Topical tacrolimus for repigmentation of vitiligo

Vitiligo e emoções

FUNDAMENTOS: O vitiligo acomete, em média, 1% da população mundial. Mais de 75% dos pacientes têm autoimagem depreciativa em relação à doença. Seu impacto emocional é muitas vezes negligenciado pelo cuidador, influenciando negativamente o prognóstico. OBJETIVO: Verificar o efeito do vitiligo sobre as emoções e discutir as últimas descobertas sobre a interação mente? corpo e seu desdobramento sobre a doença. MÉTODOS: Cem pacientes com diversas formas de vitiligo responderam, na primeira consulta, a uma pergunta sobre as emoções que a presença das manchas lhes provocava. RESULTADOS: Entre os que apresentavam manchas em áreas expostas, 80% queixaram-se de emoções desagradáveis, em contraposição a 37% dos que tinham manchas em áreas não expostas. As emoções mais referidas foram medo (71%), vergonha (57%), insegurança (55%), tristeza (55%) e inibição (53%). CONCLUSÃO: Qualquer doença crônica produz nos seres humanos uma vivência negativa propiciada pela expectativa de sofrimento. O vitiligo é um desafio à autoestima. Além de uma orientação científica adequada, o paciente de vitiligo carece de conforto emocional. A resposta e a adesão ao tratamento e até mesmo a resiliência diante de eventuais falhas terapêuticas dependem da boa relação médico-paciente. Numa época em que dispomos de respeitável terapêutica, torna-se indispensável que o dermatologista se mostre apto a avaliar seu paciente holisticamente.

Vitiligo: new and emerging treatments

Vitiligo is a cosmetically disfiguring condition, and, although there is no therapeutic full solution yet, some treatment may induce good results in most patients. The disease can be successfully treated with various medical options. Both nonfocused or focused narrowband ultraviolet B phototherapy represents the current treatment of choice, to minimize side effects and reach optimal clinical results. Topical novel approaches are also considered. Surgical methods, consisting of autologous transplantation methods, is generally recommended for focal/stable vitiligo, after medical therapy has failed. Finally, for patients with extensive vitiligo, depigmentation of the residual melanin should be taken into account.

Tacrolimus: approved and unapproved dermatologic indications/uses-physician's sequential literature survey: part II

Tacrolimus has been a useful therapeutic tool in dermatology practice ever since its inception. Accordingly, many "off-label" applications have been reported. Thus, its local immunosuppressive and steroid-sparing action stands recognized. Hence, its indications/uses were extended beyond atopic dermatitis to cover several dermatoses including other types of eczema, papulosquamous disorder of cornification, rosacea, other inflammatory skin conditions, vesicobullous disease, connective tissue disease, graft versus host disease, and follicular disorders. Many such diseases found to respond to tacrolimus therapy have been briefly recounted. It is worthwhile to conceive, however, that this topical immunomodulator should be reserved for use only as an alternative, should the conventional treatment be unresponsive. Hence, guarded use is warranted.

Narrow-band UVB phototherapy combined with tacrolimus ointment in vitiligo: a review of 110 patients

BACKGROUND

Narrow-band ultraviolet B (NB-UVB) phototherapy and topical tacrolimus are included among the most innovative approaches to vitiligo.

OBJECTIVE

To evaluate the efficacy and tolerability of combined treatment with NB-UVB and topical tacrolimus in vitiligo.

METHODS

After informed consent, adult patients with chronic (> 1-year duration) stable vitiligo refractory to conventional treatments were enrolled in an open-labelled prospective study. Treatment regimen consists of once-daily application, in the evening, of tacrolimus 0.03% ointment to the lesions of the face, or tacrolimus 0.1% ointment to the vitiligous patches located on other areas. Concomitant NB-UVB phototherapy was performed twice weekly for 16 weeks.

RESULTS

Study population included 110 patients (mean age, 42) with a total of 403 lesions. Within the treatment period, variable repigmentation was evident on more than 70% of lesions. Clinical response (repigmentation more than 50%) was observed in 42% of lesions. Response was strictly dependent on the site, being more frequent for face lesions (73%), followed by limbs (68%) and trunk (53.5%). The therapeutic effect on the extremities and genital areas was quite disappointing. Treatment was well tolerated.

