Guidelines for the management of vitiligo: the European Dermatology Forum consensus

Decreased choroidal thickness in vitiligo patients

BACKGROUND

Vitiligo is a disease characterized by depigmented macules and patches that occur as a result of the loss of functional melanocytes from the affected skin through a mechanism which has not been elucidated yet. Destruction of pigment cells in vitiligo may not remain limited to the skin; the eyelashes, iris, ciliary body, choroid, retinal pigment epithelium and meninges may also be affected. This study aims to compare the choroidal thickness of patients with and without vitiligo using optical coherence tomography (OCT).

METHODS

Spectral-domain optical coherence tomography (SD-OCT) (Retina Scan Advanced RS-3000 NIDEK, Japan) instrument (with λ = 840 nm, 27,000 A-scans/second and 5 μm axial resolution) was used for the imaging. Statistical analysis was performed using SPSS 21.0 software package.

RESULTS

In all values except optic nevre area measurements, the choroidal thickness of all vitiligo patients was found out to be thinner compared to the control group.

CONCLUSIONS

In vitiligo, the choroidal thickness may be affected by the loss of melanocytes.

Medical, Surgical, and Wound Care Management of Ulcerated Infantile Hemangiomas: A Systematic Review [Formula: see text]

Ulcerated infantile hemangiomas may present a therapeutic challenge, especially if there is concurrent hemorrhage or infection. The aim of this study was to systematically review the published evidence on the treatment of ulcerated hemangiomas, focusing on wound healing as the outcome of interest. We searched MEDLINE, Embase, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science from inception to July 2016. Seventy-seven studies met our inclusion criteria. One study was a randomized controlled trial, 30 were observational studies, and 46 were case reports or case series. There is significant heterogeneity among the methods used. We reviewed 1239 patients in total. Of the 197 treated with oral propranolol, 191 (97.0%) achieved complete ulcer healing. Thirty-one patients failed corticosteroid therapy (oral, intralesional, or topical) and were subsequently successfully treated with other therapies. Surgical resections were typically performed for larger hemangiomas and those causing complications. None of the therapies discussed appear to offer significant advantages over others. Therefore, treatment decisions should be individualized based on location of disease, extent, symptoms, feasibility, cost, and parental preference.

Home interventions and light therapy for the treatment of vitiligo (HI-Light Vitiligo Trial): study protocol for a randomised controlled trial

INTRODUCTION

Vitiligo is a condition resulting in white patches on the skin. People with vitiligo can suffer from low self-esteem, psychological disturbance and diminished quality of life. Vitiligo is often poorly managed, partly due to lack of high-quality evidence to inform clinical care. We describe here a large, independent, randomised controlled trial (RCT) assessing the comparative effectiveness of potent topical corticosteroid, home-based hand-held narrowband ultraviolet B-light (NB-UVB) or combination of the two, for the management of vitiligo.

METHODS AND ANALYSIS

The HI-Light Vitiligo Trial is a multicentre, three-arm, parallel group, pragmatic, placebo-controlled RCT. 516 adults and children with actively spreading, but limited, vitiligo are randomised (1:1:1) to one of three groups: mometasone furoate 0.1% ointment plus dummy NB-UVB light, vehicle ointment plus NB-UVB light or mometasone furoate 0.1% ointment plus NB-UVB light. Treatment of up to three patches of vitiligo is continued for up to 9 months with clinic visits at baseline, 3, 6 and 9 months and four post-treatment questionnaires.The HI-Light Vitiligo Trial assesses outcomes included in the vitiligo core outcome set and places emphasis on participants' views of treatment success. The primary outcome is proportion of participants achieving treatment success (patient-rated Vitiligo Noticeability Scale) for a target patch of vitiligo at 9 months with further independent blinded assessment using digital images of the target lesion before and after treatment. Secondary outcomes include time to onset of treatment response, treatment success by body region, percentage repigmentation, quality of life, time-burden of treatment, maintenance of response, safety and within-trial cost-effectiveness.

ETHICS AND DISSEMINATION

Approvals were granted by East Midlands-Derby Research Ethics Committee (14/EM/1173) and the MHRA (EudraCT 2014-003473-42). The trial was registered 8 January 2015 ISRCTN (17160087). Results will be published in full as open access in the NIHR Journal library and elsewhere.

TRIAL REGISTRATION NUMBER

ISRCTN17160087.

