Temozolomide-induced vitiligo-like reaction: An extremely rare phenomenon

ABSTRACT

Temozolomide (TMZ) is an alkylating chemotherapeutic drug, often used in high-grade glioma and metastatic melanoma. Common side effects of this include myelosuppression and gastrointestinal side effects. Vitiligo-like reaction is extremely rare after TMZ. Here, we report a case of a 55-year-old patient of glioblastoma who developed vitiligo-like reaction after starting adjuvant TMZ.

A Rare Case Presentation of Vitiligo Associated With Atezolizumab

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies used in the treatment of solid and hematologic malignancies. Immune checkpoint inhibitors target the T-cell deactivation system via the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) receptor, programmed cell death protein 1 (PD-1) receptor, and programmed cell death ligand 1 (PD-L1). As a result, the activated T-cell enhances the host tumor response. However, even with their essential clinical benefits, ICIs are associated with a broad spectrum of adverse effects that can be generalized or tissue-specific inflammatory responses known as immune-related adverse events (irAEs). The most common dermatologic toxicity manifests mainly as maculopapular rash and pruritus. Understanding the complexity of immune-mediated response and the importance of clinical histopathologic correlation in recognizing irAEs allows for appropriate intervention and patient care due. We present the case of a 71-year-old African American male diagnosed with a large-cell poorly differentiated neuroendocrine tumor in the gastroesophageal junction of the stomach with mediastinal lymphadenopathy. He was treated with carboplatin, etoposide, and atezolizumab for 4 cycles. However, he developed vitiligo while on maintenance atezolizumab, which is rarely seen with atezolizumab use. Despite the improving clinical outcomes in oncology with ICIs, their adverse effects should not be ignored. When promptly recognized and treated, patients on ICI monotherapy may not need treatment interruption or discontinuation.

A Potential Alternative Treatment for Vitiligo: An Observational Study on Tacrolimus 0.3% Lotion

Vitiligo is a complex multifactorial disorder of depigmentation affecting 0.5 to 2% of the world's population without specific gender or racial prevalence.1 Though no treatments are FDA approved to repigment vitiligo, topical medications along with phototherapy alone or in combination remain the mainstay of therapy. While Janus Kinase inhibitors and other agents are in development, current topical options are mainly limited to steroid formulations of various potencies or immunomodulatory steroid-sparing agents such as tacrolimus 0.03% or 0.1%.

Simvastatin and non-segmental vitiligo: A new potential treatment option?

There is a paucity of data about the impact of systemic statins on vitiliginous lesions in non-segmental vitiligo (NSV) patients. To the best of our knowledge, no other studies have considered the correlation between lipid disturbances in vitiligo and vitiligo disease activity (VIDA) score. We sought in this study to evaluate the influence of simvastatin on vitiliginous lesions in NSV patients with dyslipidemia and study the correlation between VIDA score and lipid profile. This clinical trial started with 120 patients with NSV, 79 patients had dyslipidemia and received simvastatin 80 mg daily (till normalization of lipid profile or for 4 months, which came first) and only 63 patients continued till the end of the study. Lipid profile, vitiligo area severity index and VIDA were assessed before and 6 months after the end of simvastatin use. Serum total cholesterol (TC), triglycerides, high-density lipoprotein (HDL), low-density lipoprotein (LDL), very low-density lipoprotein, and LDL/HDL ratio showed statistically significant increases in the NSV than in the control group (p ˂ 0.001). There was a statistically significant positive correlation between VIDA and serum levels of TC and LDL and with LDL/HDL ratio. Simvastatin significantly improved the lipid profile and significantly decreased VIDA (p < 0.011). Negative moderate correlation was found between the decrease in VIDA and duration of disease (r = -0.562, p < 0.001). Simvastatin 80 mg daily could be a helpful treatment for NSV patients with dyslipidemia, controlling the vitiligo activity and protecting against the hazardous effects of dyslipidemia. Better results can be obtained in patients with short duration of the disease.

