Nonsegmental vitiligo and autoimmune mechanism

Acquired Idiopathic Generalized Anhidrosis (AIGA) and Its Complications: Implications for AIGA as an Autoimmune Disease

Acquired idiopathic generalized anhidrosis (AIGA) is a rare disorder in which systemic anhidrosis/hypohidrosis occurs without causative dermatological, metabolic or neurological disorder. Most cases of AIGA have been reported in Asia, especially in Japan, but there have been only a few reports in Europe and the United States. Severe AIGA may result in heatstroke and can reduce quality of life due to restriction of exercise and outdoor works. AIGA is often accompanied by cholinergic urticaria (CholU), and it is thought that AIGA and CholU with anhidrosis/hypohidrosis belong to the same spectrum of the disease. However, the pathophysiology of AIGA has not yet been clarified. Decreased expression of cholinergic receptor M3 on the epithelial cells of eccrine sweat glands is often accompanied by T cell infiltration around eccrine apparatus, suggesting an immunological mechanism of disordered perspiration. AIGA is occasionally associated with various complications indicative of autoimmune disorders. The association of autoimmune complications further suggests that AIGA is an autoimmune disorder. Studies on complications may lead to a better understanding of the pathophysiology of AIGA.

The effects of tacrolimus plus phototherapy in the treatment of vitiligo: a meta-analysis

The objective of this meta-analysis was performed to compare the effects of tacrolimus plus phototherapy in the treatment of patients with vitiligo. Relevant studies were identified by searching PubMed, Embase, and Web of Science databases. The main outcomes of interest included excellent response (≥ 75% repigmentation), good response (50-75% repigmentation), moderate response (25%-50% repigmentation), and poor response (< 25% repigmentation). Risk ratio (RR) with 95% confidence intervals (95% CIs) was used to calculate the data. Eleven studies were included in this study. Compared with phototherapy alone, combination treatment of tacrolimus and phototherapy significantly improved excellent response rate (RR = 1.40, 95% CI 1.16, 1.69; P < 0.001) and reduced the poor response rate (RR = 0.37, 95% CI 0.22, 0.61; P = 0.001). However, the good response rate (RR = 1.00, 95% CI 0.59, 1.69, P = 1.000) and moderate response rate (RR = 0.91, 95% CI 0.60, 1.38; P = 0.653) were not significantly different between the two treatments. Subgroup analysis suggested that combination treatment had a higher excellent response rate than phototherapy alone for lesions located in the face and proximal limbs. Both NB-UVB and EL, when added to tacrolimus, resulted in a significantly higher excellent response rate than they were used alone. Meta-regression analysis showed that age was a predictive factor that influenced the effect of combination treatment on an excellent response, in which children had a high excellent response to the treatment. Other demographic and clinical variables, including gender, disease duration, family history, and type of vitiligo, did not have any impact on the treatment effect. Combination treatment with tacrolimus and phototherapy was more effective than phototherapy monotherapy for patients with vitiligo, especially in the lesions located in the face and proximal limbs. More large-scale, well-performed trials are needed to verify our findings.

Serum Zinc Level in Vitiligo: A Case-control Study

Background:

Vitiligo is characterized by the idiopathic destruction of melanocytes, probably of autoimmune etiology, that results in depigmented patches of skin and mucosal surfaces. Oxidative stress may contribute to the pathogenesis of vitiligo. Zinc, a trace element with antiapoptotic properties, plays a major role in the process of melanogenesis and elimination of free radicals. The present study was conducted with the aim of comparing serum zinc levels in patients with vitiligo and in normal controls.

Materials and Methods:

In this case–control study, we studied 103 patients with vitiligo and 103 healthy sex-and age-matched controls. Serum zinc levels were measured in these two groups using atomic absorption spectrophotometry and compared with each other.

Results:

The mean serum zinc level was 92.1 mcg/dl in the focal vitiligo, 81.3 mcg/dl in the generalized vitiligo, and 91.8 mcg/dl in the control group. A significant difference in serum zinc levels was observed between the patients with generalized vitiligo and the controls. Lower serum zinc levels were also correlated with longer duration of the disease. Furthermore, a negative relationship was found between serum zinc level and age of patients with vitiligo.

Conclusion:

Serum zinc level is low in patients with generalized vitiligo. In these patients, serum zinc level is in negative correlation with patient's age and disease duration.

Prevalence and Clinical Characteristics of Itch in Vitiligo and Its Clinical Significance

Objective

Vitiligo usually presented as asymptomatic depigmented macules and patches. Little is known regarding itch in vitiligo. This study aimed to evaluate the prevalence and characteristics of itch in vitiligo patients.

