The efficacy of low-dose oral corticosteroids in the treatment of vitiligo patients

Healthcare Resource Use and Costs Among Individuals with Vitiligo and Psychosocial Comorbidities: Retrospective Analysis of an Insured US Population

Purpose

This study aimed to describe healthcare resource utilization and costs among individuals with vitiligo who were diagnosed with ≥1 psychosocial comorbidity, using data from US claims databases.

Patients and Methods

A retrospective, observational cohort analysis of the IBM MarketScan Commercial and Medicare supplemental claims databases for US individuals with vitiligo aged ≥12 years and a first vitiligo claim between January 1 and December 31, 2018, was undertaken to assess psychosocial burden, including mental and behavioral health comorbidities.

Results

Of the 12,427 individuals included in the analysis, nearly 1 in 4 (23.5%) who had vitiligo were also diagnosed with ≥1 psychosocial comorbidity. A greater percentage of these individuals versus those who were not diagnosed with a psychosocial comorbidity had a vitiligo-related prescription claim (50.2% vs 45.4%; P<0.0001), especially for oral corticosteroids (25.4% vs 16.6%; P<0.0001) and low-potency topical corticosteroids (9.0% vs 7.6%; P<0.05). Total vitiligo-related healthcare resource utilization and costs were consistent among individuals with and without psychosocial comorbidity despite significantly (P<0.05) higher vitiligo-related ER visit utilization and expenditure among those with psychosocial comorbidity. Furthermore, individuals diagnosed with vitiligo and ≥1 psychosocial comorbidity had significantly (P<0.0001) greater utilization of all-cause mean prescription claims (25.0 vs 12.8), outpatient services (other than physician and ER visits: 19.5 vs 11.3), outpatient physician visits (10.1 vs 6.4), inpatient stays (0.6 vs 0.1), and ER visits (0.4 vs 0.2) and incurred significantly higher mean (SD) direct medical expenditures ($18,804 [$46,621] vs $9833 [$29,094] per patient per year; P<0.0001).

Conclusion

Individuals with vitiligo who were diagnosed with ≥1 psychosocial comorbidity incurred greater total all-cause but not vitiligo-related healthcare resource utilization and expenditures than those without diagnosis of psychosocial comorbidities. Identification of psychosocial comorbidities in individuals with vitiligo may be important for multidisciplinary management of vitiligo to reduce overall burden for individuals with vitiligo.

Comparison of Oral Azathioprine and Oral Mini Pulse Steroid in the Treatment of Vitiligo: An Open-Label Randomized Controlled Trial

Background

Vitiligo is a common acquired depigmentory skin disorder supposed to be of autoimmune aetiology. Different immunosuppressants have been tried with varying success. Azathioprine has been less studied in vitiligo.

Aims and Objectives

To study the efficacy of oral azathioprine and compare with systemic steroid in the treatment of vitiligo.

Materials and Methods

It was an interventional study with multi-armed (three), parallel group, an open-label, randomized controlled trial with allocation ratio of 1:1:1. Patients of vitiligo aged between 18 and 60 years having more than 5% body surface involvement were included in the study. Patients were divided into three groups. Group A-patients received oral azathioprine 50 mg OD daily, group B-patients received combination of oral azathioprine 50 mg OD and PUVASOL and group C-patients received combination of betamethasone oral mini pulse (OMP) and PUVASOL. All the groups were treated for 1 year. Repigmentation was evaluated by vitiligo area severity index (VASI), and stabilization was evaluated by vitiligo disease activity (VIDA).

Results

Group A, group B and group C showed 24.24%, 53.24% and 47.28% improvement in VASI score, respectively, at the end of 1 year. Group B and group C showed statistically significant superior repigmentation as compared to azathioprine monotherapy. Though azathioprine and betamethasone showed equivalent efficacy, azathioprine has a better safety profile. Side effects were minimal in azathioprine groups, whereas 50% patients developed various side effects in group C.

Conclusion

Azathioprine is safe and effective option in the treatment of vitiligo.

Systemic therapies in vitiligo: a review

Vitiligo is characterized by the development of depigmented macules and patches. Autoimmunity has been established as a factor in disease pathogenesis, leading to utilization of immunosuppressive agents. Topical immunosuppressants are commonly used; however, this treatment modality is often cumbersome and inefficient, as many patients have active disease with extensive body surface area involvement. Prompt and aggressive treatment of vitiligo is important, as this may prevent progression and improve quality of life. To meet these challenges and improve patient outcomes, interest in systemic therapies has grown. Currently, oral therapies are rarely prescribed, likely due to concerns with systemic side effects and unclear efficacy. This article provides a brief overview on the use of systemic agents in treating vitiligo in order to provide additional therapeutic options to clinicians.

Vitiligo Treatments: Review of Current Therapeutic Modalities and JAK Inhibitors

Vitiligo is a chronic autoimmune disease characterized by loss of pigment of the skin, affecting 0.5-2% of the population worldwide. It can have a significant impact on patients' quality of life. In recent years, there has been significant progress in our understanding of the pathogenesis of vitiligo. It is believed that vitiligo develops due to a complex combination of genetics, oxidative stress, inflammation, and environmental triggers. Conventional treatments include camouflage, topical corticosteroids, topical calcineurin inhibitors, oral corticosteroids, phototherapy, and surgical procedures, with the treatment regimen dependent on the patient's preferences and characteristics. With increased understanding of the importance of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway in the pathogenesis of vitiligo, treatment has expanded to include the first US FDA-approved cream to repigment patients with vitiligo. This review summarizes our understanding of the major mechanisms involved in the pathogenesis of vitiligo and its most common available treatments.

