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Childhood Vitiligo: Treatment Paradigms
Abstract
Childhood vitiligo differs from the adults by showing a higher incidence in females, segmental vitiligo being more common and less frequent association with other systemic autoimmune and endocrine disorders. Childhood vitiligo is often associated with a marked psychosocial and long lasting effect on the self-esteem of the affected children and their parents, hence an adequate treatment is very essential. Treatment of vitiligo is indeed a tough challenge for the dermatologists' more so in the background of childhood vitiligo. Although multiple therapeutic modalities are available in the therapeutic armamentarium, not all can be used in children. This brief report updates regarding various therapies available in the treatment of childhood vitiligo.
... tachyphylaxis, suppression of hypothalamic-pituitaryadrenal axis, Cushing's syndrome and growth retardation). In detail, the use of TCs on vitiligo patches of the face should be avoided or limited in time because of the higher risk of topical side effects, including glaucoma [6] [7]. ...
... skin cancers and lymphoma), TCIs cannot be used in children < 2 years. The major limit to treat vitiligo with CIs is due to their costs [6]. ...
... Surgical therapies are not recommended in childhood vitiligo and must to be limited to patients with stable localised lesions, unresponsive to the more conventional therapies. Surgical techniques in young children have to be also avoided because of their natural body growth in which lesions tend to extends, and they're difficult to stand still in the postoperative time [4][5] [6]. ...
Vitiligo is an important skin disease of childhood, which may lead to deep psychological trauma, resulting in a poor quality of life and low self-esteem. The Authors discuss a short review of the more conventional therapies available for the treatment of vitiligo in children.
... NBUVB also has been increasingly tested in the pediatric population as a therapy for diseases, including vitiligo and atopic dermatitis. [1][2][3][4][5] In 1997, Westerhof and Nieuweboer-Krobotova [6] were the first to study the effect of NBUVB in vitiligo. In 2000, Njoo et al. [7] and 2005, Kanwar and Dogra [8] ABSTRACT Background: Management of vitiligo in children is difficult as therapeutic options are restricted when compared to that in adult patients. ...
... NBUVB therapy is now a more or less established and recommended phototherapy for generalized vitiligo, pregnant women, and children because of the high safety profile. [3][4][5] Determination of MEDs is essential for rational treatment with UV light. Serish and Srinivas reported that the mean MED for NBUVB was 300 mJ/cm 2 for the Indian adults skin. ...
... 6 Vitiligo in childhood is frequently linked to several detrimental outcomes, most notably a significant psychosocial impact and an intractable influence on the children's self-esteem. 7 In an online survey, more than 25% were associated with selfconsciousness, difficulty with friendships and schoolwork, teasing, and bullying. 8 In which the vitiligo in the face and legs was reported as the most bothersome site for both children. ...
Introduction: Vitiligo is a depigmentation disorder characterized by well-demarcated white macules and patches on the skin. Vitiligo commonly occurs in children or young adults. Vitiligo can be classified into segmental, non-segmental and mixed type. Childhood vitiligo is often associated with many negative consequences, especially marked psychosocial and long-lasting effects on the self-esteem of the affected children. This study investigated characteristics and risk factors associated with vitiligo in childhood. Method: This was a retrospective descriptive study of patient aged 0-18 years old that was diagnosed with vitiligo derived from interview and medical records of Dermatovenereology Outpatient Clinic in Mangusada Hospital, Badung, Bali, from January to September 2023. This study included profiling data such as gender, the onset of vitiligo, clinical distribution, risk factors, and family history that suggested influencing the development of vitiligo. This study used a total sampling method, and 21 patients were participating. Results: Vitiligo in childhood was found in 11 patients female (52%) and 10 male (48%) patients in this study. A third of the patients were in elementary school, and only one (5,5%) was in preschool. The age of vitiligo patients was 13-15 (23,81%). The site of onset vitiligo was mostly in the face (21,42%), lower limb (17,85%), scalp, lumbar, and foot (10,71%). The distribution type focal distribution was predominant (38,09%), followed by segmental and generalized distribution (23,8%) and acrofacial (14,28%). Conclusions: Vitiligo was predominantly affected in a female patient. Idiopathic was the most common risk factor for vitiligo, and focal distribution was the most common type of lesion. Since vitiligo is a cosmetic skin problem and is not contagious or threatening the patient’s life, the available treatment is sufficient.
... Vitiligo can be classified into two main types, segmental and non-segmental (3). Since segmental vitiligo is less associated with autoimmune diseases (4), this study focused on nonsegmental vitiligo, which is the most common type of vitiligo. The autoantibodies of vitiligo can lead to the occurrence of autoimmune complications (5,6). ...
Background
Vitiligo is an autoimmune skin disease mainly mediated by CD8⁺ T cells, which affects about 0.1%-2% population of the world. Leptin plays a critical role in regulating the activation of CD8⁺ T cells. However, the effect of Leptin on vitiligo remains unclear.
Objectives
To explore the effect of leptin on CD8⁺ T cells and its influence on vitiligo.
Methods
RNA sequencing and Quantitative Real-time PCR (RT-qPCR) were used to explore the differentially expressed genes. Immunofluorescence staining was performed on skin lesions. Leptin in serum was detected by enzyme linked immunosorbent assay (ELISA). The peripheral blood mononuclear cells were detected by flow cytometry after leptin stimulation for 72 hours. A vitiligo model was established by monobenzone on Leptin KO mice.
Results
557 differentially expressed genes were found, including 154 up-regulated and 403 down-regulated genes. Lipid metabolism pathways showed a close relationship to the pathogenesis of vitiligo, especially the PPAR signaling pathway. RT-qPCR (p = 0.013) and immunofluorescence staining (p = 0.0053) verified that LEPR expressed significantly higher in vitiligo. The serum leptin level of vitiligo patients was significantly lower than that of healthy controls (p = 0.0245). The interferon-γ subset of CD8⁺LEPR⁺ T cells from vitiligo patients was significantly higher (p = 0.0189). The protein level of interferon-γ was significantly increased after leptin stimulation in vitro (p = 0.0217). In mice, Leptin deficiency resulted in less severe hair depigmentation. Leptin deficiency also resulted in significantly lower expressed vitiligo-related genes, such as Cxcl9 (p = 0.0497), Gzmb (p < 0.001), Ifng (p = 0.0159), and Mx1 (p < 0.001) after modeling.
Conclusion
Leptin could promote the progression of vitiligo by enhancing the cytotoxic function of CD8⁺ T cells. Leptin may become a new target for vitiligo treatment.
... Many etiological hypotheses have been suggested to explain vitiligo, among which the most engrossing one is an association of genetic and immunologic factors, which interrelate with each other resulting in an autoimmune melanocyte destruction. [4] Childhood vitiligo varies from the adults by showing a higher rate in females, segmental vitiligo being more widespread and less frequent association with other systemic autoimmune and endocrine disorders. [5] Most of the times childhood vitiligo is associated with a major psychosocial and long term effect on the self-confidence of the affected children and their parents, hence a proper treatment is very essential. ...
Patients of vitiligo are hated and neglected lot in the society. Great researches in the world have done lot of studies and experiments but no medicine has proved satisfactory in total eradication of the disease. Objective: To see the effect of multi-modality Ayurveda regime in the management of Childhood vitiligo/Shwitra. Methodology: Female patient 07yrs old had been experiencing symptoms of white Patches around the b/l eye and elbow since 5months. Ayurvedic medicines were used in the study for one year and six months. Discussion: The major goal of the multi-modality regime is to help to eliminate white patches. Bakuchi Ghanvati, Mahamanjishtadi kadha, Panchtikta ghruta guggul, Krumikuthar rasa were given orally. Bakuchi tail for local application and daily Hanuman chalisa path advised to patient. This treatment for one half year continued which showed excellent result in the patient. Conclusion: The effect of Dravya and Adravya shaman chikitsa has shown encouraging results in the repigmentation of the affected skin. Not many complications were observed in the patients at the end of the study. Ayurveda has distinctive concepts with all disease called as Chikitsa siddhanta, which work and stand for a long period of time. Since the therapy for Vitiligo has limitation in other pathies, Ayurvedic management of vitiligo is one of the most effective therapy and which have less chances of recurrence.
... Gyorsan progrediál, a kezelésre adott válaszkészsége rosszabb. Általában soliter, esetleg multiplex, szegmentális lokalizációjú, társulhat leukotrichiával (13,14,15) (3. ábra). ...
The prevalence of vitiligo is between 0.5% and 1% in the population, the most common acquired depigmentation disorder. Hypopigmented macules are formed as a result of melanocyte death. Its etiology is still not fully elucidated, it is a multifactorial disease. Polygenic type genetic susceptibility is supported by familial accumulation (15- 30%). The complex interaction of non-immunological and immunological factors is key during the development of the disease. Due to intensive research in recent years, it has become clear that cells other than melanocytes, such as keratinocytes, fibroblasts, natural killer (NK) cells, and other cells of the innate immune system are involved in its pathogenesis. Furthermore, a special group of T lymphocytes, the tissue-resident memory T cells, play a key role also in the development and recurrence of the disease. The aim of the treatment is to stop progression, to achieve repigmentation, which is transient in 40% of cases.
... Several treatment modalities are available: each having certain indications and limitations [21,22]. "The treatment can be broadly classified under medical and surgical modalities. ...
Background: Vitiligo is a chronic cutaneous disease characterized by hypo- or depigmented patches that leave psychological impact on the patients. New treatment modalities have been developed to shorten the duration of treatment of vitiligo with fewer side effects. Objective: To evaluate the effect of low-level laser therapy (LLLT) in the treatment of stable vitiligo. Patients and Methods: The study included 20 stable vitiligo patients with overall symmetrical lesions. For each patient, one site was treated with LLLT & NB-UVB twice weekly for 3 month. Results: There was statistically significant improvement in the re-pigmentation, 25% of patients showed excellent improvement, 40% of patients showed good improvement, 20% of patients showed moderate improvement, 10% of patients showed poor improvement and 5% of patients showed no improvement after 3 months therapy. Side effects were minimal and transient in both sides. Conclusion: LLLT in combination with NB-UVB therapy could be considered as safe and tolerable technique for treatment of vitiligo. Longer follow up is needed.
