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

Motor nerve conduction velocity is affected in segmental vitiligo lesional limbs

To evaluate the effects of segmental vitiligo (SV) on nerve conduction velocity (NCV) in different nerves, we compared the patient's lesional side of their body to the contralateral normal side. The 106 participants were selected from outpatients visiting the dermatological clinics of Huashan Hospital, Fudan University, from November 2011 to March 2014. NCVs were measured on the limbs and the face, including both motor and sensory nerves. The parameters for NCVs included motor nerve conduction velocity (MCV) and its distal conduction latency, sensory nerve conduction velocity, sensory nerve action potentials amplitude, and compound muscle action potential amplitude. MCV on the limbs was compromised by SV state, which was significantly slower on the lesional side of the body compared with the normal contralateral side (P = 0.006). Furthermore, SV at the stable stage significantly impaired MCV compared with the SV at progressive stage. There was no significant difference in the other parameters of NCV between lesional and normal sides of the body. Compound muscle action potentials in the face did not differ between lesional and healthy sides. Motor nerves in the limbs were compromised by SV, particularly when the disease was at the stable stage.

[Treatment of vitiligo]

The range of treatment options for vitiligo has significantly expanded in the last 10 years and we can offer our patients more effective treatment strategies supported by European guidelines and consensus findings. Topical and UV therapy are-often in combination-the main components of vitiligo treatment. The main outcome parameters include extent and maintenance of gained repigmentation, cessation of spreading, avoidance of side effects and the influence of the treatment on the quality of life. The efficacy of the currently available treatments is often limited. New options include antioxidative or melanocyte-stimulating adjuvant therapies in combination with UV or laser light as well as a topical maintenance treatment to reduce the risk of recurrences. In many cases, psychological support is indicated.

Efficacy and Safety of 308-nm Monochromatic Excimer Lamp Versus Other Phototherapy Devices for Vitiligo: A Systematic Review with Meta-Analysis

BACKGROUND

Various phototherapy methods are used to treat vitiligo; however, the recent emergence of new devices has heightened debate concerning the best treatment method.

OBJECTIVE

We aimed to systematically review and meta-analyze published data comparing the efficacy and adverse effects of monochromatic excimer lamps versus excimer laser and narrowband ultraviolet B (NB-UVB) in treating vitiligo.

METHODS

A systematic search of PubMed, EMBASE, LILACS, Cochrane Central Register of Controlled Trials (CENTRAL), and clinical trials registries identified randomized controlled trials that included vitiligo patients, regardless of age, sex, or study language. We evaluated studies comparing excimer lamps with excimer laser or NB-UVB phototherapy.

RESULTS

The review included six studies (411 patients, 764 lesions). No study found significantly different efficacy between excimer lamps and excimer laser using the outcomes of ≥50% repigmentation [risk ratio (RR) = 0.97, 95% confidence interval (CI) 0.84-1.11] and ≥75% repigmentation (RR = 0.96, 95% CI 0.71-1.30). Likewise, no study found significant differences between excimer lamps and NB-UVB (RR = 1.14, 95% CI 0.88-1.48 for ≥50% repigmentation; RR = 1.81, 95% CI 0.11-29.52 for ≥75% repigmentation). Adverse effects were mild, including pruritus, burning sensation, and dryness, none of which interrupted treatment.

CONCLUSIONS

To our knowledge, this is the first systematic review of the efficacy and safety of excimer lamp treatment for vitiligo. Excimer lamps, excimer laser, and NB-UVB are all safe and effective in repigmentation of vitiligo lesions. Safety, effectiveness, and cost are considerations when choosing treatment.

PROSPERO REGISTRATION NUMBER

CRD42014015237.

Comparative study between excimer light and topical antioxidant versus excimer light alone for treatment of vitiligo

BACKGROUND

Vitiligo is an acquired idiopathic cutaneous disease characterized by pearly white patches of variable shapes and sizes. Various medical and surgical therapeutic options have been proposed to achieve repigmentation; phototherapy is one of the most efficient options. Topical therapies have been a mainstay of vitiligo treatment, with or without phototherapy.

