Vitiligo and Other Hypomelanoses of Hair and Skin
Chapters (12)
The skin is a complex organ system endowed with the capacity to undergo a wide array of color changes. Normal skin color arises from a mixture of red, blue, yellow, and brown colored pigments (Fig. 1). In normal skin, melanin is the major pigment or color determinant and imparts a color ranging from a very light tan to a deep brown or black, depending on the quantity of melanin in the epidermis. A yellow hue may be imparted by carotenoids, red by oxygenated hemoglobin in the capillaries, and blue by reduced hemoglobin in the dermal venules and by pigment in the dermis.
The study of diminished skin color requires a special vocabulary. Various terms have been used to refer to decreased melanin content in the skin. These terms are intended to be purely descriptive and not to imply any one particular diagnosis or disease entity.
One purpose of any classification is to categorize, organize, and increase understanding of the disorders classified. For hereditary leukodermas, the presence or absence of certain common features permits a useful subclassification (see Table 13, page 60). Those disorders with features of oculocutaneous albinism (3+ hypomelanosis) must be distinguished from those having a relative (1 or 2+ hypomelanosis) generalized pigmentary dilution. In the latter, the hypomelanosis may be apparent only in comparison to family members or individuals of the same ethnic background, and these are readily distinguished from entities usually featuring circumscribed hypomelanosis. The fourth category involves hereditary disorders in which pigmentation of the hair but not of the skin is affected.
Kwashiorkor is a result of dietary deficiency of protein in the weaning and early postweaning stage of childhood. In underdeveloped nations it remains a significant cause of death among children from one to four years of age.
The association of vitiligo with hyperthyroidism has been discussed (see “Vitiligo” in Chapter 1). Premature graying of hair may also accompany hyperthyroidism [1].
Melanocytes are vulnerable to nonspecific trauma. In animals or in humans, dark skin or hair may lose pigment in areas exposed to various types of injury (x-rays and ionizing radiations, ultraviolet rays, thermal burns, freezing, physical traumas) (Fig. 190).
A large number of chemical compounds induce depigmentation in humans and in experimental animals (Fig. 191, Table 112). Cutaneous chemical depigmentation, which often resembles vitiligo in clinical appearance, may result from direct contact or from systemic exposure (ingestion or particularly inhalation) to various phenol derivatives, sulfhydryl compounds, and others (Fig. 192). Some of these compounds have also purportedly been found in commercially available consumer products, and accidental exposures have occurred historically in the course of many industrial processes. Both careful research discovery and serendipity seem to increase the growing list of known chemical depigmenting agents. There are likely important and common depigmenting agents yet to be revealed.
Hypomelanosis resulting from a wide variety of inflammatory dermatoses (Fig. 199) is a common problem in dark-skinned people [1] but may occur in many skin types. The most frequent causes of postinflammatory hypopigmentation include discoid lupus erythematosus, atopic dermatitis, eczematous dermatitis, chronic guttate parapsoriasis, lichen striatus, and probably pityriasis alba. The primary defect may be a pathologic change in the malpighian cells or increased keratinocyte turnover. A disturbance of transfer of melanosomes from melanocytes to keratinocytes is probably responsible for the pigmentary dilution.
Leprosy is a chronic and contagious human disease that mainly affects the skin and the peripheral nervous system, but which may also involve the mucous membranes of the upper respiratory tract, the eye, the superficial lymph nodes, the testes, and other organs. Hypopigmentation is one of the main cutaneous features of leprosy (Figs. 209, 210).
The term “leukoderma acquisitum centrifugum” is a somewhat generic one commonly used synonymously with “halo nevus” but applicable to various tumors, including primary or secondary melanomas, surrounded by leukoderma (Table 119). This entity has been described as “leukopigmentary nevus” [2], “perinevoid vitiligo” [3], and “perinevoid leukoderma” [4]. While leukoderma acquisitum centrifugum applies to all nevi surrounded by a macule of leukoderma, the term “halo nevus” is restricted to nevus cell nevus.
Sarcoidosis is an idiopathic systemic granulomatous disease that frequently presents with cutaneous manifestations of which leukoderma is one of the less commonly observed. Although sarcoidosis was first described in 1875 by Hutchinson [1], the associated leukoderma was first mentioned by Mayock et al. [2] in 1963. It was later described by Harmon and Peterson [3] in a patient with asthma and generalized lymphadenopathy, by Kotler and Zwi [4] in a review from South Africa, and by Cornelius et al. [5] in four additional patients. A series of eight cases was assembled by Clayton et al. [6] who also performed ultrastructural studies.
Nevus anemicus, first described by Vörner [1] in 1906, is a congenital malformation characterized by macules of varying size and shape which appear distinctly pallid compared to the surrounding skin.
... Ekstremitelerdeki favori bölgeler diz, dirsek, parmaklar, el bileğinin fleksör kısmı, ayağın dorsal kısmı ve tibia üzeridir. Tekrarlayan travmadan dolayı ellerin ve ayakların dorsal kısımlarında tekrarlanan friksiyona bağlı olarak vücut kıvrımları, aksilla, genital bölge ve perianal bölge sık tutulan kısımlardır (8,9,10). ...
... Görüntü ve lezyonun dağılımına göre sınıflandırma: (10,11,12) 1.Akrofasiyal vitiligo: Lezyonların dağılımı simetriktir. Bedenin uç (akral) kısımları ve mukokütanöz bileşke yerleri, yani yüz, eller, ayak ve dudakları tutar. ...
... 4.Yaygın vitiligo: Lezyonlar bedenin tümünde simetrik ya da asimetrik olarak mevcut olup, özellikle kemik çıkıntıları üzerinde belirgindir. 5.Halo nevüs / Sutton nevüsü: Oval ya da dairesel biçimde, pigmente leke etrafında, keskin bir şekilde sınırlandırılmış, hipo veya depigmente halo ile karakterizedir (10,11,12). ...
... Vitiligo is a disorder characterized by milky white macules and patches with a chronic and unpredictable course (1) that typically develops before age 20 (2). The worldwide vitiligo prevalence ranges from 0.5 to 2% (3). ...
... Vitiligo is known to cause substantial psychological challenges, impacting various facets of patients' lives and diminishing their overall quality of life, particularly within the Iranian population, where it has been observed that the quality of life tends to be lower. The hypotheses that are used in this study to achieve its goal include: (1) There is a significant difference between the mean and standard deviation of age, education, marriage, sex, and job in patients with vitiligo in experimental and control groups (2) there is a significant difference in resilience, shame, internal self-criticism, and the quality of life between pre-and post-test of CFT in vitiligo patients, (3) there is a significant difference between the score means of post-test of resilience, shame, and internal self-criticism, and the quality of life in patients with vitiligo in experimental and control groups. ...
