An Innovative Therapeutic Protocol for Vitiligo: Experience with the Use of Fraxel Herbium Laser, Topical Latanoprost and Successive Irradiation with UVA - 1 Laser

Narrowband ultraviolet B phototherapy combined with intralesional injection of either latanoprost or platelet-rich plasma for stable nonsegmental vitiligo

BACKGROUND

Narrowband ultraviolet B (NB-UVB) phototherapy is the cornerstone of vitiligo treatment. Its combination with other treatments usually yields a better response. Latanoprost, a prostaglandin F2α analog, and autologous platelet-rich plasma (PRP) have been reported to be effective for vitiligo.

AIM

To evaluate the efficacy of NB-UVB combined with intralesional latanoprost or PRP for stable nonsegmental vitiligo (NSV).

METHODS

Sixty patients with stable NSV were recruited and randomly allocated to two equal groups. NB-UVB phototherapy was administered twice a week for all patients. Additionally, group A received intralesional latanoprost injections once weekly, while group B received intralesional autologous PRP injections every 2 weeks.

RESULTS

At 24 weeks, excellent repigmentation response was observed in 26.7% and 13.3% of patients in the latanoprost/NB-UVB and PRP/NB-UVB groups, respectively, with no significant difference in degrees of repigmentation between the two groups. However, the Vitiligo Extent Score for a Target Area (VESTA) score was significantly higher in the latanoprost/NB-UVB group (p = .032). Moreover, lesions located on nonacral skin responded significantly better than those on acral skin. Only erythema was significantly higher in the PRP/NB-UVB group, while the recurrence of depigmentation was significantly higher in the latanoprost/NB-UVB group.

CONCLUSIONS

Both latanoprost and PRP have the potential to be effective add-on therapies to NB-UVB phototherapy for stable NSV, with latanoprost resulting in a greater repigmentation response and PRP producing a more stable response.

Efficacy of prostaglandin E2 versus prostaglandin F2 alpha assisted with narrowband-UVB in stable vitiligo

In the recent decades, prostaglandins were recommended as a new therapeutic modality of stable vitiligo with promising efficacy. Therefore, we designed the current work to compare the significance of two different subtypes of prostaglandins [prostaglandin E2 (PGE2) versus prostaglandin F2 alpha (PGF2α)], assisted with NB-UVB phototherapy, in treatment of stable vitiligo. This study was conducted on 30 patients with stable non-segmental vitiligo. Three approximately similar vitiliginous areas were chosen in each patient and assigned into 3 groups. Each group treated with intradermal injection of either PGE2 (group I), PGF2α (group II), or saline as placebo (group III) at frequency once/week for 12 weeks. Concomitantly, all groups received NB-UVB phototherapy twice weekly for 3 months. The outcomes of this study discovered that the therapeutic efficacy of intradermal injection of either PGE2 or PGF2α assisted with NB-UVB phototherapy was comparable with non-significant difference between them in spite of being significantly higher than NB-UVB alone. However, there were a significantly earlier onset of repigmentation and higher degree of satisfaction regarding areas treated with PGE2 than those treated with PGF2α. In conclusion, both PGF2α and PGE2 intradermal injection could be considered as quite simple and affordable techniques in the treatment of stable vitiligo with no reported side effects and good patient satisfaction.

Research Progress of Small Molecules as Anti-vitiligo Agents

Vitiligo is a disease characterized by skin discoloration, and no safe and effective drugs have been developed until now. New drug research and development are imminent. This article reviews the research on small-molecule drugs for vitiligo from 1990 to 2021 at home and abroad. They are classified according to their structures and mechanisms of action, including natural products and derivatives, anti-oxidative stress drugs, immunosuppressants, prostaglandins, etc. The research on their anti-vitiligo activity, structural modification, new dosage forms, clinical trials, and the development trend in new anti-vitiligo drugs are reviewed, which provides important references for the development of new drugs.

