A review of the worldwide prevalence of vitiligo in children/adolescents and adults

Intradermal injection of Fluorouracil versus triamcinolone in localized vitiligo treatment

BACKGROUND

Vitiligo is an autoimmune disease with a prevalence of 1.22% in Egypt. Intralesional steroids use in localized vitiligo treatment still a matter of debate. Fluorouracil was tried in vitiligo treatment after lesion dermabrasion, ablative laser, or micro-needling. The study aimed to compare the efficacy of intradermal fluorouracil and triamcinolone acetonide without any adjuvant therapy in localized vitiligo treatment.

PATIENTS AND METHODS

Sixty patients with localized non-segmental stable vitiligo were assigned randomly and equally into groups. Patients subjected to intradermal injection of either fluorouracil (50 mg/mL), triamcinolone acetonide (3 mg/mL) or an equal mixture of both drugs. All patients had four treatment sessions every 2 weeks were followed up for 6 months.

RESULTS

Intradermal fluorouracil showed the best overall improvement (median 52.27, IQR 36.25-68.18) when compared with triamcinolone (median 13.86, IQR 3.83-33.32) and the drug mixture (median 17.15, IQR 7.48-41.67). During follow-up, the vitiliginous patches continued to repigment for 6 months in fluorouracil and the drug mixture groups. The improvement stopped 1 month after the last session in the triamcinolone group.

CONCLUSION

The intradermal fluorouracil injection is an effective treatment of localized vitiligo. The intradermal steroid has a short-acting therapeutic effect, but the mixture of drugs added no therapeutic effect.

Clinical and epidemiological characteristics of childhood vitiligo: a study of 701 patients from Brazil

BACKGROUND

Vitiligo is an acquired pigmentary disorder that affects approximately 0.5-2% of the world's population, and 25% of cases begin before 10 years of age. Although prevalent, there are few studies on the characterization of childhood vitiligo.

OBJECTIVE

To evaluate the clinical and epidemiological characteristics of childhood vitiligo.

METHODS

Transverse study conducted by reviewing data records of patients under the age of 18 in which disease onset occurred before 13 years of age.

RESULTS

Predominance of females (62%). The most common subtype was generalized vitiligo (53.8%). The average age of disease onset was 5.9 years. The most affected initial site was head/neck (44.22%). The Koebner phenomenon was present in 38.2%, emotional triggering factors in 67.0% of the patients, halo nevus in 17.4%, and associated autoimmune disease in 6.5% of the patients. Family history of vitiligo was observed in 16.9% of the patients, and stability was reported by 20.1% of patients. The presence of positive family history did not significantly influence the age of onset. We found a significant difference between segmental vitiligo (SV) and nonsegmental vitiligo (NSV) regarding the age of onset, Koebner phenomenon, hypothyroidism, anti-TPO antibodies, family history of psoriasis, and halo nevus.

CONCLUSION

Childhood vitiligo has its own characteristics. Vitiligo different subtypes have distinct characteristics. Our study presents a great number of patients, helping to elucidate the peculiarities of childhood vitiligo in the Brazilian population.

MicroRNA‑155 inhibits the proliferation of CD8+ T cells via upregulating regulatory T cells in vitiligo

It has been reported that loss and degradation of epidermal melanocytes is closely associated with the pathogenesis of vitiligo. In addition, CD8⁺ T and regulatory T (Treg) cells serve an important role during these two processes. MicroRNA-155 (miR-155) is known to contribute to the pathogenesis of vitiligo; however, the mechanism by which miR-155 regulates the development of vitiligo remains unclear. In the present study, naïve T and CD8⁺ T cells were isolated from a patient with non-segmental vitiligo by flow cytometry. The cells were differentiated into Treg cells by treatment with interleukin-2, transforming growth factor-β and retinoic acid. In addition, miR-155 agonists and antagonists were used to investigate the effect of miR-155 on the proliferation of CD8⁺ T cells, Treg cells and melanocytes. The results demonstrated that the miR-155 agonist significantly decreased the rate of CD8⁺ T cell growth, as well as promoted the proliferation of melanocytes by inducing an increase in the percentage of Treg cells. By contrast, the miR-155 antagonist inhibited the proliferation of melanocytes by decreasing the percentage of Treg cells. miR-155 protected melanocyte survival by increasing the number of Treg cells and by decreasing the number of CD8⁺ T cells. Therefore, these data may provide a new prospect for the treatment of vitiligo.