Background: Vitiligo is a disease of progressive and permanent skin depigmentation. This disease impacts patients' quality of life through psychological distress, which shows itself in various ways. This distress includes shame and internal self-criticism in patients with vitiligo. Resilience can appear as the strength against distress. Objectives: This research aimed to assess the impact of compassion-focused therapy (CFT) on various outcomes, including resilience, shame, internal self-criticism, and quality of life in individuals with vitiligo. Methods: In this study, an RCT design was employed, incorporating both pre- and post-test evaluations alongside a control group, to examine the impact of CFT on resilience, shame, internal self-criticism, and quality of life in patients with vitiligo. Forty patients with vitiligo were selected from Razi Dermatology Hospital in Tehran in 2019. The participants were randomly assigned to either a control or experimental group. The World Health Organization Quality of Life Questionnaire, Connor-Davidson Resilience Scale, levels of self-criticism scale, and Internalized Shame Scale were used to complete the pre-and post-test phases. Compassion-focused therapy based on the Gilbert therapy package was held in eight 2 h sessions once a week for the experimental group. The control group received the intervention after the end of the experimental group intervention. Results: The results of the covariance analysis indicated that CFT significantly increased the quality of life (P < 0.05, F = 308.97) and resilience (P < 0.05, F = 125.75) and reduced shame (P < 0.05, F = 228.30) and internal self-criticism (P < 0.05, F = 53.44) of patients with vitiligo. Conclusions: Compassion-focused therapy can improve the quality of life and resilience and reduce the shame and internal self-criticism of patients with vitiligo.
... 16,23,21,1,18 Based on presence of combination of clinical features, WS is divided into 4 major types including WSI, WSII, WSIII and WSIV. 17,14 Mutations in several genes have been reported as an underlying cause of WS and a genotype-phenotype correlation exists between a causative gene mutation and various clinical features in WS. Mutations in EDN3, EDNRB, MITF, PAX3, SNAI2 and SOX10 are the six currently reported genes implicated in the pathogenesis of WS. 20,12,15 Mutations in PAX3 gene is mainly responsible for the clinical features of WS type I and III, whereas mutations in genes MITF, SOX10 and SNAI2 are identified in WS type II. ...
... WS is classified into 4 types (WSI, WSII, WSIII and WSIV) based on the presence of a combination of certain clinical features and their underlying genetic cause. 17,14 WS type I is characterized by dystopia canthorum, congenital sensorineural hearing loss, pigmentation abnormalities of the eyes, hair and/or skin. WS type II, however, is characterized by varying degrees of deafness and pigmentation abnormalities of the eyes, hair and/or skin colour. ...
Objectives:
Waardenburg syndrome is a rare genetic disorder. It is characterized by sensorineural hearing impairment and pigment defects of the skin, hair and iris. In some cases abnormalities in the tissues derived from neural crest have also been reported. Mutations in several genes have been reported as an underlying cause of Waardenburg syndrome. Objective of this study is to identify the chromosomal region(s) associated with Waardenburg syndrome in an extended Saudi family.
Methods:
Genomic DNA was extracted from fifteen individuals of a Saudi family segregating Waardenburg syndrome. Whole genome SNP genotyping was performed to identify common identity by descent chromosomal region(s) shared by affected individuals.
Results:
Pedigree analysis confirm autosomal dominant inheritance of Waardenburg syndrome type II in a family. Whole genome SNP genotypes were analyzed using AutoSNPa and DominantMapper tools. Shared identity by descent chromosomal regions were identified on chromosome 2 and chromosome 18. Regions were checked for known Waardenburg syndrome genes. No known gene is present in both regions.
Conclusions:
In summary, we identified novel chromosomal regions associated with Waardenburg syndrome type II in a Saudi family. Deep sequencing of a complete candidate regions are required to identify the gene underlying Waardenburg syndrome in this family.
... This used an unbiased approach in a large cohort to support earlier case studies that implicated hair dyes in causing vitiligo. One caveat of the study was that it couldn't rule out an association between early hair graying and vitiligo, which has been reported previously 2,44 , as the causative factor in the use of hair dyes at a young age. ...
... Skin depigmentation following exposure to chemical phenols is indistinguishable from vitiligo 2,29,40,65 , and appears to be due to activation of melanocyte-specific autoimmunity, as is also seen in non-chemically induced vitiligo 81,82 . In fact, chemicals may simply accelerate stress pathways that are already present in healthy melanocytes, but push them above a tolerated threshold to exceed the capacity that can be appropriately managed by healthy cells, leading to autoimmune inflammation. ...
Chemical-induced depigmentation of the skin has been recognized for more than 75 years, first as an occupational hazard but then extending to those using household commercial products as common as hair dyes. Since their discovery, these chemicals have been used therapeutically in patients with severe vitiligo to depigment their remaining skin and improve their appearance. Because chemical-induced depigmentation is clinically and histologically indistinguishable from nonchemically induced vitiligo, and because these chemicals appear to induce melanocyte autoimmunity, this phenomenon should be known as "chemical-induced vitiligo," rather than less accurate terms that have been previously used.
... O metoxipsoralen na concentração de 0,1% é o mais freqüente psoraleno utilizado no tratamento do vitiligo. 56,57 Deve ser aplicado nas áreas acometidas 30 a 60 minutos antes da exposição à radiação. A dose inicial de UVA deve ser 0,25J/cm 2 com aumento de 0,12 a 0,25J/cm 2 até que o eritema seja atingido. ...
... Methoxypsoralen in a concentration of 0.1% is the psoralen most frequently used in the treatment of vitiligo. 56,57 It should be applied on the affected areas 30 to 60 minutes before exposure to radiation. The initial level of UVA should be 0.25J/cm 2 with an increase of 0.12 the 0.25J/cm 2 until the onset of erythema. ...
O vitiligo é doença de pele de causa desconhecida que acomete cerca de 1% da população, comprometendo de modo semelhante homens e mulheres, preferencialmente entre 10 e 30 anos de idade. Alguns fatores precipitantes para essa doença são: estresse físico e emocional, traumas mecânicos e substâncias químicas, como derivados do fenol. Doenças auto-imunes, principalmente as tireoidianas, podem estar associadas ao vitiligo. Novas terapias têm sido propostas, como o uso de imunomoduladores tópicos, aliadas àquelas já consolidadas, como os psoralenos e os corticosteróides; o sucesso terapêutico, entretanto, está estritamente relacionado à qualidade da relação médico/paciente.