... show a gross lack of DOPA-positive melanocytes in the basal layer (11). ...
Background: Hypopigmentary skin disorders are the most worrisome complaints from Indian and Indian subcontinent people. Pityriasis alba (PA), polymorphic light eruption (PLE), and vitiligo are clinically look-alike conditions commonly seen in children. Objectives: We attempted to characterize the dermoscopic features of PA and PLE and differentiate them from vitiligo in the facial region in skin of color. Methods: Dermoscopic evaluation was done using a handheld dermoscope at 10X magnification on facial lesions of a total of 60 patients with PA, PLE, and vitiligo. Dermoscopic features of all three conditions were compared and correlated with histological features. Results: Out of 60 patients, 30 (50%), 20 (33.33%), and 10 (16.66%) patients were diagnosed with PA, PLE, and vitiligo clinically and histologically, respectively. Dermoscopy of PA showed white structureless areas (100%), ill-defined margins (86%), faint brownish pigmentation (70%), and fine scales (70%) (P value = 0.001). Besides, 70% of PLE cases showed white structureless areas and ill-defined margins, and 10% showed faint brownish pigmentation (P value = 0.0001). Coarse scales and clustered dots were the most common findings (75%) in PLE lesions, followed by light brown background (60%), crusts (40%), and yellow clods (30%) (P value = 0.0001). Also, 40% and 35% of the PLE cases showed white and brown course scales, respectively (P value = 0.0001). Moreover, 13.33% of PA cases showed coarse white scales, and 3.33% showed a light brown background. All vitiligo cases showed a white glow appearance (100%), followed by perifollicular pigmentation, leukotrichia, and koebnerization shown by 40% of the cases (P value = 0.0001). Finally, 20% of the cases showed perilesional pigmentation and satellite lesions. Conclusions: PA lesions are dermoscopically characterized by ill-defined white areas with fine branny scales, whereas PLE shows coarse brown scales, ring scales, crusts, and yellow clods along with the above findings. Vitiligo lesions are devoid of scales with various pigment network abnormalities, perilesional and perifollicular pigmentation, and leukotrichia.
... Third-line option is "surgical techniques," and fourth-line option is "depigmenting treatments." 5,8 Both topical and systemic treatments that blockinterferon-gamma (IFNγ) signaling can effectively reverse vitiligo in humans; however, disease relapse is common after stopping treatments, occurring in 40% of cases.[16][17][18] Autoreactive resident memory T cells are responsible for relapse, and new treatment strategies focus on eliminating these cells to promote long-lasting benefit.17 ...
Background
Updates of treatment methods of stable vitiligo are needed to give better outcomes with a shorter duration of treatment.
Objective
To test the effect of transdermal 5-fluorouracil (5-FU) delivery using fractional CO2 (FrCO2) laser versus intralesional 5-FU injection, with narrow-band type ultraviolet B (UVB) (NB-UVB) therapy after both, in the treatment of stable vitiligo.
Patients and methods
The present study comprised 40 patients with nearly symmetrical stable vitiligo lesions. The left side was treated with FrCO2 laser followed by topical 5-FU (FrCO2 + 5-FU), while the right side was treated with 5-FU intradermal injection. Both procedures were done at 2-week intervals for 3 sessions followed by 24 sessions of narrow-band UVB for both sides.
Results
Repigmentation was demonstrated on the left side of 90% of patients and the right side of 85% of patients. As much as >50% improvement was demonstrated on the left side of 50% of patients, and the right side of 55% of patients. Intralesional 5-FU showed a statistically significant difference in repigmentation compared to FrCO2 + 5-FU.
Conclusion
Both 5-FU injection and FrCO2 + 5-FU were effective therapeutic modalities for vitiligo. Patients were more compliant with FrCO2 + 5-FU.
... -Psychological therapy: due to the previously mentioned exposure to stigma, patients with vitiligo should have easy access to psychological care or psychiatric. The condition of the patient's social and emotional functioning is impaired it has a significant impact on the psychological development of a child, so the possible one should not be underestimated the need to introduce psychological therapy during the treatment of the child in question dermatosis [18]. ...
Vitiligo is a chronic skin condition which affects 0,5-2% of the world’s population, without any sex or ethnical predilection. Clinically it is characterized by the development of well-defined depigmented macules. Although its etiopathogenesis is exquisitely compound and remains not fully anderstood, it is known that it results from the destruction of melanocytes present in the skin. The aim of this paper is to present vitiligo clinical picture in a children population, its etiopathogenesis and available therapeutical methods. There are many therapeutic options for vitiligo, none of which is fully effective, hence appropriate patients education concerning various medical and cosmetic therapies, as well as the psychological aspects of the disease, is extremely important.
... The available treatment methods have different indications and specific limitations. The treatment modalities can be classified into medical and surgical [10]. A lot of procedures were tried over years in terms of improving the clinical results with its impact on the quality of life of the patients and to decrease the possible side effects [11]. ...
Background: Vitiligo is a chronic cutaneous disease characterized by depigmented patches that leave psychological impact on the patients. New treatment modalities have been developed to improve the results vitiligo with less side effects. Objective: To evaluate intralesional injection of 5-fluorouracil in treatment of vitiligo. Patients and Methods: The study included 20 localized stable vitiligo patients. Each patient was treated with intralesional injection of 5-fluorouracil every 2 weeks for 3 sessions followed by narrow band sessions twice weekly for 3 months. Results: There was statistically significant repigmentation after treatment with intralesional 5-FU (mean of 50.30 ± 34.60, P value =0.001 Wilcoxon signed ranks test between before and after). 55% of patients showed >50% repigmentation. after 3 months therapy. Side effects were minimal and transient. Conclusion: Intralesional injection of 5-FU is safe and effective in the treatment of vitiligo.
... [1] Vitiligo is classified according to Picardo and Taieb into four types: Non-segmental vitiligo (NSV), segmental vitiligo (SV), mixed NSV and SV, and unclassifiable types e.g., focal, multifocal asymmetrical non-segmental and mucosal at one site. [2] The aim of treatment in vitiligo is to restore the normal appearance, morphology, and function of skin. Narrowband UVB has become the first-line treatment for adults. ...
... [1,2] With a global frequency of 0.5%-4%, vitiligo occurs in both sexes and all races and ages. [3][4][5][6][7][8][9] Nevertheless, the most common age of onset of the disease is 10-30 years. [9] Since patches of depigmentation mainly develop in the exposed areas of the body, mostly in young individuals, vitiligo can be associated with lower self-confidence, disturbed social and sexual performance, isolation, depression, and ultimately lower quality of life. ...
Background:
Vitiligo is characterized by the idiopathic destruction of melanocytes, probably of autoimmune etiology, that results in depigmented patches of skin and mucosal surfaces. Oxidative stress may contribute to the pathogenesis of vitiligo. Zinc, a trace element with antiapoptotic properties, plays a major role in the process of melanogenesis and elimination of free radicals. The present study was conducted with the aim of comparing serum zinc levels in patients with vitiligo and in normal controls.
Materials and methods:
In this case-control study, we studied 103 patients with vitiligo and 103 healthy sex-and age-matched controls. Serum zinc levels were measured in these two groups using atomic absorption spectrophotometry and compared with each other.
Results:
The mean serum zinc level was 92.1 mcg/dl in the focal vitiligo, 81.3 mcg/dl in the generalized vitiligo, and 91.8 mcg/dl in the control group. A significant difference in serum zinc levels was observed between the patients with generalized vitiligo and the controls. Lower serum zinc levels were also correlated with longer duration of the disease. Furthermore, a negative relationship was found between serum zinc level and age of patients with vitiligo.
Conclusion:
Serum zinc level is low in patients with generalized vitiligo. In these patients, serum zinc level is in negative correlation with patient's age and disease duration.
... Vitiligo is an acquired chronic hypopigmentary disorder, which usually stars in childhood. Even if today different kind of therapies, both medical and surgical, are available [1] (Table 1), none of them may be considered as a standard gold treatment for the variable results in term of repigmentation and the risk of side effects. ...
Vitiligo is an acquired chronic hypopigmentary disorder, which usually stars in childhood. The Authors discuss a short review of the more innovative therapies for childhood vitiligo.
... Por sua vez, o vitiligo caracteriza-se por ser uma doença crônica de pele assintomática, bem demarcada, cuja principal característica é a presença de manchas ou máculas acrômicas, com ausência total de pigmentação da pele (Palit & Inamadar, 2012;Silva, Gontijo, Pereira & Ribeiro, 2007;Silverberg, 2014). A prevalência do vitiligo na infância pode variar entre 0,1 % e 4 % da população, especialmente em meninas (Kanwar & Kumaran, 2012). ...
Se tuvo como objetivo comparar el perfil comportamental
de niños con enfermedades crónicas de la piel
(dermatitis atópica, psioriasis y vitiligo). Fue realizado
un estudio transversal con un muestreo por conveniencia.
Participaron 26 madres, con hijos entre 6 y 12 años
y diagnósticos de enfermedades crónicas de la piel.
Los instrumentos utilizados fueron el Child Behavior
Checklist for ages 4/18 (cbcl 4/18) y el formulario
sociodemográfico. Se realizó una comparación entre
grupos de niños con diferentes enfermedades crónicas
de piel en cuanto a las competencias sociales y problemas
de comportamiento, por medio de la prueba no
paramétrica de Kruskal-Walis (p < 0,05). Los resultados
indicaron diferencias estadísticamente significativas
entre los tres grupos en cuanto a la competencia global,
social, escolar y para actividades. Niños con dermatitis
atópica presentaron menor competencia para actividades
y niños con vitiligo para competencia social. Los tres
grupos presentaron baja frecuencia de niños con perfil
clínico para competencia escolar y alta frecuencia
de niños clasificados como clínicas para problemas de
comportamiento. Se discute el papel de las dermatosis
crónicas en el desarrollo de problemas de comportamiento
y competencias sociales
... Also, the patchy appearance leads to psychological disturbance to the sufferer [3]. It leads to emotional distress, low self-esteem [4] and affects sexual life of the patients [5]. Often the affected persons, especially the children, get bullied and stigmatized [6]. ...
