Is the combination of calcipotriol and PUVA effective in vitiligo?

Using a Topical Formulation of Vitamin D for the Treatment of Vitiligo: A Systematic Review

Vitamin D is one significant prohormone substance in human organ systems. It is a steroidal hormone produced in the skin upon exposure to UVB rays. This paper presents a systematic review of the utilization of topical vitamin D, specifically cholecalciferol, calcipotriol, and tacalcitol, in the treatment of vitiligo. It considers the role of vitamin D in stimulating the synthesis of melanin and melanogenesis, which can help with the process of repigmentation. The inclusion of calcipotriol or tacalcitol in Narrowband Ultraviolet Phototherapy (NB-UVB) has shown the potential to enhance therapeutic outcomes for vitiligo. However, their effectiveness in combination with Psoralens Long Wave Ultraviolet Radiation (PUVA) and Monochromatic Excimer Light (MEL) treatment for vitiligo is limited. In contrast, combining topical corticosteroids with vitamin D analogues has demonstrated superior efficacy in treating vitiligo compared to using vitamin D analogues alone, while also providing the added benefit of reducing corticosteroid-related adverse effects. In addition, treating stable vitiligo with topical cholecalciferol and microneedling has shown success. Future studies are needed to ascertain an efficient method of administering vitamin D topically as an anti-vitiligo agent.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

The Medical Treatment of Vitiligo: An Historical Review

Discolorations of the skin, such as vitiligo, were recognized thousands of years ago. White spots caused by vitiligo and other disorders have caused significant social opprobrium to those disfigured by these pigmentary disorders, throughout history and still in the present day. Treatments have been desperately sought with only partial success. Recent advances suggest that vitiligo and other pigmentary disorders might soon be curable.

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.

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).

Evidence-based, non-surgical treatments for vitiligo: a review

Vitiligo is an acquired pigmentary disorder characterized by depigmented macules and patches secondary to the loss of functional melanocytes. It is a chronic disease that affects between 0.1% and 2% of the general population, affecting both sexes and all races. The appearance and the unpredictable course are psychologically and socially devastating. The success of current therapeutic options is limited. The objective of this review was to assess non-surgical treatments of vitiligo and to determine if comparing these studies can lead to (1) practical applications in the clinical setting and (2) recommendations for future research including study design and topics to be investigated further. Combination therapies were found to be more effective than monotherapy, and most combinations included a form of phototherapy, of which narrow-band-UVB was found to be most effective with the least adverse effects. Topical treatment with corticosteroids, immunomodulators, vitamin D analogs, and psoralens had mixed outcomes. Oral therapies including antioxidants were helpful adjuvants to treatment. Studies lacked consistent design, mechanism of disease assessment, and long-term follow-up. Sample size was also frequently limited. This review found that while several non-surgical therapies exist for the treatment of vitiligo, their usefulness, especially in the long term, is not well understood. Those studies that were able to elicit repigmentation often lacked an assessment on quality of life and/or patient satisfaction. More standardized methods of study design and assessment are needed to compare outcomes and make definitive conclusions on treatment effectiveness.

Vitiligo treatment in childhood: a state of the art review

Vitiligo is a common depigmenting disorder affecting about 1-2% of the world population. Approximately half of the affected individuals develop the disease before adulthood. Etiologic hypotheses for vitiligo include biochemical, neural and autoimmune mechanisms. The most compelling of these suggests a combination of genetic and immunologic factors that result in an autoimmune melanocyte destruction. We reviewed studies carried out on various treatment modalities used in childhood vitiligo. Topical corticosteroids were found to have excellent repigmentation rates, whereas calcineurin inhibitors have comparable efficacy and a better safety profile compared with topical corticosteroids. These two groups of topical medications are good first-line treatment modalities for localized vitiligo. For the treatment of generalized vitiligo, phototherapy has excellent efficacy. Narrow-band ultraviolet B (UVB) has better overall repigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA). Other treatment modalities may be considered depending on a patient's specific condition, such as surgical options and depigmentation. With adequate sun protection, the option of no treatment with or without corrective camouflage, is an innocuous alternative to any of these treatment modalities.

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.

Vitiligo: new and emerging treatments

Vitiligo is a cosmetically disfiguring condition, and, although there is no therapeutic full solution yet, some treatment may induce good results in most patients. The disease can be successfully treated with various medical options. Both nonfocused or focused narrowband ultraviolet B phototherapy represents the current treatment of choice, to minimize side effects and reach optimal clinical results. Topical novel approaches are also considered. Surgical methods, consisting of autologous transplantation methods, is generally recommended for focal/stable vitiligo, after medical therapy has failed. Finally, for patients with extensive vitiligo, depigmentation of the residual melanin should be taken into account.