... This may be related to the random collection of patients. Many researchers [10,14] reported that the most common site of ND is the trunk. The results of this study coincide with this finding where the trunk was involved in 46.67% of the patients followed by the lower and upper limbs (20% for each), and lastly the neck (13.33%). ...
... The results of this study coincide with this finding where the trunk was involved in 46.67% of the patients followed by the lower and upper limbs (20% for each), and lastly the neck (13.33%). Most of the studied patients showed only one lesion (80%), whereas in vitiligo, the lesions always appear on the exposed parts, and developed at several locations [14] . The studied patients exhibited that ND lesions had irregular shape and serrated border, as described by Lee et al. [1] and Xu et al. [10]. ...
Background
Nevus depigmentosus is a congenital, non-progressive, hypopigmented macule or patch that is stable in its relative size and distribution throughout life. The lesions are often single but may be multiple, circumscribed and either isolated, dermatomal or in whorls. The lesions are uniformly hypomelanoic but not amelanotic. The aetiopathogenesis of nevus depigmentosus is not yet fully understood. A defect in the transfer of melanosomes from melanocytes to keratinocytes has been reported.
Objective
This work aimed at evaluation of the clinical and ultrastructural characteristics of nevus depigmentosus in a trial to understand its pathogenesis.
Patients and methods
This study included 15 patients having nevus depigmentosus. Ultrastructural study was performed for 5 patients. 2 punch biopsies were taken from each patient, one from the center of the lesion and another from the nearby apparently normal skin as a control.
Results
The lesions were mostly present before 3 years of age, mostly on the trunk. Six patients (40%) had the isolated type and 9 (60%) had the segmental type. Under Wood's lamp, the lesions exhibited an off-white accentuation without fluorescence. Ultrastructural study showed apparent reduction in melanosomal content of lesional melanocytes and keratinocytes. Immature and aggregated melanosomes were more present in lesional keratinocytes. Electron microscopic DOPA oxidase reaction was decreased in lesional skin compared to control indicating a reduced tyrosinase activity.
Conclusion
The results of this study support the hypothesis that nevus depigmentosus is caused by functional defect of melanocytes and morphologic abnormalities of melanosomes.
... Melanocyte abnormalities include alterations in pigmentation, autoimmunity, or melanoma and are mainly related to environmental factors such as UV light and chemical exposures, posing significant risks. Depigmentation arises from a perturbed melanogenesis process owing to the diminished synthesis of melanin or/and decrease in melanosome export, resulting in dermatological disorders of vitiligo, leukoderma, or progressive macular hypomelanosis (PMH) (Yamaguchi and Hearing, 2014;Lambert et al., 2019;Relyveld et al., 2008;Ortonne, 2012). Occupational exposure to phenol-based chemicals that induce depigmentation often causes vitiligo (Boissy and Manga, 2004). ...
... 3 Ortonne et al. were the first to mention the association between diabetes and vitiligo, and they attributed the skin discoloration to some pancreatic influence. 4 In most studies, many cases of diabetes with vitiligo have been published. 5,6 Dawber suggested that diabetes mellitus should be excluded in all cases of late-onset vitiligo. ...
... 3 Ortonne et al. were the first to mention the association between diabetes and vitiligo, and they attributed the skin discoloration to some pancreatic influence. 4 In most studies, many cases of diabetes with vitiligo have been published. 5,6 Dawber suggested that diabetes mellitus should be excluded in all cases of late-onset vitiligo. ...
... Psikolojik etkenlerle deri hastal›klar›n›n iliflkisi çok çeflitli aç›lardan 19 yy dan beri tart›fl›lm›fl, deri hastal›klar›na stresin neden oldu¤u varsay›m› ortaya at›lm›flt›r 7 . Son y›llarda yap›lan çal›flmalar bu görüflleri desteklemifl ve genel olarak stresli yaflam olay-lar› ile deri hastal›klar›n›n ortaya ç›k›fl› aras›nda bir iliflki oldu¤u üzerinde görüfl birli¤ine var›lm›flt›r 8,9,10 . S.Freud'un gelifltirdi¤i psikanalitik söylemden yola ç›kan baz› araflt›rmac›lar, deri has-tal›klar›n› psikolojik baz› çat›flmalar›n konversiyon mekanizma-lar› arac›l›¤› ile bedensel belirtilere neden olmas›yla aç›klam›fl ya da özgün nörofizyolojik bozukluklara ba¤lam›fllard›r 11 . ...
... Vitiligo is an acquired pigment disorder caused by several overlapping pathogenic mechanisms that lead to the loss of functional melanocytes, affecting 0.5-4 % of the world population 1 . Its etiology has not been completely elucidated, but previous studies have suggested that autoimmune, genetic, toxic / metabolic and neural mechanisms may play a role in the pathogenesis of this skin disorder [2][3][4][5][6][7] . ...
Fatty acids have shown to regulate melanogenesis in B16F10 mouse melanoma cells. We investigated the in vitro melanogenic activity of subfractions enriched in fatty acids obtained from the oil of Macadamia integrifolia. The composition of fatty acids in the oil, fractions, and subfractions was determined by gas chromatography. In addition, a randomized, placebo-controlled trial was carried out to evaluate whether a pharmaceutical formulation containing the macadamia oil was capable of re-establishing pigmentation in patients with vitiligo. The results revealed that subfractions 9 and 10 obtained from the chloroform fraction by column chromatography showed greater melanogenic activity than the crude oil and other subfractions. The formulation caused an improvement in the patients' depigmented patches. No toxic effects were observed in patients treated with the pharmaceutical formulation. In conclusion, these findings indicate that macadamia oil could be used as an active compound of the pharmaceutical formulation for vitiligo treatment.
... Six to thirty-eight percent of patients with this complex disorder were reported to be associated with family background of vitiligo [34]. The present study was comprised of 40% of the patients with the familial history of NSV. ...
