Vitiligo. Pathogenesis and treatment

Chemical leukoderma: An insight of pathophysiology and contributing factors

Chemical leukoderma, or chemical-based vitiligo, is a dermal disease triggered by exposure to chemicals and characterized by the emergence of depigmentation or hypopigmentation of the skin. The etiology of this condition is associated with exposure to various chemical substances present in both occupational and non-occupational settings. The precise mechanism that underlies chemical leukoderma remains elusive and is believed to result from the demise of melanocytes, which are responsible for producing skin pigments. This condition has gained particular prominence in developing countries like India. An interesting connection between chemical leukoderma and vitiligo has been identified; studies suggest that exposure to many household chemicals, which are derivatives of phenols and catechol, may serve as a primary etiological factor for the condition. Similar to autoimmune diseases, its pathogenesis involves contributions from both genetic and environmental factors. Furthermore, over the last few decades, various studies have demonstrated that exposure to chemicals plays a crucial role in initiating and progressing chemical leukoderma, including cases stemming from occupational exposure.

Impact of Vitiligo on Quality of Life in Patients of Skin of Color and Its Correlation With Clinical Severity Assessment Scores Utilizing Disease Specific Scores: A Cross-Sectional Study

INTRODUCTION

Assessment of disease severity of vitiligo is exigent as it is a psychosomatic ailment. VIDA (vitiligo disease activity score) and VASI (vitiligo area severity index) were previously used for this evaluation. Recently, the introduction of two vitiligo specific tools, vitiligo impact scale (VIS)-22 and Vitiligo Quality of Life Index (VitiQoL) has aided in assessing the quality of life (QOL) in a pertinent manner.

OBJECTIVES

To measure the QOL in vitiligo using disease specific indices (VitiQoL and VIS-22), to assess their relationship with disease severity (VASI and VIDA) and to determine the correlation between QOL scores (VIS-22 and VitiQoL).

METHODS

This observational cross-sectional study included 195 patients with vitiligo, and their disease severity was calculated using VASI and VIDA scoring. Patients were asked to fill questionnaires for assessing the QOL using validated tools i.e. VIS-22 and VitiQoL.

RESULTS

Significant correlation was demonstrated between both QOL scores and VASI score (P value 0.001) with slightly higher values for VitiQoL (r = 0.824) than with VIS 22 (r = 0.693). Both scores exhibited a significant association with VIDA score (P value < 0.001). Moreover, statistically significant correlation was found between VIS-22 and VitiQoL, thereby proving the concordance between these scores.

CONCLUSIONS

The study infers that QOL seemed to be remarkably dependent on the clinical severity scores and that higher disease activity corresponds to poorer QOL. It is imperative to precisely assess burden of vitiligo and the impairments caused by it in order to aid multi-modality management and allow more standardized research.

Psychiatric morbidity among patients suffering from Vitiligo

Background

Vitiligo is a chronic acquired, stigmatizing disease characterized by discoloration of skin and mucous membranes. Patients suffering from this condition suffer from a lack of confidence and psychological stress.

Aim

To assess depression, anxiety, and social anxiety among patients suffering from vitiligo.

Material and Method

This hospital-based cross-sectional, observational, descriptive study was carried out in a tertiary care center on 100 patients suffering from vitiligo, who were consecutively enrolled after informed consent from the outpatient department (OPD) of the dermatology department. Permission was obtained from the institutional ethics committee Diagnosis of vitiligo was made by two consultants from the department of dermatology. Sociodemographic variables were recorded in the sociodemographic form. The General Health Questionnaire-12 (GHQ-12) was applied to all 100 patients. Patients who scored >3 on GHQ-12 were further subjected to the Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Social Interaction Anxiety Scale. Results were statistically analyzed on SPSS-22.0 (IBM, Armonk, USA).

Results

Of all the patients, 55% (n = 55) had a GHQ score >3 (i.e., Psychiatric morbidity was present in 55% of patients.). Out of 50 patients in the age group of 18-25 years, 41 patients in the age groups of 26-35 years, and 9 patients in the age groups of 36-45 years, 22 (44%), 17 (42.1%), and 6 patients had psychiatric morbidity, respectively. Of the total number of patients, 46% had depression according to the HAM-D scale. Of all the patients, 18% had mild, 22% had moderate, and 6% had severe depression. Age-wise analysis showed that out of 50 patients in the age group of 18-25 years, 41 patients in the age group of 26-35 years, and 9 patients in the age group of 36-45 years, 22 (44%), 20 (48.7%), and 4 patients had depression, respectively. Of the patients who had depression, 39% were male and 58% were female. On HAM-A, 47% of the patients had anxiety; 33% had mild, 12% had moderate, and 2% had severe anxiety. Age-wise analysis showed that out of 50 patients in the age group of 18-25, 41 patients in the age group of 26-35 years, and 9 patients in the age group of 36-45 years, 20 (40%), 23 (56.1%), and 3 patients had anxiety, respectively. On SIAS, 36% of the patients had social anxiety. Out of 50 patients in the age group of 18-25 years, 41 patients in the age group of 26-35 years, and 9 patients in the age group of 36-45 years, 23 (46%), 9 (7.8%) and 4 patients had social anxiety, respectively. According to gender-wise distribution, 17% of male and 63% of female patients had social anxiety.

Conclusion

A high prevalence of anxiety, depression, and social anxiety has been observed in this present study. Therefore, importance should be given to psychiatric evaluation of such patients and, if required, necessary interventions should be undertaken to improve their quality of life.

Generalized Vitiligo Following Radiation Therapy for a B2 Thymoma: A Case Report

Vitiligo is an idiopathic skin disorder of multifactorial etiology that is characterized by skin depigmentation. Generalized vitiligo following radiation therapy has rarely been reported in the literature. The mechanism underlying radiation-induced disseminated vitiligo is not yet fully understood. However, multiple factors, including genetic susceptibility and autoimmunity, are likely involved in the pathogenesis of the condition. We report a case of disseminated vitiligo in a patient with no preexisting personal or family history of the condition following three months of localized radiation therapy to the mediastinum.

Vitiligo, from Pathogenesis to Therapeutic Advances: State of the Art

Vitiligo is an acquired hypopigmentation of the skin due to a progressive selective loss of melanocytes; it has a prevalence of 1-2% and appears as rounded, well-demarcated white macules. The etiopathology of the disease has not been well defined, but multiple factors contribute to melanocyte loss: metabolic abnormalities, oxidative stress, inflammation, and autoimmunity. Therefore, a convergence theory was proposed that combines all existing theories into a comprehensive one in which several mechanisms contribute to the reduction of melanocyte viability. In addition, increasingly in-depth knowledge about the disease's pathogenetic processes has enabled the development of increasingly targeted therapeutic strategies with high efficacy and fewer side effects. The aim of this paper is, by conducting a narrative review of the literature, to analyze the pathogenesis of vitiligo and the most recent treatments available for this condition.