Patients and Methods

A cross-sectional study was conducted on vitiligo patients. Itch character and intensity were determined through questionnaires. Evaluation was also made by dermatologists to define vitiligo subtype, body surface area, Koebner phenomenon (KP), and so on. Data were assessed by computer software. Results were considered statistically significant if p < 0.05.

Results

Among 402 patients, itch on vitiliginous lesion presented in 20.2%. Prevalence of itch was most common in focal vitiligo (29.4%), followed by segmental vitiligo (20.3%) and nonsegmental vitiligo (19.6%), respectively. Tingling sensation was the most common itch-related symptom (82.7%). The median itch intensity is 5 by 10-point visual analog scale. Daily activity and sleep disturbance were observed in 60.5% and 39.5% of patients who experience itch. Itch occurred approximately 3 days prior to the development of lesions in 48.1% of patients. Thirty-two patients (78.1%) with both itch and KP type IIb had active disease.

Conclusions

Itch in vitiligo is not uncommon. The presence of itch with KP type IIb may warrant the active vitiligo.

Immune and molecular correlates in melanoma treated with immune checkpoint blockade

Immunotherapy for metastatic melanoma has a decades-long history, and the relatively recent use of checkpoint inhibitors has revolutionized treatment. Durable and sometimes complete remission of metastatic melanoma is now achievable in some patients who receive checkpoint-blocking therapy. However, it is unclear why some patients fare better than others. This review highlights several molecular indicators of response to checkpoint inhibition in metastatic melanoma, focusing on tumor programmed death ligand 1 expression, major histocompatibility complex class I expression, mutational load in the tumor, and T-cell infiltration into the tumor. In addition, clinical correlates of response, notably vitiligo and other immune-related adverse events, can potentially shed light on the mechanisms by which checkpoint blockade may achieve such great success, particularly in melanoma. The authors propose that microphthalmia-associated transcription factor-a key regulator of melanocyte survival, melanin production, and melanoma transformation-produces a molecular landscape in melanocytes and melanoma cells that can make melanomas particularly susceptible to checkpoint blockade and also can result in immune attack on normal melanocytes. Cancer 2017;123:2143-53. © 2017 American Cancer Society.

Evaluation of the serum zinc level in patients with vitiligo

Introduction

Vitiligo is an acquired, idiopathic disorder characterized by circumscribed depigmented macules and patches, which affects approximately 0.1–2% of the general population worldwide. Zinc is an essential trace element that is necessary for growth and development at all stages of life. Some studies have reported an association between serum zinc levels and vitiligo.

Aim

To measure the serum zinc level in patients with vitiligo compared to healthy subjects.

Material and methods

One hundred patients with vitiligo and 100 healthy controls were referred to our clinic. The two groups were matched for age and sex. Atomic absorption spectrophotometry was used to measure serum zinc levels. The statistical analysis was performed using SPSS software.

Results

The mean serum level of zinc in vitiligo patients and controls was 80.11 ±17.10 μg/dl and 96.10 ±16.16 μg/dl, respectively. The serum zinc level in patients with vitiligo was significantly lower than in healthy controls (p = 0.0001).

Conclusions

The results of our study revealed a significant association between vitiligo and serum zinc levels. A relative decrease in the serum zinc level in vitiligo patients can highlight the role of zinc in the pathogenesis of vitiligo, and large-scale studies need to be conducted to confirm these findings and assess the effect of oral zinc supplements in patients with low zinc levels.

Decreased Circulating T Regulatory Cells in Egyptian Patients with Nonsegmental Vitiligo: Correlation with Disease Activity

Background. Vitiligo is an acquired depigmentary skin disorder resulting from autoimmune destruction of melanocytes. Regulatory T cells (Tregs), specifically CD4⁺CD25⁺ and Forkhead box P3⁺ (FoxP3⁺) Tregs, acquired notable attention because of their role in a variety of autoimmune pathologies. Dysregulation of Tregs may be one of the factors that can break tolerance to melanocyte self-antigens and contribute to vitiligo pathogenesis. Methods. In order to sustain the role of Tregs in pathogenesis and disease activity of vitiligo, surface markers for CD4⁺CD25⁺ and FoxP3⁺ peripheral Tregs were evaluated by flow cytometry in 80 Egyptian patients with nonsegmental vitiligo in addition to 60 healthy control subjects and correlated with clinical findings. Results. Vitiligo patients had significantly decreased numbers of both peripheral CD4⁺CD25⁺ and FoxP3⁺ T cells compared to control subjects (11.49%  ± 8.58% of CD4⁺ T cells versus 21.20%  ± 3.08%, and 1.09%  ± 0.96% versus 1.44%  ± 0.24%, resp., P < 0.05 for both). Peripheral numbers of CD4⁺CD25⁺ and FoxP3⁺ Tregs correlated negatively with VIDA score. Conclusion. Treg depletion with impaired immune downregulatory function might play a key role in the autoimmune conditions beyond nonsegmental vitiligo particularly in active cases. Effective Treg cell-based immunotherapies might be a future hope for patients with progressive vitiligo.

