New and emerging therapies for vitiligo

Efficacy of prostaglandin E2 versus prostaglandin F2 alpha assisted with narrowband-UVB in stable vitiligo

In the recent decades, prostaglandins were recommended as a new therapeutic modality of stable vitiligo with promising efficacy. Therefore, we designed the current work to compare the significance of two different subtypes of prostaglandins [prostaglandin E2 (PGE2) versus prostaglandin F2 alpha (PGF2α)], assisted with NB-UVB phototherapy, in treatment of stable vitiligo. This study was conducted on 30 patients with stable non-segmental vitiligo. Three approximately similar vitiliginous areas were chosen in each patient and assigned into 3 groups. Each group treated with intradermal injection of either PGE2 (group I), PGF2α (group II), or saline as placebo (group III) at frequency once/week for 12 weeks. Concomitantly, all groups received NB-UVB phototherapy twice weekly for 3 months. The outcomes of this study discovered that the therapeutic efficacy of intradermal injection of either PGE2 or PGF2α assisted with NB-UVB phototherapy was comparable with non-significant difference between them in spite of being significantly higher than NB-UVB alone. However, there were a significantly earlier onset of repigmentation and higher degree of satisfaction regarding areas treated with PGE2 than those treated with PGF2α. In conclusion, both PGF2α and PGE2 intradermal injection could be considered as quite simple and affordable techniques in the treatment of stable vitiligo with no reported side effects and good patient satisfaction.

Successful Treatment of Refractory Vitiligo with a Combination of Khellin and 308-nm Excimer Lamp: An Open-Label, 1-Year Prospective Study

Introduction

Phototherapy is the cornerstone of treatment of vitiligo. The 308-nm excimer lamp (EL) induces T cell apoptosis and the stimulation of melanocyte proliferation. Khellin is a furanochromone with a chemical structure close to psoralens. The objective of the study was to evaluate the safety and efficacy of 1-year treatment of recalcitrant vitiligo with a combination of 308-nm EL and khellin.

Methods

Twenty patients with resistant vitiligo were included. Khellin was applied 45 min before irradiation with EL, twice a week, at a dose of 250 mJ/cm². The repigmentation was assessed in four categories: excellent repigmentation (ER) (> 75% repigmentation), good repigmentation (GR) (50–75% repigmentation), moderate repigmentation (MR) (25–50% repigmentation), and poor repigmentation (PR) (< 25% repigmentation).

Results

An ER was observed in 45% of patients (9/20), 5/20 (25%) achieved a GR, 3/20 (15%) an MR, and 3/20 (15%) a PR. Better response was observed on the face, neck, upper limb, hands, and abdomen. The mean number of procedures was 54.1 and the mean cumulative dose was 2967.5 mJ/cm². Six months after the last session no recurrences were observed.

Conclusion

The combination of 308-nm EL and khellin is a safe and effective treatment and represents a new alternative therapy for vitiligo. Further comparative controlled randomized investigations are needed to confirm these promising results with the appropriate therapeutic protocols.

A combination of Yiqiqubai granule and 308-nm excimer laser in treatment of segmental vitiligo: a prospective study of 233 patients

OBJECTIVE

To study the effect of Yiqiqubai granule combined with 308-nm excimer laser treatment for segmental vitiligo (SV).

METHODS

A prospective research was performed in 233 patients with SV treated in Shanghai General Hospital from 11 February 2015 to 25 August 2016, they were divided into group A (n = 75), group B (n = 78) and group C (n = 80) according to the random number table. Group A was treated with Yiqiqubai granule, group B treated with 308-nm excimer laser and group C treated with combined treatments. The treatment time lasts for 6 months. The clinical efficacy, color-reverse rate and quality of life of the three groups were assessed.

RESULTS

After treatment, the effective rate and markedly effective rate of group C (87.5%, 51.3%) were significantly higher than group A (74.7%, 42.7%) and group B (80.8%, 47.4%) (p < .05). Color-reverse rate of group C (66.5 ± 17.6%) was much higher than group A (47.2 ± 16.4%) and group B (49.9 ± 24.2%) (p < .05). Significant differences were found among three groups after treatment in terms of embarrassment, social and work (p < .05).

CONCLUSIONS

The combination of 308-nm excimer laser and Yiqiqubai granule in the treatment of SV has good clinical effect.