A review of JAK and IL-23 inhibitors to treat vitiligo

Vitiligo is an autoimmune skin disorder resulting in the depigmentation of skin characterised by patches of varying sizes and shapes. A common disorder of pigmentation that affects 0.5%-2% of the global population. Despite its well-understood autoimmune pathogenesis, the targets for effective cytokine intervention remain unclear. Current first-line treatments include oral or topical corticosteroids, calcineurin inhibitors and phototherapy. These treatments are limited, have varying efficacies, and are associated with significant adverse events or can be time-consuming. Therefore, biologics should be explored as a potential treatment for vitiligo. There are currently limited data for the use of JAK and IL-23 inhibitors for vitiligo. A total of 25 studies were identified in the review. There is promising evidence regarding the use of JAK and IL-23 inhibitors for the treatment of vitiligo.

Current Debates on Etiopathogenesis and Treatment Strategies for Vitiligo

Vitiligo is an acquired, chronic, and progressive depigmentation or hypopigmentation characterized by the destruction of melanocytes and the occurrence of white patches or macules in the skin, mucosal surface of eyes, and ears. Melanocytes are the melanin pigment-producing cells of the skin which are destroyed in pathological conditions called vitiligo. Approximately 0.5 - 2.0% of the population is suffering from vitiligo, and a higher prevalence rate of up to 8.8% has been reported in India. It is caused by various pathogenic factors like genetic predisposition, hyperimmune activation, increased oxidative stress, and alteration in neuropeptides level. Genetic research has revealed a multi- genetic inheritance that exhibits an overlap with other autoimmune disorders. However, melanocytes specific genes are also affected (such as DDR1, XBP1, NLRP1, PTPN22, COMT, FOXP3, ACE, APE, GSTP1, TLR, SOD, and CTLA-4). A number of therapeutic options are employed for the treatment of vitiligo. The topical corticosteroids and immunomodulators are currently in practice for the management of vitiligo. Phototherapies alone and in combinations with other approaches are used in those patients who do not respond to the topical treatment. The main focus of this review is on the etiopathological factors, pharmacological management (phototherapy, topical, systemic, and surgical therapy), and herbal drugs used to treat vitiligo.

Chronic Rhinosinusitis and the Increased Incidence of Atopic Dermatitis

BACKGROUND

Chronic rhinosinusitis (CRS) is often associated with other comorbidities due to chronic inflammation. However, no population-based, longitudinal study has investigated the relationship between CRS and chronic skin inflammation.

OBJECTIVE

To investigate the potential relationship between CRS and chronic skin inflammatory diseases, such as atopic dermatitis (AD), vitiligo, and psoriasis.

METHODS

A total of 5638 patients with CRS and 11 276 without CRS as a comparison group, were included from the Korean National Health Insurance Service database from 2002-2013. A propensity score matching (1:2) was performed using the nearest neighbor matching method, sociodemographic factors, and enrollment year. The Cox proportional hazards model was used to analyze the hazard ratio of CRS for AD, vitiligo, and psoriasis.

RESULTS

Results from this study showed that patients with CRS had no significant risk of the subsequent development of vitiligo or psoriasis compared to patients without CRS. However, we found a significantly higher incidence of AD in CRS patients than in those without CRS. The incidence of AD was 63.59 per 1000 person-years in the CRS group and 45.38 per 1000 person-years in the comparison group. Additionally, young and middle-aged CRS patients were independently associated with a higher incidence of subsequent AD events, but we could not find a significantly higher incidence of AD events in the elderly group.

CONCLUSIONS

Our findings suggest there are no significant differences in the overall risk of vitiligo and psoriasis events in patients with CRS; however, we detected a higher risk of AD in young and middle-aged CRS patients. Therefore, clinicians should consider the risk of developing AD in specific patients who are newly diagnosed with CRS.

The PI3K/Akt Pathway: Emerging Roles in Skin Homeostasis and a Group of Non-Malignant Skin Disorders

The phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) signaling pathway regulates cell proliferation, differentiation, and migration, along with angiogenesis and metabolism. Additionally, it could mediate skin development and homeostasis. There is much evidence to suggest that dysregulation of PI3K/Akt pathway is frequently associated with several human cutaneous malignancies like malignant melanoma (MM), basal cell carcinoma (BCC), and cutaneous squamous cell carcinoma (SCC), as well as their poor outcomes. Nevertheless, emerging roles of PI3K/Akt pathway cascade in a group of common non-malignant skin disorders including acne and psoriasis, among others, have been recognized. The enhanced understanding of dysfunction of PI3K/Akt pathway in patients with these non-malignant disorders has offered a solid foundation for the progress of updated therapeutic targets. This article reviews the latest advances in the roles of PI3K/Akt pathway and their targets in the skin homeostasis and progression of a wide range of non-malignant skin disorders and describes the current progress in preclinical and clinical researches on the involvement of PI3K/Akt pathway targeted therapies.

Immune-modulatory effects of lenalidomide inhibited the progression of lesions in a vitiligo mouse model

Vitiligo, an autoimmune disorder, is associated with altered cytokine levels and T lymphocytes. Lenalidomide modulates immune system components by altering cytokine production and regulating T-cell stimulation. In this study, effect of lenalidomide was checked on the development of vitiligo lesions, level of various cytokines, and T lymphocytes in the mouse model. The vitiligo mouse model was developed by immunizing C57BL/6 mouse with anti-mouse tyrosine-related protein 2. Lenalidomide was orally given to mice daily, and the effect was observed on the development of vitiligo lesions. The level of T lymphocytes in blood was checked by flow cytometry. Serum cytokine levels were checked by enzyme-linked immunosorbent assay. Vitiligo lesions were found significantly smaller in lenalidomide-treated mice models. It significantly decreased the serum levels of IFN-γ, TNF-α, IL-1β, and IL-6 but elevated the levels of IL-4 and IL-10. It non-significantly elevated CD4⁺ /CD8⁺ T-cell ratio. Lenalidomide had an inhibitory effect on the development of vitiligo lesions in mice models by suppressing the serum level of pro-inflammatory cytokines and increasing anti-inflammatory cytokine levels. It modulated the immune response in vitiligo mice models toward an anti-inflammatory profile suggesting its use in the management of vitiligo.

Dendritic cells sub-sets are associated with inflammatory cytokine production in progressive vitiligo disease

In autoimmune onset of vitiligo, perilesional area shows inflammatory cells including T cytotoxic, helper cells and macrophages. Dendritic Cells (DCs) regulate immune activities by antigen presentation to T cells or cytokine production. It is evident that pro- and anti-inflammatory DCs are responsible for their respective cytokines release. However, role of DCs in vitiligo is enigmatic. In the present study, we assessed DCs markers (CD11b and CD11c) along with pro- and anti-inflammatory cytokines (IL-17A, IL-10 and IL-12p70) in stable and active vitiligo patients. Our results revealed a significant augmented expression of CD11b⁺CD11c⁺ (pro-inflammatory DC) in peripheral blood mononuclear cells (PBMCs) and skin tissues of active vitiligo patients versus control and stable vitiligo group. Unlikely, CD11b⁺ (anti-inflammatory DC) levels were significantly impeded in active vitiligo group as compared to another two groups. CD11c (T helper 1 stimulating DC) presented no significant alterations in any group. Furthermore, we perceived significantly up-regulated IL-17A (pro-inflammatory cytokine) and down-regulated IL-10 (anti-inflammatory cytokine) expressions in active vitiligo group as compared to control and stable group (in sera, PBMCs and skin tissue). Also, a significant positive correlation was observed between CD11b⁺CD11c⁺ and IL-17A; and CD11b⁺ and IL-10. Contrarily, CD11b⁺CD11c⁺ and CD11b⁺ were negatively correlated with IL-10 and IL-17A, respectively. In conclusion, modulation of pro- and anti-inflammatory DCs in active vitiligo patients may affect cytokines production and thereby, lead to further depigmentation of skin.

