Alternative Systemic Treatments for Vitiligo: A Review

Efficacy and safety of fire needle therapy in treating non-segmental stable vitiligo: A randomized self-controlled clinical trial

BACKGROUND

Vitiligo remains a challenging condition to treat. Fire needle therapy, a traditional Chinese medicine technique, has potential as an alternative therapeutic strategy. However, rigorous evidence on its efficacy is lacking.

OBJECTIVE

We aimed to evaluate the efficacy and safety of fire needle therapy, alone and combined with topical tacrolimus ointment, for non-segmental stable vitiligo.

METHODS

In this 6-month randomized self-controlled trial, 35 vitiligo patients were enrolled, providing three similar lesions each. Lesions were randomly allocated to receive fire needle monotherapy, 0.1% tacrolimus ointment monotherapy, or combined fire needle and tacrolimus ointment therapy. The main outcome was change in vitiligo surface area.

RESULTS

In total, 29 patients completed the 6-month follow-up. The combination therapy group showed significantly greater reductions in vitiligo surface area compared to monotherapy groups starting at months 4 and 5. By the end of the study, combination therapy resulted in remarkably higher repigmentation responses, with 89.7% of lesions showing at least mild (≥25%) repigmentation and 51.7% showing good (≥50%) repigmentation. This significantly exceeded the outcomes with topical tacrolimus ointment alone, which only achieved 6.9% mild response and 6.9% good response. Fire needle monotherapy also demonstrated steady repigmentation over time, with 69% of lesions attaining a mild response by month 6. Importantly, no major adverse events occurred.

CONCLUSION

This study provides promising preliminary evidence supporting the use of fire needle therapy, alone or in combination with topical tacrolimus ointment, for inducing repigmentation in non-segmental stable vitiligo. As a non-pharmacological approach, fire needle therapy warrants further study as an alternative vitiligo treatment.

Topological Indices of Novel Drugs Used in Autoimmune Disease Vitiligo Treatment and Its QSPR Modeling

A topological index is a real number derived from the structure of a chemical graph. It is helpful to determine the physicochemical and biological properties of a wide range of drugs, and it better reflects the theoretical properties of organic compounds. This is accomplished using degree-based topological indices. Vitiligo is a common, acquired skin pigmentation disorder that significantly impacts the quality of life. It frequently embodies a therapeutic challenge, resulting in interest in alternative treatments based on vitamin and herbal supplements. In this article, azathioprine, clobetasol, desonide, hydrocortisone valerate, and other drugs utilized to cure vitiligo have discoursed, and the goal of QSPR revision is to determine the mathematical relationship between properties under investigation (e.g., polarity and enthalpy) and diverse descriptors associated with the drugs' molecule. The QSPR model will help to predict physical properties. In this study, topological indices (TIs) imposed on said drugs were found to have a good correlation with physicochemical properties in this course. Finally, this work can be helpful to design and synthesize new vitiligo treatments and other disease drugs.

Current Debates on Etiopathogenesis and Treatment Strategies for Vitiligo

Vitiligo is an acquired, chronic, and progressive depigmentation or hypopigmentation characterized by the destruction of melanocytes and the occurrence of white patches or macules in the skin, mucosal surface of eyes, and ears. Melanocytes are the melanin pigment-producing cells of the skin which are destroyed in pathological conditions called vitiligo. Approximately 0.5 - 2.0% of the population is suffering from vitiligo, and a higher prevalence rate of up to 8.8% has been reported in India. It is caused by various pathogenic factors like genetic predisposition, hyperimmune activation, increased oxidative stress, and alteration in neuropeptides level. Genetic research has revealed a multi- genetic inheritance that exhibits an overlap with other autoimmune disorders. However, melanocytes specific genes are also affected (such as DDR1, XBP1, NLRP1, PTPN22, COMT, FOXP3, ACE, APE, GSTP1, TLR, SOD, and CTLA-4). A number of therapeutic options are employed for the treatment of vitiligo. The topical corticosteroids and immunomodulators are currently in practice for the management of vitiligo. Phototherapies alone and in combinations with other approaches are used in those patients who do not respond to the topical treatment. The main focus of this review is on the etiopathological factors, pharmacological management (phototherapy, topical, systemic, and surgical therapy), and herbal drugs used to treat vitiligo.

