Topical calcipotriol as monotherapy and in combination with psoralen plus ultraviolet A in the treatment of vitiligo

Systematic Evaluation and Meta-Analysis of Randomized Controlled Trials of Fire Needle Combined Phototherapy for the Treatment of Vitiligo

This study investigated the fire needle and phototherapy combination for treating vitiligo through a meta-analysis of the published literature. Indeed, vitiligo is a common chronic skin condition characterized by the appearance of white patches. It is the most prevalent disorder, affecting approximately 1% of the global population. There is no known cure or clinical recommendation for treating vitiligo. The majority of medical guidelines suggest vitiligo treatment with the use of fire needles. Here, vitiligo was treated with a novel mechanism combining a fire needle with phototherapy. The handheld phototherapy devices include a fire needle option for disease treatment. Miniature lesions that could be used to detect and treat vitiligo at an early stage could be managed by hybrid-capable devices. The real-time study included more than 3,435 patients. The dosages were altered to control the adverse effects. Following treatment, granulation tissues developed on the injured skin, diminishing the shallow area and wound surface. The case studies demonstrate that combining phototherapy and fire needle therapy is more practical than the other methods.

The Safety of Medicinal Plants Used in the Treatment of Vitiligo and Hypermelanosis: A Systematic Review of Use and Reports of Harm

INTRODUCTION

Vitiligo is disfiguring and devastating condition that can humans feel stigmatic and devalued. Melasma is a general condition of hyperpigmentation particularly involving the face. The pigmentation disorders of vitiligo (hypopigmentation or de-pigmentation) and melasma (Hypermelanosis) are common among the world's population (around 1% for vitiligo).

OBJECTIVE

The identification of medicinal plants used in the treatment of vitiligo and hypermelanosis. A systematic literature review on harms associated with the medicinal plants used in the treatment of vitiligo and hypermelanosis. To review and summarize information on reported adverse drug reactions (ADRs) associated with these medicinal plants contained in (where access is available) national and global individual case safety report databases.

METHODS

A systematic review of the literature with special reference to all types of clinical trial and case reports using biomedical databases including Medline, EMBASE, Scopus, International Pharmaceutical Abstracts and so forth to identify medicinal plants alone or as an adjuvant with other treatments and their safety/tolerability in the treatment of vitiligo and Hypermelanosis. Other sources of this search were medicinal plants text books, pharmacopoeias and authentic websites discussing possible treatments for vitiligo/hypermelanosis. It also included databases such as VigiAccess containing data from spontaneous reporting schemes for ADRs.

RESULTS

A total of 55 articles (47 clinical trials and 8 case reports) met the inclusion criteria. Some trials did not reported safety information, some did report, but not very well. Reports of blistering, erythema, acute hepatitis and mutagenesis with Psoralea corylifolia. Adverse effects of erythema (mild to severe), phototoxic reactions, mild raise in liver transaminases, gastrointestinal disturbances, burns, itching, scaling, depigmented macules, pruritis, and giddiness with the use of psoralens. Khellin-related erythema, perilesional hyperpigmentation, gastrointestinal disturbances, mild raise in liver transaminases and orthostatic complaints. Infrequent side effects with Ginkgo biloba. Lower grade of erythema and edema reported with the use of Polypodium leucotomos.

CONCLUSION

Primarily the retrieved clinical studies were efficacy oriented and safety parameters were secondary in priority whilst the general protocol of clinical trials requires the screening of drugs/medicinal plants on the basis of safety studies before testing the clinical aspects of efficacy. Thereby it is recommended that efficacy studies may be followed once the safety has been established for a particular medicinal plant in treating vitiligo and hypermelanosis.

Nuclear factor erythroid 2-related factor 2 (Nrf2) as a potential therapeutic target for vitiligo

Vitiligo is an autoimmune disease of the skin which causes loss of melanocytes from the epidermis. Recently, it is demonstrated that oxidative stress (OS) plays a significant role in the immuno-pathogenesis of vitiligo. A major mechanism in the cellular defense against OS is activation of the nuclear factor erythroid2-related factor (Nrf2)-Kelch-like ECH-associated protein 1(Keap1)-antioxidant responsive element (ARE) signaling pathway. Recently it has been shown that vitiligo melanocytes have impaired Nrf2-ARE signaling. A number of drugs including those known as Nrf2 activators and those known to possess effects to activate Nrf2, have been used in treating vitiligo with certain therapeutic effects. Also, studies have shown that a number of compounds can protect melanocytes against OS via activating Nrf2. These compounds may be considered as candidates for developing new drugs for vitiligo in the future. Nrf2 can be considered as a potential therapeutic target for vitiligo.

Role of Vitamin D Beyond the Skeletal Function: A Review of the Molecular and Clinical Studies

The classical function of Vitamin D, which involves mineral balance and skeletal maintenance, has been known for many years. With the discovery of vitamin D receptors in various tissues, several other biological functions of vitamin D are increasingly recognized and its role in many human diseases like cancer, diabetes, hypertension, cardiovascular, and autoimmune and dermatological diseases is being extensively explored. The non-classical function of vitamin D involves regulation of cellular proliferation, differentiation, apoptosis, and innate and adaptive immunity. In this review, we discuss and summarize the latest findings on the non-classical functions of vitamin D at the cellular/molecular level and its role in complex human diseases.

