Efficacy of narrow band UVB with or without OMP in stabilization of vitiligo activity in skin photo-types (III-V): A double-blind, randomized, placebo-controlled, prospective, multicenter study

Combination of Baricitinib and Phototherapy in Adults With Active Vitiligo: A Randomized Clinical Trial

Importance

Vitiligo is a chronic autoimmune disorder leading to skin depigmentation and reduced quality of life (QOL). Patients with extensive and very active disease are the most difficult to treat.

Objective

To assess the efficacy and adverse events of baricitinib combined with narrowband UV-B in adults with severe, active, nonsegmental vitiligo.

Design, Setting, and Participants

This academic, multicenter, double-blind, noncomparative randomized clinical trial was conducted at 4 dermatology departments between July 2021 and April 2023 and included adult patients with extensive and active nonsegmental vitiligo. The study was designed to evaluate the effect of baricitinib plus narrowband UV-B based solely on the results from this experimental group. The placebo group was used as a calibration group. Data were analyzed from August to November 2023.

Interventions

Participants were randomized 3:1 to baricitinib, 4 mg per day, or placebo for 36 weeks alone for the first 12 weeks and then in combination with narrowband UV-B twice a week from weeks 12 to 36.

Main Outcomes and Measures

The primary outcome was mean percentage change in total Vitiligo Area Scoring Index (VASI) score from baseline to week 36 (baricitinib group). The prespecified aim of the study was to show that the reduction in the baricitinib plus narrowband UV-B was significantly greater than 42.9%, a repigmented surface threshold previously observed in patients treated with narrowband UV-B alone. Adverse events and secondary outcomes of change in disease activity and QOL were assessed. Post hoc analyses were additionally performed.

Results

Of 49 included patients, 35 (71%) were female, and the median (IQR) age was 49.9 (38.4-59.8) years. A total of 37 patients were randomized to the baricitinib group and 12 to the placebo group. The mean change in total VASI at week 36 was -44.8% (95% CI, -58.4% to -31.3%) for the baricitinib group and -9.2% (95% CI, -27.7% to 24.7%) for the placebo group. This was not significantly greater than the sufficient repigmented surface threshold of 42.9%. Post hoc analyses showed a significant difference at week 36 for total VASI score in the baricitinib plus narrowband UV-B group compared with placebo plus narrowband UV-B (-44.8% vs -9.2%, respectively; P = .02). There was a greater improvement in disease activity and QOL in the baricitinib group vs placebo group and no significant difference in the number of adverse events.

Conclusions and Relevance

This proof-of-concept randomized clinical trial confirmed the efficacy of baricitinib combined with narrowband UV-B in the treatment of patients with extensive and active vitiligo.

Trial Registration

ClinicalTrials.gov Identifier: NCT04822584.

Combination Therapy with Baricitinib and Narrowband Ultraviolet B for Active Non-Segmental Vitiligo: A Retrospective Controlled Study

Background

Vitiligo is a chronic autoimmune disease manifested by depigmented patches of skin devoid of melanocytes. Baricitinib, a JAK inhibitor selectively targeting JAK1/2, has shown preliminary efficacy for vitiligo. We aimed to assess the efficacy and tolerability of combination therapy with baricitinib and narrowband UV-B (NB-UVB) to treat active nonsegmental vitiligo (NSV).

Methods

We formed a combination group of 52 patients with NSV receiving baricitinib and NB-UVB irradiation, and a control group of 49 patients with NSV receiving oral mini-pulse (OMP) methylprednisolone and NB-UVB irradiation. Efficacy analysis was conducted for the 6-month period. Six months after the last treatment, the recurrence rates were investigated through follow-up.

