Evaluating prevalence of depression, anxiety and hopelessness in patients with Vitiligo on an Iranian population

Fractional CO2 Laser Versus Microneedling Combined with Narrowband Ultraviolet and Topical Steroid for Treating Non-Segmental Vitiligo in Treatment-Resistant Localizations: A Comparative Randomized Clinical Trial Study

Introduction: Vitiligo poses a significant challenge, particularly in treatment-resistant areas such as acral regions. This study aimed to evaluate the effectiveness and safety of combining fractional CO2 laser and microneedling with conventional therapies for non-segmental vitiligo in resistant areas. Methods: A randomized clinical trial with a paired design was conducted on 84 individuals with non-segmental vitiligo and treatment-resistant lesions. Participants in two separate groups received various combinations of interventions, including narrowband ultraviolet B (NB-UVB) and topical steroid (Clobetasol ointment) as conventional treatments, with fractional CO2 laser or microneedling as add-ons for four symmetrical treatment-resistant lesions. The treatment duration was 16 weeks, followed by observation until six months post-intervention for each patient, and it focused on assessing the percentage of repigmentation, safety, patient satisfaction, and potential adverse effects. Results: The results of the study revealed a significant difference in average efficacy, with treatments involving fractional CO2 laser and microneedling compared with other interventions without them showing a higher percentage of repigmentation. No notable distinction in repigmentation patterns was observed, except for slightly higher marginal repigmentation with microneedling. Side effects, including pain, burning sensation, and erythema, were more frequent, with no significant difference between the groups. Itching and crusting had a significant difference in the two groups. Patient satisfaction levels were comparable, with the first group slightly more than the second. Conclusion: In conclusion, combining NB-UVB and topical steroid therapies with the fractional CO2 laser or microneedling seems to be effective for vitiligo treatment in resistant areas. Attention to variations in patients' characteristics and specific body locations is necessary when applying these modalities. This study provides valuable insights into novel approaches for managing vitiligo and highlights the potential benefits of these innovative treatments in combination with conventional therapy.

Patient Burden of Nonsegmental Vitiligo: A US Real-World Survey of Dermatologists and Their Patients

INTRODUCTION

Vitiligo is a chronic autoimmune disease characterized by destruction of melanocytes, leading to skin depigmentation. Vitiligo can have a high quality-of-life burden and profound impact on psychosocial well-being. The objectives of this study were to describe the self-reported patient burden among patients with nonsegmental vitiligo with ≤ 10% affected body surface area, summarize the physician-reported psychosocial and psychological impact of vitiligo on patient lives, and describe disease characteristics and treatment history, goals, and satisfaction.

METHODS

Data were drawn from the Adelphi Vitiligo Disease Specific Programme™, a real-world, cross-sectional survey with retrospective data collection of physicians and patients with vitiligo, collected in the United States between October 2021 and April 2022. Separate surveys for dermatologists and patients contained questions on clinical and demographic characteristics of patients with vitiligo and burden of vitiligo. Treatment history, goals, and satisfaction were assessed together with the impact of vitiligo on quality of life.

RESULTS

Sixty-one dermatologists provided data for 326 patients with ≤ 10% affected body surface area (adults, n = 221; adolescents, n = 105); 90 of those patients also responded to the survey. The most common treatments were topical corticosteroids, topical calcineurin inhibitors, and narrow-band ultraviolet-B phototherapy, with the main treatment goal being repigmentation. Physician-reported treatment satisfaction was 56%; 25% of patients reported frustration with treatment options. Physicians reported impact of vitiligo on everyday life in 46% of patients. Patients reported 12.7% overall work impairment; mean scores for Hospital Anxiety and Depression Scale anxiety and depression domains were 3.5 and 2.2, respectively, and mean Vitiligo-specific Quality of Life index score was 26.9. Patients with facial involvement experienced higher burden than those without.

CONCLUSION

A high patient burden was reported by dermatologists and their patients with vitiligo who had ≤ 10% affected body surface area, including psychosocial and psychological consequences. These findings highlight an unmet need in the treatment of vitiligo.

Exploring the Efficacy of Fractional Carbon Dioxide Laser as an Add-on Combination to Conventional Therapies for Treatment-Resistant Vitiligo (A Review Article)

Introduction: Vitiligo, a dermatological disorder that leads to depigmented skin patches, presents a significant challenge, particularly in resistant areas such as acral regions. Fractional CO2 laser therapy holds promise as an adjunct to conventional treatment, enhancing repigmentation. This review comprehensively explores its efficacy and safety in resistant-to-treatment vitiligo. Methods: We conducted extensive database searches in PubMed, Embase, and Cochrane, focusing on English-language literature published between 2012 and 2023. We included comparative studies that met the following criteria: (1) Participants had non-segmental vitiligo, with resistant-to-treatment localization engagement; (2) The treatment involved the use of fractional CO2 laser in combination with conventional therapies; and (3) Outcomes were assessed based on the repigmentation ratio or significant difference. We excluded studies from which data from published results could not be extracted. Results: After extensive screening of 52 articles, we finally selected five studies. The results showed that fractional CO2 laser therapy, when combined with other treatments, often shows promise in vitiligo treatment in refractory cases. Although individual responses varied, overall efficacy and safety were promising, with minimal adverse effects and no severe complications. Conclusion: The fractional CO2 laser, when used in conjunction with conventional therapies, emerges as a promising option for treating refractory vitiligo. Large-scale randomized trials and a deeper understanding of the underlying mechanisms are vital for future progress in optimizing treatment protocols, case selection, and safety.

