Treatment of vitiligo with narrowband-UVB (TL01) combined with tacrolimus ointment (0.1%) vs. placebo ointment, a randomized right/left double-blind comparative study

Comparison of the efficacy of tacrolimus 0.1% ointment vs calcipotriol/betamethasone in combination with NBUVB in treatment of vitiligo

Purpose: Vitiligo is an idiopathic depigmenting skin disorder. The study compares the efficacy of topical tacrolimus 0.1% with calcipotriol/betamethasone dipropionate in vitiligo patients receiving NB-UVB treatment.Materials and methods: Forty-one adult patients with generalized type vitiligo were recruited. Patients were assigned to phototherapy and then classified into either group one (20 patients), receiving calcipotriol/betamethasone dipropionate cream (D group), or group two (21 patients), receiving tacrolimus 0.1% ointment (T group). They were followed-up at 3 and 6 months.Results: The D group witnessed an increase in the repigmentation area from 35.4% in the third month to 54.7% in the sixth month (p = 0.001) and the T group from 32.2% to 45.6% (p = 0.011). However, the differences between the treatment groups were not statistically significant. Body sites demonstrated different levels of improvement ranging from the highest in the face to the lowest in the Hand & Feet with the other body sites in between. A negative correlation was identified between the duration since diagnosis and the response to D treatment (3 months: r = -0.612, p = 0.007; 6 months: r = -0.755, p = 0.001).Conclusions: Although both combinations are efficacious, they did not significantly differ in efficacy at three and six months follow-up points.Clinical trial registration: The study was registered at clinicaltrials.gov (NCT04440371).

Phototherapy: Theory and practice

Despite the development of highly effective biologics for skin diseases such as psoriasis or atopic dermatitis, UVA and UVB therapy, alone or in combination, are still essential components of various guidelines. Phototherapy is not only a first-line treatment and highly effective for a number of skin diseases, but is also economical and has few side effects. The targeted use of UVA and UVB, if necessary, in combination with the photosensitizer psoralen in the context of PUVA therapy, enables the dermatologist to effectively treat a wide variety of skin diseases. Indications for phototherapy include epidermal diseases such as atopic dermatitis, psoriasis and vitiligo, as well as photodermatoses, mycosis fungoides, graft-versus-host disease and deep dermal diseases such as scleroderma. This article reviews the physical principles, molecular mechanisms, current treatment regimens, and individual indications for phototherapy and photochemotherapy.

Phototherapie in Theorie und Praxis

Die Therapie oder Kombinationstherapie mit UV‐A‐ oder UV‐B‐Strahlen ist trotz der Entwicklung hochwirksamer Biologika bei Hauterkrankungen wie Psoriasis oder atopischer Dermatitis nach wie vor unverzichtbarer Bestandteil verschiedener Leitlinienempfehlungen. Die Phototherapie ist nicht nur eine sehr effektive Erstlinientherapie bei verschiedenen Hauterkrankungen, sondern auch kostengünstig und nebenwirkungsarm. Der gezielte Einsatz von UV‐A und UV‐B, gegebenenfalls auch in Kombination mit dem Photosensibilisator Psoralen im Rahmen einer PUVA‐Therapie, ermöglicht dem Dermatologen eine effektive Behandlung verschiedener Hautkrankheiten. Indikationen für die Phototherapie sind epidermale Erkrankungen wie die atopische Dermatitis, die Psoriasis und die Vitiligo, ferner Photodermatosen, die Mycosis fungoides, die Graft‐versus‐Host‐Erkrankung sowie tiefe dermale Erkrankungen wie die Sklerodermie. Dieser Artikel gibt einen Überblick über die physikalischen Grundlagen, die molekularen Mechanismen, die derzeitigen Behandlungsmethoden und die einzelnen Indikationen für die Phototherapie und die Photochemotherapie.

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.