Results

From the first month, the mean total vitiligo area scoring index (VASI) score was significantly reduced in the combination group when compared to that in the control group. Starting on the fourth month, the overall response rates (ORRs) were significantly higher in the combination group than in the control group (P=0.034). By the sixth month, the ORRs reached 86.5% in the combination group, whereas they reached 67.3% in the control group (P=0.022). The serum levels of IFN-γ and CXCL10 in the combination group decreased from 38.52±5.98 pg/mL and 976.67±150.57 pg/mL at baseline to 26.46±5.93 pg/mL and 704.14±103.38 pg/mL at the 6-month juncture, respectively (P<0.001). Moreover, we found that there was no significant difference in recurrence rates within 6 months after stopping treatment in both groups. Three patients (5.8%) in the combination group reported developing itchy skin during the first month of treatment period, and one patient (1.9%) developed erythema; no other serious adverse events occurred.

Conclusion

Our observations suggest that the combination therapy with baricitinib and NB-UVB is a promising strategy against NSV. Patients tolerated the treatment well without serious AEs, these results expand treatment options for vitiligo patients, warranting larger clinical trials.

Impact of Combined Phototherapy and Melanocyte Transplantation on Indicators of Vitiligo Activity

OBJECTIVE

To investigate the effect of phototherapy combined with melanocyte transplantation on the activity index of vitiligo.

METHODS

One hundred twenty patients with stable vitiligo were selected and divided into 2 groups: phototherapy group ( n = 60) and phototherapy combined with melanocyte therapy group ( n = 60). Patients' vitiligo activity scores before and 6 months after treatment, patients' skin pigmentation responses 6 months after treatment, and patients' new Koebner cases 6 months after treatment were compared. The expression of tyrosinase and Melan-A in the skin samples was analyzed by immunohistochemistry.

RESULTS

The effect of skin surface repigmentation in the observation group was better than that in the control group ( p < .05). The expression of tyrosinase and Melan-A in the observation group was higher than that in the control group ( p < .05), indicating that the combined treatment could enhance the function of melanocytes. After 6 months of treatment, the incidence of the Koebner phenomenon in the observation group was lower than that in the control group ( p < .05).

CONCLUSION

The combination of phototherapy and melanocyte transplantation can obviously improve the activity index of vitiligo, slow down the spread of white spots, reduce the formation of new white spots, and reduce the occurrence of the Koebner phenomenon.

Combination of total glucosides of paeony, narrow-band ultraviolet B, and oral corticosteroid mini-pulse therapy for nonsegmental vitiligo: A retrospective study

BACKGROUND

The total glucoside of paeony (TGP) is recognized for its immunomodulatory properties and anti-inflammatory effects. This study evaluates the efficacy of TGP combined with oral mini-pulse therapy (OMP) and narrow-band ultraviolet B (NB-UVB) in treating active nonsegmental vitiligo (NSV).

MATERIALS AND METHODS

The combination therapy was contrasted against those from a group treated solely with OMP and NB-UVB. Data from 62 patients undergoing TGP combination treatment and 55 without were analyzed over a 3-month period. After 6 months, the differences in recurrence rate were investigated by follow-up.

RESULTS

The findings indicate that integrating TGP may yield superior outcomes compared to OMP + NB-UVB alone. Moreover, the patient's oxidative stress makers were significantly reduced after the treatment. The majority of patients in the TGP cohort exhibited enhanced skin pigmentation over the duration. Notably, no increase in side effects or recurrence was observed in this group. Especially, patients with vitiligo on their head and neck experienced pronounced improvements.

CONCLUSION

The efficacy of the combination treatment group was better than that of the control group at 2 and 3 months, and there was no difference in recurrence rate and side effects, suggesting that TGP may continue to show efficacy in NSV for a longer period of time by reducing the level of oxidative stress, and is especially suitable for patients with head and neck lesions.

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.

Worldwide expert recommendations for the diagnosis and management of vitiligo: Position statement from the International Vitiligo Task Force Part 1: towards a new management algorithm

BACKGROUND

The treatment of vitiligo can be challenging and depends on several factors such as the subtype, disease activity, vitiligo extent, and treatment goals. Vitiligo usually requires a long-term approach. To improve the management of vitiligo worldwide, a clear and up-to-date guide based on international consensus with uniform stepwise recommendations is needed.

OBJECTIVES

To reach an international consensus on the nomenclature and to develop a management algorithm for the diagnosis, assessment, and treatment of vitiligo.