Vitiligo is an idiopathic systemic autoimmune disease affecting skin, hair and oral mucosa. This genetic yet acquired disease characterized by melanin loss is a cause of morbidity across all races. Though thyroid disturbance has been recognized as a key trigger of this pathology, an array of other factors plays critical role in its manifestation. Multiple hormones (corticotropin-releasing hormone, adrenocorticotropic hormone, α-melanocyte-stimulating hormone, melatonin, calcitriol, testosterone, estrogen), genes (Human leukocyte antigen (HLA), Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), Forkhead box D3 (FOXD3), Cluster of differentiation 117 (CD117), Estrogen receptor (ESR) 1, Cyclooxygenase-2 (COX2), Vitiligo-associated protein 1 (VIT1)), and lifestyle choices (stress, diet, cosmetic products, and medications) have been suspected as drivers of this disorder. The pathological mechanisms have been understood in recent times, with the aid of genomic studies; however a universally-effective therapy is yet to be achieved. This review discusses these under-investigated facets of vitiligo onset and progression; hence, it is expected to enrich vitiligo research.
Vitiligo comprises of one of the commonest reasons for a dermatology consultation in the pediatric age group, worldwide. The incidence of childhood vitiligo varies from 1% to 8%, making it a significant pediatric condition. Various theories have been put forward to explain the occurrence of depigmentation in vitiligo, of which genetic factors play a predominant role in childhood vitiligo. The various modalities of treatment of childhood vitiligo are reviewed in this article. The management of vitiligo is extremely challenging, more so in the pediatric age group, as it can lead to significant psychologic trauma and dysregulation of social development in a child. The goals of management of childhood vitiligo should be aimed at addressing all these issues and achieving an optimum result out of the available modalities.
Vitiligo is a chronic pigmentation disorder characterized by the appearance of milky white macules on the skin due to progressive loss of epidermal melanocytes, it can occur at any time in life, including childhood. Twenty five percent of patients usually occur before the age of 8 years. Nonsegmental vitiligo can be diagnosed based on history, physical examination, and dermoscopy examination. On dermoscopy, we can find milk-white macules, perifollicular depigmentation and leukotrichia. Vitiligo can be treated in many ways, but these therapies are not entirely safe and effective. Therapy generally aims to stimulate melanocyte proliferation or interfere with inflammatory or neural factors that affect the structure and function of melanocytes. Each therapeutic approach shows advantages and disadvantages and is patient dependent. Not all vitiligo therapy for adult patients can be recommended to treat pediatric patients. In children, vitiligo therapy is usually based on the extent of the lesion.
Objectives: The objectives of the study were to assess clinical profile (age of onset, age of presentation, gender, site of involvement, severity (stage), type of vitiligo, triggering factors, and associated diseases), prescription patterns (monotherapy, combination therapy, oral, topical, and therapeutic categories of drugs prescribed) and to monitor and report adverse drug reactions (based on World Health Organization [WHO] causality assessment scale) in vitiligo patients. Methods: A hospital-based prospective observational study was carried out by evaluating and assessing the clinical profile and prescription patterns of 85 patients who attended dermatology venereology and leprosy (DVL) outpatient department at Sri Padmavathi Medical College for Women, SVIMS, Tirupati, over a period of 6 months from June 2019 to December 2019. Results: In our study, forty four (51.77%) patients were female, vitiligo vulgaris is the most common morphological type observed in twenty seven (31.76%) patients. 31–50 years was the predominant age group. The mean age of onset and presentation was 38.35 (standard deviation of 18.37) and 43.27 (standard deviation of 17.96) years, respectively. Forty-one (48.23%) patients were having Stage 1 vitiligo. Fifty (58.85%) patients were having vitiligo at more than 1 site. Twelve (14.11%) patients were having a positive family history of vitiligo. Thirty-seven (43.53%) patients had triggering factors. Associated diseases were found in thirty (35%) patients. Combination therapy was given to sixty one (71.77%) patients. Topical medications were given to fifty two (61.18%) patients. During the study, we did not have a single patient complaining of any adverse drug reaction. Conclusion: Longer the time after appearance of vitiligo, lesser the number of patients attending follow-up. If vitiligo is diagnosed at the earliest stage, more are the chances for complete repigmentation. Patients with a poor economic background are less bothered about their skin condition and are not using medications properly.
Vitiligo is the most common acquired pigmentary disorder, which afflicts 0.5‐1% of the world population, and is characterized by depigmented skin patches resulting from melanocyte loss. Vitiligo has a complex etiology, and varies in its manifestations, progression, and response to treatment. It presents as an autoimmune disease, evidenced by circulating melanocyte‐specific antibodies, and association with other autoimmune diseases. However, autoimmunity may be secondary to the high oxidative stress in vitiligo skin and to intrinsic defects in melanocytes and their microenvironment, which contribute to aberrant stress response, neo‐antigenicity, and susceptibility of melanocytes to immune attack and apoptosis. There is also a genetic predisposition to vitiligo, which sensitizes melanocytes to environmental agents, such as phenolic compounds. Currently, there are different treatment modalities for re‐pigmenting vitiligo skin. However, when repigmentation is achieved, the major challenge is maintaining the pigmentation, which is lost in 40% of cases. In this review, we present an overview of the clinical aspects of vitiligo, its pathophysiology, the intrinsic defects in melanocytes and their microenvironment, and treatment strategies. Based on lessons from the biology of human melanocytes, we present our perspective of how repigmentation of vitiligo skin can be achieved and sustained.
Vitiligo adalah gangguan pigmentasi didapat yang ditandai dengan lesi putih yang tidak berpigmen pada kulit dan rambut karena kehilangan fungsi melanosit. Sekitar 50% pasien vitiligo menunjukkan awitan sebelum usia 18 tahun, sehingga seringkali menimbulkan masalah di bidang pediatrik, baik dalam diagnosis maupun tata laksana. Penegakan diagnosis vitiligo umumnya berdasarkan anamnesis dan pemeriksaan fisik, namun dapat dilakukan pemeriksaan penunjang untuk memastikan diagnosis ataupun mencari penyakit komorbiditas. Fototerapi diberikan hanya pada pasien anak dengan vitiligo yang tetap stabil dan tidak responsif terhadap terapi topikal. Terdapat beberapa perbedaan dalam hal indikasi dan dosis yang diberikan pada fototerapi anak dan dewasa. Perkembangan dan temperamen/perilaku anak harus dinilai termasuk mempertimbangkan kecemasan, ketakutan terhadap ruangan tertutup, dan kemampuan untuk tetap diam selama perawatan, sehingga penatalaksanaannya perlu perhatian khusus. Rata-rata pemberian fototerapi pada anak dapat sampai 12-24 bulan. Oleh sebab itu efek samping pemberian fototerapi jangka panjang penting disampaikan kepada orang tua.Kata kunci: anak, fototerapi, vitiligo
Vitiligo is an acquired, chronic, pigmentary disorder characterized by the progressive loss of cutaneous melanocytes and/or abnormality in their normal function, resulting in hypopigmented skin areas which progressively become amelanotic. The vitiligo is classified into three main types: the nonsegmental vitiligo (NSV), the segmental vitiligo (SV), and the indeterminate forms. The progressive accumulation of reactive oxygen species (ROS) in melanocytes causes DNA damage, lipid, and protein peroxidation. Different studies underline how vitiligo has a deep impact on the quality of life (QoL) of patients, who often suffer from shame, embarrassment, and low self‐confidence and socialization. The typical leopard skin‐like appearance of vitiligo patients usually results in dissatisfaction in their appearance which leads to a weak self‐perception. Depression is one of the most important vitiligo‐related problems. Unlike other dermatological diseases, vitiligo does not need a particular skin care. Medical treatment can be divided into topical, systemic, and phototherapy.
The etiology of vitiligo is still unclear. The aim is to investigate a neural and hormonal etio-pathology of vitiligo. Sixty acrofacial vitiligo patients were divided into two subgroups as active vitiligo patients group (AVPs; n = 35) and stable vitiligo patients group (SVP; n = 25). Forty healthy subjects without any systemic or dermatological disease were used as controls. Blood samples were collected, and the samples were used for measurement of free triiodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), adrenocorticotrophic hormone (ACTH), cortisol, estrogen, testosterone, melatonin, and prolactin levels by ELISA, while norepinephrine (NE), epinephrine (Epi), dopamine (DA), homo-vanillic acid (HVA), serotonin, and 5-hydroxyindoleacetic acid (5-HIAA) by high-pressure liquid chromatography. The current results showed a significant increase in plasma levels of Epi, NE, DA, HVA, serotonin, 5-HIAA, melatonin, and in serum level of TSH and prolactin either in SVP or AVP groups than the control group and in AVP than SVP group. The serum levels of fT3 and fT4 were significantly decreased either in SVP or AVP groups than the control group. A significant increase in estradiol levels was observed in females within AVP than females in either SVP or control groups. There was a significant increase in serum level of cortisol in AVP than either SVP or control group. There was a significant decrease in serum level of ACTH in either AVP or SVP than control and in AVP than SVP group. In conclusion, there are some neural and endocrine markers that play a pivotal role in pathogenesis and/or consequences of vitiligo. The abnormally disturbed levels of theses markers lead to melanocyte destruction and/or depigmentation.