UVB phototherapy in the treatment of vitiligo: State of the art and clinical perspectives

Vitiligo is a chronic pigmentary skin disorder that results in white, hypopigmented macules and patches. It causes a considerable psychological and emotional burden on the affected individuals and their families. Several therapeutic options have been employed in vitiligo including topical and oral drugs, surgical techniques, and phototherapy which is considered the cornerstone treatment. Different wavelengths and modalities are available, but narrowband UVB (NB-UVB) is considered the safest and the most effective phototherapy alternative. NB-UVB acts on multiple steps in vitiligo pathogenesis, and it is capable of inducing stabilization and repigmentation of vitiligo lesions. Technological advances have led to the development of both new phototherapy devices and new medical and surgical therapeutic options that can be combined with phototherapy to achieve optimal results. There is no standard treatment, and individual patient and disease characteristics should be considered. We review the current evidence in what concerns UVB phototherapy for vitiligo treatment, including novel combination treatments that may help to provide the best care for these patients.

Triple combination therapy of narrowband ultraviolet B, fractional carbon dioxide laser and topical bimatoprost 0.01% for non-segmental vitiligo on non-facial areas: A randomized half-body, double-blind, placebo-controlled, comparative study

Combination therapy shows superior outcomes over monotherapy in treating vitiligo. Topical bimatoprost is a melanogenic agent effectively used to induce repigmentation. However, topical bimatoprost 0.01% has never been explored in non-facial vitiligo, and triple therapy of phototherapy, fractional laser and topical bimatoprost has never been examined. This study aims to investigate the efficacy and safety of triple-modality treatment, combining narrowband ultraviolet B (NB-UVB), fractional carbon dioxide (CO₂ ) laser and topical bimatoprost 0.01% for stable non-segmental vitiligo on non-facial areas. Fifteen vitiligo patients with at least two symmetrical, comparable-sized lesions on non-facial regions were included. The paired lesions were randomized to receive a treatment regimen of twice-daily application of either bimatoprost 0.01% solution or placebo in combination with once-monthly fractional CO₂ laser and twice-weekly NB-UVB therapy for 12 weeks. There were no statistically significant differences in the vitiligo surface area (VSA) and melanin concentration (MC) at baseline between treatment sides. After 12 weeks of treatment, the percentage change from baseline of MC on the triple-therapy side was significantly higher than that on the dual-therapy side, 27.17 ± 13.62% versus 22.82 ± 10.10% (p = 0.028). The change from baseline of VSA was also greater on the triple-therapy side; however, a statistically significant difference was not reached. Improvement grades of repigmentation and adverse events were similar on both sides. Triple therapy with NB-UVB, fractional CO₂ laser and topical bimatoprost 0.01% tends to be safe and more effective as compared to dual therapy of NB-UVB and fractional CO₂ laser in non-facial vitiligo.

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 Skin Biomarkers Associated With Favorable Therapeutic Response

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

Combined microneedling with tacrolimus vs tacrolimus monotherapy for vitiligo treatment

Background: Miconeedling has been used to augment the transdermal drug delivery. Combination modalities may accelerate and improve the repigmentation in vitiligo.Objective: To determine the efficacy and tolerability of combined microneedling with tacrolimus vs tacrolimus 0.1% ointment for the treatment of vitiligo.Patients and Method: Forty-eight patients with vitiligo were randomized into two groups: group I applied tacrolimus once daily for 6 months. Group II received microneedling with topical tacrolimus at 2 weeks intervals for a maximum of 6 months. The assessment was based on the clinical improvement and immunohistochemical changes. Skin biopsies were taken at baseline and after the treatment for c-kit + expression.Results: After treatment, the repigmentation >75% was observed in 50% of the patients in group II compared to 29.2% in group I (p .02). There was an earlier response in group II than in group I (p .002). The improvement was significantly higher in the legs and extremities in group II than in group I (0.003). The immunohistochemical results showed significantly higher expression of c-kit in group II than group I (p .01). No severe side effects were reported.Conclusion: The results suggest the superiority of the combination regimen (tacrolimus and microneedling) for 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.

