A double-blind, randomized, placebo-controlled trial of topical tacrolimus 0·1% vs. clobetasol propionate 0·05% in childhood vitiligo

Efficacy and safety of 308-nm Excimer lamp combined with Tacrolimus 0.1% ointment vs Tacrolimus 0.1% ointment as monotherapy in treating children with limited vitiligo: a randomized controlled trial

OBJECTIVE

This study aims to assess the efficacy and safety of combining the 308-nm Excimer lamp with Tacrolimus 0.1% ointment, compared to Tacrolimus 0.1% ointment monotherapy, for treating pediatric vitiligo involving less than 10% of the body surface area.

METHODS

Fifty pediatric patients with vitiligo were randomly assigned to two groups. Group A received Tacrolimus 0.1% ointment twice daily and Excimer light at 308-nm twice weekly, while Group B received Tacrolimus 0.1% ointment alone, administered twice daily. Repigmentation percentages were evaluated after 30, 90, and 180 days using the rule of nine.

RESULTS

Group A exhibited a significant improvement in repigmentation, increasing from 10% after one month to 65% after six months. In contrast, Group B observed an increase from 10% to 30% over the same timeframe. The efficacy of the treatment was significantly higher in Group A at both the 3-month and 6-month follow-up points (p-value < .001). Moreover, Group A achieved notably higher repigmentation rates in the face, trunk, and lower limbs.

CONCLUSION

The combination of Tacrolimus and the 308-nm excimer lamp yielded superior repigmentation results compared to Tacrolimus monotherapy in pediatric vitiligo patients. This combined approach may offer an effective new treatment protocol for pediatric vitiligo.

Vitiligo: advances in pathophysiology research and treatment development

The autoimmune condition vitiligo, characterized by skin depigmentation, presents challenges for effective treatment design, with Janus kinase (JAK) inhibitors and other repurposed drugs offering a promising strategy for symptom management. This review explores advantages and shortcomings of current therapies, while presenting the urgent need for further innovative approaches. We emphasize the growing understanding of autoimmune involvement in vitiligo, highlighting several novel treatment avenues including relieving melanocyte stress, preventing dendritic cell activation, halting T cell migration, and suppressing inflammation and autoimmunity. Integrating psychodrama therapy to remediate stress alongside medical interventions marks a holistic approach to enhance patient well-being. The molecular underpinnings of vitiligo care are covered, emphasizing exciting advances revolutionizing vitiligo treatment and improving the quality of life for affected individuals.

Design and Methodological Issues of Within-Person (Split-Body) Randomized Controlled Trials Evaluating a Topical Treatment: A Systematic Review

BACKGROUND

Topical drugs are often used as first-line treatment for dermatological conditions. A within-person design may then be well adapted: it consists of randomizing lesions/body sites rather than patients, which are then concomitantly treated by the different drugs compared, reducing inter-group variability and therefore requiring fewer patients than the classical parallel-group trial.

OBJECTIVES

The aim of this review was to provide a methodological overview of within-person randomized trials (WP-RCTs) in dermatology.

METHODS

We searched for eligible trials published between 2017 and 2021 in MEDLINE, Embase, and Central in dermatology journals and the 6 highest-impact-factor general medical journals. Two authors selected publications and extracted data independently.

RESULTS

From 1,034 articles identified, we included 54 WP-RCTs, mainly for acne vulgaris, psoriasis, actinic keratosis, and atopic dermatitis. In most of the trials, patients had only 2 lesions/body sites. In none of the trials, did we detect a potential carry-across effect (known to be the major methodological problem in WP-RCTs). Twelve studies reported a care provider applying the treatment, and in 26 studies, the patients themselves applied the treatment. Finally, we also highlight statistical issues for the statistical analysis: overall, 14 (26.9%) studies used a test for independent observations, thus ignoring the between-lesion correlation.

CONCLUSION

Our systematic review highlights that despite the publication of the CONSORT checklist extension for WP-RCTs in 2017, this design is rarely used, and when it is, there are methodological and reporting concerns.

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.

Has the core outcome (domain) set for vitiligo been implemented? An updated systematic review on outcomes and outcome measures in vitiligo randomized clinical trials

BACKGROUND

In 2015, a major achievement in vitiligo research was the development of an internationally agreed upon core outcome domain set for randomized clinical trials (RCTs). Three outcomes were identified as being essential: repigmentation, side-effects/harms and maintenance of gained repigmentation. Four items were further recommended for inclusion. The following recommendations then followed: repigmentation should be assessed by measuring the percentage of repigmentation in quartiles (0-25%, 26-50%, 51-79%, 80-100%) and cosmetic acceptability of the results should be assessed using the Vitiligo Noticeability Scale.

