Pimecrolimus Cream in Repigmentation of Vitiligo

Expert Recommendations on Use of Topical Therapeutics for Vitiligo in Pediatric, Adolescent, and Young Adult Patients

Importance

Evidence-based recommendations for the treatment of vitiligo in pediatric, adolescent, and young adult patients in the US are needed.

Objective

To develop evidence- and consensus-based expert recommendations on the diagnosis and treatment of vitiligo in young patients.

Evidence Review

A process was developed to produce consensus recommendations addressing questions regarding pediatric vitiligo. A librarian-conducted literature review was performed using articles that met the inclusion criteria: published in English, containing primary data (including meta-analysis) and pediatric-specific data, and analysis of 6 or more patients. Included articles were graded by the Strength of Recommendation Taxonomy criteria and Oxford Centre for Evidence-based Medicine's Levels of Evidence and Grades of Recommendation. Research questions were reviewed on May 9, 2022, through a video conference. One month after the conference, participants participated in an online survey documenting their level of agreement with the generated statements, using a 5-point Likert scale.

Findings

Articles on topical corticosteroids and/or topical calcineurin inhibitors (n = 50), topical Janus kinase inhibitors (n = 5), pseudocatalase (n = 2), and microdermabrasion (n = 2) met inclusion criteria. Forty-two recommendations were made on the diagnosis of vitiligo and optimal topical therapeutics, with 33 recommendations obtaining a 70% or greater composite agreement and strong agreement. Topical calcineurin inhibitors twice daily, topical corticosteroids with time limitation due to atrophy risk, and topical ruxolitinib, 1.5%, cream-used off-label for patients younger than 12 years and limited to nonsegmental vitiligo-were identified as evidence-based first-line therapies in the management of pediatric and adolescent patients, with specific guidance on age-based data, minimum therapeutic trial of 6 months or greater, prolonged therapy to prevent recurrence, and the positive benefit of coordinated use of UV therapeutic sources.

Conclusions and Relevance

Evidence supports the use of topical calcineurin inhibitors, topical corticosteroids, and topical Janus kinase inhibitors as effective therapeutics for vitiligo in pediatric, adolescent, and young adult patients, with specific decisions on choice of agent based on factors such as site location, body surface area, and age.

Antioxidant mechanisms of mesenchymal stem cells and their therapeutic potential in vitiligo

Vitiligo is a skin pigmentation disorder caused by melanocyte damage or abnormal function. Reac-tive oxygen species Reactive oxygen species can cause oxidative stress damage to melanocytes, which in turn induces vitiligo. Traditional treatments such as phototherapy, drugs, and other methods of treatment are long and result in frequent recurrences. Currently, mesenchymal stem cells (MSCs) are widely used in the research of various disease treatments due to their excellent paracrine effects, making them a promising immunoregulatory and tissue repair strategy. Furthermore, an increasing body of evi-dence suggests that utilizing the paracrine functions of MSCs can downregulate oxidative stress in the testes, liver, kidneys, and other affected organs in animal models of certain diseases. Addition-ally, MSCs can help create a microenvironment that promotes tissue repair and regeneration in are-as with oxidative stress damage, improving the disordered state of the injured site. In this article, we review the pathogenesis of oxidative stress in vitiligo and promising strategies for its treatment.

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.

A pilot study of 1% pimecrolimus cream for the treatment of childhood segmental vitiligo

Background

There is as yet no effective and safe treatment for vitiligo. One percent pimecrolimus cream, a topical calcineurin inhibitor, has been tried for the treatment of vitiligo, with its therapeutic efficacy having mostly been reported in non-segmental vitiligo. However, questions about the therapeutic efficacy of 1% pimecrolimus cream have remained unanswered regarding segmental vitiligo.

Objective

The aim of this study was to study the therapeutic efficacy and safety of 1% pimecrolimus cream for segmental childhood vitiligo.

Methods

Nine childhood patients with segmental vitiligo were treated with 1% pimecrolimus cream twice daily for three months, after which good responders were scheduled to continue with the 1% pimecrolimus cream monotherapy. The efficacy and safety of this treatment were determined by the levels of repigmentation, initial response time and the presence of adverse events including burning, dryness, stinging and itching.

Results

Four of nine patients achieved mild to moderate responses after three months of treatment and thus continued with treatment. Among these four patients, three achieved an excellent response and one patient achieved a moderate response, with a mean treatment duration of 7.3 months. Transient local burning sensation was the most common adverse event. In comparison with the patients with poor response, those patients with good response showed a shorter disease duration (8.5±10.5 mo vs. 13.4±10.1 mo), more frequent facial involvement (4/4 patients vs. 3/5 patients) and earlier initial response after treatment (1.0±0.0 mo vs. 2.0±1.0 mo).

