Autoimmune aspects of vitiligo

Macrophage inhibitory factor alters the functionality of macrophages and their involvement in disease pathogenesis of active generalized vitiligo patients

INTRODUCTION

In autoimmune dermatitis patients, a macrophage migration inhibitory factor (MIF) is widely used to determine the severity of the diseases with other clinical parameters. Moreover, in vitiligo, MIF has shown significant positive correlation with the VASI (Vitiligo Area Scoring Index) score of both generalized and localized vitiligo patients. MIF function as pro-inflammatory cytokine and inhibited random migration of macrophages from inflammation loci. Hence, activated macrophage infiltrates promote the diseases pathogenesis. Till date, macrophages and involvement of their secreted MIF in disease severity of vitiligo patients remains undetermined.

MATERIAL AND METHOD

The frequency of both M1 and M2 macrophages was evaluated in active GV patients (n = 20) using flow cytometry in blood and in tissues by confocal microscopy (n = 10). Relative m-RNA expression and cytokine profiling of pro and anti-inflammatory mediators were estimated in PBMCs and in serum of patients. Lastly, concentration of nitric oxide and phagocytic activity from macrophages of active patients were calculated to understand the diseases pathology in detail.

RESULT

Both in circulation as well as in tissues, the infiltration of M1 macrophages was increased in active GV patients, while the percentage of M2 macrophages was comparable to healthy tissues. Aberrant expression of pro and anti-inflammatory molecules including IL-1β, IL-6, TNF-α, IL-12 and MIF impair the cellular hemostasis and induce systematic inflammation. Elevated nitric oxide and higher phagocytic activity of macrophages enhanced the destruction and/or depigmentation of melanocytes causing vitiligo.

CONCLUSION

Elevated macrophages in both tissue and blood enhanced the secretion of MIF and other inflammatory mediators that further enforce the production of nitric oxide, activation and phagocytic activity of macrophages against melanocytes and melanocytes antigens. As a result, destruction of melanocytes and melanin production occurred and caused the depigmentation and/or white macules on the skin.

Pigmentary complications after non-medical male circumcision

BACKGROUND

A wide spectrum of complications are reported after male circumcision (MC), the non-aesthetic complications are well known, but the pigmentary complications scale are not reported precisely.

METHODS

This is a prospective cohort study of 550 circumcised boys; aged from 6 months to 14 years (62% aged 5 years) who were examined and appropriately investigated for the incidence of pigmentary complications after circumcision. Most diagnoses were clinically, but dermoscopy was done for 17 case and a skin biopsy for 14 cases. Patients with personal or family history of vitiligo, or congenital nevi were excluded. Available hospital records details and parents' statements were revised. The main outcome measures are the incidence of different pigmentary complications and circumcision details; data were analyzed by a non-parametric tests including the Mann-Whitney U test.

RESULTS

69 cases had 72 confirmed pigmentary complications discovered at 2-36 months after commencement of circumcision (mean 18). 48 cases had pigmentary complications directly related to MC, 11 cases were probably related and 10 unrelated to MC. The most common lesion is the circular hyperpigmented scar (29 cases); liner hyperpigmented scar in 13, spotted exogenous melanosis in 18 cases, melanocytic nevi (7), hypopigmentation diagnosed in 3 cases, but kissing nevus is the rarest finding (2). Topical corticosteroid was tried in 15 cases, surgical excision of pigmented scar were done for 19 cases, local laser used for 4 resistant cases and reassurance with follow up for the rest.

CONCLUSION

Pigmentary complications after male circumcision are not rare and its management is challenging.

Patho-immunological mechanisms of vitiligo: the role of the innate and adaptive immunities and environmental stress factors

Epidermal melanocyte loss in vitiligo, triggered by stresses ranging from trauma to emotional stress, chemical exposure or metabolite imbalance, to the unknown, can stimulate oxidative stress in pigment cells, which secrete damage-associated molecular patterns that then initiate innate immune responses. Antigen presentation to melanocytes leads to stimulation of autoreactive T-cell responses, with further targeting of pigment cells. Studies show a pathogenic basis for cellular stress, innate immune responses and adaptive immunity in vitiligo. Improved understanding of the aetiological mechanisms in vitiligo has already resulted in successful use of the Jak inhibitors in vitiligo. In this review, we outline the current understanding of the pathological mechanisms in vitiligo and locate loci to which therapeutic attack might be directed.

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.

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.

Effect of vitiligo treatment using compound glycyrrhizin combined with fractional carbon dioxide laser and topical triamcinolone acetonide on serum interleukin-17 and tissue growth factor- levels

Objective

Vitiligo is a common pigmentation disorder of the skin, and its pathogenesis remains unclear. We evaluated the effectiveness of compound glycyrrhizin combined with fractional carbon dioxide (CO₂) laser and triamcinolone acetonide solution in patients with vitiligo.

Methods

Patients with stable vitiligo treated at our hospital between May 2016 and August 2017 were randomized to a control group or an observation group. Both groups were treated with fractional CO₂ laser and triamcinolone acetonide solution, while the observation group also received compound glycyrrhizin. Clinical effectiveness, serum IL-17 and TGF-β levels, and adverse drug reactions were compared between the groups.