Genetic polymorphism of liver X receptor gene in vitiligo: Does it have an association?

BACKGROUND

Vitiligo is an acquired depigmentation of the skin and the mucous membranes, exhibited as white macules and patches due to selective loss of melanocytes. Etiological theories of vitiligo include genetic, immunological, neurohormonal, cytotoxic, biochemical, oxidative stress, and newer theories of melanocytorrhagy and diminished melanocytes survival. It has been revealed that liver X receptor alpha gene is expressed in skin tissue such as sebaceous glands, hair follicle, keratinocytes, and fibroblasts and is linked to various skin disorders as acne vulgaris and psoriasis.

AIM OF THE STUDY

To evaluate the association between liver X receptor-α gene polymorphism (rs11039155 and rs2279238) and vitiligo and whether they are related to disease activity and severity or not.

SUBJECTS AND METHODS

50 vitiligo patients and 20 age- and sex-matched apparently healthy controls were enrolled. All the included subjects were genotyped using polymerase chain reaction-restriction fragment length polymorphism analysis technique for (-6G/A) and (+1257C/T) SNPs.

RESULTS

Significant statistical difference between cases and controls regarding genotype and allele frequencies for -6G/A polymorphism with predominance of AA genotype (OR: 5.1, 95% CI: 1.6-15.9) and A allele (OR: 5.3, 95% CI: 1.6-15.9) in cases and also for +1257C/T polymorphism with predominance of TT genotype OR: 9.2 (95% CI: 1.4-82.9) and T allele OR: 3.4 (95% CI: 1.4-8.1) in vitiligo cases. No significant relationship between -6G/A genotypes nor +1257C/T genotypes and disease activity and severity.

CONCLUSION

The study showed significant association between Liver X receptor gene polymorphisms (-6G/A, +1257 C/T) and development of vitiligo in Egyptian patients. However, it failed to show any relation with disease activity nor severity.

Can monocyte to HDL cholesterol ratio and monocyte to lymphocyte ratio be markers for inflammation and oxidative stress in patients with vitiligo? A preliminary study

Both systemic inflammation and oxidative stress play crucial roles in the pathogenesis of vitiligo. In recent studies, monocyte to high-density lipoprotein cholesterol ratio (MHR), monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV) and plateletcrit (PCT) have been shown to reflect inflammation and oxidative stress in chronic inflammatory and autoimmune diseases. In this study, we aimed to investigate the hematological and inflammatory parameters in patients with vitiligo and to evaluate their possible relationship with disease severity. The parameters including MHR, MLR, NLR, PLR, MPV, and PCT were retrospectively investigated in patients with vitiligo and healthy controls. Disease severity was evaluated using the vitiligo extent tensity index (VETI) score. A total of 180 patients with vitiligo, and age-gender-matched 180 healthy controls were enrolled in the study. MHR, MLR, PLR, PCT values were found to be significantly higher in patients with vitiligo (p < 0.05). MPV and NLR values showed no statistically significant difference between the two groups. A positive correlation was also detected between MHR and MLR values, disease duration, and VETI score (p < 0.05). We suggest that MHR and MLR can be used as markers of inflammation and oxidative stress in patients with vitiligo. Both markers may also reflect disease severity.

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.

Dermoscopic and Clinical Response Predictor Factors in Nonsegmental Vitiligo Treated with Narrowband Ultraviolet B Phototherapy: A Prospective Observational Study

Introduction

Few data on possible local factors that can influence the achievement of response in nonsegmental vitiligo (NSV) treated with narrowband ultraviolet B (Nb-UVB) phototherapy are available. Our objective is to evaluate possible correlations between therapeutic outcomes and dermoscopic and local (lesional) clinical findings of vitiligous lesions undergoing Nb-UVB phototherapy to find positive and/or negative response predictor factors to such treatment.

Methods

For each target patch, we calculated the extension area using a computer-aided method and assessed dermoscopic and local (lesional) clinical findings at baseline. After 30 phototherapy sessions (twice weekly), surface area of the lesions was reevaluated to assess clinical improvement, correlating the therapeutic outcome with initial clinical and dermoscopic features.

Results

A total of 70 lesions were finally included in the study. At the end of therapy, 18 patches (25.7%) achieved improvement, and the presence of perifollicular pigmentation on baseline dermoscopic examination was found to be associated with a 12-fold higher probability of having a positive therapeutic outcome. Similarly, face localization was also correlated with clinical amelioration, with a sevenfold higher probability for improvement. No association (p > 0.05) between therapeutic outcomes (either good or poor) and other dermoscopic or local clinical variables (including leukotrichia) was observed.

Conclusions

Therapeutic response of vitiligo to Nb-UVB phototherapy may be positively affected by local features of the lesions, i.e., face localization and presence of perifollicular pigmentation on baseline dermoscopic examination, which might be considered as positive response predictor factors to optimize treatment of vitiligo.

Vitiligo and Rise in Blood Pressure - a Case-Control Study in a Referral Dermatology Clinic in Southern Iran

Purpose

Vitiligo is an acquired hypopigmentation condition in which well-defined macules can develop virtually everywhere on the patients’ skin. This analytic case–control study was conducted in Faghihi Hospital outpatient dermatology clinic, affiliated to Shiraz University of Medical Sciences, southern Iran from June to September 2019. Furthermore, we studied the relationship of hypertension with activity, age of onset, duration, affected body surface area and type of vitiligo.

Patients and Methods

In the current case–control study, 166 individuals were enrolled in total (the case group was comprised of 83 vitiligo patients and 83 individuals actedas control group). The case group was made up of vitiligo patients (both segmental and non-segmental) between 20 and 50 years of age, no prior history of systemic disease and other hypopigmentation disorders, while individuals with any form of dermatologic findings were excluded from the control group. Individuals aged younger than 20 years old or older than 50, having a dermatologic disease other than vitiligo, being afflicted with the diseases which may lead to secondary hypertension, pregnancy, taking substances, and medication which can lead to hypertension were chosen as the exclusion criteria in this study.

Results

Data obtained from our study revealed that vitiligo patients had a higher prevalence of essential hypertension diagnosis than the control group (P=0.040). Also, no significant relationship was found between patients’ age at the first lesion appearance (P=0.856), duration of vitiligo involvement (P=0.497), and percentage of vitiligo involvement (P=0.681) with hypertension.

Conclusion

According to our results, vitiligo patients were more susceptible to hypertension while no association could be found between characteristics of the disease and rise in blood pressure.