Background
Pityriasis lichenoides (PL) is a dermatologic disorder that manifests in either the acute (pityriasis lichenoides et varioliformis acuta) or the chronic form (pityriasis lichenoides chronica, also known as parapsoriasis chronica). Traditional first-line therapy consists of corticosteroids or antibiotics; however, these treatments are often accompanied with multiple side effects and may be ineffective. Objective
The goal of this study was to review the use of phototherapy for treating PL in the pediatric population. Materials and methodsWe performed a systematic review of the literature in the National Library of Medicine’s PubMed database and the SCOPUS database discussing phototherapy for treatment of PL in the pediatric population. The following search terms were used: ‘pityriasis lichenoides’, ‘pityriasis lichenoides chronica’, ‘pityriasis lichenoides et varioliformis acuta’, and ‘febrile ulceronecrotic Mucha-Habermann disease’. ResultsThe systematic search and screening of articles resulted in 14 articles including a total of 64 patients with PL treated with phototherapy. Three different modalities were utilized, with five studies using broadband ultraviolet B (BB-UVB) radiation, nine studies utilizing narrowband UVB (NB-UVB), and two studies employing psoralen with ultraviolet A (PUVA) therapy. Overall, the use of BB-UVB had an initial clearance rate of 89.6 % with 23.1 % recurrence, whereas NB-UVB cleared 73 % of the lesions with no recurrence, and PUVA therapy initially cleared 83 % of the lesions with 60 % recurrence. The side-effect profiles were similar and revealed limited toxicity. Conclusion
Phototherapy shows promising results and a favorable side-effect profile in the treatment of PL. Ultimately, large randomized controlled trials are needed to determine optimal treatments.
Vitiligo is an acquired cutaneous achromia characterized by depigmented macules of various shapes and sizes occurring irrespective of age, sex, and race. Vitiligo in children differs from that in adults by showing a higher incidence in females, segmental vitiligo being more common and less frequently associated with other systemic autoimmune and endocrine disorders. Childhood vitiligo deserves special attention not only because of its frequent occurrence but also being a tough challenge as regards to treatment is concerned.
The present review includes the study of vitiligo, its different types and treatments available into the market. Vitiligo is a skin disorder in which white patches occurs on the skin may be in the form of lesions or on the whole body. These white patches occur due to destruction of colour producing cells melanocytes. Different drugs like methoxsalen, trioxsalen and psoralen are available for the treatment of vitiligo in oral capsule form or topical cream or lotion form. Psoralen with light therapy is also given which is also known as PUVA therapy. Treatment of vitiligo always poses a problem as the patient compliance is less. Most of the times the treatment gets discontinued by the patients as the effect are very slow. This inefficiency leads to frustration in patients. This may be one of the reasons for discontinuation or 'give up' by the patients. Some patients also face the problem of additional symptoms or side effect like itching, burning, gastric disturbances etc. This review discusses on all above mentioned issues with problems associated with treatment and the related possible solutions.
With regard to the lack of effective treatment modalities for childhood localized vitiligo, the search for newer therapeutic agents continues.
To conduct an open, comparative trial to evaluate the clinical efficacy and safety of topical mometasone cream and pimecrolimus cream in the treatment of childhood vitiligo.
Fifty patients with childhood vitiligo were included in the study. Patients were treated for 3 months either with mometasone cream (0.1%) once daily or with pimecrolimus cream (1%) twice daily.
Forty patients, 20 from each group, completed the study. The two drugs were found to be statistically significantly effective for diminishing lesion size (Z = 3.070,p = 0.002 andZ = 3.845,p < 0.001, respectively). There were no statistical differences between the two drugs:Z = 1.427,p = 0.154 (mometasone non-inferiority to pimecrolimus). The mean repigmentation rate was 65% in the mometasone group and 42% in the pimecrolimus group at the end of therapy. Atrophy, telangiectasia and erythema were observed in two patients (10%) in the mometasone cream group and a burning sensation and pruritus were observed in two patients (10%) in the pimecrolimus cream group; drop-out was not related to the observed adverse effects.
Mometasone cream was found to be effective in the treatment of vitiligo on any part of the body. Pimecrolimus was not effective on the body except for the face in childhood localized vitiligo.
Current vitiligo therapies require many months of treatment and often result in disappointing outcomes. Treatment with a 308-nm excimer laser has shown promising results in patients with vitiligo.
This controlled prospective trial studied the effectiveness of the 308-nm excimer laser for treating vitiligo in Asians.
Thirty-four patients (14 males and 20 females) with localized vitiligo were enrolled in the study. Vitiligo patches were treated using a 308-nm excimer laser. Lesions were treated twice weekly for 13 weeks. The treatment was started with 50 to 100 mJ/cm2 (according to site) and increased by 50 mJ/cm2 in every session until erythema appeared. Patients were treated for 25 sessions, or until 100% repigmentation, whichever was achieved first. The overall response rate was assessed clinically and by comparison of photographs before and after treatment by two independent investigators.
Twenty-nine patients (12 males and 17 females) completed the study. Lesions on the face responded better than elsewhere on the body. The least responsive areas were the hands and feet. The average number of treatment sessions prior to repigmentation was 11. Untreated control patches remained unchanged. In higher skin phototypes the response was more favorable. There was no significant correlation between the age of the patients and their response to treatment.
The use of the 308-nm excimer laser for the treatment of vitiligo is effective, relatively safe, and more convenient compared to other available modalities of treatment for stable vitiligo with small patches. However, similar to other modalities of treatment, the therapeutic effect is mainly dependent on the location of vitiligo lesions.
To assess the safety and efficacy of topical 0.1% tacrolimus vs 0.05% clobetasol propionate.
Randomized double-blind trial.
Department of Dermatology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, México.
From 20 children with vitiligo, 2 symmetrical lesions of about the same size and evolution time were selected. They were devoid of any topical or systemic therapy for 2 months prior to inclusion. Interventions Treatment with topical tacrolimus and clobetasol for a 2-month period.
The grade of repigmentation was evaluated by color slides at baseline and again at every 2-week visit. The slides were analyzed by 2 clinicians unrelated to the study and by a morphometric digitalized computer program. Characteristics of pigment, time of response, symptoms, telangiectasias, and atrophy were evaluated every 2 weeks.
Eighteen (90%) of the 20 patients experienced some repigmentation. The mean percentage of repigmentation was 49.3% for clobetasol and 41.3% for tacrolimus. Lesions in 3 patients using clobetasol presented atrophy, and 2 lesions incurred telangiectasias; tacrolimus caused a burning sensation in 2 lesions.
Tacrolimus proved almost as effective as clobetasol propionate to restore skin color in lesions of vitiligo in children. Because it does not produce atrophy or other adverse effects, tacrolimus may be very useful for younger patients and for sensitive areas of the skin such as eyelids, and it should be considered in other skin disorders currently treated with topical steroids for prolonged periods.
Although the treatment of vitiligo has improved during the last decade, therapy is still not satisfactory for many patients. Recently topical calcineurin inhibitors were introduced in the treatment of atopic dermatitis. Considering the autoimmune hypothesis of vitiligo pathogenesis, the use of these topical calcineurin inhibitors seems reasonable. Most clinical vitiligo trials have been performed with tacrolimus and show beneficial effects. Concerning the value of pimecrolimus in the treatment of vitiligo only few data are available. Therefore we performed an open pilot study in 26 patients to evaluate the efficacy and safety of 1% pimecrolimus in the treatment of vitiliginous lesions in the head and neck region. In 13 of 26 (50%) evaluated target lesions, repigmentation was noted after a 6 month treatment period with a median percentage of repigmentation of 72.9% (interquartile range: 30.5-98.3%). Duration of vitiligo and total affected body surface area tended to be inversely correlated with the success rate of treatment. Side effects were mainly limited to a burning sensation at the application site. Despite the promising results of topical immunomodulators in the treatment of vitiligo, prudence is in order, as long-term follow up studies are still lacking.
Surgery is a well-established treatment for stable vitiligo in adults. However, there are few studies to date reporting the use of surgery in children and adolescents.
To assess the efficacy and safety of transplantation of autologous noncultured epidermal suspension for the treatment of stable vitiligo in children and adolescents.
Noncultured epidermal suspension transplantation was performed in 13 children and adolescents (age 8-17 years), with a total of 19 lesions of stable vitiligo. Patients were followed up for at least 1 year. Results were assessed for degree of repigmentation, colour match compared with normal skin, and adverse events.
Of the 19 lesions, 15 (79%) had > 90% repigmentation at the end of 1 year, and the remaining 4 lesions (21%) had 75-90% repigmentation. Results were not influenced by age, gender, site or size of lesions, type of vitiligo, or duration of stability of disease, although the small sample size makes conclusions tentative. The colour match at the final visit was excellent for 16 of the 19 lesions (84.2%). No major adverse effects were seen except for infection at the recipient site in one patient.
Transplantation of noncultured epidermal suspension is a safe and effective treatment for stable vitiligo in childhood. Considering its good efficacy and safety as a day-care procedure under local anaesthesia, it may be considered one of the treatments of choice for stable vitiligo in children and adolescents, especially for cases resistant to other therapies.
Both clobetasol propionate 0·05% (CP 0·05%) and tacrolimus 0·1% (T 0·1%) ointments have been shown to be efficacious and safe in treating vitiligo in the paediatric population.
To assess efficacy and safety of these two therapies compared with each other and with placebo.
In this prospective study, children aged 2-16 years with vitiligo, stratified into 'facial' (n = 55) and 'nonfacial' (n = 45) groups, were randomized into three arms: CP 0·05% ointment (n = 30), T 0·1% ointment (n = 31) and placebo (n = 29) for 6 months. Successful repigmentation, defined as > 50% improvement, was evaluated by comparing photographs taken at baseline and at 2, 4 and 6 months.
In the facial group, 58% of the CP 0·05% group responded successfully compared with 58% of the T 0·1% group, and in the nonfacial group, 39% of the CP 0·05% group responded compared with 23% of the T 0·1% group (P > 0·05). There was a significant difference in response between the CP 0·05% group vs. placebo (P < 0·0001) and the T 0·1% group vs. placebo (P = 0·0004). Spontaneous repigmentation was evaluated as 2·4%. No significant clinical adverse events were noted in any group.
