欧洲白癜风治疗指南

REVIEWARTICLEBJDBritishJournalofDermatologyGuidelinesforthemanagementofvitiligo:theEuropeanDermatologyForumconsensusA.Taieb,1A.Alomar,2M.Bo¨hm,3M.L.Dell’Anna,4A.DePase,5V.Eleftheriadou,6K.Ezzedine,1Y.Gauthier,1D.J.Gawkrodger,7T.Jouary,1G.Leone,4S.Moretti,8L.Nieuweboer-Krobotova,9M.J.Olsson,10D.Parsad,11T.Passeron,12A.Tanew,13W.vanderVeen,9N.vanGeel,14M.Whitton,15A.Wolkerstorfer9andM.Picardo4;thewritinggroupoftheVitiligoEuropeanTaskForce(VETF)incooperationwiththeEuropeanAcademyofDermatologyandVenereology(EADV)andtheUnionEurope´ennedesMe´decinsSpe´cialistes(UEMS)1ServicedeDermatologie,CHUdeBordeaux,BordeauxCedex,France2InstitutUniversitariDexeus,UniversitatAutonomaBarcelona,Barcelona,Spain3DepartmentofDermatology,UniversityofMu¨nster,Mu¨nster,Germany4SanGallicanoDermatologicInstitute,IRCCS,Roma,Italy5ARIV,Bergamo,Italy6CentreofEvidenceBasedDermatology,UniversityofNottingham,Nottingham,U.K.7DepartmentofDermatology,RoyalHallamshireHospital,Sheffield,U.K.8DivisionofClinicalPreventiveandOncologicDermatology,UniversityofFlorence,Florence,Italy9DepartmentofDermatology,NetherlandsInstituteforPigmentDisorders,AMC⁄UniversityofAmsterdam,Amsterdam,theNetherlands10DepartmentofMedicalSciences,DermatologyandVenereology,UppsalaUniversity,Uppsala,Sweden11DepartmentofDermatology,PIGMER,Chandigarh,India12DepartmentofDermatology,Universite´deNice-SophiaAntipolis,Nice,France13DepartmentofDermatology,ViennaGeneralHospital,Vienna,Austria14DepartmentofDermatology,GhentUniversityHospital,Ghent,Belgium15TheCochraneSkinGroup,CentreforEvidenceBasedDermatology,UniversityofNottingham,Nottingham,U.K.CorrespondenceMauroPicardo.E-mail:[e-mail]flictsofinterestNonedeclared.DOI10.1111/j.1365-2133.2012.11197.xSummaryTheaetiopathogenicmechanismsofvitiligoarestillpoorlyunderstood,andthishasheldbackprogressindiagnosisandtreatment.Upuntilnow,treatmentguidelineshaveexistedatnationallevels,butnocommonEuropeanviewpointhasemerged.ThisguidelineforthetreatmentofsegmentalandnonsegmentalvitiligohasbeendevelopedbythemembersoftheVitiligoEuropeanTaskForceandothercolleagues.Itsummarizesevidence-basedandexpert-basedrecommen-dations(S1level).Vitiligoisanacquireddepigmentingdisorderaffecting0Æ5%oftheworldpopulation,withoutsexorracialdifferences.Itaffectsallagegroups.1,2Accordingtotheconsensusdefinitiongiventogeneralized⁄vulgarisornonsegmentalvitiligo(NSV)bytheVitiligoEuropeanTaskForce(VETF)1‘vitiligovulga-ris⁄NSVisanacquiredchronicpigmentationdisordercharac-terizedbywhitepatches,oftensymmetrical,whichusuallyincreaseinsizewithtime,correspondingtoasubstantiallossoffunctioningepidermalandsometimeshairfolliclemelano-cytes’;however,thisisnotspecificenough.Itneedstobecompletedbyalistofdisorders(theacquiredgeneralizedhypo-melanoses)whichmayclinicallyoverlapwithNSV,butwhichareclearlyattributabletoknownaetiologicalfactors.Incasesofuncertaindiagnosis,additionalnoninvasiveandinvasiveproceduresmaybeneeded(Table1).Segmentalvitiligo(SV)isdefineddescriptivelyasforNSVexceptforaunilateraldistribution(asymmetricvitiligo)thatmaytotallyorpartiallymatchacutaneoussegment(e.g.der-matomal-like).SomespecificfeaturesofSVarerapidonsetandinvolvementofthehairfolliclepigmentarysystem.Oneuniquesegmentisinvolvedinmostpatients(Table2).ConcerningtherapyandNSVtopographicsubtypes,acrallesionsshowtheworstresponserate.3DistinctionbetweenSVandNSVmayaffectprognosisintermsofresistanceto2012TheAuthorsBJD2012BritishAssociationofDermatologists2013168,pp5–195repigmentation.Otherformsofvitiligo(suchasmucosaloreyelidvitiligo)maynecessitatespecificapproachesnotdetailedindepthinthisguideline.Intermsoftherapy,theimmune-mediatedinflammatoryphaseofvitiligoneedstobebetterdefinedinordertodevelopspecificapproachestargetedtothisimportantphaseofthedis-easepathogenesis.Thisphaseismostlysilentandonlyrevealedwhenskinbiopsiesaretakenatthemarginsofpro-gressinglesions.Stablevitiligoneedsatreatmenttoregeneratethemelanocytesfromhairfollicleorinterfollicularprecursors.Intheassessmentstepsitisimportanttoconsiderage,pre-existingdiseases,inparticularautoimmunedisorders,previousmedications,andobjectiveandsubjectiveparameters(Table3).4–6Asthecareoftenextendsoveralongperiodoftime,patientsarefrequentlyfrustratedbythefailureofprevi-oustreatments.Psychologicalstressiscommon.Thetreatmentplanshouldbediscussedwiththepatienttoobtainahighlevelofcompliance.Itmustberememberedthatsomethera-piesarenotlicensedforvitiligoandcanonlybeprescribed‘off-label’.6Table1RecommendeddiagnosticproceduresinvitiligoIfdiagnosisiscertainIfdiagnosisisuncertainAnti-TPO,antithyroglobulinantibodiesPunchbiopsyfromlesionalandnonlesionalskinTSHandothertestsifneededtoassessthyroidfunctionordiagnosis(e.g.anti-TSHRantibodiesifGravesdisease)Othertestsifneeded(mycology,molecularbiologytodetectlymphomacells,etc.)Additionalautoantibodies(onlyifpatient’shistory,familyhistoryand⁄orlaboratoryparameterspointtoastrongriskofadditionalautoimmunedisease),endocrinologist⁄immunologistadviceifmultipleautoimmunesyndromedetectedTPO,thyroi