards non-segmental forms.
The appearance of targeted treatments is linked to a better understanding of the pathophysiology of the disease: vitiligo arises from an autoimmune process, favored by different genetic and immunological factors. These pathogenic processes involve T cells which target melanocytes. These cells then activate the production of IFN gamma, which will notably activate the JAK/STAT pathways.
