Vitiligo is a common depigmenting disorder affecting about 1-2% of the world population. Approximately half of the affected individuals develop the disease before adulthood. Etiologic hypotheses for vitiligo include biochemical, neural and autoimmune mechanisms. The most compelling of these suggests a combination of genetic and immunologic factors that result in an autoimmune melanocyte destruction. We reviewed studies carried out on various treatment modalities used in childhood vitiligo. Topical corticosteroids were found to have excellent repigmentation rates, whereas calcineurin inhibitors have comparable efficacy and a better safety profile compared with topical corticosteroids. These two groups of topical medications are good first-line treatment modalities for localized vitiligo. For the treatment of generalized vitiligo, phototherapy has excellent efficacy. Narrow-band ultraviolet B (UVB) has better overall repigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA). Other treatment modalities may be considered depending on a patient's specific condition, such as surgical options and depigmentation. With adequate sun protection, the option of no treatment with or without corrective camouflage, is an innocuous alternative to any of these treatment modalities.

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We certainly agree that the best and, we might add, easiest type of medicine to practice is when there are multiple randomized controlled trials (RCTs) that clearly demonstrate that one treatment modality is far superior to and safer than others. Then any new treatments should be tested in a RCT not only to vehicle, but to the accepted standard of care. Unfortunately, for many conditions seen in pediatric dermatology, this is rarely the case.Therefore, we set out to thoroughly review the entire literature on childhood vitiligo, knowing full well that rigorous study was limited. What you have read was not our initial submission. Our initial submission included all of the articles on the treatment of vitiligo in childhood that we could find. The editors asked us to decrease the size of our initial submission by more than 50% and to spend more time discussing what we felt was a rational approach to the treatment of vitiligo in childhood. That is why you see the article in its final form. We read with interest Tamesis and Morelli's 'State of the Art Review' of treatment for childhood vitiligo (1), an area that has been neglected for many years in terms of basic and clinical research. Given that most people with generalized vitiligo develop the disease before the age of 20, there is a pressing need for research into treatment for this group of patients.The title of the review led us to believe that it would be conducted using robust, systematic methodology, but unfortunately this did not appear to be the case. Randomized controlled trials (RCTs) are the criterion standard for providing high-quality evidence for decision-making. Although some RCTs were discussed in this review, there were some notable omissions (e.g., Ruiz-Maldonado et al (2) and Farajzadeh et al (3)). We were also puzzled that the RCT by Hui-Lan et al was discussed in the review but that the RCT by Farajzadeh et al (3), published in the same issue of Pediatric Dermatology, was omitted with no reason given. Moreover, the review included quite a number of studies with no control groups. These are liable to be biased and thus unhelpful for making clinical decisions. The review did not state its objectives and was not conducted according to explicit and reproducible methodology, as described by Greenhalgh (4). Which databases were searched? Was there an attempt to find and assess studies published in languages other than English?The article mentioned that many studies assessed adults and children and that there were few, poorly powered studies of vitiligo in children, but the lack of a systematic approach means that selection of the studies could have been subjective. Therefore, any conclusions and recommendations will not necessarily be based on the best available evidence (in the form of high-quality RCTs) and will be at a high risk of bias.Our recent Cochrane Systematic Review of Interventions for Vitiligo (5) reported on interventions for all age groups, discovering only three RCTs in children in the literature up until January 2009. This was an updat...