Results

Following treatment, the clinical effective rate was significantly higher in the observation group than in the control group (75.00% vs. 52.50%). Furthermore, IL-17 decreased in both groups but was significantly lower in the observation group, while TGF-β increased in both groups but was significantly higher in the observation group. The incidence of adverse drug reactions was not significantly different between the groups.

Conclusion

Compound glycyrrhizin in combination with fractional CO₂ laser and triamcinolone acetonide solution can be used to treat vitiligo and appears to modulate cytokine levels.

Trial registration: Hebei Provincial Administration of Traditional Chinese Medicine (no. 2019366; http://www.hebwst.gov.cn/index.do?templet=cs_zyj)

A case series pilot study on the combination of 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) for treatment of vitiligo

BACKGROUND

To study the effective therapeutic concentration, drug application duration, irradiation duration and irradiation dosage of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) for treating vitiligo and observe its clinical efficacy.

OBJECTIVE

To assess the clinical efficacy of ALA-PDT for treating vitiligo.

METHODS

ALA with different drug concentrations, drug application durations, irradiation durations and irradiation dosages were adopted to treat skin lesions caused by vitiligo to determine the effective drug concentration, drug application duration, irradiation duration and irradiation dosage for treating three vitiligo volunteers and observe the therapeutic results.

RESULTS

The clinical trial suggested that ALA at a drug concentration of 1.5%, drug application duration for 3 hours, irradiation dosage of 80mw/cm2 and irradiation duration for 20 min was effective in treating vitiligo. Under these parameters, ALA-PDT was effective to the three vitiligo volunteers, with mild pain and feeling of burning but no other adverse reaction during treatment.

STUDY LIMITATIONS

Due to the small sample size in this study for the effectiveness of PDT in treating vitiligo and the potential variations in the efficacy for treating the disease at different areas, further studies shall be conducted for confirmation.

CONCLUSIONS

ALA with a drug concentration at 1.5%, drug application duration for 3 hours, irradiation dosage of 80 mw/cm2 and irradiation duration for 20 min is effective in treating vitiligo. Therefore, ALA-PDT is safe and effective in treating the disease, with minor adverse events, providing a new method for treating vitiligo in the future.

Differential Expression of Nitric Oxide Synthase Isoforms nNOS and iNOS in Patients with Non-Segmental Generalized Vitiligo

Nitric oxide (NO) is involved in several biological processes, but its role in human melanogenesis is still not well understood. Exposure to UVA and UVB induces nitric oxide production in keratinocytes and melanocytes through the activation of constitutive nitric oxide synthase, increasing tyrosinase activity and melanin synthesis, whereas inducible nitric oxide synthase over expression might be involved in hypopigmentary disorders. The aim of this study was to evaluate whether inducible nitric oxide synthase and neuronal nitric oxide synthase expression were modified in vitiligo skin compared to healthy controls. Skin biopsies were obtained from inflammatory/lesional and white/lesional skin in 12 patients with active, non-segmental vitiligo; site-matched biopsies of normal skin from eight patients were used as controls. Nitric oxide synthase isoforms expression was evaluated by confocal laser scanning microscopy and Western Blot analysis. Inducible nitric oxide synthase expression was significantly increased in inflammatory/lesional skin compared to healthy skin; melanocytes showed a moderate neuronal nitric oxide synthase expression in white/lesional skin, demonstrating that metabolic function still goes on. The obtained data demonstrated that vitiligo lesions were characterized by modifications of nitric oxide synthase isoforms, thus confirming the hypothesis that nitric oxide imbalance is involved in vitiligo and supporting the idea that nitric oxide synthase inhibitors might be used as a possible therapeutic approach for the management of vitiligo.

Case Report: Behçet's disease accompanied with vitiligo

Recently, a few case reports and clinical studies have been published that explore the association of Behçet’s Disease (BD) and vitiligo, with conflicting results. Genetic and immunological properties of BD and presence of autoantibodies support autoimmunity, but clinical features suggest autoinflammatory diseases. BD is thought to be a cornerstone between autoimmune and autoinflammatory diseases. On the other hand, vitiligo has been accepted as an autoimmune disease with associations of other autoimmune disorders and there is a possible role of autoimmunity in pathogenesis of the disease. Significant advances have been made understanding the pathogenesis and genetics of BD. However, it is worth presenting rare clinical variants for improving the clinical understanding of BD. Herein, we are presenting a case with diagnosis of both Behçet’s disease and vitiligo in same patient, which is a rare occurrence. Discussion and demonstrating the association of these two diseases may give rise to understanding similar and different aspects of autoimmunity and autoinflammatory pathogenesis of both diseases.