A novel psoralen derivative-MPFC enhances melanogenesis via activation of p38 MAPK and PKA signaling pathways in B16 cells

As an active compound, psoralen is present in various Chinese herbal medicines and has exhibited significant activity in skin disease treatment. Its derivative 8-methoxypsoralan (8-MOP) is the most commonly used drug to induce repigmentation of vitiligo. In our previous screening assays, 4-methyl-6-phenyl-2H-furo[3,2-g]chromen-2-one (MPFC), a psoralen derivative, was identified as more effective tyrosinase and melanin activator than the positive control 8-MOP in consideration of low doses, as well as low toxicity. The overall purpose of this study was to characterize the melanogenic effect and mechanisms of MPFC in B16 cells. The melanin biosynthesis effects of MPFC were determined by examination of cellular melanin contents, tyrosinase activity assay, cyclic adenosinemonophosphate (cAMP) assay, and western blotting of MPFC-stimulated B16 mouse melanoma cells. Our results showed that MPFC enhanced both melanin synthesis and tyrosinase activity in a concentration-dependent manner as well as significantly activated the expression of melanogenic proteins such as tyrosinase, tyrosinase-related protein-1 and tyrosinase-related protein-2. Western blot analysis showed that MPFC increased the phosphorylation of p38 mitogen-activated protein kinase and cAMP response element-binding protein (CREB) as well as the expression of microphthalmia-associated transcription factor (MITF). Moreover, MPFC stimulated intracellular cAMP levels and induced tyrosinase activity and melanin synthesis were attenuated by H89, a protein kinase A inhibitor. These results indicated that MPFC-mediated activation of the p38 MAPK and the protein kinase A (PKA) pathway may shed light on a novel approach for an effective therapy for vitiligo.

Views and experiences of seeking information and help for vitiligo: a qualitative study of written accounts

OBJECTIVES

Vitiligo is a relatively common autoimmune condition causing loss of skin pigment. Around 1 in 100 people in the UK develop vitiligo. It can have a significant impact on quality of life for many of those affected. How people access information and help for vitiligo may influence how they manage such impact. We aimed to explore people's views and experiences of seeking health information and help for vitiligo.

DESIGN

Qualitative analysis of free-text responses to four open-ended questions in an online survey.

SETTING

Online survey conducted in the UK between February and March 2016.

PARTICIPANTS

A survey link was emailed to 675 members of The Vitiligo Society, a UK-based charity providing information and support for people with vitiligo. One hundred and sixty-one members responded to the survey (24%).

RESULTS

Many participants wrote extensive free text, often reporting frustration with help-seeking. They perceived general practitioners (GP) as their primary source of advice but felt that GPs had low awareness of available treatments. Where GPs appeared sympathetic or signposted towards further information this was appreciated, even where people felt their GP had not seemed knowledgeable. Many felt that vitiligo was dismissed by health professionals including GPs and dermatologists as 'cosmetic', which upset those who experienced substantial impact. Participants expressed concerns about the credibility of online information on vitiligo and the need for reliable, detailed information, as well as a desire for support with managing its psychosocial impact.

CONCLUSIONS

Information and help-seeking needs of people with vitiligo currently appear to be poorly met, even among members of The Vitiligo Society, who are likely to have received more information than others. People with vitiligo would welcome greater health professional awareness of available vitiligo treatments. Acknowledging the psychosocial impacts of vitiligo and signposting towards credible information are also welcomed.

The early repigmentation pattern of vitiligo is related to the source of melanocytes and by the choice of therapy: a retrospective cohort study

BACKGROUND

Patients with vitiligo present with different repigmentation patterns in the early recovery stage.

OBJECTIVES

To analyze the relationships between early repigmentation patterns in vitiliginous patches, their clinical characteristics, and therapeutic choices.

METHODS

Patients with vitiligo seen in the Department of Dermatology, The First Affiliated Hospital of Nanjing Medical University from 2010 to 2015, were included, and their clinical records, especially photographs and medical treatments, were reviewed.