Childhood Vitiligo

Vitiligo is a common acquired depigmenting skin disease characterized by a progressive loss of functional melanocytes. It may appear from the first years of life to late adulthood. Childhood vitiligo (CV), defined as vitiligo that begins before the age of 12 years, is common and may differ from post-CV in terms of epidemiology, clinical presentation, comorbidities, and treatment options. Taking into consideration the potential significant psychosocial impact of the disease on both children and their parents, all available therapeutic options must be offered to patients who desire treatment. According to the most recent guidelines, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the most commonly used treatment modalities for vitiligo in children. This review presents recent data regarding the whole spectrum of CV. Differences between CV and post-CV are also discussed.

Immunopathological manifestations in Kabuki syndrome: a registry study of 177 individuals

PURPOSE

Kabuki syndrome (KS) (OMIM 147920 and 300867) is a rare genetic disorder characterized by specific facial features, intellectual disability, and various malformations. Immunopathological manifestations seem prevalent and increase the morbimortality. To assess the frequency and severity of the manifestations, we measured the prevalence of immunopathological manifestations as well as genotype-phenotype correlations in KS individuals from a registry.

METHODS

Data were for 177 KS individuals with KDM6A or KMT2D pathogenic variants. Questionnaires to clinicians were used to assess the presence of immunodeficiency and autoimmune diseases both on a clinical and biological basis.

RESULTS

Overall, 44.1% (78/177) and 58.2% (46/79) of KS individuals exhibited infection susceptibility and hypogammaglobulinemia, respectively; 13.6% (24/177) had autoimmune disease (AID; 25.6% [11/43] in adults), 5.6% (10/177) with ≥2 AID manifestations. The most frequent AID manifestations were immune thrombocytopenic purpura (7.3% [13/177]) and autoimmune hemolytic anemia (4.0% [7/177]). Among nonhematological manifestations, vitiligo was frequent. Immune thrombocytopenic purpura was frequent with missense versus other types of variants (p = 0.027).

CONCLUSION

The high prevalence of immunopathological manifestations in KS demonstrates the importance of systematic screening and efficient preventive management of these treatable and sometimes life-threatening conditions.

The color of skin: white diseases of the skin, nails, and mucosa

White diseases are a heterogenous group characterized by hypopigmentation or depigmentation. Skin and eye color are determined by the number and size of melanosomes present. Melanin is produced by melanosomes in the melanocytes present within the epidermis of the skin, uvea, and retinal pigmented epithelium (RPE). Conditions altering the number of melanocytes or concentration of melanin result in a lack of pigmentation, appearing as "white diseases" ranging from the well-known albinism and vitiligo to more esoteric white hand syndrome and Degos disease.

Catalase but not vitamin D receptor gene polymorphisms are associated with nonsegmental vitiligo in Northwestern Mexicans

BACKGROUND

Vitiligo is an acquired pigmentation disorder characterized by melanocyte loss via autoimmune mechanisms triggered by oxidative stress. Gene polymorphisms in antioxidant enzymes and immunomodulators such as catalase (CAT) and vitamin D receptor (VDR), respectively, have been linked to vitiligo in European and Asian populations. Our aim was to evaluate the role of CAT and VDR gene polymorphisms as well as CAT and vitamin D in nonsegmental vitiligo in Northwestern Mexicans.

METHODS

A total of 357 subjects, 173 nonsegmental vitiligo patients and 184 age-gender matched healthy controls, were genotyped by PCR-restriction fragment length polymorphism. CAT activity was determined in 39 patients and in 39 controls and vitamin D (VitD) levels in 35 individuals per group.

RESULTS

CAT 419 C/T gene polymorphism was not informative, -89 A/T was associated with risk (P = 0.02), and 389 C/T conferred protection against vitiligo along with AT haplotype (P < 0.01 in both cases). VDR BsmI, ApaI, and TaqI gene polymorphisms were not associated with vitiligo, but BsmI was more prevalent in patients with Koebner phenomenon (P = 0.02). Serum CAT activity and VitD levels were lower in patients than in controls, but they showed no association with any vitiligo clinical characteristics neither with their gene polymorphisms.