Background and Objectives. Cytokines regulate immune response and inflammation and play a crucial role in depigmentation process of vitiligo. The present study aimed to estimate the serum levels of pro-and anti-inflammatory cytokines, IFN-í µí»¾ and IL-10, and their ratios in nonsegmental vitiligo patients and healthy individuals from India. Methods. Blood samples were collected from 280 subjects and serum IFN-í µí»¾ and IL-10 levels were measured using standard ELISA. Results. Nonsegmental vitiligo patients showed increased levels of IFN-í µí»¾ (12.4 ± 3.2 versus 9.9 ± 4.4 pg/mL) and decreased levels of IL-10 (9.3 ± 1.7 versus 11.5 ± 5 pg/mL) compared to controls. Ratio of IFN-í µí»¾ : IL-10 differed significantly from patients to controls (í µí± < 0.05). IFN-í µí»¾ concentrations and IFN-í µí»¾ : IL-10 ratio varied significantly with respect to clinical variants, disease stability, and social habits (smoking and alcohol consumption) and showed a positive correlation with disease duration. Family history of vitiligo was significantly associated with IFN-í µí»¾ : IL-10 ratio but not with their individual levels. Conclusion. The ratio of IFN-í µí»¾ : IL-10 serum levels may be considered as one of the promising immunological markers in nonsegmental vitiligo. This is the first study considering multiple aspects in relation to ratio of cytokine levels. Similar studies with large samples are warranted to confirm our observations.
... Vitiligo is an autoimmune disorder of melanocytes, characterized by circumscribed depigmented ma‐ cules. [1] It affects approximately 0.5‐2% of the world population. Although the onset may occur at any age, it is usually in the second and third decades of life [2] while 50% of the patients are younger than 20 years old. [3] The clinical presentations of vitiligo include ge‐ neralized, segmental, focal, and acrofacial subtypes. The main mechanism is destruction of melanocytes by an autoimmune T‐cell lymphocytic attack. [4] The strongest association of vitiligo is with thyroid dis‐ eases (hyper or hypothyroidism). [5,6] Another possible mechanism for vitilig ...
BACKGROUND: Vitiligo is an acquired, autoimmune melanocytic disorder characterized by circumscribed depigmented macules and patches. It affects approximately 0.5-2% of the general population worldwide. Many medical treatments have been attempted with partial success, but there has been no previous trial on the combination of topical 5-fluorouracil (5FU) 5% and clobetasol. METHODS: The aim of this study was to evaluate and compare the therapeutic efficacy of topical clobetasol (as a standard method for treatment of vitiligo) versus a combination of topical clobetasol plus 5FU. In this double-blind clinical trial study, 45 patients who had at least two vitiligo patches were treated with topical clobetasol on one side of the body, and with a combination of clobeta-sol and 5FU on the other side. Treatment was repeated every other day, once a day, for three months. At the end of the treatment, patients were visited again to be evaluated for the therapeutic efficacy of the drugs. RESULTS: Paired t-test revealed a significant improvement in both sides (the right side which was treated with 5-FU+clobetasol and the left side which was treated with clobetasol alone). Therefore, both drugs seem to have been effective in the improvement of vitiligo (p < 0.0001). Comparing the percentage of improvement in the lesion size, there was a statistical difference between the two groups (right side = 38.1 ± 4.3%, left side =24.2 ± 3.3%; p < 0.0001). CONCLUSIONS: Adding topical 5FU to clobetasol increases its efficacy in treatment of vitiligo without significant side effects.
... Vitiligo thus forms a major social dysfunction curtailing patients' ability to lead a normal work, social or married life. [9,10] Restoration of self-confidence, self-esteem is important. ...
Vitiligo is a hypopigmentation causing malady of skin occurring in blotches. It is impossible to envisage the extent of skin that can be affected. It has no age, sex or ethnic discrimination, but most develop by the age of 20 and more noticeable in dark skin people. Some acquire sparing white dots while others have white patches affecting larger areas of the skin. It may also affect hair, the inside of the mouth and even the eyes. Most widely accepted to be of autoimmune in nature but is of multifactorial origin. It is commonly associated with other autoimmune disorders affecting thyroid, adrenals and pancreas. Many variants are described depending on the pattern and extent of the skin involved. It is clinically diagnosed sometimes requiring biopsy to differentiate from other hypopigmentation disorders. Currently available treatment options for vitiligo include sunscreens for photosensitive skin, cosmetic cover-up, restoration of normal skin color with use of medical options like PUVA or surgically by autografting, tattooing and depigmentation of normal skin to make an even color. Results of these are not constant with only partial recovery. But the most commonly neglected imperative factor in the treatment of vitiligo is the psychological trauma and fear of social disgrace sustained by the patient. In this case report, we state a rare pattern of vitiligo involving only half of the body and the importance and effect of psychological treatment.
Background
Vitiligo is an idiopathic acquired illness characterized by limited depigmented macules and patches. We aim to compare intravenous (IV) methylprednisolone pulse therapy with oral prednisolone minipulse therapy in the treatment of progressive vitiligo.
Objective
The assessment of the efficacy of both treatment methods in the arrest of the progression of vitiligo and repigmentation of the existing lesions.
Materials and Methods
A total of 60 patients, 30 in each group, were enrolled for the study. Each patient underwent a detailed clinical, general physical, systemic, and thorough dermatological examination. A set of routine investigations, consisting of hemoglobin%, total leukocyte count, differential leukocyte count, urine routine examination, blood sugar (fasting and postprandial), liver function tests, renal function test, serum electrolytes, Montoux test, chest X-ray posteroanterior view, and thyroid profile were carried out before the analysis. Clinical photographs were taken before the start of therapy and after each month thereafter were used for the analysis after taking written consent.
Results
The age of vitiligo patients considered for the study ranged from 13 to 70 years. The ratio of male-to-female patients considered for the study was 22:38 (36.6%: 63.3%). The duration of instability in vitiligo cases studied varied from 6 months to 2 years. In both Group A and Group B, the maximum number of patients (66.7% and 86.7%, respectively) had unstable vitiligo for 6 months to 1 year. Percentage repigmentation was better in Group A (IV) than Group B (OMP). In Group A, 17 out of 20 (85%) patients had shown different degrees of repigmentation, while 20 out of 30 (66.7%) patients of Group B had shown the same. This was statistically insignificant. Types of repigmentation observed in patients were of the following types: perifollicular, marginal, and combined. In both groups, all patients showed perifollicular regimentation.
Conclusions
In progressive vitiligo, it was observed that oral mini pulse with prednisolone is superior to IV methylprednisolone pulse therapy for the arrest of progression. Considering the cost, mode of administration, hospital admission, loss of man-hours, and patients’ compliance, OMP was considered simpler and cost-effective.
