The treatment of vitiligo with psoralens and triamcinolone by mouth

The Use of Herbal Medicine in the Treatment of Vitiligo: An Updated Review

Vitiligo is a chronic disease of unknown etiology that causes progressive cutaneous depigmentation. Current pharmacological treatments have limited success and present significant risks. Many efforts have been made in recent years to explore new anti-vitiligo therapeutic strategies, including herbal-based therapies. The objective of the present review is to provide an updated overview on the most frequently used medicinal plants in the treatment of vitiligo. A bibliographical search was carried out in scientific databases Pubmed, Scifinder, Scopus, Google Scholar, and Medline up to October 2021 using the descriptors vitiligo, herbal, medicinal plants, and alternative therapies. In our search, the highest number of published studies comprise plants commonly used in traditional herbal medicine, highlighting the usefulness of ethnopharmacology in the discovery of new therapeutic agents. The review outlines current understanding and provides an insight into the role of psoralens and khellin (photosensitizing agents obtained from plants such as Cullen corylifolium or Ammi visnaga). The paper also describes other traditional herbs such as Ginkgo biloba, Phlebodium aureum, Piper nigrum, Picrorhiza kurroa, and Baccharoides anthelmintica that can likewise act as potential therapeutical agents. Based on our findings, photosensitizing agents in combination with phototherapy, the association of oral Phebodium aureum with phototherapies as well as oral G. biloba in monotherapy showed greater scientific evidence as therapeutic options. The research results emphasize that further investigation in this area is merited. More long-term follow up clinical trials and higher quality randomized trials are needed.

A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease

Background

Skin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).

Objective

To set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.

Design

Mixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.

Setting

Secondary care, primary care and the general population.

Participants

Patients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.

Interventions

Our three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).

Results

Systematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.

Conclusions

Findings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.

Trial registration

Current Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Interventions for vitiligo

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Which outcomes should we measure in vitiligo? Results of a systematic review and a survey among patients and clinicians on outcomes in vitiligo trials

BACKGROUND

Relevant and reliable outcomes play a crucial role in the correct interpretation and comparison of the results of clinical trials. There is a lack of consensus around methods of assessment and outcome measures for vitiligo, which makes it difficult to compare results of randomized controlled trials (RCTs) and perform meta-analysis.

OBJECTIVES

To describe the heterogeneity in outcome measures used in published RCTs of vitiligo treatments, and to report the most desirable outcomes from patients' and clinicians' perspectives.

METHODS

We conducted a systematic review of outcome measures used in RCTs as well as a survey of the most desirable outcomes identified by patients and clinicians as part of a Vitiligo Priority Setting Partnership.

RESULTS

Outcomes from 54 eligible trials were analysed and compared with outcomes suggested by patients and clinicians. In the systematic review, 25 different outcomes were reported. Only 22% of trials had clearly stated primary outcome measures. Repigmentation was the most frequently reported outcome in 96% of trials and was measured using 48 different scales. Only 9% of trials assessed quality of life. Thirteen per cent measured cessation of spreading of the disease and 17% of studies reported patients' opinions and satisfaction with the treatment. In contrast, out of 438 suggestions made by patients and clinicians, cosmetically acceptable repigmentation (rather than percentage of repigmentation) was the most desirable outcome (68%), followed by cessation of spread of vitiligo (15%), quality of life (8%) and maintenance of repigmentation (4%).

CONCLUSIONS

We propose that future vitiligo trials should include repigmentation, cosmetic acceptability of results, global assessment of the disease, quality of life, maintenance of repigmentation, stabilization of vitiligo and side-effects. International consensus among clinicians, researchers and patients is needed to establish an agreed core outcome set for future vitiligo trials.

Interventions for vitiligo

BACKGROUND

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

OBJECTIVES

To assess all interventions used to manage vitiligo.