The effect of vitamin C on oxidative stress indices and skin regimentation of vitiligo patients

It has been suggested that vitamin C is involved in suppressing stress oxidation signaling in vitiligo disease. However, the effect of vitamin C supplementation on stress oxidative factors has not been investigated in vitiligo subjects. This study was designed to examine the effects on vitamin C supplementation on serum levels of stress oxidative factors and regimentation in vitiligo patients. Forty-four vitiligo patients will be recruited in this study. After block matching for sex and number of phototherapy sessions, they will be randomly assigned to receive 1000 mg/d vitamin C or placebo for 8 weeks. The weight, height, and waist circumference of participants will be measured. Determination of serum stress oxidative indices (CAT, SOD, GPX, MDA, TOS, TAC) will be done at study baseline and at the end of the trial. Also, the regimentation will be determined using the VASI score. This is the first randomized controlled trial that will determine the effect of vitamin C supplementation on serum levels of stress oxidative indices and regimentation in vitiligo patients. The results of this trial will provide clinical evidence on the effectiveness of vitamin C supplementation in controlling oxidative stress in vitiligo patients. Trial registration number: This study is registered in the Iranian Registry of Clinical Trials website (available at http://www.irct.ir , identifier: IRCT20230123057193N1), Registration date: 2023/04/17.

Unveiling the Unseen Struggles: A Comprehensive Review of Vitiligo's Psychological, Social, and Quality of Life Impacts

This review explores the psychosocial impact of vitiligo on patients, its consequences for their quality of life, and the need for holistic support. Vitiligo's psychosocial burden, driven by the need to conceal lesions and societal beauty ideals, leads to stress, sadness, and low self-esteem. Social stigma affects self-esteem, especially in cultural contexts, exacerbating the need for culturally sensitive support. Anxiety and depression are common due to visible differences and societal pressures. Vitiligo significantly reduces the quality of life, especially in younger patients, impacting daily activities, careers, and relationships. Disease severity worsens these effects, particularly in visible areas and among individuals with darker skin tones. Long-term disease activity may improve acceptance and quality of life. Psychological support and counseling are crucial, as many patients don't seek medical help. Education plays a key role, improving understanding and reducing anxiety. Raising awareness about the impact of vitiligo can challenge perceptions and contribute to enhancing patients' well-being. In conclusion, this review highlights the interplay between psychosocial factors, quality of life, and the importance of addressing social stigma, providing psychological support, and advancing education and awareness for those with vitiligo.

Public Knowledge and Attitude towards Vitiligo: A Cross-Sectional Survey in Jordan

BACKGROUND

Vitiligo is an autoimmune disease affecting approximately 2% of the world's population. Besides vitiligo cosmetic issues, patients suffer from psychological comorbidities. This results from the stigmatization they encounter from surrounding individuals. Accordingly, the current study was the first to assess Jordanians' knowledge and attitude toward vitiligo.

METHODS

Data collection was completed by an online questionnaire consisting of four sections to capture participants' sociodemographic characteristics, previous exposure, and knowledge and attitude toward vitiligo. The analysis took place through R and RStudio.

RESULTS

Of our 994 surveyed participants, only 8.45% and 12.47% had a low level of vitiligo knowledge and negative total attitude score, respectively. Moreover, independent predictors of positive attitudes included younger age (18-30), high school education or lower, hearing about or living with a vitiligo patient, and higher knowledge scores. The highest prevalence of positive attitudes was observed when physicians were the source of knowledge.

CONCLUSION

Some critical misconceptions were identified despite the Jordanian public having sufficient overall knowledge. Furthermore, higher knowledge reflected a higher prevalence of positive attitudes toward the patients. We recommend that future efforts target the public understanding of the nature of the disease and its being non-communicable. Moreover, we emphasize that medical knowledge should be communicated through qualified healthcare providers.

Anxiety, coping style and hopelessness during COVID-19 pandemic: An Iranian population-based study

Background and Aims

The COVID-19 pandemic has caused new conditions such as nationwide quarantine, a dramatic decrease in-person interaction and an increase in death anxiety for governments and people. The pandemic of an unpredictable disease with no definite treatment can pose physical and psychological risks to individuals. The present study aimed to investigate the state of anxiety, coping styles, and hopelessness of people in the lockdown period and reopening in Iran.

Methods

In this national population-based cross-sectional study, a total of 1191 people who had access to social networks from all over Iran completed the anxiety, hopelessness, and coping style questionnaires online using the snowball sampling method. Analysis was conducted using Stata software version 12 (Stat Corp). The significance level was set at 0.05.