Design, synthesis and structure-activity relationship optimization of phenanthridine derivatives as new anti-vitiligo compounds

Humans have been suffering from vitiligo for a long time. Target vitiligo drugs have yet been approved. Activation of Wnt/β-catenin signalling has potential in the therapeutic use of vitiligo, so exploring new drugs that specifically directly activate Wnt is worthwhile to obtain new anti-vitiligo agents. In this work, two portions design and synthesis were put into effect. firstly, 17 phenanthridine derivatives with C-4 substitutes were designed and synthesized, which compounds 4, 6, 12, 13 served as H-acceptor with protein showed enhance melanogenesis activity; Secondly, 7 hybrid new scaffolds of compounds were designed and synthesized, scaffold hopping compound 36 that aromatic benzene was replaced pyrazole on ring C showed enhance melanogenesis and tyrosinase activity; The last and most important, a comprehensive optimization and SARs of compound 36 were carried out, compounds 41 and 43 shared phenolic hydroxyl or 3-methyl-pyridine substitutes at C-7 position remarkably improved the capacity of melanogenesis and tyrosinase activity. Compound 43 were identified as new anti-vitiligo agents that specifically activate the Wnt/β-catenin signalling pathway by targeting Axin. Structure-activity relationship analysis implied that H-acceptor substitutions at the C-4 position and phenolic hydroxyl or pyridine substitutions at the C-7 position would improve the activities of the compounds. These findings reveal a new therapeutic strategy for vitiligo, and compounds 41 and 43 may represent potential compounds for vitiligo treatment.

Zinc supplementation for prevention and management of recurrent aphthous stomatitis: a systematic review

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a very common oral ulcerative disease with no definitive cure. Growing evidence suggests a significant association between zinc deficiency and RAS.

OBJECTIVES

To assess the efficacy of systemic zinc supplementations in the prevention and management of RAS.

METHODS

Five databases were searched for all English and Chinese studies published up to November 2020. All clinical trials that assessed the efficacy of zinc supplementations in the management and/or prevention of RAS were included.

RESULTS

Seven clinical trials comprising 482 RAS patients (250 in zinc group) fulfilled the inclusion criteria. The follow-up period ranged from three months to one year. Five studies showed significantly better efficacy of zinc in reducing the recurrence rates of RAS, whereas two studies did not report any significant differences compared to the controls. Four studies reported on signs/symptoms of RAS, three of which showed superior outcomes in favour of zinc, while one study reported comparable results.

CONCLUSION

Zinc supplementation seems to be efficacious in the management and prevention of RAS. However, further clinical trials with standardized methodologies and adequate follow-up periods are required to confirm the efficacy of zinc supplementations.

Diet in Dermatology: Review of Diet's Influence on the Conditions of Rosacea, Hidradenitis Suppurativa, Herpes Labialis, and Vitiligo

The influence of dietary patterns on cutaneous disease has been an oft-posed question to dermatologists by patients in a clinical setting. Similarly, the popularity of nutritional supplementation with vitamins, minerals, and nutraceutical blends has been increasing. Dermatologists, primary care physicians, and other providers should be familiar with dietary interventions that are evidence-based and those that are more marketable than efficacious. In this review, the modification of diet, including dietary exclusion and dietary supplementation for the treatment of rosacea, hidradenitis suppurativa (HS), herpes labialis, and vitiligo was investigated. Despite abundant anecdotal evidence, the literature search found no high-quality evidence that an elimination diet for rosacea "trigger foods" improved rosacea symptoms though these elimination diets (of hot, spicy, alcohol-containing, or cinnamaldehyde-containing foods) had low risk of harm. There is evidence that zinc supplementation and vitamin D supplementation in deficient patients is helpful for treating HS. For herpes labialis, L-lysine supplementation was found to be effective for prophylaxis but not for decreasing duration of active lesions. For vitiligo, the use of the herb Polypodium leucotomos in conjunction with phototherapy was found to increase repigmentation, as well as vitamin D supplementation in deficient patients.