OBJECTIVES

The primary objective of this study was to assess uptake of the core outcome domain set for RCTs in vitiligo. Secondary objectives were to update the systematic review on outcomes reported in vitiligo RCTs, and to assess whether repigmentation and cosmetic acceptability of the results were measured using the above-mentioned recommended scales.

METHODS

We searched PubMed, Cochrane Library (CENTRAL and Systematic Reviews) and ClinicalTrials.gov for vitiligo RCTs between November 2009 and March 2021. Screening and data extraction were independently performed on title and summary by two researchers. All outcomes and outcome measures reported in eligible RCTs were retrieved and collated.

RESULTS

In total, 174 RCTs were identified: 62 were published between 2009 and 2015, and 112 were published between 2016 and 2021.Thirty-eight different outcomes were reported. Repigmentation was the primary outcome in 89% of trials (150 of 169). Forty-nine different tools were used to measure repigmentation. Side-effects and harms were reported in 78% of trials (136 of 174). Maintenance of gained repigmentation was reported in only 11% of trials (20 of 174) and duration of follow-up varied greatly from 1 to 14 months. Cosmetic acceptability of the results and cessation of disease activity were assessed in only 2% of trials (four of 174). Quality of life of patients with vitiligo was assessed in 13% of trials (22 of 174). Finally, only 11 of 112 RCTs (10%) published between 2016 and 2021 reported all three essential core outcome domains (repigmentation, side-effects and maintenance of gained repigmentation) and none of the trials reported both essential and recommended core outcome domains.

CONCLUSIONS

Efforts are still needed to close the gap between set recommendations and RCT outcome reporting.

Impacts of exposure to topical calcineurin inhibitors on metabolism in vitiligo infants

BACKGROUND

Tacrolimus ointment is a recently developed topical immunomodulator that has been approved for use in patients with vitiligo older than 2 years. Concern regarding potential systemic toxic effects has limited treatment options for children younger than 2 years. We wanted to determine whether topical tacrolimus therapy is safe and effective in patients with vitiligo younger than 2 years.

METHODS

The present 6-month clinical trial was conducted to evaluate the efficacy and safety of 0.03% tacrolimus in the treatment of vitiligo in children under 2 years of age. Meanwhile, serum and urine samples were collected, and liquid chromatography-mass spectrometry was performed to generate the serum and urine metabolic profile data of patients and healthy controls.

RESULTS

The overall response rate at the sixth month, which was defined by the degree of re-pigmentation, was 100%. As revealed by blood monitoring and metabolite detection 6 months later, there was no difference between the treatment group and the control group. There is no evidence that long-term topical application of 0.03% tacrolimus ointment will cause metabolite or other physical changes in the body.

CONCLUSIONS

Tacrolimus ointment appears to be effective and safe in the treatment of vitiligo in children younger than 2 year.

TRIAL REGISTRATION

http://www.chictr.org.cn identifier: ChiCTR 2100045920.

IMPACT

We first reported the efficacy and safety of topical application of 0.03% tacrolimus ointment in infants with vitiligo characterized by the metabolites. There is no evidence that long-term topical application of 0.03% tacrolimus ointment will cause metabolite or other physical changes in the body. This study provide evidence for the TCI treatment of infants with vitiligo.

S1 Guideline: Diagnosis and therapy of vitiligo

Vitiligo is a common skin disorder characterized by immune-mediated destruction of melanocytes. Non-segmental vitiligo, the most common clinical subtype, has usually a chronic course and often results in significant psychosocial consequences for the affected patient. Early recognition, awareness of comorbidity, precise assessment of disease extent and activity, evaluation of impairment of quality of life as well as rapid initiation of treatment based on currently available evidence-based therapies are crucial cornerstones in the management of vitiligo. This S1 guideline helps German dermatologists to better diagnose and treat vitiligo.

