What Is New in Narrow-Band Ultraviolet-B Therapy for Vitiligo?

Bridging Molecular Mechanism and Clinical Practice in Vitiligo Treatment: An Updated Review

BACKGROUND

Treatment of vitiligo seeks to achieve three goals: cessation of disease progression, regeneration of pigmentation, and prevention of recurrence.

SUMMARY

Number of nonsurgical interventions are available that suppress the autoimmune response and regenerate the melanocytes from the reservoir: phototherapy including psoralen and ultraviolet A, narrowband ultraviolet B, and 308-nm excimer and 311-nm Titanium:Sapphire lasers; topical agents including topical calcineurin inhibitors, topical corticosteroids, and topical 5-fluorouracil; and systemic agents including corticosteorids, mycophenolate mofetil, cyclosporine, methotrexate, minocycline, afamelanotide, and antioxidants. In recent years, a great advance has been made in the understanding of pathogenesis of vitiligo, and JAK inhibitors are being investigated as a new treatment. Minimally invasive procedures such as fractional lasers or microneedling can help achieve the optimal treatment outcome when used properly.

KEY MESSAGES

Our review describes various treatment modalities for vitiligo based on their molecular mechanism of action. Bridging the gap between molecular mechanisms and therapeutic options would be a valuable reference for physicians in clinical practice.

The use of Janus kinase inhibitors and narrowband ultraviolet B combination therapy in non-segmental vitiligo

Vitiligo is a depigmentation disorder of the skin that occurs secondary to the destruction of melanocytes by an immune-mediated process. Vitiligo clinically presents with depigmented macules and patches, most commonly on the face, acral sites, and genitalia. It can be characterized as generalized or localized based on distribution. The localized form can be further divided into segmental (linear, band-like, or Blaschkoid) and non-segmental vitiligo. The classical treatment of vitiligo includes topical steroids, pulsed oral steroids in unstable vitiligo, phototherapy, a combination of steroid therapy and phototherapy, surgical grafting, as well as intentional depigmentation therapy in severe cases. However, recent advances in understanding the immune mechanisms implicated in the pathogenesis of vitiligo have led to the use of an FDA-approved topical Janus kinase (JAK) inhibitors for vitiligo. Despite this novel therapy advancement, we recommend the addition of narrowband ultraviolet B (NB-UVB) to JAK inhibitors in patients with extensive and progressive lesions, or those not fully responsive to JAK inhibitor monotherapy.

Could α MSH-MIFT Axis and IDH2 be Considered Promising Predictors of Non-segmental Vitiligo Response to NB-UVB Phototherapy?

Background

The search for objective factors that help in predicting the response of vitiligo treatment is very important.

Objective

We sought to evaluate the effect of NB-UVB phototherapy on both the alpha melanocyte stimulating hormone-microphthalmia-associated transcription factor (α-MSH-MIFT) axis, and isocitrate dehydrogenase 2 (IDH2) in non-segmental vitiligo (NSV).

Methods

This prospective clinical trial included 50 NSV patients and 50 healthy control subjects. α-MSH tissue levels as well as MITF and IDH2 immunostaining were assessed in normal and vitiliginous skin biopsies before treatment and then in the repigmented areas following 24 NB-UVB phototherapy treatment sessions using ELISA technique and immunohistochemical study, respectively.

Results

There was a significant negative correlation between baseline VASI scores and the tissue levels of α-MSH (p=0.006) and the expression of both MITF (p<0.00001) and IDH-2 (p= 0.001). The mean α-MSH tissue levels increased significantly after treatment (p<0.001). Tissue expression of both MTIF and IDH-2 was significantly upregulated following treatment (P-value <0.001). The percentage of improvement showed a significant positive correlation with the studied markers (p<0.00001).

Conclusion

α-MSH- MIFT axis and the antioxidant protein IDH2 are promising objective markers of non-segmental vitiligo severity, and are suggested as predictors of vitiligo response to treatment.

Clinical efficacy analysis of 110 cases of childhood vitiligo with non-surgical combined therapy

BACKGROUND

Vitiligo has a negative effect on children's physical and psychological health. Few studies have examined long-term treatment efficacy for childhood vitiligo. Therefore, we evaluated the long-term effectiveness of non-surgical combination therapy in pediatric patients with vitiligo and analyzed factors that affect its efficacy.

METHODS

Pediatric patients (⩽12 years) with vitiligo who were treated with topical corticosteroids/topical calcineurin inhibitors and phototherapy for 12 months were retrospectively studied. Short-term systemic corticosteroids were administered according to individual clinical conditions. All lesions were photographed to assess repigmentation at 3-month intervals. Clinical data, the treatment effectiveness, and factors affecting the therapeutic effect were analyzed.