AIM OF THE WORK

To compare the efficacy of combined topical antioxidant hydrogel and excimer light versus excimer light alone in treating vitiligo.

PATIENTS AND METHODS

Thirty patients were included in this comparative, prospective, randomized study. For each patient, at least 2-4 vitiliginous macules were randomly selected and treated while an untreated vitiliginous macule served as control. Lesions were divided into two groups: Group A received combination therapy of daily topical antioxidant plus excimer light, while Group B received only excimer light. Lesions were treated twice a week for a maximum of 24 sessions. Initial fluencies were adjusted individually according to the minimal erythema dose in vitiliginous skin. Efficacy based on repigmentation percentages were blindly evaluated by two independent physicians.

RESULTS

Group A lesions showed significant efficacy than group B (p < 0.001), specially on treating UV-sensitive lesions with no side effects.

CONCLUSION

Topical antioxidant and excimer light represents a valuable, effective therapy for localized vitiligo.

The Safety and Efficacy of Narrow Band Ultraviolet B Treatment in Dermatology: A Review

Narrow-band ultraviolet B (NBUVB) phototherapy is an important treatment modality in dermatology. The most common dermatological indications for NBUVB include psoriasis, atopic dermatitis and vitiligo; however, it has been found to be an effective and well-tolerated treatment option in various other dermatoses. The efficacy of NBUVB phototherapy compares favorably with other available photo(chemo)therapy options and its efficacy is further augmented by a number of topical and systemic adjuncts. The long-term safety of NBUVB phototherapy remains to be fully elucidated; however, available data now suggest that it is safe and well-tolerated. The objective of this review was to summarize the current understanding of the safety and efficacy of NBUVB phototherapy in dermatology.

[Differential diagnostics of hypomelanoses]

Hypomelanoses of the skin encompass a wide spectrum of congenital and acquired alterations in melanin pigmentation. These diseases can be localized or universal. The pathobiology of cutaneous hypomelanoses is heterogeneous and includes defects in melanoblast migration from the neural crest to the epidermis, alterations in melanogenesis and melanin transfer to keratinocytes, and destruction of pigment cells by autoimmune and inflammatory processes. Importantly, some congenital forms of universal hypomelanoses are associated with involvement of internal organs (e.g., Hermansky-Pudlack or Chédiak-Higashi syndrome) and require interdisciplinary patient management. In recent years, significant progress has been made in our current understanding of the pathophysiology especially of vitiligo, thus, resulting in promising new treatment strategies. This disease being one of the most common forms of acquired hypomelanoses of the skin can now be treated in a guideline-oriented and evidence-based manner.

Transcriptional Analysis of Vitiligo Skin Reveals the Alteration of WNT Pathway: A Promising Target for Repigmenting Vitiligo Patients

Vitiligo affects 1% of the worldwide population. Halting disease progression and repigmenting the lesional skin represent the two faces of therapeutic challenge in vitiligo. We performed transcriptome analysis on lesional, perilesional, and non-depigmented skin from vitiligo patients and on matched skin from healthy subjects. We found a significant increase in CXCL10 in non-depigmented and perilesional vitiligo skin compared with levels in healthy control skin; however, neither CXCL10 nor other immune factors were deregulated in depigmented vitiligo skin. Interestingly, the WNT pathway, which is involved in melanocyte differentiation, was altered specifically in vitiligo skin. We demonstrated that oxidative stress decreases WNT expression/activation in keratinocytes and melanocytes. We developed an ex vivo skin model and confirmed the decrease activation of the WNT pathway in human skin subjected to oxidative stress. Finally, using pharmacological agents that activate the WNT pathway, we treated ex vivo depigmented skin from vitiligo patients and successfully induced differentiation of resident stem cells into pre-melanocytes. Our results shed light on the previously unrecognized role of decreased WNT activation in the prevention of melanocyte differentiation in depigmented vitiligo skin. Furthermore, these results support further clinical exploration of WNT agonists to repigment vitiligo lesions.