Biomimetic Melanosomes Promote Orientation-Selective Delivery and Melanocyte Pigmentation in the H2O2-Induced Vitiligo Mouse Model

Extremely limited drug retention and depigmentation represent the greatest barriers against vitiligo treatment advancement. Here, inspired by biological melanosomes, the primary melanin transporter, we developed biomimetic melanosomes to combat reactive oxygen species (ROS)-mediated melanocyte damage and depigmentation. Briefly, methylprednisolone (MPS) and melanin-mimicking polydopamine (PDA) were encapsulated inside lysine-proline-valine (KPV)-modified deformable liposomes (KPV-Lipos). Owing to their phospholipid bilayer flexibility and the specific affinity for melanocortin 1 receptor (MC1R), KPV-Lipos exhibited 1.43-fold greater skin deposition than traditional liposomes. The binding of KPV and its receptor also contributed to activating the cAMP-tyrosinase (TYR) signaling pathway, improving the endogenous melanin content. In addition, PDA mimicked melanosomes as it effectively increased the exogenous melanin content and scavenged ROS. Meanwhile, MPS inhibited inflammatory cytokine secretion, limiting the depigmented area. Ultimately, the biomimetic melanosomes affected the skin color of mice with H₂O₂-induced vitiligo. These melanosomes show potential as a universal platform for the self-supply of melanin by self-driven melanin synthesis with exogenous supplementation. Furthermore, this study offers ideas for the production of artificial packed melanosome substitutes for melanocyte-related diseases.

Vitiligo: Translational research and effective therapeutic strategies

This is an exciting phase of vitiligo research with the current understanding of vitiligo pathogenesis and its translation to successful treatment. The pathogenetic origin of vitiligo revolves around autoimmunity with supporting role from many other factors like oxidative stress, inherent melanocyte defects, or defective keratinocytes and fibroblasts. Vitiligo can be classified into segmental or non-segmental depending upon the clinical presentation, or it can be classified as progressing or stable based on the activity of the disease. Vitiligo treatments need to be stratified depending upon which type of vitiligo we are treating and at which phase the vitiligo patient presents to us. There are two different aims of treatment of vitiligo. The first involves rescuing the melanocytes from the damage to arrest the depigmentation. The second strategy focuses on replenishing the melanocytes so that successful repigmentation is achieved. It is also important to maintain the disease in a stable phase or prevent relapse. As stability in non-segmental vitiligo is a dynamic process, maintenance of the stability of repigmentation is also an important consideration in the management of vitiligo. In this review, we shall briefly discuss the current options and future insight into the management of vitiligo.

A Novel Pro-Melanogenic Effect of Standardized Dry Olive Leaf Extract on Primary Human Melanocytes from Lightly Pigmented and Moderately Pigmented Skin

Benolea^® (EFLA^®943) is a standardized dry olive leaf extract (DOLE) considered safe for food consumption and has demonstrated superior pharmaceutical benefits such as antioxidant, anti-obesity, and anti-hypertensive activities. However, there is no study on its effects on melanogenesis yet. Disruption in the sequence of steps in melanogenesis can lead to hypopigmentary disorders which occur due to reduced production or export of pigment melanin in the skin. There is a need for safe and nontoxic therapeutics for the treatment of hypopigmentation disorders. Herein, we studied the effects of DOLE over a concentration range of 10-200 µg/mL on melanin synthesis and melanin secretion in B16F10 mouse melanoma cells and MNT-1 human melanoma cells and validated our results in primary human melanocytes (obtained from lightly pigmented (LP) and moderately pigmented (MP) cells) as well as their cocultures with keratinocytes. The capacity of melanocytes to export melanosomes was also estimated indirectly by the quantitation of melanocyte dendrite lengths and numbers. Our results show that DOLE significantly enhanced levels of extracellular melanin in the absence of effects on intracellular melanin, demonstrating that this plant extract's pro-melanogenic activity is primarily based on its capacity to augment melanin secretion and stimulate melanocyte dendricity. In summary, our preliminary results demonstrate that DOLE may hold promise as a pro-pigmenting agent for vitiligo therapy and gray hair treatment by its exclusive and novel mechanism of functioning as a dendrite elongator. Further studies to elucidate the mechanisms of action of the pro-melanogenic activity and effects of DOLE on melanosome export as well as the last steps of melanogenesis are warranted.

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: An Updated Narrative Review

BACKGROUND

Vitiligo is a relatively common acquired pigmentation disorder that can cause significant psychological stress and stigmatism.

OBJECTIVE

This article aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis, and management of vitiligo.