A copy number variant is associated with a spectrum of pigmentation patterns in the rock pigeon (Columba livia)

Rock pigeons (Columba livia) display an extraordinary array of pigment pattern variation. One such pattern, Almond, is characterized by a variegated patchwork of plumage colors that are distributed in an apparently random manner. Almond is a sex-linked, semi-dominant trait controlled by the classical Stipper (St) locus. Heterozygous males (Z^StZ⁺ sex chromosomes) and hemizygous Almond females (Z^StW) are favored by breeders for their attractive plumage. In contrast, homozygous Almond males (Z^StZ^St) develop severe eye defects and often lack plumage pigmentation, suggesting that higher dosage of the mutant allele is deleterious. To determine the molecular basis of Almond, we compared the genomes of Almond pigeons to non-Almond pigeons and identified a candidate St locus on the Z chromosome. We found a copy number variant (CNV) within the differentiated region that captures complete or partial coding sequences of four genes, including the melanosome maturation gene Mlana. We did not find fixed coding changes in genes within the CNV, but all genes are misexpressed in regenerating feather bud collar cells of Almond birds. Notably, six other alleles at the St locus are associated with depigmentation phenotypes, and all exhibit expansion of the same CNV. Structural variation at St is linked to diversity in plumage pigmentation and gene expression, and thus provides a potential mode of rapid phenotypic evolution in pigeons.

The genetic changes responsible for different animal color patterns are poorly understood, due in part to a paucity of research organisms that are both genetically tractable and phenotypically diverse. Domestic pigeons (Columba livia) have been artificially selected for many traits, including an enormous variety of color patterns that are variable both within and among different breeds of this single species. We investigated the genetic basis of a sex-linked color pattern in pigeons called Almond that is characterized by a sprinkled pattern of plumage pigmentation. Pigeons with one copy of the Almond allele have desirable color pattern; however, male pigeons with two copies of the Almond mutation have severely depleted pigmentation and congenital eye defects. By comparing the genomes of Almond and non-Almond pigeons, we discovered that Almond pigeons have extra copies of a chromosome region that contains a gene that is critical for the formation of pigment granules. We also found that different numbers of copies of this region are associated with varying degrees of pigment reduction. The Almond phenotype in pigeons bears a remarkable resemblance to Merle coat color mutants in dogs, and our new results from pigeons suggest that similar genetic mechanisms underlie these traits in both species. Our work highlights the role of gene copy number variation as a potential driver of rapid phenotypic evolution.

A Review Article About Some Herbs Affecting Vitiligo Based on Avicenna's Canon

BACKGROUND

Vitiligo is a pigmentary disorder characterizing by white macules due to loss of melanocytes. Vitiligo affects about 1 to 4% of people around the world. The treatment of vitiligo has a high cost and the long process of treatment in spite of no complete remedy. It has various psychological side-effects such as depression and anxiety affecting the quality of life seriously. Avicenna in his Canon treated these patients over a thousand years ago. This study aimed to introduce some herbal drugs in vitiligo based on the Canon of Avicenna besides the conventional medical treatments.

METHODS

This is a review study, according to the Canon with the term Baras and also searching through the electronic websites with the keywords vitiligo, treatment, and herbal drugs.

RESULTS

The study found some herbs affecting the vitiligo from the Canon.

CONCLUSION

The researchers suggest conducting clinical trials on the patients with vitiligo based on the Canon besides the conventional techniques to obtain a better result in the treatment.

Factors affecting the outcome of the suction blisters using two different harvesting techniques in vitiligo patients

BACKGROUND

Suction blister grafting (SBG) technique has been used for long to treat various skin conditions. Different suction methods have been used such as syringes, Chinese cups, and suction device. There are some limitations of its use as time consumption, failure of induction or incomplete blister formation and pain.

AIM

The aim of this work was to evaluate the outcome of using two different suction techniques, namely the syringes and the Chinese cups in induction of suction blisters. The effect of the device diameter and preheating of the donor area on the suction blister induction time (SBIT) was studied. The effect of saline injection in the blister formation and its completion was also evaluated.

METHODS

The study was a left-right comparative study that included 50 patients with stable nonsegmental vitiligo. They were classified into four groups: Group 1 included 15 patients where different diameters of syringes (1.3, 1.7, and 2 cm) were compared against each other, group 2 included 15 patients where different diameters of cups (2, 3.5, and 5 cm) were compared against each other, group 3 included 20 patients subdivided into two groups; 10 patients each, where the effect of preheating the skin on blister induction was tested with use of cups (3a) and syringes (3b). Lastly, group 4 included randomly chosen 40 incomplete or multilocular blisters where the effect of saline injection on blister completion and coalescence of multilobulation was examined. SBIT was calculated in all patients.

RESULTS

The use of the small diameter syringes or cups gave shorter SBIT; however, the difference, which was significant between all sizes of cups, was significant between the 1.3- and 2-cm-diameter syringes only. Preheating of the donor area shorten SBIT significantly. No complications were reported at the donor site except for transient postinflammatory hyperpigmentation in all patients.

CONCLUSION

The small diameter syringes or cups and preheating of the donor area shorten the SBIT, while intra-blister saline injection increased the blister size and turns the multilocular blisters to unilocular ones.

Predominant role of innate pro-inflammatory cytokines in vitiligo disease

Vitiligo is a skin disorder with melanocyte destruction and an autoimmune basis. Given the importance of cytokines in autoimmunity, we aimed to find the cytokine profile of innate and adaptive immunity in vitiligo patients, and correlate them with clinical parameters. The serum levels of innate immunity [interleukin(IL)-1α, IL-1β, IL-6, IL-8, IL-12, IL-15 and tumor necrosis factor (TNF)-α] and T helper(Th)1 [IL-2, interferon (IFN)-γ, TNF-β], Th2 (IL-4, IL-5, IL-10, IL-13) and Th17 (IL-17, IL-23) cytokines in 44 vitiligo patients were measured by multiplex cytokine assay and compared with 44 healthy subjects. All innate immunity (p < 0.04), Th1 (p < 0.01), Th2 (p < 0.05) and Th17 (p < 0.001) cytokines were higher in patients than controls. Total summation levels of innate immunity and adaptive immunity cytokines showed a remarkable up-regulation in the patients (p < 0.0001). The ratio of innate immunity to Th1 (p = 0.03), Th2 (p = 0.01) and Th17 (p = 0.03) cytokines was significantly higher in patients vs. controls. We found significant higher ratio of Th1 to Th2 cytokines and TNF-β elevated levels in patients with a family history of autoimmunity (p < 0.05). IL-4 and IL-13 (p < 0.04) levels were lower in patients with amelanotic hair. Increased IL-10 level was observed in patients with stable disease (p = 0.02).In conclusion, the profile of cytokines in patients showed a dominant role of innate immunity pro-inflammatory cytokines in vitiligo, which suggests the potential of targeting these cytokines for vitiligo treatment. While a higher ratio of Th1/Th2 cytokines was observed in the patients, association of decreased Th2 cytokines with disease complications suggests a protective role for Th2 pathway.

Study the effect of erbium:YAG laser plus topical 5-flurouracil in stable vitiligo resistant to NB-UVB phototherapy

BACKGROUND

NB-UVB phototherapy is still an effective treatment in vitiligo but requires more than 1 year for its completion. Topical 5-flurouracil could improve the proliferation and migration of melanocytes. Laser-assisted dermabrasion results in stimulation of the inactive melanocytes present at the outer root sheath of the lower portion of the hair follicle, which migrates upward until they reach the surface of the skin.