RESULTS

Overall, 110 children (51 [53.6%] girls; mean [SD] age, 7.1 ± 3.0 years; 104 [94.5%] with activity status) were treated for a mean period of 23.13 ± 14.03 months (range, 5-86 months). The overall >50% repigmentation rate was 64.5%. A longer duration of treatment was associated with a higher repigmentation rate (X² _trend = 36.229, P < .001). The vitiligo disease activity score at the first visit was positively correlated with the overall repigmentation rate (r_s = 0.301, P = .001).

CONCLUSIONS

Treatment lasting longer than 1 year is recommended in children with vitiligo. The best repigmentation effect can be achieved by combination therapy in the rapid progression stage.

Efficacy and hazards of 425 nm oral cavity light dosing to inactivate SARS-CoV-2

Objective

Using a battery of preclinical tests to support development of a light-based treatment for COVID-19, establish a range of 425 nm light doses that are non-hazardous to the tissues of the oral cavity and assess whether a 425 nm light dose in this non-hazardous range can inactivate SARS-CoV-2 in artificial saliva.

Methods

The potential hazards to oral tissues associated with a range of acute 425 nm light doses were assessed using a battery of four preclinical tests: (1) cytotoxicity, using well-differentiated human large airway and buccal epithelial models; (2) toxicity to commensal oral bacteria, using a panel of model organisms; (3) light-induced histopathological changes, using ex vivo porcine esophageal tissue, and (4) thermal damage, by dosing the oropharynx of intact porcine head specimens. Then, 425 nm light doses established as non-hazardous using these tests were evaluated for their potential to inactivate SARS-CoV-2 in artificial saliva.

Results

A dose range was established at which 425 nm light is not cytotoxic in well-differentiated human large airway or buccal epithelial models, is not cytotoxic to a panel of commensal oral bacteria, does not induce histopathological damage in ex vivo porcine esophageal tissue, and does not induce thermal damage to the oropharynx of intact porcine head specimens. Using these tests, no hazards were observed for 425 nm light doses less than 63 J/cm² delivered at irradiance less than 200 mW/cm². A non-hazardous 425 nm light dose in this range (30 J/cm² at 50 mW/cm²) was shown to inactivate SARS-CoV-2 in vitro in artificial saliva.

Conclusion

Preclinical hazard assessments and SARS-CoV-2 inactivation efficacy testing were combined to guide the development of a 425 nm light-based treatment for COVID-19.

Clinical significance

The process used here to evaluate the potential hazards associated with 425 nm acute light dosing of the oral cavity to treat COVID-19 can be extended to other wavelengths, anatomical targets, and therapeutic applications to accelerate the development of novel photomedicine treatments.

UVB phototherapy in the treatment of vitiligo: State of the art and clinical perspectives

Vitiligo is a chronic pigmentary skin disorder that results in white, hypopigmented macules and patches. It causes a considerable psychological and emotional burden on the affected individuals and their families. Several therapeutic options have been employed in vitiligo including topical and oral drugs, surgical techniques, and phototherapy which is considered the cornerstone treatment. Different wavelengths and modalities are available, but narrowband UVB (NB-UVB) is considered the safest and the most effective phototherapy alternative. NB-UVB acts on multiple steps in vitiligo pathogenesis, and it is capable of inducing stabilization and repigmentation of vitiligo lesions. Technological advances have led to the development of both new phototherapy devices and new medical and surgical therapeutic options that can be combined with phototherapy to achieve optimal results. There is no standard treatment, and individual patient and disease characteristics should be considered. We review the current evidence in what concerns UVB phototherapy for vitiligo treatment, including novel combination treatments that may help to provide the best care for these patients.

Prescribing and using vitiligo treatments - lessons from a nested Process Evaluation within the HI-Light Vitiligo Randomised Controlled Trial

Background

The HI‐Light Trial demonstrated that for active, limited vitiligo, combination treatment with potent topical corticosteroid (TCS) and handheld narrowband ultraviolet B offers a better treatment response than potent TCS alone. However, it is unclear how to implement these findings.

Aim

We sought to answer three questions: (i) Can combination treatment be used safely and effectively by people with vitiligo?; (ii) Should combination treatment be made available as routine clinical care?; and (iii) Can combination treatment be integrated within current healthcare provision?

Methods

This was a mixed‐methods process evaluation, including semi‐structured interviews with a purposive sample of trial participants, structured interviews with commissioners, and an online survey and focus groups with trial staff. Transcripts were coded by framework analysis, with thematic development by multiple researchers.

