Vitiligo: a comprehensive overview Part II: treatment options and approach to treatment

Multiple gene-drug prediction tool reveals Rosiglitazone based treatment pathway for non-segmental vitiligo

Vitiligo is a skin disease characterized by selective loss of melanocytes, which seriously affects the appearance and causes great psychological stress to patients. In this study, we performed a comprehensive analysis of two vitiligo microarray datasets from the GEO database using bioinformatics tools to identify 297 up-regulated mRNAs and 186 down-regulated mRNAs, revealing important roles for pathways related to melanin synthesis, tyrosine metabolism, and inflammatory factors, such as "PPAR signaling pathway", "tyrosine metabolism", "nonalcoholic fatty liver disease (NAFLD) pathway", "melanogenesis", and "IL-17 signaling pathway". Combining the Search Tool for Interacting Chemicals (STITCH) database 5.0 and the drug-gene interaction database 3.0 (DGIdb), we identified that the PPAR-γ agonist rosiglitazone may promote melanin synthesis via EDNRB. Next, we investigated the mechanism of rosiglitazone and PPAR-γ pathway in promoting melanin production. Consistent with the results of bioinformatics analysis, the expression levels of PPAR-γ, EDNRB, and TYR were significantly reduced in human non-segmental vitiligo skin along with the reduction of MITF, a key gene for epidermal melanogenesis. Meanwhile, rosiglitazone increased melanin synthesis capacity in melanocytes and zebrafish by activating PPAR-γ and upregulating TYR, TYRP-1, and TYRP-2. Conversely, treatment of melanocytes with the PPAR-γ antagonist GW resulted in inhibition of melanin synthesis and expression of melanin-related factors. At the same time, simultaneous treatment of rosiglitazone with GW reversed the inhibitory effect of GW on melanin synthesis. In this study, we identified that rosiglitazone, an important insulin sensitizer, promotes melanin synthesis in melanocytes by increasing PPAR-γ activity and upregulating the expression levels of EDNRB and TYR. These findings may provide new ideas for exploring the pathogenesis and potential therapeutic targets of non-segmental vitiligo.

Small-molecule agents for treating skin diseases

Skin diseases are a class of common and frequently occurring diseases that significantly impact daily lives. Currently, the limited effective therapeutic drugs are far from meeting the clinical needs; most drugs typically only provide symptomatic relief rather than a cure. Developing small-molecule drugs with improved efficacy holds paramount importance for treating skin diseases. This review aimed to systematically introduce the pathogenesis of common skin diseases in daily life, list related drugs applied in the clinic, and summarize the clinical research status of candidate drugs and the latest research progress of candidate compounds in the drug discovery stage. Also, it statistically analyzed the number of publications and global attention trends for the involved skin diseases. This review might provide practical information for researchers engaged in dermatological drugs and further increase research attention to this disease area.

Vitamin D supplementation can enhance therapeutic effects of excimer laser in patients with vitiligo

PURPOSE

Vitiligo is a disease of acquired depigmentation characterized by the destruction of melanocytes. A theoretical association between low level of 25-hydroxyvitamin D [25(OH)D] and vitiligo has been previously suggested. The objective of this study was to determine the efficacy of intramuscular injection of cholecalciferol with excimer laser compared with the excimer laser alone for vitiligo treatment.

METHODS

This study included 26 patients diagnosed with non-segmental vitiligo and low serum 25(OH)D levels (<20 ng/mL). The participants were randomly divided into two groups through randomization. The treatment using a 308-nm excimer laser was administered to both groups, and the study group additionally received cholecalciferol injection.

RESULTS

The Vitiligo Area Scoring Index (VASI) scores showed an 83.6% improvement over the initial score in the study group, whereas the control group showed a 54.7% improvement after 6 months of treatment. After 6 months of treatment, the study group showed a significantly higher proportion of patients who achieved VASI50 and VASI75 compared with the control group.

CONCLUSION

Intramuscular injection of cholecalciferol can be a supplemental option for the treatment of vitiligo patients with vitamin D deficiency with excimer laser therapy.

A systematic review of case series and clinical trials investigating systemic oral or injectable therapies for the treatment of vitiligo

AIMS AND OBJECTIVES

The purpose of this study is to investigate the effectiveness and safety of oral and injectable systemic treatments, such as methotrexate, azathioprine, cyclosporine, tofacitinib, baricitinib, corticosteroids, statins, zinc, apremilast, etc., for treating vitiligo lesions.

METHOD

Databases including PubMed, Scopus, and Web of Science were meticulously searched for studies spanning from 2010 to August 2023, focusing on systemic oral and injectable therapies for vitiligo, using comprehensive keywords and search syntaxes tailored to each database. Key data extracted included study design, treatment efficacy, patient outcomes, patient satisfaction, and safety profiles.

RESULTS

In a total of 42 included studies, oral mini-pulse corticosteroid therapy (OMP) was the subject of six studies (14.2%). Minocycline was the focus of five studies (11.9%), while methotrexate, apremilast, and tofacitinib each were examined in four studies (9.5%). Antioxidants and Afamelanotide were the subjects of three studies each (7.1%). Cyclosporine, simvastatin, oral zinc, oral corticosteroids (excluding OMP) and injections, and baricitinib were each explored in two studies (4.8%). Azathioprine, mycophenolate mofetil, and Alefacept were the subjects of one study each (2.4%).

CONCLUSION

Systemic treatments for vitiligo have been successful in controlling lesions without notable side effects. OMP, Methotrexate, Azathioprine, Cyclosporine, Mycophenolate mofetil, Simvastatin, Apremilast, Minocycline, Afamelanotide, Tofacitinib, Baricitinib, Antioxidants, and oral/injectable corticosteroids are effective treatment methods. However, oral zinc and alefacept did not show effectiveness.

Current landscape of clinical trials for vitiligo: improving outcome standardization and trial diversity

We assessed interventional clinical trials for vitiligo from 2015 to 2021 noting patient demographics, intervention types and reported outcomes. We discuss that across studies, more consistent documentation of patient characteristics as well as more variable intervention types may broaden trial generalizability and provide benefit to more patients.

Dermatologic manifestations of thyroid disease: a literature review

Introduction

Thyroid hormone is considered one of the key regulatory hormones for skin homeostasis. Multiple organs are affected by the release of peripheral thyroid hormones (T4 and T3) further regulating various functions at a cellular level. Specifically, skin is considered an important target organ in which the thyroid hormone has a significant impact. Multiple skin diseases are associated with thyroid hormone dysregulation. However, other striking dermatologic manifestations are seen in nails and hair as well. Hypothyroidism, hyperthyroidism, and thyroid cancer can have an array of cutaneous manifestations, and we present the recent updates in this field.

Methods

A PubMed search was performed for updates in any new skin disease findings and treatments between 2010 and 2022. Research published in the past decade and previously known foundational skin findings associated with thyroid disease were presented in this review.

Conclusion

Cutaneous manifestations of thyroid disease is one of the first notable signs of thyroid hormone dysregulation. This article reviews the recent updates on the thyroid and skin interplay, and it further discusses overt visible findings and various available treatment modalities.