OBJECTIVE

To evaluate the effect of Er:YAG laser skin ablation followed by topical 5-flurouracil on the outcome of NB-UVB phototherapy as a short term technique in resistant and stable vitiligo.

METHODS

The current study included 40 patients suffering from bilateral stable vitiligo resistant to NB-UVB. For each patient, one side of the body subjected to 4 months NB-UVB sessions (control side). While the other side of the body subjected to one session of Er:YAG laser ablation combined with topical 5% 5-flurouracil application under occlusion followed by NB-UVB sessions for 4 months after complete re-epithelization. Outcomes were evaluated objectively based on standard digital photographs, histopathological examination, patient satisfaction, and adverse effects.

RESULTS

There was a statistically significant improvement in the repigmentation in laser side compared with control side. Histopathological examination revealed expression of prominent melanin pigmentation, with marked expression for Melan-A in laser side, whereas these findings were negative in control side.

CONCLUSION

Er:YAG laser ablation, followed by 5FU application before NB-UVB phototherapy for vitiligo, is a safe and tolerable technique that improves the outcome of short-term NB-UVB therapy and is expected to increase patient compliance.

The color of skin: white diseases of the skin, nails, and mucosa

White diseases are a heterogenous group characterized by hypopigmentation or depigmentation. Skin and eye color are determined by the number and size of melanosomes present. Melanin is produced by melanosomes in the melanocytes present within the epidermis of the skin, uvea, and retinal pigmented epithelium (RPE). Conditions altering the number of melanocytes or concentration of melanin result in a lack of pigmentation, appearing as "white diseases" ranging from the well-known albinism and vitiligo to more esoteric white hand syndrome and Degos disease.

Home phototherapy for patients with vitiligo: challenges and solutions

Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is well-demarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo.

Glycyrrhizin protects human melanocytes from H2O2‑induced oxidative damage via the Nrf2‑dependent induction of HO‑1

Oxidative stress serves a critical role in melanocyte death and is considered to be a major cause of vitiligo. The nuclear factor E2-related factor 2 (Nrf2) signaling pathway has an important role in the antioxidative stress mechanisms of melanocytes. Glycyrrhizin (GR) is a derivative of herbal medicines used to treat hepatitis and allergic disease due to its antiviral and anti-allergy effects. GR also activates Nrf2 and induces the expression of heme oxygenase (HO)-1 in macrophages. Whether GR can protect human melanocytes from oxidative stress remains unknown. The present study investigated the potential protective effects of GR against oxidative stress in human melanocytes and the mechanisms involved. Following exposure to 0.5 mM hydrogen peroxide (H₂O₂), human primary melanocytes were treated with 1 mM GR. Cell viability was determined using a Cell Counting Kit-8 assay, and apoptosis was evaluated by flow cytometry. GR treatment significantly improved cell viability, reduced the apoptotic rate of melanocytes and reduced the level of reactive oxygen species in human melanocytes. Furthermore, GR induced the nuclear translocation of Nrf2 and induced the expression of HO-1 in melanocytes. The knockdown of Nrf2 by small interfering RNA or the inhibition of HO-1 by ZnPP reversed the protective effect of GR on melanocytes against H₂O₂-induced cytotoxicity and apoptosis. These data demonstrate that GR protects human melanocytes from H₂O₂-induced oxidative damage via the Nrf2-dependent induction of HO-1, providing evidence for the application of GR in the treatment of vitiligo.

The Use of Janus Kinase Inhibitors in Vitiligo: A Review of the Literature

Vitiligo is a common acquired depigmenting disorder characterized by the development of white macules and patches due to the loss of melanocytes. Patients with vitiligo can be stigmatized by society, making the disease a source of psychological stress that can considerably affect quality of life. The goal of vitiligo treatment is to obtain skin repigmentation in the majority of cases, and less commonly to depigment the remaining normal skin. There is no consistent, long-term, durable therapy for vitiligo for all patients, highlighting the unmet need for new safe and effective therapies to control this disease. Recently, JAK inhibitors have been explored as a promising novel treatment option in vitiligo. The JAK and signal transducers and activators of transcription (STAT) pathway is an attractive therapeutic target because IFN-γ-dependent cytokines produced through this pathway have been implicated in the pathogenesis of disease. This literature review describes vitiligo pathophysiology, explains the usefulness of the JAK inhibitors for treatment, and summarizes published case reports, case series, and open-label studies. Research outlined here shows JAK inhibitors in patients with vitiligo have a favorable safety profile and effectively produce repigmentation of lesions, especially with concomitant ultraviolet exposure. Additional studies are required to confirm efficacy, establish safety, and investigate durability of repigmentation.

Objective Assessment of Skin Repigmentation Using a Multilayer Perceptron

Background:

Vitiligo is a pathology that causes the appearance of achromic macules on the skin that can spread on to other areas of the body. It is estimated that it affects 1.2% of the world population and can disrupt the mental state of people in whom this disease has developed, generating negative feelings that can become suicidal in the worst of cases. The present work focuses on the development of a support tool that allows to objectively quantifying the repigmentation of the skin.

Methods:

We propose a novel method based on artificial neural networks that use characteristics of the interaction of light with the skin to determine areas of healthy skin and skin with vitiligo. We used photographs of specific areas of skin containing vitiligo. We select as independent variables: the type of skin, the amount of skin with vitiligo and the amount of repigmented skin. Considering these variables, the experiments were organized in an orthogonal table. We analyzed the result of the method based on three parameters (sensitivity, specificity, and F1-Score) and finally, its results were compared with other methods proposed in similar research.

Results:

The proposed method demonstrated the best performance of the three methods, and it also showed its capability to detect healthy skin and skin with vitiligo in areas up to 1 × 1 pixels.

Conclusion:

The results show that the proposed method has the potential to be used in clinical applications. It should be noted that the performance could be significantly improved by increasing the training patterns.

A comparative study between suction blistering graft, mini punch graft, and hair follicle transplant in treatment of patients with stable vitiligo

Background: Vitiligo is an acquired disfiguring common depigmented skin disease. Objectives: This study aimed to compare the clinical efficacy and safety of suction blistering graft, mini punch and hair follicle techniques in treatment of patients with stable vitiligo. Methods: Thirty patients with stable vitiligo were included. Patients were divided into 3 groups, in group (A) 10 patient underwent suction blistering technique, in group (B) 10 patients underwent mini punch technique and in group (C) 10 patients underwent hair follicle technique. Then all patients in the three techniques were subjected to narrow-band ultraviolet B (NB-UVB) phototherapy for 3 months. All patients were assessed by determining the percentage of repigmentation and Dermatology Life Quality Index (DLQI) before and 3 months after the operation. Results: The percentage of repigmentation of vitiligo in suction blister technique was significantly higher than both mini punch and hair follicle techniques (p value .001 and .0001 respectively). There was a statistically significant difference between the three techniques regarding DLQI score after operation (p value = .0001). Conclusion: This study concluded that suction blistering technique is more effective and safe than mini punch technique and hair follicle technique in treatment of stable vitiligo.