Results

Participants found individual treatments easy to use, but the combination treatment was complicated and required nurse support. Both participants and site investigators felt that combination treatment should be made available, although commissioners were less certain. There was support for the development of services offering combination treatment, although this might not be prioritized above treatment for other conditions. A ‘mixed economy’ model was suggested, involving patients purchasing their own devices, although concerns regarding the safe use of treatments mean that training, monitoring and ongoing support are essential. The need for medical physics support may mean that a regional service is more practical.

Conclusion

Combination treatment should be made available for people seeking treatment for vitiligo, but services require partnership with medical physics and ongoing training and support for patients.

Assessment of CXCL10 Before and After Narrow Band UVB Phototherapy in Non-Segmental Vitiligo Patients

Background

Vitiligo is a common depigmenting skin disorder characterized by white macules and patches accompanied by local melanocyte loss, caused by autoimmune destruction. Vitiligo is classified into two major forms: segmental vitiligo (SV) and non-segmental vitiligo (NSV). It was also found that the IFN-ȣ/CXCL10 axis is functionally required for both progression and maintenance of the disease. Chemokine 10 (CXCL10) is a pro-inflammatory chemokine which was found to be elevated in the serum of vitiligo patients. UVB has been found to be a useful therapy that results in rapid repigmentation in NSV patients.

Objectives

To evaluate CXCL10 in vitiligo patients before and after narrow band UVB (NB-UVB) phototherapy, which if targeted could provide new insights for therapeutic intervention for vitiligo.

Patients and Methods

The study included 25 active NSV patients who were able to comply with the study protocol in the Center of Excellence, Dermatology Outpatient Clinic, National Research Center, Egypt (February 2020-2021). All recruited patients were subjected to documentation of complete history. Dermatological assessment of vitiligo lesions, including vitiligo area score index (VASI) score, CXCL10 and extent of the disease were performed. A 3 mm punch biopsy from active vitiligo lesion (site of biopsy) was taken before and after treatment by NB-UVB, and then immunohistochemical staining was performed to evaluate expression of CXCL10.

Results

After treatment by NB-UVB there was a significant decrease in VASI score, extent of the disease and CXCL10 expression.

Conclusion

The decrease in CXCL10 levels could be attributed to the effect of NB-UVB which leads to decrease in IFN-γ level, necessary to release CXCL10 through its pathway resulting in repigmentation and decrease in the extent of the disease and VASI scores.

Fototerapia – metoda wykorzystywana w leczeniu przewlekłych schorzeń dermatologicznych

Wykorzystanie energii świetlnej w terapii schorzeń o różnej etiologii towarzyszy człowiekowi od czasów starożytnych. Elementem decydującym o powodzeniu terapii jest dobranie odpowiedniej długości promieniowania (terapia NB-UVB, BB-UVB i UVA1) lub wystąpienie interakcji między substancją światłoczułą skumulowaną w zmienionej chorobowo tkance a zastosowanym promieniowaniem (terapia PUVA oraz terapia fotodynamiczna). Metody terapeutyczne wykorzystujące energię świetlną są klasyfikowane na podstawie wykorzystywanego zakresu promieniowania. Obecnie wyróżnia się fototerapię UV, wykorzystującą promieniowanie UVA lub UVB oraz terapię fotodynamiczną (PDT; photodynamic therapy), podczas której stosowane jest promieniowanie o długości fali 350-700 nm.

Fototerapia UV wykorzystywana jest do leczenia schorzeń dermatologicznych, takich jak łuszczyca, bielactwo oraz atopowe zapalenie skóry, ze względu na jej działanie immunosupresyjne i antyproliferacyjne. Jest dostępna w postaci terapii PUVA polegającej na wykorzystaniu synergicznego działania promieniowania ultrafioletowego (UVA) oraz związków o działaniu światłouczulającym (8-metoksypsolaren, 5-metoksypsolaren). Ponadto wyróżniono monoterapię promieniowaniem ultrafioletowym A1 (UVA1), szerokozakresowym UVB (BB-UVB) i wąskozakresowym UVB (NB-UVB). Terapia fotodynamiczna obok konwencjonalnych metod leczenia jest nowoczesną i nieinwazyjną alternatywą wykorzystywaną zarówno w diagnostyce, jak i terapii chorób o różnej etiologii. W 90% przypadków PDT jest stosowana w schorzeniach dermatologicznych, takich jak trądzik pospolity czy łuszczyca. Selektywna aktywność cytotoksyczna wykazywana w kierunku złośliwych komórek nowotworowych powoduje, że terapia fotodynamiczna stosowana jest także z powodzeniem w leczeniu zmian onkologicznych. Duży postęp, przejawiający się zarówno w opracowywaniu innowacyjnych substancji światłoczułych, jak i nowych źródeł promieniowania, sprawia, iż zakres stosowalności terapii fotodynamicznej ciągle się poszerza.

