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Renert-Yuval Y, Ezzedine K, Grimes P, Rosmarin D, Eichenfield LF, Castelo-Soccio L, Huang V, Desai SR, Walsh S, Silverberg JI, Paller AS, Rodrigues M, Weingarten M, Narla S, Gardner J, Siegel M, Ibad S, Silverberg NB. Expert Recommendations on Use of Topical Therapeutics for Vitiligo in Pediatric, Adolescent, and Young Adult Patients. JAMA Dermatol 2024; 160:453-461. [PMID: 38477910 DOI: 10.1001/jamadermatol.2024.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Importance Evidence-based recommendations for the treatment of vitiligo in pediatric, adolescent, and young adult patients in the US are needed. Objective To develop evidence- and consensus-based expert recommendations on the diagnosis and treatment of vitiligo in young patients. Evidence Review A process was developed to produce consensus recommendations addressing questions regarding pediatric vitiligo. A librarian-conducted literature review was performed using articles that met the inclusion criteria: published in English, containing primary data (including meta-analysis) and pediatric-specific data, and analysis of 6 or more patients. Included articles were graded by the Strength of Recommendation Taxonomy criteria and Oxford Centre for Evidence-based Medicine's Levels of Evidence and Grades of Recommendation. Research questions were reviewed on May 9, 2022, through a video conference. One month after the conference, participants participated in an online survey documenting their level of agreement with the generated statements, using a 5-point Likert scale. Findings Articles on topical corticosteroids and/or topical calcineurin inhibitors (n = 50), topical Janus kinase inhibitors (n = 5), pseudocatalase (n = 2), and microdermabrasion (n = 2) met inclusion criteria. Forty-two recommendations were made on the diagnosis of vitiligo and optimal topical therapeutics, with 33 recommendations obtaining a 70% or greater composite agreement and strong agreement. Topical calcineurin inhibitors twice daily, topical corticosteroids with time limitation due to atrophy risk, and topical ruxolitinib, 1.5%, cream-used off-label for patients younger than 12 years and limited to nonsegmental vitiligo-were identified as evidence-based first-line therapies in the management of pediatric and adolescent patients, with specific guidance on age-based data, minimum therapeutic trial of 6 months or greater, prolonged therapy to prevent recurrence, and the positive benefit of coordinated use of UV therapeutic sources. Conclusions and Relevance Evidence supports the use of topical calcineurin inhibitors, topical corticosteroids, and topical Janus kinase inhibitors as effective therapeutics for vitiligo in pediatric, adolescent, and young adult patients, with specific decisions on choice of agent based on factors such as site location, body surface area, and age.
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Affiliation(s)
- Yael Renert-Yuval
- Department of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
- Pediatric Dermatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel, and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Khaled Ezzedine
- Hôpital Henri Mondor, Department of Dermatology and Université Paris Est Créteil, Epidemiology in Dermatology and Evaluation of Therapeutics, Créteil, France
| | - Pearl Grimes
- Departments of Dermatology, University of California, Los Angeles
| | - David Rosmarin
- Department of Dermatology, Indiana University School of Medicine, Indianapolis
| | - Lawrence F Eichenfield
- Dermatology and Pediatrics, University of California, San Diego School of Medicine, San Diego
- Pediatrics and Adolescent Dermatology, Rady Children's Hospital, San Diego, California
| | - Leslie Castelo-Soccio
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, US National Institutes of Health, Bethesda, Maryland
| | - Victor Huang
- Department of Dermatology, University of California, Davis
| | - Seemal R Desai
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas
- Innovative Dermatology, Plano, Texas
| | | | | | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michele Rodrigues
- Department of Dermatology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Mark Weingarten