CONCLUSIONS

Our results suggest a role for CAT gene polymorphisms in vitiligo susceptibility in the Mexican population and a lack of association with VDR gene polymorphisms.

Glycyrrhizin protects human melanocytes from H2O2‑induced oxidative damage via the Nrf2‑dependent induction of HO‑1

Oxidative stress serves a critical role in melanocyte death and is considered to be a major cause of vitiligo. The nuclear factor E2-related factor 2 (Nrf2) signaling pathway has an important role in the antioxidative stress mechanisms of melanocytes. Glycyrrhizin (GR) is a derivative of herbal medicines used to treat hepatitis and allergic disease due to its antiviral and anti-allergy effects. GR also activates Nrf2 and induces the expression of heme oxygenase (HO)-1 in macrophages. Whether GR can protect human melanocytes from oxidative stress remains unknown. The present study investigated the potential protective effects of GR against oxidative stress in human melanocytes and the mechanisms involved. Following exposure to 0.5 mM hydrogen peroxide (H₂O₂), human primary melanocytes were treated with 1 mM GR. Cell viability was determined using a Cell Counting Kit-8 assay, and apoptosis was evaluated by flow cytometry. GR treatment significantly improved cell viability, reduced the apoptotic rate of melanocytes and reduced the level of reactive oxygen species in human melanocytes. Furthermore, GR induced the nuclear translocation of Nrf2 and induced the expression of HO-1 in melanocytes. The knockdown of Nrf2 by small interfering RNA or the inhibition of HO-1 by ZnPP reversed the protective effect of GR on melanocytes against H₂O₂-induced cytotoxicity and apoptosis. These data demonstrate that GR protects human melanocytes from H₂O₂-induced oxidative damage via the Nrf2-dependent induction of HO-1, providing evidence for the application of GR in the treatment of vitiligo.

Systemic Redox Imbalance Along with Increased Serum Sialic Acid is Prevalent in Patients with Active Vitiligo: A Study from a Tertiary Care Teaching Hospital of Eastern India

Background:

Vitiligo is one of the common depigmenting disorders causing disfigurement and affecting the quality of life. Redox imbalance is known to play a contributory role in melanocyte destruction. Serum sialic acid (SA) is an important marker of the acute-phase response and is associated with oxidative protein damage.

Aim:

The aim of this study was to analyze the status of oxidative stress markers and serum SA in vitiligo patients and to correlate the same with disease activity.

Materials and Methods:

The different oxidative stress parameters namely superoxide dismutase (SOD), malondialdehyde (MDA), and serum SA were measured spectrophotometrically using standard biochemical methodologies in all the study subjects.

Results:

Serum SOD and MDA values were higher in patients with active vitiligo (n = 23) as compared to stable vitiligo (n = 20) and healthy controls (n = 20). The MDA/SOD ratio was higher in patients with active vitiligo (P<0.0001). Serum SA was increased in active vitiligo as compared to stable vitiligo and healthy controls (P<0.0001).

Conclusion:

This study indicates that patients with active vitiligo demonstrate enhanced MDA/SOD ratio and increased serum SA. The studied parameters can serve as an important tool to monitor disease activity in vitiligo.

Association Between Psoriasis and Vitiligo: A Systematic Review and Meta-Analysis

BACKGROUND

The relationship between psoriasis and vitiligo has not been previously confirmed, and we therefore aimed to investigate this association.

METHODS

We conducted a search of the MEDLINE and EMBASE electronic databases on 22 January 2018 for case-control, cross-sectional, and cohort studies examining the association between psoriasis and vitiligo. A customized Newcastle-Ottawa Scale was used to assess the risk of bias of the included studies. We performed a random effects meta-analysis to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs) for case-control and cross-sectional studies.

RESULTS

Of 2453 citations identified from the literature search, 10 case-control/cross-sectional studies with a total of 120,866 psoriasis cases and 79,907 vitiligo cases were included in our study. Four of these studies were rated as high risk of bias. We found a significantly increased odds for vitiligo in psoriasis patients (summary OR 2.29, 95% CI 1.56-3.37, studies = 7), as well as a significantly elevated odds for psoriasis in vitiligo patients (summary OR 3.43, 95% CI 1.86-6.33, studies = 4).