W artykule przedstawiono obecnie dostępne formy fototerapii poprzez opis mechanizmu ich działania, zastosowania oraz możliwości powstania skutków niepożądanych.

Discovery of small-molecule modulators of melanogenesis by docking-based virtual screening

Background: Vitiligo is a relatively common depigmenting skin disorder. UV light stimulation is often used to obtain repigmentation. Wnt signaling regulates melanocyte differentiation, and expression of TYR is upregulated in narrow-band UVB-treated epidermis. Manipulation of these two pathways by drugs could serve as one of the therapeutic approaches for durable repigmentation. Methods and results: CD9 was identified as a novel TYR activator by virtual screening and bioactivity assay. CD9 activated the Wnt signaling pathway through triggering translocation of β-catenin from cytoplasm to nucleus. Conclusion: The pathogenesis of vitiligo is complicated and varies with each individual, so combination therapy may be much more suitable for treatment of vitiligo. CD9 could synergize with other anti-inflammatory compounds or autoimmune suppressors to shorten repigmentation time and improve efficacy.

Atopic dermatitis: Role of the skin barrier, environment, microbiome, and therapeutic agents

Atopic dermatitis (AD) is a chronic, inflammatory skin disorder characterized by eczematous and pruritic skin lesions. In recent decades, the prevalence of AD has increased worldwide, most notably in developing countries. The enormous progress in our understanding of the complex composition and functions of the epidermal barrier allows for a deeper appreciation of the active role that the skin barrier plays in the initiation and maintenance of skin inflammation. The epidermis forms a physical, chemical, immunological, neuro-sensory, and microbial barrier between the internal and external environment. Not only lesional, but also non-lesional areas of AD skin display many morphological, biochemical and functional differences compared with healthy skin. Supporting this notion, genetic defects affecting structural proteins of the skin barrier, including filaggrin, contribute to an increased risk of AD. There is evidence to suggest that natural environmental allergens and man-made pollutants are associated with an increased likelihood of developing AD. A compromised epidermal barrier predisposes the skin to increased permeability of these compounds. Numerous topical and systemic therapies for AD are currently available or in development; while anti-inflammatory therapy is central to the treatment of AD, some existing and novel therapies also appear to exert beneficial effects on skin barrier function. Further research on the skin barrier, particularly addressing epidermal differentiation and inflammation, lipid metabolism, and the role of bacterial communities for skin barrier function, will likely expand our understanding of the complex etiology of AD and lead to identification of novel targets and the development of new therapies.

Stem Cell Therapy Offers a Possible Safe and Promising Alternative Approach for Treating Vitiligo: A Review

BACKGROUND

Normal skin pigmentation pattern is an extremely important component of the appearance of a person, as it can be a significant factor in the social context of any person. A condition known as vitiligo is caused by the death of melanocytes leading to pigmentation loss in the skin. This affects all races across the globe and sometimes leads to social avoidance as in some communities, it is stigmatized. Although there are different pathobiological processes suspected because of the different underlying causes of vitiligo, autoimmunity and oxidative stress are suspected to be the most probable ones.

OBJECTIVE

In this review, we present an overview of the underlying mechanisms causing and developing the disease. Also, some of the most successful treatments along with the clinical applications of Mesenchymal Stem Cells (MSCs) as a comprehensive approach for treating this condition will be covered.

RESULTS

Autoreactive CD8+ T-cells are the primary suspect considered to be responsible for the destruction of melanocytes. Therefore, topical use of autoimmune inhibitors including those derived from MSCs, thanks to their immune-modulatory properties, have been reported to be successful in the promotion of repigmentation. MSCs can suppress the proliferation of CD8+T via the NKG2D pathway while inducing T-cell apoptosis. The use of pharmacological agents for reducing cellular oxidative stress with the help of topical application of antioxidants and growth factors also have been in use. Intravenous administration of MSCs has been shown to regulate the level of reactive oxidative species (ROS) in a mice model. Growth factors derived from platelet-rich-plasma (PRP) or from MSCs caused rapid tissue regeneration.

CONCLUSIONS

Finally, MSC therapy also has been shown to stimulate the mobilization of healthy melanocytes, leading to successful repigmentation of skin lesions in vitiligo patients.