RESULTS

One hundred and sixteen patients were included in this study, and 326 lesions with different degrees of depigmentation, locations, stages, distributions, therapies, and repigmentation patterns were included and analyzed. Perifollicular repigmentation occurred more frequently in lesions with complete depigmentation (P = 0.005), in non-sun exposed areas (P < 0.001), a stable stage (P = 0.008), and lesions treated with narrow band ultraviolet B (NB-UVB) (P < 0.001, despite lesion distributions). Marginal repigmentation is more frequent in lesions with complete depigmentation (P = 0.016), lesions treated without NB-UVB (P = 0.002), and facial lesions treated with topical vitamin D analogs (TVDAs) monotherapy (P = 0.022). Diffuse repigmentation is the predominant pattern in lesions with incomplete depigmentation (P < 0.001), in sun-exposed areas (P < 0.001), progressive stage (P = 0.044), and truncal lesions treated with TVDAs (P < 0.001).

CONCLUSIONS

The different repigmentation patterns of vitiligo lesions depend on the different source and status of melanocytes and their abilities to produce melanin on the choice of therapy.

Preclinical evaluation of melanocyte transplantation by chitosan-based melanocyte spheroid patch to skin prepared by controlled sunburn blistering

Transplantation of autologous cultured melanocytes as cell suspension has been used for the treatment of vitiligo. The recipient site is often prepared by laser-mediated dermabrasion. Such procedures encounter disadvantages including prolonged transplantation duration, unsecured cell adherence to lesional skin and potential scarring. To improve this, here we propose a method by preparing recipient sites before transplantation by psoralen and ultraviolet A (PUVA)-induced sunburn followed by transplanting cells with a chitosan-based melanocyte spheroid patch. We evaluated the method in nude mice. Application of methoxsalen-soaked filter paper on skin for 30 min followed by ultraviolet A exposure induced controlled sunburn blisters in 2 days. Upon transplantation, the blister roof could be quickly peeled off by a waxing patch. The chitosan membrane on which melanocytes were precultured into multicellular spheroids was transplanted with cells facing the skin. The chitosan patch adhered well to skin and secured the contact of melanocytes with the recipient site. One day later, melanocyte spheroids already detached from the chitosan membrane and adhered to the recipient skin. Our results suggest that the combination of chitosan-based melanocyte spheroid patch with epidermal ablation by PUVA-induced sunburn reaction can be a feasible method to facilitate melanocyte transplantation. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2535-2543, 2018.

[Vitiligo and psoriasis : An underdiagnosed coincidence?]

We report the case of a 59-year-old woman who simultaneously suffered from psoriasis and vitiligo. The depigmented areas were predominantly but not exclusively limited to current or former psoriatic plaques. These two diseases share many common features, e. g., both are T‑cell-mediated autoimmune diseases in which the Koebner phenomenon occurs. However, it is still not known whether the coincidence is random or significant. Prospective clinical and epidemiological research will hopefully reveal the association soon.

Evaluation of serum immunoglobulins concentrations and distributions in vitiligo patients

Vitiligo is a dermatological disorder with an autoimmune mechanism characterized by production of a variety of autoantibodies. Different levels of immunoglobulins can indicate the presence and the stage of some autoimmune diseases. We aimed to investigate serum IgA, IgM and IgG subclass levels and melanocyte-reactive antibodies in 65 vitiligo patients by the immunonephelometric assay (35 healthy people as controls). Compared with normal controls, a significant increase in total IgG, IgG1 and IgG2 (p = .005, p = .003 and p = .043, respectively) was observed in progressive nonsegmental vitiligo patients. Also, we found a significant decrease in IgG3 (p = .000 and p = .023) in progressive nonsegmental vitiligo patients and segmental patients. Moreover, we found the serum levels of IgG4 subclass in stable nonsegmental patients were significantly higher than those in normal controls (p = .018). Compared with controls, the positive rates of melanocyte-reactive antibodies were higher in progressive nonsegmental patients and stable nonsegmental patients (p = .032 and p = .046, respectively). Furthermore, we found higher level of IgG4 and lower level of IgM in male than those in female. Higher IgG1 level was also observed in patients with a family history than in those without a family history. In addition, there was a significant inverse correlation between the concentrations of IgG4 and disease duration. Our evaluation about the level of immunoglobulins might provide a useful insight into the pathological process of vitiligo.

