Depigmentation therapy in vitiligo universalis with topical 4-methoxyphenol and the Q-switched ruby laser

Background: Monobenzylether of hydroquinone is used worldwide to remove res idual pigment in patients with vitiligo universalis. Because of the side ef fects reported with this drug, the use of monobenzylether of hydroquinone h as been restricted in The Netherlands. Objective: Our purpose was to evaluate the long-term effectiveness and safe ty of a combination therapy consisting of topical 4-methoxyphenol (4-MP) cr eam and Q-switched ruby (QSR) laser in 16 patients with vitiligo universali s. Methods: In a retrospective study patient record forms were evaluated. Data were collected regarding history as well as physical and histologic examin ation. The patients came to the institute for a follow-up visit after a tre atment-free period of 2 to 36 months. Results: Thirteen patients received both therapies. Three patients only use d the cream. None of the areas was treated by the cream and QSR laser at th e same time. In 11 of the 16 patients (69%; 95% confidence interval [CI], 4 1%-89%) total depigmentation was achieved using the 4-MP cream. Onset of de pigmentation was between 4 and 12 months. Four of the 5 patients who did no t respond to the 4-MP cream had successful depigmentation with the QSR lase r. Mild burning or itching was reported with the cream in 4 cases (25%). Of the 11 patients who responded to the 4-MP cream, 4 had recurrence of pigme ntation (relapse rate of 36%; 95% CI 11%-69%) after a treatment-free period of 2 to 36 months. In 9 of the 13 patients (69%; 95% CI, 39%-91%) total de pigmentation was achieved after QSR laser therapy. Onset of depigmentation was between 7 and 14 days after the treatment. Three of the 4 unresponsive patients showed total depigmentation after application of the 4-MP cream. N o side effects were observed. Of the 9 patients who responded to QSR laser therapy, 4 had recurrence of pigmentation (relapse rate of 44%; 95% CI, 14% -79%) after a treatment-free period of 2 to 18 months. These patients had a negative Koebner phenomenon. Conclusion: Depigmentation therapy using a 4-MP cream and/or QSR laser ther apy is an effective and safe method to remove disfiguring residual pigment in patients with vitiligo universalis. Patients should be warned that repig mentation may occur, even after total depigmentation has been achieved.