SEARCH STRATEGY

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

SELECTION CRITERIA

Randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

Interventions for vitiligo

BACKGROUND

Around 1% of the world's population has vitiligo, which causes a loss of skin colour in patches. The methods currently available to treat vitiligo are largely unsatisfactory and vary widely between cultures and within health systems.

OBJECTIVES

To assess the effects of interventions used to manage vitiligo.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED and other databases (last searched September 2004). Reference lists of articles and conference proceedings were searched. Authors of reviews were contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed study eligibility and methodological quality and carried out data extraction. The included studies compared different interventions and used different outcome measures so we considered it inappropriate to combine their results.

MAIN RESULTS

Nineteen trials with a total of 1350 participants were included. The RCTs generally had low numbers of participants and only RCTs of repigmentation and not other methods of managing vitiligo were able to be included. In one study, potent topical steroids resulted in better repigmentation than placebo and they were also better than oral psoralens plus sunlight in another study (RR 4.70 95% CI 1.14 to 19.39) although their long-term use is limited by adverse effects. Two studies suggested that topical calcipotriol enhanced repigmentation rates from PUVAsol and PUVA when compared with placebo. Another two studies showed higher repigmentation rates with oral PUVAsol versus placebo plus sunlight (RR 19.20 95% CI 1.21 to 304.50 in 79 adults and RR 2.29 95% CI 1.14 to 4.58 in a study of 50 children). The safety of these interventions was poorly described and none of the studies was able to demonstrate long term benefits. Very few studies were carried out on children or included segmental vitiligo. No trials evaluating micropigmentation, melanocyte transplantation, depigmentation or cosmetic camouflage could be found. Despite the fact that the main impact of vitiligo is psychosocial only one study on psychological therapy was found and it is awaiting assessment.

AUTHORS' CONCLUSIONS

This review has found some evidence to support existing therapies for vitiligo, but the different designs and outcome measurements, lack of quality of life measures and adverse effect reporting in the studies limit the usefulness of their findings. There is a pressing need for high quality randomised trials using standardised measures of repigmentation and which address relevant clinical outcomes including quality of life.

Treatment of vitiligo with the 308-nm excimer laser: a pilot study

BACKGROUND

Present vitiligo therapies require many months of treatment and often result in disappointing outcomes. Common therapeutic options include phototherapy with psoralens plus ultraviolet A (UVA) radiation and broadband or narrowband UVB radiation phototherapy. Some of these modalities require regular phototherapy sessions several times a week for up to a year to achieve a therapeutic response. Targeted phototherapy with single-wavelength laser light is a treatment alternative that may prove to be a time-efficient and effective therapeutic option for the management of vitiligo.

METHODS

This intervention study was designed as a before and after trial with a single arm. Twenty-nine patches of vitiligo from 18 patients (6 males and 12 females) were treated at the start of the study. Vitiligo patches were treated by using a 308-nm xenon-chloride excimer laser. Lesions were treated 3 times a week for a maximum of 12 treatments. Treatment was withheld if sunburn was observed and held until resolution. All patients had untreated vitiligo patches that served as control sites.

RESULTS

Twenty-three vitiligo patches from 12 patients received at least 6 treatments and resulted in some repigmentation in 57% of the treated patches. Eleven vitiligo patches from 6 patients received all 12 treatments and resulted in some repigmentation in 82% of the treated patches. Untreated control patches remained unchanged.

CONCLUSION

This degree of repigmentation in a period of 2 to 4 weeks is much higher than that achieved with any other present vitiligo therapy. The xenon-chloride excimer laser may represent a new treatment modality for the management of stable vitiligo.

Vitiligo

The destruction of melanocytes is the cause of depigmented maculae that clinically represent the disease vitiligo. Although the cause is unknown, various theories such as the autoimmune, autocytotoxic, and neural hypotheses have been proposed. Extensive research has provided numerous answers regarding the pathogenesis, histopathologic evidence, and treatment of vitiligo. This discussion of vitiligo summarizes the varied clinical presentations of the disease, theories attempting to explain the mechanism of melanocyte destruction, histopathologic findings, and different treatment modalities currently available.

