Treatment of vitiligo vulgaris with narrow-band UVB and oral Polypodium leucotomos extract: a randomized double-blind placebo-controlled study

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.

Understanding Active Photoprotection: DNA-Repair Enzymes and Antioxidants

The detrimental effects of ultraviolet radiation (UVR) on human skin are well-documented, encompassing DNA damage, oxidative stress, and an increased risk of carcinogenesis. Conventional photoprotective measures predominantly rely on filters, which scatter or absorb UV radiation, yet fail to address the cellular damage incurred post-exposure. To fill this gap, antioxidant molecules and DNA-repair enzymes have been extensively researched, offering a paradigm shift towards active photoprotection capable of both preventing and reversing UV-induced damage. In the current review, we focused on "active photoprotection", assessing the state-of-the-art, latest advancements and scientific data from clinical trials and in vivo models concerning the use of DNA-repair enzymes and naturally occurring antioxidant molecules.

Phototherapy for vitiligo: A narrative review on the clinical and molecular aspects, and recent literature

BACKGROUND

Vitiligo is characterized by depigmented patches resulting from loss of melanocytes. Phototherapy has emerged as a prominent treatment option for vitiligo, utilizing various light modalities to induce disease stability and repigmentation.

AIMS AND METHODS

This narrative review aims to explore the clinical applications and molecular mechanisms of phototherapy in vitiligo.

RESULTS AND DISCUSSION

The review evaluates existing literature on phototherapy for vitiligo, analyzing studies on hospital-based and home-based phototherapy, as well as outcomes related to stabilization and repigmentation. Narrowband ultra-violet B, that is, NBUVB remains the most commonly employed, studied and effective phototherapy modality for vitiligo. Special attention is given to assessing different types of lamps, dosimetry, published guidelines, and the utilization of targeted phototherapy modalities. Additionally, the integration of phototherapy with other treatment modalities, including its use as a depigmenting therapy in generalized/universal vitiligo, is discussed. Screening for anti-nuclear antibodies and tailoring approaches for non-photo-adapters are also examined.

CONCLUSION

In conclusion, this review provides a comprehensive overview of phototherapy for vitiligo treatment. It underscores the evolving landscape of phototherapy and offers insights into optimizing therapeutic outcomes and addressing the challenges ahead. By integrating clinical evidence with molecular understanding, phototherapy emerges as a valuable therapeutic option for managing vitiligo, with potential for further advancements in the field.

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.

The Impact of Antioxidants on Vitiligo and Melasma: A Scoping Review and Meta-Analysis

Reactive oxygen species (ROS) generated during melanogenesis make melanocytes particularly vulnerable to oxidative stress, influencing their survival and melanin synthesis. Oxidative stress, significantly present in vitiligo and recently also detected in melasma, triggers inflammatory cascades and melanogenesis, making antioxidants a promising therapeutic avenue. A systematic search was conducted on Embase and Pubmed to study the efficacy of antioxidants for treating vitiligo and/or melasma. Meta-analysis was performed to assess the difference in Melasma Severity Index (MASI) scores between baseline and follow-up. Various antioxidants like polypodium leucotomos, ginkgo biloba, catalase/superoxide dismutase, and vitamin E have potential in vitiligo. For melasma, vitamin C, silymarin, and niacinamide were among those showing promise in reducing pigmentation, with vitamin C displaying significant effects in meta-analysis. Different antioxidants improve both vitiligo and melasma, with an increased minimal erythema dose (MED) following UV exposure being significant for vitiligo and tyrosinase inhibition being crucial for melasma. However, the efficacy of individual antioxidants varies, and their exact mechanisms, especially in stimulating melanocyte proliferation and anti-inflammatory pathways, require further investigation to understand better and optimize their use.

Oxidative Stress and Potential Antioxidant Therapies in Vitiligo: A Narrative Review

Vitiligo is a chronic skin disorder characterised by the loss of melanocytes and subsequent skin depigmentation. Although many theories have been proposed in the literature, none alone explains the pathogenesis of vitiligo. Oxidative stress has been identified as a potential factor in the pathogenesis of vitiligo. A growing body of evidence suggests that antioxidant therapies may offer a promising approach to managing this condition. This review summarises the potential mechanisms of oxidative stress and the types of melanocyte death in vitiligo. We also provide a brief overview of the most commonly studied antioxidants. Melanocytes in vitiligo are thought to be damaged by an accumulation of reactive oxygen species to destroy the structural and functional integrity of their DNA, lipids, and proteins. Various causes, including exogenous and endogenous stress factors, an imbalance between prooxidants and antioxidants, disruption of antioxidant pathways, and gene polymorphisms, lead to the overproduction of reactive oxygen species. Although necroptosis, pyroptosis, ferroptosis, and oxeiptosis are newer types of cell death that may contribute to the pathophysiology of vitiligo, apoptosis remains the most studied cell death mechanism in vitiligo. According to studies, vitamin E helps to treat lipid peroxidation of the skin caused by psoralen ultra-violet A treatment. In addition, Polypodium leucotomos increased the efficacy of psoralen ultra-violet A or narrow-band ultraviolet B therapy. Our review provides valuable insights into the potential role of oxidative stress in pathogenesis and antioxidant-based supporting therapies in treating vitiligo, offering a promising avenue for further research and the development of effective treatment strategies.

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.