A combination of excimer laser treatment and topical tacrolimus is more effective in treating vitiligo than either therapy alone for the initial 6 months, but not thereafter

BACKGROUND

There are insufficient data on the long-term outcome of a combination therapy that comprises phototherapy and topical administration of tacrolimus.

AIM

To evaluate the clinical efficacy according to the duration of treatment and in vitro results of a combination therapy involving topical tacrolimus and an excimer laser in the treatment of vitiligo.

METHODS

In total, 276 patients with nonsegmental vitiligo were treated with an excimer laser twice weekly, or with tacrolimus ointment twice daily, or both. The melanin contents and levels of melanogenic enzymes were measured in cultured human melanocytes treated with tacrolimus and/or excimer laser.

RESULTS

After adjusting for potential confounders, the combination of tacrolimus plus excimer laser was significantly more effective than either tacrolimus or excimer laser alone (P < 0.001 and P < 0.01, respectively) for the first 6 months. However, this superiority was not observed after the initial 6 months of treatment. In vitro, the combination of tacrolimus plus excimer laser led to a higher level of melanogenesis than with either treatment alone.

CONCLUSIONS

A combination treatment with topical tacrolimus and an excimer laser may be useful as an induction therapy for up to 6 months, but continuation of this therapy for > 6 months might not provide a better final outcome than monotherapy.

Current Management of Pediatric Vitiligo

Vitiligo is a common inflammatory disorder with worldwide prevalence of 0.4-2 % of the population, with half of cases beginning in childhood. The management of childhood vitiligo should be tailored to avoid negative effects on the overall growth and psychological development of the patient. Therapy of vitiligo in childhood is chosen based on the location of the lesions, lesion age, and extent of lesions in the context of the child's age and the developmental status of the child. There are four age categories in childhood vitiligo: [1] infantile and toddler (rare) (ages 0-3 years), [2] ages 4-8 years, [3] ages 9-12 years, and [4] 13+ years of age, based on developmental stage, psychological maturation, and ability to comply or participate in therapy. These categories are also differentiated psychologically by susceptibility to bullying, self-image development, and personal concern with lesion appearance, which increases with time. Intervention is advisable in cases with facial and leg involvement due to prominence of lesions and cosmetic defect. Medical interventions are largely the usage of topical therapies including corticosteroids and calcineurin inhibitors, some vitamin therapy (oral and topical vitamin D), and judicious introduction of phototherapy sources based on age and severity. Screening and appropriate subspecialist referral for co-morbidities (e.g., thyroid disease, celiac disease, psychological distress, and vitamin D deficiency) may enhance overall health. Cosmesis and camouflage are generally safe in childhood and have been noted to improve overall quality of life in this grouping. Genetic transmission of vitiligo is minimal at 5-6 % in first-degree relatives. This article reviews the therapeutics of pediatric vitiligo from the perspective of developmental stages and response to therapy.

Correlation of Serum Thyroid Hormones Autoantibodies with Self-Reported Exposure to Thyroid Disruptors in a Group of Nonsegmental Vitiligo Patients

Vitiligo is a pigmentary disorder strongly associated with autoimmune thyroid disorders (ATD). Thyroid hormones antibodies (THAb) directed toward thyroxine (T3) and triiodothyronine (T4) (T3- and T4-Ab) are rare in the general population but are increased in individuals wit ATD and extrathyroid autoimmune disorders. Because it is known that alcohol, smoke, iodine, and some thyroid disruptors can elicit the appearance of ATD, the aim of our study was to evaluate possible correlation between T3- and T4-Ab expression and past toxic exposures in vitiligo patients. Seventy vitiligo patients were examined and self-reported exposure to thyroid disruptors (4,4'-isopropylidenediphenol, perchlorates, polychlorinated biphenyls (PCBs), hexachlorobenzene, resorcinol, dichlorodiphenyltrichloroethane, alachlor/amitriole, nitrate, thiocyanate, soy isoflavones), iodine intake, smoke, and alcohol consumption were investigated through standardized questionnaires. Immunoglobulin (Ig)M-T3-Ab, IgG-T3-Ab, IgM-T4-Ab,and IgG-T4-Ab were dosed by a radioimmunoprecipitation technique. Seventy-seven (95.7 %) patients had at least one type of THAb. Most of them had contemporarily both T3- and T4-Ab (50/70). We found a significant association between PCBs and T4-IgG-Ab (P = 0.039) and between food intake containing nitrate, thiocyanate, and soy isoflavones with (IgM + IgG)-T3-Ab (P = 0.041). Our study underlines a possible influence of diet and environment in vitiligo patients in eliciting THAb. Therefore, in the event of a positive exposure to thyroid disruptors, an evaluation of thyroid function might be useful to early detect possible associated thyroid autoantibodies such as THAb.