Treatment of stable vitiligo with autologous epidermal grafting and PUVA

BACKGROUND

Previous reports have shown the benefits of epidermal grafting for vitiligo.

OBJECTIVE

Our purpose was to evaluate the effectiveness and complications of epidermal grafting in combination with PUVA on stable vitiligo refractory to conventional treatments.

METHODS

In 100 patients with stable refractory vitiligo we performed epidermal grafting with suction blisters followed by PUVA treatment. The grafted sites were examined for repigmentation for up to 5 years.

RESULTS

Excellent repigmentation was observed at all grafted sites, especially on the face except for the lip and the alae nasae. PUVA treatment resulted in spreading of the pigmentation. Poor results were observed on the neck, axillae, and overlying bony prominences. Hyperpigmentation of the recipient and donor sites was frequently observed. Only six patients had recurrence and/or adjacent new lesions. Depigmentation developed at the donor site in only one patient with generalized vitiligo. Long-term observation in these patients indicates that repigmentation obtained by this method is permanent.

CONCLUSION

Although epidermal grafting in combination with PUVA has some limitations, it is an easy, safe, inexpensive, and effective treatment for various types of stable refractory vitiligo.

Phenylalanine and UVA light for the treatment of vitiligo

The administration of phenylalanine (Phe) combined with UVA exposure was found to be effective in vitiligo. Phe is an amino acid which constitutes part of the daily dietary protein, and when orally administered in a dose of 50 mg/kg body weight, it results in an elevated plasma level. Since peak concentrations of Phe in the blood are reached between 30 and 45 min after ingestion, UVA exposure was administered at this time. After 4 months (32 treatments) reasonable repigmentation preferentially occurred in the skin area of subcutaneous fat (adipose tissue). Apart from the repigmentation of hypo-pigmented macules, vitiligo patients can tolerate more sun than usual, especially at the vitiliginous lesion, and they experience no sunburn as a result of Phe-UVA therapy. Normal skin also tans very well.

8-Methoxypsoralen (8-MOP) in human skin: penetration kinetics

Penetration kinetics of 8-methoxypsoralen (8-MOP) into human skin have been investigated under in vitro conditions. The dependence of the resulting tissue concentration on time of penetration, drug concentration in the applied preparation and vehicle composition has been studied. Tissue concentration of the drug was found to increase with time of penetration; however, in both horny layer and epidermis, this increase was followed by a significant decrease in concentration, (after 100 to 300 min), although a large amount of unpenetrated drug was present on the horny layer surface at all times. In contrast to this, 8-MOP accumulated in the lower corium and subcutis and reached concentrations higher then those found in the upper corium and epidermis. This accumulation of the drug is a consequence of the in vitro conditions and its amount is proportional to that amount that under in vivo conditions would have been taken up by the capillary system. Penetration was dependent on vehicle characteristics and was found to increase with increasing polarity of the vehicle. The penetration was found to be directly proportional to the applied concentration; however, the percentage of the drug that actually penetrated was inversely proportional to the applied concentration.

Vitiligo: a new classification and therapy

Local injection of physostigmine revealed that dermatomally distributed vitiligo was associated with a dysfunction of the sympathetic nerves in the affected skin and that non-dermatomally distributed vitiligo was not. These observations led to the hypothesis that the primary disturbance of dermatomally distributed vitiligo lies in the sympathetic nerves of the affected area and that non-dermatomally distributed vitiligo has its primary disturbance in the melanocyte itself, where an autoimmune mechanism is suspect. Results of therapy supported this hypothesis by showing that topical cortisteroid is effective only in the latter, while the former reacts to oral nialamide. It is proposed that non-dermatomally distributed vitiligo be referred to as Type A and dermatomally distributed vitiligo as Type B.