Systemic therapies in vitiligo: a review

Vitiligo is characterized by the development of depigmented macules and patches. Autoimmunity has been established as a factor in disease pathogenesis, leading to utilization of immunosuppressive agents. Topical immunosuppressants are commonly used; however, this treatment modality is often cumbersome and inefficient, as many patients have active disease with extensive body surface area involvement. Prompt and aggressive treatment of vitiligo is important, as this may prevent progression and improve quality of life. To meet these challenges and improve patient outcomes, interest in systemic therapies has grown. Currently, oral therapies are rarely prescribed, likely due to concerns with systemic side effects and unclear efficacy. This article provides a brief overview on the use of systemic agents in treating vitiligo in order to provide additional therapeutic options to clinicians.

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.

Uses of Polypodium leucotomos Extract in Oncodermatology

The effects of UV radiation on the skin and its damage mechanisms are well known. New modalities of exogenous photoprotection have been studied. It was demonstrated that Polypodium leucotomos extract acts as an antioxidant, photoprotectant, antimutagenic, anti-inflammatory, and immunoregulator. It is effective when taken orally and/or applied topically to support the prevention of skin cancers. It also has an important role in preventing photoaging. This review aims to report the mechanisms through which Polypodium leucotomos acts and to analyze its uses in oncodermatology with references to in vitro and in vivo studies. Additionally, alternative uses in non-neoplastic diseases, such as pigmentary disorders, photosensitivity, and atopic dermatitis, have been considered.

Antioxidant and photoprotective potential of Polypodium leucotomos

In recent years, Polypodium leucotomos has emerged with a great interest for having medicinal and therapeutic potential. It is producing very promising results due to the presence of antioxidant and photoprotective properties. Electronic libraries and databases, including Scopus, PubMed, Google Scholar, Science Direct, and Web of Science were searched to identify relevant studies; 79 publications contributed to this review regarding Polypodium leucotomos botanical aspects, chemical composition, antioxidant and photoprotective activity. It is used in complementary and alternative therapies with various pharmaceutical dosage forms (systemic or topical). Thanks to the composition of phytochemical constituents present in the leaves and rhizomes which confer antioxidant and photoprotective activity that has clinical therapeutic potential to be used as systemic and topical sunscreen of natural origin for the prevention of different types of skin diseases caused by harmful ultraviolet A and ultraviolet B radiations. However, more studies are needed in the future to test the ability and enhance the capacity of sunscreen and sunblock in cosmetic formulations. To conclude, it is recommended to carry out scientific studies based on different analytical methods to evaluate the phytoconstituents potential and to develop stable pharmaceutical formulations according to the skin phototype.

Very Low-Efficiency Droop in 293 nm AlGaN-Based Light-Emitting Diodes Featuring a Subtly Designed p-Type Layer

This paper reports an AlGaN-based ultraviolet-B light-emitting diode (UVB-LED) with a peak wavelength at 293 nm that was almost free of efficiency droop in the temperature range from 298 to 358 K. Its maximum external quantum efficiencies (EQEs), which were measured at a current density of 88.6 A cm-2, when operated at 298, 318, and 338 K were 2.93, 2.84, and 2.76%, respectively; notably, however, the current droop (J-droop) in each of these cases was less than 1%. When the temperature was 358 K, the maximum EQE of 2.61% occurred at a current density of 63.3 A cm-2, and the J-droop was 1.52%. We believe that the main mechanism responsible for overcoming the J-droop was the uniform distribution of the concentrations of injected electrons and holes within the multiple quantum wells. Through the subtle design of the p-type AlGaN layer, with the optimization of the composition and doping level, the hole injection efficiency was enhanced, and the Auger recombination mechanism was inhibited in an experimental setting.

Medicinal pteridophytes: ethnopharmacological, phytochemical, and clinical attributes

Background

Almost from the very beginning of human existence, man has been interacting with plants. Throughout human history, plants have provided humans with basic needs such as sustenance, firewood, livestock feed, and wood. The world has approximately 3 million vascular plants. The treatment of primary health problems is provided primarily by traditional medicines by around 80% of the world's population. Compared to other vascular plants, pteridophytes remain underexplored in ethnobotanical aspects, despite being regarded as a valuable component of healthcare for centuries. As an alternative medicine, pteridophytes are being investigated for their pharmacological activity. Almost 2000 years ago, humans were exploring and using plant species from this lineage because of its beneficial properties since pteridophytes were the first vascular plants.

Main body of the abstract

All popular search engines such as PubMed, Google Scholar, ScienceDirect, and Scopus were searched to retrieve the relevant literature using various search strings relevant to the topic. Pteridophytes belonging to thirty different families have been documented as medicinal plants. For instance, Selaginella sp. has been demonstrated to have numerous therapeutic properties, including antioxidative, inflammation-reducing, anti-carcinogenic, diabetes-fighting, virucidal, antibacterial, and anti-senile dementia effects. In addition, clinical trials and studies performed on pteridophytes and derived compounds are also discussed in details.

Short conclusion

This review offers a compilation of therapeutically valuable pteridophytes utilized by local ethnic groups, as well as the public.

Graphical Abstract

The humanistic burden of vitiligo: a systematic literature review of quality-of-life outcomes

