2013欧洲白癜风指南
白癜风患者要如何选择适合自己的治疗方法
白癜风患者要如何选择适合自己的治疗方法白癜风怎么治疗?白癜风是常见的一种皮肤病，比较难以治疗。
很多白癜风患者遭受着白癜风的折磨，却不知白癜风怎么治疗。
其实白癜风的治疗方法有很多，只要选择适合自己的治疗方法，治疗效果肯定会很好。
下面是专家讲解的白癜风的治疗方法，希望对大家有所帮助。
白癜风怎么治疗1、紫外光(含日光)照射法白癜风怎么治疗?紫外光在光谱上位于紫色光的外侧，也叫紫外线。
日光中含有大量紫外光。
紫外光照射法理论上能增加色素细胞的光敏反应，促使色素细胞制造更多的黑色素，是一种传统的治疗方法。
目前，仍有书刊资料介绍使用。
据我们临床观察，此法对本病治疗并无益处，原因有两点：(1)过量的紫外光能对人体造成损伤;(2)人体患病后对紫外光的抵御能力下降。
所以我们认为白癜风患者应减少或避免紫外光的照射。
人体每天都或多或少从阳光中接受一定量的紫外光照射，对正常人体组织并无损害，这是因为人的体表有完整的保护机制，其中，色素细胞制造分泌黑色素以抵御紫外光辐射、保护机体免受损伤就是重要的自我保护功能。
当光照时间延长，光照量增强，色素细胞即呈代偿性生理反应，根据光照时间和光线强弱相应的增加黑色素的制造量，皮肤便明显增黑，以阻挡、减弱紫外光对体表的辐射，保护机体组织(也保护色素细胞自体)不受损伤。
患病后的机体与正常完全不同，体表的某些色素细胞大多处于不同程度的损伤状态，其功能减弱甚至丧失，保护功能受到了破坏，而紫外光疗法非但不减少反而增加光照量，必然给色素细胞增加工作负荷而加重色素细胞的损伤，同时也给其它组织细胞造成较重损伤。
临床所见紫外光照射后，局部皮肤红肿、起泡反应即是皮肤及皮下组织严重受损伤的表现。
有时临床也能见到增加光照后白斑周围皮肤黑色加深，或白斑中心出现少量色素岛，这是由于部分色素细胞还有一定的代偿功能，呈暂时性代偿反应。
但随着光照时间延长，强度增大，色素细胞损伤加重，便失去了制造黑色素的功能，白斑周围及中心的黑色素逐渐消退，白斑面积扩大，白色加深，甚至引发病情迅速扩散。
vitiligo surger 白癜风手术治疗指南
RecommendationsStandard guidelines of care for vitiligo surgeryDavinder Parsad, Somesh Gupta #Members, IADVL Dermatosurgery Task Force*, Department of Dermatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India, #Department of Dermatology & Venereology, All India Institute of Medical Sciences, New Delhi, IndiaAddress for correspondence:Address for correspondence: Dr Davinder Parsad, Department of Dermatology, Postgraduate Institute of Medical Education & Research, Chandigarh. Email: dprs@.inABSTRACTVitiligo surgery is an effective method of treatment for selected, resistant vitiligo patches in patients with vitiligo. Physician’s quali fi cations: The physician performing vitiligo surgery should have completed postgraduate training in dermatology which included training in vitiligo surgery. If the center for postgraduation does not provide education and training in cutaneous surgery, the training may be obtained at the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatosurgeon at a center that routinely performs the procedure. Training may also be obtained in dedicated workshops. In addition to the surgical techniques, training should include local anesthesia and emergency resuscitation and care. Facility: Vitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place, with which all nursing staff should be familiar. Vitiligo grafting for extensive areas may need general anesthesia and full operation theater facility in a hospital setting and the presence of an anesthetist is recommended in such cases. Indications for vitiligo surgery : Surgery is indicated for stable vitiligo that does not respond to medical treatment. While there is no consensus on de fi nitive parameters for stability, the Task Force suggests the absence of progression of disease for the past one year as a de fi nition of stability. Test grafting may be performed in doubtful cases to detect stability. Preoperative counseling and Informed consent: A detailed consent form elaborating the procedure and possible complications should be signed by the patient. The patient should be informed of the nature of the disease and that the determination of stability is only a vague guide. The consent form should speci fi cally state the limitations of the procedure, about the possible future progression of disease and whether more procedures will be needed for proper results. The patient should be provided with adequate opportunity to seek information through brochures and one-to-one discussions. The need for concomitant medical therapy should be emphasized and the patient should understand that proper results take time (a few months to a year). Preoperative laboratory studies include hemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), and blood chemistry pro fi le. Screening for antibodies for hepatitis B surface antigen and HIV is recommended depending on individual requirements. Anesthesia: Lignocaine (2%) with or without adrenaline is generally used for anesthesia; in fi ltration and nerve block anesthesia are adequate in most cases. General anesthesia may be needed in patients with extensive lesions. Postoperative care: Proper postoperative immobilization and care are very important to obtain satisfactory results.Key Words: Vitiligo, Skin grafting, Punch grafting, Suction blister graftingHow to cite this article: Prasad D, Gupta S. Standard guidelines of care for vitiligo surgery. Indian J Dermatol Venereol Leprol 2008;74:S37-S45.Received: August, 2007. Accepted: May, 2008. Source of Support: Nil. Con fl ict of Interest: Nil.The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Dermatosurgery Task Force consisted of the following members: Dr. Venkataram Mysore (co-ordinator), Dr. Satish