Vitiligo after the resolution of psoriatic plaques during treatment with adalimumab

Treatment update for vitiligo based on autoimmune inhibition and melanocyte protection

INTRODUCTION

The treatment of vitiligo remains challenging due to the complexity of its pathogenesis, influenced by genetic factors, oxidative stress and abnormal cell adhesion that collectively impact melanocyte survival and trigger immune system attacks, resulting in melanocyte death. Melanocytes in vitiligo are believed to exhibit genetic susceptibility and defects in cellular mechanisms, such as defects in autophagy, that reduce their ability to resist oxidative stress, leading to increased expression of the pro-inflammatory protein HSP70. The low expression of adhesion molecules, such as DDR1 and E-cadherin, accelerates melanocyte damage and antigen exposure. Consequently, autoimmune attacks centered on IFN-γ-CXCR9/10-CXCR3-CD8⁺ T cells are initiated, causing vitiligo.

AREAS COVERED

This review discusses the latest knowledge on the pathogenesis of vitiligo and potential therapeutic targets from the perspective of suppressing autoimmune attacks and activating melanocytes functions.

EXPERT OPINION

Vitiligo is one of the most challenging dermatological diseases due to its complex pathogenesis with diverse therapeutic targets. Immune suppression, such as corticosteroids and emerging JAK inhibitors, has proven effective in disease progression. However, during the early stages of the disease, it is also important to optimize therapeutic strategies to activate melanocytes for alleviating oxidative stress and improving treatment outcomes.

Advances in vitiligo: Update on therapeutic targets

Vitiligo, whose treatment remains a serious concern and challenge, is an autoimmune skin disease characterized by patches of depigmentation. The increasing application of molecular-targeted therapy in skin diseases, such as psoriasis and systemic lupus erythematosus, has dramatically improved their condition. Besides, there is a favorable effect of repigmentation in the treatment of the above diseases combined with vitiligo, implying that molecular-targeted therapy may also have utility in vitiligo treatment. Recently, the role of cytokine and signaling pathways in vitiligo pathogenesis are increasingly recognized. Thus, investigations are underway targeting the molecules described above. In this paper, we present a synopsis of current practices in vitiligo treatment and introduce the improvement in identifying new molecular targets and applying molecular-targeted therapies, including those under development in vitiligo treatment, providing valuable insight into establishing further precision medicine for vitiligo patients.

Psoriasis, Vitiligo, and Biologic Therapy: Case Report and Narrative Review

Psoriasis and vitiligo are 2 multifactorial immune-mediated diseases, partially sharing pathogenetic underpinnings. Their coexistence in the same patient, although uncommon, is documented in the literature. Further, several cases of vitiligo induced by biological drugs in psoriatic patients are reported. However, improvements in psoriasis and pre-existing vitiligo after the introduction of biological therapy are also described. To date, anti-TNF-alpha is the most cited group of biological drugs that induce new-onset vitiligo or progression of pre-existence vitiligo in psoriatic patients. Even anti-IL-12/23 class would seem to induce vitiligo (as in our case) or even worse it. Anti-IL-17 drugs induce a progression of pre-existing vitiligo while, to date, no cases are reported in literature considering anti-IL-23 class.

The role of tumor necrosis factor-α in the pathogenesis of vitiligo

Vitiligo is an acquired immune disorder of the skin characterized by the presence of white depigmented macules. Its immunopathogenesis is not completely understood, but inflammatory alterations in the skin microenvironment, and particularly increased expression of the cytokine tumor necrosis factor-α (TNFα), are thought to be essential regulators of melanocyte dysfunction and death. In this article we review the evidence that implicates TNFα in the pathogenesis of vitiligo, including studies on serum and tissue levels of TNFα, TNFα gene polymorphisms, in vitro studies, and therapeutic trials using TNFα inhibitors. TNFα emerges as a complex mediator with apparently conflicting roles in vitiligo.