Update on pharmacology, actions, dosimetry and regimens of oral glucocorticoids in dermatology

Glucocorticoids are arguably the most widely used and misused drug in dermatology. There have been recent updates in its mode of action which can impact on its judicious use. There is need to use the correct steroid preparation to maximize results and minimize side effects. We present an updated review on glucocorticoids focusing on its mode of action, rationale of its prescribing considerations and dosing regimens in dermatology. This is based on PubMed search with a focus on mode of actions and dosimetry with additional updates from standard drug books, databases and rheumatology books.

Current Debates on Etiopathogenesis and Treatment Strategies for Vitiligo

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

Clinical efficacy analysis of 110 cases of childhood vitiligo with non-surgical combined therapy

BACKGROUND

Vitiligo has a negative effect on children's physical and psychological health. Few studies have examined long-term treatment efficacy for childhood vitiligo. Therefore, we evaluated the long-term effectiveness of non-surgical combination therapy in pediatric patients with vitiligo and analyzed factors that affect its efficacy.

METHODS

Pediatric patients (⩽12 years) with vitiligo who were treated with topical corticosteroids/topical calcineurin inhibitors and phototherapy for 12 months were retrospectively studied. Short-term systemic corticosteroids were administered according to individual clinical conditions. All lesions were photographed to assess repigmentation at 3-month intervals. Clinical data, the treatment effectiveness, and factors affecting the therapeutic effect were analyzed.

RESULTS

Overall, 110 children (51 [53.6%] girls; mean [SD] age, 7.1 ± 3.0 years; 104 [94.5%] with activity status) were treated for a mean period of 23.13 ± 14.03 months (range, 5-86 months). The overall >50% repigmentation rate was 64.5%. A longer duration of treatment was associated with a higher repigmentation rate (X² _trend = 36.229, P < .001). The vitiligo disease activity score at the first visit was positively correlated with the overall repigmentation rate (r_s = 0.301, P = .001).

CONCLUSIONS

Treatment lasting longer than 1 year is recommended in children with vitiligo. The best repigmentation effect can be achieved by combination therapy in the rapid progression stage.

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.

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.

Systemic CXCL10 is a predictive biomarker of vitiligo lesional skin infiltration, PUVA, NB-UVB and corticosteroid treatment response and outcome

Vitiligo is an acquired pigmentary skin disorder that currently lacks standardized treatment and validated biomarkers to objectively evaluate disease state or therapeutic response. Although prior studies have linked vitiligo autoimmunity with CXCL10/CXCL9-mediated recruitment of leukocytes to the skin, only limited clinical data are available regarding CXCL10 as vitiligo biomarker. To evaluate the utility of systemic CXCL10 as a predictor of disease progression and treatment response on a large cohort of vitiligo patients. CXCL10 levels in lesional, perilesional, and unaffected skin of vitiligo patient (n = 30) and in the serum (n = 51) were measured by quantitative ELISA. CXCL10 expression, recruitment of leukocytes, and inflammatory infiltrates were evaluated by histochemical (n = 32) and immunofluorescence (n = 10) staining. Rigorous cross-sectional and longitudinal biostatistical analysis were employed to correlate CXCL10 levels with disease variables, treatment response, and outcome. We demonstrated that elevated CXCL10 level (2 pg/mm² and higher) in lesional skin correlates with increased leukocytic infiltrate, disease duration (< 2 year), and its higher level in the serum (50 pg/ml and higher). Changes in CXCL10 serum levels in patients treated with psoralen plus UVA (PUVA) phototherapy, narrowband UVB (NB-UVB) phototherapy, and systemic steroids (SS) correlated with changes in the intralesional CXCL10 levels in repigmented skin. NB-UVB and SS regimens provided most consistent CXCL10 mean change, suggesting that these regimens are most effective in harnessing CXCR3-mediated inflammatory response. Serum CXCL10 is a useful vitiligo biomarker, which predicts lesional skin leukocytic infiltration, and vitiligo treatment response and outcome.

Oral mini-pulse therapy in vitiligo: a systematic review

BACKGROUND

There is limited evidence supporting the use of alternative treatments for patients with nonstable vitiligo.

OBJECTIVE

This study aimed to review the effects of oral mini-pulse (OMP) therapy in the management of nonsegmental vitiligo.

METHODS

The following databases were searched between inception and May 2020 for relevant studies: Scopus, Web of Science, MEDLINE, and Embase. All randomized controlled trials that compared OMP therapy with any other active treatment or placebo for nonstable vitiligo were included. The Cochrane's risk of bias tool was used to evaluate the risk of bias (ROB) in selected studies, and the overall quality of evidence of each outcome was assessed using the Grading Recommendations, Assessment, Development, and Evaluations (GRADE) system.