Vitiligo: An Update on Pathophysiology and Treatment Options

The pathophysiology of vitiligo is becoming increasingly clarified. In non-segmental vitiligo, early factors include activation of innate immunity, inflammasome activation, oxidative stress, and loss of melanocyte adhesion. Nonetheless, the main mechanism leading to non-segmental vitiligo involves an immune-mediated destruction of melanocytes. Anti-melanocyte-specific cytotoxic T cells exert a central role in the final effector stage. Genetic research revealed a multi-genetic inheritance displaying an overlap with other autoimmune disorders. However, some melanocyte-specific genes were also affected. Segmental vitiligo carries a different pathogenesis with most evidence indicating a mosaic skin disorder. Current management includes topical corticosteroids and immunomodulators. Narrow-band ultraviolet B can be used in patients not responding to topical treatment or in patients with extensive disease. Pigment cell transplantation offers an alternative for the treatment of segmental vitiligo or stable non-segmental lesions. Recent findings have revealed new targets for treatment that could lead to more efficient therapies. Targeted immunotherapy may halt the active immune pathways, although combination therapy may still be required to induce satisfying repigmentation. A recently established core set of outcome measures, new measurement instruments, and biomarker research pave the way for future standardized clinical trials.

Energetic mitochondrial failing in vitiligo and possible rescue by cardiolipin

Vitiligo is characterized by death or functional defects of epidermal melanocytes through still controversial pathogenic process. Previously, we showed that mitochondria-driven pre-senescent phenotype diminishes the capability of vitiligo melanocytes to cope with stressful stimuli. In the current study, we investigated markers of mitochondrial energy metabolism including the PGC1a axis, and then we determined the index of mitochondrial impairment using a cytomic approach. We found in cultured epidermal vitiligo melanocytes, compared to healthy ones, low ATP, increased proton leakage, and altered expression of several glycolytic enzymes (hexokinase II, pyruvic dehydrogenase kinase 1 and pyruvic kinase M2), We suggest that the low ATP production may be sufficient in steady-state conditions but it is unable to cover further needs. We also found in vitiligo melanocyrtes hyper-activation of the PGC1α axis, finalized to counteract the energy defect. Cytomic analysis, supported by MitoTracker Red pattern and ex-vivo immunohistochemistry, suggested an increased mitochondrial mass, possibly useful to ensure the essential ATP level. Finally, pharmacological cardiolipin stabilization reverted the energetic impairment, confirming the initial mitochondrial role. In conclusion, we report new insight in the pathogenetic mechanism of viitligo and indicate that the mitochondrial failure rescue by cardiolipin manipulation may be a new intriguing target in treatment development.

A single-arm open-label clinical trial of autologous epidermal cell transplantation for stable vitiligo: A 30-month follow-up

BACKGROUND

Recently, we introduced intralesional injection of autologous epidermal cells as a safe and feasible approach for transplantation in patients with stable vitiligo. This approach resulted in less pain during and after the procedure, no scarring or cobblestone formation at the recipient site, and was more feasible to perform on curved surfaces such as joints, lips, eyelids, ears, and face.

OBJECTIVE

In this study, we aimed to investigate the long-term efficacy and safety of this transplantation technique.

METHODS

In this open-label and single-arm clinical trial, we enrolled 300 patients with stable vitiligo. We obtained a partial thickness normo-pigmented skin specimen from the patients' thigh-buttock junction with an area of one tenth to one third of the recipient site area. The epidermal cell suspension was prepared by processing the autologous skin specimen. We injected the cell suspension into 1060 vitiligo patches in 300 patients. Patients did not use any adjuvant phototherapy during the study. An experienced dermatologist and patients respectively defined the repigmentation score and self-assessment score at regular follow-up visits for up to 30 months after treatment. The scores represented the repigmentation percentage as follows: 0 (0), I (1%-24%), II (25%-49%), III (50%-74%), and IV (75%-100%).

RESULTS

The mean repigmentation score at 3 months post-transplantation was 1.12±0.73. A significant upward trend existed in the mean repigmentation score until 9 months after cell transplantation, when the mean repigmentation score reached to 1.98±1.20. At 9 months after treatment, repigmentation of >50% was obtained in 32.2% of treated patches. Acquired repigmentation remained stable in 79.3% of treated patches during the follow-up period. The number of received cells per cm² positively influenced the repigmentation score. Patches located on face, neck and trunk showed significantly higher response to the treatment.

CONCLUSION

The results of our study demonstrated efficacy and safety of autologus epidermal cell transplantation on repigmentation of vitiligo patches. The achieved repigmentation was stable in the majority of treated patches during the follow-up period.