Despite historical mischaracterization as a cosmetic condition, patients with the autoimmune disorder vitiligo experience substantial quality-of-life (QoL) burden. This systematic literature review of peer-reviewed observational and interventional studies describes comprehensive evidence for humanistic burden in patients with vitiligo. PubMed, EMBASE, Scopus and the Cochrane databases were searched through February 10, 2021, to qualitatively assess QoL in vitiligo. Two independent reviewers assessed articles for inclusion and extracted data for qualitative synthesis. A total of 130 included studies were published between 1996 and 2021. Geographical regions with the most studies were Europe (32.3%) and the Middle East (26.9%). Dermatology-specific instruments, including the Dermatology Life Quality Index (DLQI; 80 studies) and its variants for children (CDLQI; 10 studies) and families (FDLQI; 4 studies), as well as Skindex instruments (Skindex-29, 15 studies; Skindex-16, 4 studies), were most commonly used to measure humanistic burden. Vitiligo-specific instruments, including the Vitiligo-specific QoL (VitiQoL; 11 studies) instrument and 22-item Vitiligo Impact Scale (VIS-22; 4 studies), were administered in fewer studies. Among studies that reported total scores for the overall population, a majority revealed moderate or worse effects of vitiligo on patient QoL (DLQI, 35/54 studies; Skindex, 8/8 studies; VitiQoL, 6/6 studies; VIS-22, 3/3 studies). Vitiligo also had a significant impact on the QoL of families and caregivers; 4/4 studies reporting FDLQI scores indicated moderate or worse effects on QoL. In general, treatment significantly (P < 0.05) improved QoL, but there were no trends for types or duration of treatment. Among studies that reported factors significantly (P ≤ 0.05) associated with reduced QoL, female sex and visible lesions and/or lesions in sensitive areas were most common. In summary, vitiligo has clinically meaningful effects on the QoL of patients, highlighting that greater attention should be dedicated to QoL decrement awareness and improvement in patients with vitiligo.

Diet and Vitiligo: The Story So Far

Vitiligo is an acquired skin pigmentation disease with a global burden of 0.5 to 2 percent of the population. Vitiligo therapy frequently poses a difficulty, which has sparked interest in alternative treatment modalities, including multivitamins and herbal supplementation. It has previously been established that nutrition plays a crucial role in developing, amplifying, or rehabilitating an array of human disorders. However, the correlation between diet diversity and immune-mediated skin diseases is still up to interpretation. Several supplements have been studied, including vitamins, minerals, and herbal supplements. Most studies agree that combining vitamin B12, folic acid, and sun exposure is good for inducing repigmentation. Supplementation of zinc and phenylalanine when used in conjunction with topical steroids or UV-B (ultraviolet B) treatment shows therapeutic effects on vitiligo due to their role in the melanin synthesis pathway. Investigations conducted on herbal supplements have revealed that most of them contain antioxidants, which aid in repigmentation. This narrative review's purpose is to discuss nutrition's function in immune-mediated inflammatory skin diseases from the perspective of the most recent and reliable information available. 

Efficiency Droop and Degradation in AlGaN-Based UVB Light-Emitting Diodes

In this study, we found that the current droop (J-droop) in AlGaN-based UVB light-emitting diodes was more obvious at higher temperatures, despite both the main and parasitic peaks undergoing monotonic decreases in their intensity upon an increase in the temperature. The slower temperature droop (T-droop) did not occur when the forward current was increased to temperatures greater than 298 K. After an aging time of 6000 h, the emission wavelengths did not undergo any obvious changes, while the intensity of the parasitic peak barely changed. Thus, the degradation in the light output power during long-term operation was not obviously correlated to the existence of the parasitic peak.

Modulating the Antioxidant Response for Better Oxidative Stress-Inducing Therapies: How to Take Advantage of Two Sides of the Same Medal?

Oxidative stress-inducing therapies are characterized as a specific treatment that involves the production of reactive oxygen and nitrogen species (RONS) by external or internal sources. To protect cells against oxidative stress, cells have evolved a strong antioxidant defense system to either prevent RONS formation or scavenge them. The maintenance of the redox balance ensures signal transduction, development, cell proliferation, regulation of the mechanisms of cell death, among others. Oxidative stress can beneficially be used to treat several diseases such as neurodegenerative disorders, heart disease, cancer, and other diseases by regulating the antioxidant system. Understanding the mechanisms of various endogenous antioxidant systems can increase the therapeutic efficacy of oxidative stress-based therapies, leading to clinical success in medical treatment. This review deals with the recent novel findings of various cellular endogenous antioxidant responses behind oxidative stress, highlighting their implication in various human diseases, such as ulcers, skin pathologies, oncology, and viral infections such as SARS-CoV-2.

Dietary Supplements and the Skin: Focus on Photoprotection and Antioxidant Activity—A Review

Skin health is not only significantly affected by ageing, but also by other lifestyle-related factors, such as sun exposure, exercise and eating habits, smoking or alcohol intake. It is known that the cutaneous tissue can exhibit visible signs of senescence, in the form of, for example, dull complexion, loss of firmness, or changes in pigmentation. Consumers attempt to improve skin health and appearance not only by cosmetic products, but also with the consumption of food supplements. Recently, there has been an increase in the amount of food supplements with claims that are related to skin and hair health. Nevertheless, the literature is still scarce in evidence of the efficacy of this type of products. Considering this scenario, we aim in this review to assemble studies and methodologies that are directed at the substantiation of the cutaneous health claims of food supplements. For example, we reviewed those that were indicative of antioxidant properties, improvement in pigmentation disorders, increased hydration or protection against the damages caused by ultraviolet radiation.

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.