Various aspects of the relationship between vitiligo and the COVID-19 pandemic or SARS-CoV-2 vaccines: Clinical pearls for dermatologists

BACKGROUND

Coronavirus disease 2019 (COVID-19) has given rise to several new onset or exacerbated dermatologic disorders including vitiligo.

AIM AND METHOD

Here, we present different aspects of relationship between SARS-CoV-2 infection or its associated vaccines and vitiligo and aim to provide solutions to overcome the potential challenges.

RESULTS AND CONCLUSION

In brief, as the benefits overweigh the risks and since vaccine-triggered de novo or flares of vitiligo are uncommon and benign, these patients are recommended to get SARS-CoV-2 vaccines. Moreover, in individuals with previously recognized vitiligo, who are at risk of developing SARS-CoV-2 infection or those who are currently infected, special dermatologic consultation is needed in order to balance the immunosuppressive agents in their therapeutic regimen to prevent COVID-related morbidity and mortality.

Current Status of Cell-Based Therapies for Vitiligo

Vitiligo is a chronic pigmentary disease with complex etiology, the signs of which are caused by the destruction of melanocytes in the epidermis, leading to the lack of melanin pigment responsible for skin coloration. The treatment of vitiligo, which aims at repigmentation, depends both on the clinical characteristics of the disease as well as on molecular markers that may predict the response to treatment. The aim of this review is to provide an overview of the clinical evidence for vitiligo cell-based therapies taking into account the required procedures and equipment necessary to carry them out as well as their effectiveness in repigmentation, assessed using the percentage of repigmentation of the treated area. This review was conducted by assessing 55 primary clinical studies published in PubMed and ClinicalTrails.gov between 2000 and 2022. This review concludes that the extent of repigmentation, regardless of the treatment method, is highest in stable localized vitiligo patients. Moreover, therapies that combine more than one cell type, such as melanocytes and keratinocytes, or more than one method of treatment, such as the addition of NV-UVB to another treatment, increase the chances of >90% repigmentation. Lastly, this review concludes that various body parts respond differently to all treatments.

Where Microneedle Meets Biomarkers: Futuristic Application for Diagnosing and Monitoring Localized External Organ Diseases

Extracellular tissue fluids are interesting biomatrices that have recently attracted scientists' interest. Many significant biomarkers for localized external organ diseases have been isolated from this biofluid. In the diagnostic and disease monitoring context, measuring biochemical entities from the fluids surrounding the diseased tissues may give more important clinical value than measuring them at a systemic level. Despite all these facts, pushing tissue fluid-based diagnosis and monitoring forward to clinical settings faces one major problem: its accessibility. Most extracellular tissue fluid, such as interstitial fluid (ISF), is abundant but hard to collect, and the currently available technologies are invasive and expensive. This is where novel microneedle technology can help tackle this significant obstacle. The ability of microneedle technology to minimally invasively access tissue fluid-containing biomarkers will enable ISF and other tissue fluid utilization in the clinical diagnosis and monitoring of localized diseases. This review attempts to present the current pursuit of the application of microneedle systems as a diagnostic and monitoring platform, along with the recent progress of biomarker detection in diagnosing and monitoring localized external organ diseases. Then, the potential use of various microneedles in future clinical diagnostics and monitoring of localized diseases is discussed by presenting the currently studied cases.

Meta-analysis of the efficacy of adding platelet-rich plasma to 308-nm excimer laser for patients with vitiligo

Objective

Platelet-rich plasma (PRP) is a novel treatment option for vitiligo. PRP has been reported to be effective in combination with 308-nm excimer laser therapy, but there is no consensus on their combination use. Therefore, this meta-analysis assessed the efficacy and safety of the combination regimen in patients with vitiligo compared with laser therapy alone.

Methods

The meta-analysis was performed by searching PubMed, EMBASE, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang to identify relevant publications published through 1 February 2022.

Results

Six studies involving 302 patients were included. Compared with phototherapy alone, combination treatment with PRP and 308-nm excimer laser therapy significantly improved the total response rate and reduced the no response rate. Additionally, the proportions of patients with repigmentation rates of ≥75%, ≥50%, and ≥25% were significantly higher in the combination group than in the monotherapy group. In addition, the rates of adverse events for combination therapy were comparable to those for laser therapy alone, and the recurrence rates were low.

Conclusions

This meta-analysis provided evidence supporting the combined use of PRP and 308-nm excimer laser therapy as a valuable treatment modality for patients with vitiligo based on its superiority to monotherapy.

Efficacy of narrow band UVB with or without OMP in stabilization of vitiligo activity in skin photo-types (III-V): A double-blind, randomized, placebo-controlled, prospective, multicenter study

BACKGROUND

NB-UVB has long been the vitiligo management pillar with capability of achieving the main treatment outcomes; repigmentation and stabilization. Its stabilizing effect in dark skin has been debatable. However, randomized controlled trials regarding NB-UVB ability to control disease activity are lacking.

PURPOSE

To assess stabilizing effect of NB-UVB in comparison to systemic corticosteroids, the mainstay in vitiligo stabilization, in skin photo-types (III-V).

METHODS

This is a multicenter, placebo-controlled, randomized, prospective study. Eighty patients with active nonsegmental vitiligo (NSV) (Vitiligo disease activity (VIDA) ≥2) were randomized to either NB-UVB and placebo (NB-placebo) or NB-UVB and dexamethasone oral mini-pulse (OMP) therapy (NB-OMP) for 6 months. Sixty four patients completed the study, 34 in the NB-OMP group and 30 in the NB-placebo group. Patients were evaluated fortnightly according to presence or absence of symptoms/signs of activity.

RESULTS

In spite of earlier control of disease activity observed in the NB-OMP group, it was comparable in both groups by the end of the study period. Disease activity prior to therapy, but not extent, was found to influence control of activity in both groups. Thus, NB-UVB is a safe sole therapeutic tool in vitiligo management. Not only does it efficiently achieve repigmentation, but also it is a comparable stabilizing tool for systemic corticosteroids in spite of slightly delayed control.

CONCLUSION

NB-UVB is the only well-established vitiligo therapy that can be used solely whenever corticosteroids are contraindicated or immune-suppression is unjustified. Nonetheless, its combination with corticosteroids expedites response and improves compliance.

The application of electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation for the treatment of vitiligo-associated leukotrichia

BACKGROUND

Leukotrichia is one of the difficulties of vitiligo treatment. Hair follicle transplantation is an efficient method to treat vitiligo-associated leukotrichia. A trichiasis electrolyzer, commonly used for treating trichiasis, can be used to damage and remove the depigmented hair follicles.

OBJECTIVE

To evaluate the efficacy of the electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation for the treatment of vitiligo-associated leukotrichia.

METHODS

A total of 15 patients with stable vitiligo-associated eyebrow and eyelash leukotrichia were enrolled from Department of Dermatology, Hangzhou Third People's Hospital between January 2020 and January 2021. All patients were treated using a trichiasis electrolyzer combined with single hair follicle transplantation. The patients were followed up at the first week, the first month, the third month, and the sixth month after surgery. The texture and growth state of the transplanted hair were observed, and the number of surviving transplanted follicles and regenerating depigmented follicles were recorded.