METHODS

A Pubmed search was conducted in Clinical Queries using the key term "vitiligo". The search included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English language. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Approximately one quarter of patients with vitiligo have the onset before 10 years of age. Genetic, immunological, neurogenic and environmental factors may have a role to play in the pathogenesis. Vitiligo typically presents as acquired depigmented, well-demarcated macules/patches that appear milk- or chalk-white in color. Lesions tend to increase in number and enlarge centrifugally in size with time. Sites of predilection include the face, followed by the neck, lower limbs, trunk, and upper limbs. The clinical course is generally unpredictable. In children with fair skin, no active treatment is usually necessary other than the use of sunscreens and camouflage cosmetics. If treatment is preferred for cosmesis, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the mainstays of treatment.

CONCLUSION

The therapeutic effect of all the treatment modalities varies considerably from individual to individual. As such, treatment must be individualized. In general, the best treatment response is seen in younger patients, recent disease onset, darker skin types, and head and neck lesions. Topical corticosteroids and calcineurin inhibitors are the treatment choice for those with localized disease. Topical calcineurin inhibitors are generally preferred for lesions on genitalia, intertriginous areas, face, and neck. Narrowband ultraviolet B phototherapy should be considered in patients who have widespread vitiligo or those with localized vitiligo associated with a significant impact on the quality of life who do not respond to treatment with topical corticosteroids and calcineurin inhibitors.

Consensus on the treatment of vitiligo - Brazilian Society of Dermatology

Background

Vitiligo is a muco-cutaneous, autoimmune, localized, or disseminated disease, which manifests through hypochromic or achromic macules, with loss in quality of life. The prevalence of vitiligo in Brazil was determined to be 0.54%. There is no on-label medication for its treatment. To date, no Brazilian consensus on the treatment of vitiligo had been written.

Objectives

The objective of this group of Brazilian dermatologists with experience in the treatment of this disease was to reach a consensus on the clinical and surgical treatment of vitiligo, based on articles with the best scientific evidence.

Methods

Seven dermatologists were invited, and each was assigned two treatment modalities to review. Each treatment (topical, systemic, and phototherapy) was reviewed by three experts. Two experts reviewed the surgical treatment. Subsequently, the coordinator compiled the different versions and drafted a text about each type of treatment. The new version was returned to all experts, who expressed their opinions and made suggestions for clarity. The final text was written by the coordinator and sent to all participants to prepare the final consensus.

Results/Conclusion

The experts defined the following as standard treatments of vitiligo: the use of topical corticosteroids and calcineurin inhibitors for localized and unstable cases; corticosteroid minipulse in progressive generalized vitiligo; narrowband UVB phototherapy for extensive forms of the disease. Surgical modalities should be indicated for segmental and stable generalized vitiligo. Topical and systemic anti-JAK drugs are being tested, with promising results.

Off-Label Therapeutic Potential of Crisaborole

Crisaborole, a topical phosphodiesterase-4 inhibitor, was recently approved in 2016 for the treatment of mild to moderate atopic dermatitis in adults and children greater than 2 years of age. Since that time, several case reports and a small randomized controlled trial have been published regarding the off-label use of crisaborole for the treatment of other inflammatory dermatologic disorders. This paper reviews the current, albeit limited, evidence for off-label use of crisaborole for psoriasis, seborrheic dermatitis, vitiligo, and inflammatory linear verrucous epidermal nevus. Additional potential therapeutic uses for crisaborole are also postulated, based on its mechanism of action. Future studies are required to elucidate the full therapeutic potential of crisaborole; however, it is a welcome addition to the current nonsteroid topical treatments for inflammatory dermatologic disease.

Off-Label Use of Topical Calcineurin Inhibitors in Dermatologic Disorders

Off-label prescribing is a common practice in dermatology, particularly when uncommon dermatologic diseases have limited or no approved treatment options. Topical calcineurin inhibitors are approved for the treatment of eczema, and their anti-inflammatory, immunomodulatory, and steroid-sparing effects make them an attractive therapeutic option for a wide variety of other dermatologic diseases. This review summarizes and qualifies the available evidence supporting the clinical effectiveness of tacrolimus ointment and pimecrolimus cream in non-eczema indications. There is high-quality evidence supporting the effectiveness of topical calcineurin inhibitors in multiple dermatological disorders including vitiligo; psoriasis of the face, folds, and genitals; seborrheic dermatitis; chronic hand dermatitis; contact dermatitis; oral lichen planus; lichen sclerosus; morphea; and cutaneous lupus erythematosus. Lower-quality evidence suggests they may be considered as an option in many other cutaneous disorders.

A cross-sectional study of spontaneous repigmentation in vitiligo

Background

Spontaneous regression is well documented in several chronic skin diseases such as psoriasis, alopecia areata, and atopic dermatitis. However, information on vitiligo is scarce.