Effect of Associated Autoimmune Diseases on Type 1 Diabetes Mellitus Incidence and Metabolic Control in Children and Adolescents

Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases developing in childhood. The incidence of the disease in children increases for unknown reasons at a rate from 3 to 5% every year worldwide. The background of T1DM is associated with the autoimmune process of pancreatic beta cell destruction, which leads to absolute insulin deficiency and organ damage. Complex interactions between environmental and genetic factors contribute to the development of T1DM in genetically predisposed patients. The T1DM-inducing autoimmune process can also affect other organs, resulting in development of additional autoimmune diseases in the patient, thereby impeding diabetes control. The most common T1DM comorbidities include autoimmune thyroid diseases, celiac disease, and autoimmune gastritis; additionally, diabetes can be a component of PAS (Polyglandular Autoimmune Syndrome). The aim of this review is to assess the prevalence of T1DM-associated autoimmune diseases in children and adolescents and their impact on the course of T1DM. We also present suggestions concerning screening tests.

The Frequency of Autoimmune Thyroid Disease in Alopecia Areata and Vitiligo Patients

Aim. Many studies demonstrated that alopecia areata (AA) and vitiligo are commonly associated with autoimmune thyroid diseases. We aimed to investigate the frequency of thyroid dysfunctions and autoimmunity related with vitiligo and AA. Material and Methods. 200 patients, 92 AA and 108 vitiligo diagnosed, were surveyed retrospectively. The control population was in reference range and from Konya, central Anatolian region of Turkey. Thyroid function tests (free T₃, free T₄, and TSH) and serum thyroid autoantibody (anti-TG, anti-TPO) levels were evaluated in all patients. Results. In vitiligo patients, 9 (8.3%) had elevated anti-TG levels and 16 (14.8%) had elevated anti-TPO, and in 17 patients (15.7%) TSH levels were elevated and 3 (2.8%) patients had elevated fT₄ levels and 5 (4.6%) had elevated fT₃ levels. Within AA patients, 2 (2.2%) had anti-TG elevation and 13 (14.1%) had anti-TPO elevation, in 7 patients (7.6%) TSH were elevated, and in 1 patient (1.1%) fT₄ were elevated and 5 (5.4%) patients had elevated fT₃ levels. Conclusion. In our study, impaired thyroid functions and thyroid autoantibodies in vitiligo and AA patients were identified at lower rates than the previous studies. According to results of this study there is no need for detailed examination in alopecia areata and vitiligo patients without clinical history.

Association of Vitiligo and Response in Patients with Metastatic Malignant Melanoma on Temozolomide

Vitiligo-like lesions, although rare, are believed to be a prognostic factor in malignant melanoma. While a predictive role for such lesions was shown with immunomodulatory therapies, this relation was not demonstrated with temozolomide. We present 3 patients with metastatic malignant melanoma who developed vitiligo-like skin lesions accompanying good response to treatment and prolonged survival. Onset of vitiligo-like lesions with temozolomide in metastatic malignant melanoma may predict long-term response for this 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.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

T Cell Subpopulations and IL-2R in Vitiligo

Immunological alterations have been implicated in the etiopathogenesis of vitiligo. The aim of this study was to determine peripheral lymphocyte subpopulations and interleukin-2 receptor (IL-2R) in patients with vitiligo. Forty-five vitiligo patients (24 female, 21 male) and 34 healthy controls (11 female, 23 male) were included into the study. Eight (17.8%) of the patients had the segmental type, and 37 (82.2%) had generalized vitiligo. The disease was active in 25 (55.6%) patients; the other 20 (44.4%) patients had static vitiligo. Flow cytometry was used to determine the percentages of total T-lymphocytes, B-lymphocytes, helper/inducer T cells, suppressor/cytotoxic T cells, natural killer (NK) cells, activated T cells and interleukin-2 receptor (IL-2R) with the use of CD3, CD19, CD4, CD8, CD16, HLA-DR and CD25 monoclonal antibodies, respectively. The mean value of helper T cells showed a significant difference (p=0.01) between the two groups with the value being 32.5% in patients and 38.1% in control subjects. CD4/CD8 was significantly lower in vitiligo patients (p=0.04). There was also a statistically significant difference in the mean percentage of activated T cells between vitiligo patients and control subjects (4.7 and 8.1, respectively; p=0.001). No statistically significant differences were found when the values were compared between segmental and generalized vitiligo patients, or between active and static cases. In conclusion, T helper/inducer cells, CD4/CD8 ratio and activated (HLA-DR+) T cells are decreased in vitiligo patients, suggesting a role for changes in cellular immunity.

A Multicenter Collaborative Study by the Korean Society of Vitiligo about Patients' Occupations and the Provoking Factors of Vitiligo

Background

It was previously thought that persons with genetic predispositions to vitiligo develop the condition after exposure to various precipitating environmental factors. However, in many cases, the aggravating factors of vitiligo have not been clearly identified.

Objective

To identify the aggravating factors of vitiligo in the working environment and daily life.

Methods

A total of 489 vitiligo patients were recruited from 10 institutions in South Korea; patients were provided with a questionnaire about environmental factors and behavior patterns in the workplace and in daily life, and their association with vitiligo.

Results

Ninety-five of the 470 enrolled patients (20.2%) answered that environmental risk factors in daily life and in the workplace affected the development of vitiligo. The most frequently attributed causes were trauma and burn (13.6%), followed by sunlight (12.8%), stress (12.8%), cleaning products/disinfectant/chemicals (4.9%), and hair dye (2.1%).