CONCLUSIONS

Our preliminary data suggest that the combination of topical tacrolimus with NB-UVB phototherapy can represent an alternative highly effective approach to refractory vitiligo located on the face, trunk and limbs. Long-term safety data and randomized controlled trials on a large number of patients are required.

Apoptosis of melanocytes in vitiligo results from antibody penetration

Vitiligo is a rather common disease characterized by depigmentation of skin and mucosae due to the loss of melanocytes, most likely as a result of autoimmune phenomena. In this study we demonstrated apoptotic markers in residual melanocytes in skin biopsies of patients with vitiligo, as well as the presence of serum antibodies to melanocyte-specific antigens in the vast majority of patients. Moreover, we were able to prove that serum IgG antibodies from vitiligo patients, but not from healthy controls, were capable to penetrate into cultured melanocytes in vitro, and trigger them to engage in apoptosis. Our results are consonant with the theory that melanocyte-specific antibodies are responsible for the deletion of melanocytes through antibody penetration and apoptosis.

Two therapeutic challenges: periocular and genital vitiligo in children successfully treated with pimecrolimus cream

Vitiligo is characterized by the selective destruction of melanocytes resulting in patches of skin depigmentation. Vitiligo is a therapeutic challenge. Eyebrows, eyelids and genital vitiligo are a therapeutic dilemma, especially in children. The possible side effects of topical corticosteroids and the difficulties for choosing any other adequate treatment option are a major concern. We present two children, one with vitiligo of the eyelids and the other with genital vitiligo, both treated with pimecrolimus 1% cream with almost full repigmentation of the lesions, showing pimecrolimus could be an adequate option for the treatment of vitiligo for these special vitiligo areas in children.

The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis

The topical calcineurin inhibitors (TCIs) pimecrolimus and tacrolimus are approved for atopic dermatitis but have additional potential in other inflammatory skin diseases. This article reviews their clinical use in non-atopic dermatitis diseases. In seborrheic dermatitis, asteatotic eczema, and contact dermatitis, TCIs are of great benefit and can compete with topical corticosteroids. In psoriasis, TCIs have shown clinical efficacy and safety in facial and intertriginous lesions. Further investigations into possible combinations of TCIs with other established treatments such as UVB irradiation in this disorder are necessary. Initial studies in cutaneous lupus erythematosus have been promising, whereas the response in rosacea and rosacea-like eruptions has been mixed. TCIs have been associated with good clinical responses in oral lichen planus and anogenital lichen sclerosus et atrophicus. In vitiligo, TCIs are associated with some degree of repigmentation, with better results being seen in children and in facial and neck areas. TCIs have a synergistic effect with UVB irradiation in vitiligo. There is a long list of small series and case reports documenting use of TCIs in various other skin conditions that warrant further validation. Although the established mode of action of TCIs is T-cell control, other effects also need to be considered. Specifically, TCIs reduce pruritus and erythema, which cannot be explained by T-cell interactions, and further investigations are needed in these fields.

Narrowband UVB therapy for vitiligo: does the repigmentation last?

BACKGROUND

Since 1997, a number of trials have shown promising results in treating generalized vitiligo with narrowband ultraviolet B (UVB) both in adults and children. However, there is little knowledge concerning the duration and permanency of the treatment-induced repigmentation.

OBJECTIVE

Our main objective was to perform a follow-up trial of successfully treated patients receiving narrowband UVB for generalized vitiligo.

METHODS

We have investigated to what degree the treatment-induced repigmentation remains stable for up to 2 years post-treatment. We performed an initial open trial including 31 patients with generalized vitiligo. They received narrowband UVB thrice weekly for up to 12 months. Patients experiencing > 75% repigmentation were defined responders and were included in the follow-up trial. Responders were followed every 6 months for up to 2 years after cessation of treatment. We observed the pigmentation status and registered any changes indicating loss of pigmentation and relapse.