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

The aetiopathogenic mechanisms of vitiligo are still poorly understood, and this has held back progress in diagnosis and treatment. Up until now, treatment guidelines have existed at national levels, but no common European viewpoint has emerged. This guideline for the treatment of segmental and nonsegmental vitiligo has been developed by the members of the Vitiligo European Task Force and other colleagues. It summarizes evidence-based and expert-based recommendations (S1 level).

The Coexistence of Psoriasis and Vitiligo: A review

Background:

Psoriasis and vitiligo are both autoimmune diseases with an increased incidence noted in genetic relatives. They share similar trigger factors and have been observed to coexist in individuals.

Objective:

The purpose was to review the literature on the coexistence of psoriasis and vitiligo and to determine if there is a higher than expected prevalence of psoriasis in patients with vitiligo and vice versa.

Methods:

A literature review was conducted using Medline, EMBASE, and the Cochrane Library from 1968 to 2010. All articles that included reports of individuals with both psoriasis and vitiligo in the English language were documented.

Results:

We identified 338 articles, among which 35 case reports and 7 case series were mentioned. For each case series, the prevalence of psoriasis in patients with vitiligo, or vice versa, falls within the prevalence range of the background population on which the study was based.

Conclusion:

An increase in the expected prevalence of psoriasis in individuals with vitiligo, or vice versa, was not found in our study, suggesting that the coexistence of the two diseases appears to be due to chance alone. Large epidemiologic studies are required to address with certainty whether psoriasis is more common in individuals with vitiligo and vice versa.

Renseignements de base:

Le psoriasis et le vitiligo sont deux affections auto-immunes qui ont une incidence accrue observée chez les membres de la famille apparentée. Ils partagent des facteurs déclencheurs similaires, et des études ont démontré leur coexistence chez les personnes.

Objectif:

Le but était de faire une analyse documentaire sur la coexistence du psoriasis et du vitiligo et de déterminer s'il y a une prévalence plus élevée que prévu du psoriasis chez les patients atteints de vitiligo et vice versa.

Méthodes:

Une analyse documentaire a été effectuée en utilisant Medline, EMBASE, et la Cochrane Library de 1968 à 2010. Tous les articles comportant des rapports sur des personnes souffrant à la fois de psoriasis et de vitiligo rédigés en anglais ont été documentés.

Résultats:

Nous avons trouvé 338 articles, parmi lesquels 35 exposés de cas et 7 séries de cas ont été mentionnés. Pour chaque série de cas, la prévalence du psoriasis chez les patients atteints de vitiligo, ou vice versa, s'inscrit dans la fourchette de prévalence de la population de base qui a fait l'objet de l'étude.

Conclusion:

Notre étude n'a pas démontré une augmentation de la prévalence de psoriasis attendue chez les personnes atteintes de vitiligo, ou vice versa, ce qui suggère que la coexistence des deux affections semble être due au seul hasard. D'importantes études épidémiologiques sont nécessaires pour démontrer avec certitude que le psoriasis est plus fréquent chez les personnes atteintes de vitiligo et vice versa.

Vitiligo: an update on current pharmacotherapy and future directions

INTRODUCTION

Vitiligo is a common pigmentary skin disorder, characterized by the appearance of white macules on the skin, mucosal or hair. Treatment is often a tough challenge and involves a wide range of therapies.

AREAS COVERED

This review focuses on available first- and second-line pharmacological treatments for vitiligo. In particular, the mechanisms of action, the main indications, the efficacy and the most important side effects are reviewed. Moreover, a brief discussion is provided, regarding other nonpharmacological treatments, such as phototherapy and surgical options, due to their importance and successful outcomes in vitiligo treatment. Finally, a concise overview regarding the future directions in vitiligo therapy is presented.

EXPERT OPINION

The promising outcomes reported here demonstrate that it is possible to achieve a satisfactory and often stable repigmentation of vitiligo lesions. Topical corticosteroids, calcineurin inhibitors, phototherapy and photochemotherapy represent the first-line therapeutic options, due to their safety and efficacy, whereas vitamin D analogues, targeted phototherapy, oral corticosteroids and surgery should be used as second-line therapies. Other therapies, such as antioxidants, can be used in association with other therapeutic options, whereas depigmenting agents should be used only in cases of extensive vitiligo, recalcitrant to other treatments.