Autoimmunity as an aetiological factor in vitiligo

Vitiligo is a common dermatological disorder characterized by the presence on the skin of depigmented macules resulting from the destruction of cutaneous melanocytes. Autoimmunity is an important hypothesis with regard to vitiligo aetiology and the evidence for autoimmune responses being involved in the pathogenesis of this disorder will be discussed in the present review. All immune system compartments, including innate and adaptive immunity have been implicated in vitiligo development. Particularly relevant are autoantibodies and autoreactive T cells in vitiligo patients that have cytotoxic effects upon pigment cells. Furthermore, predisposition to vitiligo appears to be associated with certain alleles of the major histocompatibility complex class II antigens as well as with other autoimmune-susceptibility genes. Moreover, the association of vitiligo with autoimmune disorders, the animal models of the disease, and the positive response to immunosuppressive therapeutic agents emphasize the role of autoimmunity in the development of this disorder.

Autologous cultured melanocytes in vitiligo treatment

BACKGROUND

Surgical treatment of vitiligo is indicated when lesions are localized in poorly responding areas.

OBJECTIVES

The objectives were: (1) to establish the melanocyte culture obtained from the epidermis of vitiligo patients for future treatment; (2) to estimate the influence of selected factors on the formation of suction blisters and the results of culture; and (3) to compare the results of treatment of vitiliginous macules localized in the dorsum of the hands and lower limbs by transplantation of cultured autologous melanocytes plus psoralen and ultraviolet A (PUVA) therapy (CMP), suction blister transplantation plus PUVA therapy (SBP), cryotherapy plus PUVA-therapy (CP), and only PUVA therapy (OP).

METHODS

Forty patients were qualified for the study. The roofs of the suction blisters were used as a melanocyte source for culture establishment or were directly transplanted.

RESULTS

The CMP procedure was successfully performed on only 10 of 20 patients because of the difficulties in cell culture establishment. The SBP method was carried out on all 20 patients. A total lack of effectiveness was found in CP and OP methods.

CONCLUSIONS

The effectiveness of culture depends on time of suction blister forming, phototype, and previous PUVA therapy. This study demonstrated the advantage of the SBP over the CMP method.

Fototerapia: aplicações clínicas

Fototerapia é a modalidade terapêutica que aplica exposições repetidas e controladas de radiação ultravioleta para alterar a fisiologia cutânea de modo a induzir a regressão ou controlar a evolução de diversas dermatoses. Este texto apresenta uma visão geral das práticas correntes que utilizam a radiação ultravioleta isolada ou em combinação com fotossensibilizantes ou outras medicações. Serão ainda discutidos os mecanismos de ação de cada modalidade, as indicações mais aceitas, seus esquemas de prescrição, efeitos adversos e cuidados especiais.

Evaluation of the effects of NB-UVB in both segmental and non-segmental vitiligo affecting different body sites

BACKGROUND

Narrow band (NB)-UVB has been used in the treatment of vitiligo for years but statistical evaluation of the clinical response in both segmental and non-segmental vitiligo patients has yet to be assessed.

OBJECTIVES

Statistical evaluation of the clinical response of vitiligo patients to NB-UVB in both segmental and non-segmental types affecting different body sites.

METHODS

This study included 150 patients with vitiligo either segmental (10%) or non-segmental (90%). NB-UVB therapy was given twice weekly till reaching our end point of 100% re-pigmentation or a cut point in unresponsive cases. Evaluation of the percentage of re-pigmentation was performed by total body photography and planimetry every 8 weeks.

RESULTS

The overall response to therapy in the non-segmental vitiligo group demonstrated that 48% of the patients showed marked response, 27% showed moderate response and 25% showed mild response after UVB therapy. The patients showed marked response in 76.3% in face lesions, 41.9% in trunk lesions and 37.6% in limbs lesions. None of the patients in the acral areas achieved marked response. The mean duration of therapy was 7.8 months. Moreover, the results demonstrated that the earlier the patient was treated, the better the response was especially for lesions on the face, trunk and limbs. On the other hand, in the segmental vitiligo group, patients showed no more than mild response to NB-UVB whatever the site of the lesion was. No side effects were encountered with NB-UVB therapy except for aggravation of the disease in two cases and erythema in one patient who was an outdoor worker and was skin type II.

CONCLUSION

The type of vitiligo, the affected anatomical area and the disease duration are important factors that influence potential re-pigmentation.