- Department of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shanthi Narla
- Department of Dermatology, St Luke's University Health Network, Easton, Pennsylvania
| | | | - Michael Siegel
- Pediatric Dermatology Research Alliance, Portland, Oregon
| | - Sidra Ibad
- Department of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nanette B Silverberg
- Department of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
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Karagaiah P, Valle Y, Sigova J, Zerbinati N, Vojvodic P, Parsad D, Schwartz RA, Grabbe S, Goldust M, Lotti T. Emerging drugs for the treatment of vitiligo. Expert Opin Emerg Drugs 2020; 25:7-24. [PMID: 31958256 DOI: 10.1080/14728214.2020.1712358] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Vitiligo is a relatively common autoimmune depigmenting disorder of the skin. There has been a great advance in understanding the pathological basis, which has led to the development and utilization of various new molecules in treating vitiligo. This review aims at a comprehensively describing the treatments available and the emerging treatment aspects and the scope for future developments.Areas covered: This study comprehensively summarizes the current concepts in the pathogenesis of vitiligo with special focus on the cytokine and signaling pathways, which are the targets for newer drugs. JAK kinase signaling pathways and the cytokines involved are the focus of vitiligo treatment in current research, followed by antioxidant mechanisms and repigmenting mechanisms. Topical immunosuppressants may be an alternative to steroids in localized vitiligo. Newer repigmenting agents like basic fibroblast growth factors, afamelanotide have been included and a special emphasis is laid on the upcoming targeted immunotherapy.Expert opinion: The treatment of vitiligo needs to be multimodal with emphasis on targeting different limbs of the pathogenesis. Topical and oral JAK inhibitors are the most promising new class of drugs currently available for treating vitiligo and acts best in conjunction with NB-UVB.
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Affiliation(s)
- Priyanka Karagaiah
- Department of Dermatology, Bangalore Medical College and Research Institute, Bangalore, India
| | - Yan Valle
- Vitiligo Research Foundation, New York, NY, USA
| | - Julia Sigova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Nicola Zerbinati
- Universita degli Studi dell'Insubria Dipartimento di Scienze Chirurgiche e Morfologiche, Varese, Italy
| | - Petar Vojvodic
- Clinic for Mental Disorders "Dr Laza Lazarevic", Belgrade, Serbia
| | | | | | - Stephan Grabbe
- Department of Dermatology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Mohamad Goldust
- University of Rome Guglielmo Marconi, Rome, Italy, Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Torello Lotti
- Department of Dermatology, University of Studies Guglielmo Marconi, Rome, Italy
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Lee JH, Kwon HS, Jung HM, Lee H, Kim GM, Yim HW, Bae JM. Treatment Outcomes of Topical Calcineurin Inhibitor Therapy for Patients With Vitiligo: A Systematic Review and Meta-analysis. JAMA Dermatol 2019; 155:929-938. [PMID: 31141108 DOI: 10.1001/jamadermatol.2019.0696] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Topical calcineurin inhibitors (TCIs), including tacrolimus and pimecrolimus, have been widely used for the treatment of vitiligo; however, the efficacy of TCI monotherapy is often underestimated. Objectives To estimate the treatment responses to both TCI monotherapy and TCI accompanied by phototherapy for vitiligo, based on relevant prospective studies, and to systematically review the mechanism of action of TCIs for vitiligo treatment. Data Sources A comprehensive search of the MEDLINE, Embase, Web of Science and Cochrane Library databases from the date of database inception to August 6, 2018, was conducted. The main key words used were vitiligo, topical calcineurin inhibitor, tacrolimus, pimecrolimus, and FK506. Study Selection Of 250 studies initially identified, the full texts of 102 articles were assessed for eligibility. A total of 56 studies were identified: 11 studies on the TCI mechanism, 36 studies on TCI