METHODS

In this consensus statement, a consortium of 42 international vitiligo experts and four patient representatives participated in online and live meetings to develop a consensus management strategy for vitiligo. At least two vitiligo experts summarized the evidence of topics included in the algorithms. A survey was utilized to resolve remaining issues among a core group of eight experts. Subsequently, the unanimous recommendations were finalized and validated based on further input from the entire group during two live meetings.

RESULTS

The algorithms highlight the importance of shared decision-making. Dermatologists are encouraged to provide patients with detailed explanations of the prognosis and expected therapeutic outcomes based on clinical examination. The treatment goal should be discussed and clearly emphasized to patients given the different approaches for disease stabilization and repigmentation. The evaluation of disease activity remains a cornerstone in the tailor-made approach to vitiligo patients.

CONCLUSIONS

These new treatment algorithms are intended to guide clinical decision-making in clinical practice. Promising novel therapies for vitiligo are on the horizon, further highlighting the need for reliable outcome measurement instruments and greater emphasis on shared decision-making.

Worldwide expert recommendations for the diagnosis and management of vitiligo: Position statement from the international Vitiligo Task Force-Part 2: Specific treatment recommendations

BACKGROUND

The treatment of vitiligo can be challenging. Up-to-date agreed consensus recommendations on the use of topical and systemic therapies to facilitate the clinical management of vitiligo are currently lacking.

OBJECTIVES

To develop internationally agreed-upon expert-based recommendations for the treatment of vitiligo.

METHODS

In this consensus statement, a consortium of 42 international vitiligo experts and four patient representatives participated in different online and live meetings to develop a consensus management strategy for vitiligo. At least two vitiligo experts summarized the evidence for different topics included in the algorithms. A survey was then given to a core group of eight experts to resolve the remaining issues. Subsequently, the recommendations were finalized and validated based on further input from the entire group during two live meetings.

RESULTS

The recommendations provided summarize the latest evidence regarding the use of topical therapies (steroids, calcineurin inhibitors and Jak-inhibitors) and systemic therapies, including steroids and other systemic immunomodulating or antioxidant agents. The different modalities of phototherapies (NB-UVB, photochemotherapy, excimer devices and home phototherapy), which are often combined with other therapies, are also summarized. Interventional approaches as well as depigmentation strategies are presented for specific indications. Finally, the status of innovative and targeted therapies under development is discussed.

CONCLUSIONS

This international consensus statement culminated in expert-based clinical practice recommendations for the treatment of vitiligo. The development of new therapies is ongoing in vitiligo, and this will likely improve the future management of vitiligo, a disease that still has many unmet needs.

The value of adding platelet-rich plasma (PRP) to noncultured epidermal cell suspension (NCECS) in surgical treatment of stable resistant vitiligo: A self-controlled randomised double-blinded study

BACKGROUND

Noncultured epidermal cell suspension (NCECS) is a commonly used surgical treatment for resistant stable acral vitiligo and vitiligo overlying joints. Platelet-rich plasma (PRP) has been reported to enhance the repigmentation response of different therapeutic modalities for vitiligo, including vitiligo surgery.

OBJECTIVE

To assess the value of adding of PRP to NCECS in the surgical treatment of acral vitiligo and vitiligo overlying joints.

PATIENTS AND METHODS

This self-controlled randomised trial included 15 patients with 30 lesions in which NCECS suspended in PRP was performed for one lesion and NCECS in ringer's lactate for another comparable lesion. Following NCECS, patients underwent thrice weekly excimer light sessions for 3 months. After 8 weeks, patients underwent preliminary assessment. By the end of the 3 months, both lesions were compared as regards improvement in surface area and pigmentation. Additionally, physician global assessment was made by a blinded investigator.

RESULTS

Significant improvement was reported in both lesional extent and pigmentation (after PRP and lactated ringer NCECS) with no statistical difference between them.

CONCLUSION

Despite previous promising results, suspending NCECS in PRP offered no privilege in surgical treatment of acral vitiligo and vitiligo overlying joints, which are quite resistant to treat.