Determination of the minimal phototoxic dose and colorimetry in psoralen plus ultraviolet A radiation therapy

BACKGROUND

The use of an adequate initial dose of ultraviolet A (UVA) radiation for photochemotherapy is important to prevent burns secondary to overdosage, meanwhile avoiding a reduced clinical improvement and long-term risks secondary to underdosage. The ideal initial dose of UVA can be achieved based on the phototype and the minimal phototoxic dose (MPD). The objective measurement of constitutive skin color (colorimetry) is another method commonly used to quantify the erythematous skin reaction to ultraviolet radiation exposure. The aim of this study was to determine variations in MPD and constitutional skin color (coordinate L(*)) within different phototypes in order to establish the best initial dose of UVA radiation for photochemotherapy patients.

METHODS

Thirty-six patients with dermatological conditions and 13 healthy volunteers were divided into five groups according to phototype. Constitutional skin color of the infra-axillary area was assessed by colorimetry. The infra-axillary area was subsequently divided into twelve 1.5 cm(2) regions to determine the MPD; readings were performed 72 h after oral administration of 8-methoxypsoralen (MOP) followed by exposure of the demarcated regions to increasing doses of UVA.

RESULTS

The majority of the participants were women (73.5%) and their mean age was 38.8 years. The MPD ranged from 4 to 12 J/cm(2) in phototypes II and III; from 10 to 18 J/cm(2) in type IV; from 12 to 24 J/cm(2) in type V and from 18 to 32 J/cm(2) in type VI. The analysis of colorimetric values (L(*) coordinate) and MPD values allowed the definition of three distinctive groups of individuals composed by phototypes II and III (group 1), types IV and V (group 2), and phototype VI (group 3).

CONCLUSIONS

MPD and L(*) coordinate showed variation within the same phototype and superposition between adjacent phototypes. The values of the L(*) coordinate and the MPD lead to the definition of three distinct sensitivity groups: phototypes II and III, IV and V and type VI. Also, the MPD values bear a strong correlation to coordinate L(*) values. Mean MPD values described for each of the three major sensitivity groups were higher than the values commonly used in clinical settings for the different phototypes. Therefore, phototype alone is not a good parameter to define the initial UVA dose. MPD and colorimetry could be used in pre-treatment evaluation of patients who are to be submitted to photochemotherapy, in a non-invasive and more accurate way when compared with the classical phenotype clinical criteria.

Autologous epidermal cultures and narrow-band ultraviolet B in the surgical treatment of vitiligo

BACKGROUND

Vitiligo is an acquired skin disorder with a great social impact. It can be successfully treated with autologous epidermal grafting.

OBJECTIVE

To evaluate the possibility of treating vitiligo by autologous grafting of epidermal cells and narrow-band ultraviolet B (UVB).

METHODS

Autologous epidermal cultures were prepared starting from small biopsies of normally pigmented skin. Cells were cultured on hyaluronic acid membranes using medium supplemented with patient's serum. Cell cultures were grafted onto laser-abraded depigmented areas. Patients underwent narrow-band UVB therapy 3 weeks after grafting.

RESULTS

Repigmentation of the grafted areas started 1 month after transplant and continued until 4 months after grafting. All patients were evaluated 3, 6, 12, and 18 months after grafting. At the 18-month follow-up, repigmentation was observed in 75% of patients with focal and segmental vitiligo and in 30% of patients with generalized vitiligo.

CONCLUSIONS

This therapy can be considered for the treatment of stable vitiligo (especially focal and segmental) resistant to standard therapies. Their results are encouraging from the clinical and esthetic point of view, although the treatment is costly and highly specialized.

Comparison of melanocytes transplantation methods for the treatment of vitiligo

BACKGROUND

Surgical therapy of vitiligo is indicated when depigmented macules are localized in areas that are known to respond poorly.

OBJECTIVE

The objective was to compare the results of treatment of vitiliginous macules localized in the dorsum of the hands and lower limbs by transplantation of cultured autologous melanocytes plus PUVA therapy (CMP), suction blister transplantation plus PUVA therapy (SBP), cryotherapy plus PUVA therapy (CP), and only PUVA therapy (OP).

METHODS

Twenty patients qualified for the study. The patients were split into two groups of 10 patients. In the first group, the CMP procedure was performed on one limb and OP on the other. In the second group, SBP and CP were used, respectively.

RESULTS

The CMP procedure was successfully performed on only 6 of 10 patients, whereas SBP was carried out on all 10 patients. No significant difference was found between the number of successful transplants in both groups of patients. A total lack of effectiveness was found in CP and OP methods.