Aims

We studied the frequency, extent, and factors affecting spontaneous repigmentation in vitiligo.

Methods

A cross-sectional descriptive study was undertaken in 167 patients with vitiligo with an emphasis on history of spontaneous repigmentation. Where available, photographs documenting spontaneous repigmentation were also obtained. Repigmentation was defined as spontaneous if it occurred when the patient was off treatment for at least 3 consecutive months.

Results

Spontaneous repigmentation occurred in 36 (21.5%) patients with complete repigmentation in 6 (3.6%) patients. The extent varied from 0.5% to 100% (mean, 35.4 ± 37.9%) of vitiliginous skin. It occurred after 3 months to 47 years (mean, 8.7 ± 9.5 years) of onset of vitiligo and persisted for 2 months to 27 years (mean, 4.4 ± 6.2 years). Diffuse repigmentation was the most common pattern observed in 20 (55.6%) patients and there was a good color match in 26 (72.2%) patients. Likelihood of spontaneous repigmentation was 3.5 times greater in patients with more than 3 years of stable disease (P = 0.001).

Limitations

The chief limitation was the dependence on patient recall for the data, except when documented by images.

Conclusion

Spontaneous repigmentation occurs in one-fifth of patients with vitiligo. In some patients, the repigmentation is clinically significant and long-lasting. Considering its frequency and extent, spontaneous repigmentation should be taken into account both when evaluating novel interventions and counselling patients about the course of the disease.

Childhood Vitiligo

Vitiligo is a common acquired depigmenting skin disease characterized by a progressive loss of functional melanocytes. It may appear from the first years of life to late adulthood. Childhood vitiligo (CV), defined as vitiligo that begins before the age of 12 years, is common and may differ from post-CV in terms of epidemiology, clinical presentation, comorbidities, and treatment options. Taking into consideration the potential significant psychosocial impact of the disease on both children and their parents, all available therapeutic options must be offered to patients who desire treatment. According to the most recent guidelines, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the most commonly used treatment modalities for vitiligo in children. This review presents recent data regarding the whole spectrum of CV. Differences between CV and post-CV are also discussed.

New insights in vitiligo treatments using bioactive compounds from Piper nigrum

Although vitiligo is one of the most frequently occurring depigmentary disorder, its pathophysiology is still not fully clarified, resulting in the incapacity to find a targeted cure. Most of the treatment options available at the time have an anti-inflammatory or immunosuppressive effect, influencing the immune factor in vitiligo but without having a direct effect on melanocyte differentiation, migration or proliferation. This study shows that Piper nigrum (PN) extract and its main alkaloid, piperine, promote melanocyte proliferation in vivo, being consistent with previous study. A PN fruit extract and pure piperine were integrated in two different ointments and tested on human subjects affected by vitiligo. A number of 9 areas were treated: 3 using the extract, 3 using pure piperine, 1 using travoprost solution, and 2 using an association of travoprost (prostaglandin F2α analogue) solution and our products. Pigmentation was achieved in all the treated areas. The extract caused faster and more remarkable results than the pure piperine. The association of the travoprost solution speed up the process and changed the pigmentation pattern, especially when associated with the PN extract. Our early studies suggest that PN extract may represent, in the future, a new treatment option for vitiligo, especially considering the mild side effects of the tested products and the reduced amount of time needed for repigmentation. However, more studies are needed to validate this experimental data.

Mycophenolic Acid for Topical Immunosuppression in Vascularized Composite Allotransplantation: Optimizing Formulation and Preliminary Evaluation of Bioavailability and Pharmacokinetics

Mycophenolic acid (MPA), is the active form of the ester prodrug mycophenolate mofetil (MMF). MMF is an FDA approved immunosuppressive drug that has been successfully used in systemic therapy in combination with other agents for the prevention of acute rejection (AR) following solid organ transplantation (SOT) as well as in vascularized composite allotransplantation (VCA). Systemic use of MMF is associated with gastrointestinal adverse effects. Topical delivery of the prodrug could thus provide graft-targeted immunosuppression while minimizing systemic drug exposure. Our goal was to develop a topical formulation of MPA with optimal in vitro/in vivo characteristics such as release, permeation, and tissue bioavailability to enable safety and efficacy evaluation in clinical VCA.

Permeation studies were performed with a solution of MPA (10 mg/ml). In vitro release and permeation studies were performed for different semisolid formulations (Aladerm, Lipoderm, emollient, and VersaBase) of MPA (1% w/w) using a Franz Diffusion Cell System (FDCS). In vivo pharmacokinetic characterization of MPA release from Lipoderm was performed in rats.

