[Clinical observation on treatment of vitiligo with xiaobai mixture]

OBJECTIVE

To observe the therapeutic effect of Xiaobai Mixture (XBM) in treating vitiligo.

METHODS

Seventy-four patients with vitiligo were randomly divided into the XBM group treated with XBM and the control group treated with 8-MOP. The therapeutic effect, nail-fold microcirculation, plasma endothelin-1, serum immunoglobulin were observed and compared.

RESULTS

The therapeutic effect of XBM was better than that of 8-MOP (P < 0.05). XBM could also obviously improve the nail-fold microcirculation, elevate the plasma endothelin-1 level and lower the serum IgG (P < 0.01).

CONCLUSION

XBM has superiority in treating vitiligo.

Vitiligo in association with human immunodeficiency virus infection

Autoimmune disorders such as vitiligo have been previously reported in patients with human immunodeficiency virus (HIV) infection. We describe a case of vitiligo in association with HIV where a rising CD4 lymphocyte count due to highly active antiretroviral therapy (HAART) closely correlated with changes in the skin. This effect, to our knowledge, has not been previously observed.

Open trial of topical tacalcitol [1 alpha 24(OH)2D3] and solar irradiation for vitiligo vulgaris: upregulation of c-Kit mRNA by cultured melanocytes

Vitiligo vulgaris is a common skin disease, however some cases show poor clinical responses to topical steroid ointment or PUVA therapy. Such regimens are generally avoided in the treatment of facial lesions or in pediatric cases because of the undesirable side effects. To confirm the excellent response to combination therapy with topical vitamin D3 ointment and solar irradiation for vitiligo achieved in the initial patients, we conducted an open trial on other patients, most of whom had poor clinical responses to the prior therapies. Fifteen patients (9 men and 6 women) with vitiligo vulgaris were enrolled in this study. Each patient was instructed to sunbathe for 30 minutes within 1 hour after topical application of the tacalcitol [1 alpha 24(OH)(2)D(3)] ointment or cream to the skin lesions every day. Six of 15 patients showed a fair and excellent clinical response to the combination therapy (more than 30% clearance of the vitiligo). The clinical effect was more apparent in patients with a history of less than 5 years of vitiligo (4 of 6 cases) in contrast to those with a history of more than 5 years (2 of 9 cases). In vitro experiments revealed that tacalcitol upregulated the expression of c-Kit mRNA by melanocytes irradiated with linear polarized infrared, UVA or short period solar irradiation. These results suggest that combination therapy with topical vitamin D(3) ointment and solar irradiation can be used as an alternate therapy for vitiligo vulgaris.

Effectiveness of oral Ginkgo biloba in treating limited, slowly spreading vitiligo

For effective treatment of vitiligo, it is as important to arrest the progression of the disease as it is to induce repigmentation. Recently, oxidative stress has been shown to play an important role in the pathogenesis of vitiligo. Ginkgo biloba extract has been shown to have antioxidant and immunomodulatory properties. In a double-blind placebo-controlled trial, we evaluated the efficacy of G. biloba extract in controlling the activity of the disease process in patients with limited and slow-spreading vitiligo and in inducing repigmentation of vitiliginous areas. Fifty-two patients were assigned to two treatment groups (A and B) in a double-blind fashion, but only 47 patients could be evaluated, because one patient in group A and four patients in group B withdrew for reasons unrelated to the study. Patients in group A were given G. biloba extract 40 mg three times daily whereas patients in group B received placebo in similar doses. A statistically significant cessation of active progression of depigmentation was noted in patients treated with G. biloba (P = 0.006). Marked to complete repigmentation was seen in 10 patients in group A, whereas only two patients in group B showed similar repigmentation. The G. biloba extract was well tolerated. G. biloba extract seems to be a simple, safe and fairly effective therapy for arresting the progression of the disease.

A double-blind randomized trial of 0.1% tacrolimus vs 0.05% clobetasol for the treatment of childhood vitiligo

OBJECTIVE

To assess the safety and efficacy of topical 0.1% tacrolimus vs 0.05% clobetasol propionate.