Vitiligo

Vitiligo, an acquired pigmentary disorder of unknown origin, is the most frequent cause of depigmentation worldwide, with an estimated prevalence of 1%. The disorder can be psychologically devastating and stigmatising, especially in dark skinned individuals. Vitiligo is clinically characterised by the development of white macules due to the loss of functioning melanocytes in the skin or hair, or both. Two forms of the disease are well recognised: segmental and non-segmental vitiligo (the commonest form). To distinguish between these two forms is of prime importance because therapeutic options and prognosis are quite different. The importance of early treatment and understanding of the profound psychosocial effect of vitiligo will be emphasised throughout this Seminar.

Vitiligo

Vitiligo is an acquired depigmenting disorder that affects 0.5% to 2% of the world population. Three different forms are classified according to the distribution of lesions; namely non-segmental, segmental and mixed vitiligo. Vitiligo is associated with polymorphisms in genes involved in the immune response and in melanogenesis. However, environmental factors are required for the development of manifest disease. In general, the diagnosis is clinical and no laboratory tests or biopsies are required. Metabolic alterations are central to current concepts in pathophysiology. They induce an increased generation of reactive oxygen species and susceptibility to mild exogenous stimuli in the epidermis. This produces a senescent phenotype of skin cells, leads to the release of innate immune molecules, which trigger autoimmunity, and ultimately causes dysfunction and death of melanocytes. Clinical management aims to halt depigmentation, and to either repigment or depigment the skin, depending on the extent of disease. New therapeutic approaches include stimulation of melanocyte differentiation and proliferation through α-melanocyte-stimulating hormone analogues and through epidermal stem cell engineering. Several questions remain unsolved, including the connection between melanocyte depletion and stem cell exhaustion, the underlying degenerative mechanisms and the biological mediators of cell death. Overall, vitiligo is an excellent model for studying degenerative and autoimmune processes and for testing novel approaches in regenerative medicine. For an illustrated summary of this Primer, visit: http://go.nature.com/vIhFSC.

The role of neuropeptides in the control of regional immunity

Neuropeptides (NPs) and neurotransmitters are a heterogeneous group of soluble factors that make connections within the neuroendocrine and immune systems. NPs, including substance P (SP), vasoactive intestinal peptide (VIP), α melanocyte-stimulating hormone (α-MSH), and calcitonin gene-related peptide (CGRP), released by nerves that innervate the skin, can modulate the action of innate and adaptive skin immunity as well as the skin cells functions. Their role in several inflammatory skin diseases, such as atopic dermatitis, psoriasis, and vitiligo, and in the isotopic response has been reported. Further progress in understanding the various processes that modulate the interactions of the nervous and the skin immune system is essential to develop effective treatment for inflammatory skin conditions with neurogenic components and for understanding signs and symptoms in the isotopic response and, in general, in the control of global and regional immunity.

Vitiligo--Part 2--classification, histopathology and treatment

In an unprecedented effort in the field of vitiligo, a global consensus resulted on a suggested new classification protocol for the disease. The main histopathological finding in vitiligo is the total absence of functioning melanocytes in the lesions, while the inflammatory cells most commonly found on the edges of the lesions are CD4+ and CD8+ T lymphocytes. Physical and pharmacological treatment strategies aim to control the autoimmune damage and stimulate melanocyte migration from the unaffected edges of lesions and the outer hair follicle root sheath to the affected skin; moreover, surgical treatments can be combined with topical and physical treatments.

