Vitiligo Treatment: How Phototherapy Works and Why It’s Combined with Topical Therapy, Not Depigmentation

When people hear "vitiligo treatment," they often assume depigmentation and phototherapy go together. That’s a common misunderstanding. In reality, these are two completely different strategies - and they’re never used at the same time. Phototherapy is about bringing color back. Depigmentation is about removing what’s left. You don’t mix them. You choose one based on how much of your skin is affected.

What Phototherapy Actually Does for Vitiligo

Phototherapy doesn’t cure vitiligo. But it does something powerful: it helps your skin make pigment again. Vitiligo happens when your immune system attacks melanocytes - the cells that give your skin color. Phototherapy uses controlled doses of ultraviolet light to calm that attack and wake up the leftover melanocytes hiding in your hair follicles.

The most common type is narrowband ultraviolet B (NB-UVB). It uses a specific wavelength - 311 to 313 nanometers - that’s safe and effective. Unlike older methods, it doesn’t require taking pills or applying chemicals. You just stand in a light box for a few minutes, two to three times a week. Sessions start short - sometimes just 30 seconds - and slowly get longer as your skin gets used to it.

Studies show this works. In a major 2017 analysis of over 1,200 patients, 37% saw at least half their white patches turn color after six months. By the end of a year, that number jumped to over 56%. And 36% got 75% or more repigmentation. That’s not a cure, but for many, it’s life-changing.

Why Face and Neck Respond Best - and Hands and Feet Don’t

Not all areas of the body respond the same. Your face and neck? They’re the easiest to treat. Up to 80% of patients see strong repigmentation there within six months. That’s because the skin there has more hair follicles - and more melanocytes hiding inside them.

Hands, feet, lips, and fingers? Those are the toughest. Even after a full year of treatment, only 15% to 20% see noticeable color return. Why? Fewer follicles. Less blood flow. And the skin there is thicker. Many people get discouraged and quit when they don’t see results on their fingers. But if your face is improving, that’s still a win.

Phototherapy vs. Depigmentation: Two Opposite Paths

Depigmentation is not a treatment for early vitiligo. It’s a last-resort option - only for people who have lost pigment over 80% of their body. The goal isn’t to restore color. It’s to remove the remaining patches of normal skin so everything matches.

This is done with a topical cream called monobenzone. It permanently destroys melanocytes. It’s harsh. It causes redness, itching, and sometimes severe sun sensitivity. And once you start, you can’t go back. Your skin will stay pale forever.

No dermatologist combines this with phototherapy. That would be like trying to paint a wall while sanding it down at the same time. You pick one path: repigmentation for limited vitiligo, depigmentation only when most of your skin is already white.

How NB-UVB Beats PUVA and Excimer Lasers

There are other light therapies, but NB-UVB is the gold standard. PUVA uses UVA light plus a plant-based drug called psoralen. It works, but it comes with side effects: nausea in up to 30% of users, and a 13-times higher risk of skin cancer after 200 treatments. It’s rarely used anymore.

Excimer lasers deliver focused UVB to small spots. Great if you have a few patches on your arm or face. But if you have vitiligo on your back, legs, and arms? You’d need hours of laser sessions. It’s not practical. NB-UVB covers your whole body in one go.

And then there’s home phototherapy. More people are using it now. A 2020 study found home units worked just as well as clinic visits - 78% vs. 82% repigmentation at six months. The big plus? You don’t have to take time off work or drive across town three times a week. The downside? 22% more burns from wrong dosing. That’s why using a device with built-in timers and automatic shut-offs matters.

Combining Phototherapy With Creams - That’s the Real Trick

The most effective approach isn’t just light. It’s light plus cream. Dermatologists now routinely pair NB-UVB with topical calcineurin inhibitors like tacrolimus or pimecrolimus. These are the same creams used for eczema. They don’t bleach skin. They calm the immune system right where it’s attacking.

Studies show this combo boosts repigmentation by 25% to 30%. One 2023 trial even added ruxolitinib cream - a JAK inhibitor - to NB-UVB. Result? 54% of patients got over 50% repigmentation in just six months. That’s faster than light alone.

It’s not magic. But it’s smart. You’re not just stimulating pigment. You’re protecting it.

How Long Does It Really Take? And Why Most People Quit Too Soon

You need patience. Six months is the minimum. Many doctors used to say three months was enough. That was wrong. The 2017 JAMA study proved you need at least six to see real results. Twelve months? Even better.

But here’s the problem: most people give up. A Reddit survey of 142 people found 68% missed at least a quarter of their sessions. Why? Time. Travel. Fatigue. It’s hard to show up twice a week for a year. That’s 100+ visits.

Home units help. So do apps that remind you and log your progress. UC Davis Health found 92% of patients who used tracking apps stuck with treatment. Those who didn’t? Half dropped out by month four.

Cost, Insurance, and What’s New in 2025

Phototherapy is one of the most affordable options. A full year of NB-UVB at a clinic costs $1,200 to $2,500. Topical ruxolitinib? Over $5,000 a year. And it’s not even covered by all insurance.

Home units cost $2,500 to $5,000 upfront. But Medicare covers 80% if you qualify. Private insurers are catching up.

New tech is coming. In October 2023, the FDA cleared the first AI-powered phototherapy device - Vitilux AI. It takes a photo of your patch with your phone and calculates the exact dose you need. No guesswork. No burns. Clinical trials showed it cut dosing errors by 37%.

And trials are starting in 2024 for afamelanotide implants - tiny rods placed under the skin that boost pigment production. Early results suggest they could cut phototherapy time in half.

What to Do If You’re Starting Phototherapy

If you’re considering this, here’s what actually works:

• Start with NB-UVB - not PUVA or laser - unless your patches are tiny.
• Ask your dermatologist about adding tacrolimus cream to your routine.
• Use a home device if clinic visits are too hard - but only one with safety features.
• Track every session with an app. Don’t rely on memory.
• Expect no change for the first 8 to 12 weeks. That’s normal.
• Don’t quit if your hands aren’t improving. Focus on your face, chest, or arms.
• Wear UV-blocking sunglasses during every session. Protect your eyes.

What to Expect After 6 Months

If you’ve stuck with it for half a year, here’s what you might see:

• Small dots of color returning around hair follicles - that’s the first sign it’s working.
• Patches getting less sharp-edged, blending into surrounding skin.
• Your face, neck, or chest looking noticeably darker.
• Less contrast between white and normal skin.

If you see none of this? Talk to your dermatologist. Maybe your dose needs adjusting. Or maybe you need to add a cream. Or maybe you need more time. But don’t assume it’s failed. Vitiligo doesn’t move fast. But it moves.

Phototherapy isn’t perfect. But for most people with vitiligo covering more than 5% of their body, it’s the best tool we have. It’s safe. It’s affordable. And when paired with the right cream, it gives back more than just color - it gives back confidence.