Overexpression of improved EPSPS gene results in field level glyphosate tolerance and higher grain yield in rice

Glyphosate is a popular, systemic, broad-spectrum herbicide used in modern agriculture. Being a structural analog of phosphoenolpyruvate (PEP), it inhibits 5-enolpyruvylshikimate 3-phosphate synthase (EPSPS) which is responsible for the biosynthesis of aromatic amino acids and various aromatic secondary metabolites. Taking a lead from glyphosate-resistant weeds, two mutant variants of the rice EPSPS gene were developed by amino acid substitution (T173I + P177S; TIPS-OsEPSPS and G172A + T173I + P177S; GATIPS-OsEPSPS). These mutated EPSPS genes were overexpressed in rice under the control of either native EPSPS or constitutive promoters (maize ubiquitin [ZmUbi] promoter). The overexpression of TIPS-OsEPSPS under the control of the ZmUbi promoter resulted in higher tolerance to glyphosate (up to threefold of the recommended dose) without affecting the fitness and related agronomic traits of plants in both controlled and field conditions. Furthermore, such rice lines produced 17%-19% more grains compared to the wild type (WT) in the absence of glyphosate application and the phenylalanine and tryptophan contents in the transgenic seeds were found to be significantly higher in comparison with WT seeds. Our results also revealed that the native promoter guided expression of modified EPSPS genes did not significantly improve the glyphosate tolerance. The present study describing the introduction of a crop-specific TIPS mutation in class I aroA gene of rice and its overexpression have potential to substantially improve the yield and field level glyphosate tolerance in rice. This is the first report to observe that the EPSPS has role to play in improving grain yield of rice.

Phytochemical and Nutritional Quality Changes During Irrigation and Postharvest Processing of the Underutilized Vegetable African Nightshade

Underutilized or traditional leafy vegetables are grown in the wild and cultivated. They are consumed as nutritional accompaniments to staples, either raw (fresh), cooked, or in a dried form, through custom, habit, and tradition. These traditional leafy vegetables are natural rich sources of phytochemicals and nutritional compounds. Over time, the keenness for consumption of traditional vegetables has become less popular. Poor nutrient diets are the main cause of mortality and morbidity, especially in developing countries, where the problem is predominant due to poverty. Consumption of traditional vegetables can assist in the prevention of chronic disease development, as they contain various bioactive compounds that exhibit multiple health benefits. Traditional leafy vegetables play a vital role in combatting hunger, food insecurity, and malnutrition, and most are suitable for food intervention programs. African nightshade (Solanum family) is one such commonly consumed traditional leafy vegetable. During dry seasons, communities often face shortages of vegetables; thus, the preservation of edible leaves is one strategy to help overcome this problem. The adoption of solar drying and fermentation are traditional methods to extend the availability of African nightshade vegetables. Additionally, the agronomy practices and postharvest processing methods affect the phytochemicals and nutritional compounds of African nightshade accessions. This mini-review provides information on changes in phytochemicals, nutrition, and antinutritive compounds with different postharvest processing methods and irrigation. The review provides the justification to promote the cultivation for consumption, by identifying the potential African nightshade accessions that are rich in phytonutritional compounds. This mini-review summarizes and discusses the major information on (i) the micro- and macronutrients present in Solanum retroflexum, the most commonly consumed nightshade species compared with other traditional vegetables in Southern Africa, (ii) the composition of phytochemical compounds present in different nightshade accessions, (iii) the impact of irrigation on phytochemical composition in different nightshade species, and (iv) the impact of postharvest processing on phytochemicals and antinutritive compounds in S. retroflexum. Inclusion of African nightshade, especially S. retroflexum, with the main staple foods can improve protein, iron, and calcium levels in daily diets, which will help to improve people's health and well-being.

Application of medicinal plants in several dermatovenerological entities

Treatment of skin conditions with medicinal plants has been an ongoing human activity lasting over thousands of years. The use of specific plant species developed regionally, based on local flora. Commonly used medicinal plants for dermatological complaints are: Phlebodium aureum (L.) J. Sm., Ginkgo biloba L., Rosmarinus officinalis L., Panax ginseng C.A.Mey., Allium cepa L., Aloe vera (L.) Burm.f., Capsicum annuum L., Berbe ris aquifolium Pursh, Camellia sinensis (L.) Kuntze, and Podophyllum peltatum L. The demand for complementary therapeutics is an emerging trend due to the awareness of potential side effects that synthetic drugs might cause. More scientific evidence and better documentation are needed before advising dermatologic patients on herbal medicinal treatment. Standardised extracts and formulations with proven clinical efficacy should be developed for this cause. Here provided review entails the use of herbal medicinal products in the treatment of frequent chronic skin diseases, such as vitiligo, alopecia, psoriasis and genital warts.