CONCLUSIONS

Our meta-analysis showed that psoriasis and vitiligo are associated with each other. Several studies had a high risk of bias, and further investigation is needed to confirm this association and amplify treatment options.

Noncultured Extracted Hair Follicle Outer Root Sheath Cell Suspension versus Noncultured Epidermal Cell Suspension in the Treatment of Stable Vitiligo

Background:

Various treatment modalities exist for vitiligo, yet none of them are curative. Vitiligo is still considered a challenging disease to manage. Surgical treatment offers an excellent option for patients with stable vitiligo, especially those who fail to respond to medical treatment. Cell suspension techniques carry the advantage of covering large surface areas.

Objective:

To compare noncultured extracted hair follicle outer root sheath cell suspension (NCORSHFS) and noncultured epidermal cell suspension (NCES) in producing repigmentation.

Subjects and Methods:

Twenty patients were randomly allocated into two groups. They were objectively evaluated for the extent of repigmentation (after 1, 2, and 3 months), complications, cosmetic outcome, and satisfaction.

Results:

In NCORSHFS group, 10% showed excellent pigmentation, 20% showed good pigmentation, 50% fair, and 20% poor pigmentation. In NCES group, 10% showed excellent pigmentation, 10% good pigmentation, 40% fair, and 40% poor pigmentation. This difference was not statistically significant. Excellent color match was observed in 80% of NCORSHFS and in 70% of NCES. Donor area complications were absent in NCORSHFS group, whereas in NCES, mild scarring in 20% and hyperpigmentation in 40% of patients was observed. The difference in patients’ satisfaction between the two groups was not statistically significant.

Conclusion:

Both NCORSHFS and NCES are effective in producing good repigmentation with perfect color match and patients’ satisfaction. NCORSHFS has no donor area complications because it is a scarless procedure.

A comparative study between suction blistering graft, mini punch graft, and hair follicle transplant in treatment of patients with stable vitiligo

Background: Vitiligo is an acquired disfiguring common depigmented skin disease. Objectives: This study aimed to compare the clinical efficacy and safety of suction blistering graft, mini punch and hair follicle techniques in treatment of patients with stable vitiligo. Methods: Thirty patients with stable vitiligo were included. Patients were divided into 3 groups, in group (A) 10 patient underwent suction blistering technique, in group (B) 10 patients underwent mini punch technique and in group (C) 10 patients underwent hair follicle technique. Then all patients in the three techniques were subjected to narrow-band ultraviolet B (NB-UVB) phototherapy for 3 months. All patients were assessed by determining the percentage of repigmentation and Dermatology Life Quality Index (DLQI) before and 3 months after the operation. Results: The percentage of repigmentation of vitiligo in suction blister technique was significantly higher than both mini punch and hair follicle techniques (p value .001 and .0001 respectively). There was a statistically significant difference between the three techniques regarding DLQI score after operation (p value = .0001). Conclusion: This study concluded that suction blistering technique is more effective and safe than mini punch technique and hair follicle technique in treatment of stable vitiligo.

A Newly Authenticated Compound from Traditional Chinese Medicine Decoction Induces Melanogenesis in B16-F10 Cells by Increasing Tyrosinase Activity

Vitiligo is a kind of skin dysfunction on melanogenesis. The highly prevalent, chronic, and distinctive complexion changes on patients have imposed enormous psychic and economic burden on both individuals and society. Traditional Chinese Medicine (TCM) is a kind of precious source on chronic disease treatment, including skin dysfunctional diseases. In our previous study, a new compound named apigenin-7-butylene glucoside has been authenticated and purified from a prescription of Chinese traditional medicine formula which has been used clinically in vitiligo treatment. The aim of this work is to evaluate the effects of this compound on melanogenesis using melanoma cell B16-F10 in vitro. The results showed that apigenin-7-butylene glucoside had almost no cytotoxicity on B16-F10 cells within a lower dose of 5.0 μg ml⁻¹ and enhanced the melanin level to about 41% and tyrosinase activity to 1.32-fold when compared with controls. The compound showed minor cytotoxicity to B16-F10 cells at the higher concentration of 10 μg ml⁻¹ and 50 μg ml⁻¹, the inhibition rate was 8.4% and 11.8%, and the melanin level and tyrosinase activity showed a decreased trend because of the lower cell number at the higher concentrations. The results indicated that apigenin-7-butylene glucoside was safe to B16-F10 cells within a lower concentration, <5.0 μg ml⁻¹. Incubated with 5.0 ug ml⁻¹of apigenin-7-butylene glucoside for 48 hours, the mRNA and protein levels of Tyr, Trp-1, and Trp-2 genes were all increased except Mitf in B16-F10 cells. The stimulation of apigenin-7-butylene glucoside on melanogenesis of B16-F10 cells through Tyr, Trp-1, and Trp-2 pathway highlighted the potential usage of the compound in vitiligo treatment.