Results

The results of the study suggested that women experienced higher levels of anxiety than men, and, in stressful situations, women were more likely to use emotion-focused coping styles, while men frequently used problem-focused coping styles. The majority of participants reported moderate levels of anxiety and low levels of hopelessness (64.04%). The results of multiple linear regression show any level of anxiety mild (ß = 0.59, 95% confidence interval [CI]: 0.32-0.85), moderate (ß = 0.72, 95% CI: 1.36-1.08), and severe (ß = 2, 95% CI: 1.36-2.56) relative to the none anxiety significantly increase the hopelessness, Furthermore, showing a negative significant adjusted association with the problem-focused coping style (ß = -0.06, 95% CI: -0.07 to -0.04), and a significant positive association with the emotion-focused coping style (ß = 0.04, 95% CI: 0.02-0.06).

Conclusion

Our findings could be used to prevent psychological damage in societies and suggested addressing problem-focused coping style, especially during a crisis, and providing people with preprepared mental health protocols at this pandemic.

Treatment update for vitiligo based on autoimmune inhibition and melanocyte protection

INTRODUCTION

The treatment of vitiligo remains challenging due to the complexity of its pathogenesis, influenced by genetic factors, oxidative stress and abnormal cell adhesion that collectively impact melanocyte survival and trigger immune system attacks, resulting in melanocyte death. Melanocytes in vitiligo are believed to exhibit genetic susceptibility and defects in cellular mechanisms, such as defects in autophagy, that reduce their ability to resist oxidative stress, leading to increased expression of the pro-inflammatory protein HSP70. The low expression of adhesion molecules, such as DDR1 and E-cadherin, accelerates melanocyte damage and antigen exposure. Consequently, autoimmune attacks centered on IFN-γ-CXCR9/10-CXCR3-CD8⁺ T cells are initiated, causing vitiligo.

AREAS COVERED

This review discusses the latest knowledge on the pathogenesis of vitiligo and potential therapeutic targets from the perspective of suppressing autoimmune attacks and activating melanocytes functions.

EXPERT OPINION

Vitiligo is one of the most challenging dermatological diseases due to its complex pathogenesis with diverse therapeutic targets. Immune suppression, such as corticosteroids and emerging JAK inhibitors, has proven effective in disease progression. However, during the early stages of the disease, it is also important to optimize therapeutic strategies to activate melanocytes for alleviating oxidative stress and improving treatment outcomes.

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.

Spontaneous Reversal of Vitiligo, a Rare Phenomenon Reported in a Case in Saudi Arabia with an Insight into Metabolic Biochemical Derangements

Background and Objectives: Vitiligo is a skin disorder characterized by hypopigmented macules occurring due to melanocyte destruction. An interplay of several biochemical mechanisms has been proposed to explain the etiopathogenesis of vitiligo, such as genetic, autoimmune responses, generation of inflammatory mediators, oxidative stress, and melanocyte detachment mechanisms. There is no cure for vitiligo; however, pharmacological treatment measures (cosmetic camouflage creams, steroids, psoralen and ultraviolet A (PUVA) therapy, narrowband UVB) are available, but they could have certain side effects. We reported an interesting case of vitiligo in Saudi Arabia that showed reversal of vitiligo, which is an extremely rare phenomenon, with the objective of probing the probable reasons for this reversal. To the best of our knowledge, there is no study on vitiligo that has reported spontaneous reversal of vitiligo in Saudi Arabia so far. Materials and Method: The patient presented to the Family Medicine clinic with a history of restoration of melanin pigment in his lesions after 3 years of the onset of vitiligo. Patients history was taken carefully along with clinical examination, carried out necessary biomedical lab investigations and compiled the data. The data at the time of pigment restoration were compared to the previous data when he developed the lesions. Result: The probable reasons for vitiligo reversal could be markedly decreased psychological stress, regular consumption of an antioxidant-rich herbal drink made of curcumin and honey, and dietary switchover to vegetarianism and an alcohol-free lifestyle. Conclusions: Curcumin-based herbal remedies could be an alternative option to treat vitiligo. These methods must be further explored through clinical trials as they are safer, easily available, and more affordable.

Vitiligo and Mental Health: Natural Compounds' Usefulness

Vitiligo is an autoimmune dermatosis frequently associated with other comorbidities, such as mental health disorders. It is unclear if vitiligo triggers mental disorders or if mental disorders trigger vitiligo, but each one affects and worsen the other, if present at the same time. Both mental health disorders and vitiligo present a multifactorial pathogenesis and often require prolonged periods of therapy, sometimes with poor results. Given the possible link of common pathogenetic factors and the need of integrated therapies, the aim of this review is to look at natural compounds as possible supplements for both conditions. The results yielded show a possible role of these supplements in ameliorating both conditions, thus helping these patients to achieve a better quality of life and reduce the need for prolonged therapies. The limitations regarding the relative lack of in vivo studies, and the increasing need to lighten the burden of these chronic diseases, suggests that it is mandatory to proceed with further trials.

Transplantation of autologous epidermal melanocyte-keratinocyte cells suspension for cell therapy of vitiligo: A clinical evaluation and biometric assessment

INTRODUCTION

Among several surgical treatments, the use of transplantation of epidermal cultured melanocytes or melanocytes-keratinocytes cell suspension has gained many researchers and dermatologists' attention as a new technique for the treatment of vitiligo. The present study aimed to transplant autologous epidermal melanocytes-keratinocytes cell suspension for the treatment of vitiligo.