PAN AFRICAN CLINICAL TRIAL REGISTRY ID

PACTR202108873035929, Date: 16 August 2021.

Comparative Analysis of the Most Used Versus the Recently Developed Vitiligo Activity and Extent Scores and Their Change with Treatment

INTRODUCTION

There are diverse assessment tools for vitiligo, with no standardized approach that helps unify treatment outcome measures. Thus, comparing different treatment modalities and developing evidence-based recommendations for vitiligo management has been quite challenging.

OBJECTIVES

We compared the most commonly used tools assessing both vitiligo activity and extent, namely, Vitiligo Disease Activity Score (VIDA) and Vitiligo Area and Severity Index (VASI) score to their newly developed counterparts, namely, Vitiligo Extent Score Plus (VES plus) and Vitiligo Signs of Activity score (VSAS), to provide insights that would help set recommendations for a unified outcome assessment protocol for vitiligo patients.

METHODS

Thirty-six active non-segmental vitiligo cases were recruited, 30 of whom completed 48 sessions of narrow band ultraviolet B (NB-UVB). Patients were assessed for both extent and activity both before and after treatment with NB-UVB. Scores were correlated. Additionally, VES plus was assessed for its reliability in comparison to VASI score.

RESULTS

Both extent (VASI and VES plus) and activity scores (VIDA and VSAS) showed significant improvement following treatment. Additionally, VES plus and VASI were positively correlating both before and after treatment as well as their percent change. Furthermore, VES plus proved as reliable as VASI. Regarding activity scores, total, hypochromic and Koebner VSAS only correlated with VIDA following treatment. Confetti VSAS neither correlated with VIDA before nor after treatment.

CONCLUSIONS

VES plus and VASI scores have proven of comparable reliability. While examination-based VSAS score comes as an additive tool to the history-based VIDA score.

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.

Acceleration of melanocyte senescence by the proinflammatory cytokines IFNγ and TNFα impairs the repigmentation response of vitiligo patients to narrowband ultraviolet B (NBUVB) phototherapy

Vitiligo is a chronic autoimmune disease characterized by the T helper 1 (Th1) cytokine-driven immune destruction of melanocytes (MCs). Although narrowband ultraviolet B (NBUVB) phototherapy has been proven to be an effective therapeutic option, the repigmentation response to that phototherapy varies greatly in different vitiligo patients. Here, we demonstrate that there is an increase of NBUVB-induced cellular senescence in vitiligo MCs exposed to Th1 cytokine interferon γ (IFNγ) and/or tumor necrosis factor α (TNFα) in lesional vitiligo skin from poor responders who had undergone NBUVB phototherapy. Supplementation with exogenous recombinant human stem cell factor (rhSCF) in the culture medium as well as the lentiviral vector-mediated overexpression of cKIT could prevent the MCs from the IFNγ/TNFα-accelerated cellular senescence. Mechanistic studies indicated that the reduced ratio of membrane-bound KIT (mKIT) to the soluble form of KIT (sKIT) is directly related to the cellular senescence of vitiligo MCs following exposure to IFNγ and TNFα. Furthermore, the matrix metalloprotease 9 (MMP9) inhibitor GM6001 attenuates the production of sKIT via the suppression of cKIT ectodomain shedding. Altogether, our study indicates that the presence of Th1 cytokines IFNγ and/or TNFα in the epidermal milieu might impair the repigmentation response of vitiligo patients to NBUVB phototherapy.

Update on pharmacology, actions, dosimetry and regimens of oral glucocorticoids in dermatology

Glucocorticoids are arguably the most widely used and misused drug in dermatology. There have been recent updates in its mode of action which can impact on its judicious use. There is need to use the correct steroid preparation to maximize results and minimize side effects. We present an updated review on glucocorticoids focusing on its mode of action, rationale of its prescribing considerations and dosing regimens in dermatology. This is based on PubMed search with a focus on mode of actions and dosimetry with additional updates from standard drug books, databases and rheumatology books.