Conclusion

Vitiligo of the hand and foot was associated with frequent exposure to aggravating materials and overexposure to sunlight, along with frequent trauma of these areas, all of which could be considered important risk factors of vitiligo. The development of vitiligo could potentially be controlled through the early detection of aggravating factors.

Relationship of macrophage migration inhibitory factor levels in PBMCs, lesional skin and serum with disease severity and activity in vitiligo vulgaris

Melanocyte loss in vitiligo vulgaris is believed to be an autoimmune process. Macrophage migration inhibitory factor (MIF) is involved in many autoimmune skin diseases. We determined the possible role of MIF in the pathogenesis of vitiligo vulgaris, and describe the relationship between MIF expressions and disease severity and activity. Serum MIF concentrations and mRNA levels in PBMCs were measured in 44 vitiligo vulgaris patients and 32 normal controls, using ELISA and real-time RT-PCR. Skin biopsies from 15 patients and 6 controls were analyzed by real-time RT-PCR. Values are reported as median (25th-75th percentile). Serum MIF concentrations were significantly increased in patients [35.81 (10.98-43.66) ng/mL] compared to controls [7.69 (6.01-9.03) ng/mL]. MIF mRNA levels were significantly higher in PBMCs from patients [7.17 (3.59-8.87)] than controls [1.67 (1.23-2.42)]. There was also a significant difference in MIF mRNA levels in PBMCs between progressive and stable patients [7.86 (5.85-9.13) vs 4.33 (2.23-8.39)] and in serum MIF concentrations [40.47 (27.71-46.79) vs 26.80 (10.55-36.07) ng/mL]. In addition, the vitiligo area severity index scores of patients correlated positively with changes of both serum MIF concentrations (r = 0.488) and MIF mRNA levels in PBMCs (r = 0.426). MIF mRNA levels were significantly higher in lesional than in normal skin [2.43 (2.13-7.59) vs 1.18 (0.94-1.83)] and in patients in the progressive stage than in the stable stage [7.52 (2.43-8.84) vs 2.13 (1.98-2.64)]. These correlations suggest that MIF participates in the pathogenesis of vitiligo vulgaris and may be useful as an index of disease severity and activity.

Association study between nonsense polymorphism (rs2039381, Gln71Stop) of interferon-ε and susceptibility to vitiligo in Korean population

Interferons (IFNs) are related to autoimmune responses. IFN-epsilon (IFNE) is included in IFN family, and may modulate immunological functions. Inflammation modulating functions of IFNE may be related with the pathophysiology of vitiligo. To investigate the association of nonsense polymorphism (rs2039381, Gln71Stop) of interferon-ε (IFNE) and susceptibility to vitiligo, we conducted a case-control association study in 265 non-segmental vitiligo (NSV) patients and 320 healthy controls. The nonsense single nucleotide polymorphism (SNP) (rs2039381, Gln71Stop) of IFNE was genotyped by direct sequencing. Multiple logistic regression models (log-additive, dominant, and recessive models) were applied to determine odds ratios (OR), 95% confidence interval (CI), and p values. The rs2039381 (Gln71Stop) of IFNE did not show significant differences between NSV patient group and control group. However, we found that in childhood onset NSV groups, the IFNE nonsense polymorphism (rs2039381, Gln71Stop) showed a significant association. There was significantly different distribution of nonsense polymorphism of rs2039381 (Gln71Stop) of IFNE between NSV patients (childhood <18 years) and control subjects. This study suggests that rs2039381 (Gln71Stop) polymorphism of IFNE may be related to onset time of vitiligo in NSV patients.

Whole Transcriptome Analysis (RNA Sequencing) of Peripheral Blood Mononuclear Cells of Vitiligo Patients

Vitiligo is an idiopathic disorder characterized by depigmented patches on the skin due to a loss of melanocytes. The cause of melanocyte destruction is not fully understood. The aim of this study was to detect the potential pathways involved in the vitiligo pathogenesis to further understand the causes and entity of vitiligo. For that the transcriptome of peripheral blood mononuclear cells of 4 vitiligo patients and 4 control subjects was analyzed using the SOLiD System platform and whole transcriptome RNA sequencing application. Altogether 2,470 genes were expressed differently and GRID2IP showed the highest deviation in patients compared to controls. Using functional analysis, altogether 993 associations between the gene groups and diseases were found. The analysis revealed associations between vitiligo and diseases such as lichen planus, limb-girdle muscular dystrophy type 2B, and facioscapulohumeral muscular dystrophy. Additionally, the gene groups with an altered expression pattern are participating in processes such as cell death, survival and signaling, inflammation, and oxidative stress. In conclusion, vitiligo is rather a systemic than a local skin disease; the findings from an enormous amount of RNA sequencing data support the previous findings about vitiligo and should be further analyzed.