METHODS

In this study, 15 volunteer patients aged between 18 and 45 years old were studied. The autologous melanocytes-keratinocytes cell suspension was then transplanted to the region after dermabrasion. The included patients were evaluated by VisioFace, MPA9, and Skin Scanner-DUB once before and 1, 2, and 6 months after the transplantation, while the extents of stainability and changes in the transplanted region were recorded.

RESULTS

The color contrast between the lesion and normal skin significantly decreased after 1, 2, and 6 months of the melanocytes transplantation compared with the pre-procedure (13.8 ± 0.45 before vs. 12.9 ± 0.43, 12.2 ± 0.45, and 10.2 ± 0.34 at months 1, 2, and 6, p < 0.001). Furthermore, melanin index significantly increased six months after cell transplantation compared to the pretreatment (168.3 ± 4.22 vs. 130.5 ± 3.98, p < 0.001).

CONCLUSION

Transplantation of melanocytes cells with dermabrasion can be effective on vitiligo improvement, so it is recommended.

Impact of Vitiligo on Life Quality of Patients: Assessment of Currently Available Tools

BACKGROUND

How different tools for evaluating health-related quality of life (QoL) reflect the burden of vitiligo has rarely been compared. In this study, we aim to evaluate the impact of vitiligo on QoL using currently available tools.

METHODS

A single-center, cross-sectional study of vitiligo patients was performed. QoL was evaluated using the dermatology life quality index (DLQI), short form-36 (SF-36), and willingness to pay (WTP). As the original DLQI cutoff score (>10) indicating aginificantly impated QoL was found to underestimate QoL, receiver operating characteristic (ROC) curve was use to determine a new cutoff point discriminating vitiligo patients with positive mental stress (SF-36 mental health ≤ 52).

RESULTS

Of the 143 patients enrolled, 24.5% were identified having significant mental stress by SF-36 mental health domain score ≤ 52 while there were only 13.3% patients with significantly hampered QoL indicated by DLQI >10. Using ROC analysis, DLQI ≥ 7 was found to be a more appropriate DLQI cutoff value for identifying mental stress in vitiligo patients. Additionally, the median WTP for treating vitiligo was comparable to other inflammatory skin diseases.

CONCLUSIONS

There exist discrepancies in the outcomes identifying significant disease burden of vitiligo using DLQI and SF-36, making the current DLQI cutoff score (>10) for identifying significantly affected QoL inappropriate for these patients.

Role of HMGB1 in Vitiligo: Current Perceptions and Future Perspectives

Vitiligo is a chronic depigmenting disorder of the skin and mucosa caused by the destruction of epidermal melanocytes. Although the exact mechanism has not been elucidated, studies have shown that oxidative stress plays an important role in the pathogenesis of vitiligo. High mobility group box protein B1 (HMGB1) is a major nonhistone protein and an extracellular proinflammatory or chemotactic molecule that is actively secreted or passively released by necrotic cells. Recent data showed that HMGB1 is overexpressed in both blood and lesional specimens from vitiligo patients. Moreover, oxidative stress triggers the release of HMGB1 from keratinocytes and melanocytes, indicating that HMGB1 may participate in the pathological process of vitiligo. Overall, this review mainly focuses on the role of HMGB1 in the potential mechanisms underlying vitiligo depigmentation under oxidative stress. In this review, we hope to provide new insights into vitiligo pathogenesis and treatment strategies.

A mouse model of vitiligo based on endogenous auto-reactive CD8 + T cell targeting skin melanocyte

Vitiligo is the most common human skin depigmenting disorder. It is mediated by endogenous autoreactive CD8 + T cells that destruct skin melanocytes. This disease has an estimated prevalence of 1% of the global population and currently has no cure. Animal models are indispensable tools for understanding vitiligo pathogenesis and for developing new therapies. Here, we describe a vitiligo mouse model which recapitulates key clinical features of vitiligo, including epidermis depigmentation, CD8 + T cell infiltration in skin, and melanocyte loss. To activate endogenous autoreactive cytotoxic CD8 + T cells targeting melanocytes, this model relies on transient inoculation of B16F10 melanoma cells and depletion of CD4 + regulatory T cells. At cellular level, epidermal CD8 + T cell infiltration and melanocyte loss start as early as Day 19 after treatment. Visually apparent epidermis depigmentation occurs 2 months later. This protocol can efficiently induce vitiligo in any C57BL/6 background mouse strain, using only commercially available reagents. This enables researchers to carry out in-depth in vivo vitiligo studies utilizing mouse genetics tools, and provides a powerful platform for drug discovery.

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

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

Neuroticism, stress, and rumination in anxiety and depression of people with Vitiligo: An explanatory model

Psychological impacts of Vitiligo have been demonstrated, and associations of the skin disease with anxiety and depression disorders have already been shown. However, it is still unclear the role of individuals' personality factors, such as neuroticism, stress, and rumination, as well as sociodemographic characteristics of people with Vitiligo in such disorders. We conducted a study in a community sample of individuals with Vitiligo (N = 324) aiming to test the hypothesis that neuroticism, stress, and rumination are subjacent to these individuals' anxiety and depression symptomatology. We also explored whether individuals' gender might favor the onset or worsening of the psychological consequences of such disorders. Results showed that the relationship between neuroticism, anxiety and depression was mediated by stress and rumination (brooding), being this effect moderated by the participants' gender. Specifically, women's reflection and stress seemed to be important mechanisms to predict their anxiety and depression symptoms, whereas brooding predicts such disorders' symptomatology in men with Vitiligo. These findings may guide future research and clinical interventions for this population, for which it is necessary to consider the psychological consequences of the disease and not just its physiological aspects.