MPA in solution exhibited a steady state flux (3.8 ± 0.1 µg/cm²/h) and permeability (1.1 × 10⁻⁷ ± 3.2 × 10⁻⁹ cm/s). MPA in Lipoderm exhibited a steady state flux of 1.12 ± 0.24 µg/cm²/h, and permeability of 6.2 × 10⁻⁰⁹ ± 1.3 × 10⁻⁹ cm/s across the biomimetic membrane. The cumulative release of MPA from Lipoderm, showed a linear single-phase profile with a R² of 0.969. In vivo studies with MPA in Lipoderm showed markedly higher local tissue MPA levels and lower systemic MPA exposure as compared to values obtained after intravenous delivery of the same dose of drug (p < 0.05).

We successfully developed for the first time, a topical formulation of MPA in Lipoderm with optimal in vitro/in vivo permeability characteristics and no undesirable local or systemic adverse effects in vivo. Our study provides key preliminary groundwork for translational efficacy studies of topical MPA in pre-clinical large animal VCA models and for effectiveness evaluation in patients receiving VCA.

Vitiligo: An Update on Pathophysiology and Treatment Options

The pathophysiology of vitiligo is becoming increasingly clarified. In non-segmental vitiligo, early factors include activation of innate immunity, inflammasome activation, oxidative stress, and loss of melanocyte adhesion. Nonetheless, the main mechanism leading to non-segmental vitiligo involves an immune-mediated destruction of melanocytes. Anti-melanocyte-specific cytotoxic T cells exert a central role in the final effector stage. Genetic research revealed a multi-genetic inheritance displaying an overlap with other autoimmune disorders. However, some melanocyte-specific genes were also affected. Segmental vitiligo carries a different pathogenesis with most evidence indicating a mosaic skin disorder. Current management includes topical corticosteroids and immunomodulators. Narrow-band ultraviolet B can be used in patients not responding to topical treatment or in patients with extensive disease. Pigment cell transplantation offers an alternative for the treatment of segmental vitiligo or stable non-segmental lesions. Recent findings have revealed new targets for treatment that could lead to more efficient therapies. Targeted immunotherapy may halt the active immune pathways, although combination therapy may still be required to induce satisfying repigmentation. A recently established core set of outcome measures, new measurement instruments, and biomarker research pave the way for future standardized clinical trials.

Medical and Maintenance Treatments for Vitiligo

Medical treatments alone, or in combination with phototherapy, are key approaches for treating nonsegmental vitiligo and, to a lesser extent, segmental vitiligo. The treatments are useful for halting disease progression and have been proven effective for inducing repigmentation and decreasing risk of relapses. Although the treatments have side effects and limitations, vitiligo often induces a marked decrease in quality of life and in most cases the risk:benefit ratio is in favor of an active approach. Systemic and topical agents targeting the pathways involved in loss of melanocytes and in differentiation of melanocyte stem cells should provide more effective approaches in the near future.

Effectiveness and safety of topical tacrolimus monotherapy for repigmentation in vitiligo: a comprehensive literature review

Thus far, several small studies and case reports on the use of topical immunomodulators in vitiligo have been published. We undertook a comprehensive literature review, searching for studies evaluating clinical response to tacrolimus topical therapy for vitiligo. A search was performed on PubMed/Medline using the term “vitiligo”, combined with “topical” and “ointment”. Our inclusion criteria were: use of tacrolimus ointment as monotherapy to treat vitiligo. We found 29 studies from 2002 to 2014. Overall, 709 patients were treated in 29 studies. Pooling the lesions, 50% repigmentation of vitiligo patches was never achieved before 2 months of treatment, with a peak after 6 months of therapy. The best results were obtained on lesions of the cephalic region, especially the face, with tacrolimus 0.1% ointment two times daily. The percentage of non-responsive patients ranged from 0% to 14%. Treatment was generally well-tolerated; only localized adverse effects were reported. Our objective was to verify the effectiveness and safety of tacrolimus ointment monotherapy. It has good efficacy and tolerability. At present, only small trials and case series are available in the literature. Further, standardized investigations on a larger number of patients are needed.

Pharmacologic Treatment of Vitiligo in Children and Adolescents: A Systematic Review

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.