RESULTS

The transplanted hair grew as expected with natural shape. No local infection or obvious scar were observed. Most of the depigmented hair in the lesion area re-pigmented and only a few depigmented hairs regenerated. The average survival rate of the transplanted hair follicles was 71.6%, and the average regeneration rate of the depigmented hair was 11.6%.

CONCLUSION

The electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation was an effective and safe method to treat vitiligo-associated leukotrichia.

A comparative study of suction blister epidermal grafting and automated blister epidermal micrograft in stable vitiligo

The automated blister epidermal micrograft (ABEM) is a newly introduced surgical transplantation for refractory vitiligo. Comparative analysis of other surgical methods is lacking. We conducted a retrospective study to compare the efficacy, safety, and experience of ABEM with conventional suction blister epidermal graft (SBEG). A total of 118 anatomically based vitiligo lesions from 75 patients were included. The primary outcome was the degree of repigmentation; the patient and operator experience were evaluated. SBEG had a significantly greater incidence of repigmentation (p < 0.001), as measured by the Physician Global Assessment, as well as improvements in the Vitiligo Area Scoring Index, particularly on the face/neck area (p < 0.001). ABEM, on the contrary, had reduced donor harvest time, a better patient operative experience, and more significant Dermatology Life Quality Index improvements. In a subgroup of 38 lesions from ten patients who received both SBEG and ABEM concomitantly, there was no difference in the degree of repigmentation in the same recipient area. Overall, the degree of repigmentation for SBEG is higher than ABEM, especially in the mobilized region, and the cost is less expensive. On the contrary, ABEM requires less procedure learning curve and can supply a greater transplanting zone with shorter donor site recovery. Understanding the benefits and drawbacks of two blister grafting procedures is essential for optimal surgical outcomes for vitiligo grafting.

Microneedling in Combination with Topical Pimecrolimus 1% versus Topical Pimecrolimus 1% for the Treatment of Refractory Stable Vitiligo: A Randomized Clinical Trial

Objective

Vitiligo is a common, autoimmune disease that results in the destruction of the melanocytes and manifests as depigmented macules on various areas of the skin. Numerous treatment options have been proposed for vitiligo. The purpose of this study was to compare the efficacy of microneedling plus topical pimecrolimus 1% versus the sole use of topical pimecrolimus 1% for the treatment of vitiligo.

Methods

This clinical trial was conducted on 30 skin lesions on 15 Al-Zahra hospital patients. Each patient had two similar lesions in the limb area, and each lesion was considered a separate treatment group. The left or right side of the patient's lesion was randomly assigned to receive microneedling plus topical pimecrolimus for three months, while the other side received only topical pimecrolimus 1%. As part of the follow-up, digital photography was taken at the baseline and biweekly for three months after treatment and six months' follow-up. The following methods were used to evaluate the results: DLQI questionnaires, patient satisfaction questionnaires, and two independent dermatologists comparing the improvement rate for each group.

Results

Topical pimecrolimus 1% treatment led to unsatisfactory results, whereas the combination of microneedling and topical pimecrolimus1% treatment produced a more favorable overall outcome (P < 0.001).

Conclusion

This study established that combination therapy results in more significant patient improvement. Additionally, one patient experienced mild skin irritation as a side effect of topical pimecrolimus.

Biomimetic Melanosomes Promote Orientation-Selective Delivery and Melanocyte Pigmentation in the H2O2-Induced Vitiligo Mouse Model

Extremely limited drug retention and depigmentation represent the greatest barriers against vitiligo treatment advancement. Here, inspired by biological melanosomes, the primary melanin transporter, we developed biomimetic melanosomes to combat reactive oxygen species (ROS)-mediated melanocyte damage and depigmentation. Briefly, methylprednisolone (MPS) and melanin-mimicking polydopamine (PDA) were encapsulated inside lysine-proline-valine (KPV)-modified deformable liposomes (KPV-Lipos). Owing to their phospholipid bilayer flexibility and the specific affinity for melanocortin 1 receptor (MC1R), KPV-Lipos exhibited 1.43-fold greater skin deposition than traditional liposomes. The binding of KPV and its receptor also contributed to activating the cAMP-tyrosinase (TYR) signaling pathway, improving the endogenous melanin content. In addition, PDA mimicked melanosomes as it effectively increased the exogenous melanin content and scavenged ROS. Meanwhile, MPS inhibited inflammatory cytokine secretion, limiting the depigmented area. Ultimately, the biomimetic melanosomes affected the skin color of mice with H₂O₂-induced vitiligo. These melanosomes show potential as a universal platform for the self-supply of melanin by self-driven melanin synthesis with exogenous supplementation. Furthermore, this study offers ideas for the production of artificial packed melanosome substitutes for melanocyte-related diseases.

Successful Treatment of Vitiligo with Cold Atmospheric Plasma‒Activated Hydrogel

Vitiligo shows insufficient response to current therapies largely owing to T-lymphocyte dysfunction, abnormal inflammatory activation, and excessive oxidative stress in lesions. Cold atmospheric plasma (CAP) possesses pleiotropic antioxidant and anti-inflammatory properties and may offer an improvement to current treatment options. In this study, the efficacy and safety of CAP were investigated in a mouse model of vitiligo and a randomized and controlled trial of patients with active focal vitiligo. Skin biopsies showed that topical treatment of vitiligo-like lesions on mouse dorsal skin by CAP restored the distribution of melanin. In addition, CAP treatment reduced the infiltration of CD11c+ dendritic cells, CD3+ T cells, and CD8+ T cells; inhibited the release of CXCL10 and cytokine IFN-γ; and enhanced cellular resistance to oxidative stress and excessive immune response by enhancing the expression of the transcription factor NRF2 and attenuating the activity of inducible nitric oxide synthase. In a randomized and controlled trial, CAP treatment achieved partial and complete repigmentation in 80% and 20% of vitiligo lesions, respectively, without hyperpigmentation in surrounding areas or other adverse events during the treatment period and its follow-up period. In conclusion, CAP offers a promising option for the management of vitiligo.

Feasibility of oral tranexamic acid for vitiligo patients with melasma

Melasma and vitiligo are both common pigmentary disorders, and the treatment is challenging. Oral tranexamic acid (TA) is effective for refractory melasma; however, the feasibility of TA in vitiligo patients with melasma was not studied. To evaluate the treatment outcomes and adverse effects of oral TA in vitiligo patients with melasma. We conducted a retrospective analysis of vitiligo patients who received oral TA for melasma in a tertiary dermatologic center from January 2017 to August 2020. We enrolled 32 patients with concomitant vitiligo and melasma on the face. The mean duration of the improvement of melasma that patients reported is around 1.64 months of treatment. The first sign of repigmentation of the vitiligo lesions occurred at 1 month of treatment. 84.38% of the patients achieved a mild to good degree of improvement of melasma (0%-75% improvement), whereas 81.25% of the patients achieved a moderate to excellent degree of improvement of vitiligo (25%-100% improvement) via physician global assessments. No significant adverse event was noted. No patients experience vitiligo disease deterioration during TA treatment. Oral TA may be a feasible option for melasma in vitiligo patients.

