The efficacy and safety of tacrolimus as mono‐ and adjunctive therapy for vitiligo: A systematic review of randomised clinical trials

Tacrolimus: Physicochemical stability challenges, analytical methods, and new formulations

Tacrolimus, a potent immunosuppressant, is widely used in several formulations to treat organ rejection in transplant patients. However, its physicochemical stability poses significant challenges, including thermal instability, photostability issues, low solubility, and drug-excipient incompatibility. This review article focuses on the details of these challenges and discusses the analytical methods employed to study tacrolimus stability, such as thermal, spectroscopic, and chromatographic methods in different formulations. New formulations to enhance tacrolimus stability are explored, including lipid-based nanocarriers, polymers, and thin film freezing. Researchers and formulators can optimize tacrolimus formulations to improve efficacy and patient outcomes by understanding and addressing these stability challenges.

Bridging Molecular Mechanism and Clinical Practice in Vitiligo Treatment: An Updated Review

BACKGROUND

Treatment of vitiligo seeks to achieve three goals: cessation of disease progression, regeneration of pigmentation, and prevention of recurrence.

SUMMARY

Number of nonsurgical interventions are available that suppress the autoimmune response and regenerate the melanocytes from the reservoir: phototherapy including psoralen and ultraviolet A, narrowband ultraviolet B, and 308-nm excimer and 311-nm Titanium:Sapphire lasers; topical agents including topical calcineurin inhibitors, topical corticosteroids, and topical 5-fluorouracil; and systemic agents including corticosteorids, mycophenolate mofetil, cyclosporine, methotrexate, minocycline, afamelanotide, and antioxidants. In recent years, a great advance has been made in the understanding of pathogenesis of vitiligo, and JAK inhibitors are being investigated as a new treatment. Minimally invasive procedures such as fractional lasers or microneedling can help achieve the optimal treatment outcome when used properly.

KEY MESSAGES

Our review describes various treatment modalities for vitiligo based on their molecular mechanism of action. Bridging the gap between molecular mechanisms and therapeutic options would be a valuable reference for physicians in clinical practice.

Nonsteroidal Approaches for Atopic Dermatitis: A Clinical Update

Topical corticosteroids (TCSs) are the most widely used treatment for atopic dermatitis (AD), but they can have adverse effects such as skin atrophy, telangiectasias, and hypopigmentation, especially with prolonged use of higher potency steroids. Many patients also have a fear of using TCSs, known as "corticophobia." With the development of biologics and Janus kinase inhibitors, a nonsteroidal approach to the treatment of AD may be possible and may be preferred by certain patients. Given what is known about these nonsteroidal therapies, we propose a structured treatment ladder and action plan that can guide clinicians and patients on the use of these therapies for the treatment of AD. The ladder divides nonsteroidal medication classes into treatments for exacerbation versus maintenance therapies in an escalating order of increasing potential for adverse effects, both real and perceived. This treatment algorithm proposal paves the way for a potential nonsteroidal approach to managing AD.

Comparison of NB-UVB combination therapy regimens for vitiligo: A systematic review and network meta-analysis

BACKGROUND

Vitiligo was an autoimmune disease and some guidelines for the management of vitiligo encouraged the use of NB-UVB combination therapies to enhance repigmentation.

OBJECTIVES

To compare the effectiveness of current NB-UVB combination regimen at the improvement in repigmentation through a systematic review and network meta-analysis.

METHODS

We searched the electronic databases for randomized controlled trials related to NB-UVB combination therapy for vitiligo till October 2022. STATA15.0 software was applied to carrying out data analysis.

RESULTS

A total of 28 eligible studies involving 1194 participants were enrolled in the analysis. The NMA results revealed that compared with NB-UVB, carboxytherapy [OR = 32.35, 95% CI (1.79, 586.05)], Er: YAG laser+ topical 5% 5-FU [OR = 10.74, 95% CI (4.05, 28.49)], needling/micro-needling [OR = 3.42, 95% CI (1.18, 9.88)], betamethasone intramuscular injection [OR = 3.08, 95% CI (1.17, 8.13)], topical tacrolimus [OR = 2.54, 95% CI (1.30, 4.94)], and oral Chinese herbal medicine compound [OR = 2.51, 95% CI (1.40, 4.50)] integrated with NB-UVB were more efficacious in excellent to complete repigmentation response rate (≥75%). Besides, NB-UVB+ Er: YAG laser+ topical 5% 5-FU [OR = 0.17, 95% CI (0.04, 0.67)] and NB-UVB+ needling/micro-needling [OR = 0.24, 95% CI (0.06, 0.88)] were less likely evaluated as ineffective repigmentation response (≤25%).