FK506 positively regulates the migratory potential of melanocyte-derived cells by enhancing syndecan-2 expression

Although topical tacrolimus (FK506) is known to promote repigmentation by increasing the pigmentation and migration of melanocytes, the mechanism through which FK506 regulates cell migration remains unclear. Here, we report that FK506 treatment enhanced cell spreading on laminin-332 and increased migration in both melanocytes and melanoma cells. Interestingly, FK506 also increased the expression of syndecan-2, a transmembrane heparan sulfate proteoglycan through c-jun terminal kinase activation. Moreover, siRNA-mediated reduction of syndecan-2 expression decreased FK506-mediated cell spreading and migration in melanoma cells and decreased focal adhesion kinase phosphorylation in both melanocytes and melanoma cells. Consistent with these effects on syndecan-2 expression, FK506 enhanced the membrane and melanosome localizations of PKCβII, a regulator of tyrosinase activity. This suggests that FK506 may play a dual regulatory role by affecting both melanogenesis and migration in melanocyte-derived cells. Interestingly, however, FK506 failed to show any synergistic effect on the migration of UVB-treated melanocyte-derived cells. Taken together, these data indicate that FK506 regulates cell migration by enhancing syndecan-2 expression, further suggesting that syndecan-2 could be a potential target for the treatment of patients with vitiligo.

Off-label uses of topical vitamin D in dermatology: a systematic review

BACKGROUND

Topical vitamin D is approved by the US Food and Drug Administration for the treatment of psoriasis but is also used off-label in the treatment of a variety of cutaneous diseases despite a lack of evidence-based guidelines.

OBJECTIVE

The objective of this study was to provide evidence-based clinical guidelines for the off-label use of topical vitamin D in the treatment of dermatologic disease.

METHODS

A systematic literature review was conducted via the MEDLINE, Embase, and CENTRAL databases for off-label uses of topical vitamin D analogues in the treatment of dermatologic disease other than psoriasis. The data were synthesized, and evidence-based recommendations were rendered according to the highest level of evidence available.

RESULTS

A total of 165 articles met the inclusion criteria. A moderate to strong recommendation was given for the use of topical vitamin D in combination with corticosteroids and phototherapy in vitiligo and as monotherapy for various ichthyoses, morphea, pityriasis alba, prurigo nodularis, and polymorphous light eruption. There is evidence showing that topical vitamin D is ineffective in the treatment of actinic keratosis, seborrheic keratosis, lichen planus, seborrheic dermatitis, alopecia areata, chemotherapy-induced alopecia, and hypertrophic scars.

CONCLUSION

Topical vitamin D analogues have an important role in the off-label treatment of dermatologic disease, but higher quality studies are still required.

Vitiligo road map

Vitiligo is a depigmenting disorder stemming from melanocyte loss or dysfunction. It has a complex, multifaceted etiology. We constructed a "vitiligo road map," consisting of basic science, clinical, and treatment components, in order to better portray our current understanding of vitiligo pathogenesis and reflect upon novel biomarkers and therapeutic targets for future research. The melanocyte map elaborates on the molecular processes and intracellular signaling pathways initiated by various external autocrine/paracrine factors in representing normal melanocyte homeostatic functions modulating its viability, proliferation, differentiation, dendricity, migration, and melanogenic processes. This vitiligo map identifies known inducers/triggers of vitiligo onset and progression that cultivate a microenvironment for melanocyte disappearance, real or functional. This map describes the molecular mechanisms of currently utilized clinical and experimental treatments of vitiligo that facilitate repigmentation.

Vitiligo: an update on current pharmacotherapy and future directions

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Current remedies for vitiligo

Vitiligo is a disorder with complex causes and is a type of autoimmune disease in which the immune system targets the body's own pigment cells and tissues. Our aim is to present an overall view of the current remedies widely adopted for the treatment of vitiligo. Medical treatments target the immune system, and try to reverse the destruction. The goal is to restore the skin's color by restoring healthy melanocytes to the affected area. Apart from melanocytes, vitiligo autoantigens appear also on other cells. Even though antibodies to pigment cells are not an agent of vitiligo, the most valuable contribution is that anti-melanocyte antibody reactivity can help in identifying relevant antigens. T cells from vitiligo skin are highly reactive towards melanoma cells and serve as an effective source to treat melanoma and stays as a solution for vitiligo. There have been many treatments to cure vitiligo such as use of steroid creams, PUVA (psoralen and ultraviolet A light), narrow band UVB (ultraviolet B), various surgical techniques, vitamin D analogues and pseudocatalase. These treatments are subjected for undesired side effects whereas some herbal and natural treatments act against the immune system with no side effects.