Savant, Dr. Niti Khunger, Dr. Narendra Patwardhan, Dr. Davinder Prasad, Dr. Rajesh Buddhadev, Lt. Col. Dr. Manas Chatterjee, Dr. Somesh Gupta, Dr. MK Shetty, Dr. Krupashankar DS, Dr. KHS Rao, Dr. Maya Vedamurthy, Ex of fi -cio members: Dr. Chetan Oberai, President IADVL (2007-2008), Dr. Koushik Lahiri, Secretary IADVL, Dr. Sachidanand S, President IADVL (2008-2009), and Dr. Suresh Joshipura, Immediate Past president IADVL (2007-2008).Evidence - Level A- Strong research-based evidence- Multiple relevant, high-quality scienti fi c studies with homogeneous results, Level B- Moderate research-based evidence- At least one relevant, high-quality study or multiple adequate studies, Level C- Limited research-based evidence- At least one adequate scienti fi c study, Level D- No research-based evidence- Based on expert panel evaluation of other informationFor Disclaimers and Disclosures, please refer to the table of contents page (page 1) of this supplement. The printing of this document was funded by the IADVL.INTRODUCTIONVitiligo is a common acquired depigmentation disorder of great cosmetic importance. The basic pathogenesis of vitiligo or for any of the putative subsets of vitiligo, still remains unknown. The medical treatment of vitiligo is dependent upon the presence of a melanocyte reservoir and is effective in only 60-70% of the patients. Certain types of vitiligo do not respond well to medical treatment and resistant lesions do persist even in those who respond. In light of these limitations of medical treatment, surgical treatment of vitiligo was first proposed in the 1960s. Over the years, the concept of surgical treatment has been expanded to include surgical “biotherapies” such as autologous, cultured melanocyte transplantation. The disease has a major impact on the quality of life of patients, particularly the Indian population, in which there is a severe stigma attached to the disease, affecting the social and psychological aspects of the patients. Due to these effects, there is a considerable need for active treatment of this disease, in contrast to fair-skinned patients in whom the disease is less apparent.RATIONALE AND SCOPEAs such, there are no uniformly acceptable measurement tools and indices for measurement of the efficacy of outcomes of the surgical modalities of vitiligo treatment. Assessment of quality of life and global assessment should be performed because the percentage of regimentation may not always be a good indicator of patient satisfaction. There is an urgent need for universally acceptable, objective, reproducible and easy-to-use measurements to evaluate the efficacy of surgical vitiligo studies. These guidelines provide minimal standards of care for various surgical methods of treatment of vitiligo, with a brief description of the procedures as well as their advantages and disadvantages.PHYSICIAN’S QUALIFICATIONSThe physician performing vitiligo surgery should have completed postgraduate training in dermatology; he/she should also have had adequate training in vitiligo surgery during postgraduation. Alternatively, training in vitiligo surgery may be obtained on the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatological surgeon. The training may also be obtained in dedicated workshops. In addition to the surgical technique, training should include techniques in local anesthesia and emergency resuscitation and care.FACILITYVitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility under local anesthesia. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place with which all nursing staff should be familiar. Transplantation for extensive areas of vitiligo may need general anesthesia and in such cases, an operation theater facility in a hospital setting and the presence of an anesthetist are recommended. INDICATIONS FOR SURGERY AND PATIENT SELECTIONSurgery is indicated for all types of stable vitiligo including segmental, generalized and acrofacial types that do not respond to medical treatment. While there is no consensus on definitive parameters for stability, various recommendations suggest a period of disease inactivity ranging from six months to two years. The task force agrees on a year of disease inactivity as the cut-off period for defining stability (Level D). Test grafting may be performed in doubtful cases to detect stability. The choice of surgical intervention should be individualized according to the type of vitiligo, stability, localization of lesions and cost-effectiveness of the procedure. Patient counseling about the nature of the disease and about the fact that the determination of stability is only a rough guide is