Flavonoids as adjuvant in psoralen based photochemotherapy in the management of vitiligo/leucoderma

Vitiligo is a disorder characterized by the decrease in melanin pigment of skin. This depigmenting disorder has prevalence among worldwide, irrespective of age and sex. There is an existence of different treatment modalities for the management of vitiligo. But irrespective of treatment methods, the main drawback in the management of vitiligo is the occurrence of side effects during the implication of treatment. Among the treatment modalities, photochemotherapy seems to be the better choice of treatment for vitiligo. Photochemotherapy involves the usage of UV rays for photoactivation of the drug to cause photosensitization of skin which in turn leads to repigmentation. The main aim of the study is to develop novel combination strategy of lipid based nanoemulsion gel for the treatment of leucoderma using trimethylpsoralen and flavonoid. We assume that if this hypothesis of combination therapy proves successful it can be used as an additional novel treatment strategy in the management of vitiligo.

Prevalence of choroidal nevus and retinal pigment epithelial alterations in vitiligo patients

PURPOSE

To investigate ocular manifestations in patients with vitiligo by multimodal imaging, including optical coherence tomography (OCT), color fundus photography, and fundus autofluorescence (FAF).

METHODS

In this prospective, observational clinical study, vitiligo patients underwent ophthalmologic and dermatologic clinical assessment and imaging by spectral-domain OCT, FAF, and color fundus imaging. Ocular echography was performed as indicated. Statistical analysis was performed using paired T test and Pearson correlation.

RESULTS

A total of 61 eyes of 31 vitiligo patients were examined. Ocular findings consisted of choroidal nevi (n = 10, 32%), of which four (40%) were bilateral; two patients (6.5%) had a prominent choroidal pattern, two (6.5%) had hypopigmentary retinal pigment epithelium (RPE) lesions, and one (3.2%) had peripapillary atrophy of the RPE. Choroidal nevi were demonstrated only in eyes of patients with generalized vitiligo and were more common with upper body involvement (p = 0.02) and more prevalent in women (p = 0.02). Hypopigmentary lesions were detected in two patients and demonstrated on OCT as RPE atrophy and as photoreceptor/RPE changes.

CONCLUSIONS

In this case series, vitiligo patients had a higher rate of choroidal nevi than previously reported. The hypopigmentary vitiliginous fundus lesions were depicted on OCT as photoreceptor and RPE atrophy. These findings may suggest the advisability of regular ocular monitoring for vitiligo patients.

Efficacy and safety of noncultured melanocyte-keratinocyte transplant procedure for vitiligo and other leukodermas: a critical analysis of the evidence

Vitiligo is an acquired pigmentary skin of depigmentation occurring secondary to melanocyte destruction. Vitiligo and other leukodermas have a profound impact on quality of life. Current therapies include medical options, such as phototherapy, topical and systemic corticosteroids, topical calcineurin inhibitors, immunomodulators, and antioxidiants, and surgical options. Surgical options provide melanocytic cells to previously depigmented areas and use either tissue grafting or cellular grafting methods. Topical treatments are often insufficient, and many of the current surgical procedures have shown variable response rates. In this review, we discuss the process of the cellular grafting melanocyte-keratinocyte transplantation procedure (MKTP) and critically analyze its efficacy and safety in the treatment of vitiligo and other leukodermas. PubMed was searched for studies (2001-2017) describing the use of MKTP in patients with vitiligo or other leukodermas. Articles or trials discussing the use of MKTP for these patients were selected for in-depth review. Clinically relevant results regarding efficacy and safety of MKTP in vitiligo and leukoderma patients were analyzed. Numerous trials and case series/reports have demonstrated tolerability and efficacy of MKTP with repigmentation for patients with refractory, stable vitiligo. However, the response rates have been variable, likely influenced by vitiligo type and affected areas. Future research and clinical reporting will provide more insight on which phenotypes may benefit from MKTP.

Comprehensive survey of vitiligo patients in the northeast of China using a predesigned questionnaire

To assess the sociodemographic data and clinical information of outpatients affected by vitiligo in the northeast of China, vitiligo patients or guardians who presented to the clinic were invited to participate in an exploratory questionnaire. The questionnaire consisted of two sections related to vitiligo, including sociodemographic data and clinical information. A total of 983 vitiligo patients answered the questionnaire. The rates of female and male patients were comparable. The investigated patients were mostly young and middle-aged. Most patients suffered from vitiligo in childhood or young adulthood. Vitiligo vulgaris was the most common type of vitiligo in clinic and 53.0% of patients were categorized as body surface area (BSA) of 10% or less. In response to the latest treatment, 43.6% of patients achieved good response (completely stopped or almost disappeared). More patients at active stage showed good response than the patients at stable stage (χ² = 7.866, P < 0.05). Chronic comorbid condition(s) were observed in 12.6% of patients with BSA of more than 10%, whereas those were seen in 6.0% of patients with BSA of 10% or less (χ² = 12.969, P < 0.05). In conclusion, active vitiligo seems to respond better than stable vitiligo and complications with other autoimmune diseases more frequently observed in severe patients than mild patients. The current study presented a comprehensive understanding of vitiligo in the northeast of China.

Bioreactor Microcarrier Cell Culture System (Bio-MCCS) for Large-Scale Production of Autologous Melanocytes

Restoration of cutaneous pigmentation can be achieved in stable vitiligo by autologous cultured melanocyte transplantation. It was the goal of this study to construct a bioreactor microcarrier cell culture system (Bio-MCCS) to produce autologous melanocytes in large scale. In this Bio-MCCS, porcine gelatin microbeads were used as microcarriers, spinning bottle as fermented tank. Autologous melanocytes were able to attach to and proliferate on the gelatin microbeads in serum-free melanocyte medium in the Bio-MCCS, reaching up to 24-fold the cells seeded on day 15 (MTT assay). These autologous melanocytes cultured on gelatin microbeads could leave the microbeads and proliferate on the bottom of tissue culture flasks. Although Pluronic F68 has been widely used to protect animal cells from hydrodynamic stress in animal cell bioreactors, Pluronic F68 at a concentration of 0.25–1.0% showed no significant protective effects on the autologous melanocytes cultured on the microbeads and subjected to mechanical stress in the Bio-MCCS. This Bio-MCCS using porcine gelatin microbeads as microcarriers enabled large-scale production of autologous mela-nocytes, offering a potential treatment for large-area stable vitiligo by direct administration of the melanocytes cultured on the gelatin microbeads to the vitiliginous site.

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.

A Comparison of Betamethasone Valerate 0.1% Cream Twice Daily Plus Oral Simvastatin Versus Betamethasone Valerate 0.1% Cream Alone in the Treatment of Vitiligo Patients

BACKGROUND

Vitiligo, a common disorder of depigmentation, is often difficult to treat. Corticosteroids are known to be effective, but with modest results. Although simvastatin has been reported to be effective for immunorelated dermatologic disorders including vitiligo, controlled trials are lacking. This study was conducted to compare the efficacy of topical betamethasone valerate 0.1% cream (as a standard method of treatment for vitiligo) versus a combination of betamethasone valerate plus oral simvastatin in the treatment of vitiligo.