[Systemic treatment of vitiligo : Balance and current developments]

Systemic drug treatment of vitiligo is currently limited to predominantly adjuvant measures for increasing the effectiveness of UV light therapy. We here present new approaches for the systemic treatment of vitiligo currently under clinical investigation. These include the α‑MSH-analogue afamelatonide and oral immunosuppressants such as the Janus kinase (JAK) inhibitors which target interferon-α-dependent autotoxic inflammatory reactions. In 2015 the first publications on the successful systemic use of Janus kinase (JAK) inhibitors in vitiligo appeared. The effectiveness was experimentally supported by animal models of vitiligo and by the characterization of new biomarkers in the serum of vitiligo patients. This may significantly expand the range of treatment options for vitiligo. Topical antiinflammatory and UV therapies are still the main components of vitiligo treatment, often in combination. The main outcome parameters include the extent and duration of repigmentation, cessation of spreading, avoidance of side effects and improvement in the quality of life of patients.

Phototherapy and Combination Therapies for Vitiligo

Vitiligo is a disease characterized by disappearance of melanocytes from the skin. It can negatively influence the physical appearance of affected individuals, and may profoundly affect a person's psychosocial function and quality of life. Therefore, vitiligo should not be considered as merely a condition that affects a patient's appearance, but needs to be actively treated in patients who seek medical help. Phototherapy has been used as the main treatment modality for patients with vitiligo. Different forms of phototherapy for vitiligo include broadband UVB, narrowband UVB, excimer light and excimer laser, and psoralen plus UVA.

Medical and Maintenance Treatments for Vitiligo

Medical treatments alone, or in combination with phototherapy, are key approaches for treating nonsegmental vitiligo and, to a lesser extent, segmental vitiligo. The treatments are useful for halting disease progression and have been proven effective for inducing repigmentation and decreasing risk of relapses. Although the treatments have side effects and limitations, vitiligo often induces a marked decrease in quality of life and in most cases the risk:benefit ratio is in favor of an active approach. Systemic and topical agents targeting the pathways involved in loss of melanocytes and in differentiation of melanocyte stem cells should provide more effective approaches in the near future.

Differential Effects of Angelicin Analogues on NF-κB Activity and IL-8 Gene Expression in Cystic Fibrosis IB3-1 Cells

The angelicin analogue 4,6,4′-trimethylangelicin (TMA) was recently reported as a strong inhibitor of nuclear factor-κB (NF-κB) activity and of the expression of the interleukin-8 (IL-8) gene in bronchial epithelial cells in which the inflammatory response has been challenged with P. aeruginosa, the most common bacterium found in the airways of patients affected by cystic fibrosis (CF). These findings encouraged us to analyze new synthetic analogues of TMA in order to evaluate their biological activities on human bronchial epithelial CF IB3-1 cells and to find more potent anti-NF-κB agents exhibiting only minor antiproliferative effects. Analogues able to inhibit NF-κB/DNA interaction at lower concentration than TMA were found and selected to investigate their biological activity on IB3-1 cells induced with TNF-α. In this biological system, NF-κB-mediated IL-8 gene expression was investigated. Some analogues showed similar activity to the lead compound TMA. Other analogues displayed higher activities; in particular, the most interesting compounds showing relevant anti-inflammatory effects were found to cause 56–83% reduction of IL-8 mRNA expression at low concentrations (1–10 μM), without changes in cell proliferation pattern, demonstrating their potential interest for a possible development of anti-inflammatory therapy of cystic fibrosis.

Design and implementation of population-based specialty care programs

PURPOSE

The development, implementation, and scaling of 3 population-based specialty care programs in a large integrated healthcare system are reviewed, and the role of clinical pharmacy services in ensuring safe, effective, and affordable care is highlighted.

SUMMARY

The Kaiser Permanente (KP) integrated healthcare delivery model allows for rapid development and expansion of innovative population management programs involving pharmacy services. Clinical pharmacists have assumed integral roles in improving the safety and effectiveness of high-complexity, high-cost care for specialty populations. These roles require an appropriate practice scope and are supported by an advanced electronic health record with disease registries and electronic surveillance tools for care-gap identification. The 3 specialty population programs described were implemented to address variation or unrecognized gaps in care for at-risk specialty populations. The Home Phototherapy Program has leveraged internal partnerships with clinical pharmacists to improve access to cost-effective nonpharmacologic interventions for psoriasis and other skin disorders. The Multiple Sclerosis Care Program has incorporated clinical pharmacists into neurology care in order to apply clinical guidelines in a systematic manner. The KP SureNet program has used clinical pharmacists and data analytics to identify opportunities to prevent drug-related adverse outcomes and ensure timely follow-up.