RESULTS

Four studies met our selection criteria. All of them were conducted in India and included 246 patients. OMP therapy included betamethasone or dexamethasone. The duration of treatment was 6 months in all studies. Up to 32% of patients achieved a repigmentation rate of >75% when OMP therapy was administered as monotherapy. No difference was observed between OMP therapy and other treatments in arresting the disease, and weight gain was the most frequent adverse effect. The overall ROB in all included studies was relatively high because of the randomization process, outcome measurement and informed selection of outcomes.

CONCLUSION

Based on the findings of these studies, OMP therapy did not demonstrate additional value compared with other treatments. Hence, there is an urgent need to conduct high-quality clinical trials to evaluate this therapy.

Non-surgical treatment of vitiligo

Vitiligo is an acquired depigmenting skin disorder that affects 0.5% to 2% of the population. Skin lesions from vitiligo, white macules and patches on the skin, can pose a substantial psychological burdencan, causing a significant decrease in one’s quality of life. Recent basic and clinical studies have found that vitiligo is an autoimmune disorder, mediated by CD8+ T-cell and interferon-γ-mediated cytokine/chemokines. Although no treatment modality presents a complete cure for vitiligo, current treatment modalities have a modest effect on vitiligo by reversing the disease’s progression, inducing its stabilization, and promoting melanocyte regeneration. Current non-surgical treatment modalities include topical corticosteroids, topical calcineurin inhibitors, systemic corticosteroids, and phototherapy such as narrowband ultraviolet B phototherapy and excimer laser. In addition, clinicians have used and combined non-surgical treatment modalities based on the activity and extent of vitiligo. Moreover, considering the high risk of vitiligo relapse, maintenance therapy for re-pigmented lesions has also been introduced. Lastly, based on the results of recent translational research, new and emerging treatment modalities have been introduced, such as Janus kinase inhibitors. This review presents an overview of the current non-surgical treatment modalities for vitiligo and discusses emerging treatments.

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

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

Therapeutic management of vitiligo

Affecting 0.5 % of the world's population, vitiligo is an acquired skin disorder that poses major challenges in terms of dermatological care. Characterized by patchy depigmentation, the disease is frequently associated with cosmetic disfigurement and considerable psychological distress. The primary pathophysiological causes for the loss of functional melanocytes are thought to include genetic predisposition, autoimmune mechanisms, and oxidative stress. The present article highlights treatment recommendations contained in the European guidelines as well as those provided by recent reviews on vitiligo. Current therapeutic options are based on three approaches: (1) Regulation of the autoimmune response using topical and systemic immunomodulatory agents (corticosteroids and calcineurin inhibitors); (2) decrease in oxidative stress in melanocytes by means of topical and systemic antioxidants; and (3) activation of melanocyte regeneration using phototherapy (UVB in particular) and transplantation of pigment cells. In addition, patients should be educated in techniques for cosmetic camouflage. Following successful repigmentation, application of calcineurin inhibitors is recommended to prevent recurrences. Combination therapies of the aforementioned approaches are generally considered to be more successful than monotherapies. Early initiation of treatment is associated with a more favorable prognosis. Using the above treatment options, it may be possible to halt disease progression, stabilize depigmented lesions, and achieve repigmentation. Only in exceptional cases should permanent depigmentation be considered as a possible option. New insights into the pathogenesis of vitiligo will likely give rise to novel therapeutic approaches.

Concurrent extrahepatic autoimmune disorders: unexplored dimension of autoimmune liver disease in children

BACKGROUND AND AIM

No comprehensive and prospective data are available for concurrent extrahepatic autoimmune disorders (CEAIDs) in children with autoimmune liver disease (AILD). The aim of this study was to evaluate CEAIDs in AILD and their effect on AILD outcome.

PATIENTS AND METHODS

Enrolled AILD and CEAIDs children were diagnosed on the basis of simplified and standard diagnostic criteria, respectively. The clinicopathological profile, treatment response, and outcome were compared between AILD with CEAIDs (group A) and AILD without CEAIDs (group B).

RESULTS

In 62 AILD children, CEAIDs were found in 42% (n=26) [vitiligo (42%), celiac disease (CD) (15%), potential CD (15%), autoimmune hemolytic anemia (AIHA) (15%)]. CEAIDs were asymptomatic in 75%. Single CEAID was found in 81% (21/26) and multiple CEAID was found in 19% (5/26). Significantly less biochemical remission (46.1 vs. 74.2%, P=0.03), more treatment failure (23 vs. 3.2%, P=0.04), and higher mortality (15.3 vs. 3.2%, P=0.04) were encountered in group A compared with group B. On multivariate analysis (n=57), less biochemical remission in vitiligo (P=0.04); more treatment failure in AIHA (P=0.004) and vitiligo (P=0.04); and high mortality in AIHA (P=0.02) subgroups were reported. CD treatment has good impact on AILD outcome. All cases of diabetes mellitus in AILD were steroid-induced rather than because of autoimmunity (absence of antibody against tyrosine phosphatase and glutamic acid decarboxylase and elevated C-peptide).

CONCLUSION

All AILD children should be screened for CEAIDs as the majority are asymptomatic. The AILD outcome was favorable in CD, but poor in vitiligo and AIHA. We suggest the incorporation of CEAIDs in a pediatric AILD scoring system.