Peroxisome proliferator-activated receptors (PPARs) and the human skin: importance of PPARs in skin physiology and dermatologic diseases

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear receptor superfamily that regulate lipid, glucose, and amino acid metabolism. More recently, PPARs and corresponding ligands have been shown in skin and other organs to regulate important cellular functions, including cell proliferation and differentiation, as well as inflammatory responses. These new functions identify PPARs and corresponding ligands as potential targets for the treatment of various skin diseases and other disorders. It has been shown that in inflammatory skin disorders, including hyperproliferative psoriatic epidermis and the skin of patients with atopic dermatitis, the expression of both PPARalpha and PPARgamma is decreased. This observation suggests the possibility that PPARalpha and PPARgamma activators, or compounds that positively regulate PPAR gene expression, may represent novel NSAIDs for the topical or systemic treatment of common inflammatory skin diseases such as atopic dermatitis, psoriasis, and allergic contact dermatitis. Moreover, recent findings indicate that PPAR-signaling pathways may act as a promising therapeutic target for the treatment of hyperproliferative skin diseases including skin malignancies. Studies in non-diabetic patients suggest that oral thiazolidinediones, which are synthetic ligands of PPARgamma, not only exert an antidiabetic effect but also may be beneficial for moderate chronic plaque psoriasis by suppressing proliferation and inducing differentiation of keratinocytes; furthermore, they may even induce cell growth arrest, apoptosis, and terminal differentiation in various human malignant tumors. It has been reported that PPARalpha immunoreactivity is reduced in human keratinocytes of squamous cell carcinoma (SCC) and actinic keratosis (AK), while PPARdelta appears to be upregulated. Additionally, the microvessel density is significantly higher in AK and SCC that express high levels of PPARdelta. PPARdelta has been demonstrated to have an anti-apoptotic role and to maintain survival and differentiation of epithelial cells, whereas PPARalpha and PPARgamma activators induce differentiation and inhibit proliferation and regulate apoptosis. In melanoma, the growth inhibitory effect of PPARgamma activation is independent of apoptosis and seems to occur primarily through induction of cell cycle arrest in the G1 phase of the cell cycle or induction of re-differentiation. PPARalpha activation causes inhibition of migration of melanoma cells and anchorage-independent growth, whereas primary tumor growth remains unaltered. In clinical trials of gemfibrozil, a PPARalpha ligand, significantly fewer patients treated with this lipid-lowering drug were diagnosed with melanoma as compared to those in the control group. In conclusion, an increasing body of evidence indicates that PPAR signaling pathways may represent interesting therapeutic targets for a broad variety of skin disorders, including inflammatory skin diseases such as psoriasis and atopic dermatitis, and skin malignancies.

A Rational Approach to the Treatment of Vitiligo and Other Hypomelanoses

A rational approach to hypopigmented disorders needs a clear and widely accepted classification and meta-analysis of the literature to position the medical, physical, surgical, and combined treatments available in terms of safety and effectiveness profiles. Best available scientific evidence must be rationally adapted to the patient's expectations and to the clinical presentation of the hypopigmentary disease, to reach the most valid final results.

New and Experimental Treatments of Vitiligo and Other Hypomelanoses

This article deals with new and experimental treatments that can be used to treat various forms of depigmenting disorders. Ultraviolet B-focused therapies and new surgical approaches are analyzed in this article. These therapies were mainly or only developed to treat vitiligo, which is the most studied and probably the most challenging of all the hypomelanoses, but the results obtained in trials and clinical experiences about vitiligo sometimes can be referred to other depigmenting disorders.

Vitiligo et qualité de vie : étude cas-témoins

BACKGROUND

Vitiligo is a common and visible form of leukoderma that can adversely affect the quality of life of patients. The aim of this study was to assess the impact of vitiligo on the quality of life of patients.

PATIENTS AND METHODS

This was a cross-sectional case-control study performed between 1 September 2000 and 31 December 2001. Sixty patients with vitiligo and 60 controls paired for age and gender were collated. Quality of life was assessed using the Dermatology Life Quality Index (DLQI).

RESULTS

Mean patient age was 38.9 years. The sex-ratio M/F was 1.1. Vitiligo was generalized in 80% of cases. Quality of life was significantly impaired in patients and to a greater extent in women and in cases affecting more than 10% of the body surface. All aspects of quality of life were affected.

CONCLUSION

Because of its visible nature, vitiligo can impair patients' quality of life and have marked psychological impact.

PPAR-gamma agonist, ciglitazone, increases pigmentation and migration of human melanocytes

Peroxisome proliferator-activated receptors (PPARs) play an important role in cellular responses. It was reported that three subtypes of PPAR are expressed in human melanocytes. In this study, we investigated the effects of the PPAR-gamma agonist, ciglitazone, on pigmentation and migration of human melanocytes. Ciglitazone stimulated the melanin content of cells and cultured skin. This increase in pigmentation was due to the stimulation of tyrosinase activity and expression of tyrosinase and microphthalmia-associated transcription factor protein of the melanocytes. Migration was increased after ciglitazone treatment, which was observed by the Boyden chamber checkerboard analysis and a scratch motility assay. These results suggest the regulatory role of PPAR-gamma in pigmentation and migration of human melanocytes.