Combination of 308-nm xenon chloride excimer laser and topical calcipotriol in vitiligo

BACKGROUND

A large variety of therapeutic agents are being used for the treatment of vitiligo, but treatment remains a challenge. Recently, monochromatic phototherapies such as 311-nm narrowband ultraviolet B therapy and 308-nm xenon chloride excimer laser have been reported to be an effective and safe therapeutic option in children and adult patients with vitiligo. Single reports stipulate that the addition of topically applied calcipotriol to phototherapy increases its effectiveness.

OBJECTIVE

The purpose of the present pilot study was to determine if the addition of topical calcipotriol increases the efficacy of the 308-nm xenon chloride excimer in the treatment of vitiligo.

METHODS

Ten patients with vitiligo with essentially bilateral symmetrical lesions were enrolled in this prospective right/left comparative, single-blinded trial conducted over a 15-month period. All patients received 308-nm XeCl excimer laser therapy three times weekly. Calcipotriol ointment (Daivonex) was applied to lesions on one side of the body twice daily.

RESULTS

After 24 treatments (8 weeks), nine patients were evaluated. Eight patients showed evidence of repigmentation on both body sides, with no significant difference between the body side treated with calcipotriol and excimer laser and the side treated with excimer laser alone. The mean repigmentation rate was 22.4% (1-37%).

CONCLUSION

The addition of calcipotriol ointment to 308-nm xenon chloride excimer laser phototherapy does not significantly enhance its efficacy. Small additive effects must be investigated in a larger trial.

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.

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.

What's new in hypochromy

Hypochromy is a common dermatological disorder. However, its treatment still gives unsatisfactory results. Interesting clues into the understanding of the pathophysiology of hypochromy have been recently brought about thanks to the pigmentary side effects reported with the new tyrosine kinase inhibition treatments. New therapeutic approaches to hypochromy are further discussed.

Psoralen cream plus ultraviolet A photochemotherapy (PUVA cream): our experience

BACKGROUND

Psoralen ultraviolet A (PUVA) bath photochemotherapy has been proved highly effective in the treatment of various dermatoses without potential side-effects of systemic therapy. Another form of topical PUVA therapy (PUVA cream) without the logistical requirements for bath tubs has recently been developed.

OBJECTIVE

We sought to develop preparation and treatment standards to PUVA cream and to confirm its clinical efficacy in the treatment of various dermatoses.

METHODS

In the first phase, the safety of a novel cream containing 0.002% 8-methoxypsoralen (8-MOP) was determined in six healthy volunteers. In a second phase, 40 patients with different dermatoses were treated with a minor concentration (0.001% 8-MOP), following the guidelines for topical PUVA of the British Photodermatology Group.

RESULTS

Plasma levels of psoralen after the application of the novel cream containing 0.002% 8-MOP, were less than 34 ng/mL, the maximum 8-MOP concentration reported for topical PUVA. With a minor concentration (0.001% 8-MOP), important improvement or healing was found in 53.3% of the cycles, generally with a good response since the first month of treatment. Only mild side-effects were detected in 14 patients.

CONCLUSIONS

Based on our data, PUVA cream photochemotherapy is well accepted by patients and may be a highly effective treatment even if previous therapy was unsuccessful. In addition, PUVA cream is easier to use than PUVA bath.

Documento de consenso sobre fototerapia: terapias PUVA y UVB de banda estrecha

It is essential to develop a consensus document on phototherapy in order to adapt this procedure to the specific characteristics, needs and reality of our milieu. Using a review of existing literature on the subject and the experience of its own members as a reference, the Spanish Photobiology Group (GEF) of the Spanish Academy of Dermatology and Venereology (AEDV) has developed some therapeutic guidelines for the most widely used modes of phototherapy: PUVA therapy and narrow-band UVB (NBUVB) therapy. These guidelines deal with generalities about the equipment, calibration and regulation in phototherapy booths, and the concept and indications for these forms of treatment are reviewed. Recommendations are also proposed regarding patient selection, therapeutic procedures, associated pharmacological agents of interest and the prevention and management of adverse effects. The consensus document is designed as a flexible and practical instrument intended for use in daily clinical practice, aimed at optimizing the possibilities of phototherapy while reducing risks for patients and therapists.

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.