CONCLUSIONS

All combination therapies ranked higher than NB-UVB monotherapy in inducing successful repigmentation and avoiding failed treatment in patients with vitiligo. Comprehensive consideration, NB-UVB+ Er: YAG laser+ topical 5% 5-FU and NB-UVB+ needling/microneedling would be the preferred therapeutic approaches.

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.

The efficacy of adding topical 5-fluorouracil to micro-needling in the treatment of vitiligo: A randomized controlled trial

BACKGROUND AND AIM

Vitiligo is an autoimmune skin disorder characterized by circumscribed depigmented macules and patches caused by the loss of functional melanocytes. Although there is no definitive treatment for vitiligo, several treatment options have been associated with relative satisfactory outcomes. The purpose of this study was to compare the efficacy of micro-needling in conjunction with topical 5-fluorouracil (5-FU) versus topical tacrolimus ointment in treating vitiligo patches.

PATIENTS AND METHODS

This study included nineteen participants, each of whom received both treatments on two randomly selected vitiligo patches of approximately the same size and location. On one patch, a combination of weekly micro-needling and topical application of 5-FU solution was used every other day, while on the other, 0.1% tacrolimus topical ointment was applied twice daily. The G-score was used to compare treatment outcomes after 3 months.

RESULTS

The median duration of the disease in our population was 7 years. Six patients (32%) in the micro-needling plus topical 5-FU treated group showed a moderate to excellent response, indicating a significant improvement between both treatments (p-value = 0.019). In contrast, all other patches treated with topical tacrolimus showed poor improvement. Lower extremity and trunk responded more to treatment with micro-needling plus topical 5-FU than upper extremity and acral areas. Moreover, none of those who have had the disease for more than ten years have responded to treatment. Mild erythema, pinpoint bleeding, and irritation were detected only in the micro-needling treated group.

CONCLUSION

The current study showed that using micro-needling in conjunction with 5-FU could treat vitiligo patients more efficiently than tacrolimus monotherapy. Despite showing moderate to excellent improvement in patches treated with micro-needling and 5-FU, this well-tolerated office-based modality still requires additional research.

Comparison of the efficacy and safety of 308-nm excimer laser as monotherapy and combination therapy with topical tacrolimus in the treatment of periocular vitiligo

Vitiligo is an acquired depigmenting disorder in which destruction of skin melanocytes. In recent years, 308-nm excimer laser (308-nm EL) and topical tacrolimus have been extensively used to treat vitiligo. This study aimed to investigate the effectiveness and safety of combined treatment of 308-nm EL and topical tacrolimus for treating periocular vitiligo compared to 308-nm EL monotherapy. This study is a retrospective observational study, involving 58 Chinese patients of periocular vitiligo, divided into two groups: the control group (28 patients) treated with 308-nm EL; and the experimental group (30 patients) treated with 308-nm EL and topical tacrolimus 0.1% ointment. Repigmentation was assessed at four grades. In the control group, there were four patients (14%) with poor repigmentation, eleven patients (39%) with moderate repigmentation, ten patients (36%) with good repigmentation, three patients (11%) with excellent repigmentation. In the experimental group, two patients (7%) experienced poor repigmentation, six patients (20%) experienced moderate repigmentation, fifteen patients (50%) experienced good repigmentation, seven patients (23%) experienced excellent repigmentation. The experimental group efficacy rate (good and excellent repigmentation) was 73.3%, higher than 46.4% for the control group (p=0.037). Our findings suggest that both treatments are safe and the combination of tacrolimus and 308-nm EL is more effective than 308-nm EL alone for periocular vitiligo.