The Current Status of Antioxidants in the Treatment of Vitiligo in China

Little is known about the use of antioxidants in the clinical treatment of vitiligo. To investigate the specific use of antioxidants in the treatment of vitiligo and the possible reasons behind its use in China, we conducted a prospective questionnaire-based study using an online questionnaire comprising 26 questions in 5 areas. A total of 323 clinical frontline dermatologists participated in this study. Differences among groups were compared using Pearson’s chi-square test. Ordinal logistic regression was used to develop knowledge–use multiple regression models. Among the 323 dermatologists, 293 (90.7%) approved the oxidative stress theory of vitiligo, and 182 (56.3%) encouraged the use of antioxidants for treating vitiligo; nonetheless, only 11.8% frequently treated vitiligo with antioxidants. Insufficient knowledge of antioxidants was a significant predictor of lower frequency of antioxidant usage (adjusted odds ratio, 0.401 [95% confidence interval, 0.256-0.629]; $P<.001$ ). The predictors associated with higher antioxidant efficacy included advanced or rapid progression, moderate or moderate-to-severe vitiligo, age of 0–2 years or 13–18 years, segmental vitiligo, oral and topical combination therapy, and course duration of <1 month. The use of antioxidants for treating vitiligo is highly encouraged; however, the rates of their clinical use are considerably low. Insufficient knowledge of antioxidants is associated with a lower frequency of antioxidant usage. The synergistic curative efficacy of antioxidants could be affected by the stage, type, severity, age of patients with vitiligo, and method of using antioxidants.

The Role of Nutrition in Immune-Mediated, Inflammatory Skin Disease: A Narrative Review

Immune-mediated inflammatory skin diseases are characterized by a complex multifactorial etiology, in which genetic and environmental factors interact both in genesis and development of the disease. Nutrition is a complex and fascinating scenario, whose pivotal role in induction, exacerbation, or amelioration of several human diseases has already been well documented. However, owing to the complexity of immune-mediated skin disease clinical course and breadth and variability of human nutrition, their correlation still remains an open debate in literature. It is therefore important for dermatologists to be aware about the scientific basis linking nutrition to inflammatory skin diseases such as psoriasis, atopic dermatitis, hidradenitis suppurativa, bullous diseases, vitiligo, and alopecia areata, and whether changes in diet can influence the clinical course of these diseases. The purpose of this narrative review is to address the role of nutrition in immune-mediated inflammatory skin diseases, in light of the most recent and validate knowledge on this topic. Moreover, whether specific dietary modifications could provide meaningful implementation in planning a therapeutic strategy for patients is evaluated, in accordance with regenerative medicine precepts, a healing-oriented medicine that considers the whole person, including all aspects of the lifestyle.

Treatment options for androgenetic alopecia: Efficacy, side effects, compliance, financial considerations, and ethics

Background

Androgenetic alopecia (AGA) is the most common form of hair loss consisting of a characteristic receding frontal hairline in men and diffuse hair thinning in women, with frontal hairline retention, and can impact an individual's quality of life. The condition is primarily mediated by 5‐alpha‐reductase and dihydrotestosterone (DHT) which causes hair follicles to undergo miniaturization and shortening of successive anagen cycles. Although a variety of medical, surgical, light‐based and nutraceutical treatment options are available to slow or reverse the progression of AGA, it can be challenging to select appropriate therapies for this chronic condition.

Aims

To highlight treatment options for androgenetic alopecia taking into consideration the efficacy, side effect profiles, practicality of treatment (compliance), and costs to help clinicians offer ethically appropriate treatment regimens to their patients.

Materials and Methods

A literature search was conducted using electronic databases (Medline, PubMed, Embase, CINAHL, EBSCO) and textbooks, in addition to the authors' and other practitioners' clinical experiences in treating androgenetic alopecia, and the findings are presented here.

Results

Although topical minoxidil, oral finasteride, and low‐level light therapy are the only FDA‐approved therapies to treat AGA, they are just a fraction of the treatment options available, including other oral and topical modalities, hormonal therapies, nutraceuticals, PRP and exosome treatments, and hair transplantation.

Discussion

Androgenetic alopecia therapy remains challenging as treatment selection involves ethical, evidence‐based decision‐making and consideration of each individual patient's needs, compliance, budget, extent of hair loss, and aesthetic goals, independent of potential financial benefits to the practitioners.

Role of nutritional supplements in selected dermatological disorders: A review

BACKGROUND

While a plethora of literature continues to be published on the role of nutritional agents both in lay press and indexed journals, the data is not on a firm footing and leaves the dermatologist in a quandry and the patient confused. The various agents include vitamins, minerals, amino acids, antioxidants, diets & gluten. A proper knowledge of the role of nutritional supplements in dermatological diseases can be a useful tool in advising the patients and in certain cases ameliorating the disorder.

PATIENTS/METHODS

Literature review of last 15 years was made using the terms "diet in dermatology," "nutrition and skin," "nutritional supplements in dermatology," "nutritional agents and acne," "nutritional agents and alopecia," and "nutritional agents and psoriasis."

RESULTS

While there are multiple publications on the use of nutritional supplements for amelioration of skin diseases, most of them are based on either associations or in vitro studies, but very few transcend the rigors of a clinical trial or the holey grail of a double-blinded randomized controlled trial. There seem to be some evidence in acne, psoriasis, telogen effluvium, urticaria & vitiligo. Coeliac disease and dermatitis herpetiformis have a strong link with diet. Rosacea has a strong link with certain foods, but the other disorders like melasma, aphthous stomatitis do not have any scientifically validated association with diet.

CONCLUSIONS

Our updated review examines the role of nutritional supplements and antioxidants in various dermatological disorders. We have found that there are varying levels of evidence with notable associations of low glycemic diet & acne, fish oil & weight loss with psoriasis, fish oils & probiotics with atopic dermatitis & vitamins & botanical extracts with vitiligo. The evidence for diet and nutrition in bullous disorders and photoageing is scarce. The role of low histamine diet in urticaria is useful in select cases of episodic urticaria. Rosacea is triggered by hot and spicy food . Apart from gluten and Dermatitis Herpetiformis, no diet can be considered disease modifying in our reveiw. The lack of comparison of nutritional or dietary modiffication with conventional validated agents, makes the data difficult to translate in real world patient management.