Recent advances in understanding vitiligo

Vitiligo, an acquired depigmentation disorder, manifests as white macules on the skin and can cause significant psychological stress and stigmatization. Recent advances have shed light on key components that drive disease onset and progression as well as therapeutic approaches. Vitiligo can be triggered by stress to the melanin pigment-producing cells of the skin, the melanocytes. The triggers, which range from sunburn to mechanical trauma and chemical exposures, ultimately cause an autoimmune response that targets melanocytes, driving progressive skin depigmentation. The most significant progress in our understanding of disease etiology has been made on three fronts: (1) identifying cellular responses to stress, including antioxidant pathways and the unfolded protein response (UPR), as key players in disease onset, (2) characterizing immune responses that target melanocytes and drive disease progression, and (3) identifying major susceptibility genes. The current model for vitiligo pathogenesis postulates that oxidative stress causes cellular disruptions, including interruption of protein maturation in the endoplasmic reticulum (ER), leading to the activation of the UPR and expression of UPR-regulated chemokines such as interleukin 6 (IL-6) and IL-8. These chemokines recruit immune components to the skin, causing melanocytes to be targeted for destruction. Oxidative stress can further increase melanocyte targeting by promoting antigen presentation. Two key components of the autoimmune response that promote disease progression are the interferon (IFN)-γ/CXCL10 axis and IL-17-mediated responses. Several genome-wide association studies support a role for these pathways, with the antioxidant gene NRF2, UPR gene XBP1, and numerous immune-related genes including class I and class II major histocompatibility genes associated with a risk for developing vitiligo. Novel approaches to promote repigmentation in vitiligo are being investigated and may yield effective, long-lasting therapies.

Current Management of Pediatric Vitiligo

Vitiligo is a common inflammatory disorder with worldwide prevalence of 0.4-2 % of the population, with half of cases beginning in childhood. The management of childhood vitiligo should be tailored to avoid negative effects on the overall growth and psychological development of the patient. Therapy of vitiligo in childhood is chosen based on the location of the lesions, lesion age, and extent of lesions in the context of the child's age and the developmental status of the child. There are four age categories in childhood vitiligo: [1] infantile and toddler (rare) (ages 0-3 years), [2] ages 4-8 years, [3] ages 9-12 years, and [4] 13+ years of age, based on developmental stage, psychological maturation, and ability to comply or participate in therapy. These categories are also differentiated psychologically by susceptibility to bullying, self-image development, and personal concern with lesion appearance, which increases with time. Intervention is advisable in cases with facial and leg involvement due to prominence of lesions and cosmetic defect. Medical interventions are largely the usage of topical therapies including corticosteroids and calcineurin inhibitors, some vitamin therapy (oral and topical vitamin D), and judicious introduction of phototherapy sources based on age and severity. Screening and appropriate subspecialist referral for co-morbidities (e.g., thyroid disease, celiac disease, psychological distress, and vitamin D deficiency) may enhance overall health. Cosmesis and camouflage are generally safe in childhood and have been noted to improve overall quality of life in this grouping. Genetic transmission of vitiligo is minimal at 5-6 % in first-degree relatives. This article reviews the therapeutics of pediatric vitiligo from the perspective of developmental stages and response to therapy.

Phototherapy for the treatment of vitiligo in Asian children

Vitiligo is a common acquired progressive depigmenting condition that can have devastating psychological effects in dark-skinned patients. We performed a retrospective review of patients younger than 16 years of age with a clinical diagnosis of vitiligo treated using phototherapy at the National Skin Center, Singapore, over a 5-year period. Seventy-one Asian patients ages 5 to 15 years when they underwent phototherapy were identified. There was a higher proportion of Indian patients in our cohort than in the population. The duration of disease ranged from 2 months to 12 years. More than half of the patients had generalized vitiligo and more than one-third had segmental vitiligo. Patients with generalized vitiligo had a better response than those with segmental vitiligo. Reported response rates were highest for narrowband ultraviolet B (UVB) phototherapy, followed by targeted phototherapy combining ultraviolet A1 (UVA1) and UVB; 308-nm excimer lamp phototherapy and paint psoralen-UVA photochemotherapy had marginally lower reported response rates. The duration of treatment ranged from 3 to 40 months and the total number of treatments ranged from 20 to 209 sessions. Reported side effects were mild and included itching, scaling, erythema, pain, sunburn, blistering, and phototoxicity. We consider phototherapy to be a safe and efficacious modality for the treatment of vitiligo in Asian children.

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.