Fototerapia – metoda wykorzystywana w leczeniu przewlekłych schorzeń dermatologicznych

Wykorzystanie energii świetlnej w terapii schorzeń o różnej etiologii towarzyszy człowiekowi od czasów starożytnych. Elementem decydującym o powodzeniu terapii jest dobranie odpowiedniej długości promieniowania (terapia NB-UVB, BB-UVB i UVA1) lub wystąpienie interakcji między substancją światłoczułą skumulowaną w zmienionej chorobowo tkance a zastosowanym promieniowaniem (terapia PUVA oraz terapia fotodynamiczna). Metody terapeutyczne wykorzystujące energię świetlną są klasyfikowane na podstawie wykorzystywanego zakresu promieniowania. Obecnie wyróżnia się fototerapię UV, wykorzystującą promieniowanie UVA lub UVB oraz terapię fotodynamiczną (PDT; photodynamic therapy), podczas której stosowane jest promieniowanie o długości fali 350-700 nm.

Fototerapia UV wykorzystywana jest do leczenia schorzeń dermatologicznych, takich jak łuszczyca, bielactwo oraz atopowe zapalenie skóry, ze względu na jej działanie immunosupresyjne i antyproliferacyjne. Jest dostępna w postaci terapii PUVA polegającej na wykorzystaniu synergicznego działania promieniowania ultrafioletowego (UVA) oraz związków o działaniu światłouczulającym (8-metoksypsolaren, 5-metoksypsolaren). Ponadto wyróżniono monoterapię promieniowaniem ultrafioletowym A1 (UVA1), szerokozakresowym UVB (BB-UVB) i wąskozakresowym UVB (NB-UVB). Terapia fotodynamiczna obok konwencjonalnych metod leczenia jest nowoczesną i nieinwazyjną alternatywą wykorzystywaną zarówno w diagnostyce, jak i terapii chorób o różnej etiologii. W 90% przypadków PDT jest stosowana w schorzeniach dermatologicznych, takich jak trądzik pospolity czy łuszczyca. Selektywna aktywność cytotoksyczna wykazywana w kierunku złośliwych komórek nowotworowych powoduje, że terapia fotodynamiczna stosowana jest także z powodzeniem w leczeniu zmian onkologicznych. Duży postęp, przejawiający się zarówno w opracowywaniu innowacyjnych substancji światłoczułych, jak i nowych źródeł promieniowania, sprawia, iż zakres stosowalności terapii fotodynamicznej ciągle się poszerza.

W artykule przedstawiono obecnie dostępne formy fototerapii poprzez opis mechanizmu ich działania, zastosowania oraz możliwości powstania skutków niepożądanych.

An Update on Narrowband Ultraviolet B Therapy for the Treatment of Skin Diseases

The objective of this review is to provide an update on narrowband ultraviolet B (NB-UVB) as a treatment for various skin conditions. NB-UVB works by suppressing the cutaneous cell-mediated immune response and has been shown to be an efficacious and clinically tolerable treatment for a range of inflammatory dermatoses. A literature search was conducted by advanced searches of PubMed for NB-UVB treatment of dermatologic skin diseases with a focus on reports from 2010 to 2021, including both office-based and home-based phototherapy (HBPT). Data were prioritized based on studies with a high level of evidence using the Oxford Evidence-Based Medicine guidance.

We found that NB-UVB continues to serve as an effective form of therapy for several cutaneous conditions, including vitiligo, psoriasis, atopic dermatitis, mycosis fungoides, and other inflammatory dermatoses. The recent introduction of Janus kinase inhibitors in combination with NB-UVB suggests future promise in the treatment of vitiligo. Despite its rise in popularity, a decline was seen in office-based NB-UVB treatment during the coronavirus disease 2019 pandemic. Options are available to deliver NB-UVB at home with comparable efficacy to office-based treatments. In conclusion, for a select group of patients and conditions, NB-UVB continues to serve as an effective treatment modality with minimal side effects, with HBPT serving as an option to improve patient compliance.

Efficacy of topical tacrolimus 0.03% monotherapy in the treatment of non-segmental vitiligo: a randomized, controlled trial

BACKGROUND

Topical tacrolimus is increasingly used nowadays in the treatment of vitiligo.

OBJECTIVE

We evaluated therapeutic outcomes of tacrolimus 0.03% in non-segmental vitiligo (NSV).