Functional characteristics of macrophages in the vitiligo foci

Objective. Study of the chemotactic activity of macrophages and local production of cytokines in sterile skin inflammatory exudate in patients with generalized vitiligo (vitiligo vulgaris). Materials and methods. The authors conducted a study of 22 patients with generalized vitiligo and 22 healthy volunteers. The functional activity of macrophages was assessed with the use of the skin window method based on the method of D.N. Mayansky as amended by V.V. Klimov. The composition of sterile cell exudate was examined with the use of impression smears taken after 6 hours from an epidermis scarification section on the healthy and depigmented skin colored according to the Romanovsky-Gimza method with the use of light microscopy. In addition, cytokines were determined in the supernatant fluid of the skin window exudate from the vitiligo focus obtained by means of centrifugation. Results. The prevalence of mononuclear phagocytes over polymorphonuclear leukocytes was revealed in the depigmentation site, which confirms that macrophages take an active part in the disease pathogenesis (along with a high level of interleukin-18). A low level of IL-10 in the skin window exudate confirms that the suppressor effect in the melanocyte damage zone is weak. These results confirm the important role played by such cells of the immune system as phagocytes in vitiligo pathogenesis, which makes it possible to consider them as potential target cells for developing pathogenetically substantiated approaches to the treatment of the disease.

Autoimmune thyroid disease in patients with vitiligo: prevalence study in India

OBJECTIVE

To identify the prevalence of autoimmune thyroid disease (AITD) in Asian Indian patients with vitiligo and to compare the clinical profile between thyroid peroxidase (TPO) antibody-positive and TPO antibody-negative groups.

METHODS

In this cross-sectional, case-controlled study, 50 patients with vitiligo (29 women and 21 men) were included. Patients with previous disorders, irradiation, or surgical procedures involving the thyroid were excluded from the study. All participants underwent a complete physical examination, and a single fasting blood sample was analyzed for thyroid function (triiodothyronine, thyroxine, thyroid-stimulating hormone, and TPO and thyroglobulin antibodies), inflammatory and immunologic markers (erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor), and serum calcium, phosphorus, and alkaline phosphatase concentrations. All patients underwent thyroid ultrasonography, and the data were analyzed by appropriate statistical methods.

RESULTS

The mean age of the study participants was 42.7 ± 17 years, and 14 of 50 patients (28%) had TPO antibody positivity. A goiter was present in 11 of 50 patients, and the thyroid volume by ultrasonography was similar between the 2 groups. Subclinical hypothyroidism was found in 14 of 50 patients (28%) but more frequently in the TPO antibody-positive group (8 of 14 or 57%) than in the TPO antibody-negative group (6 of 36 or 17%). The prevalence of AITD was 20 of 50 patients (40%) when the TPO antibody-positive group and those with subclinical hypothyroidism were considered collectively. None of the patients had overt hypothyroidism or hyperthyroidism. All other clinical, biochemical, and inflammatory variables did not differ significantly between the TPO antibody-positive and antibody-negative groups.

CONCLUSION

Our data showed a 40% prevalence of thyroid disease in patients with vitiligo in India. The risk is exacerbated in patients with thyroid autoimmunity; thus, regular screening of patients with vitiligo for AITD is needed.

Vitiligo and Associated Autoimmune Disease: Retrospective Review of 300 Patients

Background:

Vitiligo, the most common cutaneous depigmentation disorder, has reported associations with other autoimmune diseases. However, literature on the strengths of the associations is conflicting, and no data on the subject exist from a Canadian population.

Objective:

To determine autoimmune disease associations with vitiligo and which, if any, screening bloodwork is appropriate in vitiligo patients.

Methods:

A retrospective review of vitiligo patients admitted to the Toronto Western Hospital phototherapy unit was conducted from January 1, 2000, to August 30, 2009. Data regarding patient characteristics, vitiligo clinical features (family history, age at onset, type, extent), associated diseases in the patient and family, and admission bloodwork (hemoglobin, vitamin B12, thyroid-stimulating hormone [TSH], antinuclear antibody) were recorded and compared, using the Fisher exact test where applicable.

Results:

A total of 300 patient charts were reviewed (average age 41.5 ± 15.5 years; 47% male, 53% female). Hypothyroidism was present in 12.0% and pernicious anemia in 1.3% of patients—significant increases over the population prevalence. No other differences in prevalence were seen compared to the general population. TSH was increased in 3.7% of patients without a history of hypothyroidism. Hemoglobin and vitamin B12 were decreased in 0.3% of vitiligo patients without a history of pernicious anemia.

Conclusion:

We found a significantly higher prevalence of hypothyroidism and pernicious anemia in vitiligo patients.