Assessment of prostaglandin F2-alpha (PGF2α) in lesional and nonlesional skin of vitiligo patients

BACKGROUND

F2-isoprostane is one of the members of biologically active prostaglandins. It is considered a reliable marker of oxidative stress. This study aimed at investigating and studying the hypothesis of the possible role of prostaglandin F2-alpha (PGF2α) in the pathogenesis of vitiligo and to know if there is a possibility of using it in therapy.

METHODS

This case-control study involved 30 patients with nonsegmental vitiligo and 30 healthy sex- and age-matched controls over a period of 7 months. Skin biopsies were taken from lesional and nonlesional vitiliginous skin of patients and from normal skin of controls for measurement of PGF2α in tissue by ELISA.

RESULTS

The tissue levels of PGF2α in vitiligo patients were significantly higher in both lesional and nonlesional skin than in healthy controls (P < 0.001). The tissue levels of PGF2α in lesional skin were significantly higher than in nonlesional skin (P < 0.001).

CONCLUSION

Based on the fact that PGF2α is a reliable biomarker of oxidative stress, in addition to our results that revealed higher tissue levels of PGF2α in vitiliginous skin than in healthy skin, we can conclude that PGF2α may be incriminated in the pathogenesis of vitiligo. This finding could help in the treatment of this disease by using anti-PGF2α drugs.

Surgical Treatment of Vitiligo

Vitiligo is described as a dermatological condition characterized by pigmentation disorders in both the skin and mucous membranes. Clinically, this disease is characterized by the presence of well-defined white areas of various shapes and sizes, which are a manifestation of a reduced number of melanocytes. Due to the fact that vitiligo can be a significant cosmetic problem for patients, a number of methods are currently available to help fight for a better skin appearance. If all the available non-invasive procedures turn out to be ineffective, surgery can help, which is a very good alternative in the case of difficult-to-treat but stable changes. Both the development of new techniques and modifications to the already available treatment of cell and tissue transplantation give hope to numerous patients around the world. The effectiveness of a particular method is determined by its appropriate selection depending on the lesions undergoing therapy. Each form of surgical intervention has its advantages and disadvantages, which, along with the location or size of the treated hypopigmentation area, should be analyzed by a doctor and discussed with their patient. This article is an overview of the currently available methods of surgical treatment of vitiligo and a comparison of their pros and cons.

Combination of epidermal keratinocyte - melanocyte cells suspension and microneedling: Safe surgical approach in vitiligo

INTRODUCTION

Vitiligo is a skin disease that is associated with impaired skin immune systems and pigment degradation in skin melanocyte cells. Despite the significant impact of the disease on the quality of life of patients, treatment of the disease using effective method such as the transplantation of uncultivated melanocytes was considered by researchers around the world. The goal of this research was to use microneedling to transplant epidermal keratinocyte-melanocyte cells suspension for the treatment of vitiligo patients.

METHODS

In this study, 15 male and female vitiligo in face region patients aged 18 to 45 years were studied. In this study, melanocyte-keratinocyte cells suspension was sprayed. Patients underwent microneedling treatment after spraying the cells. Before and after transplantation, patients were biometrically examined, and the quantity of pigmentation and changes in the transplanted region were documented. Statistical software was used to examine the results.

RESULTS

The color difference between the lesion area and normal skin in one, two, and six months after treatment with cell suspension was significantly reduced compared to before treatment (by 48.95 %). Moreover, the amount of melanin was significantly increased 6 months after treatment compared to before treatment (129.8±4.16 vs. 195.2±3.54, P = 0.000). A significant decrease in skin brightness in the skin of the lesion area was observed compared to normal skin, 6 months after treatment compared to before treatment (43.7±1.44 vs. 27.9±1.24, P = 0.000).

CONCLUSION

Epidermal keratinocyte - melanocyte cells suspension in combination with microneedling could be considered as an effective treatment of vitiligo.

Psychosocial Effects of Vitiligo: A Systematic Literature Review

Background

Patients with vitiligo experience reduced quality of life.

Objective

To comprehensively describe the available evidence for psychosocial burden in vitiligo.

Methods

A systematic review of observational studies and clinical trials identified using PubMed, EMBASE, Scopus, and the Cochrane databases was performed through 1 March, 2021, to assess psychosocial comorbidities in vitiligo. Two independent reviewers performed an assessment of articles and extracted data for qualitative synthesis.

Results

Included studies (N = 168) were published between 1979 and 1 March, 2021; 72.6% were published since 2010. Disorders including or related to depression (41 studies, 0.1–62.3%) and anxiety (20 studies, 1.9–67.9%) were the most commonly reported. The most prevalent psychosocial comorbidities were feelings of stigmatization (eight studies, 17.3–100%), adjustment disorders (12 studies, 4–93.9%), sleep disturbance (seven studies, 4.6–89.0%), relationship difficulties including sexual dysfunction (ten studies, 2.0–81.8%), and avoidance or restriction behavior (12.5–76%). The prevalence of most psychosocial comorbidities was significantly higher vs healthy individuals. Factors associated with a significantly higher burden included female sex, visible or genital lesions, age < 30 years (particularly adolescents), and greater body surface area involvement, among others. The most commonly reported patient coping strategy was lesion concealment.