CONCLUSION

This study demonstrated the advantage of the suction blister transplantation method over the autologous cultured melanocytes transplantation method because of the difficulties in cell culture establishment in some cases.

Management of dyschromias in ethnic skin

Pigmentary disorders are one of the most common skin disorders among people of color. Dyspigmentation in the form of either hyperpigmentation or hypopigmentation is often psychologically devastating to patients with darker skin. There is marked contrast between normally pigmented hyperpigmented, hypopigmented or depigmented skin in people of color. Despite being common, pigmentary disorders remain difficult to treat.

Treatment of vitiligo with the 308 nm excimer laser

Several therapeutic modalities have been proposed for the treatment of vitiligo either to achive repigmentation in the lesions or to stabilize the disease. Narrow-band UVB therapy has been shown to be effective and safe for use in the management of vitiligo; its wavelength is not so different from 308 nm XeCl excimer laser radiation. We present an open and uncontrolled pilot study of 24 patients (12 men, 12 women) in whom vitiligous patches were treated twice a week, for 9 months with 308 nm XeCl laser radiation. Seven of the 24 patients showed greater than 75% repigmentation, six patients showed repigmentation of between 25 and 75% and six patients showed less than 25% repigmentation. In five patients no signs of repigmentation were noted. The therapeutic benefit was stable during the 12-month follow-up period. Although these results are promising, treatment has so far been limited to small numbers of patients and a short follow-up period. Other prospective studies are needed to assess the efficacy of this treatment modality.

Cutaneous diseases in the black races

Laser therapy is routinely used today to treat a myriad of general and cosmetic dermatologic conditions. Most laser procedures are performed on lighter skin types with an abundance of published literature. There is a dearth of information about lasers on darker ethnic skin types. The demand for laser procedures on ethnic skin is growing dramatically. The dermatologic surgeon needs a conservative approach combined with ingenuity, sound judgment, and a clear understanding of laser optics in treating ethnic skin.

Pigmentary disorders in ethnic skin

Pigmentary disorders are commonly seen in ethnic skin. They are psychologically problematic in darker skin. Treatment of many of these disorders remains difficult.

Ethnic skin disorders overview

With the changing demographics of the US population, there is a need to understand the variety of dermatologic disorders that manifest in ethnic groups of non-Caucasian skin types. This article provides a review of presentations and current treatments of several common dermatologic diagnoses in black, Hispanic, and Asian racial groups and compares them with the presentations in Caucasian skin. The specific diagnoses discussed in the different racial groups include acne; pigmentary disorders such as postinflammatory hyperpigmentation and hypopigmentation, vitiligo, and melasma; and photoaging. Because the majority of the world's population already consists of people with pigmented skin and the population within the United States is approximately one-third non-Caucasian, physicians who practice in the field of dermatology today need a thorough understanding of non-Caucasian dermatoses.

Evidence for an autoimmune pathogenesis of vitiligo

Vitiligo is a depigmenting disorder characterized by the development of white patches in various distributions, which are due to the loss of melanocytes from the epidermis. A variety of arguments from clinical observations to research findings in human and animal models support the hypothesis of autoimmunity and are reviewed in this article. The association with autoimmune diseases and organ-specific autoantibodies is well known. Various effective treatment options have an immunosuppressive effect. Today the autoimmune pathogenesis of the disease has become a rapidly evolving field of research. Detection of circulating melanocyte antibodies in human and animal models implicates a possible role of humoral immunity. Histological and immunohistochemical studies in perilesional skin suggest the involvement of cellular immunity in vitiligo. Recently, T-cell analyses in peripheral blood further support this hypothesis. Interestingly, new insights in the association of vitiligo and melanoma may help to clarify the role of autoimmunity in the development of vitiligo.