Medical and Maintenance Treatments for Vitiligo

Medical treatments alone, or in combination with phototherapy, are key approaches for treating nonsegmental vitiligo and, to a lesser extent, segmental vitiligo. The treatments are useful for halting disease progression and have been proven effective for inducing repigmentation and decreasing risk of relapses. Although the treatments have side effects and limitations, vitiligo often induces a marked decrease in quality of life and in most cases the risk:benefit ratio is in favor of an active approach. Systemic and topical agents targeting the pathways involved in loss of melanocytes and in differentiation of melanocyte stem cells should provide more effective approaches in the near future.

Systematic Review of the Toxicity of Long-Course Oral Corticosteroids in Children

Background

Long courses of oral corticosteroids are commonly used in children in the management of chronic conditions. Various adverse drug reactions (ADRs) are known to occur with their use. This systematic review aimed to identify the most common and serious ADRs and to determine their relative risk levels.

Methods

A literature search of Embase, Medline, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions in order to identify studies where oral corticosteroids were administered to patients aged 28 days to 18 years of age for at least 15 days of treatment. Each database was searched from their earliest dates to January 2016. All studies providing clear information on ADRs were included.

Results

One hundred and one studies including 33 prospective cohort studies; 21 randomised controlled trials; 21 case series and 26 case reports met the inclusion criteria. These involved 6817 children and reported 4321 ADRs. The three ADRs experienced by the highest number of patients were weight gain, growth retardation and Cushingoid features with respective incidence rates of 21.1%, 18.1% and 19.4% of patients assessed for these ADRs. 21.5% of patients measured showed decreased bone density and 0.8% of patients showed osteoporosis. Biochemical HPA axis suppression was detected in 269 of 487 patients where it was measured. Infection was the most serious ADR, with twenty one deaths. Varicella zoster was the most frequent infection (9 deaths).

Conclusions

Weight gain, growth retardation and Cushingoid features were the most frequent ADRs seen when long-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR.

Low-Dose Oral Mini-Pulse Dexamethasone Therapy in Progressive Unstable Vitiligo

Background:

The course of vitiligo is unpredictable. If the disease is spreading rapidly, the progression can be controlled with the use of systemic steroids daily or in pulsed form. The present study was planned to assess the efficacy of low-dose dexamethasone oral mini-pulse therapy in progressive unstable vitiligo.

Materials and Methods:

In this retrospective study, the case records of patients with vitiligo during the period from January 2006 to December 2010 were studied. Patients who had progressive unstable disease were included. These patients were administered oral dexamethasone 2.5 mg per day on 2 consecutive days after breakfast in a week. The patients were asked to come for regular follow-up to assess the arrest of disease activity, relapse of disease activity, and adverse effects.

Results:

A total of 444 patients were analyzed. In 408 (91.8%) patients, arrest of disease activity was achieved at a mean duration of 13.2 ± 3.1 weeks. In addition, some repigmentation of the lesions was seen in all patients after a mean of 16.1 ± 5.9 weeks. During the follow-up, 50 of 408 (12.25%) patients experienced one or two episodes of relapse in disease activity, which were treated with reinstitution of low-dose dexamethasone oral mini-pulse therapy. The mean disease-free survival (DFS) until the first relapse was 55.7 ± 26.7 weeks, and the mean DFS until the second relapse was 43.8 ± 7.2 weeks. Adverse reactions such as weight gain, lethargy, and acneiform eruptions were observed in 41 (9.2%) patients.

Conclusion:

Low-dose oral mini-pulse dexamethasone therapy is a good option for arresting progressive unstable vitiligo with minimal adverse effects.

A Retrospective Study of Methylprednisolone Mini-Pulse Therapy Combined with Narrow-Band UVB in Non-Segmental Vitiligo

BACKGROUND

Systemic corticosteroids have been used to arrest the progression of vitiligo. However, side effects have been a constant issue.

OBJECTIVE

We evaluated the clinical efficacy and side effect of oral methylprednisolone (MPD) mini-pulse therapy combined with narrow-band UVB (NBUVB) for adults with non-segmental vitiligo retrospectively.

METHODS

32 patients with extensive and/or spreading vitiligo received 0.5 mg/kg MPD on 2 consecutive days per week with NBUVB therapy for at least 3 months.

RESULTS

All of the 32 patients (100%) showed progression arrest within 12 weeks. Nineteen out of 32 patients (59.4%) presented repigmentation on more than 25% of lesions. Thirteen patients (40.6%) achieved satisfactory repigmentation in more than 50% of lesions. Only 2 patients discontinued the medication due to gastrointestinal trouble.

CONCLUSION

Oral MPD mini-pulse therapy combined with NBUVB appears effective in arresting vitiligo progression and rapidly inducing repigmentation with minimal side effects.

Vitiligo--Part 2--classification, histopathology and treatment

In an unprecedented effort in the field of vitiligo, a global consensus resulted on a suggested new classification protocol for the disease. The main histopathological finding in vitiligo is the total absence of functioning melanocytes in the lesions, while the inflammatory cells most commonly found on the edges of the lesions are CD4+ and CD8+ T lymphocytes. Physical and pharmacological treatment strategies aim to control the autoimmune damage and stimulate melanocyte migration from the unaffected edges of lesions and the outer hair follicle root sheath to the affected skin; moreover, surgical treatments can be combined with topical and physical treatments.