Topical tacalcitol and 308-nm monochromatic excimer light: a synergistic combination for the treatment of vitiligo

BACKGROUND/PURPOSE

To study and compare the efficacy of combined 308-nm monochromatic excimer light (MEL) therapy with tacalcitol vs. that of MEL 308-nm therapy alone in treatment of vitiligo.

METHODS

Thirty-eight patients with vitiligo were enrolled in a single-blind, within patient controlled clinical trial. Symmetrical or nearby lesions were randomly applied with either topical tacalcitol cream or vehicle. Each lesion was treated weekly with the 308-nm MEL, for a total of 12 sessions. Patients were examined at monthly intervals. The mean number of sessions and the cumulative dosage for initial repigmentation were calculated.

RESULT

Thirty-five patients were evaluated. Treatment with tacalcitol and MEL resulted in higher percentages for excellent repigmentation (25.7%) compared with vehicle and MEL (5.7%) (P<0.05). Percentages for total response were 71.4% and 60%, respectively (P>0.05). The mean+/-SEM cumulative dose and number of excimer light exposures for initial repigmentation were, respectively, 3.93+/-0.59 J/cm2 and 4.52+/-0.49 at the tacalcitol side, and, respectively, 4.99+/-0.68 J/cm2 and 5.3+/-0.52 at the vehicle side (P<0.05).

CONCLUSION

Our results have shown that concurrent topical tacalcitol potentiates the efficacy of the 308-nm MEL in the treatment of vitiligo, and that this combination achieves earlier pigmentation with a lower total dosage.

Treatment of localized vitiligo with targeted broadband UVB phototherapy: a pilot study

BACKGROUND

Narrowband ultraviolet B (UVB) phototherapy and 308 nm excimer laser have produced encouraging therapeutic results for vitiligo. Repigmentation of various degrees was obtained in different studies.

MATERIALS AND METHODS

Twenty-nine vitiliginous lesions from six patients were treated with targeted, broadband UV-B phototherapy. UV fluences were started at 50% of the minimal erythema dose, then increased gradually. Treatments were carried out twice weekly for 12 weeks.

RESULTS

Some degree of repigmentation occurred in all subjects. Responses varied among the different anatomic locations, with acral lesions achieving the least improvement. Onset of repigmentation was as early as 3 weeks of treatment in some subjects. Treatments were well tolerated, with only minimal erythema and hyperpigmentation.

LIMITATIONS

This study was carried out in a smaller number of patients with skin types III and IV. The irradiation device was a broadband UVB device, and thus the results may not be similar to those obtained from a more monochromatic system such as an excimer laser.

CONCLUSIONS

Targeted broadband UVB is an efficacious and safe modality for the treatment of localized vitiligo.

Combination of narrow band UVB and topical calcipotriol for the treatment of vitiligo

BACKGROUND

Narrow band ultraviolet B (NB-UVB) phototherapy has been used successfully for the treatment of vitiligo. Recently, topical calcipotriol has also been claimed to be effective, either as monotherapy or as a part of combination therapies.

OBJECTIVE

The aim of the present study was to compare the clinical efficacy of NB-UVB and NB-UVB plus topical calcipotriol in the treatment of vitiligo.

METHODS

NB-UVB treatment was given to 24 patients with generalized vitiligo three times weekly. Topical calcipotriol cream was only applied to the lesions located on the right side of the body. Treatment was continued for 6 months. Treatment efficacy was evaluated by determining the average response rates of the lesions at 3-month intervals.

RESULTS

The average response rates of patients receiving combination of NB-UVB plus calcipotriol and NB-UVB alone were 51 +/- 19.6% and 39 +/- 18.9%, respectively. The median cumulative UVB dose and number of UVB exposures for initial repigmentation were 6345 mj/cm(2) (range; 2930-30980) and 18 (range; 12-67) for the combination therapy, and 8867.5 mj/cm(2) (range; 2500-30980) and 24 (range; 15-67) for the narrow band UVB therapy, respectively.

CONCLUSIONS

These findings indicate that concurrent topical calcipotriol potentates the efficacy of NB-UVB in the treatment of vitiligo. This combination not only provides earlier pigmentation with lower total UVB dosage and less adverse UVB effects, but also reduces the duration and cost of treatment as well.