RESULTS

Eleven of the 31 treated patients were included in the follow-up trial. Six patients had relapse and five patients had stable response 24 months after cessation of treatment. Four out of six relapses were within 6 months post-treatment.

CONCLUSION

In our study population of 31 patients with generalized vitiligo, five patients (16%) experienced > 75% stable repigmentation 2 years after cessation of a treatment programme of up to 1 years narrowband UVB therapy.

New and Experimental Treatments of Vitiligo and Other Hypomelanoses

This article deals with new and experimental treatments that can be used to treat various forms of depigmenting disorders. Ultraviolet B-focused therapies and new surgical approaches are analyzed in this article. These therapies were mainly or only developed to treat vitiligo, which is the most studied and probably the most challenging of all the hypomelanoses, but the results obtained in trials and clinical experiences about vitiligo sometimes can be referred to other depigmenting disorders.

Tacrolimus (Topical): Vitiligo

Off-Label Drug Uses — This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Wolters Kluwer Health. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form, so the reader can easily identify the scope of information available. A summary of the data—including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments regarding “Off-Label Drug Uses” to hospitalpharmacy@wolterskluwer.com .

Pimecrolimus Cream in Repigmentation of Vitiligo

BACKGROUND

Vitiligo is a chronic disease that mostly affects children and young adults. Nowadays many treatment options are available; however, most of them have limited efficacy and in most cases would result in undesirable complications.

OBJECTIVE

To determine the extent of repigmentation according to the location of the lesions after applying topical cream pimecrolimus 1% in vitiligo patients.

MATERIALS AND METHODS

Thirty consecutive patients with vitiligo lesions affecting less than 20% of body surface area without any previous history of spontaneous repigmentation were treated with pimecrolimus cream 1% twice daily for 12 weeks. The extent of repigmentation in vitiligo lesions was determined in each patient after 6 and 12 weeks.

RESULTS

Moderate to excellent response (repigmentation >26%) was observed in 6.6 and 25.9% of vitiligo lesions 6 and 12 weeks after treatment, respectively. More responsive lesions were located on the trunk, face and elbow (85.7, 75 and 70%).

CONCLUSION

Pimecrolimus cream 1% results in repigmentation in vitiligo in different extents according to the location of the lesion; however, to clearly prove its efficacy as monotherapy or in combination with other available treatment options, double-blind placebo-controlled studies are essential.

Treatment of localized vitiligo with targeted broadband UVB phototherapy: a pilot study

BACKGROUND

Narrowband ultraviolet B (UVB) phototherapy and 308 nm excimer laser have produced encouraging therapeutic results for vitiligo. Repigmentation of various degrees was obtained in different studies.

MATERIALS AND METHODS

Twenty-nine vitiliginous lesions from six patients were treated with targeted, broadband UV-B phototherapy. UV fluences were started at 50% of the minimal erythema dose, then increased gradually. Treatments were carried out twice weekly for 12 weeks.

RESULTS

Some degree of repigmentation occurred in all subjects. Responses varied among the different anatomic locations, with acral lesions achieving the least improvement. Onset of repigmentation was as early as 3 weeks of treatment in some subjects. Treatments were well tolerated, with only minimal erythema and hyperpigmentation.

LIMITATIONS

This study was carried out in a smaller number of patients with skin types III and IV. The irradiation device was a broadband UVB device, and thus the results may not be similar to those obtained from a more monochromatic system such as an excimer laser.

CONCLUSIONS

Targeted broadband UVB is an efficacious and safe modality for the treatment of localized vitiligo.

Topical macrolide immunomodulators: a role in the treatment of vitiligo?

Recently, topical macrolide immunomodulators have been successfully introduced in the treatment of atopic dermatitis. With the growing interest in this new line of topical immunosuppressants, research into the efficacy of these medicines in other T-cell-mediated skin diseases, such as psoriasis, lichen planus, and even vitiligo, is expanding rapidly. It is generally accepted that autoimmune factors play an important role in vitiligo. In this article, the possible use and mechanism of topical macrolide immunomodulators in the treatment of vitiligo are discussed, together with the current state of clinical studies and case reports. These limited reports indicate that topical macrolide immunomodulators may play a role in the treatment of vitiligo, particularly in areas where use of potent corticosteroids is contraindicated.