Obtainment of pellets using the standardized liquid extract of Brosimum gaudichaudii Trécul (Moraceae)

Background:

The standardized liquid extract of Brosimum gaudichaudii Trécul is an alternative for the treatment of vitiligo. There is a shortage of solid oral dosage forms developed from standardized extracts of this plant specie.

Objective:

This study is aimed to obtain pellets with a standardized liquid extract of B. gaudichaudii.

Results:

The standardized liquid extract of B. gaudichaudii was obtained through maceration and percolation with a 55% ethanol-water solution (v/v). Pellets were obtained through a mixture of extract of 500 g of B. gaudichaudii standardized extract, 500 g of microcrystalline cellulose PH101 and 10 g of hydroxypropyl methylcellulose K100. The pellets obtained presented a homogeneity yield of 92%, aspect ratio of 1.16 ± 0.65, shape fator e_R of 0.35 ± 0.09 and Feret diammeter of 0.87 ± 0.27. These pellets were coated with a suspension composed of titanium dioxide, aluminum red lacquer, ethyl cellulose, talc and magnesium stearate. Before the photostability test, the uncoated pellets showed psoralen content equal to 0.13 ± 0.01% and to the 5-MOP was 1.40 ± 0.27%. After exposure to one level (3 J.cm^-2) of UVB irradiation the uncoated pellets presented a degradation of 2.16% of psoralen and 8.1% of 5-MOP. After exposure to three levels (10, 20 and 30 J.cm^-2) of UVA irradiation the uncoated pellets exhibited photodegradation of 9.78, 17.64, 24.21% of psoralen and 18.95, 23.68, 28.48% for 5-MOP. The coated pellets where unaffected after photostability test.

Conclusion:

Pellets were obtained with the standardized liquid extract of B. gaudichaudii and coating is a technological alternative to ensure the stability of the formula.

Beyond vitiligo guidelines: combined stratified/personalized approaches for the vitiligo patient

'Vitiligo' is a word that bears endless possibilities and no promises. Each vitiligo patient has a different story that demands a different therapeutic approach. Even though great efforts have been made to evaluate, study, compare and document the different therapeutic modalities available for vitiligo, clearly handling their modes of actions as well as their side effects and establishing clear stratified guidelines, numerous dilemmas are frequently met on practical grounds. 'Stabilize', 'repigment', 'depigment' or 'camouflage'? 'for whom and how do we achieve the best results' ? 'Separately or in combination ? - questions that need to be answered and decisions need to be taken in the appropriate timing and altered when the necessity arises. In the current viewpoint, we have utilized the available knowledge and exploited years of experience in an attempt to go beyond the guidelines to set the rationale for an optimal and personalized therapy, within the framework of a stratified approach.

Maintenance therapy of adult vitiligo with 0.1% tacrolimus ointment: a randomized, double blind, placebo-controlled study

The risk of relapse after successful repigmentation in vitiligo is estimated to 40% within the first year. It has been shown in atopic dermatitis that continuous low-level use of topical corticosteroids and calcineurin inhibitors in previously affected skin can prevent new flares. We hypothesized that a twice-weekly application of 0.1% tacrolimus ointment might be effective for maintaining repigmentation in therapeutically repigmented lesions of vitiligo patients. After randomization, sixteen patients with 31 patches were assigned to the placebo group and 19 patients with 41 patches were assigned to the tacrolimus group. In the intention-to-treat analysis, 48.4% of lesions showed depigmentation in the placebo group, whereas 26.8% did in the tacrolimus group (P=0.059). The intention-to-treat results did not remain significant after adjustment for within-patient clustering, odds ratio (OR) 2.55; 95% confidence interval (CI; 0.65-9.97); P=0.1765. The per-protocol analysis (n=56) showed that 40% of lesions had some depigmentation in the placebo group, whereas only 9.7% did in the tacrolimus group (P=0.0075). The per-protocol results remained significant after adjustment for within-patient clustering: OR 6.22; 95% CI (1.48-26.12); P=0.0299. Our study shows that twice-weekly application of 0.1% tacrolimus ointment is effective in preventing the depigmentation of vitiligo patches that have been previously successfully repigmented.