Both CP 0·05% and T 0·1% ointments offer similar benefit in paediatric vitiligo, both facial and nonfacial. The facial lesions responded faster than the nonfacial ones.
Topical corticosteroids and phototherapy are the conventional treatments of vitiligo. However, the acrofacial and segmental types are often unresponsive to these treatments. Nowadays, a few studies have been conducted on efficacy of topical tacrolimus in treatment of vitiligo including vulgaris and segmental types. Nevertheless, the acrofacial type has never been investigated with this topical therapy. The aim of our study is to evaluate the effectiveness of 0.1% tacrolimus ointment in patients including all types of vitiligo. Forty-two patients with vitiligo (22 adults, 20 children) were enrolled in this study. They were treated with 0.1% tacrolimus ointment twice daily for 6 months. Of these 42 patients, 38 of them completed the treatment process. The mean age of the patients was 27.8 years. The response rate was 76.09%. The vulgaris and focalis had a maximum response rate of 94.12%. The response rates for segmentalis and acrofacialis were 76.92% and 56.25% respectively. Concerning the response, age groups, types and location of vitiligo, there was significant difference in all variables (P = 0.001, P = 0.001, P = 0.025, respectively). Children had approximately nine times higher odds (95% CI = 1.09, 81.88) of having better response to the treatment than adults. The disease duration of 5 years or less also showed a better response. In conclusion, topical tacrolimus can be used for the treatment of patients with vitiligo. We recommend that, other than in the vulgaris type, topical tacrolimus may be considered as a treatment for two difficult to treat types of vitiligo, acrofacialis and segmentalis, before considering other modalities.
Numerous modalities have been used to treat vitiligo in children. Up to now, phototherapy and topical corticosteroids are the most commonly used treatments for adult vitiligo but studies evaluating the efficacy of these treatments in the pediatric population remain insufficient.
This study was a retrospective review to evaluate the efficacy and safety of 308-nm excimer laser treatment in 30 childhood vitiligo patients.
Thirty vitiligo patients with 40 vitiligo patches were evaluated after the cessation of 308-nm excimer laser treatment.
Seventeen patients (56.7%) with 20 patches (50%) achieved an acceptable degree (>50%) of repigmentation at the end of the treatment, with five patches (12.5%) showing >75% of repigmentation. The treatment response showed anatomical preferences, favoring the face, neck and trunk. However, the treatment response did not correlate to the cumulative dose or duration of treatment. Side effects occurred in nine patients, but were transient and minimal.
The results of this study shows that the 308-nm excimer laser can be an effective and promising device for the treatment of various vitiligo types, other than generalized, in childhood.
ABSTRACT: Hundred children (upto 12 years of age) with vitiligo seen over a 1-year period were evaluated for their clinical pattern and therapeutic response to various modalities. Maximum number (29 percent) of patients were in the age group 6 to 9 years. Most of the patients (94 percent) had upto 5 percent skin involvement and the commonest (61 percent) clinical variant was vitiligo vulgaris followed by focal vitiligo (23 percent). None of the patients had any associated systemic diseases. Most satisfactory response was seen with PUVA-Sol and systemic corticosteroid combination. Overall good response with topical corticosteroids was seen in 44 (55 percent) patients. Lesions over the face showed best response. There was no correlation of response to treatment with age, sex, duration of disease and family history of vitiligo.
Vitiligo is a common depigmenting disorder affecting about 1-2% of the world population. Approximately half of the affected individuals develop the disease before adulthood. Etiologic hypotheses for vitiligo include biochemical, neural and autoimmune mechanisms. The most compelling of these suggests a combination of genetic and immunologic factors that result in an autoimmune melanocyte destruction. We reviewed studies carried out on various treatment modalities used in childhood vitiligo. Topical corticosteroids were found to have excellent repigmentation rates, whereas calcineurin inhibitors have comparable efficacy and a better safety profile compared with topical corticosteroids. These two groups of topical medications are good first-line treatment modalities for localized vitiligo. For the treatment of generalized vitiligo, phototherapy has excellent efficacy. Narrow-band ultraviolet B (UVB) has better overall repigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA). Other treatment modalities may be considered depending on a patient's specific condition, such as surgical options and depigmentation. With adequate sun protection, the option of no treatment with or without corrective camouflage, is an innocuous alternative to any of these treatment modalities.
Segmental type was the second most commonly reported in childhood vitiligo. No significant difference has been reported in the prevalence of childhood and adult focal vitiligo. However, the prevalence of segmental vitiligo has been found to be higher in children compared with that in adults. All available medical and phototherapy options are limited by adverse effects or unsatisfactory efficacy. Surgical techniques may be preferred but are not recommended for children as they are time consuming and associated with technical difficulties. In a retrospective review, 25 children aged 4 to 16 years were treated by autologous, noncultured cellular grafting performed under sedation supplemented with local anaesthesia and were followed up for a period of 9 to 54 months postgrafting. Repigmentation was graded as excellent with 95% to 100% pigmentation, good with 65% to 94%, fair with 25% to 64%, and poor with 0% to 24% of the treated area. In the segmental group, eight (62%) showed excellent, two (15%) good, one (8%) fair, and two (15%) poor pigmentation, which was retained until the end of the respective follow-up period. In the focal group, nine (75%) showed excellent, and one (8%) each showed good, fair, and poor pigmentation, which was retained until the end of the respective follow-up period. Noncultured cellular grafting may be considered to treat childhood localized vitiligo.
Forty-nine patients enrolled in a single-blinded, randomized, comparing 308-nm excimer laser therapy together with topical 1% pimecrolimus cream twice daily (group A) with excimer laser therapy twice per week (group B). Of 48 patients evaluated after 30 weeks of treatment, 71% of patients from group A achieved Grade 3 or 4 repigmentation compared with 50% in group B. Significant difference was found between group A and B at the end of 30 weeks of treatment (p = 0.001).
The exposure to stressing situations may play a role in the appearance of vitiligo. Patients with the disease have a greater sensitivity to environmental stress and a lower threshold to generate catecholamine mediated responses.
To evaluate the temperament and character of patients with vitiligo and explore the relationship of the disease with negative life events and life quality impairment.
The study population were 21 patients with vitiligo aged 5 to 12 years, and two control groups (Gl and G2). Gl was composed by 14 healthy siblings of vitiligo patients. G2 was composed by 21 age and gender matched healthy students from two schools in Santiago, Chile. The Junior Temperament and Character Inventory (JTCI), the Qualitative Psychosocial Development Survey (QPDS), the Life Event Checklist (LEC) and the Children's Life Quality index (CDLQI) were applied (LEC only to vitiligo patients).
On the temperament dimensions, vitiligo patients scored high on the "harm avoidance" scale in comparison to G2 (13.7 v/s 10.6). Compared with Gl, QPDS showed in vitiligo patients a higher frequency of fear to strangers (71% and 36%, respectively) and a predominant feeling of fear and shyness in response to changes in a close relative (80% and 8%, respectively). There was a negative correlation (protective factor) between the character dimension "self-directedness" and CDLQI score (r =-0.703).
In this group of patients, we found a possible relationship between a specific temperament dimension, vitiligo and its impact on life quality.
Several modalities of treatment have been tried in vitiligo with varied results; however, Indian data on comparative studies of two or more therapies are limited.
We compared different phototherapy methods with an oral steroid as an adjunct to determine the method with the best tolerability and efficacy.
Eighty-six patients with progressive vitiligo were randomly assigned to different study groups according to a continuous selection method over a period of one year. Group 1 was given OMP + PUVA, group 2 OMP + UVB (NB), group 3 OMP + UVB (BB) and group 4 was given OMP alone. Each patient was followed up for six months and then released from treatment. Clinical evaluation was made at the end of three and six months.
In group 1 (OMP + PUVA), marked improvement was seen in 18.51% while moderate improvement was seen in 66.66% of the patients. Marked improvement was seen in 37.03% in group 2 (OMP + NB-UVB) while 44.44% had moderate improvement. In group 3 (OMP + BB UVB), 8.33% showed marked improvement while moderate improvement was seen in 25% of the patients. Marked and moderate improvement was seen in 5 and 10% of group 4 (OMP) patients, respectively.
Our study compared four treatment modalities in vitiligo patients, out of which oral minipulse of steroids (OMP) only had an adjunct value and was not very effective by itself. Narrow band UVB has a definite edge over broad band UVB and should be preferred when both options are available. NB-UVB and PUVA showed comparable efficacy.
L-Phenylalanine is a promising agent for the treatment of vitiligo when taken orally and followed with ultraviolet light (UVA) irradiation. Of 13 children so treated, 3 experienced repigmentation of all vitiliginous areas, 6 showed 50% to 90% improvement, and 4 failed to respond. None of the children experienced side effects during the treatment.
Eighty-two children (ages 6 months to 12 years) with clinical and/or histopathologic diagnoses of vitiligo were evaluated; 35 were male and 47, female. Fifty-six were black, 25 white, and 3 classified as "other." Children were compared with control groups of children with other skin diseases and with adults with vitiligo. Children had an increased incidence of segmental vitiligo (p less than 0.01). Children had an increased incidence of autoimmune and/or endocrine disease and also of premature graying in their immediate and extended family members (p less than 0.001). Six of 33 children with vitiligo tested had positive organ-specific serum autoantibodies, which was a higher incidence than in the control group of children (p less than 0.05). Eighteen percent of children treated with topical psoralens and long-wave ultraviolet light (PUVA) therapy had an acceptable response, which was less than an adult group similarly treated. We have found childhood vitiligo to be a distinct subset of vitiligo, showing increased segmental presentation; strong autoimmune and/or endocrine disease background and high incidence of premature graying in the families of affected children; the presence of organ-specific serum autoantibodies and a poor response to topical PUVA therapy.
Systemic corticosteroids can arrest the progression of vitiligo and lead to repigmentation in a significant proportion of patients, but may also produce unacceptable side effects. To minimize the side effects, we tried a new approach using mini-pulse therapy with betamethasone.
