Advances in the treatment options for vitiligo: activated low-dose cytokines-based therapy

A Mendelian randomization study on the causal effects of circulating cytokines on the risk of vitiligo

Background

Accumulating evidence reveals an association between circulating cytokine levels and vitiligo. However, the causal association between circulating cytokine levels and vitiligo remains unrevealed.

Methods

We performed a two-sample Mendelian randomization (MR) analysis using a genome-wide association study of the 41 cytokines dataset, which was conducted with 3 Finnish cohorts (n = 8,293). Vitiligo data were acquired from strictly defined vitiligo data collected by FinnGenbiobank analysis, which included 207,613 European ancestors (131 vitiligo patients, 207,482 controls). The inverse-variance weighted (IVW) method, weighted median (WME), simple model, weighted model, and MR-Egger were used to determine the changes in vitiligo pathogenic cytokine taxa, followed by sensitivity analysis, including horizontal pleiotropy analysis. The MR Steiger test evaluated the strength of a causal association, and the leave-one-out method was used to assess the reliability of the results. The possibility of reverse causality was also investigated using a reverse MR study.

Results

We observed that rising IL-4 levels generated an enhanced probability of vitiligo in IVW (OR 2.72, 95%CI 1.19-6.22, p = 0.018). According to the results of the MR analysis, there were causal links between IL-4 and vitiligo. Results were steady after sensitivity and heterogeneity analyses.

Conclusion

Our research reveals that a genetically determined increased level of circulating IL-4 may be linked to a higher risk of developing vitiligo. The development of innovative treatment approaches (such as tofacitinib or dupilumab) that focus on blocking IL-4 as a novel way of preventing and treating vitiligo is significantly impacted by our findings.

Uncoupling melanogenesis from proliferation in epidermal melanocytes responding to stimulation with psoriasis-related proinflammatory cytokines

BACKGROUND

Few studies have addressed the impact of the psoriasis-related proinflammatory cytokines on the proliferation and melanogenesis of melanocytes (MCs) in lesional psoriatic skin.

OBJECTIVE

We investigated the effects of TNFα, IL17A, and IL8 on the proliferation and melanin synthesis of MCs.

METHODS

Skin specimens were biopsied from patients with psoriasis vulgaris at the active stage, or from the tail skin of Dct-LacZ mice with imiquimod (IMQ)-induced psoriasiform dermatitis. Cultured keratinocytes (KCs), MCs, and human skin explants were used in this study. The numbers of MCs were measured via β-galactosidase staining, EdU incorporation and HMB45 immunohistochemical staining. The expression of human β-defensin 3 (hBD3) in KCs was silenced by siRNA, the conditioned medium (CM) from siRNA-transfected KCs was used to treat MCs, then followed by αMSH stimulation. The melanogenesis-related genes were examined by using qRT-PCR and western blotting.

RESULTS

The increased number of MCs and decreased melanin content were highly relevant to the enhanced expression of IL8 and BD3 both in human psoriatic skin and in IMQ-treated mouse tail skin. IL8 expression in KCs and CXCR2 expression in MCs was significantly increased by IL17A and TNFα, the αMSH-induced upregulations of microphthalmia-associated transcription factor (MITF) and tyrosinase in MCs were abrogated by the CM from hBD3-unsilenced KCs, but not from hBD3-silenced KCs.

CONCLUSION

Our results suggest the roles of IL8-CXCR2 activation in promoting MC proliferation and of BD3 upregulation in reducing melanogenesis. These findings have been implicated in the underlying mechanism that active psoriasis prefers hypopigmentation despite chronic inflammation.

Potential Role of Chronic Physical Exercise as a Treatment in the Development of Vitiligo