DESIGN

Randomized double-blind trial.

SETTING

Department of Dermatology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosí, México.

PARTICIPANTS

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.

MAIN OUTCOMES MEASURES

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.

RESULTS

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.

CONCLUSIONS

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.

Is the combination of calcipotriol and PUVA effective in vitiligo?

OBJECTIVE

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.

BACKGROUND

There are several reports on the response rate of patients with vitiligo treated with the combination of PUVA and calcipotriol or calcipotriol alone.

SUBJECTS AND METHODS

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.

RESULTS

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.

Treatment of vitiligo vulgaris with narrow band UVB (311 nm) for one year and the effect of addition of folic acid and vitamin B12

Narrow band UVB is succeeding psoralen and UVA irradiation as the main treatment of vitiligo vulgaris in several European countries. Vitamin B12 and folic acid deficiency in some vitiligo patients has prompted researchers to investigate the efficacy of these vitamins in the treatment of vitiligo. In the present controlled study we investigated the value of narrow band UVB phototherapy in the treatment of vitiligo and the possible additive effect of vitamin B12 and folic acid. Twenty-seven patients with long-term stable vitiligo were included and randomized in a "UVB only" (UVB) or "UVB combined with vitamin B12 and folic acid" (UVB+) group. Patients were irradiated thrice weekly for one year, whilst repigmentation was carefully monitored. In 92% (25/27) of the patients up to 100% repigmentation was seen. Repigmentation was notable in lesions on the face, neck and throat, lower arm, chest, back and lower legs, whilst repigmentation on the hands, wrists, feet and ankles proved to be minimal. Maximum repigmentation rates did not differ significantly between the UVB group and the UVB+ group. Our study reconfirms that narrow band UVB phototherapy is an effective treatment for vitiligo and shows that co-treatment with vitamin B12 and folic acid does not improve the outcome of treatment of vitiligo with narrow band UVB phototherapy.

Tacrolimus ointment 0.1% produces repigmentation in patients with vitiligo: results of a prospective patient series

The cause of the selective melanocyte destruction in vitiligo may be due to an autoimmune disorder. A series of 15 patients with vitiligo were treated with a topical immunomodulator, tacrolimus ointment 0.1%, twice daily for a minimum of 45 days. Thirteen patients (87%) experienced at least partial repigmentation, and 3 of those patients had greater than 75% repigmentation. Patients with the greatest treatment response likely benefited from concomitant natural sunlight exposure. Further studies investigating the safety and efficacy of tacrolimus ointment either as monotherapy or in combination with other therapeutic measures are warranted.

Photo(chemo) therapy for vitiligo

Vitiligo has always been difficult to treat. Several modes of treatment are available, but the therapeutic effect varies greatly, and rarely does one achieve complete repigmentation. One of the most efficient treatment methods is photo(chemo) therapy. Already in ancient Egypt, vitiligo lesions were treated with extracts of the Ammi maius plant followed by exposure to the sun. This principle is at the basis of the photochemotherapy or PUVA therapy, whereby UVA irradiations are given 2 h after administration of 8-methoxypsoralen, a photosensitizer. Another efficient treatment form is UVB phototherapy, particularly narrow-band UVB. This not only gives good therapeutic results but also has the advantage of eliminating the need for a photosensitizer. All these treatments must be applied for many months to be efficient. They can also be combined with various surgical skin-grafting techniques. A newer approach is targeted UVB phototherapy, whereby xenon-chloride lasers or monochromatic excimer light is used.

Topical prostaglandin analog (PGE2) in vitiligo--a preliminary study

BACKGROUND

Several therapeutic options are available for the treatment of vitiligo, but none is uniformly effective. Prostaglandin has been shown to play a role in melanocyte proliferation and melanogenesis. Topical application of prostaglandin E2 (PGE2) over mice skin has been shown to increase melanocyte density.

AIM

To evaluate the role of topical PGE2 in the treatment of vitiligo.

METHODS

We enrolled 27 patients with limited vitiligo lesions in this study. Patients were instructed to apply a translucent gel containing 0.5 mg/3 g (166.6 micro g/g) PGE2 to depigmented skin.