essential.EXPLANATION FOR STABILITYThe outcome of surgery is good in stable lesions whereas unstable lesions respond poorly. Thus, the stability status of vitiligo is the single, most important prerequisite in case selection. However, despite many studies, there is no consensus regarding the minimum required period of stability. The recommended period of stability in different studies has varied from four months to three years. Most authors have suggested that vitiligo can be classified as being stable when there is no progression of old lesions and/or development of new lesions during the past one year. A set of objective criteria-the Vitiligo disease activity score (VIDA), was suggested by Njoo et al.[7] in 1999 to follow the progress of the patient. It is a 6-point scale on which the activity of the disease is evaluated by the appearance of new vitiligo lesions or the enlargement of preexisting lesions gauged during a period ranging from < 6 weeks to one year [Table 1]. The task force recommends that surgeryParsad and Gupta: Guidelines of care for vitiligo surgeryfor vitiligo should be performed only in patients with VIDA scores of -1 or 0 (Level D).EVIDENCEDas SS, Pasricha JS. Punch grafting as a treatment of 1.residual lesions of vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9.Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo 2.vulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5.Falabella R. Repigmentation of segmental vitiligo by 3.autologous minigrafting. J Am Acad Dermatol 1983;9:514-21.Falabella R. Grafting and transplantation of melanocytes for 4.repigmenting vitiligo and other types of leukoderma. Int J Dermatol 1989;28:363-9.Falabella R. Surgical treatment of vitiligo: Why, when and 5.how. J Eur Acad Dermatol Venereol 2003;17:518-20.Savant SS. Autologous miniature punch grafting in vitiligo.6.Indian J Dermatol Venereol Leprol 1992;58:310-4.Njoo MD, Das PK, Bos JD, Westerhof W. Association of the 7.Kobner phenomenon with disease activity and therapeutic responsiveness in vitiligo vulgaris. Arch Dermatol 1999;135:407-13.Falabella R. Surgical therapies for vitiligo and other 8.leukodermas, part 1: Minigrafting and suction epidermal grafting. Dermatol Ther 2001;14:7-14.In contrast, other authors have questioned the concept of stability and stated that existing parameters are arbitrary. EVIDENCE1. Malakar S, Dhar S. Treatment of stable and recalcitrant vitiligoby autologous miniature punch grafting: A prospective study of 1,000 patients. Dermatology 1999;198:133-9.2. Malakar S, Lahiri K. How unstable is the concept of stabilityin surgical repigmentation of vitiligo? Dermatology 2000;201:182-3.Considering the variety of opinions, it is preferable to take multiple factors during patient selection for vitiligo surgery into account.PARAMETERS FOR ESTABLISHING STABILITYOF VITILIGO1. History of progression: Absence of new lesions2. Extension of old lesions: No extension of old lesions3. Koebner phenomenon: Absence of Koebnerphenomenon either based on history or by checkingfor experimentally induced vitiligo4. Mini-grafting test or test-grafting: The original testwas proposed by Falabella et al.[1] to select patientswith stable vitiligo who may respond to melanocytetransplantation. The test was considered positive ifunequivocal repigmentation took place beyond 1mm from the border of the implanted graft over aperiod of three months. Although this test has beenconsidered as a gold standard for establishing thestability and success of repigmentation, doubts havebeen expressed over its utility. It has been seen thateven when the minigraft test is positive, the diseaseitself may be unstable.EVIDENCE1. Falabella R, Arrunategui A, Barona MI, Alzate A. Theminigrafting test for vitiligo: Detection of stable lesions formelanocyte transplantation. J Am Acad Dermatol 1995;32:228-32.CONSENSUS RECOMMENDATION OF THE TASKFORCE ON STABILITYThe available evidence is insufficient to recommend a single cut-off period to assess stability. To facilitate consensus on this issue, the task force attempts to provide a clear definition of stability-a patient reporting no new lesions, no progression of existing lesions, and absence of Koebner phenomenon during the past one year. Spontaneous repigmentation should be considered as a favorable sign for the transplantation procedure. A test graft may be considered whenever there is a doubt about the stability, or the patient is unable to give a clear history on stability. It needs to be stressed here that the treating physician should always consider each patient individually and exercise his/ her judgment (LEVEL D).2. The age of the patient