Autoimmunity in vitiligo: Therapeutic implications and opportunities

Vitiligo is an acquired chronic pigmentary disorder affecting the melanocytes, mainly in the skin and mucosae. It occurs due to the dynamic interaction between genetic and environmental factors leading to autoimmune destruction of melanocytes. Defects in melanocyte adhesion and increased oxidative stress further augment the immune response in vitiligo. It is a cosmetically disfiguring condition with a substantial psychological burden. Its autoimmune nature with resultant chronicity, variable responses to therapeutic modalities, and frequent recurrences have further diminished the quality of life. Hence, treatment should aim to provide more extended remission periods, prevent recurrences, provide good cosmetic outcomes and ensure patient satisfaction. These treatment goals seem plausible with the recent progress in our understanding of the complex pathogenic mechanisms underlying vitiligo at a molecular and genetic level. We provide a literature review of the pathogenic mechanisms and the therapies targeting these mechanisms.

Vitiligo: What's old, what's new

Vitiligo is an acquired pigmentary disorder afflicting 0.5-2% of the world population for both sexes and all races with a capricious and unpredictable course. It has a complex etiology and varies in its manifestation, progression and response to treatment. Even if the precise aetiology and pathobiology of the disease are complex and still debated, recent evidence supports that vitiligo is a T CD8+ cell-mediated autoimmune disease triggered by oxidative stress. To date no clinical, biological and histological criteria allow us to establish the prognosis with certainty. The choice of the best therapy for adult and childhood vitiligo is based on various factors, such as the patient's age, psychological condition and expectations, distribution and extension of skin lesions, type of vitiligo (stable or not) and availability and cost of therapeutic options. Since vitiligo has a deep psychological impact on patients and their quality of life, treating the disease is very important. As dermatologists, we have important goals in the treatment of vitiligo patients: stabilization of the disease progression, repigmentation of the lesions and especially the persistence of the aforementioned repigmentation. Although several medical and surgical therapeutic options have been proposed, no definite cure has yet been developed and the long-term persistence of repigmentation is unpredictable. We review the different therapeutic options with particular attention on the recurrence rate.

Therapies with Antioxidant Potential in Psoriasis, Vitiligo, and Lichen Planus

Oxidative stress plays an important pathogenetic role in many chronic inflammatory diseases, including those of dermatological interest. In particular, regarding psoriasis, vitiligo, and lichen planus, excess reactive oxygen species and a decline in endogenous antioxidant systems are observed. In this regard, treatments with antioxidant properties could be appropriate therapeutic options. To date, clinical trials in dermatology on these treatments are limited. We reviewed the available studies on the efficacy of antioxidant therapies in psoriasis, vitiligo, and lichen planus. The role of herbal derivatives, vitamins, and trace elements was analyzed. The antioxidant properties of conventional therapies were also evaluated. Data from the literature suggest that antioxidants might be useful, but available studies on this topic are limited, heterogeneous, not completely standardized, and on small populations. Furthermore, in most cases, antioxidants alone are unable to induce significant clinical changes, except perhaps in mild forms, and must be used in conjunction with standard drug treatments to achieve measurable results. Further studies need to be conducted, considering larger populations and using internationally validated scales, in order to compare the results and clinical efficacy.

Diet in Dermatology: Review of Diet's Influence on the Conditions of Rosacea, Hidradenitis Suppurativa, Herpes Labialis, and Vitiligo

The influence of dietary patterns on cutaneous disease has been an oft-posed question to dermatologists by patients in a clinical setting. Similarly, the popularity of nutritional supplementation with vitamins, minerals, and nutraceutical blends has been increasing. Dermatologists, primary care physicians, and other providers should be familiar with dietary interventions that are evidence-based and those that are more marketable than efficacious. In this review, the modification of diet, including dietary exclusion and dietary supplementation for the treatment of rosacea, hidradenitis suppurativa (HS), herpes labialis, and vitiligo was investigated. Despite abundant anecdotal evidence, the literature search found no high-quality evidence that an elimination diet for rosacea "trigger foods" improved rosacea symptoms though these elimination diets (of hot, spicy, alcohol-containing, or cinnamaldehyde-containing foods) had low risk of harm. There is evidence that zinc supplementation and vitamin D supplementation in deficient patients is helpful for treating HS. For herpes labialis, L-lysine supplementation was found to be effective for prophylaxis but not for decreasing duration of active lesions. For vitiligo, the use of the herb Polypodium leucotomos in conjunction with phototherapy was found to increase repigmentation, as well as vitamin D supplementation in deficient patients.

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.

NB-UVB plus oral Polypodium leucotomos extract display higher efficacy than NB-UVB alone in patients with vitiligo

Polypodium leucotomos displayed a synergic effect with NB-UVB in psoriasis, but its application on vitiligo remains understudied. The aim of this study was to investigate whether oral supplementation with leaves extract of Polypodium leucotomos (PL) improves narrow band (NB) UVB phototherapy-induced repigmentation. Forty-four patients with generalized vitiligo were enrolled in this randomized, prospective, placebo controlled study. Twenty-three patients were randomly selected to receive combined treatment with NB-UVB phototherapy and 480 mg oral PL twice daily while 21 patients received NB-UVB phototherapy combined with placebo. All subjects were treated with NB-UVB twice weekly for 6 months. Our results demonstrated that oral PL combined with NB-UVB improved repigmentation as well as increased the response rate compared with patients treated with NB-UVB alone (47.8% vs 22%). Our study suggests that oral supplementation of PL and NB-UVB phototherapy enhance the extent of repigmentation.