Conclusion

This study suggests that 1% pimecrolimus cream is an effective and well-tolerated treatment for segmental childhood vitiligo.

Vitiligo: a comprehensive overview Part II: treatment options and approach to treatment

Vitiligo is a common skin disorder that results in depigmentation. With the appropriate management, many patients can minimize disease progression, attain repigmentation, and achieve cosmetically pleasing results. There are numerous medical and surgical treatments aimed at repigmentation; therapies for depigmentation are available for patients with recalcitrant or advanced disease. The use of cosmetics at all stages of treatment may be vital to the patient's quality of life. Understanding all the available options helps choose the appropriate treatment plan and tailor it to your patient. Part II of this two-part series on vitiligo discusses the indications for, evidence behind, and adverse effects associated with many of the therapies used for vitiligo. Both conventional medical and surgical options are discussed in addition to several alternative and promising new therapies.

Vitiligo treatment in childhood: a state of the art review

Vitiligo is a common depigmenting disorder affecting about 1-2% of the world population. Approximately half of the affected individuals develop the disease before adulthood. Etiologic hypotheses for vitiligo include biochemical, neural and autoimmune mechanisms. The most compelling of these suggests a combination of genetic and immunologic factors that result in an autoimmune melanocyte destruction. We reviewed studies carried out on various treatment modalities used in childhood vitiligo. Topical corticosteroids were found to have excellent repigmentation rates, whereas calcineurin inhibitors have comparable efficacy and a better safety profile compared with topical corticosteroids. These two groups of topical medications are good first-line treatment modalities for localized vitiligo. For the treatment of generalized vitiligo, phototherapy has excellent efficacy. Narrow-band ultraviolet B (UVB) has better overall repigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA). Other treatment modalities may be considered depending on a patient's specific condition, such as surgical options and depigmentation. With adequate sun protection, the option of no treatment with or without corrective camouflage, is an innocuous alternative to any of these treatment modalities.

Innovative use of topical calcineurin inhibitors

Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.

Mometasone cream versus pimecrolimus cream for the treatment of childhood localized vitiligo

BACKGROUND

With regard to the lack of effective treatment modalities for childhood localized vitiligo, the search for newer therapeutic agents continues.

OBJECTIVE

To conduct an open, comparative trial to evaluate the clinical efficacy and safety of topical mometasone cream and pimecrolimus cream in the treatment of childhood vitiligo.

METHODS

Fifty patients with childhood vitiligo were included in the study. Patients were treated for 3 months either with mometasone cream (0.1%) once daily or with pimecrolimus cream (1%) twice daily.

RESULTS

Forty patients, 20 from each group, completed the study. The two drugs were found to be statistically significantly effective for diminishing lesion size (Z = 3.070,p = 0.002 andZ = 3.845,p < 0.001, respectively). There were no statistical differences between the two drugs:Z = 1.427,p = 0.154 (mometasone non-inferiority to pimecrolimus). The mean repigmentation rate was 65% in the mometasone group and 42% in the pimecrolimus group at the end of therapy. Atrophy, telangiectasia and erythema were observed in two patients (10%) in the mometasone cream group and a burning sensation and pruritus were observed in two patients (10%) in the pimecrolimus cream group; drop-out was not related to the observed adverse effects.

CONCLUSION

Mometasone cream was found to be effective in the treatment of vitiligo on any part of the body. Pimecrolimus was not effective on the body except for the face in childhood localized vitiligo.

Vitiligo after hematopoietic cell transplantation: six cases and review of the literature

AIM

To investigate the prevalence and clinical characteristics of vitiligo after allogeneic hematopoietic cell transplantation (AHCT).

METHODS

The development of vitiligo was analyzed among 421 patients who underwent AHCT in Ibni Sina Hospital (University of Ankara) between 1988 and 2004.

RESULTS

Among 421 patients, we describe 6 with generalized vitiligo occurring after AHCT for chronic myelogenous leukemia. Five of them had severe chronic graft-versus-host disease (GVHD). Vitiligo was accompanied by alopecia areata and acquired ichthyosis in 2 patients with GVHD.

CONCLUSION

Melanocyte destruction caused by the autoimmune reactions triggered by chronic GVHD as well as a genetic predisposition might have played a role in the development of vitiligo in our patients. These data support the hypothesis that vitiligo is an autoimmune entity.