Vitiligo: an evidence-based update. Report of the 13th Evidence Based Update Meeting, 23 May 2013, Loughborough, U.K

The Evidence Based Update (EBU) meetings are annual one-day meetings held by the Centre of Evidence Based Dermatology at the University of Nottingham. The aim of the meeting is to discuss high-quality evidence, mainly in the form of systematic reviews and randomized controlled trials, on a different topic each year. The meetings are designed to be interactive with a panel discussion between international experts and delegates forming a key part of the meeting. The 13th EBU meeting was on vitiligo and took place on 23 May 2013 in Loughborough, U.K. The most recent research including new and unpublished studies was presented on the classification of vitiligo, the evidence behind different treatment options and current guidelines for vitiligo.

Pediatric vitiligo

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

Narrow band-ultraviolet B versus clobetasol propionate foam in the treatment of vitiligo: a retrospective study

INTRODUCTION

Several therapeutic options are available for the treatment of vitiligo; among these phototherapy and topical steroids are the most widely documented. A topical formulation of 0.05% clobetasol propionate foam (CPF) has been introduced in the market, but no data are available about the efficacy and tolerability of this new formulation in the treatment of vitiligo. The aim of this study was to investigate the efficacy and tolerability of CPF in the treatment of vitiligo, in comparison with narrowband-ultraviolet B (NB-UVB) phototherapy.

METHODS

The medical records of the first 60 vitiligo patients treated with NB-UVB phototherapy or with CPF were selected. Response to the treatment was determined for each anatomic site (neck, upper and lower limbs, trunk, hands/wrists, feet/ankles). Based on the area of repigmentation, treatment outcome was calculated according to a scale ranging from 0 (absent) to 4 (excellent). The incidence of adverse effects was also noted as a secondary endpoint. Significance level was set at P = 0.05.

RESULTS

For each anatomic site, statistical analyses demonstrated that the efficacy of CPF was significantly higher compared to NB-UVB. Side effects occurred in 4 patients (13.33%) in the CPF group compared to none in the NB-UVB group.

DISCUSSION

Clobetasol propionate has been used in vitiligo in different vehicles, but never in foam. The data showed that CPF is effective and seems to be superior to NB-UVB phototherapy, with furthermore a good safety profile.

CONCLUSION

This new foam formulation of clobetasol propionate may expand the options currently available for vitiligo therapy; however, further investigations are needed to confirm our preliminary observations.

Review of current clinical studies of vitiligo treatments

There is a limited number of options in vitiligo treatment, with the disease frequently refractory to all existing treatment modalities. This warrants development of novel and improving existing vitiligo treatments as well as finding predicting factors to improve treatment outcome through appropriate selection and the most efficient application of a treatment. These issues are addressed in clinical studies aiming to evaluate safety and efficiency of novel treatments, improvements and modifications introduced to existing treatments, and to define predictors of treatment efficiency and their limitations. Here, results of recent (since year 2009) clinical studies in vitiligo field are overviewed, with the emphasis on their contribution to improved vitiligo management.

[What's new in pediatric dermatology?]

This paper is based on a review of the literature focused on pediatric dermatology, from October 2011 to september 2012. Our objective was to highlight the main advances in fields such as atopic dermatitis, infantile hemangiomas, infectious diseases, inflammatory disorders, and genodermatoses.

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).

Vitiligo: an update on current pharmacotherapy and future directions

INTRODUCTION

Vitiligo is a common pigmentary skin disorder, characterized by the appearance of white macules on the skin, mucosal or hair. Treatment is often a tough challenge and involves a wide range of therapies.

AREAS COVERED

This review focuses on available first- and second-line pharmacological treatments for vitiligo. In particular, the mechanisms of action, the main indications, the efficacy and the most important side effects are reviewed. Moreover, a brief discussion is provided, regarding other nonpharmacological treatments, such as phototherapy and surgical options, due to their importance and successful outcomes in vitiligo treatment. Finally, a concise overview regarding the future directions in vitiligo therapy is presented.

EXPERT OPINION

The promising outcomes reported here demonstrate that it is possible to achieve a satisfactory and often stable repigmentation of vitiligo lesions. Topical corticosteroids, calcineurin inhibitors, phototherapy and photochemotherapy represent the first-line therapeutic options, due to their safety and efficacy, whereas vitamin D analogues, targeted phototherapy, oral corticosteroids and surgery should be used as second-line therapies. Other therapies, such as antioxidants, can be used in association with other therapeutic options, whereas depigmenting agents should be used only in cases of extensive vitiligo, recalcitrant to other treatments.