Forty patients having extensive and/or fast-spreading vitiligo were given 5 mg betamethasone/dexamethasone as a single oral dose after breakfast on 2 consecutive days per week. The response to treatment was evaluated by photographs taken every 2-4 months and recording the side effects.
Within 1-3 months, progression of the disease was arrested in 89% of the 36 patients having active disease, while 2 patients needed an increase in the dose to 7.5 mg per day to achieve complete arrest of lesions. Within 2-4 months, 80% of the patients started having spontaneous repigmentation of the existing lesions which progressed with continued treatment. The extent of repigmentation varied in different patients and even in different lesions in the same patient. It was less than 10% in 14 (35%) patients and almost complete (> 90%) in three patients. The side effects included weight gain of 5 and 7 kg in two patients, mild headache in two patients, transitory general weakness for 2 days after the pulse in two patients, and bad taste in the mouth in three patients; 23 patients, including six children, had no side effects.
Oral mini-pulse therapy with betamethasone/dexamethasone seems to be an effective treatment modality to arrest the progression of vitiligo. It also induces spontaneous repigmentation. It deserves to be tried on a large scale to evaluate its advantages over the currently available methods of treatment.
A large variety of therapeutic agents are being tried for the treatment of vitiligo, but psoralens continue to be mainstay of treatment although they are not uniformly effective. Recent advances in pathophysiology have established a perturbed calcium homeostasis in affected skin, and melanocytes were shown to express vitamin D3 receptors.
The purpose of present study was to determine the efficacy of the combination of PUVAsol with topical calcipotriol in the treatment of vitiligo.
Nineteen patients with essentially bilateral symmetrical lesions were enrolled in a randomized, double-blind, right/left comparative study of 18 months duration. An oral dose of 0.6 mg/kg 8-methoxypsoralen was given 2 h before exposure to sunlight thrice weekly to all patients. The patients were advised to apply calcipotriol (50 microgram/g) on one side of the body and placebo ointment over the lesions on the other side twice daily.
At the end of 6 months, 12 patients (70%) showed marked to complete improvement on calcipotriol-treated sides as compared to 6 patients (35%) showing similar improvement on placebo-treated sides (p <0.05). At the end of treatment, 13 patients (76%) showed marked improvement in calcipotriol-treated lesions whereas 9 patients (53%) showed moderate to marked improvement in placebo-treated lesions. The repigmentation of hands and feet was much better with the combination of PUVAsol and calcipotriol.
The combination of PUVA and calcipotriol is highly effective and works faster and may be used for shortening the therapy with PUVA in the treatment of vitiligo.
A large variety of therapeutic agents have been tried for the treatment of vitiligo, but psoralens continue to be the main treatment. Twenty-one patients age 5 to 17 years with vitiligo were enrolled in this study. The children were advised to apply calcipotriol 50 microg/g in the evening and expose themselves to sunlight the next day for 10 to 15 minutes. The patients were followed at 3-week intervals. Initial repigmentation occurred in the majority of children after 6 to 12 weeks of treatment. Marked to complete repigmentation was seen in 10 of 18 patients. Four patients showed moderate improvement while the remaining four patients showed minimal or no improvement. No patient developed new lesions. The repigmentation was cosmetically excellent in the majority of children. All patients tolerated the calcipotriol well except for three patients who complained of mild irritation on application. All of the laboratory investigations, including serum calcium levels remained normal. The rationale for this study originated from recent advances in the understanding of vitiligo at the molecular level. Furthermore, development of hyperpigmentation in patients with psoriasis receiving treatment with PUVA and calcipotriol has been observed. Our results are encouraging and offer a new and potentially efficacious treatment for this pigmentation disorder in children.
We retrospectively analyzed the clinical and epidemiological profiles of patients with vitiligo attending the pigmentary dermatoses clinic. One thousand four hundred and thirty‐six patients were seen between 1989 and 1993. Males constituted 54.5% of the group and females 45.5%. Mean age of the patients was 25 years, and average disease duration at the time of hospital visit was 3.7 years.
Vitiligo vulgaris was the commonest form of the disease in 1002 (69.8%) patients followed by focal vitiligo in 214 (14.9%) and segmental vitiligo in 72 (5.0%). The sites of onset were the face, trunk, and legs in descending order of frequency. Less than 20% body area involvement was seen in 1356 (94.4%) of the patients. Leukotrichia was present in 165 (11.5%), and Koebner's phenomenon was observed in 72 (5.0%). Twenty nine (2.0%) patients had associated halo nevi. Of the various diseases associated with vitiligo, atopic/nummular eczema was seen in 20 (1.4%) patients, bronchial asthma in 10 (0.7%), diabetes mellitus in 8 (0.6%), thyroid disease in 7 (0.5%), and alopecia in 6 (0.4%). A family history of vitiligo was present in 165 (11.5%) patients.
Only a few clinical trials have been performed on the treatment of generalized vitiligo in children. Recently, narrow-band UVB therapy has been reported to be an effective and safe therapeutic option in adult patients with vitiligo.
We studied the efficacy and safety of UVB (311 nm) therapy in children with generalized vitiligo and evaluated the effect of the therapy on the quality of life in these children.
In an open trial, 51 children (20 males, 31 females) with generalized vitiligo were treated twice weekly with narrow-band UVB radiation therapy for the maximum period of 1 year. The Children's Dermatology Life Quality Index (CDLQI) was used to evaluate the psychosocial impact of disease and treatment and was scored before and after therapy.
The treatment resulted in more than 75% overall repigmentation in 53% of patients and in stabilization of the disease in 80%. Responsiveness to therapy was positively correlated with localization of the lesions and the patients' compliance. Adverse events were limited and transient. The better the repigmentation grade, the better the CDLQI scores had improved.
Narrow-band UVB therapy is effective and safe in childhood vitiligo; it also may significantly improve the quality of life.
Eighty Korean children (ages 8 months-12 years) with clinical and/or histopathologic diagnoses of vitiligo were evaluated; 39 boys and 41 girls. The mean age at first visit was 7.9 years and the mean age at onset was 5.6 years. The most common site of onset was the head/neck area (58.8%), followed by the trunk and lower limbs. The children were compared with a control group of 422 adults with vitiligo. Children comprised 16% of the total vitiligo patients and adults comprised 84%. A family history of vitiligo was found in 11 (13.8%) children, compared to 10.7% in the adult group; poliosis in 20 (25. 0%); halo nevi in 2 (2.5%), compared to 4.0% in the adult group; combined autoimmune and endocrine diseases in 1 (1.3%), compared to 7.6% in the adult group; and segmental vitiligo in 26 (32.5%), compared to 13.0% in the adult group. The combined diseases were significantly less often found in children than adults (p < 0.01), and segmental vitiligo was significantly more often associated with children (p < 0.0001). Our study did not show a higher prevalence of vitiligo in girls as reported in other studies, which may indicate racial differences. Of the total 502 patients, only 1 patient with segmental vitiligo had halo nevi. Sixty-four percent of the children with vitiligo responded to treatment, compared to 57% of the adults.
Vitiligo is a significant problem in children. Many fail to respond to medical treatment and require melanocyte replenishment with one of the various surgical methods. Epidermal grafting using the tops of suction blisters has been found to be the most effective surgical procedure. However, the results of this procedure have never been delineated separately in adolescents and children. There are certain procedural and outcome differences in epidermal grafting among children and adolescents as compared to adults. We performed epidermal grafting in 15 recalcitrant patches of stable vitiligo in 10 children. Thirteen of 15 patches (86.66%) in 8 of the 10 patients (80%) showed more than 75% pigmentation. The results were much better than the overall response rate of 62% in 142 patients (adults as well as children) found in an earlier study. Literature analysis revealed the same trend in other studies.
The objective was to compare the effectiveness of psoralen plus ultraviolet A (PUVA) and the combination of PUVA and topical calcipotriol in the treatment of vitiligo.
There are several reports on the response rate of patients with vitiligo treated with the combination of PUVA and calcipotriol or calcipotriol alone.
Twenty-two patients with generalized vitiligo were taken into the study. PUVA treatment was applied on a twice-weekly schedule. Calcipotriol cream was applied to one of the two symmetrical lesions of each patient twice daily.
Our results showed that the addition of topical calcipotriol to PUVA treatment did not lead to a significant increase in response rate of patients with vitiligo compared with PUVA treatment alone.
The success of suction blister epidermal grafting may be influenced by various factors, all of which have not been studied to date.
We sought to determine the influence of age of the patient, site of vitiligo patch, and type of disease on the outcome of the procedure in our patients and in the cumulative data derived from literature analysis.
This was a retrospective, uncontrolled case series and literature review of suction blister epidermal grafting in patients with stable and recalcitrant vitiligo. All published studies of suction blister epidermal grafting in vitiligo involving 10 or more patients were included in the literature analysis.
The procedure was performed in 143 patients. However, sufficient length (6 postoperative months) of follow-up was available in only 117 patients, and only these patients were included for analysis. Only limited information was available about various factors in the majority of published studies. The success rates for generalized and segmental/focal disease in this study were 53% (confidence interval [CI] 42-64) and 91% (CI 81-100), respectively (P <.001), and in the literature, 61% (CI 46-76) and 88% (CI 82-94), respectively (P <.01). The success rates in patients aged < 20 years and >or= 20 years in this study were 82% (CI 67-97) and 58% (CI 48-68), respectively (P <.05), and in the literature, 100% and 66% (CI 56-76), respectively (P <.05). There was no significant difference in the success rates achieved on different body sites in this study and in the screened literature. Among adverse reactions, hyperpigmentation in 32% (CI 24-40) and 17% (CI 14-20), infection in 6% (CI 2-10) and 0%, and contact dermatitis in 1% (CI 0-3) and 1% (CI 0-2) of patients were observed in this study and in the analyzed literature, respectively.
The results were significantly better in segmental/focal vitiligo than in the generalized type, and in individuals < 20 years of age. However, unlike in medical therapies, localization of the vitiligo patch did not influence the treatment outcome significantly.