Pilot Study on the Use of the "Monocyte-Rich" Platelet-Rich Plasma in Combination with 1927 nm Fractional and 308 nm Excimer Lasers for the Treatment of Vitiligo

Background and objectives: Vitiligo is an acquired chronic and idiopathic skin disorder, characterized by selective loss of melanocytes and resulting in a cutaneous depigmentation. Treatment for vitiligo remains a challenge for dermatologists; thus, it is frustrating both for physicians and patients. The objective of this study was to evaluate a combination treatment characterized by the use of a leukocyte-rich platelet-rich plasma, which is particularly rich in monocytes (defined here as monocyte-rich PRP), in combination with a 1927 nm fraxel laser and a 308 nm excimer laser. Materials and Methods: Treatment with monocyte-rich PRP combined with 1927 nm fraxel laser and 308 nm excimer laser was performed in nine sessions in 80 days and the median follow-up of the patients was 10 months. A total of 27 Caucasian patients were included in the present study. The median age of patients was 41 years, ranging between 20 and 69 years. Results: A re-pigmentation occurred in 16 cases (59%) with a reduction of the Vitiligo Extent Score (VES) and absence of re-pigmentation in untreated areas. Performing a rank correlation between VES and re-pigmentation in the treated areas, we found that there was a significant correlation (p < 0.0001). The presence of progressive vitiligo (p = 0.1) and the anatomic areas (p = 0.1) did not influence the treatment. Untreated areas did not show any improvement of the depigmented lesions, except in one case (p < 0.0001). Conclusions: in this report, we show for the first time how PRP rich in monocytes, in combination with laser therapies, gives a long therapeutic response, which persists even after 10 months of follow-up.

Vitiligo: What's old, what's new

Vitiligo is an acquired pigmentary disorder afflicting 0.5-2% of the world population for both sexes and all races with a capricious and unpredictable course. It has a complex etiology and varies in its manifestation, progression and response to treatment. Even if the precise aetiology and pathobiology of the disease are complex and still debated, recent evidence supports that vitiligo is a T CD8+ cell-mediated autoimmune disease triggered by oxidative stress. To date no clinical, biological and histological criteria allow us to establish the prognosis with certainty. The choice of the best therapy for adult and childhood vitiligo is based on various factors, such as the patient's age, psychological condition and expectations, distribution and extension of skin lesions, type of vitiligo (stable or not) and availability and cost of therapeutic options. Since vitiligo has a deep psychological impact on patients and their quality of life, treating the disease is very important. As dermatologists, we have important goals in the treatment of vitiligo patients: stabilization of the disease progression, repigmentation of the lesions and especially the persistence of the aforementioned repigmentation. Although several medical and surgical therapeutic options have been proposed, no definite cure has yet been developed and the long-term persistence of repigmentation is unpredictable. We review the different therapeutic options with particular attention on the recurrence rate.

Updates and new medical treatments for vitiligo (Review)

Vitiligo is a multifactorial disease characterized by the loss of skin pigment, which results in achromic macules and patches. There are currently several medical treatments available, which aim to arrest progression and induce skin repigmentation. These treatments alone or combined have exhibited varying degrees of pigmentation, and the majority are safe and effective. All therapies for vitiligo are limited, and no known treatment can consistently produce repigmentation in all patients. Individualized treatment is appropriate according to the location, clinical presentation and the presence of disease activity. The present review summarizes the medical treatments available for vitiligo: Systemic and topic pharmacological therapies, physical and depigmentation treatments. Several treatments are still underway and have not yet been approved. However, due to the promising preliminary results, these are also mentioned in the present review.

A comparative study of combined microneedling and narrowband ultraviolet B phototherapy versus their combination with topical latanoprost in the treatment of vitiligo

Regardless of the continuous discovery of innovative modalities for the treatment of vitiligo, none of them ensure excellent therapeutic outcome. Microneedling had been suggested either singly or concomitantly with other therapeutic modalities for vitiligo with encouraging results. Latanoprost, a prostaglandin F2-alpha (PGF2α), and their analogues are recently recommended for vitiligo treatment. This study was designed to assess the therapeutic efficacy of microneedling in combination with NB-UVB phototherapy versus their combination with latanoprost in vitiligo. It was conducted on 50 patients presented with stable bilateral localized nonsegmental vitiligo. In every patient; two bilateral, nearly symmetrical lesions were selected and treated by microneedling (12 sessions at 2-week interval) followed by topical application of latanoprost 0.005% solution on one side, and topical saline (as placebo) on the other side. In addition, all patients received concomitant NB-UVB phototherapy (three sessions/week) for 6 months. Significant clinical improvement of vitiligo lesions with significant increase in the degree of repigmentation were reported in response to both treatment regimens. Latanoprost in combination with microneedling and NB-UVB provides more significant therapeutic outcomes than combined microneedling and NB-UVB. In conclusion, topical latanoprost 0.005% enhances the therapeutic efficacy of combined microneedling and NB-UVB phototherapy in localized stable nonsegmental vitiligo.