Unraveling the complex relationship between cancer immunity and autoimmunity: lessons from melanoma and vitiligo

A relationship between melanoma and vitiligo, a skin disorder characterized by the loss of melanocytes, has been postulated for many decades. In some cases, vitiligo is almost certainly a manifestation of autoimmune-mediated destruction of melanocytes. Melanocytes and melanoma cells share melanocyte differentiation antigens. Based on a number of observations, de novo vitiligo developing in patients with melanoma has been regarded as a sign of good prognosis. The immune system tolerates or ignores differentiation antigens because these antigens are self-derived. Therefore, immune tolerance or ignorance must be overcome to prime naive T and B cells to induce cancer immunity and autoimmunity against melanocyte differentiation antigens. Mouse models of concurrent melanoma and autoimmune vitiligo have revealed strategies to overcome immune ignorance or tolerance to melanocyte differentiation antigens: immunization with self-antigens as altered self (e.g., orthologues or mutated versions), expression in viral vectors, passive immunization with antibodies or T cells, incorporating potent adjuvants into active immunization, and blockade or removal of a downregulatory mechanism. Extensive investigations into the mechanisms that lead to tumor immunity and autoimmunity elicited by certain differentiation antigens have further revealed a variety of distinct cellular and molecular requirements, which are redundant and alternative.

Vitiligo em crianças: uma revisão de classificação, hipóteses sobre patogênese e tratamento

Vitiligo é um achado dermatológico relativamente comum, observado desde a Antiguidade. A doença caracteriza-se por despigmentação da pele, com perda de melanócitos ao exame histológico. Diversos fenótipos clínicos resultam em diferentes graus de morbidade. A causa do vitiligo ainda é desconhecida e a etiologia mais provável parece ser auto-imune. O tratamento é difícil e várias alternativas mostram um potencial terapêutico significativo. Nesta revisão, abordaremos a classificação do vitiligo na infância, as hipóteses sobre a patogênese e o tratamento.

FK506 promotes melanocyte and melanoblast growth and creates a favourable milieu for cell migration via keratinocytes: possible mechanisms of how tacrolimus ointment induces repigmentation in patients with vitiligo

BACKGROUND

Vitiligo is an acquired pigmentary disorder characterized by depigmentation of skin and hair. As the pathogenesis of this disease is still obscure, the treatment of vitiligo has generally been unsatisfactory and often disappointing. Topical tacrolimus (FK506) ointment has recently been added to the armamentarium against this pigmentary disorder. Despite its clinical efficacy, the underlying mechanisms of how topical tacrolimus induces repigmentation in vitiligo have rarely been investigated. As tacrolimus ointment is applied directly to the skin, its impact on keratinocytes (KCs) requires thorough investigation.

OBJECTIVES

To investigate the effects of FK506 on melanocyte (MC) and melanoblast (MB) growth via KCs.

METHODS

Cultured MCs and MBs were treated with supernatant of KC cultures conditioned with various concentrations of FK506. The impact of supernatant on MCs and MBs was assessed in terms of its effect on MC/MB proliferation, melanin formation and cell migration. The activities of matrix metalloproteinase (MMP)-2 and MMP-9, known for their influence on cell migration, were evaluated. The concentrations of MC/MB growth factors in the KC supernatant were also determined.

RESULTS

Results demonstrated that proliferation of both MCs and MBs was significantly enhanced by FK506-treated KC supernatant. In addition, the concentration of stem cell factor in KC supernatant increased dose-dependently with FK506 treatment. The supernatant from FK506-treated KC culture showed a significant increase in MMP-9 activity.

CONCLUSIONS

Our study provides in vitro evidence demonstrating that direct interaction between FK506 and KCs creates a favourable milieu for MC growth and migration. Furthermore, our findings provide a possible mechanism explaining how tacrolimus ointment induces repigmentation in patients with vitiligo.