Flavonoids as adjuvant in psoralen based photochemotherapy in the management of vitiligo/leucoderma

Vitiligo is a disorder characterized by the decrease in melanin pigment of skin. This depigmenting disorder has prevalence among worldwide, irrespective of age and sex. There is an existence of different treatment modalities for the management of vitiligo. But irrespective of treatment methods, the main drawback in the management of vitiligo is the occurrence of side effects during the implication of treatment. Among the treatment modalities, photochemotherapy seems to be the better choice of treatment for vitiligo. Photochemotherapy involves the usage of UV rays for photoactivation of the drug to cause photosensitization of skin which in turn leads to repigmentation. The main aim of the study is to develop novel combination strategy of lipid based nanoemulsion gel for the treatment of leucoderma using trimethylpsoralen and flavonoid. We assume that if this hypothesis of combination therapy proves successful it can be used as an additional novel treatment strategy in the management of vitiligo.

HMGB1 deficiency reduces H2 O2 -induced oxidative damage in human melanocytes via the Nrf2 pathway

Oxidative stress leads to melanocyte death and has been implicated in the pathogenesis of vitiligo. The nuclear factor, E2‐related factor 2 (Nrf2), is a critical transcription factor in protecting cells from oxidative damage. High‐mobility group box 1 (HMGB1) is a chromatin‐associated nuclear protein and an extracellular damage‐associated molecular pattern molecule. Extracellular HMGB1 released from activated immune cells, necrotic or injured cells, becomes a proinflammatory mediator through binding to cell‐surface receptors of responding cells. In this study, we investigated the role of HMGB1 from melanocytes in the response to oxidative stress and the mechanism involved. We showed that HMGB1 is expressed by primary normal human epidermal melanocytes (NHEMs). H₂O₂ treatment increased cytoplasmic translocation and extracellular release of HMGB1. HMGB1 knockdown by small interfering RNA (siRNA) led to decreased apoptosis of NHEMs. HMGB1 inhibition enhanced the expression of Nrf2 and its target genes. The expression of Nrf2 and its downstream antioxidant genes was downregulated after the supernatant of H₂O₂‐treated NHEMs was added to HMGB1‐deficient cells. HMGB1 knockdown by siRNA suppressed the expression of the autophagosome marker, LC3, and enhanced p62 expression. Coimmunoprecipitation with Keap1 showed a reduced Nrf2‐Keap1 interaction and an increased p62‐Keap1 interaction under oxidative stress. These data demonstrated that external stimuli (eg, oxidative stress) may trigger autocrine HMGB1 translocation and release by melanocytes, suppressing the expression of Nrf2 and downstream antioxidant genes to induce melanocyte apoptosis, and thereby participate in the pathological process of vitiligo.

Patient-reported outcomes: A 5-year long study reveals previously unreported therapeutic, demographic, socio-economic, and other correlations in vitiligo

Vitiligo is a non-lethal, non-communicable, immune-mediated, and generally progressive skin disease, with poorly understood etiopathogenesis and weak evidence base. The aim of the study is to contribute to the scant research on the patient-reported outcomes in vitiligo, and to examine the presence of associations between various inputs for possible use in clinical practice. The study was designed as a web-based questionnaire with 40 inputs across seven dimensions. The questions include demographics, skin type, eye and natural hair color, age of respondent and age of onset, possible triggers, disease extent, localization, progression and activity, the efficacy of most common treatment modalities, medication side-effects, heredity and diseases among parents, and out-of-pocket expenses for treatments to date. The analysis presented with this work contributes to the discussion about the relation between therapies, socio-economic factors, and treatment outcomes in vitiligo. All physicians should adequately manage patient expectations in terms of overall treatment duration and expected out-of-pocket expenses, and actively evaluate patients at shorter intervals. A more aggressive therapeutic approach using telehealth devices should be considered to supplement therapy, monitor treatment progress, and protocol compliance.

