Management of vitiligo. Results of a questionnaire among dermatologists in The Netherlands

The Vitiligo Impact Patient Scale (VIPs): Development and Validation of a Vitiligo Burden Assessment Tool

Vitiligo has a major impact on health-related quality of life. Although a few vitiligo-specific quality of life instruments exist, there is no specific vitiligo burden tool. We developed and validated a specific vitiligo burden tool according to skin phototype. In total, 301 patients completed 35 items of the Vitiligo Impact Patient scale, of whom 235 were of skin phototype I to III and 66 of phototype IV to VI. The dimensionality of the items was evaluated using factor analyses, with results suggesting three factors in fair- and dark-skinned patients ("Psychological effects on daily life," "Relationships and Sexuality," and "Economic Constraints, Care & Management of Disease"). Unidimensionality was confirmed by higher order factor analysis. Cronbach's α were high-and intradimensional coherences all demonstrated good reliability (α > 0.8). The final instrument consists of 29 items (19 items common to all patients, 3 specific to fair skin, and 7 to dark skin). The test-retest reliability demonstrated very good reproducibility. The intraclass correlation of each dimension was greater than 0.90 for each population. External validity was confirmed by the correlation coefficients and Bland and Altman plots of the Vitiligo Impact Patient scale-Fair Skin and Vitiligo Impact Patient scale-Dark Skin versus the Short-Form-12, PVC Metra, Body Image States Scale, and Daily Life Quality Index assessment tools.

Pediatric vitiligo

Vitiligo is a disease of pigment loss. Most investigators currently consider vitiligo to be a disorder that occurs as a result of autoimmune destruction of melanocytes, supported by identification of antimelanocyte antibodies in many patients, and the presence of comorbid autoimmune disease in patients with and family members of individuals with vitiligo. One-half of vitiligo cases are of childhood onset. This article presents a current overview of pediatric vitiligo including comorbidities of general health, psychological factors, therapeutic options, and long-term health considerations.

Treatment of vitiligo in children and adolescents by autologous cultured pure melanocytes transplantation with comparison of efficacy to results in adults

BACKGROUND

Transplantation of autologous cultured pure melanocytes is a well-established procedure for the treatment of refractory and stabilized vitiligo. However, there was no report specifically comparing the efficacy with the regard to defined age groups (children-adolescence-adult).

OBJECTIVE

  We analysed the efficacy of this procedure in the treatment of vitiligo in children and adolescents and compare it with the results in adults treated during the same period and using identical procedures.

METHODS

Melanocytes were isolated from the roof of suction blister, cultured and expanded with Hu16 medium in vitro, and transplanted to laser-denuded receipt area. A total of 12 children (8-12 years), 20 adolescents (13-17 years) and 70 adults with vitiligo were treated using this procedure.

RESULTS

The patients obtained satisfactory results (repigmentation of 50% or more) results in children, adolescents and adults were 83.3%, 95.0% and 84.0% respectively. The mean extent of repigmentation in children, adolescents and adults was 80.7%, 78.9% and 76.6% respectively. There was no statistical difference in repigmentation among these three groups. After adjusting for all factors (gender, type of vitiligo, period of stability, location of the lesion or transplanted cell density) individually or totally using multiple regression analysis, age still did not correlate to the extent of repigmentation.

CONCLUSIONS

The satisfactory results obtained in the treatment of vitiligo in children and adolescents by transplantation of cultured autologous pure melanocytes are comparable with the results in adults. Therefore, this procedure can be considered in refractory and stable vitiligo in children and adolescents, especially in patients with large vitiliginous lesions.

Vitiligo in children

BACKGROUND

Vitiligo is an acquired depigmentary disorder affecting around 1% of the world's population. In 25% of cases it has its onset prior to the age of 14 years.

DATA SOURCES

Articles on vitiligo in children published after 1995 were retrieved from PubMed. The prevalence, etiology, clinical presentation, differential diagnosis, treatment and management of vitiligo in children were summarized.

RESULTS

Vitiligo is characterized by acquired, sharply demarcated depigmented macules or patches on the skin, the mucous membranes and/or white hair and it is mainly differentiated from congenital achromic skin lesions. It is frequently associated with various autoimmune diseases. Hashimoto's thyroiditis is the most common association in children. Information on the nature, possible causes and course of the disease leads to acceptance of the disorder and higher compliance with the treatment. The choice of medical treatment depends on the type, location and duration of lesions as well as the eagerness of the child and his/her parents to pursue therapy.