Phototherapy for Vitiligo

Vitiligo is a common disorder with a severe impact on quality of life. The authors review recent advances in phototherapy for vitiligo focusing on narrowband ultraviolet B including mechanisms, treatment recommendations, and combination therapies. Phototherapy is the first-line treatment of choice for vitiligo with narrowband UVB preferred for widespread vitiligo and excimer used for localized lesions. However, unfamiliarity with prescribing phototherapy may be limiting clinicians from using it to its full potential. This article provides clinicians with the critical information needed to safely and effectively provide phototherapy for their patients with vitiligo.

Treatment Outcomes of Topical Calcineurin Inhibitor Therapy for Patients With Vitiligo: A Systematic Review and Meta-analysis

Importance

Topical calcineurin inhibitors (TCIs), including tacrolimus and pimecrolimus, have been widely used for the treatment of vitiligo; however, the efficacy of TCI monotherapy is often underestimated.

Objectives

To estimate the treatment responses to both TCI monotherapy and TCI accompanied by phototherapy for vitiligo, based on relevant prospective studies, and to systematically review the mechanism of action of TCIs for vitiligo treatment.

Data Sources

A comprehensive search of the MEDLINE, Embase, Web of Science and Cochrane Library databases from the date of database inception to August 6, 2018, was conducted. The main key words used were vitiligo, topical calcineurin inhibitor, tacrolimus, pimecrolimus, and FK506.

Study Selection

Of 250 studies initially identified, the full texts of 102 articles were assessed for eligibility. A total of 56 studies were identified: 11 studies on the TCI mechanism, 36 studies on TCI monotherapy, 12 studies on TCI plus phototherapy, and 1 study on TCI maintenance therapy.

Data Extraction and Synthesis

Two reviewers independently extracted data on study design, patients, intervention characteristics, and outcomes. Random-effects meta-analyses using the generic inverse variance weighting were performed for the TCI monotherapy and TCI plus phototherapy groups.

Main Outcomes and Measures

The primary outcomes were the rates of at least mild (≥25%), at least moderate (≥50%), and marked (≥75%) repigmentation responses to treatment. These rates were calculated by dividing the number of participants in an individual study who showed the corresponding repigmentation by the total number of participants who completed that study.

Results

In the 56 studies included in the analysis, 46 (1499 patients) were selected to evaluate treatment response. For TCI monotherapy, an at least mild response was achieved in 55.0% (95% CI, 42.2%-67.8%) of 560 patients in 21 studies, an at least moderate response in 38.5% (95% CI, 28.2%-48.8%) of 619 patients in 23 studies, and a marked response in 18.1% (95% CI, 13.2%-23.1%) of 520 patients in 19 studies after median treatment duration of 3 months (range, 2-7 months). In the subgroup analyses, face and neck lesions showed an at least mild response in 73.1% (95% CI, 32.6-83.5%) of patients, and a marked response in 35.4% (95% CI, 24.9-46.0%) of patients. For TCI plus phototherapy, an at least mild response to TCI plus phototherapy was achieved in 89.5% (95% CI, 81.1-97.9%) of patients, and a marked response was achieved in 47.5% (95% CI, 30.6-64.4%) of patients.

Conclusions and Relevance

The use of TCIs, both as a monotherapy and in combination with phototherapy, should be encouraged in patients with vitiligo.

Tacrolimus ointment for the treatment of adult and pediatric atopic dermatitis: Review on safety and benefits

Atopic dermatitis (AD) requires long-term management, mainly with topical anti-inflammatory agents. Topical corticosteroids (TCS) and tacrolimus ointment (TAC-O) are recommended as first-line treatments for AD. However, the long-term use of TCS is limited by cutaneous adverse events such as skin atrophy. For TAC-O, Japanese and US labelings were updated in 2003 and 2006, respectively, to include a boxed warning about a theoretical risk of skin cancer and lymphoma in patients treated with topical calcineurin inhibitors. However, TAC-O has been used worldwide for longer than 15 years to treat adult and pediatric patients with AD. Available data suggest that TAC-O is effective and well tolerated, and can improve quality of life. TAC-O has successfully been used in the proactive management of AD consisting of long-term intermittent use to prevent, delay or reduce the occurrence of AD flares. Systemic drug absorption after TAC-O application is negligible and unlikely to result in systemic immunosuppression. There is currently no strong evidence of an increased rate of malignancy in treated patients, and observational data from postmarketing surveillance studies have shown no safety concerns. In the absence of robust evidence, the warning about the carcinogenic potential in the Japanese labeling for TAC-O does not appear justified and should be reconsidered. This mitigation of description would allow adult and pediatric patients with AD to receive the effective treatment more appropriately.