The addition of topical calcipotriol to phototherapy enhance the efficacy of treatment in patients with vitiligo: A systematic review and meta-analysis

BACKGROUND

Treatment of vitiligo has several challenges. Phototherapy and topical calcipotriol have been reported to be effective in combination with other therapies, but there is no consensus on the combination use.

OBJECTIVE

To perform a systematic review and meta-analysis that elucidates the efficacy of the combination of phototherapy and topical calcipotriol.

METHODS

This systematic review was performed by searching PubMed, EMBASE, Web of Science, Cochrane Library databases, Chinese National Knowledge Infrastructure (CNKI), WanFang and VIP databases for relevant publications till February 28, 2021. Relative risk (RR) and its 95% confidence interval (CI) were used to evaluate the data. Bias assessment, heterogeneity and sensitivity analysis were conducted in this meta-analysis.

RESULTS

After screening, nine studies with 700 participants were included. The meta-analysis indicated that the combination of phototherapy and topical calcipotriol showed significantly higher effective rate (RR 1.11, 95% CI 1.02-1.22; p < 0.05) and apparent effective rate (RR 1.35, 95% CI 1.15-1.59; p < 0.01) than phototherapy monotherapy in the treatment of vitiligo. In addition, the side effects were minor, transient and tolerable.

CONCLUSIONS

This meta-analysis provides evidence supporting phototherapy combined with topical calcipotriol as a valuable treatment modality for patients with vitiligo, which has better efficacy than monotherapy.

Updates and new medical treatments for vitiligo (Review)

Vitiligo is a multifactorial disease characterized by the loss of skin pigment, which results in achromic macules and patches. There are currently several medical treatments available, which aim to arrest progression and induce skin repigmentation. These treatments alone or combined have exhibited varying degrees of pigmentation, and the majority are safe and effective. All therapies for vitiligo are limited, and no known treatment can consistently produce repigmentation in all patients. Individualized treatment is appropriate according to the location, clinical presentation and the presence of disease activity. The present review summarizes the medical treatments available for vitiligo: Systemic and topic pharmacological therapies, physical and depigmentation treatments. Several treatments are still underway and have not yet been approved. However, due to the promising preliminary results, these are also mentioned in the present review.

A retrospective study of long term follow-up of 2283 vitiligo patients treated by autologous, non-cultured melanocyte-keratinocyte transplantation

Background: Autologous non-cultured melanocyte-keratinocyte transplantation (MKTP) can be used to treat stable vitiligo cases, but there were insufficient clinical data to evaluate its safety and efficacy.

Objective: To assess the influence of various factors on the therapeutic outcome of MKTP.

Method: The single-center retrospective study included stable vitiligo patients who underwent MKTP between June 2009 and June 2018. Univariate and/or multivariable analysis were used to determine the factors affecting the outcome of repigmentation.

Result: The study comprised 2283 patients who had long-term follow-up data (12-108months). Excellent repigmentation was achieved in 400/606 (66%),788/1341 (58.8%),437/684 (63.9%),18/24 (75%) patients with segmental vitiligo, pre-MKTP phototherapy, younger than 24 years, the lesion on the perineum and scrotum, respectively. However, the patients with a positive family history, Koebner phenomenon responded worse(χ²=29.417, P<0.001; χ²=107.397, P<0.001; respectively). Overall, a significant positive correlation between duration of stability and percentage of repigmentation was found (χ²=42.053, P<0. 001).

Conclusion: MKTP is efficient and well tolerated for stable vitiligo treatment. Various factors such as duration of disease stability, vitiligo type, family history, site of lesion should be carefully assessed before using MKTP, as it would further improve the post-operative repigmentation.

Vitiligo: An Updated Narrative Review

BACKGROUND

Vitiligo is a relatively common acquired pigmentation disorder that can cause significant psychological stress and stigmatism.

OBJECTIVE

This article aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis, and management of vitiligo.

METHODS

A Pubmed search was conducted in Clinical Queries using the key term "vitiligo". The search included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English language. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Approximately one quarter of patients with vitiligo have the onset before 10 years of age. Genetic, immunological, neurogenic and environmental factors may have a role to play in the pathogenesis. Vitiligo typically presents as acquired depigmented, well-demarcated macules/patches that appear milk- or chalk-white in color. Lesions tend to increase in number and enlarge centrifugally in size with time. Sites of predilection include the face, followed by the neck, lower limbs, trunk, and upper limbs. The clinical course is generally unpredictable. In children with fair skin, no active treatment is usually necessary other than the use of sunscreens and camouflage cosmetics. If treatment is preferred for cosmesis, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the mainstays of treatment.

CONCLUSION

The therapeutic effect of all the treatment modalities varies considerably from individual to individual. As such, treatment must be individualized. In general, the best treatment response is seen in younger patients, recent disease onset, darker skin types, and head and neck lesions. Topical corticosteroids and calcineurin inhibitors are the treatment choice for those with localized disease. Topical calcineurin inhibitors are generally preferred for lesions on genitalia, intertriginous areas, face, and neck. Narrowband ultraviolet B phototherapy should be considered in patients who have widespread vitiligo or those with localized vitiligo associated with a significant impact on the quality of life who do not respond to treatment with topical corticosteroids and calcineurin inhibitors.

Astragaloside IV Enhances Melanogenesis via the AhR-Dependent AKT/GSK-3β/β-Catenin Pathway in Normal Human Epidermal Melanocytes

Astragalus membranaceus root has been widely used for repigmentation treatment in vitiligo, but its mechanism is poorly understood. We sought to investigate the effect of astragaloside IV (AS-IV), a main active extract of the Astragalus membranaceus root, on melanin synthesis in normal human epidermal melanocytes (NHEMs) and to elucidate its underlying mechanisms. Melanin content, tyrosinase activity, qPCR, western blot, and immunofluorescence were employed. Specific inhibitors and small interfering RNA were used to investigate the possible pathway. AS-IV stimulated melanin synthesis and upregulated the expression of melanogenesis-related genes in a concentration-dependent manner in NHEMs. AS-IV could activate the aryl hydrocarbon receptor (AhR), and AS-IV-induced melanogenesis was inhibited in si-AhR-transfected NHEMs. In addition, we showed that AS-IV enhanced the phosphorylation of AKT and GSK-3β and nuclear translocation of β-catenin. AS-IV-induced MITF expression upregulation and melanin synthesis were decreased in the presence of β-catenin inhibitor FH353. Furthermore, AhR antagonist CH223191 inhibited the activation of AKT/GSK-3β/β-catenin signaling, whereas the expression of CYP1A1 (marker of AhR activation) was not affected by the AKT inhibitor in AS-IV-exposed NHEMs. Our findings show that AS-IV induces melanogenesis through AhR-dependent AKT/GSK-3β/β-catenin pathway activation and could be beneficial in the therapy for depigmented skin disorders.