Background:
Vitiligo is the most common depigmenting dermatosis causing immense psychosocial concern. When medical therapies fail to cause re-pigmentation, surgical modalities are developed to combat the same in stable vitiligo patients. Here we are comparing two such surgeries: smash skin grafting (SSG) and autologous non-cultured epidermal cell suspension (NCES).
Aims and objectives:
The aim of this article is to compare the efficacy of SSG and NCES in re-pigmentation of stable vitiligo and to know the feasibility of both the surgeries.
Materials and methods:
It is an open, randomized, and prospective study conducted in dermatology outpatient department at a tertiary care center. Thirty patients with single stable vitiligo lesion were randomized into two groups: 15 each in Group A (SSG) and Group B (NCES). Following the surgery, excimer lamp phototherapy was initiated twice weekly. Patients were followed up till 16 weeks of surgery. Photo-documentation was done every month. Grading was performed for the response in the form of re-pigmentation as excellent (>75%), good (50-75%), fair (25-50%), and poor (<25%). The χ2 test was used to analyze statistical significance.
Results:
Both the surgeries showed initial specks of re-pigmentation at 10-14 days post-surgery. Excellent response (>75% re-pigmentation) was observed in 10 (66.67%) patients in Group A and 9 (60%) patients in Group B. Both the surgeries showed equal response and uniform texture of re-pigmentation.
Conclusion:
SSG is equally effective when compared with NCES, in causing re-pigmentation. Also, SSG is simple, easy to perform, faster learning curve, less time-consuming, and cost-effective when compared with NCES.
Melanocyte cell death can lead to various melanocyte-related skin diseases including vitiligo and leukoderma. Melanocytotoxic chemicals are one of the most well-known causes of nongenetic melanocyte-related diseases, which induce melanocyte cell death through apoptosis. Various chemicals used in cosmetics, medicine, industry and food additives are known to induce melanocyte cell death, which poses a significant risk to the health of consumers and industrial workers. This review summarizes recently reported melanocytotoxic chemicals and their mechanisms of toxicity in an effort to provide insight into the development of safer chemicals.
Clinical presentation is given of eruption in the case of segmental vitiligo and nevus achromicus. Literary data was presented, issues of differential diagnostics were discussed.
INTRODUCTION
With the development of technology, the use of
electrical energy in the society and the interaction with the
devices that produce electromagnetic field are increasing.(1)
Concerns about extremely low-frequency electromagnetic
fields are increasing. Research report are suggesting a
possible relationship between electromagnetic fields
and childhood cancers. Although the frequency ranges
of ELF-EMF fields vary between 1-300 Hz, most of the
electrical devices in daily life operate between 50 or 60
Hz.(2) With the rapid increase in mobile phone technology,
accessibility in society is increasing. They form an
electromagnetic field in the range of 900-2100 MHz. The
use of mobile phones by individuals at home, at school
and at work continuously has effects on human health and
living organisms. (3)
RF-emitting devices are widely used in industry,
telecommunications, medicine and everyday life.(4) In 2011,
the International Agency of Research on Cancer (IARC)
commission classified radiofrequency electromagnetic
fields as carcinogens for humans (2B). In the light of
epidemiological studies and scientific information, this
committee re-evaluated the recommendations regarding
the cancer risks of RF radiation in 2019. IARC has
proposed an update to the “probable” that RF recipients
may be potential (Group 2A) cancer agents.(5)
When a new electromagnetic source is planned or
installed, the health impact should be minimized as far
as possible according to ALARA (As Low as Reasonably
Achievable) principles.(4)
This chapter focuses on the effects of man-made
electromagnetic fields, which have been increasing in our
environment in recent years, on humans. These biological
effects are of great concern in society.
Biological effects of electromagnetic fields
The mechanisms of interaction between EMF and
biological systems have been studied for most of this
century. RF fields induce torques on molecules. Biophysical
modelling approaches contribute to the understanding of
radiofrequency interactions at the cellular and molecular
levels.(11) 900, 1800 and 2100 MHz RF fields have been
reported to cause oxidative DNA damage in brain tissue
of rats.(3) The workers working in the hairdressing salons
constantly interact with the hairdryer. It is stated that the
electromagnetic field created by this device reduces the
total antioxidant level and increases the oxidant level in
the blood serum of the employees.(8) High frequency EMF
waves have more energy than low frequency waves and
therefore tend to be more harmful. In general, according
to the literature review, although there is no relationship
between ELF-EMFs or RF-EMFs and childhood cancers,
they state that these results have short-term exposures. To
obtain definitive answers, long-term studies are needed.(9)
RF fields may alter the transmission of Na and K ions in
the cell membrane. (11) There are scientific reports that longterm
occupational exposure to ELF-MF can increase the
risk of Alzheimer’s disease and dementia in men.(12) Static
and ELF-EMFs on living organisms are altering free radical
activity in the cell. However, chronic exposure leading to
the excessive and persistent presence of free radicals can
cause oxidative stress and should be avoided. (17)
In cell culture studies, ELF-EMF exposures (50 Hz,
sinusoidal, 1–24 h, 20–1,000 microT, 5 min on/10 min
off) may cause single and double-strand DNA breaks
depending on dose and time. (13)
Electromagnetic fields and cancer
Mobile phone users who use more than the long period
of 10 years, glioma, acoustic neuroma, and has been reported
Academic Studies in Health Sciences 217
to increase the risk of intracranial tumor.(4) Long-term
exposure to radiofrequency electromagnetic fields, even
below the limits (0.04 and 0.4 W/kg SAR) for humans, has
been shown to increase significantly in the number of tumors
in the lung and liver of animals compared to the control
group.(6) There is a thermal or non-thermal mechanism that
supports tumor growth of the biological process underlying
a possible relationship between exposure to mobile phones
and cancer risk.(10) Some epidemiological studies have shown
that exposure to ELF-EMFs may pose an increased risk
in certain types of adult and childhood cancers, including
leukemia, central nervous system cancer, and lymphoma.(13)
In Denmark, the incidence of cancer has been investigated in
people with occupational exposure to electromagnetic fields.