Association of interleukin 1 receptor antagonist intron 2 variable number of tandem repeats polymorphism with vitiligo susceptibility in Gujarat population

Background

Vitiligo is a multifactorial, polygenic, autoimmune skin disorder caused by selective destruction of melanocytes. Interleukin 1 receptor antagonist intron 2 polymorphism was found to be associated with various autoimmune disorders.

Aims

We aimed to investigate the association of interleukin 1 receptor antagonist intron 2 variable number of tandem repeats polymorphism (rs2234663) with vitiligo to assess interleukin 1 receptor antagonist transcript levels and to perform possible genotype-phenotype correlation.

Methods

Three hundred and seven vitiligo patients and 316 controls were enrolled in the study, genotyping of interleukin 1 receptor antagonist rs2234663 was performed by polymerase chain reaction, and relative gene expression of interleukin 1 receptor antagonist was carried out in peripheral blood mononuclear cells from patients (n = 36) and controls (n = 36) by real-time-PCR.

Results

A significant difference was observed in the frequency of interleukin 1 receptor antagonist *A (1/2) genotype among patients with active and stable vitiligo (P = 0.0172). Interleukin 1 receptor antagonist*A (2/2) genotype and allele frequencies were significantly different between SV patients and controls (P = 0.0246 and P = 0.0046, respectively). Significant difference was also observed for interleukin 1 receptor antagonist*A2 (allele) in active and stable vitiligo patients (P = 0.0060). However, other comparisons did not show any significant difference in genotype and allele frequencies. Moreover, interleukin 1 receptor antagonist*A (3/2) genotype was observed only in patients whereas interleukin 1 receptor antagonist*A (5/2) was observed only in controls. Gene expression analysis showed no significant difference in interleukin 1 receptor antagonist transcript levels in patients compared to controls (P = 0.5962). Interestingly, genotype-phenotype correlation analysis revealed that individuals with IL1RN*A (2/2) exhibited higher interleukin 1 receptor antagonist expression compared to other major genotypes interleukin 1 receptor antagonist*A (1/2) (P = 0.01) and interleukin 1 receptor antagonist*A (1/1) (P = 0.03).

Limitations

More case-control studies on interleukin 1 receptor antagonist rs2234663 polymorphism and gene expression from different ethnic populations are required to explore the impact of interleukin 1 receptor antagonist in vitiligo susceptibility.

Conclusion

Interleukin 1 receptor antagonist*A2 might be a risk factor for progressive vitiligo.

Genetic polymorphisms of GZMB and vitiligo: A genetic association study based on Chinese Han population

Vitiligo is a skin disease that affects 1% of the population worldwide. Both environmental and genetic factors contribute to the risk of vitiligo. GZMB encodes the enzyme Granzyme B, which plays an important role in cytotoxic T cell-induced apoptosis, and it has been considered one of the candidate genes for vitiligo because of its connections with human immune system. Overall, 3,120 study subjects with Chinese Han ancestry were recruited, and 15 pre-selected SNPs of GZMB were genotyped. Genetic association analyses were performed to evaluate the genetic risk of these SNPs to vitiligo. Further bioinformatic analyses were conducted to examine the potential biological function of targeted SNPs. The SNP rs8192917, a non-synonymous coding SNP, was identified to be significantly associated with the disease status of vitiligo, with OR = 1.39 and P = 1.92 × 10-8. Differences in the association signal can be observed in the stratification analyses of multiple clinical variables. Our positive results provide additional supportive evidence that GZMB gene is an important locus for vitiligo in Han Chinese population.

MITF and UV responses in skin: From pigmentation to addiction

Ultraviolet radiation (UVR) has numerous effects on skin, including DNA damage, tanning, vitamin D synthesis, carcinogenesis, and immunomodulation. Keratinocytes containing damaged DNA secrete both α-melanocyte-stimulating hormone (α-MSH), which stimulates pigment production by melanocytes, and the opioid β-endorphin, which can trigger addiction-like responses to UVR. The pigmentation (tanning) response is an adaptation that provides some delayed protection against further DNA damage and carcinogenesis, while the opioid response may be an evolutionary adaptation for promoting sun-seeking behavior to prevent vitamin D deficiency. Here, we review the pigmentation response to UVR, driven by melanocytic microphthalmia-associated transcription factor (MITF), and evidence for UVR-induced melanomagenesis and addiction. We also discuss potential applications of a novel approach to generate protective pigmentation in the absence of UVR (sunless tanning) using a topical small-molecule inhibitor of the salt-inducible kinase (SIK) family.