Sesquiterpenoids from Seriphidium transiliense and Their Melanogenic Activity

A sesquiterpenoid with an unprecedented 5/5/4 tricyclic skeleton (1), a nor-sesquiterpenoid with a rare 6/7 bicyclic skeleton (2), 10 new sesquiterpenoids (3-12), and six known analogues (13-18) were isolated from the whole plants of Seriphidium transiliense. The structures of compounds 1-12 were elucidated by spectroscopic data analysis. Compound 7 showed melanogenic promotion activity in murine melanoma (B16) cells more potent than the positive control used, 8-methoxypsoralen (8-MOP). Further mechanistic studies indicated that compound 7 promotes melanogenesis through activating the transcription of microphthalmia-associated transcription factor (MITF) and tyrosinase family genes in B16 cells. Moreover, compound 7 also inhibited the expression of IFN-γ-chemokine through the JAK/STAT signaling pathway in immortalized human keratinocyte (HaCaT) cells. These results suggest that the sesquiterpenoid 7 shows potential activity for treating vitiligo.

Topological Indices of Novel Drugs Used in Autoimmune Disease Vitiligo Treatment and Its QSPR Modeling

A topological index is a real number derived from the structure of a chemical graph. It is helpful to determine the physicochemical and biological properties of a wide range of drugs, and it better reflects the theoretical properties of organic compounds. This is accomplished using degree-based topological indices. Vitiligo is a common, acquired skin pigmentation disorder that significantly impacts the quality of life. It frequently embodies a therapeutic challenge, resulting in interest in alternative treatments based on vitamin and herbal supplements. In this article, azathioprine, clobetasol, desonide, hydrocortisone valerate, and other drugs utilized to cure vitiligo have discoursed, and the goal of QSPR revision is to determine the mathematical relationship between properties under investigation (e.g., polarity and enthalpy) and diverse descriptors associated with the drugs' molecule. The QSPR model will help to predict physical properties. In this study, topological indices (TIs) imposed on said drugs were found to have a good correlation with physicochemical properties in this course. Finally, this work can be helpful to design and synthesize new vitiligo treatments and other disease drugs.

A Possible Modulator of Vitiligo Metabolic Impairment: Rethinking a PPARγ Agonist

Vitiligo is a complex disease wherein derangements in multiple pathways determine the loss of functional melanocytes. Since its pathogenesis is not yet completely understood, vitiligo lacks a definitive safe and efficacious treatment. At present, different therapies are available; however, each modality has its baggage of disadvantages and side effects. Recently we have described several metabolic abnormalities in cells from pigmented skin of vitiligo patients, including alterations of glucose metabolism. Therefore, we conducted a study to evaluate the effect of Pioglitazone (PGZ), a Peroxisome proliferator-activated receptor-γ (PPARγ) agonist, on cells from pigmented vitiligo skin. We treated vitiligo melanocytes and fibroblasts with low doses of PGZ and evaluated the effects on mitochondrial alterations, previously reported by our and other groups. Treatment with PGZ significantly increased mRNA and protein levels of several anaerobic glycolytic enzymes, without increasing glucose consumption. The PGZ administration fully restored the metabolic network, replacing mitochondrial membrane potential and mitochondrial DNA (mtDNA) copy number. These effects, together with a significant increase in ATP content and a decrease in reactive oxygen species (ROS) production, provide strong evidence of an overall improvement of mitochondria bioenergetics in vitiligo cells. Moreover, the expression of HMGB1, Hsp70, defined as a part of DAMPs, and PD-L1 were significantly reduced. In addition, PGZ likely reverts premature senescence phenotype. In summary, the results outline a novel mode of action of Pioglitazone, which may turn out to be relevant to the development of effective new vitiligo therapeutic strategies.

New Indication for Topical Ruxolitnib

The Food and Drug Administration has approved the Janus kinase inhibitor ruxolitnib (Opzelura) as topical treatment for nonsegmental vitiligo in children and adults ages 12 years and older.The most common adverse effects are application site acne, application site itching, common cold, headache, urinary tract infection, application site redness, and fever.