Narrow-band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of vitiligo

Vitiligo is a common, idiopathic, acquired, depigmenting disease characterized by loss of normal melanin pigments in the skin. The most interesting treatment methods for extensive vitiligo involve psoralen plus ultraviolet A (PUVA) therapy and ultraviolet (UV)-B phototherapy, particularly narrow-band UV-B. In this randomized and comparative study, we investigated the safety and efficacy of narrow band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of generalized vitiligo. Of the 40 vitiligo patients enrolled in the study, 15 were treated with the calcipotriol plus narrow-band UV-B (NBUVB) and 25 with narrow band UV-B alone. The patients were randomized into two NBUVB treatment groups. The first group, consisting of 24 patients (all male), received only NBUVB treatment; the second group, consisting of 13 patients (all male) applied 0.05% topical calcipotriol ointments twice daily. Both groups were irradiated with NBUVB (311 nm). In the NBUVB group, the percentage of the body surface affected was reduced from 27.21 +/- 10.41% to 16.25 +/- 8.54% after a mean of 30 treatment sessions. The mean repigmentation percentage was 41.6 +/- 19.4%. In clinical evaluation (moderate and marked/complete response was accepted as an effective treatment), 19 patients (19/24; 79.17%) had clinically good results. In the NBUVB plus calcipotriol group, the percentage of the body surface affected was reduced from 23.35 +/- 6.5% to 13.23 +/- 7.05% after a mean of 30 treatment sessions. The mean repigmentation percentage was 45.01 +/- 19.15%. In clinical evaluation (moderate and marked/complete response was accepted as an effective treatment), 10 patients (10/13; 76.92%) had clinically good results. Statistically significant intragroup reductions from the baseline percentage of the body surface affected were seen at the endpoint of treatment for the two treatment groups (P < 0.001). However, there was no statistically significant difference between the two treatment groups at the end of therapy with respect to the reduction of repigmentation rates (P > 0.05). The present study reconfirmed the efficacy of NBUVB phototherapy in vitiligo. It can be a therapeutic option considered in the management of patients with vitiligo. However, addition of topical calcipotriol to NBUVB did not show any advantage.

Effect of topical calcipotriol, betamethasone dipropionate and their combination in the treatment of localized vitiligo

BACKGROUND

Treatment of vitiligo is a challenge. Steroids are known to be effective but are associated with serious adverse effects. Many uncontrolled studies have shown calcipotriol to be a promising therapeutic modality in vitiligo.

OBJECTIVE

To conduct a randomized trial to evaluate the effect of topical calcipotriol ointment (0.005%) and betamethasone dipropionate (0.05%) cream, given alone or in combination, in treatment of localized vitiligo.

METHODS

Forty-nine patients with vitiligo affecting 5% of their skin were recruited. Patients were randomized into three groups. Group I patients were treated with betamethasone dipropionate (0.05%) cream twice daily. Group II patients were treated with calcipotriol ointment (0.005%) twice daily, and group III with betamethasone dipropionate (0.05%) in the morning and calcipotriol (0.005%) in the evening.

RESULTS

Forty-five patients completed the study period of 3 months with 15 patients in each group. No patient achieved excellent (> 75%) pigmentation. Marked (50% to 75%) repigmentation was observed in 2 (13.3%), 1 (6.7%) and 4 (26.7%) patients in groups I, II and III, respectively. Moderate (25-50%) repigmentation was observed in 7 (46.7%), 5 (33.3%) and 7 (46.7%) patients in groups I, II and III, respectively. Patients with < 25% pigmentation were termed as minimal pigmentation or no response. The mean time for initial pigmentation to appear was 9.04 +/- 2.0 weeks in group I, 10.18 +/- 1.6 weeks in group II and 5.17 +/- 2.4 weeks in group III (P < 0.01). The acquired pigmentation in the lesions was more stable in group III as compared with patients in groups II and I (P < 0.01). Side-effects in the form of atrophy and lesional burning sensations were more common in group I when compared with groups II and III (P < 0.05).

CONCLUSION

Combined therapy appeared to give a significantly faster onset of repigmentation along with better stability of the achieved pigmentation and with lesser number of side-effects.

Fototerapia

Fototerapia é utilizada para tratar uma grande variedade de dermatoses. Desde o século passado a fototerapia tem sido utilizada em várias modalidades, com irradiação UVA ou UVB. Está indicada para todos os tipo de dermatoses inflamatórias e com período crônico de evolução, como vitiligo, pasoríase, parapsoríase, linfomas cutâneos de células T, eczemas crônicos, demonstrando bons resultados terapêuticos. Pode ser utilizada como monoterapia ou associada a outras drogas, como retinóides, metotrexate, ciclosporina, com objetivo de diminuir o tempo de tratamento e as doses das medicações mencionadas. Como os demais tipos de tratamento, a fototerapia apresenta algumas limitações, como a necessidade de equipamentos específicos, a adesão do paciente, a possibilidade de indicação ao paciente e a dose cumulativa de irradiação UV. A fototerapia deve ser conduzida com seguimento criterioso para a obtenção de resposta efetiva com poucos efeitos colaterais.

Narrow-band UVB311 nm vs. broad-band UVB therapy in combination with topical calcipotriol vs. placebo in vitiligo

BACKGROUND

Recently, it has been shown that UVB phototherapy may be more effective than UVA in the treatment of vitiligo. Currently, however, no studies have compared the efficacy of UVB311 nm and broad-band UVB therapy. Calcipotriol has recently been reported to be effective adjunctive treatment for vitiligo, enhancing the efficacy of 8-methoxypsoralen plus UVA (PUVA) therapy.

METHODS

Ten patients were enrolled in the study; nine completed the 12 months of therapy. The upper part of the body was treated twice weekly with UVB311 nm and the lower part with broad-band UVB. Calcipotriol was applied onto the vitiligo lesions of the right side of the body and placebo on the left side. Repigmentation was documented by photography, planimetry, and Vitiligo Disease Activity (VIDA) score. The quality of life was measured by the Dermatology Life Quality Index (DLQI).