Safety and efficacy of topical calcineurin inhibitors in the treatment of childhood atopic dermatitis

Approximately 10-20% of infants in industrialized countries experience atopic dermatitis. In recent decades topical corticosteroids have been the first-choice therapy for treatment of flares. However, this form of therapy may induce skin atrophy, especially after application to facial lesions or with long-term use. Thus, development of new anti-inflammatory topical agents for the treatment of childhood atopic dermatitis was needed. The topical calcineurin inhibitors tacrolimus and pimecrolimus have an effect on various cells of the cutaneous immune system, specifically on T cells, by inhibiting the phosphatase calcineurin and preventing the transcription of proinflammatory cytokines. In several clinical studies of children and adults with atopic dermatitis, topical calcineurin inhibitors were found to be effective both on the face and the trunk and extremities, in both short- and long-term treatment regimens. Tachyphylaxis or rebound were not observed. In most patients an improvement of their eczema occurred during the first week of treatment, as measured by subjective and objective clinical signs of atopic dermatitis. Treatment significantly reduced the incidence of flares and the need for corticosteroids in children and adults. Treatment success, commonly defined as 'excellent improvement' or 'clearing of all lesions', was observed in more than one-third of all children treated with 0.03% or 0.1% tacrolimus or 1% pimecrolimus. Topical application of pimecrolimus and tacrolimus does not lead to significant blood concentrations of these agents in the majority of children with atopic dermatitis, and any increase in blood concentrations decreases after a few days of therapy. No changes in laboratory parameters were observed in short- and long-term studies in patients with atopic dermatitis. The most common adverse effect following the application of topical calcineurin inhibitors is mild to moderate symptoms of irritation such as burning, erythema and pruritus, which occurred in up to 20% of all children treated with tacrolimus and 10% of children treated with pimecrolimus, and usually faded after a few days. In contrast to topical corticosteroids, calcineurin inhibitors do not induce skin atrophy, even after long-term use. Topical calcineurin inhibitors have been proven to be effective and have a good safety profile during short-term and long-term use for up to 1 year with pimecrolimus and up to 4 years with tacrolimus. Given the lack of extensive experience with use of topical calcineurin inhibitors over longer periods, regular use of these agents, particularly in children, should be undertaken only after careful consideration of individual cases. Sun protection should also be advised.

Melanin pigmentary disorders: treatment update

Most of the melanin pigmentary disorders are cosmetically important and have a strong impact on the quality of life of affected individuals. This article examines recent advances in the treatment of melanin pigmentary disorder including hypermelanosis and hypomelanosis. The development of laser technologies has completed the use of the increasing number of bleaching agents in treating hyperpigmented lesions. The treatment of hypomelanotic disorders is still often disappointing, but new therapeutic options provide encouraging results.

Vitíligo. Tratamiento de 12 casos con tacrolimus tópico

INTRODUCTION

Vitiligo is a frequent dyschromia, characterized by achromic macules that reflect the absence of melanocytes. The cause of this selective destruction seems to be due to an autoimmune phenomenon. Tacrolimus is an immunomodulator produced by Streptomyces tsukubaensis, whose topical use has been approved for atopic dermatitis. It has been tested in other dermatoses where immunological phenomena are involved.

MATERIAL AND METHODS

During the period from September 1, 2003 to April 30, 2004, an open study was carried out on 12 cases of vitiligo treated with topical tacrolimus 0.1 % twice a day. The degree of repigmentation was analyzed using digital photography at the initial visit, and at three and six months. The response in each case was taken into consideration, as well as the response by treated area. Possible adverse effects during the treatment period were also noted.

RESULTS

50 % of the patients treated showed repigmentation with good (50 %-75 %) or excellent (> 75 %) improvement after 6 months. All of the patients with facial involvement achieved repigmentation of over 50 % in this location. Repigmentation in all cases took place homogeneously and centripetally, rather than in a perifollicular pattern. Repigmentation began before three months of treatment had elapsed in 10 patients, and after three months in the remaining two. We did not find any evidence of adverse effects except pruritus in the eyelid area in two patients during the first week of treatment.

CONCLUSION

We believe that tacrolimus 0.1 % applied topically for a minimum of six months may be a valid alternative in the treatment of vitiligo in the facial area, especially the eyelids, where other therapeutic modes are not recommended because of the possible side effects.