MATERIALS AND METHODS

Eighty-eight subjects with symmetric vitiligo who had body surface involvement up to 20% were divided randomly into two groups. Group A were treated with betamethasone valerate 01% cream twice daily and Group B with betamethasone valerate 01% cream twice daily and oral simvastatin 80 mg daily for 12 weeks. Finally, 46 patients completed treatment after 12 weeks in both groups. The results were evaluated by a blind dermatologist using Vitiligo Area Scoring Index (VASI) score at baseline, 4th, 8th, and 12th week of treatment. In a similar way, subjective assessment performed by patients based on photo evaluation at the end of the study.

RESULTS

Despite a continuous reduction in VASI score in both groups, according to both physician (P = 0.13) and patient (P = 0.374) assessment oral simvastatin was not statistically more effective than conventional treatment of vitiligo.

CONCLUSION

This study indicates that oral simvastatin is not associated with significant impacts in the treatment of vitiligo as compared to other inflammatory dermatologic conditions such as psoriasis. Indeed, other studies should be initiated regarding exact molecular and cellular effects of statins in the treatment of vitiligo.

Dermatologic conditions in patients of color who are pregnant

Certain dermatoses that present during pregnancy have a predilection for populations with skin of color (SOC). Additionally, certain systemic diseases such as systemic lupus erythematosus tend to be more aggressive during pregnancy and confer worse prognoses in women with SOC. The purpose of this review is to highlight the unique implications of selected diseases during pregnancy as it relates to SOC. Dermatologists should be vigilant for the unique clinical variations of dermatological conditions in patients of color who are pregnant to ensure correct diagnoses and optimize treatment outcomes.

Vitiligo blood transcriptomics provides new insights into disease mechanisms and identifies potential novel therapeutic targets

BACKGROUND

Significant gaps remain regarding the pathomechanisms underlying the autoimmune response in vitiligo (VL), where the loss of self-tolerance leads to the targeted killing of melanocytes. Specifically, there is incomplete information regarding alterations in the systemic environment that are relevant to the disease state.

METHODS

We undertook a genome-wide profiling approach to examine gene expression in the peripheral blood of VL patients and healthy controls in the context of our previously published VL-skin gene expression profile. We used several in silico bioinformatics-based analyses to provide new insights into disease mechanisms and suggest novel targets for future therapy.

RESULTS

Unsupervised clustering methods of the VL-blood dataset demonstrate a "disease-state"-specific set of co-expressed genes. Ontology enrichment analysis of 99 differentially expressed genes (DEGs) uncovers a down-regulated immune/inflammatory response, B-Cell antigen receptor (BCR) pathways, apoptosis and catabolic processes in VL-blood. There is evidence for both type I and II interferon (IFN) playing a role in VL pathogenesis. We used interactome analysis to identify several key blood associated transcriptional factors (TFs) from within (STAT1, STAT6 and NF-kB), as well as "hidden" (CREB1, MYC, IRF4, IRF1, and TP53) from the dataset that potentially affect disease pathogenesis. The TFs overlap with our reported lesional-skin transcriptional circuitry, underscoring their potential importance to the disease. We also identify a shared VL-blood and -skin transcriptional "hot spot" that maps to chromosome 6, and includes three VL-blood dysregulated genes (PSMB8, PSMB9 and TAP1) described as potential VL-associated genetic susceptibility loci. Finally, we provide bioinformatics-based support for prioritizing dysregulated genes in VL-blood or skin as potential therapeutic targets.

CONCLUSIONS

We examined the VL-blood transcriptome in context with our (previously published) VL-skin transcriptional profile to address a major gap in knowledge regarding the systemic changes underlying skin-specific manifestation of vitiligo. Several transcriptional "hot spots" observed in both environments offer prioritized targets for identifying disease risk genes. Finally, within the transcriptional framework of VL, we identify five novel molecules (STAT1, PRKCD, PTPN6, MYC and FGFR2) that lend themselves to being targeted by drugs for future potential VL-therapy.

Hydroxychloroquine protects melanocytes from autoantibody-induced injury by reducing the binding of antigen-antibody complexes

Vitiligo is a polygenic autoimmune disorder characterized by loss of pigmentation due to melanocyte destruction. Hydroxychloroquine (HCQ) is an effective immunosuppressant widely used in the treatment of autoimmune disorders. As generalized vitiligo (GV) is commonly considered to be a T cell and autoantibody-induced immune disorder, the present study aimed to determine whether HCQ protects melanocytes from autoantibody‑induced disruption. Anti‑melanocyte antibodies were obtained from the serum of patients with progressive GV and the effects of HCQ on prevent the autoantibody‑induced disruption of melanocytes was observed. Cell‑based ELISA, indirect immunofluorescence and western blotting were used to analyze the autoantibody content of sera samples obtained from 32 patients with progressive GV. The cytotoxicity of HCQ was detected by MTT assay, and 1 µg/ml HCQ was applied to human primary melanocytes (HMCs) to examine whether it could exert protective effects against autoantibody‑induced immune injury. Flow cytometry was used to measure autoantibody binding to the surface of HMCs. Complement‑dependent cytotoxicity (CDC) and antibody‑dependent cell‑mediated cytotoxicity (ADCC) were monitored by MTT and lactate dehydrogenase‑releasing assays. The concentration of autoantibodies in sera samples taken from GV patients was significantly higher than in controls, particularly in patients who had >10% of their body surface affected by vitiligo. The majority of the autoantibodies presented in the HMCs and human keratinocytes (HKCs) and were predominantly localized to the cell surface and cytoplasm. The molecular weights of the autoantigens were identified as 30, 37‑39, 42, 53, 60‑75, 90, 100, 110, and 126 kDa; the 30 kDa protein was observed only in HMCs. The addition of HCQ at a concentration of 1 µg/ml produced no significant cytotoxicity in HMCs and was demonstrated to reduce the binding of GV immunoglobulin G (IgG) to the surface of HMCs. HCQ also significantly decreased the effects of ADCC and CDC that were mediated by GV IgG. The present study provides evidence that HCQ dissociates autoantibody-antigen complexes on the surface of HMCs and reverses ADCC and CDC activity in vitro. Thus, in addition to its effectiveness as an antimalarial therapeutic agent, HCQ may also be a promising potential treatment for patients with vitiligo.

Combination of medical needling and non-cultured autologous skin cell transplantation (ReNovaCell) for repigmentation of hypopigmented burn scars

Burn scars remain a serious physical and psychological problem for the affected people. Clinical studies as well as basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient with regards to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling has no influence on repigmentation of large hypopigmented scars. The goal of this study is to evaluate whether two established methods - needling (for improvement of scar quality) and non-cultured autologous skin cell suspension (for repigmentation) - can be successfully combined. Twenty subjects with mean age of 33 years (6-60 years) with scars from deep second and third degree burns have been treated. The average treated surface area was 94cm² (15-250cm²) and was focused on prominent areas such as the face, neck, chest and arm. Percutaneous collagen induction or "medical needling" was performed using a roller covered with 3mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, non-cultured autologous skin cell suspension (NCASCS) was produced and applied using the ReNovaCell Autologous Cell Harvesting Device (Avita Medical), according to the manufacturer's instructions. The patients were followed 12 months postoperatively. Pigmentation changes were measured objectively, as well as with patient and observer ratings. Patient satisfaction/preference was also obtained. Taken together, the pigmentation ratings and objective measures indicate individual improvement in 17 of the study participants. The melanin increases seen 12 months after NCASCS treatment are statistically significant. Medical needling in combination with NCASCS shows promise for repigmentation of burn cars.