A comparative study on the use of fractional CO2 laser with tacrolimus or calcipotriol or narrow band ultraviolet-B in treatment of stable nonsegmental vitiligo

Conventional methods of treatment for vitiligo are often unsatisfactory to the patients and time consuming, new treatment modalities are needed. This study was conducted to evaluate the efficacy and safety of fractional carbon dioxide (CO₂ ) laser therapy followed by narrow band ultraviolet-B (NB-UVB) phototherapy, topical tacrolimus or topical calcipotriol on stable nonsegmental vitiligo. Thirty patients with stable nonsegmental vitiligo were evaluated. All patients were subjected to three sessions of fractional CO₂ laser 1 month apart. Patients were divided into three groups (each group 10 patients). Group (A) treated with tacrolimus ointment twice daily for 3 months, group (B) treated with calcipotriol ointment twice daily for 3 months, and group (C) treated with NB-UVB twice weekly for 3 months. Outcomes were evaluated by calculating vitiligo area scoring index (VASI) score change, percentage of repigmentation, patient satisfaction, and adverse effects. There was a statistical significant decrease in VASI score after treatment in the three groups. The VASI change and % of regimentation was higher in group (C) treated by laser and NB-UVB and this was significantly higher than group (B) treated with laser and calcipotriol. Otherwise, there was no statistical significant difference between other treatment groups. In concluion, NB-UVB phototherapy, topical tacrolimus, or topical calcipotriol in combination with fractional CO₂ laser could be used effectively and safely as an alternative modality for treatment of vitiligo. The combination of fractional CO₂ laser and NB-UVB was found to be more effective.

Nano-Lipid-Carriers for the Treatment of Vitiligo: A Recent Update, Pathophysiology and Mechanism of Drug Delivery

BACKGROUND

Vitiligo is an auto-immune disease with white-coloured disfiguring patches or spots on the skin surface. It is highly prevalent in several corners of the world. This disease spreads in different age groups.

AIM

The main aim of this review is to provide an overview of pathophysiology and lipid-based nano-carriers for the treatment of vitiligo.

METHODS

The conventional delivery systems available have limited efficacy due to less retention of the drug in the epidermal layer where melanocytes reside. In order to overcome these issues, an advanced delivery system with lipid-based nano-carriers for the treatment of vitiligo was proven to be better as per the literature explored.

RESULTS

This review summarizes the pathophysiology along with novel lipid-based nano-carriers for the treatment of vitiligo.

CONCLUSION

Though various treatment regimens are present for the disease, nano-lipid carrier systems are significantly gaining importance nowadays, due to their high effectivity in topically acting on the target site. Nano-lipid carrier systems such as liposomes, ethosomes, transethosomes and transferosomes can be said to be at the top of the list in acting effectively against vitiligo or several other tropical diseases.

Consensus on the treatment of vitiligo - Brazilian Society of Dermatology

Background

Vitiligo is a muco-cutaneous, autoimmune, localized, or disseminated disease, which manifests through hypochromic or achromic macules, with loss in quality of life. The prevalence of vitiligo in Brazil was determined to be 0.54%. There is no on-label medication for its treatment. To date, no Brazilian consensus on the treatment of vitiligo had been written.

Objectives

The objective of this group of Brazilian dermatologists with experience in the treatment of this disease was to reach a consensus on the clinical and surgical treatment of vitiligo, based on articles with the best scientific evidence.

Methods

Seven dermatologists were invited, and each was assigned two treatment modalities to review. Each treatment (topical, systemic, and phototherapy) was reviewed by three experts. Two experts reviewed the surgical treatment. Subsequently, the coordinator compiled the different versions and drafted a text about each type of treatment. The new version was returned to all experts, who expressed their opinions and made suggestions for clarity. The final text was written by the coordinator and sent to all participants to prepare the final consensus.

Results/Conclusion

The experts defined the following as standard treatments of vitiligo: the use of topical corticosteroids and calcineurin inhibitors for localized and unstable cases; corticosteroid minipulse in progressive generalized vitiligo; narrowband UVB phototherapy for extensive forms of the disease. Surgical modalities should be indicated for segmental and stable generalized vitiligo. Topical and systemic anti-JAK drugs are being tested, with promising results.

A Simple Drug Delivery System for Platelet-Derived Bioactive Molecules, to Improve Melanocyte Stimulation in Vitiligo Treatment

Vitiligo is the most common depigmentation disorder of the skin. Currently, its therapy focuses on the halting of the immune response and stimulation of the regenerative processes, leading to the restoration of normal melanocyte function. Platelet-rich plasma (PRP) represents a safe and cheap regenerative therapy option, as it delivers a wide spectrum of native growth factors, cytokines and other bioactive molecules. The aim of this study was to develop a simple delivery system to prolong the effects of the bioactive molecules released from platelets. The surface of electrospun and centrifugally spun poly-ε-caprolactone (PCL) fibrous scaffolds was functionalized with various concentrations of platelets; the influence of the morphology of the scaffolds and the concentration of the released platelet-derived bioactive molecules on melanocytes, was then assessed. An almost two-fold increase in the amount of the released bioactive molecules was detected on the centrifugally spun vs. electrospun scaffolds, and a sustained 14-day release of the bioactive molecules was demonstrated. A strong concentration-dependent response of melanocyte to the bioactive molecules was observed; higher concentrations of bioactive molecules resulted in improved metabolic activity and proliferation of melanocytes. This simple system improves melanocyte viability, offers on-site preparation and is suitable for prolonged topical PRP administration.

Both cardiovascular and cerebrovascular events are decreased following long-term narrowband ultraviolet B phototherapy in patients with vitiligo: a propensity score matching analysis

BACKGROUND

Systemic effects of long-term narrowband ultraviolet B (NB-UVB) phototherapy have not been well studied in vitiligo patients. An 11-year nationwide population-based retrospective cohort study was conducted using the Korean National Health Insurance claims database (2007-2017).

OBJECTIVES

To investigate the effects of long-term NB-UVB phototherapy on the risk of cardiovascular and cerebrovascular events in vitiligo patients.

METHODS

This study included vitiligo patients with ≥100 phototherapy sessions (phototherapy group, n = 3229) and <3 phototherapy sessions (no phototherapy group, n = 9687), in which covariables with age, sex, insurance type and comorbidities such as diabetes, hypertension and hyperlipidemia were matched by 1 : 3 propensity score matching. The outcomes of interest were cardiovascular (ischaemic heart disease and myocardial infarction) and cerebrovascular events (cerebrovascular infraction and haemorrhage). Cox proportional hazards models were used to assess the associations between NB-UVB phototherapy and each event.

RESULTS

The risk of cardiovascular or cerebrovascular events was significantly decreased in the phototherapy group compared with the no phototherapy group [hazard ratio (HR) 0.637, 95% confidence interval (CI) 0.523-0.776]. Subgroup analysis revealed that the risk of cardiovascular (HR: 0.682, 95% CI: 0.495-0.940) and cerebrovascular events (HR: 0.601, 95% CI: 0.470-0.769) were significantly lower in the phototherapy group than the no phototherapy group, respectively.