RESULTS

After 7-16 weeks, six of the nine patients showed initial repigmentation on the side treated with UVB311 nm. After 6 months of treatment, none of the patients showed repigmentation on the areas treated with broad-band UVB, which prompted us to apply UVB311 nm all over the body. At the end of 12 months, two patients showed > 75% repigmentation, two showed 51-75%, two showed 26-50%, and three showed 0-25%. In all patients with progressive vitiligo (seven of the nine patients), disease activity was stopped. Remarkably, vitiligo lesions treated with calcipotriol initially showed delayed repigmentation compared with control areas; however, there was no therapeutic difference between calcipotriol and placebo, both in combination with UVB311 nm, by the end of the study. The DLQI score improved significantly by an average of 28%. Conclusion UVB311 nm therapy was effective in the treatment of vitiligo, whereas broad-band UVB had no effect. Combination with calcipotriol ointment was not superior to UVB311 nm monotherapy. The quality of life significantly improved with narrow-band UVB311 nm phototherapy.

Topical calcipotriene and narrowband ultraviolet B in the treatment of vitiligo

BACKGROUND

Treatment of vitiligo, despite significant advances made in the past few years, remains to be a challenge. Narrowband ultraviolet (NB-UVB) has emerged as an important therapeutic option for this condition.

OBJECTIVE

To evaluate whether the combination of calcipotriene ointment and NB-UVB could enhance the efficacy of NB-UVB alone.

METHODS

An open, bilateral comparison study was performed in 20 patients with symmetrical vitiligo between August 2001 and October 2002. All patients received NB-UVB three times per week. Calcipotriene ointment was applied to lesions on the left side of the body. Response was graded visually as significant (66-100% repigmentation), moderate (26-65%), mild (10-25%), and minimal (< 10%).

RESULTS

Seventeen patients (six females, 11 males) completed the study. Eight patients (8/17=47%) had significant repigmentation after 67-180 treatments, six patients (35%), one patient (6%), and two patients (12%) had moderate, mild, and minimal repigmentation after 40-160, 57, and 14-21 treatments, respectively. Nine of the 17 patients had an appreciably better improvement on the NB-UVB and calcipotriene side by 29-114 treatments. In six of these patients, differences were still observed at the end of the study period. No side effects were noted.

CONCLUSION

Combination therapy of topical calcipotriene and NB-UVB is a therapeutic option that could be considered in the management of patients with vitiligo.

Peroxisome Proliferator-Activated Receptors and their Ligands

Glucocorticoids have remained one of the most frequently used classes of drugs for the treatment of skin diseases since their introduction more than 50 years ago. As a result of the discovery of new members of the nuclear hormone receptor (NR) superfamily, alternative therapeutic interventions that target retinoid and vitamin D receptors have been developed. Peroxisome proliferator-activated receptors (PPARs) comprise another important NR subfamily, consisting of three different isotypes: PPARalpha, PPARdelta (PPARbeta) and PPARgamma. These NRs are activated by a variety of natural and synthetic ligands such as fatty acids, eicosanoids, and antidiabetic and antihyperlipidaemic agents. While these receptors are established as regulators of gene expression in lipid and glucose homeostasis, evidence is now accumulating that PPARs also play a crucial role in cutaneous biology. Results from in vitro and in vivo studies have indicated the involvement of PPARs in epidermal maturation, proliferation and differentiation, as well as in immune and inflammatory responses, carcinogenesis, hyperpigmentation and skin wound healing. Furthermore, treatment of psoriatic patients with PPARgamma activators (thiazolidinediones) has been shown to induce beneficial effects. However, the effects of PPAR ligands should be carefully evaluated to determine whether they are in fact mediated via PPAR-dependent mechanisms. Nonetheless, PPARs seem to have significant potential as therapeutic targets in skin inflammatory disorders.

Melanin pigmentation in mammalian skin and its hormonal regulation

Cutaneous melanin pigment plays a critical role in camouflage, mimicry, social communication, and protection against harmful effects of solar radiation. Melanogenesis is under complex regulatory control by multiple agents interacting via pathways activated by receptor-dependent and -independent mechanisms, in hormonal, auto-, para-, or intracrine fashion. Because of the multidirectional nature and heterogeneous character of the melanogenesis modifying agents, its controlling factors are not organized into simple linear sequences, but they interphase instead in a multidimensional network, with extensive functional overlapping with connections arranged both in series and in parallel. The most important positive regulator of melanogenesis is the MC1 receptor with its ligands melanocortins and ACTH, whereas among the negative regulators agouti protein stands out, determining intensity of melanogenesis and also the type of melanin synthesized. Within the context of the skin as a stress organ, melanogenic activity serves as a unique molecular sensor and transducer of noxious signals and as regulator of local homeostasis. In keeping with these multiple roles, melanogenesis is controlled by a highly structured system, active since early embryogenesis and capable of superselective functional regulation that may reach down to the cellular level represented by single melanocytes. Indeed, the significance of melanogenesis extends beyond the mere assignment of a color trait.