Two Phase 3, Randomized, Controlled Trials of Ruxolitinib Cream for Vitiligo

BACKGROUND

Vitiligo is a chronic autoimmune disease that causes skin depigmentation. A cream formulation of ruxolitinib (an inhibitor of Janus kinase 1 and 2) resulted in repigmentation in a phase 2 trial involving adults with vitiligo.

METHODS

We conducted two phase 3, double-blind, vehicle-controlled trials (Topical Ruxolitinib Evaluation in Vitiligo Study 1 [TRuE-V1] and 2 [TRuE-V2]) in North America and Europe that involved patients 12 years of age or older who had nonsegmental vitiligo with depigmentation covering 10% or less of total body-surface area. Patients were randomly assigned in a 2:1 ratio to apply 1.5% ruxolitinib cream or vehicle control twice daily for 24 weeks to all vitiligo areas on the face and body, after which all patients could apply 1.5% ruxolitinib cream through week 52. The primary end point was a decrease (improvement) of at least 75% from baseline in the facial Vitiligo Area Scoring Index (F-VASI; range, 0 to 3, with higher scores indicating a greater area of facial depigmentation), or F-VASI75 response, at week 24. There were five key secondary end points, including improved responses on the Vitiligo Noticeability Scale.

RESULTS

A total of 674 patients were enrolled, 330 in TRuE-V1 and 344 in TRuE-V2. In TRuE-V1, the percentage of patients with an F-VASI75 response at week 24 was 29.8% in the ruxolitinib-cream group and 7.4% in the vehicle group (relative risk, 4.0; 95% confidence interval [CI], 1.9 to 8.4; P<0.001). In TRuE-V2, the percentages were 30.9% and 11.4%, respectively (relative risk, 2.7; 95% CI, 1.5 to 4.9; P<0.001). The results for key secondary end points showed superiority of ruxolitinib cream over vehicle control. Among patients who applied ruxolitinib cream throughout 52 weeks, adverse events occurred in 54.8% in TRuE-V1 and 62.3% in TRuE-V2; the most common adverse events were application-site acne (6.3% and 6.6%, respectively), nasopharyngitis (5.4% and 6.1%), and application-site pruritus (5.4% and 5.3%).

CONCLUSIONS

In two phase 3 trials, application of ruxolitinib cream resulted in greater repigmentation of vitiligo lesions than vehicle control through 52 weeks, but it was associated with acne and pruritus at the application site. Larger and longer trials are required to determine the effect and safety of ruxolitinib cream in patients with vitiligo. (Funded by Incyte; TRuE-V1 and TRuE-V2 ClinicalTrials.gov numbers, NCT04052425 and NCT04057573.).

Advances in vitiligo: Update on therapeutic targets

Vitiligo, whose treatment remains a serious concern and challenge, is an autoimmune skin disease characterized by patches of depigmentation. The increasing application of molecular-targeted therapy in skin diseases, such as psoriasis and systemic lupus erythematosus, has dramatically improved their condition. Besides, there is a favorable effect of repigmentation in the treatment of the above diseases combined with vitiligo, implying that molecular-targeted therapy may also have utility in vitiligo treatment. Recently, the role of cytokine and signaling pathways in vitiligo pathogenesis are increasingly recognized. Thus, investigations are underway targeting the molecules described above. In this paper, we present a synopsis of current practices in vitiligo treatment and introduce the improvement in identifying new molecular targets and applying molecular-targeted therapies, including those under development in vitiligo treatment, providing valuable insight into establishing further precision medicine for vitiligo patients.

Molecular mechanism of vitiligo treatment by bailing tablet based on network pharmacology and molecular docking

BACKGROUND

Bailing tablet, a patent Chinese medicine, is widely used to treat vitiligo in China. However, the underlying mechanism of this combined drug in treating vitiligo still remains unclear.

OBJECTIVE

This study aimed to investigate the pharmacological mechanism of bailing tablet in the prevention and treatment of vitiligo using network pharmacology and molecular docking.