Previous studies have documented humoral and cell-mediated immunologic defects in patients with vitiligo.
This 24-week study assessed the efficacy and safety of tacrolimus 0.1% ointment in patients with generalized vitiligo as well as the pretreatment and post-treatment expression of cytokines in the depigmented and normal skin of patients compared with controls.
Twenty-three patients were enrolled in this investigation, and 19 patients completed the study; 8 were male and 11 were female. Fifteen age-, race-, and sex-matched control subjects were also included. Patients were treated with tacrolimus 0.1% ointment applied twice daily. Repeat evaluations were performed at 4, 8, 12, 16, 20, and 24 weeks. Three-millimeter punch biopsy specimens were taken from the depigmented, non-sun-exposed skin and adjacent normal skin of patients at baseline and 24 weeks, and from normal, non-sun-exposed skin of controls. Cellular messenger RNA expression for interleukin 2 (IL-2), IL-4, IL-10, tumor necrosis factor alfa (TFN-alpha), and interferon gamma (IFN-gamma) were determined by real-time quantitative polymerase chain reaction.
At 24 weeks, 17 of 19 patients (89%) achieved varying levels of repigmentation. There was a statistically significant decrease in overall disease severity scores at 24 weeks. Thirteen patients (68%) had greater than 75% repigmentation of face and/or neck lesions. Signs and symptoms of irritation were minimal. At baseline, compared with healthy controls, vitiligo patients demonstrated a statistically significant increase in the expression of IFN-gamma in involved and adjacent uninvolved skin (P=.05 and P=.02, respectively); significantly increased TNF-alpha expression in involved and uninvolved skin (P=.01 and P=0.02, respectively); and significantly increased IL-10 expression in involved and uninvolved skin (P=.01 and P=.04, respectively). Posttreatment, TNF-alpha expression decreased in the depigmented and adjacent uninvolved skin (P <.001). There was no statistically significant change in IL-10 or IFN-gamma posttreatment. These data suggest that tacrolimus 0.1% ointment is a safe and effective therapy for patients with vitiligo. It further suggests that an imbalance in local cytokine expression may play a role in the pathogenesis of vitiligo. Suppression of TNF-alpha after topical tacrolimus application may be associated with repigmentation of vitiligo.
Corticosteroids and photochemotherapy, using a combination of psoralen and ultraviolet A (PUVA) exposure, are the most widely prescribed therapies for vitiligo. These treatments are not uniformly effective and many patients have inadequate responses. Calcipotriene has been shown to be effective in adults and children with psoriasis when used as monotherapy and in combination with corticosteroids and phototherapy. We hypothesized that since the mechanisms of action for calcipotriene and corticosteroids are different, patients may develop more repigmentation with a combination of the two agents, while decreasing the side effects from both agents.
Twelve patients with vitiligo (average age 13.1 years) were advised to use topical corticosteroids in the morning and topical calcipotriene in the evening. Of the 12 patients, 83% responded to therapy, with an average of 95% repigmentation by body surface area. Four of the patients who responded had previously failed trials of topical corticosteroids alone. All of the patients in this group had repigmentation. Eyelid and facial skin responded best to this therapy. None of the patients had adverse reactions to the treatment. Our results show that topical calcipotriene in combination with corticosteroids can repigment vitiligo, even in those patients who were previous topical corticosteroid failures.
Vitiligo is an autoimmune disorder characterized by loss of pigmentation. Phototherapy and application of topical corticosteroids are most commonly prescribed. However, these therapies are often not effective and use of corticosteroids on the face may lead to cutaneous atrophy, telangiectasia, and ocular complications.
We sought to assess the efficacy of topical tacrolimus ointment in the treatment of pediatric vitiligo.
A retrospective review was performed of 57 pediatric patients with vitiligo at two clinical sites. Patients were treated with tacrolimus ointment for at least 3 months. Clinical responses were documented during clinic visits, and by pretacrolimus and posttacrolimus photography.
At least partial response was noted to tacrolimus ointment on the head and neck in 89%, and on the trunk and extremities in 63% of patients. Facial vitiligo of the segmental type showed the best response rate. Two patients initially experienced burning on application.
Topical tacrolimus ointment is an effective alternative therapy for childhood vitiligo, particularly involving the head and neck.
Childhood vitiligo is a common disorder of pigmentation in India. Considering the lack of uniformly effective and safe treatment modalities for children with vitiligo, search for newer therapeutic agents continues. This study was designed to evaluate the role of topical tacrolimus in the treatment of childhood vitiligo. Twenty-five children with vitiligo were treated with topical 0.03% tacrolimus ointment applied twice daily for 12 weeks. Response was noted as marked to complete (> 75% repigmentation), moderate (50-75% repigmentation) and mild (< 50% repigmentation). Twenty-two children (9 boys and 13 girls) of mean age 7.2 +/- 1.4 years completed the study. Twelve (54.5%) children had vitiligo vulgaris, nine (40.9%) had focal vitiligo and one (4.5%) had segmental vitiligo. The mean duration of disease was 8 +/- 3 months. Nineteen (86.4%) children showed some repigmentation at the end of 3 months and other three had no response. Of these 19 children, repigmentation was marked to complete in 11 (57.9%), moderate in five (26.3%) and mild in three (15.7%) children. Side effects were minimal, such as the pruritus and burning noted in only three patients. Topical tacrolimus is an effective and well-tolerated treatment modality in Asian children with vitiligo.
Tacrolimus ointment (Protopic, Fujisawa) is an effective agent in a class of topical immunomodulators. Its mechanism of action is based on calcineurin inhibition, which results in decreased T-cell activation and inflammatory cytokine release. Tacrolimus ointment is safe and effective for short- and long-term treatment of atopic dermatitis (AD) in pediatric and adult patients. The most common adverse events associated with its use are a transient burning sensation and pruritus at the site of application. Unlike topical corticosteroid agents, tacrolimus ointment does not cause a reduction in collagen synthesis or skin thickness. Because tacrolimus ointment does not cause skin atrophy, it may be safely used for months or years on all skin areas, including the face and intertriginous areas.
Eighteen patients with a clinical diagnosis of vitiligo, aged between three and 12 years (mean 8.9 years), were enrolled in this study in order to evaluate the efficacy and tolerability of topical calcipotriol in the treatment of childhood vitiligo. Six patients (33.3%) were males and 12 were females (66.7%). Fourteen patients (77.8%) had focal vitiligo, two (11.1%) had mucosal vitiligo and two (11.1%) had segmental vitiligo. The face was involved in 11 patients (61.1%). The treatment was applied twice daily as 50 microg/gm cream in nine patients and as ointment in the remaining patients. Treatment assessment was carried out clinically at 2 weeks, and then monthly for 4-6 months. Four patients (28.6%) were excluded from the study (one due to irritation and three due to lost contact in follow-up). Fourteen patients (71.4%) completed the treatment course (> 3 months). Of the treated patients, ten (77.8%) showed improvement and four patients (22.2%) had no response. Among responders, three patients (21.4%) showed complete resolution, four (28.6%) showed 50%-80% improvement and three patients (21.4%) showed 30% to < 50% improvement. Only one patient (5.5%) developed irritation. In conclusion, calcipotriol is an effective treatment in vitiligo. Better results are obtained with ointment than with cream. Calcipotriol can be helpful in children in whom potent steroids and PUVA are not advisable.
Vitiligo is a common skin condition resulting from loss of normal melanin pigments in the skin which produces white patches. Topical corticosteroids are indicated for the treatment of limited areas of vitiligo. Pimecrolimus, which inhibits calcineurin, has recently been shown to be effective for the treatment of vitiligo. We performed a prospective study to evaluate the efficacy of the 0.05% clobetasol propionate and 1% pimecrolimus in the treatment of vitiligo. Ten patients with virtually bilateral symmetrical lesions of vitiligo were included. 0.05% clobetasol propionate was applied twice daily over the lesion on right side of the body, and topical 1% pimecrolimus was applied twice daily over the lesion on left side of the body. It was determined that both treatment modalities resulted in a comparable rate of repigmentation. Response to treatment was varied according to the anatomical location of the lesions where better results were seen on the trunk and extremities. Results from this pilot study indicate that topical 1% pimecrolimus is as effective as clobetasol propionate in restoring skin disfiguring due to vitiligo. For a better conclusive statement further studies involving larger groups of patients should be performed.
We report our experience with UV-B narrowband (UV-B-NB) therapy in children affected by vitiligo. We studied 10 Caucasian Italian children (six boys, four girls, mean age 9.7 years +/- 2.67). Treatment mean term was 5.6 months; frequency was three times a week on nonconsecutive days or only twice a week, because of school or family duties. The percentage of repigmentation was evaluated by comparing photographs taken before, during, and after the treatment, and showed a repigmentation level higher than 75% in five patients (5/10, 50%) and between 26% and 75% in three patients (3/10, 30%). Of our patients, 80% had a satisfactory response to phototherapy. Adverse events were limited and transient. No significant relationships between repigmentation grades and variables such as skin type, positive family history, and disease extension were observed. Some areas responded better than others; the best results were shown on the face and neck. Perhaps we studied too few patients to be conclusive, but the results obtained so far seem to indicate that children affected by recent vitiligo have a better response to the therapy. We feel that UV-B-NB therapy is a valuable and safe option for the treatment of pediatric vitiligo, and should be started as soon as possible.
Vitiligo usually begins in childhood with approximately half of the patients manifesting onset of disease prior to the age of 20 years. Treatment options in this age group are few and have disappointing response rates. This study was designed to evaluate the role of narrow-band UVB in the treatment of generalized vitiligo in children. Twenty-six children (aged 5-14 years) with generalized vitiligo (minimal extent of depigmentation of 5% of the skin) were treated three times per week with narrow-band UVB therapy for a maximum period of 1 year. Of 26 patients, 6 were lost to follow up and 20 (7 males, 13 females) completed the study. At the end of 1 year of therapy, 15 (75%) patients developed marked to complete repigmentation. Moderate and mild repigmentation was noted in four (20%) and one (5%) patients, respectively. An average number of 34 (+/- 2) treatment visits was required to achieve 50% repigmentation. Adverse events were mild and transient. Narrow-band UVB is an effective and well-tolerated treatment option for childhood vitiligo.