Vitiligo: an evidence-based update. Report of the 13th Evidence Based Update Meeting, 23 May 2013, Loughborough, U.K

The Evidence Based Update (EBU) meetings are annual one-day meetings held by the Centre of Evidence Based Dermatology at the University of Nottingham. The aim of the meeting is to discuss high-quality evidence, mainly in the form of systematic reviews and randomized controlled trials, on a different topic each year. The meetings are designed to be interactive with a panel discussion between international experts and delegates forming a key part of the meeting. The 13th EBU meeting was on vitiligo and took place on 23 May 2013 in Loughborough, U.K. The most recent research including new and unpublished studies was presented on the classification of vitiligo, the evidence behind different treatment options and current guidelines for vitiligo.

CXCL10 is critical for the progression and maintenance of depigmentation in a mouse model of vitiligo

Vitiligo is an autoimmune disease of the skin that results in disfiguring white spots. There are no U.S. Food and Drug Administration-approved treatments for vitiligo, and most off-label treatments yield unsatisfactory results. Vitiligo patients have increased numbers of autoreactive, melanocyte-specific CD8(+) T cells in the skin and blood, which are directly responsible for melanocyte destruction. We report that gene expression in lesional skin from vitiligo patients revealed an interferon-γ (IFN-γ)-specific signature, including the chemokine CXCL10. CXCL10 was elevated in both vitiligo patient skin and serum, and CXCR3, its receptor, was expressed on pathogenic T cells. To address the function of CXCL10 in vitiligo, we used a mouse model of disease that also exhibited an IFN-γ-specific gene signature, expression of CXCL10 in the skin, and up-regulation of CXCR3 on antigen-specific T cells. Mice that received Cxcr3(-/-) T cells developed minimal depigmentation, as did mice lacking Cxcl10 or treated with CXCL10-neutralizing antibody. CXCL9 promoted autoreactive T cell global recruitment to the skin but not effector function, whereas CXCL10 was required for effector function and localization within the skin. Surprisingly, CXCL10 neutralization in mice with established, widespread depigmentation induces reversal of disease, evidenced by repigmentation. These data identify a critical role for CXCL10 in both the progression and maintenance of vitiligo and thereby support inhibiting CXCL10 as a targeted treatment strategy.

[Skin disorders in diabetes mellitus]

Diabetes mellitus is one of the most common diseases in the Western industrialized countries with about 300 million affected patients worldwide. The hyperglycemic state of diabetes mellitus leads to changes in practically every cell type and organ of the human body. Skin changes are considered the most common manifestations of diabetes mellitus. As skin changes can manifest before onset of diabetes mellitus they may have a diagnostic relevance. Other changes and diseases of the skin develop during the course of diabetes mellitus and may be associated with complications in internal organs or may occur as an adverse effect of antidiabetic therapy. In particular the presence of the diabetic foot syndrome is associated with significantly increased morbidity and mortality of diabetes patients as well as with markedly elevated direct and indirect costs for the health care system. In this article the most common skin diseases of patients with diabetes mellitus as well as their pathophysiology and current treatment are reviewed.

Vitiligo: characterization of melanocytes in repigmented skin after punch grafting

BACKGROUND

Punch grafting is a surgical technique mainly applied in therapy-resistant, stable and circumscribed vitiligo.

OBJECTIVE

(i) To characterize in detail the features of the repigmented skin among punch grafts; and (ii) to correlate the ex vivo results with clinical data and punch grafting outcome.

METHODS

We evaluated by immunohistochemistry and image analysis the expression of a panel of specific melanocyte markers including HMB45, MITF, c-kit, MART-1 and TRP1, the proliferation marker Ki67 and the cell-cell adhesion molecule E-cadherin in tissue samples collected from nine patients after punch grafting.