Drug interactions of natural supplements in dermatology: a review

Limited information is available on the drug-drug interactions of natural supplements in dermatology. Many natural supplements are available over the counter, but drug-drug interactions can occur. This study reviews the clinical use and drug interactions of six natural supplements commonly recommended in dermatology: nicotinic acid (nicotinamide), polypodium leucotomos (heliocare), turmeric, horse chestnut seed extract, zinc, and N-acetylcysteine. We reviewed the drug-drug interactions of each supplement using the PubMed database and IBM Micromedex. For nicotinic acid, zinc, horse chestnut, and N-acetylcysteine, IBM Micromedex generated 11, 23, one, and two results, respectively. Further review of literature from PubMed identified two drug interactions with polypodium leucotomos, two with turmeric, and two more with zinc. Notable interactions included an increased risk of myopathy and rhabdomyolysis when nicotinic acid is taken by patients using statins, an increased risk of bleeding associated with horse chestnut seed, especially when used in combination with warfarin, and reduced plasma concentration in many drugs when taken with zinc. Furthermore, N-acetylcysteine may interfere with concentrations of other medications used in the psychiatric setting, and polypodium leucotomos and turmeric may interfere with the CYP metabolic pathway, which may affect drugs metabolized by this pathway. Prior to recommending a treatment, dermatologists should foster awareness of these interactions. In order to advance the practice as a whole, research should continue to evaluate the drug interactions of these natural supplements.

Vitiligo: an update on systemic treatments

Vitiligo is an autoimmune skin condition characterized by depigmented macules and patches, and has a huge psychosocial impact on patients. Treatment of vitiligo aims to prevent the spread of disease and facilitate repigmentation of affected lesions. The mainstay of treatment for unstable vitiligo has been topical agents (corticosteroids, calcineurin inhibitors) and phototherapy. However, systemic treatments are increasingly being shown to have a significant impact on the course of the disease as monotherapy or adjunctive therapy. Of note, oral mini-pulsed corticosteroid therapy, methotrexate, minocycline, ciclosporin, Janus kinase inhibitors and certain supplements have been used in the systemic treatment of vitiligo. We review the underlying evidence supporting the use of each of these systemic treatments.

A Systematic Review of Nutrition, Supplement, and Herbal-Based Adjunctive Therapies for Vitiligo

Background: Vitiligo is an autoimmune skin condition that affects people globally anywhere, from <0.1% to more than 8% of individuals. The disease destroys skin melanocytes, resulting in a patchy depigmentation of the skin. About 50% of all patients develop the disease before their 20s. Methods: We systematically searched the literature and reviewed the evidence for the use of nutritional supplements and diet in the management of vitiligo. Embase and Medline were searched for diet, herbal, and nutrition-based clinical studies. Additional filters were applied that looked for controlled trial or randomized controlled trial and article or article in press or letter and English and clinical study. We selected clinical studies in humans that showed how diet or natural supplements can improve the symptoms of vitiligo in all of our searches. Results: There were 62 manuscripts that resulted from the PubMed search and 259 from the Embase search. A final of 26 studies were reviewed, and other supplemental case and case-control studies were used to introduce diet components that may influence either exacerbation or amelioration of vitiligo. Possible mechanisms of action are introduced for natural and supplemental interventions. Conclusion: Some of the supplements reviewed include Gingko biloba, oral Polypodium leucotomos, alpha lipoic acid, vitamins B12, D, and E, folic acid, phenylalanine, canthaxanthin, Nigella sativa oil, and other combined herbal bio-actives. Overall, the growing evidence is promising, but more studies are needed in this area to further explore the impact that supplements and diet can have on vitiligo management. The most promising therapies included oral phenylalanine as adjuvant therapy with UVA therapy, oral G. biloba as monotherapy, both of which can be used with other traditional therapies, and oral P. leucotomos with phototherapy or photochemotherapy.

Randomized clinical trial of combined therapy with oral α-lipoic acid and NB-UVB for nonsegmental stable vitiligo

Vitiligo is associated with oxidant stress and α-lipoic acid (ALA) is an antioxidative agent. To evaluate the efficacy and safety of oral ALA in combination with NB-UVB phototherapy on nonsegmental stable vitiligo. The prospective, multi-center, parallel controlled, double-blind randomized clinical trial was conducted from 2012 to 2014, in seven comprehensive tertiary hospitals in China. The patients were randomized into oral ALA group or placebo group at a dose of 300 mg daily for 6 months. All of them received NB-UVB phototherapy three times weekly. The repigmentation rate was evaluated by 4-point grading scale of improvement: >98%, 50-98%, 10-49%, <10%. A total of 133 patients were enrolled in the study, including 72 cases in treatment group and 61 cases in control group. In treatment group, 2.04% (1/49) patients achieved ≥50% improvement at 1-month after enrollment (M1), and the percentage of patients increased to 8.51% (4/47), 14.0% (6/43), and 37.8% (14/37) at M2, M3, and M6, respectively. In control group, the percentages were similar at all timepoints. No significant difference was seen between the two groups (P > .05). For elder patients, younger patients, male or female, no significant differences were found between treatment group and control group at all timepoints. ALA did not show additional benefit to NB-UVB therapy in the treatment of nonsegmental stable vitiligo. More studies should be done to identify other protocols of ALA or other types of antioxidants for stable vitiligo.