PATIENTS AND METHODS

Sixty-three patients with NSV were divided into groups A and B. Group A received 0.03% tacrolimus ointment (n = 31) and group B received 1% hydrocortisone acetate ointment (n = 32) for 24 weeks. Vitiligo area and severity index (VASI) and repigmentation rates were determined at baseline and 4-week intervals.

RESULTS

In group A, 24-week VASI [0.5 (0.3, 1.95)] was significantly lower than baseline VASI [0.75 (0.5, 2.1); p = 0.030]. In group B, 24-week VASI [0.75 (0.4, 2.3)] was not significantly different from baseline VASI [0.73 (0.4, 2.1); p = 0.111]. Repigmentation was observed in 14/31 (45.2%) of patients in group A versus 0/32 (0.0%) in group B (p < 0.001). Repigmentation was graded as poor in 6/31 (19.4%), fair in 4/31 (12.9%), good in 1/31 (3.2%), and excellent in 3/31 (9.7%).

CONCLUSION

Repigmentation was achieved in 45% of patients with NSV following treatment with tacrolimus 0.03% monotherapy for 24 weeks. Tacrolimus-induced repigmentation is more likely in patients with vitiligo vulgaris, head and neck lesions, skin phototype III, and young age.

Vitiligo Skin Biomarkers Associated With Favorable Therapeutic Response

Vitiligo is an acquired depigmentation skin disease caused by immune-mediated death of melanocytes. The most common treatment for vitiligo is narrow band ultraviolet B phototherapy, which often is combined with topical therapies such as tacrolimus. However, patients' responses to these treatments show large variations. To date, the mechanism for this heterogeneity is unknown, and there are no molecular indicators that can predict an individual patient's response to therapy. The goal of this study is to identify clinical parameters and gene expression biomarkers associated with vitiligo response to therapy. Six patients with segmental vitiligo and 30 patients with non-segmental vitiligo underwent transcriptome sequencing of lesional and nonlesional skin at baseline before receiving combined UBUVB and tacrolimus therapy for 6 month, and were separated into good response and bad response groups based on target lesion achieving > 10% repigmentation or not. Our study revealed that treatment-responsive vitiligo lesions had significantly shorter disease duration compared with non-responsive vitiligo lesions (2.5 years vs 11.5 years, p=0.046, t-Test), while showing no significant differences in the age, gender, ethnicity, vitiligo subtype, or disease severity. Transcriptomic analyses identified a panel of 68 genes separating the good response from bad response lesions including upregulation of immune active genes, such as CXCL10, FCRL3, and TCR, Further, compared with vitiligo lesions with long disease duration, the lesions with short duration also have much higher level of expression of immune-active genes, including some (such as FCRL3 and TCR genes) that are associated with favorable therapeutic response. In conclusion, our study has identified clinical parameters such as short disease duration and a panel of immune active and other gene expression biomarkers that are associated with favorable response to immune suppressive NBUVB + tacrolimus therapy. These markers may be useful clinically for individualized therapeutic management of vitiligo patients in the future.

Therapeutic options and hot topics in vitiligo with special focus on pediatrics' vitiligo: A comprehensive review study

Vitiligo is a common skin disorder with an estimated worldwide prevalence to 2.28% which is connected with selective melanocytes loss which leads to depigmentation and chalky-white macules. Vitiligo may be dismissed as a cosmetic problem and may have psychologic impacts on patients. It is occurring in both children and adults and is considered as the most common depigmenting skin disorder in the world. There are still many unknown topics about this disease regarding to its treatment in pediatrics, curable drugs and manifestations. Therefore, we decided to evaluate the recent studies about its therapeutic strategies in pediatrics. Topical therapies should be considered as first line treatment in children, but phototherapy especially NBUVB may be used after topical treatment modalities failure or in extensive or rapidly progressive disease. Our suggestion for the treatment of this disease in children is to use combine treatment modalities with observing safety according to the patient's age.

Home-based narrowband UVB, topical corticosteroid or combination for children and adults with vitiligo: HI-Light Vitiligo three-arm RCT

BACKGROUND

Systematic reviews suggest that narrowband ultraviolet B light combined with treatments such as topical corticosteroids may be more effective than monotherapy for vitiligo.