Interventions for vitiligo

BACKGROUND

Vitiligo is a chronic skin disorder characterised by patchy loss of skin colour. Some people experience itching before the appearance of a new patch. It affects people of any age or ethnicity, more than half of whom develop it before the age of 20 years. There are two main types: generalised vitiligo, the common symmetrical form, and segmental, affecting only one side of the body. Around 1% of the world's population has vitiligo, a disease causing white patches on the skin. Several treatments are available. Some can restore pigment but none can cure the disease.

OBJECTIVES

To assess the effects of all therapeutic interventions used in the management of vitiligo.

SEARCH METHODS

We updated our searches of the following databases to October 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2013, Issue 10), MEDLINE, Embase, AMED, PsycINFO, CINAHL and LILACS. We also searched five trials databases, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the effects of treatments for vitiligo.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed study eligibility and methodological quality, and extracted data.

MAIN RESULTS

This update of the 2010 review includes 96 studies, 57 from the previous update and 39 new studies, totalling 4512 participants. Most of the studies, covering a wide range of interventions, had fewer than 50 participants. All of the studies assessed repigmentation, however only five reported on all of our three primary outcomes which were quality of life, > 75% repigmentation and adverse effects. Of our secondary outcomes, six studies measured cessation of spread but none assessed long-term permanence of repigmentation resulting from treatment at two years follow-up.Most of the studies assessed combination therapies which generally reported better results. New interventions include seven new surgical interventions.We analysed the data from 25 studies which assessed our primary outcomes. We used the effect measures risk ratio (RR), and odds ratio (OR) with their 95% confidence intervals (CI) and where N is the number of participants in the study.We were only able to analyse one of nine studies assessing quality of life and this showed no statistically significant improvement between the comparators.Nine analyses from eight studies reported >75% repigmentation. In the following studies the repigmentation was better in the combination therapy group: calcipotriol plus PUVA (psoralen with UVA light) versus PUVA (paired OR 4.25, 95% CI 1.43 to 12.64, one study, N = 27); hydrocortisone-17-butyrate plus excimer laser versus excimer laser alone (RR 2.57, 95% CI 1.20 to 5.50, one study, N = 84); oral minipulse of prednisolone (OMP) plus NB-UVB (narrowband UVB) versus OMP alone (RR 7.41, 95% CI 1.03 to 53.26, one study, N = 47); azathioprine with PUVA versus PUVA alone (RR 17.77, 95% CI 1.08 to 291.82, one study, N = 58) and 8-Methoxypsoralen (8-MOP ) plus sunlight versus psoralen (RR 2.50, 95% CI 1.06 to 5.91, one study, N = 168). In these three studies ginkgo biloba was better than placebo (RR 4.40, 95% CI 1.08 to 17.95, one study, N = 47); clobetasol propionate was better than PUVAsol (PUVA with sunlight) (RR 4.70, 95% CI 1.14 to 19.39, one study, N = 45); split skin grafts with PUVAsol was better than minipunch grafts with PUVAsol (RR 1.89, 95% CI 1.25 to 2.85, one study, N = 64).We performed one meta-analysis of three studies, in which we found a non-significant 60% increase in the proportion of participants achieving >75% repigmentation in favour of NB-UVB compared to PUVA (RR 1.60, 95% CI 0.74 to 3.45; I² = 0%).Studies assessing topical preparations, in particular topical corticosteroids, reported most adverse effects. However, in combination studies it was difficult to ascertain which treatment caused these effects. We performed two analyses from a pooled analysis of three studies on adverse effects. Where NB-UVB was compared to PUVA, the NB-UVB group reported less observations of nausea in three studies (RR 0.13, 95% CI 0.02 to 0.69; I² = 0% three studies, N = 156) and erythema in two studies (RR 0.73, 95% CI 0.55 to 0.98; I² = 0%, two studies, N = 106), but not itching in two studies (RR 0.57, 95% CI 0.20 to 1.60; I² = 0%, two studies, N = 106).Very few studies only assessed children or included segmental vitiligo. We found one study of psychological interventions but we could not include the outcomes in our statistical analyses. We found no studies evaluating micropigmentation, depigmentation, or cosmetic camouflage.

AUTHORS' CONCLUSIONS

This review has found some evidence from individual studies to support existing therapies for vitiligo, but the usefulness of the findings is limited by the different designs and outcome measurements and lack of quality of life measures. There is a need for follow-up studies to assess permanence of repigmentation as well as high- quality randomised trials using standardised measures and which also address quality of life.

Vitiligo--part 1

Vitiligo is a chronic stigmatizing disease, already known for millennia, which mainly affects melanocytes from epidermis basal layer, leading to the development of hypochromic and achromic patches. Its estimated prevalence is 0.5% worldwide. The involvement of genetic factors controlling susceptibility to vitiligo has been studied over the last decades, and results of previous studies present vitiligo as a complex, multifactorial and polygenic disease. In this context, a few genes, including DDR1, XBP1 and NLRP1 have been consistently and functionally associated with the disease. Notwithstanding, environmental factors that precipitate or maintain the disease are yet to be described. The pathogenesis of vitiligo has not been totally clarified until now and many theories have been proposed. Of these, the autoimmune hypothesis is now the most cited and studied among experts. Dysfunction in metabolic pathways, which could lead to production of toxic metabolites causing damage to melanocytes, has also been investigated. Melanocytes adhesion deficit in patients with vitiligo is mainly speculated by the appearance of Köebner phenomenon, recently, new genes and proteins involved in this deficit have been found.