Vitiligo is an autoimmune disease characterized by progressive skin depigmentation and the appearance of white patches throughout the body caused by significant apoptosis of epidermal melanocytes. Despite not causing any physical pain, vitiligo can originate several psychosocial disorders, drastically reducing patients' quality of life. Emerging evidence has shown that vitiligo is associated with several genetic polymorphisms related to auto-reactivity from the immune system to melanocytes. Melanocytes from vitiligo patients suffer from excess reactive oxygen species (ROS) produced by defective mitochondria besides a poor endogenous antioxidant system (EAS). This redox imbalance results in dramatic melanocyte oxidative stress (OS), causing significant damage in proteins, lipid membranes, and DNA. The damaged melanocytes secret damage-associated molecular pattern (DAMPs), inducing and increasing inflammatory gene expression response that ultimately leads to melanocytes apoptosis. Vitiligo severity has been also associated with increasing the prevalence and incidence of metabolic syndrome (MetS) or associated disorders such as insulin resistance and hypercholesterolemia. Thus, suggesting that in genetically predisposed individuals, the environmental context that triggers MetS (i.e., sedentary lifestyle) may also be an important trigger for the development and severity of vitiligo disease. This paper will discuss the relationship between the immune system and epidermal melanocytes and their interplay with the redox system. Based on state-of-the-art evidence from the vitiligo research, physical exercise (PE) immunology, and redox system literature, we will also propose chronic PE as a potential therapeutic strategy to treat and prevent vitiligo disease progression. We will present evidence that chronic PE can change the balance of inflammatory to an anti-inflammatory state, improve both EAS and the mitochondrial structure and function (resulting in the decrease of OS). Finally, we will highlight clinically relevant markers that can be analyzed in a new research avenue to test the potential applicability of chronic PE in vitiligo disease.

The Clinical and Biological Effects of Homeopathically Prepared Signaling Molecules: A Scoping Review

BACKGROUND

 Signaling molecules such as cytokines and interleukins are key mediators for the immune response in responding to internal or external stimuli. Homeopathically prepared signaling molecules have been used therapeutically for about five decades. However, these types of products are not available in many countries and their usage by homoeopaths is also infrequent. The aim of this scoping review is to map the available pre-clinical and clinical data related to the therapeutic use of homeopathically prepared signaling molecules.

METHODS

 We conducted a scoping review of clinical and pre-clinical studies of therapeutically used signaling molecules that have been prepared in accordance with an officially recognized homeopathic pharmacopoeia. Articles in peer-reviewed journals reporting original clinical or pre-clinical research of homeopathically prepared signaling molecules such as interleukins, cytokines, antibodies, growth factors, neuropeptides and hormones, were eligible. Non-English language papers were excluded, unless we were able to obtain an English translation. An appraisal of eligible studies took place by rating the direction of the outcomes on a five-point scale. The quality of the papers was not systematically assessed.

RESULTS

 Twenty-eight eligible papers, reporting findings for four different manufacturers' products, were identified and reviewed. Seventeen papers reported pre-clinical studies, and 11 reported clinical studies (six experimental, five observational). A wide range of signaling molecules, as well as normal T-cell expressed specific nucleic acids, were used. A majority of the products (21 of 28) contained two or more signaling molecules. The most common clinical indications were psoriasis, vitiligo, rheumatoid arthritis, respiratory allergies, polycystic ovary syndrome, and herpes. The direction of the outcomes was positive in 26 papers and unclear in two papers.

CONCLUSION

 This scoping review found that there is a body of evidence on the use of homeopathically prepared signaling molecules. From a homeopathy perspective, these substances appear to have therapeutic potential. Further steps to explore this potential are warranted.

Biochemical and immunological aspects of COVID-19 infection and therapeutical intervention of oral low dose cytokine therapy: a systematic review

The novel coronavirus (SARS-CoV-2) pandemic has now spread to all corners of the world. It causes severe respiratory syndromes which is one of the leading causes of death. Evidence shows that the novel SARS-CoV-2 has close similarities with other coronaviruses, SARS and MERS. So, SARS-CoV-2 might use the similar mechanisms of these viruses to attack the host cells. The severity of COVID-19 is associated with various factors, one of the major reasons is immune dysregulation or immune suppression. Immunity plays a significant role in maintaining the body in a healthy condition. In order to induce a timely immune response against the invaded pathogens, both innate and adaptive immunity must be in an active state. During the viral infection, there will be an excessive generation of pro-inflammatory cytokines known as cytokine storm and also, the antiviral agents in the body gets inhibited or inactivated through viral mechanisms. Thus, this might be the reason for the transition from mild symptoms to more severe medical conditions which leads to an immediate need for the invention of a new medicine.This review aims to show the host-viral interaction along with immune response, antiviral mechanism and effectiveness of oral low dose cytokines against the virus as a therapeutic approach.