CONCLUSION

Specialty care programs improve quality, cost outcomes, and the patient experience by appropriating resources to provide systematic and targeted care to high-risk patients. KP leverages an integration of people, processes, and technology to develop and scale population-based specialty care.

Topical mycophenolate mofetil in the treatment of vitiligo: a pilot study

BACKGROUND

Vitiligo is a multifactorial disease that is characterized by circumscribed depigmented macules and patches. Autoimmune reactions may play an important role in the pathogenesis of the disease. Mycophenolate mofetil is a drug that inhibits DNA synthesis in lymphocytes and has been used in autoimmune diseases such as immunobullous skin diseases, lupus erythematosus, and autoimmune hepatitis.

OBJECTIVES

The objective of this study was to show the efficacy of topical mycophenolate mofetil in the treatment of vitiligo.

METHODS

Thirty patients with limited vitiligo were enrolled in this study. The patients applied a topical preparation of mycophenolate mofetil 15% twice daily for three months and at the end of every month, repigmentation was assessed using the Vitiligo Area Scoring Index (VASI).

RESULTS

At the end of the third month, 36.6 % (n=11) of the patients showed about 25% repigmentation of the lesions. No side effects were observed throughout the study.

CONCLUSION

This study showed that topical mycophenolate mofetil can be somewhat effective in the treatment of vitiligo; however, it seems to be inferior to potent topical steroids in inducing repigmentation.

Successful Treatment of Stable Vitiligo by Low-Density Cultured Autologous Melanocyte Transplantation Combined With Narrowband Ultraviolet B Therapy

BACKGROUND

Cultured autologous melanocyte transplantation (CMT) is an effective treatment for stable vitiligo, but the current method is time consuming and expensive because of the requirement of a large number of melanocytes.

OBJECTIVE

To assess the clinical effect of low-density CMT combined with narrowband ultraviolet B (NB-UVB) in treating stable vitiligo.

MATERIALS AND METHODS

The authors treated 8 patients with CMT at a low cell density (less than 2.5 × 10 cells/cm). Among them, 6 patients underwent NB-UVB therapy after CMT.

RESULTS

All the 6 patients treated with low-density CMT combined with NB-UVB obtained more than 90% repigmentation at the 1-year follow-up.

CONCLUSION

The authors' data suggest that low-density CMT combined with NB-UVB can be an effective form of surgical treatment for stable vitiligo.

Pimecrolimus increases the melanogenesis and migration of melanocytes in vitro

Vitiligo is an intriguing depigmentary disorder and is notoriously difficult to be treated. The ultimate goal of vitiligo treatment is to replenish the lost melanocytes by immigration from hair follicle and to restore the normal function of melanogenesis by residual melanocytes. There are two types of topical calcineurin inhibitors called tacrolimus and pimecrolimus, and are recommended as the first-line treatments in vitiligo. Although pimecrolimus is efficacious for the repigmentation of vitiligo, its intrinsic mechanisms have never been investigated in vitro. This research aimed to study the ability of pimecrolimus on stimulating melanogenesis, melanocyte migration and MITF (microphthalmia associated transcription factor) protein expression. Results showed that pimecrolimus at the dosages of 1, 10, 10² nM were neither mitogenic nor cytotoxic to melanocytes. The addition of pimecrolimus at 10, 10² and 10³ nM significantly increased intracellular tyrosinase activity, which was consistent with the elevated content of melanin content at the same concentrations. The peak effect was seen at 72 h in response to 10² nM pimecrolimus. Results of the wound scratch assay and Transwell assays indicate that pimecrolimus is effective in facilitating melanocyte migration on a collagen IV-coated surface. In addition, MITF protein yield reached the highest by pimecrolimus at 10² nM. In brief, pimecrolimus enhances melanin synthesis as well as promotes migration of melanocytes directly, possibly via their effects on MITF protein expression.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

Clinical and epidemiological analysis in 149 cases of rhododendrol-induced leukoderma