CONCLUSIONS

Our findings suggest that long-term NB-UVB phototherapy could decrease the risk of cardiovascular and cerebrovascular events in patients with vitiligo.

Combined microneedling with tacrolimus vs tacrolimus monotherapy for vitiligo treatment

Background: Miconeedling has been used to augment the transdermal drug delivery. Combination modalities may accelerate and improve the repigmentation in vitiligo.Objective: To determine the efficacy and tolerability of combined microneedling with tacrolimus vs tacrolimus 0.1% ointment for the treatment of vitiligo.Patients and Method: Forty-eight patients with vitiligo were randomized into two groups: group I applied tacrolimus once daily for 6 months. Group II received microneedling with topical tacrolimus at 2 weeks intervals for a maximum of 6 months. The assessment was based on the clinical improvement and immunohistochemical changes. Skin biopsies were taken at baseline and after the treatment for c-kit + expression.Results: After treatment, the repigmentation >75% was observed in 50% of the patients in group II compared to 29.2% in group I (p .02). There was an earlier response in group II than in group I (p .002). The improvement was significantly higher in the legs and extremities in group II than in group I (0.003). The immunohistochemical results showed significantly higher expression of c-kit in group II than group I (p .01). No severe side effects were reported.Conclusion: The results suggest the superiority of the combination regimen (tacrolimus and microneedling) for vitiligo treatment.

Emerging drugs for the treatment of vitiligo

Introduction: Vitiligo is a relatively common autoimmune depigmenting disorder of the skin. There has been a great advance in understanding the pathological basis, which has led to the development and utilization of various new molecules in treating vitiligo. This review aims at a comprehensively describing the treatments available and the emerging treatment aspects and the scope for future developments.Areas covered: This study comprehensively summarizes the current concepts in the pathogenesis of vitiligo with special focus on the cytokine and signaling pathways, which are the targets for newer drugs. JAK kinase signaling pathways and the cytokines involved are the focus of vitiligo treatment in current research, followed by antioxidant mechanisms and repigmenting mechanisms. Topical immunosuppressants may be an alternative to steroids in localized vitiligo. Newer repigmenting agents like basic fibroblast growth factors, afamelanotide have been included and a special emphasis is laid on the upcoming targeted immunotherapy.Expert opinion: The treatment of vitiligo needs to be multimodal with emphasis on targeting different limbs of the pathogenesis. Topical and oral JAK inhibitors are the most promising new class of drugs currently available for treating vitiligo and acts best in conjunction with NB-UVB.

Antibody blockade of IL-15 signaling has the potential to durably reverse vitiligo

Vitiligo is an autoimmune disease of the skin mediated by CD8⁺ T cells that kill melanocytes and create white spots. Skin lesions in vitiligo frequently return after discontinuing conventional treatments, supporting the hypothesis that autoimmune memory is formed at these locations. We found that lesional T cells in mice and humans with vitiligo display a resident memory (T_RM) phenotype, similar to those that provide rapid, localized protection against reinfection from skin and mucosal-tropic viruses. Interleukin-15 (IL-15)-deficient mice reportedly have impaired T_RM formation, and IL-15 promotes T_RM function ex vivo. We found that both human and mouse T_RM express the CD122 subunit of the IL-15 receptor and that keratinocytes up-regulate CD215, the subunit required to display the cytokine on their surface to promote activation of T cells. Targeting IL-15 signaling with an anti-CD122 antibody reverses disease in mice with established vitiligo. Short-term treatment with anti-CD122 inhibits T_RM production of interferon-γ (IFNγ), and long-term treatment depletes T_RM from skin lesions. Short-term treatment with anti-CD122 can provide durable repigmentation when administered either systemically or locally in the skin. On the basis of these data, we propose that targeting CD122 may be a highly effective and even durable treatment strategy for vitiligo and other tissue-specific autoimmune diseases involving T_RM.

Oxidative stress-induced IL-15 trans-presentation in keratinocytes contributes to CD8+ T cells activation via JAK-STAT pathway in vitiligo

Oxidative stress and effector memory CD8⁺ T cells have been greatly implicated in vitiligo pathogenesis. However, the crosstalk between these two crucial pathogenic factors has been merely investigated. IL-15 has been regarded as an important cytokine exerting its facilitative effect on memory CD8⁺ T cells function in various autoimmune diseases. In the present study, we initially discovered that the IL-15 expression was significantly increased in vitiligo epidermis and highly associated with epidermal H₂O₂ content. In addition, epidermal IL-15 expression was mainly derived from keratinocytes. Then, we showed that oxidative stress promoted IL-15 and IL-15Rα expression as well as IL-15 trans-presentation by activating NF-κB signaling in keratinocytes. What's more, the trans-presented IL-15, rather than the secreted one, was accounted for the potentiation of CD8⁺ T_EMs activation. We further investigated the mechanism underlying trans-presented IL-15 in potentiating CD8⁺ T_EMs activation and found that the blockage of IL-15-JAK-STAT signaling could be a potent therapeutic approach. Taken together, our results demonstrate that oxidative stress-induced IL-15 trans-presentation in keratinocytes contributes to the activation of CD8⁺ T_EMs, providing a novel mechanism by which oxidative stress initiates autoimmunity in vitiligo.

The efficacy and safety of targeted narrowband UVB therapy: a retrospective cohort study

Background/aim

Phototherapy is a safe and effective treatment modality for numerous dermatological conditions. Recently, targeted phototherapy modalities have gained importance due to their advantages over conventional phototherapy. This retrospective study aimed to evaluate the safety and efficacy of targeted narrowband UVB phototherapy in patients with dermatological disorders.

Materials and methods

This single-center study included 173 patients who were treated with targeted narrowband UVB phototherapy. Demographic features, phototherapy parameters, and adverse effects were evaluated in all patients, and the treatment response was assessed in patients who attended at least one follow-up visit.

Results

A total of 173 patients (102 females; 71 males) with vitiligo, alopecia areata, lichen simplex chronicus, palmoplantar psoriasis, and psoriasis vulgaris were included in the study. Among 73 patients, with whom the treatment was finalized by physician, an excellent response was obtained in 10%, 52.9%, 53.8%, 28.6%, and 40% of patients with vitiligo, alopecia areata, lichen simplex chronicus, palmoplantar psoriasis, and psoriasis, respectively. The treatment was generally well tolerated and was discontinued in only two patients due to adverse effects.

Conclusion

This study demonstrates that targeted narrowband UVB therapy is a safe and effective treatment alternative, particularly for alopecia areata, lichen simplex chronicus, and palmoplantar and plaque-type psoriasis.

Preparation of novel 1,2,3-triazole furocoumarin derivatives via click chemistry and their anti-vitiligo activity

The extracts of Psoralea corylifolia L. were often used for the repigmentation of leukoderma (vitiligo) in traditional Uygur medicine thousands years ago. Nowadays, its active ingredient, furocoumarins, has been clinically applied since it exhibited strong photosensitivity. Thus, a new series of furocoumarin derivatives (8a-8o) containing 1,2,3-triazole were designed and synthesized based on our previous work. After biological evaluation for melanin contents and tyrosinase activity in B16 murine cells, the SAR was summarized. The results indicated that five compounds (8a, 8j, 8m-8o) were more potent than the positive control (8-MOP) on melanogenesis. Among them, 8a and 8o showed the best stimulating effect on tyrosinase activity as well, and were submitted for further pharmacological study of anti-vitiligo.