RESULTS

Cells positive for MITF, c-kit, MART-1 and TRP1 were detected in the repigmented skin of all biopsies, whereas no reactivity was observed for HMB45. Melanocytes were identified along the entire length of the sections, and their mature state was assessed by the immuno-reactivity for the differentiation marker MART-1, the absence of cells positively stained for Ki67 and by the co-expression of c-kit and TRP1, a marker of a differentiated and pigmented state. Clinically, smaller punch grafts aimed at repigmenting lesional areas on the face gave the faster clinical results with no side-effects. Patients subjected to bigger punch grafts on the knee exhibited a longer repigmentation time and presented cobble stoning.

CONCLUSION

Our results suggest that the repigmentation observed in the areas between the grafts is due to the activation of the melanocytes located in the donor sites. These cells start to horizontally migrate towards the lesional skin thanks to successively the enlargement of intercellular spaces in relation to a decrease of E-cadherin reactivity and the up-modulation of pro-melanogenic mediators. Production and transfer of melanin in the surrounding keratinocytes and their persistence were assessed by the reactivity for MITF, c-kit, MART-1 and TRP1 but not for the pre-melanosome marker (HMB45).

Pediatric vitiligo

Vitiligo is a disease of pigment loss. Most investigators currently consider vitiligo to be a disorder that occurs as a result of autoimmune destruction of melanocytes, supported by identification of antimelanocyte antibodies in many patients, and the presence of comorbid autoimmune disease in patients with and family members of individuals with vitiligo. One-half of vitiligo cases are of childhood onset. This article presents a current overview of pediatric vitiligo including comorbidities of general health, psychological factors, therapeutic options, and long-term health considerations.

Feasibility, double-blind, randomised, placebo-controlled, multi-centre trial of hand-held NB-UVB phototherapy for the treatment of vitiligo at home (HI-Light trial: Home Intervention of Light therapy)

BACKGROUND

Hand-held NB-UVB units are lightweight devices that may overcome the need to treat vitiligo in hospital-based phototherapy cabinets, allowing early treatment at home that may enhance the likelihood of successful repigmentation. The pilot Hi-Light trial examined the feasibility of conducting a large multi-centre randomised controlled trial (RCT) on the use of such devices by exploring recruitment, adherence, acceptability, and patient education.

METHODS

This was a feasibility, double-blind, multi-centre, parallel group randomised placebo-controlled trial of hand-held NB-UVB phototherapy for the treatment of vitiligo at home. The overall duration of the trial was seven months; three months recruitment and four months treatment. Participants were randomly allocated to active or placebo groups (2:1 ratio). The primary outcome measure was the proportion of eligible participants who were willing to be randomised. The secondary outcomes included proportion of participants expressing interest in the trial and fulfilling eligibility criteria, withdrawal rates and missing data, proportion of participants adhering to and satisfied with the treatment, and incidence of NB-UVB short-term adverse events.

RESULTS

Eighty-three percent (45/54) of vitiligo patients who expressed interest in the trial were willing to be randomised. Due to time and financial constraints, only 29/45 potential participants were booked to attend a baseline hospital visit. All 29 (100%) potential participants were confirmed as being eligible and were subsequently randomised. Willingness to participate in the study for General Practice (family physicians) surgeries and hospitals were 40% and 79%, respectively; 86% (25/29) of patients adhered to the treatment and 65% (7/11) of patients in the active group had some degree of repigmentation. Only one patient in the active group reported erythema grade 3 (3%). Both devices (Dermfix 1000 NB-UVB and Waldmann NB-UVB 109) were acceptable to participants.

CONCLUSIONS

Hand-held NB-UVB devices need evaluation in a large, pragmatic RCT. This pilot trial has explored many of the uncertainties that need to be overcome before embarking on a full scale trial, including the development of a comprehensive training package and treatment protocol. The study has shown strong willingness of participants to be randomised, very good treatment adherence and repigmentation rates, and provided evidence of feasibility for a definitive trial.

TRIAL REGISTRATION

NCT01478945.