A case series pilot study on the combination of 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) for treatment of vitiligo

BACKGROUND

To study the effective therapeutic concentration, drug application duration, irradiation duration and irradiation dosage of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) for treating vitiligo and observe its clinical efficacy.

OBJECTIVE

To assess the clinical efficacy of ALA-PDT for treating vitiligo.

METHODS

ALA with different drug concentrations, drug application durations, irradiation durations and irradiation dosages were adopted to treat skin lesions caused by vitiligo to determine the effective drug concentration, drug application duration, irradiation duration and irradiation dosage for treating three vitiligo volunteers and observe the therapeutic results.

RESULTS

The clinical trial suggested that ALA at a drug concentration of 1.5%, drug application duration for 3 hours, irradiation dosage of 80mw/cm2 and irradiation duration for 20 min was effective in treating vitiligo. Under these parameters, ALA-PDT was effective to the three vitiligo volunteers, with mild pain and feeling of burning but no other adverse reaction during treatment.

STUDY LIMITATIONS

Due to the small sample size in this study for the effectiveness of PDT in treating vitiligo and the potential variations in the efficacy for treating the disease at different areas, further studies shall be conducted for confirmation.

CONCLUSIONS

ALA with a drug concentration at 1.5%, drug application duration for 3 hours, irradiation dosage of 80 mw/cm2 and irradiation duration for 20 min is effective in treating vitiligo. Therefore, ALA-PDT is safe and effective in treating the disease, with minor adverse events, providing a new method for treating vitiligo in the future.

Replenishing Regulatory T Cells to Halt Depigmentation in Vitiligo

Vitiligo is a cutaneous autoimmune disease, especially devastating to patients with darker skin tones because of the contrast between unaffected and lesional skin. We studied immune cells infiltrating vitiligo skin and found very few regulatory T cells (Tregs). Vitiligo was not associated with a reduced frequency or function of circulating Tregs. To manipulate Treg function, we used mouse models expressing melanocyte-reactive TCRs, following changes in pelage color. We also isolated splenocytes to measure Treg function and evaluated cutaneous Treg abundance. Even small numbers of Tregs transferred into depigmenting mice could effectively interfere with depigmentation. The same holds true for treatment with rapamycin, readily translatable for use in human patients; such treatment may be well tolerated. Because vitiligo skin is relatively devoid of cells that produce the chemokine CCL22, whereas circulating Tregs express normal levels of its receptor CCR4, we overexpressed Ccl22 in the skin of vitiligo-prone mice to assess the resulting levels of depigmentation. Markedly reduced depigmentation was accompanied by Treg infiltration to the skin. With several options available to support a healthy balance between Tregs and effector T cells, the next challenge will be to render such treatment antigen specific and avoid general immunosuppression.

Effect of narrow-band ultraviolet B on the serum of 25-hydroxyvitamin D in vitiligo patients

BACKGROUND

Narrow-band ultraviolet B (NB-UVB) is the gold standard in the treatment of vitiligo. 25-hydroxyvitamin D (25-OH- vitamin D) might play a physiological role in photo-induced melanogenesis in human skin so the association between vitamin D levels and vitiligo still needs to be investigated more thoroughly.

OBJECTIVE

we aim to investigate the influence of cumulative doses of NB-UVB phototherapy on vitamin D in patients with vitiligo and their correlation with NB-UVB-induced pigmentation.

METHODS

Eighty patients of vitiligo and twenty number of age and sex matched controls were recruited in a case-control study. Patients with vitiligo were treated with NB-UVB twice weekly for 24 weeks. 25-hydroxy vitamin D levels were measured at 0, 12, and 24 weeks in the cases and at 0 only in control by enzyme-linked immunosorbent assay (ELISA) and Vitiligo Area Severity Index (VASI) were calculated at 0 (baseline) and 24 weeks.