Nuclear factor erythroid 2-related factor 2 (Nrf2) as a potential therapeutic target for vitiligo

Vitiligo is an autoimmune disease of the skin which causes loss of melanocytes from the epidermis. Recently, it is demonstrated that oxidative stress (OS) plays a significant role in the immuno-pathogenesis of vitiligo. A major mechanism in the cellular defense against OS is activation of the nuclear factor erythroid2-related factor (Nrf2)-Kelch-like ECH-associated protein 1(Keap1)-antioxidant responsive element (ARE) signaling pathway. Recently it has been shown that vitiligo melanocytes have impaired Nrf2-ARE signaling. A number of drugs including those known as Nrf2 activators and those known to possess effects to activate Nrf2, have been used in treating vitiligo with certain therapeutic effects. Also, studies have shown that a number of compounds can protect melanocytes against OS via activating Nrf2. These compounds may be considered as candidates for developing new drugs for vitiligo in the future. Nrf2 can be considered as a potential therapeutic target for vitiligo.

The role of the aqueous extract Polypodium leucotomos in photoprotection

Solar radiation in the ultraviolet (UV), visible (VIS), and infrared (IR) ranges produces different biological effects in humans. Most of these, particularly those derived from ultraviolet radiation (UVR) are harmful to the skin, and include cutaneous aging and increased risk of cutaneous diseases, particularly skin cancer. Pharmacological photoprotection is mostly topical, but it can also be systemic. Oral photoprotectives constitute a new generation of drugs to combat the deleterious effects of solar radiation. Among these, an extract of Polypodium leucotomos (PL/Fernblock®, IFC Group, Spain) contains a high content of phenolic compounds that endow it with antioxidant activity. PL can administered orally or topically and is completely safe. PL complements and enhances endogenous antioxidant systems by neutralizing superoxide anions, hydroxyl radicals, and lipoperoxides. In addition to its antioxidant activity, PL also improves DNA repair and modulates immune and inflammatory responses. These activities are likely due to its ability to inhibit the generation and release of reactive oxygen species (ROS) by UVR, VIS, and IR radiation. PL also prevents direct DNA damage by accelerating the removal of induced photoproducts and decreasing UV-induced mutations. Oral PL increases the expression of active p53, decreases cell proliferation, and inhibits UV-induced COX-2 enzyme levels. PL has been used to treat skin diseases such as photodermatoses and pigmentary disorders and recently as a complement of photodynamic phototherapy in actinic keratoses. The photoprotective capability of PL has been proven in a multitude of in vitro and in vivo studies, which include animal models and clinical trials with human subjects. Based on this evidence, PL is a new generation photoprotector with antioxidant and anti-inflammatory properties that also protects DNA integrity and enhances the immune response.

Does oxidative stress correlate with disease activity and severity in vitiligo? An analytical study

BACKGROUND

Oxidative damage to melanocytes, resulting from an imbalance between the damaging oxidative pathways and the protective anti-oxidants likely plays a pathogenic role in vitiligo.

AIM

To evaluate three parameters related to the oxidative stress (OS) pathway namely malondialdehyde (MDA), a marker of oxidative damage, and superoxide dismutase (SOD) and reduced glutathione (rGSH) (both antioxidants) in patients with active and stable vitiligo with either localized or generalized disease.

PATIENTS/METHODS

Sixty clinically diagnosed vitiligo patients were categorized into generalized (n = 30) or localized vitiligo (n = 30) and were further sub-grouped according to their disease activity into active and stable groups. Thirty healthy volunteers were included in the control group. ELISA was used for the evaluation of MDA, SOD, and r GSH.

RESULTS

The patient group demonstrated significantly raised levels of MDA and significantly decreased levels of SOD and rGSH compared with the control group. Further, the OS parameters were significantly more deranged in patients with generalized disease (all three-MDA, rGSH, and SOD) and an active disease (MDA) as compared to those with localized and stable disease, respectively.

CONCLUSION

Our findings suggest an important role of OS in relation to vitiligo activity and severity. Although the OS parameters were deranged in all subsets of patients, with respect to controls, the derangement of oxidative damage marker (MDA) in generalized and active disease groups was most marked. Disease remains active when the oxidative damage becomes higher but is unmatched with the anti-oxidant reserve which does not proportionately increase.

Recent Progress and Future Directions: The Nano-Drug Delivery System for the Treatment of Vitiligo

Vitiligo is a depigmentation disease that seriously affects the physical health, mental health and quality of life of a patient. Therapeutic aim at control immunoreaction by relieving oxidative stress. Unfortunately, the cuticle barrier function and lack of specific accumulation lead to unsatisfactory therapeutic outcomes and side effects. The introduction and innovation of nanotechnology offers inspiration and clues for the development of new strategies to treat vitiligo. However, not many studies have been done to interrogate how nanotechnology can be used for vitiligo treatment. In this review, we summarize and analyze recent studies involving nano-drug delivery systems for the treatment of vitiligo, with a special emphasis on liposomes, niosomes, nanohydrogel and nanoparticles. These studies made significant progress by either increasing drug loading efficiency or enhancing penetration. Based on these studies, there are three proposed principles for topical nano-drug delivery systems treatment of vitiligo including the promotion of transdermal penetration, enhancement of drug retention and facilitation of melanin regeneration. The presentation of these ideas may provide inspirations for the future development of topical drug delivery systems that will conquer vitiligo.

The necessity of antinuclear antibody investigation in pre-phototherapy vitiligo patients: A retrospective study

BACKGROUND

Narrowband UVB (NBUVB) phototherapy is the cornerstone treatment for vitiligo. Before its initiation, some experts recommend antinuclear antibody (ANA) screening out of concern for either photosensitivity to NBUVB or autoimmune disease exacerbation during treatment. As vitiligo is considered an autoimmune disorder, ANAs can be positively found in the disease without any clinical importance. The necessity for ANA investigations for pre-phototherapy vitiligo patients is therefore questioned.