Concise review of recent studies in vitiligo

Vitiligo is an acquired pigmentry disorder of the skin and mucous membranes which manifests as white macules and patches due to selective loss of melanocytes. Etiological hypotheses of vitiligo include genetic, immunological, neurohormonal, cytotoxic, biochemical, oxidative stress and newer theories of melanocytorrhagy and decreased melanocytes survival. There are several types of vitiligo which are usually diagnosed clinically and by using a Wood's lamp; also vitiligo may be associated with autoimmune diseases, audiological and ophthalmological findings or it can be a part of polyendocrinopathy syndromes. Several interventions are available for the treatment for vitiligo to stop disease progression and/or to attain repigmentation or even depigmentation. In this article, we will present an overall view of current standing of vitiligo research work especially in the etiological factors most notably the genetic components, also, types and associations and various and newer treatment modalities.

Relapse after methylprednisolone oral minipulse therapy in childhood vitiligo: a 12-month follow-up study

Background:

Oral minipulse (OMP) therapy with methylprednisolone is presently one of the most common oral treatments used for progressive vitiligo in children. The treatment is usually given for a period of 6 months during which majority of patients are reported to go into remission. However, there are no follow-up studies to comment upon what happens to the disease after OMP therapy is withdrawn.

Aim of the study:

To document the incidence of relapse over a period of 1 year after OMP therapy is stopped in children with vitiligo.

Materials and Methods:

The study was conducted in 180 patients of childhood vitiligo (<15 years of age) who had been on OMP therapy with oral methylprednisolone for at least 6 months and who had achieved a complete remission of their disease during the treatment period. The enrolled patients were followed up for a period of 1 year and examined clinically for any sign of reactivation of their disease over either the old lesions or at any new area of the body.

Results:

Forty-two patients were lost and could not complete the follow-up period of 1 year. Out of the 138 patients available at the end of 1 year, relapse was observed in 48 patients (34.8%). Rest of 90 patients remained in remission over the follow-up period of 1 year. Relapse was more common in patients below 10 years of age (47.4%) as compared with older children (25.9%).

Conclusion:

Relapse after using methylprednisolone OMP therapy in children with vitiligo is quite common especially in younger age groups. Studies are needed to see whether these relapses could be avoided by giving the treatment for a period longer than 6 months.

Guidelines for the diagnosis and treatment of vitiligo in Japan

Vitiligo is an acquired pigment disorder in which depigmented macules result from the loss of melanocytes from the involved regions of skin and hair. The color dissimilarity on the cosmetically sensitive regions frequently induces quality of life impairment and high willingness to pay for treatment in patients with vitiligo. The Vitiligo Japanese Task Force was organized to overcome this situation and to cooperate with the Vitiligo Global Issues Consensus Conference. This guideline for the diagnosis and treatment of vitiligo in Japan is proposed to improve the circumstances of Japanese individuals with vitiligo. Its contents include information regarding the diagnosis, pathogenesis, evaluation of disease severity and effectiveness of treatment, and evidence-based recommendations for the treatment of vitiligo. The therapeutic algorithm based on the proposed recommendation is designed to cure and improve the affected lesions and quality of life of individuals with vitiligo.

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

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

Functional characteristics of macrophages in the vitiligo foci

Objective. Study of the chemotactic activity of macrophages and local production of cytokines in sterile skin inflammatory exudate in patients with generalized vitiligo (vitiligo vulgaris). Materials and methods. The authors conducted a study of 22 patients with generalized vitiligo and 22 healthy volunteers. The functional activity of macrophages was assessed with the use of the skin window method based on the method of D.N. Mayansky as amended by V.V. Klimov. The composition of sterile cell exudate was examined with the use of impression smears taken after 6 hours from an epidermis scarification section on the healthy and depigmented skin colored according to the Romanovsky-Gimza method with the use of light microscopy. In addition, cytokines were determined in the supernatant fluid of the skin window exudate from the vitiligo focus obtained by means of centrifugation. Results. The prevalence of mononuclear phagocytes over polymorphonuclear leukocytes was revealed in the depigmentation site, which confirms that macrophages take an active part in the disease pathogenesis (along with a high level of interleukin-18). A low level of IL-10 in the skin window exudate confirms that the suppressor effect in the melanocyte damage zone is weak. These results confirm the important role played by such cells of the immune system as phagocytes in vitiligo pathogenesis, which makes it possible to consider them as potential target cells for developing pathogenetically substantiated approaches to the treatment of the disease.

Action of topical mometasone on the pigmented halos of micrografting in patients with vitiligo

BACKGROUND: Vitiligo is a prevalent skin pigmentation disorder worldwide. The treatments available still offer limited results to some patients. For patients with clinically stable vitiligo, melanocyte transplantation is an appropriate treatment option, and the technique of autologous punch grafting shows good repigmentation. OBJECTIVE: To evaluate the effect of topical mometasone on the halos of repigmentation after autologous punch grafting in patients with clinically stable vitiligo. METHODS: Between 2009 and 2010, 11 patients with clinically stable vitiligo (7 generalized, 2 focal and 2 segmental) underwent autologous punch grafting in the achromic patches. According to the clinical type of vitiligo, patients were instructed to use the corticosteroid ointment during 6 months, only on a few grafted lesions. In the first month, the mometasone ointment was used twice a day and after that just once. They were reassessed 1, 3 and 6 months after the procedure. Grafted halos were photographed and recorded using the software fotofinder. After 6 months, all the treated and untreated areas of the repigmentation halos were measured and analyzed comparatively. RESULTS: The median area of the repigmentation halos after 6 months of treatment with mometasone was larger (25,96 mm² ) than the one of the untreated halos (13,86 mm² ), showing a statistically significant difference (p = 0,026). CONCLUSION: In this study, the use of mometasone ointment increased the area of the repigmentation halos after punch grafting. However, this should be further investigated in larger samples in order to validate this positive action in the treatment of stable vitiligo.