Concise review of recent studies in vitiligo

Vitiligo is an acquired pigmentry disorder of the skin and mucous membranes which manifests as white macules and patches due to selective loss of melanocytes. Etiological hypotheses of vitiligo include genetic, immunological, neurohormonal, cytotoxic, biochemical, oxidative stress and newer theories of melanocytorrhagy and decreased melanocytes survival. There are several types of vitiligo which are usually diagnosed clinically and by using a Wood's lamp; also vitiligo may be associated with autoimmune diseases, audiological and ophthalmological findings or it can be a part of polyendocrinopathy syndromes. Several interventions are available for the treatment for vitiligo to stop disease progression and/or to attain repigmentation or even depigmentation. In this article, we will present an overall view of current standing of vitiligo research work especially in the etiological factors most notably the genetic components, also, types and associations and various and newer treatment modalities.

Vitiligo as a systemic disease

Vitiligo is an acquired depigmentary skin disorder of unknown etiology. Vitiligo is not only a disease of melanocytes of the skin. Human melanocytes are derived from the neural crest and are located on various parts of the body. The involvement of skin melanocytes is the most visible one, but a systemic involvement of melanocytes can be observed. Some types of vitiligo (nonsegmental vitiligo) may also be associated with various diseases, mainly with autoimmune pathogenesis. Vitiligo represents a spectrum of many different disorders with different etiologies and pathogeneses, causing a common phenotype: the loss of melanocytes and/or their products. This phenotype is always consistent with a systemic involvement.

Latent class analysis of a series of 717 patients with vitiligo allows the identification of two clinical subtypes

Non-segmental vitiligo (NSV) is an enigmatic disease with various clinical courses. To empirically identify underlying subtypes of NSV, we performed latent class analysis (LCA) of 717 consecutive patients with NSV seen between 2006 and 2012 and were analyzed. Median age was 32 yrs (14-45), median age at NSV onset was 18 yrs (8-32), and median NSV duration 5 yrs (0.75-78.5). A two-class model showed the best fit. Of the 717 patients, 280 (39%) belonged to LC1 and 437 (61%) to LC2. LC1 patients had high probabilities for early disease onset (<12 yrs), halo nevi, family history of premature hair greying, Koebner phenomenon, previous episodes of repigmentation, and family history of vitiligo. By contrast, LC2 patients were characterized by a late disease onset (after or at the age of 12 yrs, median age of 30 yrs) and acrofacial localization without any lesions on trunk or limbs. These two LCA classes (LC1, 'prepubertal onset'; LC2, 'post-pubertal onset') may help refining results from genome-wide association studies (GWAS) and allow a more accurate genotype-phenotype correlation and help defining more directed treatment protocols.

Quantification and comparison of psychiatric distress in African patients with albinism and vitiligo: a 5-year prospective study

BACKGROUND

Vitiligo and albinism are two disorders of pigmentation that make the affected African highly visible and strikingly different from their peers. Both pose considerable management challenges, attract significant stigma and profound impairment of quality of life.

OBJECTIVE AND METHODS

To determine and compare psychiatric distress in vitiligo and albinism using the Hospital Anxiety and Depression Scale (HADS). Participants were 87 albinos and 102 vitiligo adult patients seen at an urban tertiary hospital in Nigeria between 2004 and 2009.

RESULTS

Prevalence of psycho morbidity was 59% (60/102) in vitiligo compared with 26% (23/87) in the albinos. The mean anxiety score was estimated to be 2.55 points lower for albino patients (95% CI: 1.47 to 3.64), and the mean depression score 2.76 points lower (95% CI: 1.84 to 3.68), after adjustment for age, sex and marital status. However, significant differences were not observed when comparing the vitiligo patients with the subset of albino patients with skin cancer. Older patients had significantly higher anxiety and depression scores. Females had significantly higher anxiety scores (but not depression scores) compared to males. Genital involvement in vitiligo was significantly associated with anxiety but not depression.

CONCLUSIONS

We found that the African with vitiligo suffers significantly higher psychiatric distress than the African albino on average. Clinical evaluation of these patients would be incomplete without assessment of their psycho morbidity. There is need for increased focus on cancer prevention strategies in the African albino.