Vitiligo-inducing phenols activate the unfolded protein response in melanocytes resulting in upregulation of IL6 and IL8

Vitiligo is characterized by depigmented skin patches due to loss of epidermal melanocytes. Oxidative stress may play a role in vitiligo onset, while autoimmunity contributes to disease progression. In this study we sought to identify mechanisms that link disease triggers and spreading of lesions. A hallmark of melanocytes at the periphery of vitiligo lesions is dilation of the endoplasmic reticulum (ER). We hypothesized that oxidative stress results in redox disruptions that extend to the ER, causing accumulation of misfolded peptides, which activates the unfolded protein response (UPR). We used 4-tertiary butyl phenol (4-TBP) and monobenzyl ether of hydroquinone (MBEH), known triggers of vitiligo. We show that expression of key UPR components, including the transcription factor X-box binding protein 1 (XBP1), are increased following exposure of melanocytes to phenols. XBP1 activation increases production of immune mediators interleukin-6 (IL6) and IL8. Co-treatment with XBP1 inhibitors reduced IL6 and IL8 production induced by phenols, while over-expression of XBP1 alone increased their expression. Thus, melanocytes themselves produce cytokines associated with activation of an immune response following exposure to chemical triggers of vitiligo. These results expand our understanding of the mechanisms underlying melanocyte loss in vitiligo and pathways linking environmental stressors and autoimmunity.

The vitiligo in senegal

The aim of our study was to determine the epidemiological and clinical aspects of vitiligo in the largest dermatology department of Senegal. A cross-sectional and descriptive study in a period of 5 months was performed covering all the vitiligo cases. Fifty patients were identified (26 women and 24 men). The mean age was 26.5 years. A family history of vitiligo was found in 11 cases and a psychoaffective disturbance in 6 cases. The clinical forms distinguished were generalized vitiligo (n = 33), localized vitiligo (n = 16), vitiligo universalis (n = 4), and segmental vitiligo (n = 1). The Koebner phenomenon was found in 7 cases. Associated diseases were atopic dermatitis (n = 2), contact dermatitis (n = 1), diabetes (n = 1), and Graves' disease (n = 1). The disgraceful character of Vitiligo was the predominance of generalized forms and the elective localization in sun-exposed areas. The family character, the psychoaffective disturbances, the Koebner phenomenon increased by the lifestyle and the itching dermatosis were the aggravating factors.

Targeting skin: vitiligo and autoimmunity

In this issue, Singh and co-workers describe the results of classical typing of human leukocyte antigen (HLA) alleles in 1,404 vitiligo patients and 902 unaffected controls from North India and follow-up HLA typing in 355 cases and 441 controls from Gujarat. The increased frequency of DRB1*07:01 in North Indian and Gujarat populations with generalized and localized vitiligo and in several vitiligo populations studied previously suggests that it contributes to autoimmunity and destruction of melanocytes.

Expression of cytosolic NADP(+)-dependent isocitrate dehydrogenase in melanocytes and its role as an antioxidant

BACKGROUND

Cytosolic NADP(+)-dependent ICDH (IDPc) has an antioxidant effect as a supplier of NADPH to the cytosol, which is needed for the production of glutathione.

OBJECTIVE

To evaluate the expression of IDPc in melanocytes and to elucidate its role as an antioxidant.

METHODS

The knock-down of IDPc expression in immortalized mouse melanocyte cell lines (melan-a) was performed using the short interfering RNA (siRNA)-targeted gene silencing method. After confirming the silencing of IDPc expression with mRNA and protein levels, viability, apoptosis and necrosis, as well as ROS production in IDPc-silenced melanocytes were monitored under conditions of oxidative stress and non-stress. Also, the ratio of oxidized glutathione to total glutathione was examined, and whether the addition of glutathione recovered cell viability, decreased by oxidant stress, was checked.

RESULTS

The expression of IDPc in both primary human melanocytes and melan-a cells was confirmed by Western blot and RT-PCR. The silencing of IDPc expression by transfecting IDPc siRNA in melan-a cells was observed by Western blotting and real-time RT-PCR. IDPc knock-down cells showed significantly decreased cell viability and an increased number of cells under apoptosis and necrosis. IDPc siRNA-treated melanocytes demonstrated a higher intensity of DCFDA after the addition of H(2)O(2) compared with scrambled siRNA-treated melanocytes, and a lower ratio of reduced glutathione to oxidized glutathione were observed in IDPc siRNA transfected melanocytes. In addition, the addition of glutathione recovered cell viability, which was previously decreased after incubation with H(2)O(2).

CONCLUSIONS

This study suggests that decreased IDPc expression renders melanocytes more vulnerable to oxidative stress, and IDPc plays an important antioxidant function in melanocytes.

Incidence of vitiligo in children with Graves' disease and Hashimoto's thyroiditis

Background

Limited data are available on the association between vitiligo and autoimmune thyroid disease in pediatric patients. In addition, reported studies of pediatric patients have been based on a population known to have vitiligo and subsequently evaluated for the presence of thyroid function abnormalities.

Methods

A retrospective chart review was performed on 333 children who had been followed for thyroid disorders by endocrinologists at the Yale Pediatric Thyroid Center over the last 5 years for autoimmune thyroid disease. Demographical and clinical features of patients found to have thyroid disease and vitiligo were recorded. These studies were approved by the Yale Human Investigation Committee.

Results

Of the total 333 children and adolescents, 9 (2.7%) were noted to have vitiligo. Four patients (44%) had Graves' disease and 5 patients (66%) had Hashimoto's thyroiditis. For patients with Graves' disease and vitiligo, the average age of onset of thyroid disease was young at 4 ± 0.7 years, and the diagnosis of vitiligo usually preceded that of thyroid disease. For children with Hashimoto's thyroiditis and vitiligo, thyroid disease was diagnosed at an average age of 13.25 ± 2.8 years.