CONCLUSION

The management of childhood vitiligo includes information and reassurance of young patients and their parents on the disease, thyroid investigation, avoidance of trigger factors, topical treatment and proper follow-up.

Topical pimecrolimus: A new horizon for vitiligo treatment?

OBJECTIVES

The purpose of this study was to assess the efficacy of pimecrolimus cream 1% in vitiligo and to evaluate the effects of age of the patients, age of onset and duration of disease on response rate.

MATERIALS AND METHODS

Twenty-three patients with vitiligo were enrolled in our study; 19 patients (seven male, 12 female) completed the 6-month study period. Patients were treated with topical pimecrolimus 1% cream once daily. The response was evaluated as excellent (76-100%), moderate (51-75%), mild (26-50%), minimal (1-25%), or no response.

RESULTS

The mean age of the 19 patients was 29.3+/-16.6 (range 7-62 years) and the mean duration of vitiligo was 68.4+/-81.3 months. Three patients demonstrated an excellent response to the therapy. Four patients had moderate, six patients had mild and five patients had minimal responses; one patient had no response to the treatment. Side effects were noted as a burning and stinging sensation in only three patients. The correlations between response rate and duration of the disease (r = 0.02, p = 0.95), onset age (r = -0.17, p = 0.48), and age of the patients (r = -0.16, p = 0.53) were not significant.

CONCLUSIONS

Pimecrolimus has a mild therapeutic effect on vitiligo without significant side effects and can be an alternative therapy agent.

The burden of vitiligo: patient characteristics associated with quality of life

BACKGROUND

Vitiligo is commonly regarded as a harmless cosmetic skin problem in Western societies, and the importance of treating patients with vitiligo is often underestimated.

OBJECTIVE

We sought to determine the clinical and sociodemographic variables that adversely affect the quality of life in adult patients with generalized vitiligo so that these variables can be considered in the treatment and care.

METHODS

A total of 245 adult patients with generalized vitiligo completed two quality-of-life questionnaires (the Medical Outcomes Study 36-Item Short-form General Health Survey and the Skindex-29). Physicians assessed sociodemographic and clinical characteristics of these patients.

RESULTS

Dark skin type, vitiligo located on the chest, and treatment in the past appeared to have an adverse impact on the psychosocial domains of quality of life. Moreover, itch was reported by 20% of the patients in this study.

LIMITATIONS

Psychiatric comorbidity was not evaluated in the analyses.

CONCLUSION

Generalized vitiligo is a serious skin disorder with an adverse impact on the emotional state, comparable with that of other major skin diseases.

Pigmentary disorders in Western countries

Countries in the so-called "Western" world, especially in Europe, witnessed a dramatic change in ethnic backgrounds of their populations starting in the last decennia of the last century. This had repercussions on various aspects of our society, including medical practice. In dermatology for instance, pigmentary disorders are seen more often, and the clinical pictures and their impact on patients are different from what doctors and researchers are used to and trained for. In this article, the experience from the Netherlands Institute for Pigment Disorders and the multicenter designed Netherlands guideline on vitiligo are described and the importance of the patient's point of view, as can be measured by patient reported outcomes like quality of life, is emphasized.

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.

Psychosocial effects of vitiligo

A limited number of studies have paid attention to the psychosocial well-being of patients affected with vitiligo. We review the psychosocial effects of vitiligo, how patients deal with them and the psychiatric morbidity in vitiligo patients. Given the appreciable comorbidity, it is important to consider these observations in the management of patients, for example in patient-physician interaction but also in treatment strategies and evaluation of treatments. The effects of the psychological state on the disease itself together with the potential therapeutic implications are reviewed. Based on these data, we suggest how to further improve patient's management.

Dermatosurgical techniques for repigmentation of vitiligo

There are a number of dermatosurgery techniques available to achieve repigmentation of vitiligo, such as suction blister grafting, split-thickness skin grafting, punch grafting, follicular grafting, cultured-melanocytes transplantation, and noncultured-melanocytes transplantation. Each method has advantages and disadvantages. As there are no specific data available from the prospective studies in this field it is uneasy to recommend which surgical approach to vitiligo offers the best result. According to a systematic review by Njoo et al.,(17) suction blister and split-thickness skin grafting have the highest rates of success (87%), while the average success rates for other methods varied from 13% to 53%. Punch grafting has the highest rate of adverse effects, including cobblestoning appearance (27%) and scar formation (40%) in the donor site. Accordingly, it is also mandatory to appropriately select vitiligo patients in order to achieve a complete and permanent repigmentation.