The efficacy of intense pulsed light for Becker's nevus: A retrospective analysis of 45 cases

BACKGROUND

Becker's nevus is a common skin disorder. Lasers and light instruments are the major modalities for the treatment of Becker's nevus, but the outcomes were mixed.

OBJECTIVE

To evaluate the efficacy of the intense pulsed light for Becker's nevus in a large Chinese cohort.

METHODS

We retrospectively analyzed the efficacy of the intense pulsed light for Becker's nevus in a single center.

RESULTS

A total of 45 patients, including 26 males and 19 females (male to female ratio = 1.4), aged 5-42 years, were included in this analysis. Twenty-seven patients (60%) were with hypertrichosis. Treatments with intense pulsed light resulted in over 75% improvements in pigmentation and hair density in 1 and 2 cases, respectively. One patient displayed 51%-75% reductions in hair density. The rest displayed ≤50% improvements in pigmentation and hair density. Recurrence occurred in all cases within 6 months after the last treatment. Adverse reactions were temporary and mild hypopigmentation, hyperpigmentation, hypertrophic scar, pain, and erythema.

CONCLUSION

Intense pulsed light does not exhibit long-term benefits for Becker's nevus. Further studies in the large cohort are still required to validate the present results. Moreover, whether changes in the treatment parameters can improve the efficacy of intense pulsed light remains to be explored.

Follicular Transplantation, Microneedling, and Adjuvant Narrow-band Ultraviolet-B Irradiation as Cost-Effective Regimens for Palmar-Plantar Vitiligo: A Pilot Study

Treatment of refractory palmar-plantar vitiligo is particularly challenging because the skin in these regions has a limited supply of follicle-derived melanocytic stem cells. Autologous hair transplantation monotherapy is effective in some forms of vitiligo through the provision of melanocytic stem cells. CO₂ laser followed by exposure to light (i.e., sunlight or narrow-band ultraviolet-B [nbUVB]) has independently shown to be an effective treatment strategy. Recently, it was found that the combination of hair transplantation and CO₂ laser followed by nbUVB exposure had superior efficacy to either modality as monotherapy. Similar to CO₂ laser, microneedling produces skin cell proliferation and releases pro-pigmentary cytokines. Given the important role of the cytokines in vitiliginous skin, microneedling may also be an effective therapeutic modality for refractory vitiligo. Herein, we conducted a pilot study to evaluate the efficacy of hair transplantation and CO₂ laser or microneedling followed by nbUVB. Microneedling and fractional CO₂ laser in combination with hair transplantation and nbUVB both demonstrated utility in the induction of repigmentation in refractory palmar-plantar vitiligo; however, a larger trial would be needed to determine a difference in treatment efficacy. Nonetheless, microneedling is cost-effective and requires minimal training; therefore, microneedling can be easily incorporated into standard dermatological practice.

Emerging drugs for the treatment of vitiligo

Introduction: Vitiligo is a relatively common autoimmune depigmenting disorder of the skin. There has been a great advance in understanding the pathological basis, which has led to the development and utilization of various new molecules in treating vitiligo. This review aims at a comprehensively describing the treatments available and the emerging treatment aspects and the scope for future developments.Areas covered: This study comprehensively summarizes the current concepts in the pathogenesis of vitiligo with special focus on the cytokine and signaling pathways, which are the targets for newer drugs. JAK kinase signaling pathways and the cytokines involved are the focus of vitiligo treatment in current research, followed by antioxidant mechanisms and repigmenting mechanisms. Topical immunosuppressants may be an alternative to steroids in localized vitiligo. Newer repigmenting agents like basic fibroblast growth factors, afamelanotide have been included and a special emphasis is laid on the upcoming targeted immunotherapy.Expert opinion: The treatment of vitiligo needs to be multimodal with emphasis on targeting different limbs of the pathogenesis. Topical and oral JAK inhibitors are the most promising new class of drugs currently available for treating vitiligo and acts best in conjunction with NB-UVB.