Topical tacrolimus therapy for vitiligo: therapeutic responses and skin messenger RNA expression of proinflammatory cytokines

BACKGROUND

Previous studies have documented humoral and cell-mediated immunologic defects in patients with vitiligo.

OBJECTIVE

This 24-week study assessed the efficacy and safety of tacrolimus 0.1% ointment in patients with generalized vitiligo as well as the pretreatment and post-treatment expression of cytokines in the depigmented and normal skin of patients compared with controls.

METHODS

Twenty-three patients were enrolled in this investigation, and 19 patients completed the study; 8 were male and 11 were female. Fifteen age-, race-, and sex-matched control subjects were also included. Patients were treated with tacrolimus 0.1% ointment applied twice daily. Repeat evaluations were performed at 4, 8, 12, 16, 20, and 24 weeks. Three-millimeter punch biopsy specimens were taken from the depigmented, non-sun-exposed skin and adjacent normal skin of patients at baseline and 24 weeks, and from normal, non-sun-exposed skin of controls. Cellular messenger RNA expression for interleukin 2 (IL-2), IL-4, IL-10, tumor necrosis factor alfa (TFN-alpha), and interferon gamma (IFN-gamma) were determined by real-time quantitative polymerase chain reaction.

RESULTS

At 24 weeks, 17 of 19 patients (89%) achieved varying levels of repigmentation. There was a statistically significant decrease in overall disease severity scores at 24 weeks. Thirteen patients (68%) had greater than 75% repigmentation of face and/or neck lesions. Signs and symptoms of irritation were minimal. At baseline, compared with healthy controls, vitiligo patients demonstrated a statistically significant increase in the expression of IFN-gamma in involved and adjacent uninvolved skin (P=.05 and P=.02, respectively); significantly increased TNF-alpha expression in involved and uninvolved skin (P=.01 and P=0.02, respectively); and significantly increased IL-10 expression in involved and uninvolved skin (P=.01 and P=.04, respectively). Posttreatment, TNF-alpha expression decreased in the depigmented and adjacent uninvolved skin (P <.001). There was no statistically significant change in IL-10 or IFN-gamma posttreatment. These data suggest that tacrolimus 0.1% ointment is a safe and effective therapy for patients with vitiligo. It further suggests that an imbalance in local cytokine expression may play a role in the pathogenesis of vitiligo. Suppression of TNF-alpha after topical tacrolimus application may be associated with repigmentation of vitiligo.

Tacrolimus ointment: the treatment of atopic dermatitis and other inflammatory cutaneous disease

Topical tacrolimus (FK506, Protopic) has been developed and marketed for the treatment of atopic dermatitis (AD). Tacrolimus works as an inhibitor of calcineurin, which creates a downregulation of the inflammatory cascade. Numerous trials have shown the efficacy and safety of tacrolimus in treating AD in both adults and children. Additionally, comparison data with other medications commonly used for AD, such as topical steroids and pimecrolimus, show improved efficacy of tacrolimus. A comprehensive review of the off-label uses of tacrolimus in other dermatoses, including psoriasis, lichen planus and seborrhoeic dermatitis, is provided. The efficacy of tacrolimus in treating these diseases is based on Phase IV clinical trials and on case reports or series in the literature. Overall, tacrolimus has proven to be a safe and useful topical therapy for many inflammatory dermatological conditions, with AD being the principal indication.