In the study, it was emphasized that there is an increased risk
of leukaemia in some occupations working in the electricity
business. Besides, a slight excessive risk for male breast
cancer in these areas has been proposed, but has not been
confirmed by a coherent increase among women.(14) Studies
on cytogenetic damage and increased cancer risk in human
cells are important and needed.(15)
Some studies Show that RF fields are not related to
cancer formation.(11) Nevertheless, studies linking ELF-EMF
to cancer are weak. More and better research is needed.(16)
However, the options of cancer treatment in medicine
have been investigated. Although electromagnetic
fields (EMF) in medicine are used for therapeutic or
diagnostic purposes, the use of non-ionizing EMF for
cancer treatment is an emerging concept. Radiofrequency
radiation by clinical oncologists has been used as a
hyperthermia approach at high temperatures.(7)
Antioxidants against EMF fields
The use of ganoderma and melatonin has been reported
to protect oxidative damage caused by electromagnetic
fields.(1) Vitamins E and A play a role in reducing oxidative
stress caused by cell phone exposure to testes.(18) Different
doses of ionizing radiation were used on E.coli bacteria.
Carob, basil, ginger, rosemary, yarrow and cumin showed
a protective effect against the effects of radiation in the
study.(19)
Research methods used
Proliferative cell nuclear antigens (PCNA), TUNEL
assay, histological, histopathological and various
microscopic imaging method are used to determine the
effects of cells exposed to electromagnetic fields.(1) The
effects of electromagnetic fields on learning and memory,
the behavior of the experiment animals are made with the
Morris water tank.(2) The Comet assay method is used to
detect DNA damage at a single-cell level.(3)
Result
With the development of technology, electromagnetic
devices are increasing in our environment. Especially
in developing countries and around the world, the
interaction time with these devices increases and raises
concern. In recent years, accessibility to mobile phones
has been increasing. At the same time, occupational
electromagnetic field exposures also make workers uneasy.
Therefore, scientific studies on electromagnetic fields are
increasing and warnings are made about their effects on
the biological system. Research reports on the relationship
between cell phones and other electromagnetic field
exposures to cancer are increasing. In addition, although
there is not a complete consensus in the scientific studies,
international commissions are working on these areas.
Longer electromagnetic field exposures and more reliable
data are needed.
Adolescence is the general name of the period that starts at the age of 10-11 and lasts almost twenty years, including physical, mental and social changes. The period between 10 and 13 years of age is called pre- adolescence. In adolescence, physical, cognitive, emotional and social changes occur. . In this chapter, it was aimed to determine the hygiene characteristics of early childhood children.
Segmental vitiligo (SV) has been historically opposed to vitiligo/nonsegmental vitiligo (NSV). However, evidence that the two forms are not mutually exclusive (delineation of mixed vitiligo) and share similar inflammatory features has challenged classical views over the last decade. SV belongs to the clinical spectrum of vitiligo, including inflammatory skin features. SV has usually an early onset and spreads rapidly in the affected segment. The hair follicle melanocytic compartment is frequently involved. Distribution in SV parallels that of other acquired pigmentation disorders such as nevus spilus, pointing out to some underlying developmental defect. Neurogenic influences have been highlighted by striking clinical observations and experimental studies. Classification of SV is needed to establish a prognosis, and two recent classifications for cephalic and truncal SV have been proposed. Segmental vitiligo is a perfect model for studying repigmentation since it is a relative stable disease with limited active melanocyte loss. Early aggressive medical treatment of SV is currently recommended.
Based on the VGICC classification, vitiligo/NSV, a consensus umbrella term for all forms of generalized vitiligo, is meant to describe different clinical subtypes of vitiligo that are all clearly distinct from SV including acrofacial, generalized, mucosal (multifocal), and universal. According to the VETF definition, generalized vitiligo is characterized by asymptomatic well-circumscribed milky-white macules involving both sides of the body with usually a symmetrical pattern. In acrofacial vitiligo (AFV), the involved sites are by definition limited to the face, head, hands, and feet with typically depigmentation of the distal fingers and facial orifices. Vitiligo universalisis a rapidly progressive form of the disease, which needs a more in-depth investigation especially for associated autoimmunity.
Vitiligo was recognized long ago under different names. Firstly, the Ebers Papyrus (circa 1500 BC) mentions two types of diseases affecting the colour of the skin, one being probably leprosy and the other vitiligo. In the ancient Vedic scripture of India (circa 1400 BC), Sanskrit words “kilas” and “svitra” (white patches on the skin) can be found. The early classics of the Far East (1200 BC) mention “shirabito” (white man). The Hebrew word “Zoorat” in the bible corresponds to a group of achromic diseases including vitiligo. “Baras and alabras” were the Arabic names used to describe vitiligo. The term “vitiligo” itself was introduced in the first century of our era. The confusion of leprosy with vitiligo in the Old Testament under “Zoorat” is an important cause for the social stigma attached to white spots on the skin. Detailed and effective treatments for vitiligo are found in different sacred books. The modern photochemotherapy is an improvement of a photochemotherapy practised in the ancient world with herbals containing furocoumarins (mainly Ammi majus Linnaeus, Psoralea corylifolia) and sun. In the mid-1960s the synthetic furocoumarin (trioxsalen and trimethylpsoralen) were developed. The effectiveness of PUVA (psoralen + UVA) for the treatment of some patients with vitiligo was confirmed during 1974–1982. More recently, narrowband UVB therapy, local microphototherapy, excimer laser, topical treatments with corticosteroids and calcineurin inhibitors and melanocyte transplantation have been successively introduced.
The skin punch or surgical punch is used almost solely by dermatologists for the treatment of vitiligo. The entire depigmented and grafted area is expected to be completely repigmented within three to six months, based on the area of grafting and body part(s) involved. Cobblestoning is the most common complication, though with time this is corrected in most cases. The surgical correction of vitiligo and other cutaneous achromia has undergone major improvements. Yet, among all other methods, autologous miniature punch grafting has already established its place as the easiest, fastest, least aggressive and, of course, one of the most effective means of vitiligo therapy. Several aspects of punch grafting require special consideration: mechanism of pigmentation of grafting procedures; relapse after grafting; appearance of repigmentation time; and maximum pigment spread. Phototherapy is always necessary after grafting.
This chapter discusses a classification of vitiligo, which was first suggested at the Vitiligo Global Issues Conference. It describes the characteristics of each type of vitiligo. According to the distribution and extent of lesions, vitiligo can be divided into either generalized or localized types. The localized type is further subdivided into focal, segmental, and mucosal subtypes, while the generalized type is subdivided into acrofacial, vulgaris, and universal subtypes. Based on whether vitiligo lesions cross the midline or not, vitiligo can be classified into non-segmental, segmental, and mixed types. Non-segmental vitiligo and segmental vitiligo have distinctive clinical features and natural histories. Acrofacial vitiligo encompasses depigmentation of the distal parts of the extremities and facial orifices, the latter in a circumferential pattern. Inflammatory vitiligo, an unusual, rare variant of vitiligo has an erythematous, raised rim at the periphery of the hypopigmented or depigmented patch.