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.

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

Vitiligo is a common skin disorder that results in depigmentation. With the appropriate management, many patients can minimize disease progression, attain repigmentation, and achieve cosmetically pleasing results. There are numerous medical and surgical treatments aimed at repigmentation; therapies for depigmentation are available for patients with recalcitrant or advanced disease. The use of cosmetics at all stages of treatment may be vital to the patient's quality of life. Understanding all the available options helps choose the appropriate treatment plan and tailor it to your patient. Part II of this two-part series on vitiligo discusses the indications for, evidence behind, and adverse effects associated with many of the therapies used for vitiligo. Both conventional medical and surgical options are discussed in addition to several alternative and promising new therapies.

Vitiligo: a review of the published work

Vitiligo is a common depigmenting skin disorder, characterized by acquired, idiopathic, progressive, circumscribed hypomelanosis of the skin and hair, with total absence of melanocytes microscopically. It occurs worldwide, with an incidence rate of between 0.1% and 2%. Vitiligo is an important skin disease having a major impact on the quality of life of the patient suffering from it. The causes of this condition are uncertain but seem to be dependent on the interaction of genetic, immunological and neurological factors. Vitiligo coexists with other autoimmune disorders, Sutton or halo nevus, and malignant melanoma. The substantial disfigurement associated with vitiligo can cause serious emotional stress for the patient, which necessitates treatment. Because its pathogenesis is still not understood, there is a plethora of different treatments. Among them, topical steroids and narrowband ultraviolet B monotherapy were the most common as current treatments for localized and generalized vitiligo, respectively. Cosmetic improvement can be achieved by camouflage products and self-tanning dyes. The course of vitiligo is unpredictable, but often progressive. Spontaneous repigmentation may occur in a few people (10–20%), mainly in children, but this tends to be only partial and on sun-exposed areas. In this article, we review vitiligo as a whole, including epidemiology, pathogenesis and etiology, histopathology, clinical manifestations, classification, clinical variants, diagnosis and differential diagnoses, specific investigation, treatment, prognosis, psychosocial view and its association with other disorders.

Chemical Leukoderma Improved by Low-dose Steroid Pulse Therapy

Chemical leukoderma occurs due to the toxic effect of a specific chemical preceding allergic contact dermatitis. The mechanism is either destruction or inhibition of melanocytes by the offending substance. Clinicohistopathologically, no absolute criteria can differentiate chemical leukoderma from vitiligo. However, chemical leukoderma can be diagnosed clinically by a history of repeated exposure to a known or suspected depigmenting agent at the primary site. There is no agreed treatment guideline for chemical leukoderma. We report a healthy 51-year-old man who had multiple hypopigmented macules and patches on his face, neck, arms and legs after exposure to occupationally related chemicals. The lesions were recalcitrant to topical corticosteroids, but they showed much improvement after 3 cycles of systemic steroid pulse therapy. We suggest this therapy may be a good treatment option for chemical leukoderma.

[Methods and means for pigmentation and depigmentation. Sense or nonsense?]

Treatment of hyperpigmentation disorders can be a lengthy process. There are several topical treatment options and hydroquinone is the most frequently used. Both combination and monotherapy are employed. These treatment options apply primarily to epidermal hyperpigmentation disorders. Dermal hyperpigmentation disorders cannot yet be effectively managed with currently available therapeutic approaches. Cosmetic disfigurement caused by hypomelanosis, especially vitiligo, can constitute a serious impairment for the patient. So far there is no definitive remedy. Better cosmetic results are generally reported for combination therapies.

Interventions for vitiligo

BACKGROUND

Around one per cent of the world's population has vitiligo, a disease which causes white patches on the skin. There are a variety of treatments available, most of which are unsatisfactory.

OBJECTIVES

To assess all interventions used to manage vitiligo.

SEARCH STRATEGY

In November 2009 we updated searches of the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library (Issue 4, 2009), MEDLINE, EMBASE, AMED, PsycINFO, LILACS and ongoing trials databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

At least 2 review authors independently assessed study eligibility and methodological quality, and carried out data extraction. Two of the 57 included studies could be combined for meta-analysis.