for vitiligo surgery: As such, no uniformly accepted opinion exists concerning the minimum age for surgery. Vitiligo surgery is generally performed under local anesthesia, which would be difficultin children. General anesthesia for vitiligo surgery in aTable 1: VIDA 6-point scoreDisease activity VIDA scoreActive in past 6 weeks +4Active in past 3 months +3Active in past 6 months +2Active in past 1 year +1Stable for at least 1 year 0Stable for at least 1 year andspontaneous repigmentation -1Parsad and Gupta: Guidelines of care for vitiligo surgeryyoung child poses unacceptable risks and the progress of the disease is difficult to predict in children. Hence, many dermatologists feel that surgical procedures should not be performed in children. However, studies have suggested that results of transplantation procedures were better in younger individuals than in older ones. Thus, no consensus exists in this aspect and physicians should exercise their judgment after taking all aspects of the individual patient into consideration. (LEVEL C)EVIDENCE1. Gupta S, Kumar B. Epidermal grafting in vitiligo: Influence ofage, site of lesion, and type of disease on outcome. J Am Acad Dermatol 2003;49:99-104.2. Gupta S, Kumar B. Epidermal grafting for vitiligo in adolescents.Pediatr Dermatol 2002;19:159-62. PREOPERATIVE COUNSELING AND INFORMED CONSENTProper counseling is essential; the nature of the disease, procedure, expected outcome and possible complications should be clearly explained to the patient. The need for concomitant medical therapy should be emphasized. Patients should understand that proper results may take time to appear (few months to one year). The patient should be provided with adequate opportunity to seek information through brochures, computer presentations, and one-to-one discussions.A detailed consent form (see appendix 1) describing the procedure and possible complications should be signed by the patient. The consent form should specifically state the limitations of the procedure, possible future disease progression and whether more procedures will be needed for optimal outcome.ANESTHESIAThe recipient site is locally anesthetized by infiltration of 2% xylocaine, the pain of which can be reduced by prior application of EMLA® cream applied under occlusion for 1-2 hours. Adrenaline should not be used on the recipient site as it makes the judgment of adequacy of the denudation to the required depth difficult. Tumescent anesthesia and nerve blocks may be used in larger areas. If grafting is planned for extensive areas, general anesthesia may be needed in a hospital setting. (LEVEL D)METHODS OF SURGICAL MODALITIESMethods of surgical modalities for vitiligo include both tissue grafts and cellular grafts.TISSUE GRAFTS1. Punch grafting: In this procedure, punch grafts (of1.2-2.0 mm diameter) are taken from donor areasover the thighs, buttocks, postauricular areas/posterior earlobe or the medial aspect of the upperarm. These are grafted into recipient sites in stablevitiligo lesions, which are created by using punches1-2 mm in diameter. To ensure a better fit, recipientpunches are generally smaller by 0.5 mm than donorpunches. Smaller sized grafts may be used to yieldbetter cosmetic results.Sockets are created in the recipient area at a distance of5-10 mm and the harvested grafts are placed in thesesockets. This allows the perigraft spread of pigment tocover the surrounding depigmented skin, the extent ofwhich varies according to the skin color and site of thetreated patch (more on exposed sites). (LEVEL B)EVIDENCE1. Savant SS. Miniature punch grafting. In: Savant SS, editor.Association of scientific cosmetologists and dermatosurgeons textbook of dermatosurgery and cosmetology. 2nd ed.Mumbai: ASCAD; 2005. p. 359-69.2. Babu A, Thappa DM, Jaisankar TJ. Punch grafting versussuction blister epidermal grafting in the treatment of stable lip vitiligo. Dermatol Surg 2008;34:166-78.3. Das SS, Pasricha JS. Punch grafting as a treatment of residual lesionsof vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9.4. Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligovulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5.5. Falabella R. Repigmentation of segmental vitiligo byautologous minigrafting. J Am Acad Dermatol 1983;9:514-21.Dressings are postoperatively placed to ensure immobili- zation, and may be removed in 24 hours to check for the displacement of the grafts. Grafts are taken up in 7-10 days after which phototherapy or treatment with topical steroid is started to ensure even spread of perigraft pigment.EVIDENCE1. Barman KD, Khaitan BK, Verma KK. A comparative study ofpunch grafting followed by topical corticosteroid versusParsad and Gupta: Guidelines of care for vitiligo surgerypunch grafting followed by PUVA therapy in stable vitiligo.Dermatol Surg 2004;30:49-53.2. Lahiri K, Malakar S, Sarma N, Banerjee U. Inducingrepigmentation by regrafting and phototherapy (311 nm) in punch grafting failure cases of lip vitiligo: a pilot study. Indian J Dermatol Venereol Leprol 2004;70:156-8.Advantages: This is the easiest and least expensive method and may be used satisfactorily in all areas other than the nipples and the angle of the mouth, where involuntary muscle contraction may interfere with graft uptake. It is even suitable for ‘difficult-to-treat’ locations such as the fingers, toes, palms and soles, etc.Disadvantages and complications: This method is not suitable for large lesions as uniform pigmentation may not always be achieved. Other important complications include cobblestoning and a polka dot appearance.2. Suction blister epidermal grafting: This procedureconsists of obtaining very thin skin grafts consistingof only the epidermis. A physiological split is madeat the dermoepidermal junction by the applicationof prolonged suction at a negative pressure of -200to -500 mm of Hg to the donor site. The recipientsite is dermabraded by using either a manual or amotorized dermabrader, depending on the size and site of the lesion. Thin grafts are applied to the dermabraded recipient site. Alternatively, the recipient site may be denuded by an Erbium:YAGor carbon dioxide (CO2) Laser. Equipment neededincludes specially altered disposable syringes, suctioncups or glass funnels, suction apparatus and manual/motorized dermabraders. The graft may fall off in aperiod of a week to ten days. (LEVEL B)Advantages: It yields excellent cosmetic results as the graft is very thin. One of the major advantages of this procedure is that chances of scarring at the donor or recipient sites are minimal as the graft is purely epidermal.Disadvantages: The major disadvantage of this procedure is that it is time-consuming as donor site blistering requires a few hours. Large areas can not be treated by this method. EVIDENCE1. Falabella R. Surgical therapies for vitiligo and otherleukodermas, part 1: Minigrafting and suction epidermal grafting. Dermatol Ther 2001;14:7-14.2. Hasegawa T, Suga Y, Ikejima A, Muramatsu S, Mizuno Y,Tsuchihashi H, et al. Suction blister grafting with CO(2) Laserresurfacing of the graft recipient site for vitiligo. J Dermatol 2007;34:490-2.3. Pai GS, Vinod V, Joshi A. Efficacy of erbium: YAG Laser-assistedautologous epidermal grafting in vitiligo. J Eur Acad Dermatol Venereol 2002;16:604-6.3. Split-thickness grafting: Split-thickness skin graftinginvolves the free transfer of the epidermis along witha portion of the dermis from one site to another.The procedure is carried out under local anesthesia(for localized lesions) or general anesthesia (for extensive lesions). It consists of obtaining very thin, split thickness skin grafts, consisting of the epidermis and a part of the upper papillary dermis,and grafting them on the denuded (dermabraded or Laser-abraded) recipient site. The grafts are further secured with pressure and immobilization.Motorized dermatomes such as Padgett’s or Zimmer’sdermatomes, may be used to obtain ultra-thin, split-thickness grafts, which may give cosmetically superior results compared to those with manual dermatomes (Level B).Instruments include dermabraders, skin-grafting knives such as the Humby’s knife or any of its modifications, as well as other surgical instruments. Large areas can be grafted in a single sitting.Advantages: This method has the advantage of treating a relatively large area in a short period of time.Disadvantages: Taking split-thickness grafts of uniform thickness requires skill and experience. Other disadvantages include ‘stuck-on’ or ‘tire patch’ appearance, curling of the border with beaded appearance, color mismatch, milia, perigraft halo of depigmentation, and donor site scarring.EVIDENCE1. Achauer BM, Le Y, Vander Kam VM. Treatment of vitiligo withmelanocytic grafting.Ann Plast Surg 1994;33:644-6.2. Kahn AM, Cohen MJ. Repigmentation in vitiligo patients.Melanocyte transfer via ultra-thin grafts.Dermatol Surg 1998;24:365-7.3. Oz d emir M, Cetinkale O, Wolf R, Kotoğyan A, Mat C, Tüzün B,Tüzün Y. Comparison of two surgical approaches for treating vitiligo: a preliminary study. Int J Dermatol. 2002;41:135-8. 