Rhododendrol-induced leukoderma is an acquired depigmentation that develops mainly at the contact site after repeated use of skin-whitening cosmetics containing rhododendrol. In most cases, cessation of further depigmentation or occurrence of repigmentation is observed after discontinuing the use of cosmetics. However, some patients develop vitiligo vulgaris through the spread of depigmentation into the non-exposed areas. Our study aims to investigate the patient-specific factors that may affect the extent of depigmentation or repigmentation, as well as development of vitiligo vulgaris. The degree of depigmentation of the face, neck and hands where exposed to rhododendrol was scored using photographs over time. The relationships between depigmentation score at first visit/improvement rate of depigmentation score and patient demographics were evaluated and three important clinical observations were made. First, repigmentation of the face was superior compared with that of the hands and neck, suggesting a possible role for the migration and differentiation of melanocyte stem cells from hair follicles, as a mechanism of repigmentation. Second, the intensity of rhododendrol exposure did not contribute to differences in the severity of depigmentation. This suggested a possibility of underlying genetic susceptibility to melanocyte cytotoxicity or immune reaction. Third, depigmentation score at first visit and past history of atopic dermatitis were significantly high in patients who developed vitiligo vulgaris. This suggested that severe chemical damage of melanocytes by rhododendrol leads to a higher risk of developing vitiligo vulgaris through the possible involvement of an immune reaction. These clinical observations may help to further understand the pathogenesis of rhododendrol-induced leukoderma.

Effect of narrow band ultraviolet B phototherapy as monotherapy or combination therapy for vitiligo: a meta-analysis

BACKGROUND

The treatment of vitiligo is still one of the most difficult dermatological challenges, although there are many therapeutic options. Narrow band ultraviolet B (NB-UVB) phototherapy is considered to be a very important modality for generalized vitiligo.

OBJECTIVE

The aim of this study was to explore whether a combination of NB-UVB and topical agents would be superior to NB-UVB alone for treating vitiligo.

METHODS

We searched the electronic databases such as PUBMED, EMBASE, Cochrane Library, and Web of Science. The primary outcome was the proportion of ≥50% repigmentation (a clinical significance), and secondary outcome was the proportion of ≥75% repigmentation (an excellent response).

RESULTS

Seven randomized controlled trials (RCTs) involving 240 patients (413 lesions) were included in this meta-analysis. The study showed no significant difference between NB-UVB combination therapy (NB-UVB and topical calcineurin inhibitor or vitamin D analogs) and NB-UVB monotherapy in the outcomes of ≥50% repigmentation and ≥75% repigmentation. However, lesions located on the face and neck had better results in ≥50% repigmentation (RR = 1.40, 95% CI 1.08-1.81) and ≥75% repigmentation (RR = 1.88, 95% CI 1.10-3.20) with NB-UVB and topical calcineurin inhibitor combination therapy vs. NB-UVB monotherapy.

CONCLUSIONS

The meta-analysis suggested that adding neither topical calcineurin inhibitors nor topical vitamin-D3 analogs on NB-UVB can yield significantly superior outcomes than NB-UVB monotherapy for treatment of vitiligo. However, addition of topical calcineurin inhibitors to NB-UVB may increase treatment outcomes in vitiligo affecting face and neck.

Comparison of the efficacy of 308-nm excimer lamp monotherapy with topical tacrolimus or clobetasol 17-propionate combination therapies in localized vitiligo

BACKGROUND

In recent years, excimer light treatments have come to the fore in localized vitiligo because of their high efficacy and safety.

OBJECTIVE

We aimed to evaluate the efficacy of 308-nm excimer lamp as a monotherapy and its combination with tacrolimus 0.1% or clobetasol 17-propionate 0.05% ointment in localized vitiligo.

METHODS

We performed a retrospective study including a total of 82 patients who were treated with excimer lamp monotherapy (EL group) (n = 30), excimer lamp + topical tacrolimus (EL + T group) (n = 29), or excimer lamp + topical clobetasol 17-propionate (EL + CS group) (n = 23). We used digital morphometric analysis for the evaluation of repigmentation.

RESULTS

Median healing rate after 24 sessions was significantly higher in EL + T group (69%) than EL (42.5%) and EL + CS (44%) groups (P = 0.008 and P = 0.032). There were not any patients with face lesions in EL + CS group, so when these patients were excluded, EL + T and EL + CS groups had higher healing rates than EL group (P = 0.037 and P = 0.043). It was confirmed that combination with tacrolimus was superior to clobetasol-17 propionate (P = 0.048) with multivariate regression analysis.

CONCLUSION

We noted that 308-nm excimer lamp therapy was efficacious; adding topical tacrolimus or topical clobetasol-17 propionate could increase response to treatment.