Calcipotriene and corticosteroid combination therapy for vitiligo

Corticosteroids and photochemotherapy, using a combination of psoralen and ultraviolet A (PUVA) exposure, are the most widely prescribed therapies for vitiligo. These treatments are not uniformly effective and many patients have inadequate responses. Calcipotriene has been shown to be effective in adults and children with psoriasis when used as monotherapy and in combination with corticosteroids and phototherapy. We hypothesized that since the mechanisms of action for calcipotriene and corticosteroids are different, patients may develop more repigmentation with a combination of the two agents, while decreasing the side effects from both agents. Twelve patients with vitiligo (average age 13.1 years) were advised to use topical corticosteroids in the morning and topical calcipotriene in the evening. Of the 12 patients, 83% responded to therapy, with an average of 95% repigmentation by body surface area. Four of the patients who responded had previously failed trials of topical corticosteroids alone. All of the patients in this group had repigmentation. Eyelid and facial skin responded best to this therapy. None of the patients had adverse reactions to the treatment. Our results show that topical calcipotriene in combination with corticosteroids can repigment vitiligo, even in those patients who were previous topical corticosteroid failures.

Expression and function of peroxisome proliferator-activated receptors in human melanocytes

BACKGROUND

Peroxisome proliferator-activated receptors (PPARs) belong to the superfamily of nuclear receptors that heterodimerize with the retinoic X receptor. Agonists of PPAR have been known to play an important role in cellular responses including proliferation and differentiation. The expression and function of PPARs have not been investigated in human melanocytes, although they have been widely demonstrated in keratinocytes of the skin.

OBJECTIVES

To investigate the expression of PPARs in human melanocytes and the effects of PPAR activators on melanocyte growth and melanogenesis.

METHODS

We used immunocytochemistry and Western blot analysis to determine whether PPARs are expressed in melanocytes. To investigate further expression of PPAR subtypes, reverse transcriptase-polymerase chain reaction analysis was performed using PPAR subtype-specific oligonucleotides. The cell proliferation was measured using the Coulter counter. The effects on pigmentation were investigated with measurement of melanin contents, tyrosinase activity and its expression.

RESULTS

The mRNA of all three PPAR subtypes, PPAR-alpha, PPAR-beta/delta and PPAR-gamma, were expressed in melanocytes. Activators for PPAR-alpha (WY-14643) and PPAR-gamma (ciglitazone) inhibited proliferation of melanocytes in a dose-dependent manner, whereas bezafibrate, a preferential activator for PPAR-beta/delta, had no effect. This growth inhibition was accompanied by the morphological change of the melanocytes to an activated form with an increased number of dendrites and enlarged cell area compared with the control. The WY-14643 and ciglitazone also appeared to stimulate the melanin synthesis of melanocytes. This increase in pigmentation was due to stimulation of the tyrosinase activity without an increase in the expression of tyrosinase.

CONCLUSIONS

PPARs are expressed in human melanocytes and PPAR-alpha and PPAR-gamma activators inhibit melanocyte growth and stimulate melanogenesis.

Is the combination of calcipotriol and PUVA effective in vitiligo?

OBJECTIVE

The objective was to compare the effectiveness of psoralen plus ultraviolet A (PUVA) and the combination of PUVA and topical calcipotriol in the treatment of vitiligo.

BACKGROUND

There are several reports on the response rate of patients with vitiligo treated with the combination of PUVA and calcipotriol or calcipotriol alone.

SUBJECTS AND METHODS

Twenty-two patients with generalized vitiligo were taken into the study. PUVA treatment was applied on a twice-weekly schedule. Calcipotriol cream was applied to one of the two symmetrical lesions of each patient twice daily.

RESULTS

Our results showed that the addition of topical calcipotriol to PUVA treatment did not lead to a significant increase in response rate of patients with vitiligo compared with PUVA treatment alone.

Melanocyte detachment after skin friction in non lesional skin of patients with generalized vitiligo

BACKGROUND

In vitiligo, melanocytes are gradually lost in depigmented macules of the skin. The disappearance of melanocytes has, however, not been clearly observed and consequently the aetiology of the disease (autoimmune, neural, cytotoxic) is still elusive. The starting point of vitiligo macules is frequently determined by local conditions such as wounds and excoriations, but may also follow minor traumas such as pressure or repeated friction. This prominent feature is often neglected.

OBJECTIVES

To clarify the biological consequences of repeated friction on the attachment and survival of melanocytes in non lesional vitiligo skin.

METHODS

Light reproducible skin friction was performed for 4 min on the volar forearm of 18 patients with extensive vitiligo and five controls with normal healthy skin. Biopsies from the test area and control skin were taken at 1, 4, 24 and 48 h following friction. Serial sections were examined with standard light microscopy, transmission electron microscopy, histochemistry and immunohistochemistry (dihydroxyphenylalanine, HMB-45, E-cadherin and an early apoptosis marker, M30 cytoDEATH antibody).