4. Agrawal K, Agrawal A. Vitiligo: repigmentation withdermabrasion and thin split-thickness skin graft. Dermatol Surg 1995;21:295-300.4. Other tissue grafting procedures: Several othermethods of tissue grafting have been performed Parsad and Gupta: Guidelines of care for vitiligo surgeryby different authors. These methods or their modifications may be used by the treating physiciandepending on individual expertise and experience.Hair follicle-grafting has been performed by a fewauthors for treating small patches in hair bearingareas and has been found useful in treating lesionswith leukotrichia. A small strip of hair-bearing scalpis taken from the occipital area; single hairs areseparated and transplanted into vitiligo patches 5-10mm apart. (LEVEL C)EVIDENCE1. Na GY, Seo SK, Choi SK. Single hair grafting for the treatmentof vitiligo. J Am Acad Dermatol 1998;38:580-4.2. Agrawal K, Agrawal A. Vitiligo: Surgical repigmentation ofleucotrichia. Dermatol Surg 1995;21:711-5.3. Laxmisha C, Kumari R, Thappa DM. Surgical repigmentationof leukotrichia in localized vitiligo. Dermatol Surg 2006;32:981-2.4. Malakar S, Dhar S. Repigmentation of vitiligo patchesby transplantation of hair follicles. Int J Dermatol 1999;38:237-8.In flip-top grafting, superficial, thinly shaved biopsies that are 2-4 mm in size, are taken using a razor blade, which are then sectioned into smaller 1-2 mm grafts. A 5-mm flap of epidermis with minimal dermis is raised with a razor blade at the recipient site, and the grafts are placed under this flap. The major advantage of this procedure is that there is rapid healing and no cobblestoning. (LEVEL C) EVIDENCE1. McGovern TW, Bolognia J, Leffell DJ. Flip-top pigmenttransplantation: A novel transplantation procedure for the treatment of depigmentation. Arch Dermatol 1999;135:1305-7.CELLULAR GRAFTSThese methods represent important recent advances and need specialized training and appropriate equipments. The following cellular grafting techniques have been advocated in the surgical management of vitiligo:1. Autologous, noncultured epidermal cell suspension2. Autologous, cultured melanocyte transplantation3. Autologous, cultured epithelial grafts1) Transplantation of autologous, epidermal cellsuspension (noncultured melanocyte grafting): Inthis procedure, a shave biopsy sample is taken witha dermatome. The skin sample is immersed in atrypsin solution, the epidermis separated from the dermis, and after some additional steps, a cellular suspension of keratinocytes and melanocytes is obtained, which is transplanted on the denuded recipient site. (LEVEL B)Advantages: In comparison with other surgical methods, the basal layer suspension method has the advantage that a fairly large area can be treated with the donor-to-recipient expansion ratio ranging from 5-10 fold. (LEVEL B)Disadvantages: Taking split-thickness grafts requires skill and experience. This technique requires a properly equipped laboratory and trained personnel.EVIDENCE1. Olsson MJ, Juhlin L. Long-term follow-up of leucodermapatients treated with transplants of autologous cultured melanocytes, ultrathin epidermal sheets and basal cell layer suspension.Br J Dermatol 2002;147:893-904.2. van Geel N, Ongenae K, De Mil M, Haeghen YV, Vervaet C,Naeyaert JM. Double-blind placebo-controlled study of autologous transplanted epidermal cell suspensions for repigmenting vitiligo.Arch Dermatol 2004;140:1203-8.3. Mulekar SV. Melanocyte-keratinocyte cell transplantation forstable vitiligo.Int J Dermatol 2003;42:132-6.4. Olsson MJ, Juhlin L. Leucoderma treated by transplantationof a basal cell layer enriched suspension.Br J Dermatol 1998;138:644-8.2) Transplantation of cultured autologous melanocytes:Melanocytes are cultured in vitro for 15-30 days bythe addition of media and growth factors. Once sufficient numbers are present, melanocytes are detached from the culture plates and suspension istransplanted onto the denuded recipient area in a density of 1000-2000 melanocytes/mm2. The recipientarea can be denuded by dermabrasion, CO2,or an Erbium:YAG Laser. (LEVEL B)Advantages:The major advantage is that the procedure can treat unlimited areas; however, it is recommended that vitiligo involving > 30% of the body surface area should not be treated surgically as chances of success are minimal in such cases. (LEVEL D)Disadvantages: There have been some safety concerns about the use of cultured autografts in vitiligo. 12-tetradecanoylphorbol 13-acetate (TPA) used in the culture medium is a tumor promoter, making its long-term safety aParsad and Gupta: Guidelines of care for vitiligo surgery。
白癜风诊疗指南
祥云集团《白癜风诊疗指南》白癜风(vitiligo)是一种常见多发色素性皮肤病，该病以局部或泛发性色素脱失，形成白斑为特征，周围皮肤的色素增多或正常，患处毛发可以变白。
世界各地均有发生，印度发病率最高，我国约有1200万人发病，本病可以累及所有种族，男女发病无显著差别。
近年白癜风发病率逐年上升，引起人们的普遍关注。
为规范白癜风的治疗，避免医源性伤害的发生，在循证医学原则的指导下，根据中国国情，借鉴国外白癜风治疗指南，祥云集团制定白癜风诊疗指南。