Noncultured Extracted Hair Follicle Outer Root Sheath Cell Suspension versus Noncultured Epidermal Cell Suspension in the Treatment of Stable Vitiligo

Background:

Various treatment modalities exist for vitiligo, yet none of them are curative. Vitiligo is still considered a challenging disease to manage. Surgical treatment offers an excellent option for patients with stable vitiligo, especially those who fail to respond to medical treatment. Cell suspension techniques carry the advantage of covering large surface areas.

Objective:

To compare noncultured extracted hair follicle outer root sheath cell suspension (NCORSHFS) and noncultured epidermal cell suspension (NCES) in producing repigmentation.

Subjects and Methods:

Twenty patients were randomly allocated into two groups. They were objectively evaluated for the extent of repigmentation (after 1, 2, and 3 months), complications, cosmetic outcome, and satisfaction.

Results:

In NCORSHFS group, 10% showed excellent pigmentation, 20% showed good pigmentation, 50% fair, and 20% poor pigmentation. In NCES group, 10% showed excellent pigmentation, 10% good pigmentation, 40% fair, and 40% poor pigmentation. This difference was not statistically significant. Excellent color match was observed in 80% of NCORSHFS and in 70% of NCES. Donor area complications were absent in NCORSHFS group, whereas in NCES, mild scarring in 20% and hyperpigmentation in 40% of patients was observed. The difference in patients’ satisfaction between the two groups was not statistically significant.

Conclusion:

Both NCORSHFS and NCES are effective in producing good repigmentation with perfect color match and patients’ satisfaction. NCORSHFS has no donor area complications because it is a scarless procedure.

Objective Assessment of Skin Repigmentation Using a Multilayer Perceptron

Background:

Vitiligo is a pathology that causes the appearance of achromic macules on the skin that can spread on to other areas of the body. It is estimated that it affects 1.2% of the world population and can disrupt the mental state of people in whom this disease has developed, generating negative feelings that can become suicidal in the worst of cases. The present work focuses on the development of a support tool that allows to objectively quantifying the repigmentation of the skin.

Methods:

We propose a novel method based on artificial neural networks that use characteristics of the interaction of light with the skin to determine areas of healthy skin and skin with vitiligo. We used photographs of specific areas of skin containing vitiligo. We select as independent variables: the type of skin, the amount of skin with vitiligo and the amount of repigmented skin. Considering these variables, the experiments were organized in an orthogonal table. We analyzed the result of the method based on three parameters (sensitivity, specificity, and F1-Score) and finally, its results were compared with other methods proposed in similar research.

Results:

The proposed method demonstrated the best performance of the three methods, and it also showed its capability to detect healthy skin and skin with vitiligo in areas up to 1 × 1 pixels.

Conclusion:

The results show that the proposed method has the potential to be used in clinical applications. It should be noted that the performance could be significantly improved by increasing the training patterns.

A comparative study between suction blistering graft, mini punch graft, and hair follicle transplant in treatment of patients with stable vitiligo

Background: Vitiligo is an acquired disfiguring common depigmented skin disease. Objectives: This study aimed to compare the clinical efficacy and safety of suction blistering graft, mini punch and hair follicle techniques in treatment of patients with stable vitiligo. Methods: Thirty patients with stable vitiligo were included. Patients were divided into 3 groups, in group (A) 10 patient underwent suction blistering technique, in group (B) 10 patients underwent mini punch technique and in group (C) 10 patients underwent hair follicle technique. Then all patients in the three techniques were subjected to narrow-band ultraviolet B (NB-UVB) phototherapy for 3 months. All patients were assessed by determining the percentage of repigmentation and Dermatology Life Quality Index (DLQI) before and 3 months after the operation. Results: The percentage of repigmentation of vitiligo in suction blister technique was significantly higher than both mini punch and hair follicle techniques (p value .001 and .0001 respectively). There was a statistically significant difference between the three techniques regarding DLQI score after operation (p value = .0001). Conclusion: This study concluded that suction blistering technique is more effective and safe than mini punch technique and hair follicle technique in treatment of stable vitiligo.

Novel Furocoumarin Derivatives Stimulate Melanogenesis in B16 Melanoma Cells by Up-Regulation of MITF and TYR Family via Akt/GSK3β/β-Catenin Signaling Pathways

The extracts of Ficuscarica L. and Psoralen corylifolia L. are traditional Uygur medicines for the treatment of vitiligo, and its active ingredients furocoumarins, were are found to be the most effective agents against this skin disorder nowadays. Therefore, a series of novel easter derivatives (8a-8p) of furocoumarin were designed and synthesized based on our previous research to improve this activity in the present study. The synthesized derivatives were biologically evaluated for melanin synthesis in murine B16 cells and the SAR (structure-activity relationship) was summarized. Eight derivatives were more potent than positive control (8-MOP, 8-methoxypsoralan), especially compounds 8n (200%) and 8o (197%), which were nearly 1.5-fold potency when compared with 8-MOP (136%). Furthermore, the signaling pathway by which 8n activates the melanin biosynthesis was defined. Our results showed that it not only elevated the melanin content, but also stimulated the activity of tyrosinasein a concentration-dependent manner. Increasing of phosphorylation of Akt (also named PKB, protein kinase B) and non-activated GSK3β (glycogen synthase kinase 3 beta), which inhibited the degradation of β-catenin were observed through Western blot analysis. The accumulation of β-catenin probably led to the activation of transcription of MITF (microphthalmia-associated transcription factor) and TYR (tyrosinase) family, as well as the subsequent induction of melanin synthesis.

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.

Diversity-oriented synthesis of amide derivatives of tricyclic thieno[2,3-d]pyrimidin-4(3H)-ones and evaluation of their influence on melanin synthesis in murine B16 cells

A diversity-oriented synthesis of amide-containing thieno[2,3-d]pyrimidin-4(3H)-ones is reported. All compounds were tested for their influence on melanin synthesis in murine B16 cells. The azepine fragment in thieno[2,3-d]pyrimidin-4(3H)-one skeleton significantly increases the melanin content.

Efficacy and safety of noncultured melanocyte-keratinocyte transplant procedure for vitiligo and other leukodermas: a critical analysis of the evidence

Vitiligo is an acquired pigmentary skin of depigmentation occurring secondary to melanocyte destruction. Vitiligo and other leukodermas have a profound impact on quality of life. Current therapies include medical options, such as phototherapy, topical and systemic corticosteroids, topical calcineurin inhibitors, immunomodulators, and antioxidiants, and surgical options. Surgical options provide melanocytic cells to previously depigmented areas and use either tissue grafting or cellular grafting methods. Topical treatments are often insufficient, and many of the current surgical procedures have shown variable response rates. In this review, we discuss the process of the cellular grafting melanocyte-keratinocyte transplantation procedure (MKTP) and critically analyze its efficacy and safety in the treatment of vitiligo and other leukodermas. PubMed was searched for studies (2001-2017) describing the use of MKTP in patients with vitiligo or other leukodermas. Articles or trials discussing the use of MKTP for these patients were selected for in-depth review. Clinically relevant results regarding efficacy and safety of MKTP in vitiligo and leukoderma patients were analyzed. Numerous trials and case series/reports have demonstrated tolerability and efficacy of MKTP with repigmentation for patients with refractory, stable vitiligo. However, the response rates have been variable, likely influenced by vitiligo type and affected areas. Future research and clinical reporting will provide more insight on which phenotypes may benefit from MKTP.