Involvement of adenylate cyclase/cAMP/CREB and SOX9/MITF in melanogenesis to prevent vitiligo

Vitiligo is autoimmune, acquired, idiopathic, chronic, and progressive de/hypopigmentary cutaneous condition that targets the cell-producing pigment called melanin. It binds to a thread of great disappointment and emotional stress in societies. Combining multiple stress-related theories like toxic compound accumulation, autoimmunity, mutations, altered cellular environment, infection, impaired migration/proliferation, and immunological mismatch of anti-melanocyte and self-reactive T-cells that cause melanocytes damage is formulated resulting in vitiligo. Vitiligo has an orphan status for drug synthesis. Still, different therapies are available, with topical steroids and narrow-band ultraviolet-B monotherapy being the most common treatments, others including medical, physical, or surgical, but not effective. Each modality has its baggage of disadvantages and side effects. Stimulation of the transcriptional process for melanogenesis is mainly achieved by the cAMP-dependent activation of several melanogenic genes by MITF. In this review, we summarized that cAMP encourages the expression of the enzyme tyrosinase, TYRP1, TYRP2, and most other biological effects of cAMP are mediated through the cAMP-dependent PKA pathway resulting in CREB phosphorylation. It has been shown that TYRP1 and 2 do not have cAMP response elements (CREs) in promoting regions; the regulation of these genes by cAMP occurs through the direct participation of MITF during melanogenesis. The available medicines, therefore, only provide symptomatic relief, but do not stop the disease progression. In addition, the treatment process needs to be changed; existing approaches need to be overlooked for patients who are suffering and therefore analyze its efficacy and safety to achieve a favorable risk-benefit ratio.

A Systematic Review of Nutrition, Supplement, and Herbal-Based Adjunctive Therapies for Vitiligo

Background: Vitiligo is an autoimmune skin condition that affects people globally anywhere, from <0.1% to more than 8% of individuals. The disease destroys skin melanocytes, resulting in a patchy depigmentation of the skin. About 50% of all patients develop the disease before their 20s. Methods: We systematically searched the literature and reviewed the evidence for the use of nutritional supplements and diet in the management of vitiligo. Embase and Medline were searched for diet, herbal, and nutrition-based clinical studies. Additional filters were applied that looked for controlled trial or randomized controlled trial and article or article in press or letter and English and clinical study. We selected clinical studies in humans that showed how diet or natural supplements can improve the symptoms of vitiligo in all of our searches. Results: There were 62 manuscripts that resulted from the PubMed search and 259 from the Embase search. A final of 26 studies were reviewed, and other supplemental case and case-control studies were used to introduce diet components that may influence either exacerbation or amelioration of vitiligo. Possible mechanisms of action are introduced for natural and supplemental interventions. Conclusion: Some of the supplements reviewed include Gingko biloba, oral Polypodium leucotomos, alpha lipoic acid, vitamins B12, D, and E, folic acid, phenylalanine, canthaxanthin, Nigella sativa oil, and other combined herbal bio-actives. Overall, the growing evidence is promising, but more studies are needed in this area to further explore the impact that supplements and diet can have on vitiligo management. The most promising therapies included oral phenylalanine as adjuvant therapy with UVA therapy, oral G. biloba as monotherapy, both of which can be used with other traditional therapies, and oral P. leucotomos with phototherapy or photochemotherapy.

Consensus on the treatment of vitiligo - Brazilian Society of Dermatology

Background

Vitiligo is a muco-cutaneous, autoimmune, localized, or disseminated disease, which manifests through hypochromic or achromic macules, with loss in quality of life. The prevalence of vitiligo in Brazil was determined to be 0.54%. There is no on-label medication for its treatment. To date, no Brazilian consensus on the treatment of vitiligo had been written.

Objectives

The objective of this group of Brazilian dermatologists with experience in the treatment of this disease was to reach a consensus on the clinical and surgical treatment of vitiligo, based on articles with the best scientific evidence.

Methods

Seven dermatologists were invited, and each was assigned two treatment modalities to review. Each treatment (topical, systemic, and phototherapy) was reviewed by three experts. Two experts reviewed the surgical treatment. Subsequently, the coordinator compiled the different versions and drafted a text about each type of treatment. The new version was returned to all experts, who expressed their opinions and made suggestions for clarity. The final text was written by the coordinator and sent to all participants to prepare the final consensus.

Results/Conclusion

The experts defined the following as standard treatments of vitiligo: the use of topical corticosteroids and calcineurin inhibitors for localized and unstable cases; corticosteroid minipulse in progressive generalized vitiligo; narrowband UVB phototherapy for extensive forms of the disease. Surgical modalities should be indicated for segmental and stable generalized vitiligo. Topical and systemic anti-JAK drugs are being tested, with promising results.