MAIN RESULTS

In this update, 57 trials, including 19 from the original review, were assessed with 3139 participants. Most of the RCTs, which covered a wide range of interventions, had fewer than 50 participants. All of the studies assessed repigmentation, 6 measured cessation of spread, and 5 investigated the effect of treatment on quality of life.Most of the studies assessed combination therapies which generally reported better results. New interventions include monochromatic excimer light (MEL), Polypodium leucotomos, melanocyte transplantation, oral antioxidants, Chinese zengse pill, and pimecrolimus. We analysed the data from 28 studies that met our outcome criteria of improvement in quality of life and greater than 75% repigmentation.Fifteen analyses from studies comparing various interventions showed a statistically significant difference between the proportions of participants achieving more than 75% repigmentation. The majority of analyses showing statistically significant differences were from studies that assessed combination interventions which generally included some form of light treatment.Topical preparations, in particular corticosteroids, reported most adverse effects. However, in the combination studies it was difficult to ascertain which treatment caused these effects. None of the studies was able to demonstrate long-term benefits. Very few studies were conducted on children or included segmental vitiligo. We found one study of psychological interventions and none evaluating micropigmentation, depigmentation, or cosmetic camouflage.

AUTHORS' CONCLUSIONS

This review has found some evidence from individual studies to support existing therapies for vitiligo, but the usefulness of the findings is limited by the different designs and outcome measurements and lack of quality of life measures. There is a need for follow-up studies to assess permanence of repigmentation as well as high quality randomised trials using standardised measures and which also address quality of life.

Response of vitiligo to narrowband ultraviolet B and oral antioxidants

Narrowband ultraviolet B phototherapy (NB-UVB) is the most widely and effective therapeutic option in vitiligo. Antioxidant supplementation has also been reported to be useful. The purpose of this study was to determine the efficacy of oral antioxidants with NB-UVB in the treatment of vitiligo. Twenty-four patients with stable vitiligo were recruited and divided randomly into 2 groups. They were treated with NB-UVB plus oral vitamin E in group A and with NB-UVB only in group B. Improvement was recorded according to the extent of repigmentation in the existing lesions. Both plasma malondialdehyde (MDA; product of lipid peroxidation) and reduced glutathione (GSH) were measured before and after treatment. Twenty patients completed the study. Marked to excellent repigmentation was noted in 72.7% and 55.6% of the patients in group A and group B, respectively. Of the patients, 70% in group A and 85% in group B experienced mild erythema. After treatment, there was a significant reduction in plasma MDA in group A than in group B, but the increase in plasma GSH was not significant. In conclusion, oral vitamin E may represent a valuable adjuvant therapy, preventing lipid peroxidation in the cellular membrane of melanocytes and increasing the effectiveness of NB-UVB.

The Double Strike Hypothesis of the vitiligo pathomechanism: new approaches to vitiligo and melanoma

Based on current research, we present a consolidated set of theses which explain the pathomechanisms of vitiligo- and melanoma-associated hypopigmentation. The main thesis is the Double Strike Hypothesis, i.e. vitiligo is caused by at least two different major pathomechanisms: an antibody-based pathomechanism and a T-cell-based pathomechanism. The antibody-based pathomechanism is dominant in diffuse vitiligo, while the T-cell based pathomechanism is dominant in localised vitiligo. Based on this main thesis we derive new therapeutical approaches to vitiligo and melanoma by using the different pathomechanisms. Finally we explain why melanoma-associated hypopigmentation as a natural immunotherapy is still in statu nascendi.

Vitiligo treatment options: An evolving scenario

Sequential displays of several treatment options for vitiligo have been scanned from the literature, and are presented here. A few of the medical modalities have been resigned to history, whereas others have become customary in clinical practice. There has also been a recent surge of interest in the surgical treatment of this disease. Accordingly, this has been appraised and summarized. Special attention has been given to prevalent medical modalities so that they may be effectively utilized by those currently in practice.

Immunosuppression and melanocyte proliferation

Melanocytes are pigmented cells derived from the neural crest; their proliferation is restrained by immune system. The eruption of nevi after an immunosuppressive condition is a peculiar phenomenon indicating that the immune system may play a major role in limiting proliferation of melanocytes. In this review, we analyze the role of immunosuppressive regimens on melanocyte proliferation. In particular, we discuss the eruptive nevi phenomenon, which is determined by the inability of the immune system to inhibit melanocyte proliferation. These clinical observations indicate that the immune system has a pivotal role in restraining melanocyte proliferation. However, although the role of the immune system in the development of nonmelanoma skin cancer has been shown clearly in several studies involving organ transplant patients, the role of immunosuppression in melanoma genesis has not yet been established. Further investigations are required to establish the real immunogenicity of melanoma, particularly in the light of the dichotomy between the eruptive nevi phenomenon in immunosuppressed patients and the low incidence of melanoma in transplanted patients.

The cumulative burden of oral corticosteroid side effects and the economic implications of steroid use

Oral corticosteroids (OCS) are a key part of therapy regimens for a diverse variety of conditions. Despite their efficacy, they are associated with a wide variety of adverse events. The purpose of this review was to identify the range of adverse events that have been reported to be related to oral corticosteroids, examine the factors that influence their incidence and estimate the economic burden caused by these adverse events. In 61 identified studies, 21 different categories of OCS related adverse events were reported with increased fracture risk being the category most frequently described. Most studies that examined factors linked to the incidence of OCS related adverse events found that dose, age, gender, duration of use, treatment history, smoking habits or cholesterol level were influential in determining risk. Additionally, a cumulative economic analysis of selected adverse events found the annual cost of treating these events in the UK to be at least 165 pounds per patient taking OCS. The clinical and economic burden of OCS related adverse events highlights the need for OCS sparing therapies to be developed.