RIPK1 regulates the survival of human melanocytes upon endoplasmic reticulum stress

Vitiligo is a common congenital or acquired disfiguring skin disorder. At present, endoplasmic reticulum (ER) stress has been identified to serve a critical role in the pathogenesis of vitiligo. Receptor-interacting serine/threonine-protein kinase 1 (RIPK1) is a protein serine/threonine kinase. The specific molecular mechanism of RIPK1 in human melanocytes upon ER stress remains to be determined. In the present study, RIPK1 was significantly downregulated in tunicamycin (TM)-induced ER stressed-human melanocytes. Subsequently, to explore the role of RIPK1 in ER stress-induced human melanocytes, human melanocytes were transfected with control or RIPK1 plasmids for 24 h and then treated with 3 µM TM for 48 h. Reverse transcription-quantitative PCR and western blot analysis indicated that the expression levels of protein kinase R-like endoplasmic reticulum kinase, eukaryotic translation initiation factor 2 subunit 1 and CCAAT-enhancer-binding protein homologous protein were significantly increased in the TM-treated group compared with the controls. In addition, the effect of high RIPK1 expression on ER stress-induced human melanocyte survival was studied. The present results indicated that TM inhibited cell viability and promoted apoptosis in human primary epidermal melanocytes. Western blot analysis demonstrated that the expression of Bax and caspase-3 was upregulated and the expression of Bcl-2 was downregulated in TM-treated human melanocytes. The effects of TM on human melanocytes were reversed by RIPK1 overexpression. Therefore, RIPK1 overexpression may have an effect on the PI3K/AKT/mTOR signaling pathway in human melanocytes under ER stress. The results of the current study demonstrated that RIPK1 could protect human melanocytes from cell damage induced by ER stress by regulating the PI3K/AKT/mTOR and ER stress signaling pathways, thereby serving a protective role in the occurrence and development of vitiligo.

Safety of the current drug treatments for vitiligo

Introduction: Vitiligo is an acquired depigmenting skin disorder adversely affecting the patient's quality of life. Despite the presence of several treatment modalities, ranging from medical to physical to surgical options, none is curative. Each modality has its own drawbacks and side effects. Thus, the treatment modality needs to be tailored for each individual patient taking into consideration the disease characteristics and also its efficacy and safety to obtain a favorable risk-benefit ratio.Areas covered: This review highlights the different treatment modalities utilized in vitiligo up until 4 November 2019 along with their adverse effects and contraindications, if any.Expert opinion: All the medications have their own adverse effects and contraindications. We have included the most commonly used topical corticosteroids, which may result in striae, cutaneous atrophy, and tachyphylaxis, to the recently introduced biologics, which may induce hypersensitivity reactions, systemic toxicities, and even malignancies. However, more long-term studies are needed to assess the safety of these medications, especially the newer ones, to provide a safe and effective treatment for this disorder.

Emerging drugs for the treatment of vitiligo

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

ΜicroRNA‑421 participates in vitiligo development through regulating human melanocyte survival by targeting receptor‑interacting serine/threonine kinase 1