RESULTS

The observation of sections at 1 and 48 h after friction on vitiligo skin and at all time points in controls revealed no changes. In contrast, in vitiligo skin at 4 and 24 h after friction, several melanocytes had undergone detachment and were found in various suprabasal positions, including the stratum spinosum, granular layer, and within and outside the stratum corneum.

CONCLUSIONS

Detachment and transepidermal elimination of melanocytes following minor mechanical trauma in non lesional vitiligo skin is probably the cause of depigmentation occurring in the isomorphic response (Koebner phenomenon). We propose that transepidermal elimination of melanocytes in vitiligo should be regarded as a possible mechanism of chronic loss of pigment cells, perhaps previously damaged by another process.

Long-term follow-up of leucoderma patients treated with transplants of autologous cultured melanocytes, ultrathin epidermal sheets and basal cell layer suspension

BACKGROUND

In vitiligo and piebaldism the lack of melanin in the epidermis is due to the fact that melanocytes are missing. The patients suffer psychologically and the white areas have lost the part of the skin barrier protection normally provided by the melanocytes. Medical treatments are ineffective in many of the patients, and surgical methods have therefore been developed.

OBJECTIVES

It is important to investigate the long-term results and factors that might influence the outcome of melanocyte transplantations in order to form a basis for guidance in the selection of patients who will benefit most from the treatments.

METHODS

A follow-up of 132 patients who had been treated by transplantation on 176 occasions in total, 1-7 years previously, was carried out by questionnaires and clinical examinations. We investigated the responses in five types of leucoderma to three different transplantation methods: autologous cultured melanocytes, ultrathin epidermal sheets and basal layer cell suspension.

RESULTS

Stable types of leucoderma, i.e. segmental vitiligo and piebaldism, responded in most cases with 100% repigmentation, regardless of the surgical method used. For these types of leucoderma surgery seems to be the method of choice. The largest group, vitiligo vulgaris, was thoroughly scrutinized and three statistical models were used to analyse the data. The ultrathin epidermal sheet method gave somewhat better overall results, but was the method that gave the worst outcome in knee and elbow areas, emphasizing the importance of the right choice of method depending on the anatomical location to be treated. Irrespective of the method, fingers and elbows were the most difficult areas to repigment. The trunk and the arms and legs (not including elbows and knees) responded best. Patients with increasing and/or extensive vitiligo vulgaris more often showed incomplete repigmentation. They also had a lower chance of retaining their repigmentation compared with those with less extensive vitiligo. Patients in whom untreated white lesions had increased in recent years tended to respond less well to transplantation compared with patients with unchanged or decreased lesions. Within the vitiligo vulgaris group, patients with short disease duration or with small total vitiligo area responded best to transplantation. The subgroup of vitiligo vulgaris patients with hypothyroidism tend to respond less well to the transplantation and they were generally older at vitiligo onset. This information is of great importance for the selection of patients and when informing about the chances of improvement after transplantation. Slight hyperpigmentation was common, especially when ultrathin epidermal sheets had been used. No scars or indurations were seen in treated areas.

CONCLUSIONS

Transplantations are the methods of choice in stable types of leucoderma. Progressive, widespread vitiligo vulgaris should never be selected for transplantation.

Differentiation of murine melanocyte precursors induced by 1,25-dihydroxyvitamin D3 is associated with the stimulation of endothelin B receptor expression

The effects of 1,25-dihydroxyvitamin D3 on the differentiation of immature melanocyte precursors were studied. The NCC-/melb4 cell line is an immature melanocyte cell line established from mouse neural crest cells. 1,25-Dihydroxyvitamin D3 inhibited the growth of NCC-/melb4 cells at concentrations higher than 10(-8) m. That growth inhibition was accompanied by the induction of tyrosinase and a change in L-3,4-dihydroxyphenylalanine reactivity from negative to positive. Electron microscopy demonstrated that melanosomes were in more advanced stages after 1,25-dihydroxyvitamin D3 treatment. In primary cultures of murine neural crest cells, L-3,4-dihydroxyphenylalanine-positive cells were increased after 1,25-dihydroxyvitamin D3 treatment. These findings indicate that 1,25-dihydroxyvitamin D3 stimulates the differentiation of immature melanocyte precursors. Moreover, immunostaining and reverse transcription-polymerase chain reaction analysis revealed that endothelin B receptor expression was induced in NCC-/melb4 cells following treatment with 1,25-dihydroxyvitamin D3. The induction of endothelin B receptor by 1,25-dihydroxyvitamin D3 was also demonstrated in neural crest cell primary cultures, but not in mature melanocytes. The expression of microphthalmia-associated transcription factor was induced in NCC-/melb4 cells treated with 1,25-dihydroxyvitamin D3 and endothelin 3, but not by 1,25-dihydroxyvitamin D3 alone, suggesting that endothelin 3 may stimulate the expression of the microphthalmia-associated transcription factor gene after binding to the endothelin B receptor induced by 1,25-dihydroxyvitamin D3. These findings suggest a regulatory role for vitamin D3 in melanocyte development and melanogenesis, and may also explain the working mechanism of vitamin D3 in the treatment of vitiligo.