Immunological Parameters Associated With Vitiligo Treatments: A Literature Review Based on Clinical Studies

Vitiligo, a depigmentary disorder, caused by the loss of melanocytes, affects approximately 1% of the world population, irrespective of skin type, with a serious psychological impact on the patient quality of life. So far, the origin of vitiligo has not been traced and the pathogenesis is complex, involving the interplay of a multitude of variables. Although there is no treatment that ensures the complete cure of the disorder, there are some pharmacological, phototherapy, and surgical therapies available. A series of variables can affect treatment outcome, such as individual characteristics, emotional issues, type of vitiligo, stability of the lesions, and immunological status. The present literature review identified the main immunological parameters associated with treatments for vitiligo. Cytotoxic CD8+ T lymphocytes are the main cell type involved in treatment success, as fewer cells in skin lesions are associated with better results. Other parameters such as cytokines and regulatory T cells may also be involved. Further clinical scientific studies are needed to elucidate the complex mechanisms underlying vitiligo and its treatments, in order to expand the range of therapeutic approaches for each individual case.

Clinical Analysis of Thyroglobulin Antibody and Thyroid Peroxidase Antibody and their Association with Vitiligo

Background:

Recently, the abnormal presence of thyroglobulin antibody (TG-Ab) and thyroid peroxidase antibody (TPO-Ab) has been reported in vitiligo patients, but presence of TG-Ab and TPO-Ab in patients of different ages and gender, and its association with vitiligo and thyroid autoimmunity has rarely been reported. The aim of our research was to determine whether vitiligo was associated with thyroid autoimmunity and figure out its relationship with age and gender.

Materials and Methods:

We analyzed TG-Ab, TPO-Ab in age and gender matched 87 vitiligo patients and 90 healthy controls, the patients of vitiligo who were positive for the presence of TG-Ab and TPO-Ab were followed up to confirm autoimmune thyroid disease subsequently.

Results:

Results showed that the frequencies of TG-Ab (23.0%, 20/87) positivity and TPO-AB (24.1%, 21/87) in vitiligo patients were significantly higher than that in healthy controls (P < 0.05). Moreover, The positivity for of TG-Ab and TPO-Ab was higher in 11-20-year age group and 21-40-year age group than that in age matched healthy controls. We found female patients with vitiligo had higher positive frequencies of TG-Ab and TPO-Ab than healthy female controls. (34.1% vs. 8.8% and 34.1% vs. 11.1%, P = 0.000 and P = 0.011). When 20 patients with TG-Ab and TPO-Ab positivity were followed up for three monthes, 14 of them (70%) were diagnosed as having autoimmune thyroid disease compared with age-matched healthy controls (16.7%, χ² = 5.4, P = 0.02).

Conclusion:

TG-Ab and TPO-Ab are likely to be found in female teenagers with vitiligo, and are relevant with respect to subsequent development autoimmune thyroid disease.

Development of autoimmune hair loss disease alopecia areata is associated with cardiac dysfunction in C3H/HeJ mice

Alopecia areata (AA) is a chronic autoimmune hair loss disease that affects several million men, women and children worldwide. Previous studies have suggested a link between autoimmunity, stress hormones, and increased cardiovascular disease risk. In the current study, histology, immunohistology, quantitative PCR (qPCR) and ELISAs were used to assess heart health in the C3H/HeJ mouse model for AA and heart tissue response to adrenocorticotropic hormone (ACTH) exposure. Mice with AA exhibited both atrial and ventricular hypertrophy, and increased collagen deposition compared to normal-haired littermates. QPCR revealed significant increases in Il18 (4.6-fold), IL18 receptor-1 (Il18r1; 2.8-fold) and IL18 binding protein (Il18bp; 5.2-fold) in AA hearts. Time course studies revealed a trend towards decreased Il18 in acute AA compared to controls while Il18r1, Il18bp and Casp1 showed similar trends to those of chronic AA affected mice. Immunohistochemistry showed localization of IL18 in chronic AA mouse atria. ELISA indicated cardiac troponin-I (cTnI) was elevated in the serum and significantly increased in AA heart tissue. Cultures of heart atria revealed differential gene expression between AA and control mice in response to ACTH. ACTH treatment induced significant increase in cTnI release into the culture medium in a dose-dependent manner for both AA and control mice. In conclusion, murine AA is associated with structural, biochemical, and gene expression changes consistent with cardiac hypertrophy in response to ACTH exposure.