Vitiligo is an acquired pigmentary disorder characterized by depigmentation of skin and hair. As the pathogenesis of this disease is still obscure, the treatment of vitiligo has generally been unsatisfactory and often disappointing. Topical tacrolimus (FK506) ointment has recently been added to the armamentarium against this pigmentary disorder. Despite its clinical efficacy, the underlying mechanisms of how topical tacrolimus induces repigmentation in vitiligo have rarely been investigated. As tacrolimus ointment is applied directly to the skin, its impact on keratinocytes (KCs) requires thorough investigation.
To investigate the effects of FK506 on melanocyte (MC) and melanoblast (MB) growth via KCs.
Cultured MCs and MBs were treated with supernatant of KC cultures conditioned with various concentrations of FK506. The impact of supernatant on MCs and MBs was assessed in terms of its effect on MC/MB proliferation, melanin formation and cell migration. The activities of matrix metalloproteinase (MMP)-2 and MMP-9, known for their influence on cell migration, were evaluated. The concentrations of MC/MB growth factors in the KC supernatant were also determined.
Results demonstrated that proliferation of both MCs and MBs was significantly enhanced by FK506-treated KC supernatant. In addition, the concentration of stem cell factor in KC supernatant increased dose-dependently with FK506 treatment. The supernatant from FK506-treated KC culture showed a significant increase in MMP-9 activity.
Our study provides in vitro evidence demonstrating that direct interaction between FK506 and KCs creates a favourable milieu for MC growth and migration. Furthermore, our findings provide a possible mechanism explaining how tacrolimus ointment induces repigmentation in patients with vitiligo.
Treatment of vitiligo is a challenge. Steroids are known to be effective but are associated with serious adverse effects. Many uncontrolled studies have shown calcipotriol to be a promising therapeutic modality in vitiligo.
To conduct a randomized trial to evaluate the effect of topical calcipotriol ointment (0.005%) and betamethasone dipropionate (0.05%) cream, given alone or in combination, in treatment of localized vitiligo.
Forty-nine patients with vitiligo affecting 5% of their skin were recruited. Patients were randomized into three groups. Group I patients were treated with betamethasone dipropionate (0.05%) cream twice daily. Group II patients were treated with calcipotriol ointment (0.005%) twice daily, and group III with betamethasone dipropionate (0.05%) in the morning and calcipotriol (0.005%) in the evening.
Forty-five patients completed the study period of 3 months with 15 patients in each group. No patient achieved excellent (> 75%) pigmentation. Marked (50% to 75%) repigmentation was observed in 2 (13.3%), 1 (6.7%) and 4 (26.7%) patients in groups I, II and III, respectively. Moderate (25-50%) repigmentation was observed in 7 (46.7%), 5 (33.3%) and 7 (46.7%) patients in groups I, II and III, respectively. Patients with < 25% pigmentation were termed as minimal pigmentation or no response. The mean time for initial pigmentation to appear was 9.04 +/- 2.0 weeks in group I, 10.18 +/- 1.6 weeks in group II and 5.17 +/- 2.4 weeks in group III (P < 0.01). The acquired pigmentation in the lesions was more stable in group III as compared with patients in groups II and I (P < 0.01). Side-effects in the form of atrophy and lesional burning sensations were more common in group I when compared with groups II and III (P < 0.05).
Combined therapy appeared to give a significantly faster onset of repigmentation along with better stability of the achieved pigmentation and with lesser number of side-effects.
The association between a family history of vitiligo and other autoimmune/endocrine diseases and increased incidence of childhood vitiligo has been described; however, the influence of family history on the clinical characteristics of childhood vitiligo has rarely been investigated.
We sought to examine the relationship between family history and the incidence, extent, and course of childhood vitiligo.
A retrospective chart review and telephone interviews were performed for 137 pediatric patients with vitiligo and 140 control patients (patients with acne, warts, or molluscum contagiosum matched in age, sex, and ethnicity to the study group). Information about the age, sex, ethnicity, age of onset and diagnosis, site of onset, distribution, treatment, course of disease, and family history was obtained.
Patients with vitiligo and an extended family history of vitiligo were more likely to have an earlier age of onset of disease than those with a negative family history (odds ratio = 3.70, P = .024). There was no association between family history and site of onset, distribution, or course of disease.
A relatively small sample size, recall bias, disease misclassification, and confounding factors are potential limitations of this study.
Earlier onset of pediatric vitiligo is linked to a family history of vitiligo. Awareness of this association can allow for closer monitoring, earlier detection, and earlier initiation of treatment.
Vitiligo is a chronic disease that mostly affects children and young adults. Nowadays many treatment options are available; however, most of them have limited efficacy and in most cases would result in undesirable complications.
To determine the extent of repigmentation according to the location of the lesions after applying topical cream pimecrolimus 1% in vitiligo patients.
Thirty consecutive patients with vitiligo lesions affecting less than 20% of body surface area without any previous history of spontaneous repigmentation were treated with pimecrolimus cream 1% twice daily for 12 weeks. The extent of repigmentation in vitiligo lesions was determined in each patient after 6 and 12 weeks.
Moderate to excellent response (repigmentation >26%) was observed in 6.6 and 25.9% of vitiligo lesions 6 and 12 weeks after treatment, respectively. More responsive lesions were located on the trunk, face and elbow (85.7, 75 and 70%).
Pimecrolimus cream 1% results in repigmentation in vitiligo in different extents according to the location of the lesion; however, to clearly prove its efficacy as monotherapy or in combination with other available treatment options, double-blind placebo-controlled studies are essential.
Many dermatologic diseases, including vitiligo and other pigmentary disorders, vascular malformations, acne, and disfiguring scars from surgery or trauma, can be distressing to pediatric patients and can cause psychological alterations such as depression, loss of self-esteem, deterioration of quality of life, emotional distress, and, in some cases, body dysmorphic disorder. Corrective camouflage can help cover cutaneous unaesthetic disorders using a variety of water-resistant and light to very opaque products that provide effective and natural coverage. These products also can serve as concealers during medical treatment or after surgical procedures before healing is complete. Between May 2001 and July 2003. corrective camouflage was used on 15 children and adolescents (age range, 7-16 years; mean age, 14 years). The majority of patients were girls. Six patients had acne vulgaris; 4 had vitiligo; 2 had Becker nevus; and 1 each had striae distensae, allergic contact dermatitis. and postsurgical scarring. Parents of all patients were satisfied with the cosmetic cover results. We consider corrective makeup to be a well-received and valid adjunctive therapy for use during traditional long-term treatment and as a therapeutic alternative in patients in whom conventional therapy is ineffective.
Vitiligo is an acquired depigmentary disorder of the skin that results from the selective destruction of melanocytes. The etiology of vitiligo is poorly understood. There appears to be a genetic predisposition, but additional factors are probably involved. The purpose of this article is to outline the factors that might play a role in the development of vitiligo. These include trauma such as vaccination, radiotherapy, and sun exposure, malignancies and treatment of malignancies like lymphoma or melanoma, bone marrow transplantation, interferon, interleukin, and other drugs, psychological factors, endocrine disease and cytotoxic compounds that cause contact vitiligo. We hope future research will shed more light on the subject and identify the precipitating factors, since in the majority of vitiligo cases the contributing factors are as yet unidentified.
Over the years, the role of biochemical, immunological, genetic, and other biological aspects in the pathogenesis of vitiligo has been studied. So far, no convincing model describing the interplay of these contributing factors has been formulated. Based on existing research, we propose that vitiligo has a multi-factorial etiology, characterized by multiple steps, but always involving an increase of external or internal phenol/catechol concentration, serving as a preferred surrogate substrate of tyrosinase, competing with its physiological substrate tyrosine. The conversion of these substrates into reactive quinones is reinforced by a disturbed redox balance (increasing hydrogen peroxide). Such reactive quinones can be covalently bound to the catalytic centre of tyrosinase (haptenation). This could give rise to a new antigen, carried by Langerhans cells to the regional lymph node, stimulating the proliferation of cytotoxic T cells. However, the activation of such cytotoxic cells is only a first step in skin melanocyte killing, which also depends on a shift in the balance between immune defence and tolerance, e.g. resulting from a decrease in properly functioning T-regulatory cells. With this new model, based on a synthesis of several of the existing theories, in mind, the external and internal factors involved in the etiopathogenesis of vitiligo are reviewed, against the background of reported clinical data, experimental studies and existing and potential new therapies. A similar complex mechanism may also lead to some other autoimmune diseases.
Recently, narrow-band ultraviolet B (NB-UVB) and topical immunomodulators have been successfully used in the treatment of vitiligo.
To determine whether the combination of pimecrolimus with NB-UVB accelerates the response time and/or improves the degree of response in patients with vitiligo.
Sixty-eight patients with vitiligo enrolled in this randomized, double-blind, placebo-controlled study. The patients were randomized into two groups and treated with NB-UVB plus either pimecrolimus or placebo for 3 months. Tri-weekly radiation was started at 280 mJ/cm(2), with 15% increments for each subsequent treatment until erythema was reported or a maximum of 800 mJ/cm was achieved. At baseline and 6 and 12 weeks after commencement of therapy, vitiliginous patches were measured.
Fifty patients completed the 3-month study. No significant side effects except self-limited erythema and pruritus were observed. After 12 weeks of treatment, repigmentation of the facial lesions was higher in patients treated with combined pimecrolimus and NB-UVB compared with the placebo plus NB-UVB group (64.3 vs 25.1%) (p < 0.05%). There was no statistically significant difference in the repigmentation rate between the two groups on other body areas.
On the face, NB-UVB works better if combined with pimecrolimus 1% cream rather than used alone.