Comparative Study of Efficacy of Epidermal Melanocyte Transfer Versus Hair Follicular Melanocyte Transfer in Stable Vitiligo

Background:

Vitiligo surgery has come up a long way from punch skin grafts to epidermal cell suspension and latest to the extracted hair follicle outer root sheath cell suspension (EHFORSCS) transplantation. The progressive development from one technique to the other is always on a quest for the best. In the latest development, EHFORSCS, which is an enriched source of follicular inactive melanocyte (melanocyte stem cells), seems to be a good addition to the prevailing cell-based therapies for vitiligo. However, it needs to be explored further in larger, clinical trials.

Methodology:

A total of 11 patients with sixty stable vitiligo sites attending dermatology outpatient department were included for the open-labeled, prospective, comparative study. The sites were sequentially distributed into two groups of thirty each. Sites of one group were subjected to epidermal melanocyte transfer (EMT) and the others to hair follicular melanocyte transfer (HFMT). Response to treatment was evaluated on the basis of degree of repigmentation; final evaluation of area of involvement was done after completion of 6 months.

Results:

At the end of 6 months, repigmentation >90% was observed in 83.33% patches of EMT group and 43.33% in HFMT group. Repigmentation >75% was observed in 90% of patches in Group A and 43.34% of patches in Group B, respectively. There was statistically significant difference in the overall pigmentation between these two groups.

Conclusion:

Both noncultured autologous epidermal cell suspension transfer and noncultured EHFORSCS transfer are safe and effective surgical modalities in the management of stable vitiligo though EMT has shown a better response in the present study. Outer root sheath cell suspension transfer is a novel, minimally invasive technique in its nascent stage in the surgical management of vitiligo which requires further larger clinical trials for evaluation of its efficacy.

Radiotherapy-Induced Vitiligo in a Patient with Carcinoma Buccal Mucosa: A Case Report

Vitiligo significantly affects self-esteem and deteriorates the quality of life of affected persons. Radiotherapy has several early and late effects but it is not known to induce vitiligo. This is a case report of a patient suffering from carcinoma buccal mucosa that had developed vitiligo in the radiotherapy portal. To the best of my knowledge this is a one of the first case reports of its kind as this patient had no history of vitiligo but developed it soon after radiotherapy. Since radiotherapy is an essential component of cancer management, the radiation oncologist must be aware of this toxicity of radiotherapy. Choosing the high energy of photon beam may reduce the risk of such toxicities.

Highlights in pathogenesis of vitiligo

Vitiligo is a common pigmentary disorder. Many studies across decades and all over the world have attempted to illustrate the pathogenesis behind it; however, the pathogenesis of vitiligo remains elusive. This review article, we present the findings behind the most and updated theories behind this psychologically debilitating and disfiguring disease. The discussion begun with the role of genetic predisposition followed by neural theory first proposed in the 1950s. We highlight the autoimmune hypothesis, followed by the reactive oxygen species model, zinc-α2-glycoprotein deficiency hypothesis, viral theory, intrinsic theory and biochemical, molecular and cellular alterations accounting for loss of functioning melanocytes in vitiligo. Many theories were elaborated to clarify vitiligo pathogenesis. It is a multifactorial disease involving the interplay of several factors. Future research is needed to clarify the interaction of these factors for better understanding of vitiligo pathogenesis and subsequent successful treatment.

Increased prevalence of thyroid dysfunction and diabetes mellitus in Indian vitiligo patients: A case-control study

Background:

Though it is well-known that vitiligo is associated with other autoimmune disorders, few Indian studies have focused on the relation between vitiligo, autoimmune thyroid dysfunction and diabetes mellitus.

Materials and Methods:

This case-control study included 150 new cases of vitiligo and 100 age and sex-matched controls. A complete history and thorough dermatological examination was done. Serum samples from both patients and controls were collected and assayed for triiodothyronine, thyroxine, thyroid-stimulating hormone, anti-thyroid antibodies—anti-thyroid peroxidase and anti-thyroglobulin and fasting plasma glucose.

Results:

Thyroid hormonal profile revealed autoimmune thyroid dysfunction manifesting as hypothyroidism in 30 (20%) vitiligo patients and two controls (2%). Diabetes mellitus was present in 24 (16%) vitiligo patients and five controls. Seven (4.7%) patients had both hypothyroidism and diabetes mellitus.

Conclusion:

There is a clear association between vitiligo, autoimmune hypothyroidism and diabetes mellitus. It would be very useful to screen for thyroid dysfunction and diabetes mellitus in all patients with vitiligo.

Correlation of clinical efficacy and psychosocial impact on vitiligo patients by excimer laser treatment

BACKGROUND AND OBJECTIVES

Vitiligo is a difficult disease to treat. Recently, a 308-nm excimer laser has been shown to be effective in treating vitiligo. In addition, the patients with vitiligo have impairment in their quality of life. The aim of the study was to investigate the clinical efficacy, safety, and psychosocial impact after treating vitiligo with the 308-nm excimer laser.

DESIGN AND SETTINGS

A prospective clinical trial conducted at dermatology clinics of hospitals affiliated with Qassim University, Saudi Arabia, from May 2012 to February 2013.

PATIENTS AND METHODS

Forty-eight patients with 105 vitiliginous patches were treated using a 308-nm excimer laser. The treatment was performed twice per week for a maximum of 48 treatments or 100% repigmentation of lesions whichever was achieved first. The assessment of the clinical response and recording of side effects were performed biweekly.

RESULTS

Out of 105 lesions in these patients, 63 lesions (60.0%) achieved over 75% repigmentation by laser treatment, 12 lesions (11.4%) showed 51% to 75% repigmentation, 9 lesions (8.6%) showed 26% to 50% repigmentation, and another 9 lesions (8.6%) showed 1% to 25% repigmentation, while 12 lesions (11.4%) showed no repigmentation. The average (+/-standard deviation [SD]) number of sessions needed to achieve repigmentation was 16.8 (8.0), whereas the average (+/-SD) number of sessions needed to realize Grade IV repigmentation was 20.2 (15). The type of repigmentation varied between lesions. Diffuse repigmentation was the most common pattern and occurred in 34 lesions (36.6%). Facial lesions responded better than lesions located elsewhere. Skin type did not play a statistically significant role (P=.07) in the lesions response to treatment. All side effects were mild and disappeared shortly after end of treatment sessions.

CONCLUSION

The clinical data indicate that the treatment of vitiligo using the 308-nm excimer laser is effective and safe and improves psychosocial quality of life. Lesion location, duration of disease, and treatment duration are factors affecting the clinical and psychological outcome.