The effect of topical piperine combined with narrowband UVB on vitiligo treatment: A clinical trial study

Vitiligo is the most common acquired hypopigmentary disease in the community. Piperine as an herbal extract derived from black pepper has strong impact on the melanocyte proliferation and adverse side effects less than synthetic drugs such as corticosteroids. For the first time, this study was aimed to evaluate the effect of topical piperine combined with narrowband ultraviolet B (NB-UVB) on vitiligo treatment. In this double-blind clinical trial, 63 patients with facial vitiligo were randomly divided into 2 groups: treated with piperine (case) and placebo (control). Also, both groups received NB-UVB phototherapy every other day for 3 months. In the case group, 10 patients have burning sensation on their skin areas (p value = .002). Also, redness of the treated areas was observed in 6 patients (p value = .028). Both side effects were temporary. Regarding repigmentation at time intervals of 1, 2, and 3 months after treatment, its level in the case group was significantly higher than the control group (p value < .001). Based on our findings, the combination therapy with NB-UVB/topical piperine has more influence on facial vitiligo than that of NB-UVB alone. It could be concluded that the simultaneous use of NB-UVB and topical piperine has a remarkable effect on treatment of vitiligo.

Utility of dermoscopy for evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in localized vitiligo patients

The aim of the present study was to assess the function of dermoscopy in evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in patients with localized vitiligo. A total of 147 patients with localized vitiligo (progressive disease, n=92; stable period, n=55) were enrolled and received combination therapy for 12 weeks. The condition of the skin lesions was monitored by dermoscopy and visual observation. At the initial visit, skin lesions were observed in 61 progressive and 19 stable patients. Residual perifollicular pigmentation was more abundant in progressive-stage patients than in stable-stage patients, whereas the presence of perilesional hyperpigmentation was obviously lower in patients with progressive vitiligo. After 12 weeks of combination therapy, marked differences in residual perifollicular pigmentation were identified between the progressive- and stable-stage patients. Dermoscopy and visual observation indicated that the 12-week treatment efficacy in patients with progressive disease was significantly higher than in those with stable disease and that assessment by dermoscopy was superior to visual observation at 8 or 12 weeks of treatment. Binary logistic regression analysis revealed that the disease stage, vitiliginous areas and disease course were risk factors associated with the treatment efficacy of the combination therapy. In conclusion, dermoscopy may be used as an effective means of vitiligo therapy assessment to provide an accurate and scientific evaluation of treatment efficacy for localized vitiligo patients.

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.

Phototherapy and Combination Therapies for Vitiligo

Vitiligo is a disease characterized by disappearance of melanocytes from the skin. It can negatively influence the physical appearance of affected individuals, and may profoundly affect a person's psychosocial function and quality of life. Therefore, vitiligo should not be considered as merely a condition that affects a patient's appearance, but needs to be actively treated in patients who seek medical help. Phototherapy has been used as the main treatment modality for patients with vitiligo. Different forms of phototherapy for vitiligo include broadband UVB, narrowband UVB, excimer light and excimer laser, and psoralen plus UVA.

Phototherapy for Vitiligo: A Systematic Review and Meta-analysis

Importance

References to the expected treatment response to phototherapy would be helpful in the management of vitiligo because phototherapy requires long treatment durations over several months.

Objective

To estimate the treatment response of vitiligo to phototherapy.

Data Sources

A comprehensive database search of MEDLINE, EMBASE, and the Cochrane library from inception to January 26, 2016, was performed for all prospective studies. The main keywords used were vitiligo, phototherapy, psoralen, PUVA, ultraviolet, NBUVB, and narrowband.