Leukotrichia is tell tale sign of vitiligo and its presence even after the complete repigmentation of vitiligo patch carries cosmetic as well as psychological impact. Simultaneously it is a poor prognostic factor in the treatment of vitiligo indicating a more severe disease and treatment resistant disease. Surgical procedures involving deepithelialization using dermabrasion or suction blister grafting or thin split-thickness skin graft have resulted in repigmentation of white hair but with very limited success and highly unpredicatable. However, other surgical techniques used for repigmentation of vitiligo may also give the same result. Recently hair transplantation in vitiligo has shown more promising results compared to earlier treatments. The result is better over the eyebrow and eyelashes even in beard area but and less successful for treating leukotrichia of the scalp. Overall leukotrichia of eyebrow and eyelashes responds well to the treatment compared to scalp, beard and moustache area. The repigmentation of hair is observed later than the repigmentation of the skin vitiligo. The repigmentation of skin and the hair is permanent on long-term follow-up up to 5 years.1 The surgical repigmentation of leukotrichia proves the point that melanocytes migrate from the epidermis to the hair follicles. A lot more work is needed in this field before one can predict repigmentation of leukotrichia surgically.
Vitiligo is a common autoimmune disease that progressively destroys melanocytes in the skin, resulting in the appearance of patchy depigmentation. This disfiguring condition frequently affects the face and other visible areas of the body, which can be psychologically devastating. The onset of vitiligo often occurs in younger individuals and progresses for life, resulting in a heavy burden of disease and decreased quality of life. Presentation patterns of vitiligo vary, and recognition of these patterns provides both diagnostic and prognostic clues. Recent insights into disease pathogenesis offer a better understanding of the natural history of the disease, its associations, and potential for future treatments. The first article in this continuing medical education series outlines typical and atypical presentations of vitiligo, how they reflect disease activity, prognosis, and response to treatment. Finally, we discuss disease associations, risk factors, and our current understanding of disease pathogenesis.
Die Analyse der bei Krankheiten vorkommenden Änderungen der Haarfarbe wird dadurch erschwert, daß die biologischen Grundlagen der mit dem Auge erfaßbaren reichen Palette von Haarfarben noch ganz ungenügend bekannt sind. Die Komplexität der die Haarfarbe bestimmenden Faktoren ist erst in den letzten Jahren besser erfaßt worden.
This research evaluated the effect of (UV)(400-320A)Hz(320-220B)Hz on the patient with vitiligo , using it with our new combing therapy that include the oral (Psorlene ) topical , meladinine solution applied on the Vitiligiousns Lesions , In edition to the instralesnional injection in the Vitiligiousns Lesions by long acting steroid (kenacort-A ) by aprecentage of (5%) , after that we expose the patient to UV . The ruslets of this way of treatment more effective by using of the UV rays in the treatment of vitiligo , while the previous treatment that used the UV ray with or with out the psorlene , the results were not effective on controlling of the Vitiligio diseases comparing by the treatment used in this research as it stop’s the spread of the diseases and curing it .
Although the human hair shows a wide range of color hues, microscopic examination has revealed only two types of pigment granules: brown and black (eumelanosome) and yellow and red (phaeomelanosome) (Jimbow et al. 1983). In mice, the genetic pattern of hair color indicates that brown and black pigment granules are controlled by single genetic loci, whereas yellow and red pigment granules are controlled by other genetic loci. Therefore, there may be two separate, but possibly interrelated, metabolic pathways for the two types of pigment granules in man. It is known that brown and black pigments are derived from the enzymatic oxidation of tyrosine to melanin. Although the structure of phaeomelanin may be species specific, and phaeomelanin in the chick may not be the same as that of human hair, animal experiments on this point have yielded valuable information. Prota and Nicolaus (1967) have demonstrated that phaeomelanin of New Hampshire chick feather is a polymer of cystenyldopa which could be formed by the reaction of an amino acid containing thiol group with dopaquinone produced by the enzymatic oxidation of tyrosine.
Dieses Kapitel beschäftigt sich mit der Anwendung von Photochemotherapie und Phototherapie bei Vitiligo. Zunächst wird die Krankheit definiert und werden Differentialdiagnosen und assoziierte Phänomene beschrieben. Allgemeine therapeutische Maßnahmen und Alternativen zu phototherapeutischen Verfahren folgen. Den Hauptteil bildet die Beschreibung der praktischen Durchführung und Wirkung der Bestrahlungsbehandlung mit oder ohne Photosensibilisator sowie von kombinierten Therapieformen.
The three dendritic cell populations present in epidermis, i.e. Langerhans cell, Merkel cell and melanocytes, also occur in hair follicles. Langerhans cells have been demonstrated by both indirect immunofluorescence and electron microscopy in the upper part of the outer root sheath of hair follicles. Their presence in the hair matrix is still a matter of discussion. Very little is known on the biology of follicular Langerhans cells. Merkel cells may be associated with various types of hair including vellus hair, sinus hair, vibrissae or whiskers. They form organized intraepithelial associations with axon terminals. This is also the case of the tactile hair disk, which is usually, but not constantly, in relation to the hair follicles.
Hair follicle melanocytes synthesize the melanin pigments responsible for the hair color. This follicular compartment of melanocytes is anatomically, and at least to some extent, physiologically distinct from the epidermal one.
Vitiligo is an acquired idiopathic hypomelanotic disorder characterized by circumscribed depigmented macules. There is frequently a family history of the condition or of autoimmune endocrine disease. Vitiligo can lead to social embarrassment, psychological disturbance, and cosmetic disability.
Melanin is the most important determinant of skin color. The type of melanin and how it is packaged in melanosomes and transferred to keratinocytes determines one’s skin color. Other factors influencing skin color include the relative amounts of oxidized and reduced hemoglobin and the presence of carotenoids. Melanin provides the main protection against ultraviolet radiation. Thus, individuals with defects in melanin production, such as albinos, are at risk for marked sun-induced skin damage and tumor induction, especially if they live in countries with long hours of sunlight. In contrast, dark skin is relatively resistant to damage by chronic sunlight exposure. The only obvious disadvantage that such individuals have is impaired vitamin D synthesis when light levels are low.
The existence of various phenotypes among nonsegmental vitiligo (NSV) (e.g., Acrofacial or Vulgaris) is suggested by clinical observation and possibly by genetic associations.