Conclusion

In our population, 4.6% of children with Graves' disease and 2.0% of children with Hashimoto's thyroiditis had vitiligo. Interestingly, when vitiligo presents with Graves' disease, it occurs in younger rather than older children.

Amniotic membrane as a scaffold for melanocyte transplantation in patients with stable vitiligo

Vitiligo is an acquired skin disease that significantly impacts the quality of life of patients. Medical treatment of vitiligo includes the use of melanocyte transplant, but the results are variable. We have treated 4 patients with either focal or generalized stable vitiligo using a graft of autologous melanocytes' culture on a denuded amniotic membrane (AM). A culture biopsy was obtained in every patient and grown in melanocytes' media for 10-14 days after which cells were transferred to a denuded AM and transplanted into the achromic lesions. Patients were followed for up to 6 months using clinical assessment of achromic lesions. Treated areas ranged between 4 cm(2) and 210.6 cm(2). Response to treatment was excellent in all patients with 90-95% repigmentation success rate. Our results demonstrate that transplantation of autologous melanocytes cultured on AM is a new, simple, and effective treatment for stable vitiligo.

Relevance of autoimmune thyroiditis in children and adolescents with vitiligo

BACKGROUND

Vitiligo is the most common pigmentation-related disorder worldwide. An autoimmune etiology is widely considered, and genetic factors may play an important role in its pathogenesis. The purpose of this study was to assess the incidence of thyroid dysfunctions and autoimmune thyroiditis in children with vitiligo and to identify related factors.

METHODS

Fifty children with vitiligo and 50 control children were enrolled. Data on age, onset, duration, disease activity, presence of thyroid disorder, other autoimmune diseases, halo nevi, poliosis, and mucosal vitiligo were determined. Serum free triiodothyronine, free thyroxine, total T3, total T4, thyroid-stimulating hormone, and antibodies to thyroperoxidase and thyroglobulin were measured. Thyroid gland efficiency was evaluated.

RESULTS

The mean age at onset of vitiligo was 7.26 ± 4.43 years. The duration of vitiligo was 2.26 ± 2.95 years. Vulgaris-type vitiligo was the most common form in our patients (56%), and 42% reported at least one family member with thyroid disorder, autoimmune disease, or both. Overt hypothyroidism or hyperthyroidism were not detected. We found a significant association between autoimmune thyroiditis and both sex and disease duration (P = 0.046 and P = 0.07, respectively), but no association between autoimmune thyroiditis and age, age at onset of vitiligo, halo nevi, poliosis, mucosal involvement, disease activity, or family history of vitiligo, autoimmunity, or thyroid disorders.

CONCLUSIONS

Children with vitiligo show an increased incidence of autoimmune thyroiditis. Children with vitiligo, especially girls and subjects with generalized/vulgaris-type vitiligo, should be screened annually for thyroid function and antithyroid antibodies to assist in the early diagnosis and therapy of autoimmune thyroiditis.

Reduction of skin-homing cytotoxic T cells (CD8+ -CLA+) in patients with vitiligo

BACKGROUND

Vitiligo is a frequently acquired, hereditary disease, characterized by achromic macules due to the absence of melanocytes. In contrast with earlier studies, in which the main pathogenic role was attributed to anti-melanocyte antibodies, recent papers have emphasized a role for CD8(+) cytotoxic T lymphocytes in melanocyte destruction. Fifteen percent of peripheral T cell express cutaneous lymphocyte-associated antigen (CLA), responsible for skin-homing T cell. Phototherapy is used to treat patients with generalized vitiligo and it has been shown to interfere with CLA(+) T cells in other skin diseases.

OBJECTIVE

To describe peripheral blood T cell subpopulations' frequency and ability to express the skin-homing molecule (CLA) in patients with non-segmental vitiligo, before and after photochemotherapy (PUVA).

PATIENTS AND METHODS

Twenty-two patients with generalized and active spreading vitiligo were submitted to 30 PUVA-8MOP sessions. Lymphocyte immunophenotyping was performed by flow cytometry using anti-CD3, anti-CD8 and anti-CLA monoclonal antibodies. Fifteen healthy volunteers, sex- and age-matched, were included as a control group.

RESULTS

CD8(+) -CLA(+) T cells were significantly reduced in number in untreated vitiligo patients (P=0.008) when compared with control individuals, albeit with a more intense CLA expression (P=0.028). These findings were not altered after PUVA. No significant difference was noticed in CD4/CD8 ratios nor in CD4-CLA(+) T cell numbers between vitiligo patients and controls, both before and after PUVA.

CONCLUSIONS

CD8-CLA(+) T cells are reduced in peripheral blood of patients with non-segmental vitiligo. This finding may be related to the previously reported increase of CD8(+) cells in both lesions and perilesional skin of these patients.