Home phototherapy for patients with vitiligo: challenges and solutions

Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is well-demarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo.

Effectiveness of topical Nigella sativa for vitiligo treatment

Vitiligo is a pigment disease characterized by the disruption of melanocyte structure and function. Its etiology is unknown; however, genetic predisposition, biochemical factors, and neural mechanisms are thought to be effective. Although many agents are being used for its treatment, generally there is no absolute cure. The aim of the present study is to evaluate the effectiveness of topical Nigella sativa seed oil on vitiligo patients. Thirty-three vitiligo patients were included in the study. Totally 47 areas were evaluated in all patients. Cream containing N sativa seed oil was topically applied to hands, face, and genital region two times a day for 6 months. Statistically significant repigmentation was detected in hands, face, and genital region, the three treatment areas, and the p values are found .005, .001, and .004, respectively. N sativa can be used as an adjuvant therapy that can contribute to the treatment especially in sensitive skin areas like genital region.

The Use of Janus Kinase Inhibitors in Vitiligo: A Review of the Literature

Vitiligo is a common acquired depigmenting disorder characterized by the development of white macules and patches due to the loss of melanocytes. Patients with vitiligo can be stigmatized by society, making the disease a source of psychological stress that can considerably affect quality of life. The goal of vitiligo treatment is to obtain skin repigmentation in the majority of cases, and less commonly to depigment the remaining normal skin. There is no consistent, long-term, durable therapy for vitiligo for all patients, highlighting the unmet need for new safe and effective therapies to control this disease. Recently, JAK inhibitors have been explored as a promising novel treatment option in vitiligo. The JAK and signal transducers and activators of transcription (STAT) pathway is an attractive therapeutic target because IFN-γ-dependent cytokines produced through this pathway have been implicated in the pathogenesis of disease. This literature review describes vitiligo pathophysiology, explains the usefulness of the JAK inhibitors for treatment, and summarizes published case reports, case series, and open-label studies. Research outlined here shows JAK inhibitors in patients with vitiligo have a favorable safety profile and effectively produce repigmentation of lesions, especially with concomitant ultraviolet exposure. Additional studies are required to confirm efficacy, establish safety, and investigate durability of repigmentation.

Critical appraisal of the oxidative stress pathway in vitiligo: a systematic review and meta-analysis

BACKGROUND

The pathogenesis of vitiligo remains a topic of extensive debate. This is partly due to the moderate efficacy of current treatments. The role of the oxidative stress pathway in vitiligo is a popular although controversial research topic.

OBJECTIVE

To clarify the role of the oxidative stress pathway in vitiligo compared to other inflammatory skin disorders and to assess the therapeutic role of antioxidants.

METHODS

We conducted a systematic search of the existing literature on the aberrancies of the oxidative stress pathway in vitiligo. Subsequently, the efficacy of both topical and oral antioxidants in clinical trials was investigated.

RESULTS

A deregulated oxidative pathway is clearly evident with elevated superoxide dismutase, decreased catalase and increased lipid peroxidation. However, similar results have been obtained in other inflammatory skin diseases such as psoriasis, atopic dermatitis, lichen planus and urticaria. This questions the unique role of oxidative stress in the development of vitiligo. Some isolated successes have been reported with oral ginkgo biloba, polypodium leucotomos and vitamin C and E preparations, while other clinical trials have failed to show reproducible results. The use of topical antioxidants delivers in general no beneficial results.

CONCLUSION

The oxidative pathway is affected in vitiligo, but its unique initiating or contributory role in the pathogenesis is less evident. Interesting data support the added value of oral antioxidants in vitiligo although confirmatory studies are missing.

Serum Zinc Level in Vitiligo: A Case-control Study

Background:

Vitiligo is characterized by the idiopathic destruction of melanocytes, probably of autoimmune etiology, that results in depigmented patches of skin and mucosal surfaces. Oxidative stress may contribute to the pathogenesis of vitiligo. Zinc, a trace element with antiapoptotic properties, plays a major role in the process of melanogenesis and elimination of free radicals. The present study was conducted with the aim of comparing serum zinc levels in patients with vitiligo and in normal controls.

Materials and Methods:

In this case–control study, we studied 103 patients with vitiligo and 103 healthy sex-and age-matched controls. Serum zinc levels were measured in these two groups using atomic absorption spectrophotometry and compared with each other.