Vitiligo is a common localized or generalized skin pigmentation disorder. Endoplasmic reticulum (ER) stress may be implicated in the development of vitiligo. microRNA-421 (miR-421) has been reported to be dysregulated in various human tumors. However, there is no report to date on the role of miR-421 in vitiligo development. The present study demonstrated that 3 µM tunicamycin (TM) increased the expression of the ER stress-related proteins protein kinase RNA-like endoplasmic reticulum kinase (PERK), α subunit of eukaryotic translation initiation factor 2 (eIF2α) and C/EBP homologous protein (CHOP) in human primary epidermal melanocytes. Moreover, TM suppressed melanocyte viability and induced apoptosis. Reverse transcription-quantitative PCR analysis demonstrated that TM promoted miR-421 expression in human melanocytes. Next, TargetScan and dual luciferase reporter gene assay indicated that receptor-interacting serine/threonine kinase 1 (RIPK1) was a direct target of miR-421. RIPK1 expression was significantly downregulated in TM-induced human melanocytes. Subsequently, the effect of miR-421 downregulation on the damage of human melanocytes induced by ER stress was investigated. Human melanocytes were transfected with inhibitor control, miR-421 inhibitor, miR-421 inhibitor + control-short hairpin (sh)RNA, or miR-421 inhibitor + RIPK1-shRNA for 24 h and then treated with TM (3 µM) for 48 h. TM was found to upregulate PERK, eIF2α and CHOP protein expression in human melanocytes, which was reduced by an miR-421 inhibitor. In addition, the miR-421 inhibitor increased viability and reduced apoptosis in TM-treated melanocytes. Furthermore, all these effects of the miR-421 inhibitor on TM-induced human melanocytes were reversed by RIPK1-shRNA. Further analyses revealed that the miR-421 inhibitor activated the phosphoinositide 3 kinase/protein kinase B/mammalian target of rapamycin signaling pathway in TM-induced human melanocytes. These data collectively suggest that miR-421 may serve as a new treatment target in vitiligo development.

Successful Treatment of Vitiligo Vietnamese Patients with Vitilinex® Herbal Bio-Actives in Combination with Phototherapy

BACKGROUND

Vitiligo is an acquired pigmentary disease, that causes progressive loss of melanocytes, resulting in hypopigmented skin patches. Current treatments aim at stopping the disease progression and achieving repigmentation of the amelanotic areas. Corticosteroids, surgery, topical immunomodulators, total depigmentation of normal pigmented skin and phototherapy are current treatment options for vitiligo although phototherapy remains the treatment of choice. There is no documented evidence that herbal bio-active products may also be effective treatment options for vitiligo.

AIM

This study aimed to investigate the efficacy and safety of Vitilinex® (herbal bio- actives) alone and in combination with UVB narrowband (311 nm) phototherapy, in the treatment of localised stable or active forms of vitiligo.

MATERIAL AND METHODS

Sixty two subjects with mean age 34.5 years (range: 18-58 years) with mild to moderate vitiligo, consisting of 36 females and 26 males were randomly divided into three treatment groups - Group A (13 females, 10 males) treated with Vitilinex® alone; Group B (12 females, 11 males) were treated with Vitilinex® in combination with narrowband UVB (311 nm) phototherapy for 15 seconds, using a handheld lamp and Group C (8 females, 8 males) were treated with nbUVB (311 nm) phototherapy alone, for 15 seconds over a 12-week period.

RESULTS

In Group A, 9 patients (39%) achieved outstanding improvement with a re-pigmentation rate higher than 75%, with 2 patients experiencing total repigmentation. 6 patients (26%) had marked improvement with a repigmentation rate between 50-75% while 5 patients (22%) showed a moderate response between 25-50% re-pigmentation rate. 3 patients (13%) had minimal or no improvement. In Group B, 16 patients (69.5%) achieved outstanding improvement with a re-pigmentation rate higher than 75%, with 12 patients experiencing total re-pigmentation. 4 patients (17.5 %) achieved a marked improvement with a re-pigmentation rate between 50-75%; 2 patients (8.7%) showed a moderate response with a re-pigmentation rate between 25-50%. 1 (4.3%) patient had minimal or no improvement. In Group C, 6 patients (37.5%) achieved a re-pigmentation rate higher than 75%, with 2 patients experiencing total re-pigmentation. 4 patients (25%) achieved marked improvement with a re-pigmentation rate between 50-75% while 3 patients (18.75%) had a re-pigmentation rate between 25-50%. 3 patients (18.75%) had minimal or no improvement.

CONCLUSION

Vitilinex® herbal bio-actives in combination with nbUVB is a more effective treatment option for vitiligo with 87% of the patients achieving a re-pigmentation rate higher than 50%, compared to Vitilinex® alone (65%) or nbUVB alone (62.5%).