Study Selection

All prospective studies reporting phototherapy outcome for at least 10 participants with generalized vitiligo were included. Of 319 studies initially identified, the full texts of 141 studies were assessed for eligibility, and 35 were finally included in the analysis. Of these, 29 studies included 1201 patients undergoing narrowband UV-B (NBUVB) phototherapy, and 9 included 227 patients undergoing psoralen-UV-A (PUVA) phototherapy.

Data Extraction and Synthesis

Two reviewers independently extracted the following data: study design, number and characteristics of the participants, phototherapy protocol, and rate of repigmentation based on the quartile scale. Single-arm meta-analyses were performed for the NBUVB and PUVA groups. Sample size-weighted means were calculated using a random-effects model for the repigmentation rates of the included studies.

Main Outcomes and Measures

The primary outcomes were at least mild (≥25%), at least moderate (≥50%), and marked (≥75%) responses on a quartile scale. Response rates were calculated as the number of participants who showed the corresponding repigmentation divided by the number of all participants enrolled in the individual studies.

Results

The meta-analysis included 35 unique studies (1428 unique patients). For NBUVB phototherapy, an at least mild response occurred in 62.1% (95% CI, 46.9%-77.3%) of 130 patients in 3 studies at 3 months, 74.2% (95% CI, 68.5%-79.8%) of 232 patients in 11 studies at 6 months, and 75.0% (95% CI, 60.9%-89.2%) of 512 patients in 8 studies at 12 months. A marked response was achieved in 13.0% (95% CI, 2.1%-23.9%) of 106 patients in 2 studies at 3 months, 19.2% (95% CI, 11.4%-27.0%) of 266 patients in 13 studies at 6 months, and 35.7% (95% CI, 21.5%-49.9%) of 540 patients in 9 studies at 12 months. For PUVA phototherapy, an at least mild response occurred in 51.4% (95% CI, 28.1%-74.7%) of 103 patients in 4 studies at 6 months and 61.6% (95% CI, 20.2%-100%) of 72 patients in 3 studies at 12 months. In the subgroup analyses, marked responses were achieved on the face and neck in 44.2% (95% CI, 24.2%-64.2%), on the trunk in 26.1% (95% CI, 8.7%-43.5%), on the extremities in 17.3% (95% CI, 8.2%-26.5%), and on the hands and feet in none after at least 6 months of NBUVB phototherapy.

Conclusions and Relevance

Long-duration phototherapy should be encouraged to enhance the treatment response in vitiligo. The greatest response is anticipated on the face and neck.

Effect of narrow band ultraviolet B phototherapy as monotherapy or combination therapy for vitiligo: a meta-analysis

BACKGROUND

The treatment of vitiligo is still one of the most difficult dermatological challenges, although there are many therapeutic options. Narrow band ultraviolet B (NB-UVB) phototherapy is considered to be a very important modality for generalized vitiligo.

OBJECTIVE

The aim of this study was to explore whether a combination of NB-UVB and topical agents would be superior to NB-UVB alone for treating vitiligo.

METHODS

We searched the electronic databases such as PUBMED, EMBASE, Cochrane Library, and Web of Science. The primary outcome was the proportion of ≥50% repigmentation (a clinical significance), and secondary outcome was the proportion of ≥75% repigmentation (an excellent response).

RESULTS

Seven randomized controlled trials (RCTs) involving 240 patients (413 lesions) were included in this meta-analysis. The study showed no significant difference between NB-UVB combination therapy (NB-UVB and topical calcineurin inhibitor or vitamin D analogs) and NB-UVB monotherapy in the outcomes of ≥50% repigmentation and ≥75% repigmentation. However, lesions located on the face and neck had better results in ≥50% repigmentation (RR = 1.40, 95% CI 1.08-1.81) and ≥75% repigmentation (RR = 1.88, 95% CI 1.10-3.20) with NB-UVB and topical calcineurin inhibitor combination therapy vs. NB-UVB monotherapy.