RESULTS

Twenty-four patients were evaluated at the end of 6 months, as three patients withdrew for reasons unrelated to the study. At the end of treatment, 15 patients showed marked to complete repigmentation and three patients showed moderate repigmentation. The remaining six patients showed none to minimal repigmentation.

CONCLUSIONS

Marginal repigmentation with hyperpigmented borders was seen in the majority of lesions. Our results are encouraging and offer a new and potentially efficacious treatment for this pigmentation disorder.

In vitro migration of melanoblasts requires matrix metalloproteinase-2: implications to vitiligo therapy by photochemotherapy

It is known that the migration of melanocyte precursors (melanoblasts) from the outer root sheath of hair follicles into clinically depigmented epidermis is crucial to the repigmentation of vitiliginous skin treated with photochemotherapy (PUVA), but such migratory cells must penetrate extracellular matrix tissue barriers in vivo. To test the hypothesis that matrix metalloproteinases (MMPs) are required for this process, we determined whether cultured melb-a cells, an immortal line of melanoblasts isolated from neonatal mouse epidermis, express and secrete MMPs and whether a synthetic metalloproteinase inhibitor, GM6001 (Galardin), inhibits their migratory behavior in vitro. Reverse transcriptase-polymerase chain reaction and Western blotting were used to determine the patterns of MMP expression by melanoblasts at the mRNA and protein levels, respectively. The proteolytic activities of MMPs secreted into the culture medium were assessed by gelatin zymography. The capacity of melanoblasts to migrate on fibronectin, laminin or laminin-5 substrates was estimated using Transwell migration assays. The results show that MMP2, MMP9 and MT1-MMP transcripts are expressed by these melanoblasts, but only MMP2 is secreted and activated in the extracellular environment. Although the therapeutic efficacy of PUVA in stimulating repigmentation of vitiliginous skin might derive from direct effects of UVA and/or 8-methoxypsoralen (8MOP), recent studies have shown that keratinocyte-derived factors induced by ultraviolet radiation, especially alpha-melanocyte stimulating hormone (alpha MSH), play a major role in regulating melanocyte function. Therefore, we also examined whether 8MOP and/or alphaMSH are involved in the up-regulation of MMP2 expression in melanoblasts. Western blotting and zymographic analyses revealed that MMP2 synthesis and secretion were induced by 8MOP and/or by alpha MSH. This induction of MMP2 resulted in significant increases of migration by melanoblasts on laminin or on laminin-5 substrates, while concomitant treatment with GM6001 blocked that induced migration. Taken together, these results suggest the importance of MMP2 in melanoblast migration and in the response to PUVA therapy.

Topical pseudocatalase mousse and narrowband UVB phototherapy is not effective for vitiligo: an open, single-centre study

We report an open single-centre trial to assess the efficacy of topical pseudocatalase mousse applied twice daily to the hands and face of vitiligo patients, in combination with twice-weekly suberythemogenic narrowband UVB phototherapy. The regime was generally safe and well tolerated, although several patients experienced mild transient skin rashes in association with application of the mousse and one patient suffered severe pruritus. The primary efficacy variable was the percentage change in area affected by vitiligo as assessed by digital interpretation of standardized photographs of the face and hands. There was no clear evidence of the efficacy of the regime and in fact a slight tendency overall to worsening of the patients' vitiligo.

Topical tacrolimus for repigmentation of vitiligo

We describe 6 patients with generalized vitiligo who responded to treatment with tacrolimus ointment. Moderate to excellent repigmentation was achieved in 5 patients. Although the number of cases in this noncontrolled, nonblinded series is small, tacrolimus ointment may be an efficacious and safe treatment option for vitiligo.

Efficacy of erbium YAG laser-assisted autologous epidermal grafting in vitiligo

BACKGROUND

Of the various modalities of therapy available for the treatment of vitiligo, a combination of psoralen + ultraviolet A (PUVA) with autologous epidermal grafting appears to offer the best results. The erbium YAG laser can be used to prepare the recipient site in both punch grafting and suction blister grafting.