METHODS

Genetic data of vitiligo and normal people were obtained by gene expression omnibus (GEO) DataSets database and GEO difference analysis was conducted to obtain differential genes. The main active compounds and corresponding target genes of bailing tablet were collected from Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform. Combined with the results of GEO difference analysis, the main compounds and corresponding target genes of bailing tablet in the treatment of vitiligo were screened. The network diagram of "traditional Chinese medicine compound target" was constructed by Cytoscape software. According to the differential genes, the core targets with potential therapeutic effect were searched, the protein-protein interaction network was constructed, and the key proteins were explored by topological analysis (CytoNCA). Meanwhile, the core targets were analyzed by biological process (gene ontology) and signal pathway (Kyoto encyclopedia of genes and genomes) function enrichment. Molecular docking technology was adopted to verify the combination of main components and core targets.

RESULTS

A total of 170 active compounds and 1777 prediction targets were screened from 11 traditional Chinese medicines of bailing tablet, of which 65 active components and 68 related prediction targets were closely related to vitiligo. A total of 320 key proteins were obtained by analyzing the topological characteristics of the protein-protein interaction network, mainly including neurotrophic receptor tyrosine kinase 1, tumor protein P53, cullin 3, estrogen receptor 1, etc. The main biological processes involve oxidative stress response, cell response to reactive oxygen species, and reactive oxygen species metabolism. Bailing tablet treats vitiligo mainly by regulating immune inflammation, apoptosis, and autophagy, which involves phosphatidylinositol-4,5-bisphosphate 3-kinase Akt signal pathway, mitogen-activated protein kinase signal pathway, Janus kinase signal transducer and activator of transcription signal pathway, melanin production, and helper T cell (Th)1, Th2, and Th17 differentiation pathway, etc. Molecular docking results showed that the main components could bind to the target protein well.

CONCLUSIONS

Based on network pharmacology and molecular docking, the mechanism of bailing tablet in the treatment of vitiligo through multicomponent, multitarget, and multichannel was deeply explored.

Efficacy of narrow band UVB with or without OMP in stabilization of vitiligo activity in skin photo-types (III-V): A double-blind, randomized, placebo-controlled, prospective, multicenter study

BACKGROUND

NB-UVB has long been the vitiligo management pillar with capability of achieving the main treatment outcomes; repigmentation and stabilization. Its stabilizing effect in dark skin has been debatable. However, randomized controlled trials regarding NB-UVB ability to control disease activity are lacking.

PURPOSE

To assess stabilizing effect of NB-UVB in comparison to systemic corticosteroids, the mainstay in vitiligo stabilization, in skin photo-types (III-V).

METHODS

This is a multicenter, placebo-controlled, randomized, prospective study. Eighty patients with active nonsegmental vitiligo (NSV) (Vitiligo disease activity (VIDA) ≥2) were randomized to either NB-UVB and placebo (NB-placebo) or NB-UVB and dexamethasone oral mini-pulse (OMP) therapy (NB-OMP) for 6 months. Sixty four patients completed the study, 34 in the NB-OMP group and 30 in the NB-placebo group. Patients were evaluated fortnightly according to presence or absence of symptoms/signs of activity.

RESULTS

In spite of earlier control of disease activity observed in the NB-OMP group, it was comparable in both groups by the end of the study period. Disease activity prior to therapy, but not extent, was found to influence control of activity in both groups. Thus, NB-UVB is a safe sole therapeutic tool in vitiligo management. Not only does it efficiently achieve repigmentation, but also it is a comparable stabilizing tool for systemic corticosteroids in spite of slightly delayed control.

CONCLUSION

NB-UVB is the only well-established vitiligo therapy that can be used solely whenever corticosteroids are contraindicated or immune-suppression is unjustified. Nonetheless, its combination with corticosteroids expedites response and improves compliance.

