For localised vitiligo: 10 RCTs (approximately 381 participants) and 29 patient series (993 participants) were included. For generalised vitiligo: 10 RCTs (approximately 366 participants) and 46 patient series (1,866 participants) were included.
1. Therapies for localised vitiligo.
The mean treatment duration varied from 5 to 8 months.
RCTs: the odds ratio (OR) showed non significant differences between class 4 corticosteroids (OR 1.00, 95% confidence interval, CI: 0.16, 6.21), intralesional corticosteroids (single study OR 1.42, 95% CI: 0.31, 6.47), topical khellin (2 to 3%) plus UV-A (OR 1.18, 95% CI: 0.38, 3.62), or topical khellin (5%) plus UV-A (OR 1.00, 95% CI: 0.39, 2.54) and their respective placebos. Class 3 corticosteroids had a significant OR (14.32, 95% CI: 2.45, 83.72) versus placebo.
Patient series: class 3 corticosteroids had 56% of patients achieving more than 75% repigmentation (95% CI: 50, 62), and class 4 corticosteroids achieved 55% (95% CI: 49, 61).
Side-effects: 97% of the patient series reported side-effects. Of the topical psoralen plus UV-A group, methoxsalen had the highest proportion of patients developing phototoxic reactions (58%, 95% CI: 51, 65), followed by trioxsalen (39%, 95% CI: 23, 56) and PS (25%, 95% CI: 12, 38). Atrophy was the most common side-effect with local corticosteroids occurring mostly in patients receiving intralesional corticosteroids (33%, 95% CI: 22, 43), followed by patients using class 4 corticosteroids (14%, 95% CI: 10, 18) and class 3 corticosteroids (2%, 95% CI: 1, 5). Other less common side-effects were telangiectasia, corticosteroid-induced acne and hypertrichosis. Studies on topical khellin (2, 3 and 5%) plus UV-A did not report any side-effects.
2. Therapies for generalised vitiligo.
The mean treatment duration of photochemotherapies varied between 9 months for phenylalanine plus UV-A and 24 months for oral PS plus UV-A. The treatment with oral minipulse therapy varied between 6 and 24 months.
RCTs: ORs showed significant differences for oral methoxsalen plus sunlight (single study OR 23.37, 95% CI: 1.33, 409.93), oral PS plus sunlight (pooled OR 19.87, 95% CI: 2.37, 166.32), and oral trioxsalen plus sunlight (pooled OR 3.75, 95% CI: 1.24, 11.29) and their respective placebos. Therapies that used phenylalanine plus UV-A (OR 2.24, 95% CI: 0.35, 14.28) or oral khellin plus sunlight (single study OR 13.16, 95% CI: 0.69, 249.48) showed no significant differences between the active drug and placebo.
Patient series: phototherapy with narrowband UV-B had the highest percentage of patients who achieved more than 75% repigmentation (63%, 95% CI: 50, 76), followed by broadband UV-B (57%, 95% CI: 29, 82). Only one study of each was included. Oral methoxsalen plus UV-A and oral bergapten plus UV-A had success rates of 51% (95% CI: 46, 56) and 43% (95% CI: 38, 48), respectively. The differences between the mean success rates of narrowband UV-B, broadband UV-B, and oral methoxsalen plus UV-A were not significant.
Side-effects: 87% of the patient series that were included reported side-effects. Of the oral photochemotherapeutic modalities, methoxsalen had the highest proportion of patients who developed nausea and vomiting (29%, 95% CI: 24, 35), followed by khellin (9%, 95% CI: 2, 16) and PS (8%, 95% CI: 2, 15). Phototoxic reactions were seen mostly in patients taking methoxsalen (25%, 95% CI: 20, 30), followed by bergapten (6%, 95% CI: 4, 8). Abnormal results of liver function tests were observed mostly in patients using khellin (17%, 95% CI: 8, 26). Systemic reactions (headache, dizziness) were reported mostly in patients taking oral PS (24%, 95% CI: 14, 33). Pruritus was most frequently seen with the use of methoxsalen (31%, 95% CI: 26, 37). An increased contrast between normal and depigmented skin was reported mostly with the use of methoxsalen (10%, 95% CI: 6, 13). In comparison with daily intake of corticosteroids, oral minipulse therapy with corticosteroids was associated with a lower mean proportion of patients with systemic and cutaneous side-effects.