OBJECTIVE

To explore the clinical effectiveness and cost-effectiveness of topical corticosteroid monotherapy compared with (1) hand-held narrowband ultraviolet B light monotherapy and (2) hand-held narrowband ultraviolet B light/topical corticosteroid combination treatment for localised vitiligo.

DESIGN

Pragmatic, three-arm, randomised controlled trial with 9 months of treatment and a 12-month follow-up.

SETTING

Sixteen UK hospitals - participants were recruited from primary and secondary care and the community.

PARTICIPANTS

Adults and children (aged ≥ 5 years) with active non-segmental vitiligo affecting ≤ 10% of their body area.

INTERVENTIONS

Topical corticosteroids [mometasone furoate 0.1% (Elocon®, Merck Sharp & Dohme Corp., Merck & Co., Inc., Whitehouse Station, NJ, USA) plus dummy narrowband ultraviolet B light]; narrowband ultraviolet B light (narrowband ultraviolet B light plus placebo topical corticosteroids); or combination (topical corticosteroids plus narrowband ultraviolet B light). Topical corticosteroids were applied once daily on alternate weeks and narrowband ultraviolet B light was administered every other day in escalating doses, with a dose adjustment for erythema. All treatments were home based.

MAIN OUTCOME MEASURES

The primary outcome was self-assessed treatment success for a chosen target patch after 9 months of treatment ('a lot less noticeable' or 'no longer noticeable' on the Vitiligo Noticeability Scale). Secondary outcomes included blinded assessment of primary outcome and percentage repigmentation, onset and maintenance of treatment response, quality of life, side effects, treatment burden and cost-effectiveness (cost per additional successful treatment).

RESULTS

In total, 517 participants were randomised (adults, n = 398; and children, n =  119; 52% male; 57% paler skin types I-III, 43% darker skin types IV-VI). At the end of 9 months of treatment, 370 (72%) participants provided primary outcome data. The median percentage of narrowband ultraviolet B light treatment-days (actual/allocated) was 81% for topical corticosteroids, 77% for narrowband ultraviolet B light and 74% for combination groups; and for ointment was 79% for topical corticosteroids, 83% for narrowband ultraviolet B light and 77% for combination. Target patch location was head and neck (31%), hands and feet (32%), and rest of the body (37%). Target patch treatment 'success' was 20 out of 119 (17%) for topical corticosteroids, 27 out of 123 (22%) for narrowband ultraviolet B light and 34 out of 128 (27%) for combination. Combination treatment was superior to topical corticosteroids (adjusted risk difference 10.9%, 95% confidence interval 1.0% to 20.9%; p = 0.032; number needed to treat = 10). Narrowband ultraviolet B light was not superior to topical corticosteroids (adjusted risk difference 5.2%, 95% confidence interval -4.4% to 14.9%; p = 0.290; number needed to treat = 19). The secondary outcomes supported the primary analysis. Quality of life did not differ between the groups. Participants who adhered to the interventions for > 75% of the expected treatment protocol were more likely to achieve treatment success. Over 40% of participants had lost treatment response after 1 year with no treatment. Grade 3 or 4 erythema was experienced by 62 participants (12%) (three of whom were using the dummy) and transient skin thinning by 13 participants (2.5%) (two of whom were using the placebo). We observed no serious adverse treatment effects. For combination treatment compared with topical corticosteroids, the unadjusted incremental cost-effectiveness ratio was £2328.56 (adjusted £1932) per additional successful treatment (from an NHS perspective).

LIMITATIONS

Relatively high loss to follow-up limits the interpretation of the trial findings, especially during the post-intervention follow-up phase.

CONCLUSION

Hand-held narrowband ultraviolet B light plus topical corticosteroid combination treatment is superior to topical corticosteroids alone for treatment of localised vitiligo. Combination treatment was relatively safe and well tolerated, but was effective in around one-quarter of participants only. Whether or not combination treatment is cost-effective depends on how much decision-makers are willing to pay for the benefits observed.

FUTURE WORK

Development and testing of new vitiligo treatments with a greater treatment response and longer-lasting effects are needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17160087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 64. See the NIHR Journals Library website for further project information.