Association of FOXP3 (rs3761548) promoter polymorphism with nondermatomal vitiligo: A study from India

BACKGROUND

The rs3761548 polymorphism (-3279 C>A) of FOXP3 gene is associated with several autoimmune disorders.

OBJECTIVE

We sought to determine whether rs3761548 polymorphism is associated with nondermatomal vitiligo in Indian subjects.

METHODS

Genomic DNA was isolated from blood samples of 303 patients and 305 control subjects and genotyping was done by allele-specific primers. Data analysis was carried out for the entire cohort and separately for male and female participants as FOXP3 is an X-linked marker. Statistics were performed using software.

RESULTS

The genotype frequencies differed significantly from patients to control subjects (P = .002). Further analysis demonstrated female participants with CC genotype were protected (CC vs CA+AA; odds ratio 0.38, 95% confidence interval 0.238-0.615) and those with CA genotype were at higher risk to develop vitiligo (CA vs CC+AA; odds ratio 2.634, 95% confidence interval 1.604-4.325). However, no such statistical difference was observed in male participants.

LIMITATIONS

Our study is, to our knowledge, the first report from India with respect to vitiligo and rs3761548; however, we lack adequate literature assistance.

CONCLUSIONS

The rs3761548 of FOXP3 gene in our population may be associated with susceptibility to vitiligo because of altered expression. CC genotype appears to be protective and CA genotype seems to impart nearly 3-fold risk to develop vitiligo in women and girls.

Epigenetics, autoimmunity and hematologic malignancies: a comprehensive review

The relationships between immunological dysfunction, loss of tolerance and hematologic malignancies have been a focus of attention in attempts to understand the appearance of a higher degree of autoimmune disease and lymphoma in children with congenital immunodeficiency. Although multiple hypotheses have been offered, it is clear that stochastic processes play an important role in the immunopathology of these issues. In particular, accumulating evidence is defining a role of epigenetic mechanisms as being critical in this continuous spectrum between autoimmunity and lymphoma. In this review, we focus attention predominantly on the relationships between T helper 17 (Th17) and T regulatory populations that alter local microenvironments and ultimately the expression or transcription factors involved in cell activation and differentiation. Abnormal expression in any of the molecules involved in Th17 and/or Treg development alter immune homeostasis and in genetically susceptible hosts may lead to the appearance of autoimmunity and/or lymphoma. These observations have clinical significance in explaining the discordance of autoimmunity in identical twins. They are also particularly important in the relationships between primary immune deficiency syndromes, immune dysregulation and an increased risk of lymphoma. Indeed, defining the factors that determine epigenetic alterations and their relationships to immune homeostasis will be a challenge greater or even equal to the human genome project.

Piebaldism

Piebaldism is an uncommon autosomal dominantly inherited pigment anomaly characterized by a congenital white forelock and leukoderma on the frontal scalp, forehead, ventral trunk and extremities. It is caused by a loss-of-function mutation in the KIT gene. Genetic analyses reveal a consistent genotype-phenotype relationship in piebaldism. However, recently reported cases of piebaldism that are milder or severer than genetically expected indicate that other factors, such as a modifier gene of MC1R, influence skin and hair color. The KIT ligand/KIT that triggers the Ras/mitogen-activated protein kinase signaling pathway play essential functions in the migration, proliferation, survival, melanogenesis and melanosome transfer of the melanocytes. We summarize current research progress in piebaldism and related disorders.

Treatment of vitiligo vulgaris with the combination therapy of topical steroid and vitamin D3 compound

We report here two cases of vitiligo vulgaris successfully treated with the combination therapy of topical steroid and vitamin D3 compound and currently maintained by vitamin D3 analog without any adverse effects: skin atrophy, striae or telangiectasia on the exposed areas. The best-known mechanism of topical vitamin D3 analog is the enhancement of keratinocytes differentiation and anti-proliferative effects. Vitamin D3 analog is also reported to suppress T-cell mediated immunity, T-cell skin recruitment, and skin infiltration via down-regulating cutaneous lymphocyte antigen expression. Furthermore, vitamin D3 compounds are known to influence melanocyte maturation and differentiation and also to up-regulate melanogenesis. Autoreactive lymphocytes against melanocytes are one of the causes. Topical vitamin D3 analog may control vitiligo itself, however stronger immunosuppressive effects of topical corticosteroid may contribute to rapid re-pigmentation suppressing auto-reactive lymphocytes. The topical combination therapy is a simple, effective and safe option for vitiligo vulgaris in sun-exposed areas.