Immunophenotype of circulatory T-helper cells in patients with non-segmental vitiligo

Introduction

Non-segmental vitiligo (NSV) is an immune-mediated skin depigmentation disease. Cytokine-mediated interaction between T lymphocytes and melanocytes leads to death of melanocytes, causing a defect in melanin synthesis and thereby depigmentation. There is an increased population of T-helper cells in the skin lesions as well as in the peripheral circulation in NSV. However, the relative percentage of each T-cell phenotype in the disease pathogenesis is rarely studied.

Aim

To study the immunophenotype of the different T-helper/Treg cell subsets in patients with NSV, in comparison to healthy controls.

Material and methods

A total of 80 patients with NSV and eighty age- and gender-matched healthy controls were recruited in this cross-sectional study. Disease activity was determined by vitiligo index of disease activity (VIDA) scoring. Peripheral blood mononuclear cells were separated by Ficoll-Paque density centrifugation, and T-cell immunophenotyping was done by flow cytometric analysis.

Results

In patients with NSV, we observed an imbalance in T-cell immunophenotype, characterized by an increase in Th1 (p < 0.0001) and Th17 cells (p = 0.01). There is no difference in relative percentage of Th2/Treg cells, as compared to the healthy controls (p > 0.05).

Conclusions

There is a significant immune-dysregulation with a preponderance of circulatory Th1/Th17 phenotype in NSV patients.

An open randomized active-controlled clinical trial with low-dose SKA cytokines versus DMARDs evaluating low disease activity maintenance in patients with rheumatoid arthritis

Background

Biologic agents are currently the strongest immunosuppressive drugs able to induce remission in rheumatoid arthritis (RA). One of the objectives of the medical scientific community now is how to maintain remission or low disease activity (LDA). The aim of this trial is to evaluate the contribution of low-dose sequential kinetic activation (SKA) IL-4, IL-10, and anti-IL-1 antibodies (10 fg/mL) in patients affected by RA in maintaining LDA or remission obtained after biological therapy.

Method

This is a randomized, open, active-controlled, prospective, Phase IV trial. Disease activity score (DAS28), clinical disease activity index, simplified disease activity index, erythrocyte sedimentation rate and C-reactive protein levels, global health assessment, and pain visual analog scale were evaluated at baseline visit and then every 3 months together with an assessment of side effects till 12 months. Thirty-nine RA patients were enrolled and randomized to continue disease-modifying antirheumatic drugs (DMARDs) therapy or to receive a combination of SKA low-dose cytokines formulated in concentration of 10 fg/mL orally administered at a dose of 20 drops/d for 12 consecutive months.

Results

The rate of maintenance of LDA at 12 months was superior in the group treated with low-dose cytokines compared with patients treated with DMARDs, 66.7% and 42.1%, respectively; however, the difference between the groups was not statistically significant. No side effects were reported in both groups.

Conclusion

This is the first study using a combination of three low-dose cytokines in RA, after data published on psoriasis. These data suggest that the use of a combination of low-dose SKA cytokines may be an opportunity to explore in the management of RA.

The role of systemic steroids and phototherapy in the treatment of stable vitiligo: a randomized controlled trial

Pathogenesis of vitiligo is believed to be multifactorial disease with a wide variety of therapeutic modalities. The aim of this work is to assess the efficacy of oral mini-pulse steroids (OMP) plus Nb-U.V.B in comparison to OMP alone and Nb-U.V.B alone in treating stable vitiligo. A prospective randomized controlled study including 45 patients categorized into three groups receiving therapy for 3 months; Group A received Nb-U.V.B plus OMP, Group B received OMP alone while Group C received Nb-U.V.B alone. Clinical assessment and PCR evaluation of bFGF, ICAM1, and ELISA for AMA were done. Patients receiving Nb-U.V.B plus OMP and using Nb-U.V.B alone gave statistically significant clinical response than those treated with OMP alone. Statistically significant rise of BFGF was noticed after treatment with Nb-U.V.B plus OMP and with Nb-U.V.B alone. Patients treated with OMP alone and with Nb-U.V.B alone showed statistically significant drop of ICAM-1 after therapy. NB-U.V.B plus OMP and Nb-U.V.B alone were found to be clinically superior over OMP alone in treating stable vitiligo patients, hence suggesting that adding OMP to Nb-U.V.B can maintain clinical and laboratory success for a longer period of time and with less relapse.