monotherapy, 12 studies on TCI plus phototherapy, and 1 study on TCI maintenance therapy. Data Extraction and Synthesis Two reviewers independently extracted data on study design, patients, intervention characteristics, and outcomes. Random-effects meta-analyses using the generic inverse variance weighting were performed for the TCI monotherapy and TCI plus phototherapy groups. Main Outcomes and Measures The primary outcomes were the rates of at least mild (≥25%), at least moderate (≥50%), and marked (≥75%) repigmentation responses to treatment. These rates were calculated by dividing the number of participants in an individual study who showed the corresponding repigmentation by the total number of participants who completed that study. Results In the 56 studies included in the analysis, 46 (1499 patients) were selected to evaluate treatment response. For TCI monotherapy, an at least mild response was achieved in 55.0% (95% CI, 42.2%-67.8%) of 560 patients in 21 studies, an at least moderate response in 38.5% (95% CI, 28.2%-48.8%) of 619 patients in 23 studies, and a marked response in 18.1% (95% CI, 13.2%-23.1%) of 520 patients in 19 studies after median treatment duration of 3 months (range, 2-7 months). In the subgroup analyses, face and neck lesions showed an at least mild response in 73.1% (95% CI, 32.6-83.5%) of patients, and a marked response in 35.4% (95% CI, 24.9-46.0%) of patients. For TCI plus phototherapy, an at least mild response to TCI plus phototherapy was achieved in 89.5% (95% CI, 81.1-97.9%) of patients, and a marked response was achieved in 47.5% (95% CI, 30.6-64.4%) of patients. Conclusions and Relevance The use of TCIs, both as a monotherapy and in combination with phototherapy, should be encouraged in patients with vitiligo.
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Affiliation(s)
- Ji Hae Lee
- Department of Dermatology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyuck Sun Kwon
- Department of Dermatology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Han Mi Jung
- Department of Dermatology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyunyong Lee
- Clinical Research Coordinating Center, Catholic Medical Center, The Catholic University of Korea, Seoul, Korea
| | - Gyong Moon Kim
- Department of Dermatology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Min Bae
- Department of Dermatology, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Patel S, Rauf A, Khan H, Meher BR, Hassan SSU. A holistic review on the autoimmune disease vitiligo with emphasis on the causal factors. Biomed Pharmacother 2017; 92:501-508. [PMID: 28575807 DOI: 10.1016/j.biopha.2017.05.095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/12/2017] [Accepted: 05/22/2017] [Indexed: 12/25/2022] Open
Abstract
Vitiligo is an idiopathic systemic autoimmune disease affecting skin, hair and oral mucosa. This genetic yet acquired disease characterized by melanin loss is a cause of morbidity across all races. Though thyroid disturbance has been recognized as a key trigger of this pathology, an array of other factors plays critical role in its manifestation. Multiple hormones (corticotropin-releasing hormone, adrenocorticotropic hormone, α-melanocyte-stimulating hormone, melatonin, calcitriol, testosterone, estrogen), genes (Human leukocyte antigen (HLA), Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), Forkhead box D3 (FOXD3), Cluster of differentiation 117 (CD117), Estrogen receptor (ESR) 1, Cyclooxygenase-2 (COX2), Vitiligo-associated protein 1 (VIT1)), and lifestyle choices (stress, diet, cosmetic products, and medications) have been suspected as drivers of this disorder. The pathological mechanisms have been understood in recent times, with the aid of genomic studies; however a universally-effective therapy is yet to be achieved. This review discusses these under-investigated facets of vitiligo onset and progression; hence, it is expected to enrich vitiligo research.
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Affiliation(s)
- Seema Patel
- Bioinformatics and Medical Informatics Research Center, San Diego State University, 5500 Campanile Dr, San Diego, 92182, USA.
| | - Abdur Rauf
- Department of Chemistry, University of Swabi, Anbar, 23561, K.P.K, Pakistan.