The role of systemic steroids and phototherapy in the treatment of stable vitiligo: a randomized controlled trial

Pathogenesis of vitiligo is believed to be multifactorial disease with a wide variety of therapeutic modalities. The aim of this work is to assess the efficacy of oral mini-pulse steroids (OMP) plus Nb-U.V.B in comparison to OMP alone and Nb-U.V.B alone in treating stable vitiligo. A prospective randomized controlled study including 45 patients categorized into three groups receiving therapy for 3 months; Group A received Nb-U.V.B plus OMP, Group B received OMP alone while Group C received Nb-U.V.B alone. Clinical assessment and PCR evaluation of bFGF, ICAM1, and ELISA for AMA were done. Patients receiving Nb-U.V.B plus OMP and using Nb-U.V.B alone gave statistically significant clinical response than those treated with OMP alone. Statistically significant rise of BFGF was noticed after treatment with Nb-U.V.B plus OMP and with Nb-U.V.B alone. Patients treated with OMP alone and with Nb-U.V.B alone showed statistically significant drop of ICAM-1 after therapy. NB-U.V.B plus OMP and Nb-U.V.B alone were found to be clinically superior over OMP alone in treating stable vitiligo patients, hence suggesting that adding OMP to Nb-U.V.B can maintain clinical and laboratory success for a longer period of time and with less relapse.

IL-33 circulating serum levels are increased in patients with non-segmental generalized vitiligo

IL-33 is a recently identified cytokine, encoded by the IL-33 gene, which is a member of the IL-1 family that drives the production of T-helper-2 (Th-2)-associated cytokines. Serum levels of IL-33 have been reported to be up-regulated in various T-helper (Th)-1/Th-17-mediated diseases, such as psoriasis, rheumatoid arthritis, and inflammatory bowel. To investigate whether cytokine imbalance plays a role in the pathogenesis of vitiligo, we performed a case-control association study by enzyme-linked immunosorbent assay of IL-33 in our patients. IL-33 serum levels were measured by a quantitative enzyme immunoassay technique in patients with non-segmental generalized vitiligo and compared with those of healthy controls. IL-33 serum levels in patients with vitiligo were significantly increased than those in healthy controls. There was a positive correlation of IL-33 serum levels with extension of vitiligo and disease activity. This study suggests a possible systemic role of IL-33 in the pathogenesis of vitiligo. Inhibiting IL-33 activity might be a novel therapeutic strategy in the treatment of autoimmune inflammatory disease, like vitiligo.

A Practical Approach to the Diagnosis and Treatment of Vitiligo in Children

Vitiligo is a common inflammatory skin disease with a worldwide prevalence of 0.5% to 2.0% of the population. In the pediatric population, the exact prevalence of vitiligo is unknown, although many studies state that most cases of vitiligo are acquired early in life. The disease is disfiguring, with a major psychological impact on children and their parents. Half of vitiligo cases have a childhood onset, needing thus a treatment approach that will minimize treatment side effects while avoiding psychological impacts. Management of vitiligo should take into account several factors, including extension, psychological impact, and possible associations with other autoimmune diseases. This review discusses the epidemiology of vitiligo and outlines the various clinical presentations associated with the disorder and their differential diagnosis. In addition, the pathophysiology and genetic determinants, the psychological impact of vitiligo, and management strategies are reviewed.

Portable home phototherapy for vitiligo

Vitiligo is the most common depigmentation disorder, affecting around 1% of population worldwide. There is no cure, and no firm clinical recommendations can be made for the treatment of vitiligo. A European guideline suggests early treatment of small lesions of recent onset and childhood vitiligo with combination of phototherapy and topical agents. Suitable facilities and equipment, such as hand-held portable phototherapy devices, are needed, if this new guideline is to be implemented. Hand-held units are suitable for small lesions, making phototherapy available for patients with limited and/or early vitiligo. Recently, a pilot randomized controlled multicenter trial study was conducted to develop an educational package for patients describing how to use phototherapy at home, adjust the dose, and manage short-term side effects. The pilot trial showed that vitiligo patients are very keen to participate in trials of home phototherapy. The study has successfully demonstrated willingness of participants to be randomized and very good treatment adherence and repigmentation rates, providing evidence of feasibility for a definitive trial. The mean post-trial outputs of hand-held phototherapy devices were lower than the pretrial values. Close collaboration with a local medical physics department is essential. Hand-held phototherapy devices might overcome the need to treat vitiligo in hospital-based phototherapy cabinets and allow early treatment at home that may enhance the likelihood of successful repigmentation.