Limitations

Available studies were heterogeneous and often had limited details; additionally, publication bias is possible.

Conclusions

The results of this systematic review show that vitiligo greatly affects psychosocial well-being. The extent of psychosocial comorbidities supports the use of multidisciplinary treatment strategies and education to address the vitiligo-associated burden of disease.

Protocol Registration

PROSPERO (CRD42020162223).

Graphic Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-021-00631-6.

Epidemiological factors in patients with dermatologic conditions referring to the clinic of traditional Persian Medicine: A cross-sectional study

INTRODUCTION

Many patients with chronic diseases often use traditional medicine, as well as conventional medicine. The aim of this study was to evaluate the epidemiological factors of patients with dermatological conditions referring to traditional Persian Medicine (TPM) clinic.

MATERIALS AND METHODS

In this cross-sectional study, we reviewed all the patients' medical documents, from March 2018 to March 2019, with dermatological conditions referred to the TPM clinic at Shiraz, Southern Iran. Then, the epidemiological factors of the patients were recorded in a researcher-made data collection form. SPSS software version 22 was used to analyse the data.

RESULTS

Overall, 631 patients consisting of 151 (23.9%) males and 580 (76.1%) females were enrolled in the study. Most of the patients were aged from 31 to 40 years, 347 (55%) patients were married, and most of them were housewives. The frequency of patients in the spring was higher than in other seasons. Furthermore, most of the patients were university educated. Acne, eczema and hair loss were the three most complaints of the patients who were referred to the traditional medicine clinic. 301(47.7%) patients reported gastrointestinal problems as another complaint concomitant with their skin problems.

CONCLUSION

It seems that women with skin problems, including acne, eczema, and hair loss, were more likely to refer to the TPM clinic. Therefore, the development of TPM clinics in the dermatology field as a scientific and academic approach can be effective in the treatment of patients with dermatological conditions accompanied by traditional medicine.

Stress, anxiety, and depression in patients with vitiligo

Background

Vitiligo has a significant effect on patients’ quality of life; they feel stigmatized and disturbed by their condition. A lot of vitiligo patients, according to reports, suffer from psychological disturbances. The aim of the study is to find the relation between vitiligo and stress, anxiety, and depression and to measure how vitiligo affects the quality of life index. This study included 50 vitiligo patients and 50 matched healthy control groups. All patients were assessed by the Depression Anxiety Stress Scale (DASS) to determine the severity of anxiety, depression, and stress symptoms and the Dermatology Life Quality Index (DLQI) scale to evaluate their quality of life while the control group underwent only the Depression Anxiety Stress Scale.

Results

The prevalence of stress was 76% (n=38), anxiety was 78% (n=39), and depression was 80% (n=40); the difference was statistically significant between patient group and control group regarding stress, anxiety, and depression. Gender had a significant relationship with stress, anxiety, and depression (p < 0.05) (female affected more than male). Also, there was a statistically significant relation between the degree of vitiligo and anxiety (p < 0.05). Vitiligo has a moderate to very severe effect on the quality of life index. There was a statistically significant positive correlation between stress and feeling of embarrassment from vitiligo and clothes choice.

Conclusion

Vitiligo is a psychcutaneous disease that does not only affect the patient’s physical status, but also his mental and psychological status.

Metabolomic signature of amino acids in plasma of patients with non-segmental Vitiligo

INTRODUCTION

Vitiligo pathogenesis is complicated, and several possibilities were suggested. However, it is well-known that the metabolism of pigments plays a significant role in the pathogenicity of the disease.

OBJECTIVES

We explored the role of amino acids in vitiligo using targeted metabolomics.

METHODS

The amino acid profile was studied in plasma using liquid chromatography. First, 22 amino acids were derivatized and precisely determined. Next, the concentrations of the amino acids and the molar ratios were calculated in 31 patients and 34 healthy individuals.

RESULTS

The differential concentrations of amino acids were analyzed and eight amino acids, i.e., cysteine, arginine, lysine, ornithine, proline, glutamic acid, histidine, and glycine were observed differentially. The ratios of cysteine, glutamic acid, and proline increased significantly in Vitiligo patients, whereas arginine, lysine, ornithine, glycine, and histidine decreased significantly compared to healthy individuals. Considering the percentage of skin area, we also showed that glutamic acid significantly has a higher amount in patients with less than 25% involvement compared to others. Finally, cysteine and lysine are considered promising candidates for diagnosing and developing the disorder with high accuracy (0.96).

CONCLUSION

The findings are consistent with the previously illustrated mechanism of Vitiligo, such as production deficiency in melanin and an increase in immune activity and oxidative stress. Furthermore, new evidence was provided by using amino acids profile toward the pathogenicity of the disorder.

Location, Spreading and Oral Corticosteroids are Associated with Insomnia in Vitiligo Patients: A Case-Control Study

Background

Vitiligo can cause disfiguration, impair the social function of the patients and induce physiological burdens. However, limited research about the health-related quality of life has been conducted in vitiligo patients’ sleeping conditions.