Patients affected by vitiligo and autoimmune diseases do not show antibodies interfering with the activity of the melanocortin 1 receptor

BACKGROUND

Vitiligo is an acquired depigmenting disorder characterized by the loss of melanocytes from the epidermis with the development of white patches in various distribution. The pathogenesis of vitiligo is still unknown, but the association with autoimmune disorders and organ specific autoantibodies, supports the hypothesis of an autoimmune pathogenesis.

AIM

The aim of the present study was to investigate if autoantibodies present in sera of patients affected by vitiligo may be able to interfere with the activity of the αMSH on the melanocortin 1 receptor (MC1R). MATERIALS/ SUBJECTS AND METHODS: IgG from the sera of 41 patients with vitiligo associated or not with thyroid autoimmune diseases or other autoimmune pathologies were incubated with HBL20 cells (human malignant melanocytes expressing the MC1R) in the presence of a sub-maximal dose of αMSH. A normal IgG range was determined by using IgG extracted from 30 control sera of normal subjects.

RESULTS

None of the IgG from vitiligo patients was able to inhibit αMSH-stimulated cAMP production in HBL20 cells.

CONCLUSIONS

Autoantibodies against MC1R are rare or absent in sera of vitiligo patients.

Vitiligo at Injection Site of PEG-IFN-α 2a in Two Patients with Chronic Hepatitis C: Case Report and Literature Review

A 72-year-old female and a 57-year-old male with chronic hepatitis C were treated with a combination therapy of pegylated interferon (PEG-IFN)-α 2a (180 μg s.c. once a week) and ribavirin (1,000 mg orally daily). This resulted in the destruction of melanocytes at the injection site in both patients. In the male patient, the depigmentation progressed to the surrounding skin area. The dermatologist concurred with vitiligo as the diagnosis in both patients. Injection and surrounding site vitiligo associated with PEG-IFN-α 2b treatment for hepatitis C was noticed in previous case studies. For the first time, the case reports below highlight the same immunological adverse event secondary to PEG IFN-α 2a/ribavirin combination therapy and explain, in part, the complex interaction between host immune response and viral genotype. In addition, we systematically review drug-induced vitiligo and autoimmune diseases associated with the depigmentation disorder.

On the role of dendritic cells in the pathogenesis of vitiligo

The authors give the results of immunohistochemistry studies of the skin of 16 healthy volunteers and 16 patients suffering from vulgar vitiligo with the determination of the contents of immature (CD1a+) and mature (CD83+) subpopulations of dendritic cells (DCs) as well as CD4+ and CD8+ lymphocytes in the epidermis and perivascular infiltrates of the derma. They revealed an increased quantity of CD1a+ and CD83+ DCs in areas of depigmented, peripheral and perifocal normally pigmented skin of vitiligo foci. DCs with the CD1a+ phenotype were revealed both in the epidermis and in the derma while DCs with the CD83+ phenotype were revealed in the derma only. A higher quantity of CD4+ and CD8+ lymphocytes than in healthy volunteers was also revealed along with the increased contents of DCs in all three areas of vitiligo foci. The authors established a strong correlation between the quantity of CD83+ DCs and CD4+ lymphocytes in the depigmentation zone (r=0.84; Р

B cells require "nurturing" by CD4 T cells during development in order to respond in chronic graft-versus-host model of systemic lupus erythematosus

The murine chronic GVH (cGVH) model of SLE is induced by allo-recognition of foreign major histocompatibility complex (MHC) class II determinants. Previous studies have shown that syngeneic CD4(+) T cells are needed during B cell development in order to induce cGVH response in CD4KO mice. Our present studies show that B cells require "nurturing" by CD4 T cells through much of their ontogeny in order to respond to allo-signaling and become autoreactive. The nurturing process does not require antigen-specific cognate interactions between CD4 T cells and B cells. It is mediated by IL-4, but not IL-10, IL-6 and IFN-gamma. The CD4 T cell nurturing may be supplanted by large doses of IL-4 and/or by agonistic anti-CD40 mAb. Understanding the mechanism of this "nurturing" process may yield clues to the role of CD4 T cells in lupus and in host defense in general.

MART-1 transcript is absent in PBMCs from Vitiligo patients

Mechanisms occurring in the thymus and periphery are responsible for the generation and maintenance of tolerance in the immune system. Various reports have shown that the existence of an antigen in the peripheral circulation results in tolerance induction towards that protein. These observations imply that the lack of a self antigen can lead to induction of autoimmunity. Previously we have reported that Tyrosinase related protein-2 (TRP-2) transcripts from peripheral blood mononuclear cells (PBMCs) are absent in vitiligo patients but present in healthy individuals. Here, we show that MART1 (Melanoma antigen recognized by T cells) transcripts are not detected in the PBMCs of vitiligo patients but is detected in healthy controls. Our result suggests that as MART1 is not expressed in the PBMCs, MART1 is also not available for induction and maintenance of peripheral tolerance in vitiligo patients. We therefore conclude that nonexpression of MART1 in PBMCs of vitiligo patients may be somehow responsible for the tolerance breakdown finally resulting in the induction of autoimmunity seen against these self antigens in vitiligo.