Results:

The mean serum zinc level was 92.1 mcg/dl in the focal vitiligo, 81.3 mcg/dl in the generalized vitiligo, and 91.8 mcg/dl in the control group. A significant difference in serum zinc levels was observed between the patients with generalized vitiligo and the controls. Lower serum zinc levels were also correlated with longer duration of the disease. Furthermore, a negative relationship was found between serum zinc level and age of patients with vitiligo.

Conclusion:

Serum zinc level is low in patients with generalized vitiligo. In these patients, serum zinc level is in negative correlation with patient's age and disease duration.

Nanoemulsion containing 8-methoxypsoralen for topical treatment of dermatoses: Development, characterization and ex vivo permeation in porcine skin

Oral therapy with 8-methoxypsoralen (8-MOP) may cause major side effects, whereas the topical treatment might not be much effective due to the low penetration induced by typical formulations. Therefore, the objectives of this work are the development and characterization of a nanoemulsion (NE) containing 8-MOP together with an ex vivo permeation study, monitored by a validated HPLC-Fluo method, to determine the amount of drug retained in viable skin (epidermis (E) and dermis (D)) and in stratum corneum (SC). The optimized conditions for NE formulation were achieved by full factorial designs (2⁵ and 3²): 60 s and 60% of ultrasound time and potency, respectively; 10 mL of final volume; 2% v/v of oil phase (clove essential oil); and 10% m/v of Poloxamer 407. The NE showed mean droplet diameter of 24.98 ± 0.49 nm, polydispersity index (PDI) of 0.091 ± 0.23, pH values of 6.54 ± 0.06, refractive index of 1.3525 ± 0.0001 and apparent viscosity of 51.15 ± 3.66 mPa at 20 °C. Droplets with nanospherical diameters were also observed by transmission electron microscopy (TEM). Ex vivo permeation study showed that 8.5% of the applied 8-MOP dose permeated through the biological membranes, with flux (J) of 1.35 μg cm^-2 h^-1. The drug retention in E + D and in SC was 10.15 ± 1.36 and 1.95 ± 0.71 µg cm^-2, respectively. Retention in viable skin induced by the NE was almost two-fold higher than a compounded cream (5.04 ± 0.30 μg cm^-2). These results suggested that the developed NE is a promising alternative for 8-MOP topical therapy when compared to commercial formulations.

Herbal Compounds for the Treatment of Vitiligo: A Review

An overview of unconventional therapies for vitiligo is presented. Some herbal compounds may be considered as valid therapeutic tools for the treatment of vitiligo.

[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.

A holistic review on the autoimmune disease vitiligo with emphasis on the causal factors

Vitiligo is an idiopathic systemic autoimmune disease affecting skin, hair and oral mucosa. This genetic yet acquired disease characterized by melanin loss is a cause of morbidity across all races. Though thyroid disturbance has been recognized as a key trigger of this pathology, an array of other factors plays critical role in its manifestation. Multiple hormones (corticotropin-releasing hormone, adrenocorticotropic hormone, α-melanocyte-stimulating hormone, melatonin, calcitriol, testosterone, estrogen), genes (Human leukocyte antigen (HLA), Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), Forkhead box D3 (FOXD3), Cluster of differentiation 117 (CD117), Estrogen receptor (ESR) 1, Cyclooxygenase-2 (COX2), Vitiligo-associated protein 1 (VIT1)), and lifestyle choices (stress, diet, cosmetic products, and medications) have been suspected as drivers of this disorder. The pathological mechanisms have been understood in recent times, with the aid of genomic studies; however a universally-effective therapy is yet to be achieved. This review discusses these under-investigated facets of vitiligo onset and progression; hence, it is expected to enrich vitiligo research.

Vitiligo Pathogenesis and Emerging Treatments

The pathogenesis of vitiligo involves interplay between intrinsic and extrinsic melanocyte defects, innate immune inflammation, and T-cell-mediated melanocyte destruction. The goal of treatment is to not only halt disease progression but also promote repigmentation through melanocyte regeneration, proliferation, and migration. Treatment strategies that address all aspects of disease pathogenesis and repigmentation are likely to have greatest efficacy, a strategy that may require combination therapies. Current treatments generally involve nontargeted suppression of autoimmunity, whereas emerging treatments are likely to use a more targeted approach based on in-depth understanding of disease pathogenesis, which may provide higher efficacy with a good safety profile.