Ribociclib-induced extensive vitiligo-like lesions: possible pathomechanisms with clinical, dermoscopic and histological correlation

Cyclin dependent kinase (CDK) 4/6 inhibitors are targeted agents which act on cyclin-D and these combined with hormonal therapy have been approved for the treatment of locally advanced or metastatic breast cancer. CDK 4/6 inhibitors have been found to have a tolerable adverse event profile; however, they have been associated with various dermatological adverse events. We report a case of ribociclib-induced vitiligo and discuss the clinical, dermoscopic and histological features with a review of the various possible pathomechanisms involved.

Isolation of a Melanoblast Stimulator from Dimocarpus longan, Its Structural Modification, and Structure-Activity Relationships for Vitiligo

A novel melanoblast stimulator (1) was isolated from Dimocarpus longan. Its analogs were also synthesized to support a new furan-based melanoblast stimulator scaffold for treating vitiligo. Isolated 5-(hydroxymethyl)furfural (HMF, 1) is a well-known compound in the food industry. Surprisingly, the melanogenic activity of HMF (1) was discovered here for the first time. Both HMF and its synthetic analog (16) promote the differentiation and migration of melanoblasts in vitro. Typically, stimulator (1) upregulated MMP2 expression, which promoted the migration of melanoblasts in vitro.

Individualized Homeopathic Medicines in Treatment of Vitiligo: Double-Blind, Randomized, Placebo-Controlled Pilot Trial

Objective: The feasibility of a definitive trial was tested to evaluate individualized homeopathic medicines (IHMs) for the treatment of vitiligo. Design: This was a double-blind randomized (1:1) placebo-controlled pilot trial conducted at the National Institute Homeopathy, India. Sixty patients with vitiligo were included in the study. Interventions: IHMs and identical-looking placebos at 50-millesimal (LM) potencies. Outcome measures: Feasibility issues and scores from the Vitiligo Area Scoring Index (VASI), Vitiligo-specific Quality-of-life instrument (VitiQoL), and Dermatology Life Quality Index (DLQI) were measured at baseline and after 3 and 6 months. Results: The recruitment and retention rates were satisfactory. Mean reductions in the outcome measures were higher in the IHM group than placebo. Conclusions: Definitive efficacy trials are warranted. Clinical Trials Registry-India: CTRI/2018/10/016160; secondary identifier UTN: U1111-1221-7704.

Biomimetic Melanosomes Promote Orientation-Selective Delivery and Melanocyte Pigmentation in the H2O2-Induced Vitiligo Mouse Model

Extremely limited drug retention and depigmentation represent the greatest barriers against vitiligo treatment advancement. Here, inspired by biological melanosomes, the primary melanin transporter, we developed biomimetic melanosomes to combat reactive oxygen species (ROS)-mediated melanocyte damage and depigmentation. Briefly, methylprednisolone (MPS) and melanin-mimicking polydopamine (PDA) were encapsulated inside lysine-proline-valine (KPV)-modified deformable liposomes (KPV-Lipos). Owing to their phospholipid bilayer flexibility and the specific affinity for melanocortin 1 receptor (MC1R), KPV-Lipos exhibited 1.43-fold greater skin deposition than traditional liposomes. The binding of KPV and its receptor also contributed to activating the cAMP-tyrosinase (TYR) signaling pathway, improving the endogenous melanin content. In addition, PDA mimicked melanosomes as it effectively increased the exogenous melanin content and scavenged ROS. Meanwhile, MPS inhibited inflammatory cytokine secretion, limiting the depigmented area. Ultimately, the biomimetic melanosomes affected the skin color of mice with H₂O₂-induced vitiligo. These melanosomes show potential as a universal platform for the self-supply of melanin by self-driven melanin synthesis with exogenous supplementation. Furthermore, this study offers ideas for the production of artificial packed melanosome substitutes for melanocyte-related diseases.