祥云集团专家组将不断地根据临床研究成果的依据，定期对《指南》加以修改完善，来适应临床的需要，为病人提供最佳的医疗服务，从而最大程度地提高白癜风患者的生活质量。
本《指南》只是帮助医生对白癜风诊疗和预防作出正确决策，不是强制性标准；也不可能包括或解决白癜风诊治中的所有问题。
因此，临床医生在针对某一具体患者时，应充分了解本病的最佳临床证据和现有医疗资源，并在全面考虑患者的具体病情及其意愿的基础上，根据自己的知识和经验，制定合理的诊疗方案。
一、概述白癜风(Vitiligo)是一种由于黑素细胞特发性损害而致色素脱失的获得性皮肤病。
我国古代医家隋•巢元方（公元610年）在其《诸病源候论》中记载：“面及颈身体皮肉色变白，与肉色不同，亦不痒痛，谓之白癜”。
vitiligo这个词来源于拉丁语，“viti”来源于拉丁语的“vitium”，意思是损伤，瑕疵。
“ligo”是拉丁语里表示原因的常用结尾。
Vitiligo 就是“产生瑕疵或者损伤”病程慢性进行，病因不明。
局部色素脱失，影响美容，易诊难治。
白癜风是一种相对普遍的皮肤病。
患病率：在美国居民中估计患病不少于1％，丹麦一岛中调查，白癜风的患病率为0.38％，其中男性为0.36％，女性为0.40％。
我国居民中较欧美为低。
根据苏北地区一些农村调查，患病率为0.09％～0.15％，而城市中患病率较高，约为0.29％。
二、症状皮损是边界清楚的色素脱失斑，边界附近的皮肤正常，或是色素增多。
白癜风被治愈的例子
白癜风被治愈的例子
案例一：2013年面部发现片状白斑(原因不明)
类型：节段型、稳定期。
治疗方法：采用白癜风表皮移植手术治疗，1个月后病情慢慢稳定，后采用美国新一代308准分子激光、渗透疗法，半年后来复诊，白斑范围已缩小，特别是比较明显的部位白斑已经消失，肤色转红，恢复效果比较好。
案例二：2年前胸部出现大小不等的白斑
类型：局限型，发展期。
治疗方法：先用308激光稳定病情并配合渗透疗法、中医药浴疗法，增强免疫力，治疗3周后，病情基本稳定，白斑已经有了很明显的改善，后期经过14周的治疗后基本完全康复。
案例三：2013年因为外伤感染额头出现白斑
类型：局限型，进展期。
治疗方法：用308激光和渗透疗法一起配合对症治疗，治疗3周后，病情慢慢的好转，治疗一年后额头白斑完全消失。
案例四：10年前面部出现白斑
类型：局限型、稳定期。
治疗方法：首先采用渗透疗法，系统调节患者体内的微循环，综合提高患者的机体免疫力，并用了308激光，经过半年的治疗，恢复效果比较明显。
案例五：1年前手部出现白斑
类型：肢端型、稳定期。
治疗方法：采用了表皮移植手术，术后一个疗程再配合中药加以巩固，目前白斑患处已经开始发红，康复效果比较好。
案例六：5年前头皮出现片状白斑
类型：毛囊型、进展期。
治疗方法：用308激光诱导T细胞死亡，治疗了四个月后白斑开始逐渐变小。
新版白癜风诊疗指南解读及应用_概述及解释说明
新版白癜风诊疗指南解读及应用概述及解释说明1. 引言1.1 概述白癜风是一种常见的皮肤色素脱失疾病，严重影响患者的外貌和心理健康。
随着医学科技的进步和研究的深入，关于白癜风的诊断和治疗也在不断更新。
本文旨在解读和应用最新版本的白癜风诊疗指南，对指南内容进行概述和解释说明。
通过了解新版指南以及其中提到的治疗方法、检查手段等，我们能更全面地认识白癜风，并落实到临床实践中。
1.2 文章结构本文将按以下结构展开讨论：第2部分：新版白癜风诊疗指南解读及应用- 解读新版指南：介绍如何理解和阅读最新版本的白癜风诊疗指南。
- 指南内容概述：总结新版指南中所包含的主要内容，包括叙述病因、分类特征等方面。
- 指南的重要意义：探讨新版指南对临床实践以及对患者健康管理带来的意义。
第3部分：白癜风的诊断与鉴别诊断- 白癜风的病因与发病机制简介：介绍引起白癜风的可能原因和发病机制，为后续治疗提供理论基础。
- 白癜风的临床表现与分类特征：详细描述患者在皮肤、毛发等方面出现的临床特征，并对其进行分类与鉴别。
- 白癜风的辅助检查与鉴别诊断方法：列举常用于辅助判断和明确诊断的检查手段以及其他可能存在的类似皮肤疾病，以避免误诊。
第4部分：新版指南对白癜风治疗方案的更新和解析- 医学治疗方法的综述及更新点简介：总结医学领域目前可用于治疗白癜风的主要方法，并强调新版指南在这方面有哪些更新内容。
- 外用治疗药物推荐与使用技巧分析展望：评估和建议外用药物在治疗过程中的应用方式、适应人群等方面。
也对未来外用药物发展趋势进行展望。
- 内服治疗药物推荐与使用技巧分析展望：分析内服药物在白癜风治疗中的应用情况，并对其优势、不良反应等进行评估。
同时，对未来该领域的发展提出展望。
第5部分：结论- 对新版指南进行总结归纳：概括新版指南所阐述的重点内容和观点。
- 对于新版指南在临床实践中的应用和展望：探讨如何将新版指南运用到实际临床工作中，为患者提供更准确、有效的诊断和治疗方案。
丹归活血合剂治疗白癜风——单中心随机双盲对照临床试验
丹归活血合剂治疗白癜风——单中心随机双盲对照临床试验胡飞飞;张建中;金雪娟;高地;杨荞榕;隗祎【摘要】目的观察中药复方丹归活血合剂治疗白癜风的有效性与安全性,开展院内制剂规范化临床研究.方法采用前瞻性随机双盲对照方法,将171例白癜风患者分为中药组(丹归活血合剂口服加0.05％卤米松乳膏外用,89例)和对照组(安慰剂口服加卤米松乳膏外用,82例),3个月后评价色素情况.结果中药组总有效率57.30％,对照组总有效率40.24％,两组差异有显著统计学意义(P＜0.05);中药组白斑消退率为35.09％,而对照组为18.48％,两组差异有显著统计学意义(P＜0.001).不良反应发生率中药组为6.74％,对照组为6.10％,主要是胃肠道反应,能耐受,两组差异无统计学意义(P＞0.05).结论丹归活血合剂治疗白癜风疗效肯定,安全性良好.【期刊名称】《复旦学报（医学版）》【年(卷),期】2019(046)002【总页数】5页(P212-216)【关键词】白癜风;丹归活血合剂;随机双盲对照试验【作者】胡飞飞;张建中;金雪娟;高地;杨荞榕;隗祎【作者单位】复旦大学附属中山医院皮肤科上海200032;复旦大学附属中山医院药剂科上海200032;上海市心血管病研究所上海200032;复旦大学附属中山医院皮肤科上海200032;复旦大学附属中山医院皮肤科上海200032;复旦大学附属中山医院皮肤科上海200032【正文语种】中文【中图分类】R758.4白癜风作为一种毁容性自身免疫性皮肤病,表现为泛发性或局限性皮肤黏膜白斑,好发于面部、手足肢端等皮肤暴露部位。
白癜风易诊难治,中药尤其是复方制剂口服是国内白癜风药物治疗的主流手段[1],但仍存在许多不足之处。
一方面目前治疗白癜风的中药方剂多为大复方,常常含有10种以上药物,且多含有光敏剂,导致药物相互作用较多并易产生光敏性损伤,给患者日常生活带来不便;另一方面从循证医学角度来看,中药制剂尤其是复方制剂缺乏符合“随机双盲对照试验”(randomized double blind controlled trial,RCT)标准的规范化的临床研究,国际认同度低[2]。
白癜风诊疗指南
祥云集团《白癜风诊疗指南》白癜风(vitiligo)是一种常见多发色素性皮肤病，该病以局部或泛发性色素脱失，形成白斑为特征，周围皮肤的色素增多或正常，患处毛发可以变白。
世界各地均有发生，印度发病率最高，我国约有1200万人发病，本病可以累及所有种族，男女发病无显著差别。
近年白癜风发病率逐年上升，引起人们的普遍关注。
为规范白癜风的治疗，避免医源性伤害的发生，在循证医学原则的指导下，根据中国国情，借鉴国外白癜风治疗指南，祥云集团制定白癜风诊疗指南。
祥云集团专家组将不断地根据临床研究成果的依据，定期对《指南》加以修改完善，来适应临床的需要，为病人提供最佳的医疗服务，从而最大程度地提高白癜风患者的生活质量。
本《指南》只是帮助医生对白癜风诊疗和预防作出正确决策，不是强制性标准；也不可能包括或解决白癜风诊治中的所有问题。
因此，临床医生在针对某一具体患者时，应充分了解本病的最佳临床证据和现有医疗资源，并在全面考虑患者的具体病情及其意愿的基础上，根据自己的知识和经验，制定合理的诊疗方案。
一、概述白癜风(Vitiligo)是一种由于黑素细胞特发性损害而致色素脱失的获得性皮肤病。
我国古代医家隋•巢元方（公元610年）在其《诸病源候论》中记载：“面及颈身体皮肉色变白，与肉色不同，亦不痒痛，谓之白癜”。
vitiligo这个词来源于拉丁语，“viti”来源于拉丁语的“vitium”，意思是损伤，瑕疵。
“ligo”是拉丁语里表示原因的常用结尾。
Vitiligo 就是“产生瑕疵或者损伤”病程慢性进行，病因不明。
局部色素脱失，影响美容，易诊难治。
白癜风是一种相对普遍的皮肤病。
患病率：在美国居民中估计患病不少于1％，丹麦一岛中调查，白癜风的患病率为0.38％，其中男性为0.36％，女性为0.40％。
我国居民中较欧美为低。
根据苏北地区一些农村调查，患病率为0.09％～0.15％，而城市中患病率较高，约为0.29％。
二、症状皮损是边界清楚的色素脱失斑，边界附近的皮肤正常，或是色素增多。
白癜风治疗共识的解析
２、儿童白癜风使用激素、光疗及光化学疗法应慎重。 ３、对多种治疗无效，白斑面积＞８０％的患者，可推荐脱色治疗。
五、中医中药治则：补益肝肾、活血祛风、疏肝解郁
进展期病程短的，以调和气血、疏风散湿为主；病程长而发病年龄较轻的以疏肝解郁、活血祛 风为主；病程长而发病年龄较晚者以滋补肝肾，疏肝活血为主。
４、治疗敏感患者可以接受最长疗程为２４个月的窄波ＵⅦ治疗。经过第一阶段的１年治疗
・１３‘
专题讲座 以后，建议休息３个月再继续治疗。
５、节段型、稳定期和口唇部白癜风患者的首选治疗方法为自体表皮移植。
６、皮损面积较大的患者（＞８０％）和／或毁容性的面部皮损患者，并且对治疗药物治疗无反应 者，可以考虑脱色疗法，脱去残留的色素。对这些患者应当建议尽量避免阳光照射并且使用宽谱
・
１ ２，
专题讲座
治疗疗效显著。ＮＢ—Ｕ娜合并叶酸，ｖｉｔＢｌ２治疗，与单独用窄谱ＵＶＢ治疗相比，疗效没有显著
增加。 ７、维生素Ｄ衍生物（钙泊三醇等）
钙泊三醇与紫外线联合治疗，对儿童和成人白癜风都有较好疗效。但也有报道钙泊三醇对白
癜风疗效甚微。 ８、免疫调节剂
他克莫司软膏，治疗白癜风同样是安全有效的，复色效果最好的部位是面部和颈部。优点是 可以长期应用而没有皮肤萎缩等激素样副作用。但他克莫司治疗白癜风的远期效果尚未得到证
二、治疗措施选择应考虑的主要因素：
１．白斑累及的面积 ２．病期：疾病的活动进展部位 ３．患者的年龄 三、白癜风的分） ２期：中度（１０％－－２５％） ３期：中重度（２５％－－５０％） ４期：重度（＞５０％） ２．按疾病活动进展分为４期 静止期、缓慢进展期、中度进展期、快速进展期 ３．按患者年龄分为成人和儿童白癜风 四、治疗原则 １期：轻度局限静止 局部用皮质激素、局部光化学疗法（拟过氧化氢酶／ＵＶＢ，ＰＵＶＡ，钙泊三醇／ＰＵＶＡ）、局部 ３０８ｎｍ光疗、维生素Ｄ衍生物、局部用免疫调节剂、局部用黑素生成素，前列腺素Ｅ２，煤焦油制剂。 ２期：中度