Neural and Endocrinal Pathobiochemistry of Vitiligo: Comparative Study for a Hypothesized Mechanism

The etiology of vitiligo is still unclear. The aim is to investigate a neural and hormonal etio-pathology of vitiligo. Sixty acrofacial vitiligo patients were divided into two subgroups as active vitiligo patients group (AVPs; n = 35) and stable vitiligo patients group (SVP; n = 25). Forty healthy subjects without any systemic or dermatological disease were used as controls. Blood samples were collected, and the samples were used for measurement of free triiodothyronine (fT₃), free thyroxine (fT₄), thyroid-stimulating hormone (TSH), adrenocorticotrophic hormone (ACTH), cortisol, estrogen, testosterone, melatonin, and prolactin levels by ELISA, while norepinephrine (NE), epinephrine (Epi), dopamine (DA), homo-vanillic acid (HVA), serotonin, and 5-hydroxyindoleacetic acid (5-HIAA) by high-pressure liquid chromatography. The current results showed a significant increase in plasma levels of Epi, NE, DA, HVA, serotonin, 5-HIAA, melatonin, and in serum level of TSH and prolactin either in SVP or AVP groups than the control group and in AVP than SVP group. The serum levels of fT₃ and fT₄ were significantly decreased either in SVP or AVP groups than the control group. A significant increase in estradiol levels was observed in females within AVP than females in either SVP or control groups. There was a significant increase in serum level of cortisol in AVP than either SVP or control group. There was a significant decrease in serum level of ACTH in either AVP or SVP than control and in AVP than SVP group. In conclusion, there are some neural and endocrine markers that play a pivotal role in pathogenesis and/or consequences of vitiligo. The abnormally disturbed levels of theses markers lead to melanocyte destruction and/or depigmentation.

Artificial Pigmented Human Skin Created by Muse Cells

The skin composes physiological and chemical barrier and renews skin component cells throughout the human life. Melanocytes locate in the basal layer of the epidermis and produce melanin to protect the skin from ultraviolet. Melanin plays key roles in determining human skin and hair color. Melanocyte dysfunction observed in albinism and vitiligo not only causes cosmetic problems but also increases risk of skin cancer. As rejuvenate therapy, embryonic stem (ES) cells and induced pluripotent stem (iPS) cells have been reported to generate melanocytes. Other than ES and iPS cells, human skin tissues maintain pluripotent stem cells, named multilineage-differentiating stress-enduring (Muse) cells. We employ Muse cells isolated from human fibroblasts and adipose tissue to differentiate into melanocytes (Muse-MC). Muse-MC express melanocyte-related molecules, such as tyrosinase and DCT, and show tyrosinase activity. We also succeeded to differentiate Muse cells into fibroblasts and keratinocytes and created three-dimensional (3D) reconstituted skin with Muse cell-derived melanocytes, fibroblasts, and keratinocytes. The 3D reconstituted skin of Muse cell-derived cells coordinately showed epidermis layers and Muse-MC localized in the basal layer of the epidermis. Thus Muse cells in the human skin can be a source of rejuvenation medicine for the skin reconstruction.

An Isoxazole Chalcone Derivative Enhances Melanogenesis in B16 Melanoma Cells via the Akt/GSK3β/β-Catenin Signaling Pathways

Plants or plant-derived products have been routinely used in several traditional medicine systems for vitiligo treatment. It is well-known that melanogenesis can be promoted by certain flavonoid compounds isolated from the traditional Uyghur medicinal plant, Kaliziri. Therefore, Chalcones, one class of flavonoid compounds, has become an interesting target for the development of anti-vitiligo agents. A series of novel isoxazole chalcone derivatives have been designed, synthesized, and evaluated for biological activities by our group. Among them, derivative 1-(4-((3-phenylisoxazol-5-yl)methoxy)phenyl)-3-phenylprop-2-en-1-one (PMPP) was identified as a potent tyrosinase activator with better activity and lower toxicity than the positive control 8-methoxypsoralen (8-MOP) in this study. Further investigations revealed that Akt and GSK3β were the signaling pathways involved in the hyperpigmentation of PMPP. Overall, these studies may provide a convenient and novel approach for the further development of anti-vitiligo agents.

Efficacy of Cyclosporine After Autologous Noncultured Melanocyte Transplantation in Localized Stable Vitiligo-A Pilot, Open Label, Comparative Study

BACKGROUND

Understanding the pathogenesis of vitiligo has lead to innovation of new drugs and new uses of the existing drugs to enhance treatment outcome.

OBJECTIVE

The aim of this observational pilot study was to assess the role of cyclosporine (CsA) to tackle the commonest aesthetic problem "perilesional halo" after autologous noncultured melanocyte-keratinocyte cell transplant (NCMKT) for localized, stable vitiligo.

MATERIALS AND METHODS

Of the total 50 enrolled patients who underwent NCMKT for stable/resistant vitiligo, aged 12 to 68 years (mean 29.92 years), 18 were male and 32 were female. Group I (n = 25) patients did not receive any postoperative treatment. Group II (n = 25) patients received CsA postoperatively at 3 mg·kg·d for 3 weeks followed by 1.5 mg·kg·d for 6 weeks.

RESULTS

In Group I, results were as follows: 28% (n = 7) achieved >75% repigmentation, 16% (n = 4) achieved 50% to 75% repigmentation, 52% (n = 13) achieved 25% to 50% repigmentation, and 4% (n = 1) achieved <25% repigmentation. In Group II, 100% (n = 25) achieved >75% (median 90.7%) repigmentation post-NCMKT at the end of 6 months.

CONCLUSION

This new drug regimen using CsA resulted in rapid and uniform repigmentation without leaving any perilesional halo in Group II patients after NCMKT.

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.

Upregulation of Melanogenesis and Tyrosinase Activity: Potential Agents for Vitiligo

Melanin, the compound primarily responsible in humans for hair, eye and skin pigmentation, is produced by melanocytes through a complicated process called melanogenesis that is catalyzed by tyrosinase and other tyrosinase-related proteins. The abnormal loss of melanin causes dermatological problems such as vitiligo. Hence the regulation of melanogenesis and tyrosinase activity is very important for treating hypopigmentary disorders. Many melanogenesis stimulators have been discovered during the past decade. This article reviews recent advances in research on extracts and active ingredients of plants, synthesized compounds with stimulating effect on melanin synthesis and tyrosinase activity, as well as their influence on the expression of related proteins and possible signaling pathways for the design and development of novel anti-vitiligo agents.