METHODS

In this study 29 subjects, 26 with localized and three with generalized stable vitiligo, had received pregrafting PUVA and underwent further PUVA starting 2 weeks after surgery until maximal pigmentation was achieved. The erbium YAG laser was used on 16 subjects; the recipient site for punch grafting was prepared with laser and minigrafts harvested by manual punch were placed into the prepared sites. For suction blister grafting, the site was dermabraded with a laser and the harvested blister roof (created using suction apparatus) was transplanted on to the site.

RESULTS

More than two-thirds (68.75%) of the subjects who were punch grafted using a laser showed repigmentation of more than 75%, but only one-half of those who underwent conventional punch grafting showed a similar response. All subjects with laser-assisted suction blister grafting showed a good response, compared with only 60% of those who underwent conventional suction blister grafting.

CONCLUSIONS

The results obtained with laser-assisted grafting are more satisfactory than those achieved with conventional grafting techniques. We found that the repigmentation zones are larger (up to 9 mm in the former vs. 3 mm in the latter) and cobblestoning does not occur with laser-assisted grafting. Also, the procedure is precise, relatively atraumatic and can be performed rapidly even when covering vast areas.

[Bullous pemphigoid, primary biliary cirrhosis and vitiligo: a multiple autoimmune syndrome?]

Bullous pemphigoid is the most frequent autoimmune blistering skin disease. There have been few reports of an association with primary biliary cirrhosis and vitiligo. We report the simultaneous occurrence of bullous pemphigoid and primary biliary cirrhosis in an 86-year-old patient who also suffered from vitiligo. Multiple autoimmune syndrome, proposed by Humbert and Dupond, can be divided into three groups based on preferential associations of autoimmune disorders. The association of bullous pemphigoid, cirrhosis biliary primary and vitiligo has been reported three times in the literature. This association is probably not fortuitous and suggests a pathogenic relationship. This association is not typical of the multiple autoimmune syndrome as defined by Humbert and Dupond but the collection of such observations may contribute to revise the classification of autoimmune disease and provide a better understanding of the pathophysiological mechanisms of autoimmunity.

Oral and topical L-phenylalanine, clobetasol propionate, and UVA/sunlight--a new study for the treatment of vitiligo

BACKGROUND

Vitiligo is a hypopigmented skin condition that usually requires a combination of treatment options.

AIM

To demonstrate the effectiveness of topical and oral L-phenylalanine in combination with light plus 0.025% clobetasol propionate at night.

PATIENTS AND METHODS

We have performed an open trial on a group of 70 patients with evolutive vitiligo. Participants were treated with oral (100 mg/Kg/day) and topical (gel at 10%) L-phenylalanine, exposed to sunlight (spring-summer) or UVA lamps (autumn-winter), and given 0.025% clobetasol propionate at night. All patients were revisited every 6 months while in the study, with a maximum of 4 revisits. Biochemical studies were performed at the beginning of the treatment and at each revisit.

RESULTS

Overall, 90.9% of participants showed improvement, with 68.5% of patients achieving an improvement of 75% or more. This 75% improvement rate was reached 87.9% of the time on the face, 60.4% on the trunk, and 54.6% on the limbs. However, there was a moderate response to the treatment in patients with focal and segmental vitiligo. There was a slight additional improvement in patients receiving UVA lamp light. No biochemical abnormalities were found in any patients.

CONCLUSION

L-phenylalanine in combination with 0.025% clobetasol propionate and sunlight during sunny months or UVA lamps in winter, appears to improve evolutive vitiligo without side effects, and therefore is especially recommended on the face or for children.

A case of giant congenital nevocytic nevus with neurotization and onset of vitiligo

The authors report the case of a 21-year-old woman with a giant congenital nevocytic nevus (GCNN) who developed vitiligo at the age of 16 years on skin areas remote from the GCNN. This is the first reported case of GCNN developing neurotization combined with vitiliginous changes within the GCNN lesion. Treatment with PUVA achieved repigmentation of the vitiligo lesions, except for the hypochromic areas within the area of the nevus that were shielded from UVA radiation.