Worsening of Vitiligo and Onset of New Psoriasiform Dermatitis following Treatment with Infliximab

Background:

Vitiligo is a depigmentation disorder caused by melanocyte destruction that possibly results from an autoimmune mechanism. Psoriasis is an immune-mediated, chronic, inflammatory dermatosis. Although tumor necrosis factor α antagonists (anti-TNF-α), such as infliximab, are effective in treating psoriasis, many cases reported in the literature indicate that psoriasis might also be induced by treatment with infliximab. Some studies also suggest that TNF-α antagonists might be an effective treatment for vitiligo because the disorder is characterized by increased levels of TNF-α, indicating that it might play a role in the pathogenesis of this disease.

Objective:

We report a case of psoriasiform dermatitis with vacuolar interface reaction that occurred after infliximab therapy in a patient with vitiligo.

Method:

A 17-year-old male patient with vitiligo vulgaris was treated with an intravenous infusion of 5 mg/kg of infliximab at 0, 2, and 6 weeks and then once every 6 weeks over a span of 6 months. The patient was monitored both clinically and with laboratory investigations. He had no personal or family history of psoriasis. He tolerated the treatment well, without side effects. However, he developed a biopsy-proven psoriasiform lesion for the first time 4 months after he completed his sixth dose of infliximab. His vitiligo also worsened.

Conclusion:

This case report shows that infliximab given for vitiligo did not improve the disorder and that the vitiligo actually progressed. Moreover, psoriasiform lesions developed after this therapy. Further studies are needed to identify the effects of infliximab in patients with vitiligo.

Vitiligo during Treatment of Crohn's Disease with Adalimumab: Adverse Effect or Co-Occurrence?

Adalimumab is a fully human monoclonal anti-tumor necrosis factor-a agent that is approved for the treatment of Crohn's disease. It has a good safety profile, injection site reactions being the most common adverse effect. We report a case of a 54-year-old woman with a 30-year history of Crohn's disease who developed achromic patches on the trunk and upper extremities after initiating treatment with adalimumab. Cutaneous biopsy confirmed diagnosis of vitiligo and laboratory testing ruled out thyroid disease. Concomitant occurrence of vitiligo and inflammatory bowel disease, although rare, has been described. A common autoimmune basis could explain this fact. Moreover, multiple cutaneous adverse effects have been described in the literature secondary to biologic treatments, including vitiligo. In this report, we discuss the possibility of vitiligo as secondary to adalimumab treatment or as an association between both diseases.

Targeted treatment of psoriasis with adalimumab: a critical appraisal based on a systematic review of the literature

Psoriasis is a chronic inflammatory disease affecting 2% to 3% of the population in Western countries. Psoriasis is associated with limited quality of life, cardiovascular disease, and depression. The approval of injectable biological agents has revolutionized the management of moderate to severe psoriasis. Adalimumab is a human monoclonal antibody against tumor necrosis factor (TNF) alpha approved for moderate-to-severe plaque-type psoriasis and psoriatic arthritis (PsA). This systematic review summarizes the evidence concerning the efficacy, clinical effectiveness, safety, and cost-effectiveness of adalimumab in the treatment of psoriasis. Five randomized controlled trials demonstrated the efficacy of adalimumab in moderate-to-severe plaque-type psoriasis and PsA with PASI-75 response rates of 53% to 80% and ACR-20 response rates of 39% to 58% after 12 to 16 weeks of treatment. In clinical practice patients who have not responded to one TNF antagonist may respond to another TNF antagonist. Adalimumab has similar or better cost-effectiveness than other biologics, but is less efficient than methotrexate and cyclosporine. Adalimumab is generally well tolerated. Patients should be evaluated for active/latent tuberculosis, serious infections, and other contraindications prior to initiation of adalimumab therapy. Future studies should investigate the comparative efficacy of adalimumab and other biologic and prebiologic agents. Recently established registries will yield additional data on the effectiveness and long-term safety of adalimumab.