Objective

To evaluate the prevalence, severity, and risk factors of insomnia in vitiligo patients.

Methods

This case–control study was performed in March 2021. An online survey questionnaire including baseline information and the sleep-related instrument was sent to 762 vitiligo patients. The vitiligo-related evaluation was conducted by online video interview. According to whether having insomnia or not, patients were grouped and compared their clinical and demographic characteristics. The logistic regression model was conducted to analyze the risk factors for insomnia.

Results

A total of 409 patients were included. About 49.9% of patients (204/409) experienced insomnia. About 55.9% (114/204) of the insomnia in vitiligo patients was adjustment sleep disorder caused by vitiligo. Development, aggravation, or recurrence of vitiligo were deemed as the first reason for insomnia in 71.1% of the sample (81/114). There were significant differences in age (32.1±4.1 vs 27.9±4.2 years, P < 0.001), the percentage of female (62.8% vs 49.3%, P=0.006) and working in the urban areas (77.0% vs 66.3%, P = 0.017), vitiligo in face and neck (67.2% vs 48.8%, P < 0.001), progression in vitiligo (65.7% vs 49.3%, P=0.001), oral corticosteroids (25.0% vs 16.6%, P=0.036) and depression (5.4% vs 0.5%, P = 0.003) between groups. After adjusting for gender, age and comorbidity, the multivariate logistic regression revealed that vitiligo in face and neck (OR=2.62; P=0.032), progression in vitiligo (OR=2.50; P=0.002), and oral corticosteroids (OR=2.71; P=0.021) remained risk factors for insomnia in vitiligo patients.

Conclusion

Insomnia is prevalent in vitiligo patients. Dermatologists should identify this condition carefully, especially humanistic factors in social life, and perform individualized “non-drug” treatment.

Clinical Features, Immunopathogenesis, and Therapeutic Strategies in Vitiligo

Vitiligo is an autoimmune disease of the skin characterized by epidermal melanocyte loss resulting in white patches, with an approximate prevalence of 0.5-2% worldwide. Several precipitating factors by chemical exposure and skin injury present commonly in patients with vitiligo. Although the diagnosis appears to be straightforward for the distinct clinical phenotype and specific histological features, vitiligo provides many challenges including chronicity, treatment resistance, frequent relapse, associated profound psychosocial effect, and negative impact on quality of life. Multiple mechanisms are involved in melanocyte disappearance, including genetics, environmental factors, and immune-mediated inflammation. Compelling evidence supports the melanocyte intrinsic abnormalities with poor adaptation to stressors leading to instability and release of danger signals, which will activate dendritic cells, natural killer cells, and innate lymphoid cells to initiate innate immunity, ultimately resulting in T-cell mediated adaptive immune response and melanocyte destruction. Importantly, the cross- talk between keratinocytes, melanocytes, and immune cells, such as interferon (IFN)-γ signaling pathway, builds inflammatory loops that give rise to the disease deterioration. Improved understanding of the immune pathogenesis of vitiligo has led to the development of new therapeutic options including Janus kinase (JAK) inhibitors targeting IFN-γ signaling pathways, which can effectively reverse depigmentation. Furthermore, definition of treatment goals and integration of comorbid diseases into vitiligo management have revolutionized the way vitiligo is treated. In this review, we highlight recent developments in vitiligo clinical aspects and immune pathogenesis. Our key objective is to raise awareness of the complexity of this disease, the potential of prospective therapy strategies, and the need for early and comprehensive management.

Correlation between gastrointestinal symptoms and adherence to traditional Persian medicine dietary recommendations in patients with vitiligo; a cross-sectional study

OBJECTIVES

Vitiligo is a chronic disease associated with the depigmentation of regions of the skin secondary to structural or functional damage to melanocytes. This damage results from interactions between the immune system and oxidative stress. In traditional Persian medicine (TPM), the concept of 'Barass' or 'Pissi' encompasses a group of skin diseases including vitiligo, for which there has been an emphasis on the preventive and therapeutic role of dietary modifications.

METHODS

In this cross-sectional study, 200 vitiligo patients and 200 controls were enrolled with a random sampling method. The participants included patients with vitiligo referred to the Dermatology Clinic of Shahid Faghihi Hospital (Shiraz, Iran), with the control group being comprised individuals who referred to this clinic for cosmetic purposes. Questionnaires comparing the severity of gastrointestinal symptoms and the rate of adherence to TPM dietary recommendations were filled by all participants. Data were analyzed using SPSS version 24.0.

RESULTS

The case group was significantly less adherent to TPM recommendations than the control group (8.25 ± 27.16 vs. 31.8 ± 10.47; p<0.001). However, there was no significant difference between both groups in the Gastrointestinal Symptom Rating Scale (GSRS) scores (14.09 ± 14.84 vs. 12.62 ± 11.71; p = 0.105). In the case group, the level of adherence to the recommendations of TPM was significantly lower among patients with lower education levels (R=-0.194; p=0.017). Furthermore, there was a significant negative relationship between the length of the disease and adherence to TPM dietary recommendations (R=-0.247; p=0.002).