New Treatment Modalities for Vitiligo

The development of effective treatment modalities for vitiligo is dependent on an understanding of the events leading to depigmentation. However, the exact pathogenesis of vitiligo is still mostly unknown. Abnormalities in both humoral and cell-mediated immunity have been documented in vitiligo patients and they present a basis for using immunomodulating agents, such as corticosteroids and macrolide immunomodulators, in the treatment of vitiligo. Macrolide immunomodulators, such as tacrolimus and pimecrolimus, which can be used topically, are known as topical immunomodulators (TIMs). TIMs inhibit the action of calcineurin, and consequently inhibit T-cell activation and the production of various cytokines; this is considered the working mechanism of action of TIMs in vitiligo. Several small studies and case reports on the use of TIMs in vitiligo have been published so far. Tacrolimus achieves better results on the face and neck than on other body areas. Particular advantages of TIMs are safety in treating these areas because of lack of skin atrophy and good tolerability. The incidence of application site adverse events in vitiligo seems to be lower than in the treatment of atopic dermatitis. On the face and neck, TIMs may become a useful tool in the treatment of adults and children with vitiligo despite possibly lower efficacy than topical corticosteroids. Further, larger, controlled clinical studies are warranted to determine the definite role of TIMs as monotherapy or in combination with other modalities in the treatment of vitiligo.

Tacrolimus Ointment

Tacrolimus ointment (Protopic) is a topically applied macrolide lactone immunomodulator effective in the treatment of atopic dermatitis. Its mechanism of action primarily involves calcineurin inhibition, which interrupts cytokine gene expression and leads to the downregulation of T-cell activity. Tacrolimus ointment (0.03% and 0.1% for adults and 0.03% for children) is an effective treatment for atopic dermatitis of the trunk and limbs, as well as sensitive skin areas such as the face. Its efficacy is similar to or greater than that of hydrocortisone acetate 1%, hydrocortisone butyrate 0.1% and betamethsone valerate 0.12% ointments and pimecrolimus 1% cream. Systemic absorption of tacrolimus from the ointment is minimal, and adverse events, which are mostly associated with the application site and include skin burning and pruritus, tend to resolve early in treatment. Unlike topical corticosteroids, tacrolimus ointment is not associated with skin atrophy, and it is a well tolerated treatment for adults or children with atopic dermatitis, particularly when long-term treatment is indicated or the face or skin-fold regions are involved.

Does topical tacrolimus induce lentigines in children with atopic dermatitis? A report of three cases

Three children with severe atopic dermatitis were noted at routine follow-up to have developed multiple small pigmented macules during long-term therapy with topical tacrolimus 0.1% (Protopic, Fujisawa). Representative lesions in two of the three cases were confirmed histologically as simple lentigines. The focal distribution of lentigines to sites of tacrolimus use, and the temporal association between use of tacrolimus and development of lesions, suggest that topical tacrolimus is of direct aetiological relevance to their development. Careful long-term follow-up will be required to assess the clinical implications of these findings and whether they represent an increase in risk for melanocytic neoplasia.

Tacrolimus ointment promotes repigmentation of vitiligo in children: A review of 57 cases

BACKGROUND

Vitiligo is an autoimmune disorder characterized by loss of pigmentation. Phototherapy and application of topical corticosteroids are most commonly prescribed. However, these therapies are often not effective and use of corticosteroids on the face may lead to cutaneous atrophy, telangiectasia, and ocular complications.

OBJECTIVE

We sought to assess the efficacy of topical tacrolimus ointment in the treatment of pediatric vitiligo.

METHODS

A retrospective review was performed of 57 pediatric patients with vitiligo at two clinical sites. Patients were treated with tacrolimus ointment for at least 3 months. Clinical responses were documented during clinic visits, and by pretacrolimus and posttacrolimus photography.

RESULTS

At least partial response was noted to tacrolimus ointment on the head and neck in 89%, and on the trunk and extremities in 63% of patients. Facial vitiligo of the segmental type showed the best response rate. Two patients initially experienced burning on application.

CONCLUSIONS

Topical tacrolimus ointment is an effective alternative therapy for childhood vitiligo, particularly involving the head and neck.