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DOI ：10.11786/sypfbxzz.1674-1293.20140413作者单位：100089 北京，解放军总医院第一附属医院皮肤科（宋月星，邹先彪）作者简介：宋月星，硕士研究生，住院医师，研究方向：皮肤镜、医学美容，E-mail: m84417@通讯作者：邹先彪，E-mail: xbzou@• 继续医学教育 •2013欧洲白癜风指南宋月星，邹先彪[摘要] 欧洲不少国家都有自己的白癜风治疗指南，但尚无统一的欧洲指南版。
该指南是欧洲白癜风学组在循证医学和专家共识的基础上，第一次制定的针对节段型和非节段型白癜风的欧洲指南。
该文解读此指南以供参考。
[关键词] 白癜风；指南；专家共识[中图分类号] R758.41 [文献标识码] A [文章编号] 1674-1293(2014)04-0276-032013 European guidelines for the management of vitiligoSONG Yue-xing ，ZOU Xian-biaoDepartment of Dermatology, the First Affiliated Hospital of PLA General Hospital, Beijing 10089, China[Abstract ] The aetio-pathogenic mechanisms of vitiligo are still poorly understood, which holds back the progress in the diagnosis and treatment of the disease. Up until now, treatment guidelines have been developed at national levels, but no common European viewpoint has emerged. This guideline for the treatment of segmental and nonsegmental vitiligo has been developed by the members of the Vitiligo European Task Force and other colleagues. It summarizes evidence-based and expert-based recommendations.[Key words ] Vitiligo ；Guidelines ；Expert recommendations[J Pract Dermatol, 2014, 7(4):276-278]白癜风（vitiligo ）是一种获得性色素异常性疾病，患者占世界人口的0.5%，无性别或种族差异，包括各年龄段人群。
欧洲指南按照临床特征将白癜风分类并拟出了相应的临床特征（表1）。
节段型白癜风（segmental vitiligo ，SV ）是指除非节段型白癜风（nonsegmental vitiligo ，NSV ）以外，单侧分布（非对称性白癜风）、有可能完全或部分与皮肤节段吻合的白癜风。
迅速发生并累及毛囊色素系统是SV 的特征性表现。
在大多数患者中至少累及一个皮肤节段。
在NSV 各亚型中，肢端型疗效最差。
SV 和NSV 的持续性复色过程各有不同。
在白癜风的评估步骤中需要考虑年龄、基础疾病（特别是自身免疫性疾病）、已使用的药物，以及主观和客观的因素。
如果患者的病史或常规实验室检查提示有自身免疫性疾病，则强烈建议完善进一步检查并参考专科意见。
同时，指南也拟出了白癜风诊断的临床路径（表2）。
表1 白癜风分类和各亚型的临床特征白癜风分类亚型备注NSV面部型*、黏膜型、面部肢端型、散发型、泛发型亚型可能不能反映明显的本质，但对流行病学研究有意义 SV面部型、黏膜型、单侧、双侧或多发型进一步的分类可能根据累及的肢体，但至今尚未建立标准 混合型（NSV + SV ）与SV 严重程度相关混合型白癜风的SV 更加严重未分类（unclassified ）发生于颜面， 多中心非对称性非节段型、黏膜型（单一部位）这一类型意味着在一定时间内或在进一步检查后再进一步准确分类 注：NSV ：非节段型白癜风；SV ：节段型白癜风；*可能为NSV 起病早期表2 白癜风诊断路径如果诊断明确如果诊断不明确抗TPO ，抗甲状腺球蛋白抗体皮肤和非皮损处环钻活检TSH 和其他用以诊断甲状腺疾病的检测（如与Graves 病相关的抗TSHR 抗体）必要时检查真菌、淋巴细胞亚群等必要的自身抗体检测（患者既往史、家族史和（或）实验室检查强烈怀疑自身免疫性疾病），怀疑自身免疫性综合征需要征求内分泌或免疫学专家的意见 注：TPO ：甲状腺过氧化物酶； TSH ：促甲状腺激素； TSHR ：TSH 受体宋月星1 外用药物治疗1.1 外用糖皮质激素治疗（topical corticosteroids，TCS）TCS因其抗炎和免疫调节作用而被作为局限型白癜风的一线疗法。
TCS疗效最好（75%复色）的部位是在光暴露部位（面部和颈部）、深肤色和新近出现的皮损，而肢端皮损的反应最差。
在采用非外科方法治疗白癜风疗效的Meta分析中，氯倍他索和他克莫司，氯倍他索或糠酸莫米松和吡美莫司的疗效对比中差异无统计学意义，无论是儿童还是成人短期使用TCS均具有很好的有效性和安全性。
皮肤萎缩、毛细血管扩张症、多毛症、暴发性痤疮等不良反应主要发生于强效或超强效激素的治疗中，弱效激素和新型第3代TCS 如糠酸莫米松和甲泼尼龙基本上未出现这些不良反应。
1.2 外用钙调神经磷酸酶抑制剂（topical calcineurin inhibitors，TCI）他克莫司和吡美莫司是外用大环内酯类衍生物免疫调节剂，可以影响T细胞的活化和分化、抑制细胞因子如TNF-α的合成，亦可促进黑素细胞的迁移和分化。
TCI对成人和儿童患者的头颈部皮损治疗有较好疗效，与紫外线疗法可能有协同作用。
多个研究显示，他克莫司、吡美莫司治疗白癜风的疗效与0.05%丙酸氯倍他索相当。
多数研究显示吡美莫司和他克莫司的疗效相当或类似，但也有一项研究显示他克莫司的疗效（61%）高于吡美莫司（54.6%）。
每日2次外用他克莫司软膏的疗效优于每日1次，疗程10周～18个月不等。
最常见的不良反应为局部烧灼感、瘙痒和红斑。
2 光疗2.1 光化学疗法常用的光化学疗法包括补骨脂素（psoralens）+长波紫外线（UV A）的补骨脂素长波紫外线（PUV A）疗法和凯林（Khellin）+ UV A的KUV A疗法。
PUV A 对黑素的影响包括促进酪氨酸酶的合成、黑素小体的形成和黑化以及黑素小体在角质细胞中的转移。
接受PUVA疗法的患者的复色率为70%～80%，但完全复色的患者只占20%。
75%的患者在1～2年内复发。
因其视网膜毒性，不建议用于10～12岁以下的儿童。
在口服PUVA治疗中，服用光敏剂8-MOP（0.6～0.8 mg/kg）、5-MOP（1.2～1.8 mg/kg）或 TMP（0.68 mg/kg）1～3 h后照射UV A。
患者需要连续治疗6个月才能判断疗效，连续治疗12～24个月会获得最大程度的复色。
深肤色患者对于PUV A疗效最好。
局部 PUV A治疗需要在照射UV A前30 min外涂一层低浓度（0.001%）8-MOP 霜或油，其优点是需要更少的治疗次数和相对较小的UV A累积剂量，其主要缺点是会出现严重的大疱和皮损周围有色素沉着。
而KUV A以凯林为光敏剂，系统性KUV A因有30%的患者会出现肝毒性而已经被完全淘汰。
局部KUV A则可安全地用于家庭治疗。
2.2 窄波中波紫外线窄波中波紫外线（narrow band UVB，NB-UVB，311 nm）照射目前是活动性和（或）泛发型白癜风的首选光疗方法。
其不良反应比PUV A治疗少，但疗效相当或更佳。
起病时疾病的严重程度和活动性不影响早期光疗复色。
需注意白癜风患者白斑处皮肤的最小红斑量低于同一个体的正常皮肤。
NB-UVB治疗需每周2～3次，并持续治疗才有明显效果。
对50例NSV患者进行NB-UVB和口服 PUV A治疗的一项随机、双盲对照试验研究显示，NB-UVB组64%的患者＞50%的病情改善，而PUV A组仅为36%，且NB-UVB组患者复色面积明显大于PUV A组患者，故认为NB-UVB疗法优于口服PUV A。
在欧洲，更多的白癜风治疗中心将NV-UVB作为NSV的首选。
长期随访研究显示停止NB-UVB治疗后的复发率为21%，其中第1年为44%，第2年为55%。
308 nm准分子激光治疗作为在NB-UVB 基础上发展起来的高能单光源靶向治疗方法可以获得更快速有效地复色。
光疗最常见的急性不良反应是皮肤类型和剂量依赖性的红斑，通常在照射12～24 h后发生，并持续24 h。
皮损部位轻微的红斑反应通常被认为是剂量充分的表现。
联合疗法可以提高总体有效率，缩短显效时间，降低不良反应的发生。
3 联合治疗联合疗法可以提高疗效，缩短显效时间，降低不良反应的发生。
此外，联合疗法也可减少对单一疗法治疗抵抗的发生。
一项随机、前瞻性的对照研究表明，UV A和外用丙酸氟替卡松联合应用比单用UV A或外用糖皮质激素更有效。
一项前瞻性临床试验中，针对头部和颈部的皮损，308 nm准分子激光联合丁酸氢化可的松外用治疗的有效性明显高于单用308 nm准分子激光。
308 nm准分子激光联合他克莫司的疗效优于单用激光，其不良反应为轻微的红斑和偶发的水疱。
这一结果也与其他UVB联合外用他克莫司的研究结果一致。
吡美莫司联合NB-UVB也有类似的疗效。
但是，2种免疫抑制剂联用可能会增加皮肤肿瘤发生的风险。
卡泊三醇与自然光或PUV A也有可能有效，因为对此疗法相关试验数据的争议，其有效性还没有明确。
另一项前瞻性研究中，卡泊三醇与308 nm准分子激光联合并没有提高后者的疗效。
在一项前瞻性、单盲试验中，使用高浓度他卡西醇制剂（20 µg /L）与准分子激光联用的疗效不显著。
卡泊三醇联合糖皮质激素治疗可以降低儿童白癜风患者的皮损严重程度，并可增加已复色皮损的稳定性。
在一项前瞻性双盲安慰剂对照试验中，口服补充抗氧化剂有效，但疗效需要更大规模的研究来证实。
NB-UVB与激光皮肤磨削术可用于治疗抵抗的皮损。
尽管研究结果提示此方法可提高NB-UVB的有效率，但其不良反应影响了临床应用。
在一项小规模的随机对照试验中，NB-UVB与剥脱性CO2激光联合在顽固性皮损治疗中有效。
在一前瞻性研究中，先使用铒-YAG激光磨削皮肤，再外用5-氟尿嘧啶（5-fluorouracil，5-FU）可以缩短NB-UVB的治疗疗程，提高有效率。