CONCLUSIONS

In this study, the level of adherence to TPM recommendations was significantly lower among patients with vitiligo than the control group. Hence, further studies are suggested to identify the probable role of dietary habits in the pathogenesis of vitiligo.

Differentially expressed microRNAs in peripheral blood mononuclear cells of non-segmental vitiligo and their clinical significance

Background

Vitiligo is a frequent acquired depigmentation skin disease due to a loss of melanocytes. This study sought to characterize the expression pattern of microRNA (miRNA) in the peripheral blood mononuclear cells (PBMCs) of non‐segmental vitiligo (NSV) patients. We also screened for molecular markers that can be used to evaluate the clinical stages of NSV.

Methods

The miRNA expression profile in the PBMCs of four patients with progressive NSV and four healthy controls was determined using high‐throughput RNA sequencing. The divergently expressed miRNA was verified via qRT‐PCR in 26 progression, 26 stable NSV, and 26 healthy controls.

Results

Our findings posited that 323 miRNAs were differentially expressed in the PBMCs of NSV patients. The top 10 up‐regulated miRNAs in patients were hsa‐miR‐335‐5p, hsa‐miR‐20a‐5p, hsa‐miR‐514a‐3p, hsa‐miR‐144‐5p, hsa‐miR‐450b‐5p, hsa‐miR‐369‐3p, hsa‐miR‐101‐3p, hsa‐miR‐142‐5p, hsa‐miR‐19b‐3p, and hsa‐miR‐340‐5p. The top 10 down‐regulated miRNAs in patients were hsa‐miR‐4443, hsa‐miR‐1248, hsa‐miR‐6859‐3p, hsa‐miR‐668‐3p, hsa‐miR‐7704, hsa‐miR‐323a‐5p, hsa‐miR‐1237‐3p, hsa‐miR‐3127‐3p, hsa‐miR‐6735‐3p, and hsa‐miR‐127‐3p. The expressions of hsa‐miR‐20a‐5p in PBMCs of progressive and stable NSV were remarkably elevated relative to the healthy controls. In the characteristics curve analysis of hsa‐miR‐20a‐5p for differentiating progressive and stable NSV from normal subjects in PBMCs, the area under curve (AUC) was 0.92 and 0.81. Compared with patients in stable NSV, the hsa‐miR‐20a‐5p was markedly increased in PBMCs of progressive NSV patients, and the AUC was 0.81.

Conclusion

Our results showed that divergently expressed miRNAs contribute to the pathogenesis of NSV and that hsa‐miR‐20a‐5p can be applied as a biosignature for stage assessment in PBMCs of patients with NSV.

Vitiligo, From Physiopathology to Emerging Treatments: A Review

Vitiligo is a chronic inflammatory skin disease leading to the loss of epidermal melanocytes. To date, treatment options for vitiligo patients are limited, lack sustained efficacy, and are mainly based on off-label use of immunosuppressive agents, such as systemic or topical steroids or topical calcineurin inhibitors, in association with the use of ultraviolet light. However, recent insights into the understanding of the immune pathogenesis of the disease have led to the identification of several therapeutic targets and the development of targeted therapies that are now being tested in clinical trials. In this review, based on the physiopathology of the disease, we summarize emerging targets that could be developed for the treatment of vitiligo and discuss recent and ongoing developments of drugs for the management of the disease.

Relationship Between Depression and Quality of Life Among Vitiligo Patients: A Self-assessment Questionnaire-based Study

Background

Vitiligo is a common chronic autoimmune disease that is characterized by progressive loss of skin color due to melanocyte destruction. In addition to the physical effects of vitiligo, this condition exerts adverse psychological effects and causes social stigmatization. Earlier studies reported that individuals with vitiligo suffer from poor quality of life (QoL), but data about the QoL of Thai vitiligo patients is scarce.

Objective

This study aimed to investigate the QoL and prevalence of depression in Thai vitiligo patients, association between QoL and depression, and factors associated with QoL and depression among Thai people with vitiligo.

Methods

This cross-sectional self-assessment questionnaire-based study was conducted at the phototherapy and vitiligo clinics of the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University (Bangkok, Thailand). QoL was assessed using the Dermatology Life Quality Index (DLQI) questionnaire, and depression was evaluated via the Patient Health Questionnaire (PHQ-9).

Results

Among the 104 vitiligo patients that were recruited, the mean DLQI score was 7.46, and the prevalence of depression (PHQ-9 ≥9) was 13.5%. Factors significantly associated with a higher mean DLQI score were skin phototype IV compared to phototype III, active disease, new lesions within the last three months, lesions involving upper extremities, and PHQ-9 ≥9 (p<0.05). Moderate correlation was found between DLQI score and PHQ-9 score (Pearson’s correlation coefficient: 0.524, p<0.001). Factors significantly associated with depression were working status and developing new lesions within the last three months (p<0.05). Patients with new lesions were 4.12 times more likely to be depressed than those without new lesions (OR: 4.12, 95%CI: 1.20–14.16; p=0.025).

Conclusion

Developing new lesions, active disease, dark skin phototype (IV), and lesion on upper extremity had significant adverse effects on QoL. Vitiligo patients who were employed and who had new vitiligo lesions are significantly more likely to be depressed.