Role of Cytokines in Vitiligo: Pathogenesis and Possible Targets for Old and New Treatments

Vitiligo is a chronic autoimmune dermatosis of which the pathogenesis remains scarcely known. A wide variety of clinical studies have been proposed to investigate the immune mediators which have shown the most recurrency. However, such trials have produced controversial results. The aim of this review is to summarize the main factors involved in the pathogenesis of vitiligo, the latest findings regarding the cytokines involved and to evaluate the treatments based on the use of biological drugs in order to stop disease progression and achieve repigmentation. According to the results, the most recurrent studies dealt with inhibitors of IFN-gamma and TNF-alpha. It is possible that, given the great deal of cytokines involved in the lesion formation process of vitiligo, other biologics could be developed in the future to be used as adjuvants and/or to entirely replace the treatments that have proven to be unsatisfactory so far.

Comparison of efficacy and safety of traditional Chinese patent medicine in the treatment of vitiligo in children or adults: A protocol for systematic review and network meta-analysis

BACKGROUND

Vitiligo is a common depigmented skin disease in children or adults, which usually causes considerable psychological burden to life and work for the reason that it affects appearance. The conventional therapies, including external 308 nm excimer laser therapy along with oral administration of western medicine, are associated with distinct disadvantages. Notably, traditional Chinese patent medicine (TCPM) exerts a vital part in treating vitiligo. Currently, no existing research has examined the effectiveness and safety of different TCPMs in treating vitiligo among either child or adult patients. As a result, the present network meta-analysis was carried out for the systematic comparison of the effectiveness of different TCPMs in treating vitiligo.

METHODS

The electronic databases, like PubMed, Web of Science, EMBASE, The Cochrane Library, Chinese Scientific Journals Database, China National Knowledge Infrastructure, Wanfang database and China BioMedical Literature, were searched systemically by 2 reviewers independently from inception to August 2020 to identify relevant randomized controlled trial (RCTs) according to our study inclusion criteria. In data extraction, risk of bias among those enrolled articles was also detected. Besides, the Bayesian network meta-analysis method was utilized to evaluate the evidence and data collected. This adopted the STATA and Win BUGS software for analysis.

RESULTS

The present work assessed the safety and efficacy of different TCPMs in treating vitiligo among child or adult patients.

CONCLUSION

Our findings can shed precious lights on applying TCPMs in clinic and help the clinicians to formulate the efficient diagnostic and therapeutic strategies.

ETHICS AND DISSEMINATION

No ethical approval was needed in this study.

INPLASY REGISTRATION NUMBER

INPLASY2020120050.

Efficacy and Safety of Tacrolimus 0.1% for the Treatment of Facial Vitiligo: A Multicenter Randomized, Double-Blinded, Vehicle-Controlled Study

BACKGROUND

Topical calcineurin inhibitors are used off label in the treatment of vitiligo, and there is a lack of placebo-controlled, blinded studies to support their use.

OBJECTIVE

This study aimed to compare the efficacy of tacrolimus 0.1% ointment with that of the vehicle for repigmentation in adult patients with facial vitiligo.

DESIGN

This study was a 24-week multicenter randomized parallel double-blind study with a 24-week post-treatment follow-up extension.

POPULATION

Participants included were adult patients with recent facial vitiligo target lesions (<2 years) without changes in pigmentation or size over the previous 3 months.

INTERVENTION

Patients received either tacrolimus 0.1% ointment or vehicle twice daily.

MAIN OUTCOMES AND MEASURES

The primary outcome was a therapeutic success, defined as a change ≥75% in the repigmentation of the target lesion between baseline and week 24, measured by ImageJ software. Secondary outcome measures were a variation of the physicians' global assessment scores and patients' satisfaction scores, safety data, and the rate of relapse at week 48.

RESULTS

A total of 42 patients were included. Therapeutic success was achieved in 65% of tacrolimus-treated patients versus 0% of vehicle-treated patients at week 24 (P < 0.0001). Only 40% of relapse was observed at 48 weeks.

CONCLUSIONS AND RELEVANCE

Twice-daily tacrolimus 0.1% ointment showed superior efficacy to that of the vehicle through the 24 weeks of intervention and 24 weeks of follow-up in adult patients with facial vitiligo.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (identifier: NCT02466997).