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University, Mardan, 23200, Pakistan
| | - Biswa Ranjan Meher
- Centre for Life Sciences, Central University of Jharkhand, Brambe, Ranchi, 835205, Jharkhand, India
| | - Syed Shams Ul Hassan
- Department of Marine Chemistry and Natural Products, Ocean College, Zhejiang University, Hangzhou, 310058, PR China
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de Menezes AF, Oliveira de Carvalho F, Barreto RSS, de Santana Silva B, Shanmugam S, Gurgel RQ, de Souza Araújo AA. Pharmacologic Treatment of Vitiligo in Children and Adolescents: A Systematic Review. Pediatr Dermatol 2017; 34:13-24. [PMID: 27878842 DOI: 10.1111/pde.13024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The true pathogenic mechanism of vitiligo is still unknown. About half of the patients with this disease have onset before the age of 20 years, making it a serious dermatologic disorder in childhood. OBJECTIVES The objective of this study was to review the literature in a systematic way and identify the main pharmacologic treatments and outcomes in children and adolescents with vitiligo. METHODS Four databases-the National Library of Medicine (MEDLINE-PubMed), Web of Science, Scopus, and Latin American and Caribbean Health Sciences (LILACS)-were used for the search up to January 2015. All electronic search titles, selected abstracts and full-text articles were independently reviewed by a minimum of two reviewers. RESULTS There were 15 articles from 13 different countries: 3 were retrospective and 12 were prospective; the number of participants in the studies varied between 9 and 400, ages ranged from 0 to 18 years, and the duration of disease ranged from 1 to 17 years. The most commonly used drugs were tacrolimus alone (or combined with clobetasol), pimecrolimus, corticosteroids, and calcipotriol. Treatment duration ranged from 10 days to 6 months with a topical route of administration. CONCLUSIONS The main outcome measurements were morphometric analysis performed using a computer program, hematologic or biochemical change, and photography (predominant). It is unclear which was the most effective treatment for vitiligo, however, it was found that these therapies are all promising in the treatment of the disease. With proper care, disease control and repigmentation, even if partial, can be achieved.
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Affiliation(s)
| | | | - Rosana S S Barreto
- Núcleo de Pós-Graduação em Medicina, Universidade Federal de Sergipe-UFS, Aracaju, SE, Brazil
| | - Bruno de Santana Silva
- Núcleo de Pós-Graduação em Medicina, Universidade Federal de Sergipe-UFS, Aracaju, SE, Brazil
| | - Saravanan Shanmugam
- Núcleo de Pós-Graduação em Medicina, Universidade Federal de Sergipe-UFS, Aracaju, SE, Brazil
| | - Ricardo Queiroz Gurgel
- Núcleo de Pós-Graduação em Medicina, Universidade Federal de Sergipe-UFS, Aracaju, SE, Brazil
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Abstract
The range of treatment options for vitiligo has significantly expanded in the last 10 years and we can offer our patients more effective treatment strategies supported by European guidelines and consensus findings. Topical and UV therapy are-often in combination-the main components of vitiligo treatment. The main outcome parameters include extent and maintenance of gained repigmentation, cessation of spreading, avoidance of side effects and the influence of the treatment on the quality of life. The efficacy of the currently available treatments is often limited. New options include antioxidative or melanocyte-stimulating adjuvant therapies in combination with UV or laser light as well as a topical maintenance treatment to reduce the risk of recurrences. In many cases, psychological support is indicated.