CONCLUSIONS

The meta-analysis suggested that adding neither topical calcineurin inhibitors nor topical vitamin-D3 analogs on NB-UVB can yield significantly superior outcomes than NB-UVB monotherapy for treatment of vitiligo. However, addition of topical calcineurin inhibitors to NB-UVB may increase treatment outcomes in vitiligo affecting face and neck.

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.

Review of narrowband ultraviolet B radiation in vitiligo

Vitiligo is a common, acquired pigmentary disorder of unknown etiology with great impact on patient’s appearance and quality of life. It presents a therapeutic challenge to many dermatologists. Photochemotherapy using psoralen and ultraviolet A (UVA) therapy, topical and oral immunosuppresants, as well as cosmetic camouflage are also commonly employed with varying clinical efficacy. Phototherapy is a popular treatment option, which includes both of the generalized ultraviolet B (UVB) therapies, broadband UVB and narrowband UVB (NB-UVB). It has been used favorably, both alone as well as in combination with other agents like topical calcineurin inhibitors, vitamin-D analogs. Combination therapies are useful and may provide quicker regimentation and treat vitiligo with an additive mechanism of action than UVB phototherapy. Advances in technology may lead to the continuing use of UVB phototherapy as a treatment for vitiligo through the development of sophisticated devices and delivery systems as well as innovative application methods. These will provide increased therapeutic options for all vitiligo patients, particularly those with refractory disease. In this article, I have reviewed the available data pertaining to efficacy and safety issues for NB-UVB as monotherapy, its comparison with psoralen plus UVA and other modes of phototherapy, combination regimens that have been tried and future prospects of NB-UVB in vitiligo.

Nonsteroidal Topical Immunomodulators in Allergology and Dermatology

The purpose of this study was to review currently available literature data concerning pathomechanisms of action, indications, treatment efficacy, as well as side effects of nonsteroidal immunomodulators used in dermatology, primarily for the treatment of allergic dermatoses. MEDLINE search was undertaken using the key words “Topical Immunomodulators, Dermatology and Allergy”. Full articles, and nothing but full articles, were used.

The Safety and Efficacy of Narrow Band Ultraviolet B Treatment in Dermatology: A Review

Narrow-band ultraviolet B (NBUVB) phototherapy is an important treatment modality in dermatology. The most common dermatological indications for NBUVB include psoriasis, atopic dermatitis and vitiligo; however, it has been found to be an effective and well-tolerated treatment option in various other dermatoses. The efficacy of NBUVB phototherapy compares favorably with other available photo(chemo)therapy options and its efficacy is further augmented by a number of topical and systemic adjuncts. The long-term safety of NBUVB phototherapy remains to be fully elucidated; however, available data now suggest that it is safe and well-tolerated. The objective of this review was to summarize the current understanding of the safety and efficacy of NBUVB phototherapy in dermatology.

A combination of excimer laser treatment and topical tacrolimus is more effective in treating vitiligo than either therapy alone for the initial 6 months, but not thereafter

BACKGROUND

There are insufficient data on the long-term outcome of a combination therapy that comprises phototherapy and topical administration of tacrolimus.

AIM

To evaluate the clinical efficacy according to the duration of treatment and in vitro results of a combination therapy involving topical tacrolimus and an excimer laser in the treatment of vitiligo.

METHODS

In total, 276 patients with nonsegmental vitiligo were treated with an excimer laser twice weekly, or with tacrolimus ointment twice daily, or both. The melanin contents and levels of melanogenic enzymes were measured in cultured human melanocytes treated with tacrolimus and/or excimer laser.

RESULTS

After adjusting for potential confounders, the combination of tacrolimus plus excimer laser was significantly more effective than either tacrolimus or excimer laser alone (P < 0.001 and P < 0.01, respectively) for the first 6 months. However, this superiority was not observed after the initial 6 months of treatment. In vitro, the combination of tacrolimus plus excimer laser led to a higher level of melanogenesis than with either treatment alone.

CONCLUSIONS

A combination treatment with topical tacrolimus and an excimer laser may be useful as an induction therapy for up to 6 months, but continuation of this therapy for > 6 months might not provide a better final outcome than monotherapy.

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.

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.

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).