Tacrolimus ointment promotes repigmentation of vitiligo in children: A review of 57 cases

BACKGROUND

Vitiligo is an autoimmune disorder characterized by loss of pigmentation. Phototherapy and application of topical corticosteroids are most commonly prescribed. However, these therapies are often not effective and use of corticosteroids on the face may lead to cutaneous atrophy, telangiectasia, and ocular complications.

OBJECTIVE

We sought to assess the efficacy of topical tacrolimus ointment in the treatment of pediatric vitiligo.

METHODS

A retrospective review was performed of 57 pediatric patients with vitiligo at two clinical sites. Patients were treated with tacrolimus ointment for at least 3 months. Clinical responses were documented during clinic visits, and by pretacrolimus and posttacrolimus photography.

RESULTS

At least partial response was noted to tacrolimus ointment on the head and neck in 89%, and on the trunk and extremities in 63% of patients. Facial vitiligo of the segmental type showed the best response rate. Two patients initially experienced burning on application.

CONCLUSIONS

Topical tacrolimus ointment is an effective alternative therapy for childhood vitiligo, particularly involving the head and neck.

Narrow-band ultraviolet B treatment for vitiligo, pruritus, and inflammatory dermatoses

BACKGROUND

Narrow-band ultraviolet B (NB-UVB) therapy has been used successfully for the treatment of inflammatory and pigmentary skin disorders including atopic dermatitis, psoriasis, mycosis fungoides, polymorphous light eruption, and vitiligo.

METHODS

This is a retrospective review of the treatment outcomes of 117 consecutive patients with vitiligo, pruritus, and other inflammatory dermatoses, excluding those with psoriasis and CTCL, who were treated with NB-UVB between 1998 and 2001 at our institution.

RESULTS

Approximately 80% of all patients showed improvement in their condition. NB-UVB phototherapy was well tolerated, with no serious adverse effects. In patients with vitiligo, 6.4% had an abnormal thyroid-stimulating hormone level and 6.5% had anemia.

CONCLUSION

NB-UVB may be considered as a viable therapeutic option in the treatment of vitiligo, pruritus, and other inflammatory dermatoses. Long-term adverse effects and cost-benefit analysis of NB-UVB therapy compared to other treatment modalities remain to be determined.

Vitiligo. Pathogenesis and treatment

Vitiligo is an acquired skin disorder caused by the disappearance of pigment cells from the epidermis that gives rise to well defined white patches which are often symmetrically distributed. The lack of melanin pigment makes the lesional skin more sensitive to sunburn. Vitiligo can be cosmetically disfiguring and it is a stigmatizing condition, leading to serious psychologic problems in daily life. It occurs worldwide in about 0.5% of the population and it occurs as frequently in males as it does in females. The cause is unknown, but might involve genetic factors, autoimmunity, neurologic factors, toxic metabolites, and lack of melanocyte growth factors. Since a causative (gene) treatment is not (yet) available, current modalities are directed towards stopping progression and to achieving repigmentation in order to repair the morphology and functional deficiencies of the depigmented skin areas. Many treatments have been used for some time; however; there are some new developments: narrowband ultraviolet (UV) B (311 nm) therapy, the combination of corticosteroid cream + UVA therapy, and the transplantation of autologous pigment cells in various modalities. In widespread vitiligo, residual pigment can be removed by depigmentation agents. Sunscreens, camouflage products, and good guidance may help the patient cope better with the disease.

Generalized vitiligo after lymphocyte infusion for relapsed leukaemia

Vitiligo is an autoimmune disease caused by T-lymphocyte-mediated destruction of melanocytes. We describe two patients with generalized vitiligo caused iatrogenically after donor lymphocyte infusion (DLI) for leukaemia relapse over 3 years after bone marrow transplantation (BMT). Neither the sibling donor nor the recipient had vitiligo or other autoimmune diseases, and vitiligo did not occur after the first BMT. DLI was accompanied by skin graft-versus-host disease in both cases, which was controlled with immunosuppression. However, over several months, progressive generalized and persistent skin depigmentation occurred in both patients. Peripheral blood molecular studies showed the complete disappearance of host haematolymphopoiesis. The specific destruction of melanocytes in both patients was therefore probably mediated by new alloreactive lymphocytes infused from the donors.

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

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