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Affiliation(s)
- M Meurer
- Stiftung zur Förderung der Hochschulmedizin in Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - M Schild
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
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Shim WH, Suh SW, Jwa SW, Song M, Kim HS, Ko HC, Kim BS, Kim MB. A pilot study of 1% pimecrolimus cream for the treatment of childhood segmental vitiligo. Ann Dermatol 2013; 25:168-72. [PMID: 23717007 PMCID: PMC3662909 DOI: 10.5021/ad.2013.25.2.168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/10/2012] [Accepted: 02/14/2012] [Indexed: 11/19/2022] Open
Abstract
Background There is as yet no effective and safe treatment for vitiligo. One percent pimecrolimus cream, a topical calcineurin inhibitor, has been tried for the treatment of vitiligo, with its therapeutic efficacy having mostly been reported in non-segmental vitiligo. However, questions about the therapeutic efficacy of 1% pimecrolimus cream have remained unanswered regarding segmental vitiligo. Objective The aim of this study was to study the therapeutic efficacy and safety of 1% pimecrolimus cream for segmental childhood vitiligo. Methods Nine childhood patients with segmental vitiligo were treated with 1% pimecrolimus cream twice daily for three months, after which good responders were scheduled to continue with the 1% pimecrolimus cream monotherapy. The efficacy and safety of this treatment were determined by the levels of repigmentation, initial response time and the presence of adverse events including burning, dryness, stinging and itching. Results Four of nine patients achieved mild to moderate responses after three months of treatment and thus continued with treatment. Among these four patients, three achieved an excellent response and one patient achieved a moderate response, with a mean treatment duration of 7.3 months. Transient local burning sensation was the most common adverse event. In comparison with the patients with poor response, those patients with good response showed a shorter disease duration (8.5±10.5 mo vs. 13.4±10.1 mo), more frequent facial involvement (4/4 patients vs. 3/5 patients) and earlier initial response after treatment (1.0±0.0 mo vs. 2.0±1.0 mo). Conclusion This study suggests that 1% pimecrolimus cream is an effective and well-tolerated treatment for segmental childhood vitiligo.
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Affiliation(s)
- Woo-Haing Shim
- Department of Dermatology, School of Medicine, Pusan National University, Busan, Korea
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Wong R, Lin AN. Efficacy of topical calcineurin inhibitors in vitiligo. Int J Dermatol 2013; 52:491-6. [DOI: 10.1111/j.1365-4632.2012.05697.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 03/25/2012] [Accepted: 04/22/2012] [Indexed: 11/30/2022]
Affiliation(s)
| | - Andrew N. Lin
- Division of Dermatology and Cutaneous Sciences; Department of Medicine; University of Alberta; Edmonton; Alberta; Canada
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Abstract
Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.
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Affiliation(s)
- Andrew N Lin
- Division of Dermatology and Cutaneous Sciences, University of Alberta, 2-104 Clinical Sciences Building, Edmonton, Alberta, T6G 2G3, Canada.
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Abstract
PURPOSE OF REVIEW This review addresses recent changes in the understanding and the treatment of vitiligo vulgaris. RECENT FINDINGS Two target genes for vitiligo have been identified, NACHT-leucine-rich-repeat protein-1 (NALP1), part of the inflammasome cascade, and tyrosinase, the enzyme that produces melanin. Identification of reactive oxidation species has furthered the understanding of melanocyte destruction. Comorbid autoimmune disease, including thyroid autoimmunity seen in 25%, is genetically linked to generalized vitiligo and is noted in both childhood vitiligo patients and their families. Screening for vitamin deficiencies and concurrent autoimmunity can be beneficial to the overall health of the child with vitiligo. About half of all vitiligo vulgaris patients have onset of their illness during childhood, causing increased psychological stress during the formative years. Fortunately, therapy has improved as well, with the development of newer topical agents for vitiligo, including topical calcineurin inhibitors; new topical combinations such as topical corticosteroids and calcipotriene; and new technological advances including narrowband ultraviolet B and excimer laser. SUMMARY A cyclic approach to therapy should be used wherein topical agents are altered every 6-8 months and technology is used as an alternative after achievement of maximal topical response. With cyclic therapy and early disease intervention, good cosmetic outcomes may be achievable, particularly in localized cases.
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Bilaç DB, Ermertcan AT, Sahin MT, Oztürkcan S. Two therapeutic challenges: facial vitiligo successfully treated with 1% pimecrolimus cream and 0.005% calcipotriol cream. J Eur Acad Dermatol Venereol 2008; 23:72-3. [PMID: 18355205 DOI: 10.1111/j.1468-3083.2008.02668.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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