Carbon dioxide laser resurfacing and thin skin grafting in the treatment of "stable and recalcitrant" vitiligo

Various surgical methods have been used in the treatment of small stable vitiliginous areas, but there is no established surgical approach for larger vitiligo areas and therapy-resistant anatomic sites, such as the hands. Two years ago, we successfully treated large burn scar depigmentation areas at different anatomic sites using carbon dioxide laser resurfacing and thin (0.2 to 0.3 mm) skin grafting. The purpose of this study was to investigate the effectiveness of our method in treating large, stable, and recalcitrant vitiligo areas. Thirteen anatomic sites of seven male patients, whose ages ranged from 20 to 22 years, were treated. The locations of the treated areas were as follows: seven areas on the dorsum of the hands, two areas on the forearms, two areas in the pretibial region, one area on the lateral thigh, and one area in the presternal region. The surface area of treated vitiligo sites ranged from 0.5 to 6 percent of total body surface area (mean, 2.5 percent). Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 6 to 18 months, with an average follow-up period of 14 months. Early and complete repigmentation was achieved and the color match was good or excellent in all patients. No depigmentation occurred again in the treated areas or graft donor sites. In conclusion, with careful patient selection and delicate surgical technique, our method was effective in treating large areas of vitiligo over the extremities and dorsum of hands, which were refractory to other therapies and could not be hidden.

Vitiligo: a retrospective comparative analysis of treatment modalities in 500 patients

The major non-surgical re-pigmenting therapies for vitiligo include psoralens and corticosteroids, used both topically and systemically. In an attempt to determine the best therapeutic option, we compared the efficacy of various treatment regimens used in our department for the treatment of vitiligo. We report herein our results with six different regimens used in our clinic. Data from five hundred vitiligo patients who attended the pigmentary disorders clinic at the Nehru Hospital, PGI, Chandigarh, was analysed. For the purpose of analysis, patients were arbitrarily divided into two groups based upon the body surface area (BSA) involved: Group A (<10% BSA involved) and B (>10% BSA involved). Group A was further divided into three subgoups of patients depending upon what treatment they received: R-I [topical clobetasol propionate+sun exposure]; R-II [topical psoralen+sun exposure (topical PUVASOL)]; R-III [topical psoralen+UVA (topical PUVA)]. Group B was also subdivided into three subgroups of patients who received: R-IV [oral dexamethasone pulse therapy + sun exposure]; R-V [systemic psoralen + sun exposure (systemic PUVASOL)]; R-VI [systemic psoralen + UVA (systemic PULVA)]. Patients who had undergone, one of the above mentioned regimens and had a regular monthly follow up until total re-pigmentation or for at least one year, whichever was earlier, were included in the final assessment of the therapeutic efficacy of that regimen. At the end of the study in Group A, 207 (89%) patients out of 232 on R-I; 73 (93%) out of 78 on R-II, and 15 (79%) out of 19 patients on R-III showed moderate to excellent re-pigmentation, respectively. In group B, 45 (81%) patients out of 55 on R-IV, 48 (84%) out of 57 on RV, and 22 (84%) patients out of 26 on R-VI showed moderate to excellent re-pigmentation. Statistically, in Group A, R-I & II were significantly better than R-III. However in Group B, there was no significant difference in the responses to R-IV, V, and VI. A positive family history of vitiligo did not seem to affect the response rate. Potent topical steroids used along with sun exposure and topical PUVASOL were the most effective forms of therapy for localised vitiligo. For the generalised form of the disease, we concluded that all the systemic modalities, oral steroids, PUVASOL and PUVA, are equally efficacious over a period of one year. Phototoxic reactions were, however, more common with PUVASOL.

Specific cytotoxic T lymphocyte responses against Melan-A/MART1, tyrosinase and gp100 in vitiligo by the use of major histocompatibility complex/peptide tetramers: the role of cellular immunity in the etiopathogenesis of vitiligo

Vitiligo is a common skin disease characterized by the presence of well circumscribed, depigmented, milky white macules devoid of identifiable melanocytes. Although the detection of circulating anti-melanocytic antibodies and of infiltrating lymphocytes at the margin of lesions supports the view that vitiligo is an autoimmune disorder, its etiology remains unknown. In particular, it is still a matter of debate whether the primary pathogenic role is exerted by humoral or cellular abnormal immune responses. In this study, the presence of specific cytotoxic T lymphocyte responses against the melanocyte differentiation antigens Melan-A/MART1, tyrosinase, and gp100 in vitiligo patients have been investigated by the use of major histocompatibility complex/peptide tetramers. High frequencies of circulating melanocyte-specific CD8+ T cells were found in all vitiligo patients analyzed. These cells exerted anti-melanocytic cytotoxic activity in vitro and expressed skin-homing capacity. In one patient melanocyte-specific cells were characterized by an exceptionally high avidity for their peptide/major histocompatibility complex ligand. These findings strongly suggest a role for cellular immunity in the pathogenesis of vitiligo and impact on the common mechanisms of self tolerance.