METHODS

We conducted a retrospective study to investigate vitiligo patients who had been checked for ANA before commencing NBUVB phototherapy. Demographic data-including vitiligo type and age of onset-were collected. Samples of ANA, anti-thyroglobulin, and anti-thyroid peroxidase were obtained. The phototherapy treatment protocol and cutaneous reactions to the phototherapy were also recorded.

RESULTS

Among 85 Thai vitiligo patients, the ANA prevalence was 35.3%. The speckled ANA pattern was the most common, and the large majority of patients (80%) had a titer of ≤1:100. Factors associated with positive ANA were female gender and positive anti-thyroglobulin. There were no statistical differences between the phototoxic reactions or phototoxic doses of NBUVB of the ANA-positive vitiligo and ANA-negative vitiligo groups. No cases of SLE were detected in ANA-positive group.

CONCLUSIONS

ANA positivity was not correlated with the incidence or dose of phototoxic reaction in phototherapy treated vitiligo, and it may not a predictive factor for SLE diagnosis in vitiligo. ANA might therefore not need to be routinely checked in pre-phototherapy in vitiligo, unless there are clinical suspicions of an autoimmune disease. However, ANA might be involved in part of the cutaneous photoadaptation response to phototherapy.

Safety of the current drug treatments for vitiligo

Introduction: Vitiligo is an acquired depigmenting skin disorder adversely affecting the patient's quality of life. Despite the presence of several treatment modalities, ranging from medical to physical to surgical options, none is curative. Each modality has its own drawbacks and side effects. Thus, the treatment modality needs to be tailored for each individual patient taking into consideration the disease characteristics and also its efficacy and safety to obtain a favorable risk-benefit ratio.Areas covered: This review highlights the different treatment modalities utilized in vitiligo up until 4 November 2019 along with their adverse effects and contraindications, if any.Expert opinion: All the medications have their own adverse effects and contraindications. We have included the most commonly used topical corticosteroids, which may result in striae, cutaneous atrophy, and tachyphylaxis, to the recently introduced biologics, which may induce hypersensitivity reactions, systemic toxicities, and even malignancies. However, more long-term studies are needed to assess the safety of these medications, especially the newer ones, to provide a safe and effective treatment for this disorder.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.

Emerging drugs for the treatment of vitiligo

Introduction: Vitiligo is a relatively common autoimmune depigmenting disorder of the skin. There has been a great advance in understanding the pathological basis, which has led to the development and utilization of various new molecules in treating vitiligo. This review aims at a comprehensively describing the treatments available and the emerging treatment aspects and the scope for future developments.Areas covered: This study comprehensively summarizes the current concepts in the pathogenesis of vitiligo with special focus on the cytokine and signaling pathways, which are the targets for newer drugs. JAK kinase signaling pathways and the cytokines involved are the focus of vitiligo treatment in current research, followed by antioxidant mechanisms and repigmenting mechanisms. Topical immunosuppressants may be an alternative to steroids in localized vitiligo. Newer repigmenting agents like basic fibroblast growth factors, afamelanotide have been included and a special emphasis is laid on the upcoming targeted immunotherapy.Expert opinion: The treatment of vitiligo needs to be multimodal with emphasis on targeting different limbs of the pathogenesis. Topical and oral JAK inhibitors are the most promising new class of drugs currently available for treating vitiligo and acts best in conjunction with NB-UVB.

Application of medicinal plants in several dermatovenerological entities

Treatment of skin conditions with medicinal plants has been an ongoing human activity lasting over thousands of years. The use of specific plant species developed regionally, based on local flora. Commonly used medicinal plants for dermatological complaints are: Phlebodium aureum (L.) J. Sm., Ginkgo biloba L., Rosmarinus officinalis L., Panax ginseng C.A.Mey., Allium cepa L., Aloe vera (L.) Burm.f., Capsicum annuum L., Berbe ris aquifolium Pursh, Camellia sinensis (L.) Kuntze, and Podophyllum peltatum L. The demand for complementary therapeutics is an emerging trend due to the awareness of potential side effects that synthetic drugs might cause. More scientific evidence and better documentation are needed before advising dermatologic patients on herbal medicinal treatment. Standardised extracts and formulations with proven clinical efficacy should be developed for this cause. Here provided review entails the use of herbal medicinal products in the treatment of frequent chronic skin diseases, such as vitiligo, alopecia, psoriasis and genital warts.

Critical appraisal of the oxidative stress pathway in vitiligo: a systematic review and meta-analysis

BACKGROUND

The pathogenesis of vitiligo remains a topic of extensive debate. This is partly due to the moderate efficacy of current treatments. The role of the oxidative stress pathway in vitiligo is a popular although controversial research topic.

OBJECTIVE

To clarify the role of the oxidative stress pathway in vitiligo compared to other inflammatory skin disorders and to assess the therapeutic role of antioxidants.

METHODS

We conducted a systematic search of the existing literature on the aberrancies of the oxidative stress pathway in vitiligo. Subsequently, the efficacy of both topical and oral antioxidants in clinical trials was investigated.

RESULTS

A deregulated oxidative pathway is clearly evident with elevated superoxide dismutase, decreased catalase and increased lipid peroxidation. However, similar results have been obtained in other inflammatory skin diseases such as psoriasis, atopic dermatitis, lichen planus and urticaria. This questions the unique role of oxidative stress in the development of vitiligo. Some isolated successes have been reported with oral ginkgo biloba, polypodium leucotomos and vitamin C and E preparations, while other clinical trials have failed to show reproducible results. The use of topical antioxidants delivers in general no beneficial results.

CONCLUSION

The oxidative pathway is affected in vitiligo, but its unique initiating or contributory role in the pathogenesis is less evident. Interesting data support the added value of oral antioxidants in vitiligo although confirmatory studies are missing.