Half of initially “focal” vitiligo patients evolve into NSV.
The fingers, hands and face are frequently reported to be the initial sites by the patients.
In darker-skinned individuals, palms and soles have to be examined with Wood's lamp.
Most of the “spontaneous” repigmentation re ported by the patients is correlated to sun exposure.
Multichrome vitiligo refers to various degrees of depigmentation within a vitiligo macule, a phenomenon noted in dark skin.
Vitiligo is a relatively common condition characterized by the progressive loss of normal skin coloration in certain skin areas. It is not a life-threatening disease and therefore does not require treatment unless serious disfigurement leads to social segregation and emotional distress. Treatment is directed to reverse the progressive loss of epidermal melanocytes and to reconstitute normal skin color. Although a minority of patients with vitiligo may develop transient repigmentation when exposed to sunlight or artificial UV radiation, only photochemotherapy is effective in inducing a permanent cosmetically acceptable treatment result1–3.
Fitzpatrick and ourselves described the frequency of vitiligo lesions vulgaris at sites subjected to repeated trauma such as continuous pressure or repeated frictions of various origins.
In non-segmental vitiligo, the incidence of Kobner's Phenomenon (KP) is very varied according to reports, that is, from 15 to 70%.
Wounds, scars, burns, abrasion, laser, and other types of surgical abrasion are the more frequent inducing factors of the KP.
Many mechanisms have been hypothesised: increased release of neuropeptides noxious for melanocytes, detachment and transepidermal elimination, and lower secretion of keratino-cyte-derived factors. In normal vitiligo skin, a minor trauma (tape stripping) is possible after 72 h to induce the formation of autophagic vacuoles containing polymelanosomes and the detachment of few melanocytes from the basement membrane.
In the presence of a history of vitiligo in the family, the onset of permanent depigmentation following repeated scratches in children without vitiligo could indicate a ‘vitiligo diathesis.’
An abnormal effect of neurohormones and neuropep-tides has been speculated to explain the chronic melano-cyte loss in vitiligo, especially in SV due to its distribution, which can fit dermatomes. The neural/neurogenic theory is supported by clinical, histological, ultrastructural, experimental, pathophysiological, and biochemical arguments. Those will be reviewed with emphasis on SV.
Segmental vitiligo (SV) shares some characteristics and can be associated with nonseg-mental vitiligo (NSV). However, SV is currently considered as a distinct entity. SV usually has an early onset and it spreads rapidly in the affected dermatomal area. The hair follicle melanocytic compartment is frequently involved. The purpose of the classifi cation of SV, especially facial, is to establish a prognosis. Multiple SV should be differentiated from NSV. Early medical and UV treatment of SV is recommended based on recent data.
Purpose : This rearch aims to prove effects of an oriental medical complex therapy on vitiligo patients who have the symptoms in the hands. Method : The rearch conducted its investigation targeting these four patients who have the symptoms in the hands. The study resolved the findings through the comparison on the pictures before and after the therapy. Result : After making a comparison on the pictures, the study confirmed positive changes in the conditions of the patients. The oriental medical complex therapy turned out to be effective enough to treat the patients who have the symptoms in the hands. Conclusion : Such result leads the study to a conclusion that the oriental medical complex therapy can be an effective method to treat these patients who have the symptoms in the hands. In addition, more case studies and research will be necessary.
The clinical, ophthalmological, and biochemical characteristics of a 28-year-old black woman with brown oculocutaneous albinism were determined. Hair color was medium brown and skin color was light brown, and a faint tan developed with sun exposure. The irides were light brown in the central onethird, blue-gray in the peripheral two-thirds, and showed punctate and radial translucency. Visual acuity was 20/60 in the right eye and 20/100 in the left eye. There was a moderate pendular nystagmus, and previous surgeries had corrected an exotropia. The foveal reflex was muted, and the retinal pigment was reduced. Hairbulb tyrosinase activity was 1.75 pmoles/120 min/hairbulb, hairbulb glutathione content 0.83 nmoles/hairbulb, and urine excretion of 5-Scysteinyldopa 174.9 ng/mg creatinine. Electron microscopy of hairbulb and skin melanocytes showed arrested melanosomel development. These findings suggest that there is a partial block in the distal eumelanin pathway in this form of albinism. The ophthalmological characteristics of six additional cases of this form of albinism are also presented.
Objective:
To compare the efficacy and safety of 2 treatment modalities, topical psoralen plus UV-A (PUVA) with unsubstituted psoralen and 311-nm UV-B radiation, in patients with vitiligo.Design:
This intervention study was designed as a before-and-after trial with 2 arms, in which patients were consecutively included.Patients:
Male (n=99) and female (n=182) patients, who predominantly had skin type III, with extensive, generalized vitiligo of more than 3 months' duration.Interventions:
Two patient groups were investigated. The first group of patients was treated for 4 months with either topical PUVA (n=28) or 311-nm UV-B radiation (n=78). The second group of patients, treated twice weekly with 311-nm UV-B radiation, was followed up for 3 (n=60), 6 (n=27), 9 (n=37), or 12 months (n=51).Results:
Thirteen (46%) patients in the first group treated with topical PUVA showed repigmentation after 4 months. Fifty-two patients (67%) in the 311-nm UV-B treatment group showed repigmentation after 4 months. After 3 months, 5 patients (8%) in the second group showed more than 75% repigmentation of lesional skin compared with 32 patients (63%) after 12 months. As in other treatment modalities, the face showed good repigmentation, whereas hands and feet responded poorly. No adverse effects were encountered with treatment with narrowband UV-B radiation, contrary to those seen with topical PUVA treatment. The cumulative UV-B dose was very small compared with that of the topical PUVA treatment.Conclusions:
According to our results, the treatment of patients with vitiligo with 311-nm UV-B radiation is as efficient as with topical PUVA and has fewer adverse effects.Arch Dermatol. 1997;133:1525-1528
The Gorrespondence Section serves as a forum for opinion exchange about subjects of general in-terest such as dermatologic training, relations between dermatologists and pharmaceutical houses, governmental control of dermatology and medical practice in general, peculiarities of dermatology related to geographic, climatic, or racial factors, the flow of information and publications, as well as other concerns the readership might have. Gontributions are welcome and should conform to the usual format for correspondence. Manuscripts will undergo standard editorial procedures. Submit all correspondence to Mauricio Goihman-Yahr, M.D., Ph.D., Editor, Jet International M-154, P.O. Box 020010, Miami, FL 33102.
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