Topical tacrolimus for treatment of childhood vitiligo in Asians

Childhood vitiligo is a common disorder of pigmentation in India. Considering the lack of uniformly effective and safe treatment modalities for children with vitiligo, search for newer therapeutic agents continues. This study was designed to evaluate the role of topical tacrolimus in the treatment of childhood vitiligo. Twenty-five children with vitiligo were treated with topical 0.03% tacrolimus ointment applied twice daily for 12 weeks. Response was noted as marked to complete (> 75% repigmentation), moderate (50-75% repigmentation) and mild (< 50% repigmentation). Twenty-two children (9 boys and 13 girls) of mean age 7.2 +/- 1.4 years completed the study. Twelve (54.5%) children had vitiligo vulgaris, nine (40.9%) had focal vitiligo and one (4.5%) had segmental vitiligo. The mean duration of disease was 8 +/- 3 months. Nineteen (86.4%) children showed some repigmentation at the end of 3 months and other three had no response. Of these 19 children, repigmentation was marked to complete in 11 (57.9%), moderate in five (26.3%) and mild in three (15.7%) children. Side effects were minimal, such as the pruritus and burning noted in only three patients. Topical tacrolimus is an effective and well-tolerated treatment modality in Asian children with vitiligo.

Pimecrolimus 1% cream for cutaneous lupus erythematosus

Topical treatment of cutaneous lupus erythematosus usually includes potent glucocorticosteroids. However, prolonged use causes adverse side effects including skin atrophy as the foremost concern. In contrast to glucocorticosteroids, the anti-inflammatory and immunosuppressive macrolactam pimecrolimus has no atrophogenic potential. Affected areas of 11 patients with different forms of lupus erythematosus were treated with pimecrolimus 1% cream under semiocclusive conditions twice daily for 3 weeks. Skin involvement before and after therapy was assessed by means of a clinical score. In all patients, significant regression of skin lesions was observed after therapy (P <.001). This was an open and uncontrolled study on a limited number of cases. We suggest that pimecrolimus 1% cream could be an efficacious and safe treatment option for cutaneous lupus erythematosus.

Vitiligo

O vitiligo é doença de pele de causa desconhecida que acomete cerca de 1% da população, comprometendo de modo semelhante homens e mulheres, preferencialmente entre 10 e 30 anos de idade. Alguns fatores precipitantes para essa doença são: estresse físico e emocional, traumas mecânicos e substâncias químicas, como derivados do fenol. Doenças auto-imunes, principalmente as tireoidianas, podem estar associadas ao vitiligo. Novas terapias têm sido propostas, como o uso de imunomoduladores tópicos, aliadas àquelas já consolidadas, como os psoralenos e os corticosteróides; o sucesso terapêutico, entretanto, está estritamente relacionado à qualidade da relação médico/paciente.

Combined Excimer Laser and Topical Tacrolimus for the Treatment of Vitiligo: A Pilot Study

BACKGROUND

Vitiligo is an acquired skin disorder that is characterized by well-defined, often symmetric white patches. Although current therapeutic modalities are directed toward increasing melanocyte melanin production, few treatment modalities address the immunologic nature of the disease.

OBJECTIVE

To determine whether excimer laser, a known therapeutic modality, in combination with tacrolimus, a topical immunomodulator, accelerate response time and/or improve the degree of response in patients with this disorder.

METHODS

Eight subjects diagnosed with vitiligo were recruited to participate in this institutional review board-approved double-blind, placebo-controlled study. Twenty-four symmetric vitiliginous patches (elbows, knees) from eight subjects received excimer laser treatment three times per week for 24 treatments or 10 weeks. Additionally, topical tacrolimus 0.1% ointment (Protopic) and placebo (Aquaphor) were applied to randomized patches (left or right) twice daily throughout the length of the trial. Vitiliginous patches were monitored with photographs at baseline, every 2 weeks, and 6 months after treatment. Biopsies were performed on subjects with significant results.

RESULTS

Twenty vitiliginous patches from six subjects qualified for evaluation. Fifty percent of patches treated with combination excimer laser and tacrolimus achieved a successful response (75% repigmentation) compared with 20% for the placebo group. Subjects who responded successfully repigmented faster (19%) with combination therapy compared with excimer laser alone. Additionally, three subjects experienced transient hyperpigmentation in lesions treated with combination therapy.

CONCLUSION

Combining topical immunomodulators with known phototherapeutic modalities may represent a key advancement in the treatment of disease.

Pigmentary disorders in ethnic skin

Pigmentary disorders are commonly seen in ethnic skin. They are psychologically problematic in darker skin. Treatment of many of these disorders remains difficult.