RESULTS

The mean baseline level of 25-hydroxyvitamin D (at 0 week) was significantly lower in patients than the control group. Levels of 25(OH) vitamin D at 12 and 24 weeks showed significant improvement and Patients show significant reduction in VASI score after 24 weeks of therapy.

CONCLUSIONS

Cumulative doses of NB-UVB therapy improve low vitamin D levels in patients with vitiligo, which might have a significant role in NB-UVB-induced repigmentation and may contribute to its therapeutic efficacy but further studies with larger sample size are needed to prove the complete mechanisms of NB-UVB-induced pigmentations and vitamin D in vitiligo.

Utility of dermoscopy for evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in localized vitiligo patients

The aim of the present study was to assess the function of dermoscopy in evaluating the therapeutic efficacy of tacrolimus ointment plus 308-nm excimer laser combination therapy in patients with localized vitiligo. A total of 147 patients with localized vitiligo (progressive disease, n=92; stable period, n=55) were enrolled and received combination therapy for 12 weeks. The condition of the skin lesions was monitored by dermoscopy and visual observation. At the initial visit, skin lesions were observed in 61 progressive and 19 stable patients. Residual perifollicular pigmentation was more abundant in progressive-stage patients than in stable-stage patients, whereas the presence of perilesional hyperpigmentation was obviously lower in patients with progressive vitiligo. After 12 weeks of combination therapy, marked differences in residual perifollicular pigmentation were identified between the progressive- and stable-stage patients. Dermoscopy and visual observation indicated that the 12-week treatment efficacy in patients with progressive disease was significantly higher than in those with stable disease and that assessment by dermoscopy was superior to visual observation at 8 or 12 weeks of treatment. Binary logistic regression analysis revealed that the disease stage, vitiliginous areas and disease course were risk factors associated with the treatment efficacy of the combination therapy. In conclusion, dermoscopy may be used as an effective means of vitiligo therapy assessment to provide an accurate and scientific evaluation of treatment efficacy for localized vitiligo patients.

Diversity-oriented synthesis of amide derivatives of tricyclic thieno[2,3-d]pyrimidin-4(3H)-ones and evaluation of their influence on melanin synthesis in murine B16 cells

A diversity-oriented synthesis of amide-containing thieno[2,3-d]pyrimidin-4(3H)-ones is reported. All compounds were tested for their influence on melanin synthesis in murine B16 cells. The azepine fragment in thieno[2,3-d]pyrimidin-4(3H)-one skeleton significantly increases the melanin content.

Impact on Quality of Life in Vitiligo Patients Treated with Narrowband Ultraviolet B Phototherapy

Context:

Vitiligo is a psychosocial problem which significantly affects quality of life in Indian scenario.

Aims:

The purpose of this study was to compare the changes in quality of life in patients of vitiligo before and after treatment with narrowband ultraviolet B (NBUVB) phototherapy.

Subjects and Methods:

A total of 54 patients had completed the study. The age ranged between 16 and 70 years with a mean age of 26.77±14.2 years. The initial dose of NBUVB was 300 mJ/cm² in adults and 150 mJ/cm² in children twice weekly with 20% dose increment on subsequent visits. It was given for a maximum period of 6 months and was followed up for another 6 months to determine stability of repigmentation.

Results:

The average number of exposure given to the patients was 45.63±12.74 while the mean irradiation cumulative dose was 39.8 J/cm². Mean Dermatology Life Quality Index (DLQI) of the vitiligo patients was 8.64±4.32 while those patients with acrofacial vitiligo had a mean DLQI of 11.78±5.61. After treatment with NBUVB, mean DLQI of all vitiligo patients was significantly reduced to 5.86±2.15 (P<0.01).

Conclusions:

This study showed that phototherapy had a positive therapeutic outcome in vitiligo, especially in younger patients. Even a small, depigmented lesion in a child could be psychosocially devastating.

Neural and Endocrinal Pathobiochemistry of Vitiligo: Comparative Study for a Hypothesized Mechanism

The etiology of vitiligo is still unclear. The aim is to investigate a neural and hormonal etio-pathology of vitiligo. Sixty acrofacial vitiligo patients were divided into two subgroups as active vitiligo patients group (AVPs; n = 35) and stable vitiligo patients group (SVP; n = 25). Forty healthy subjects without any systemic or dermatological disease were used as controls. Blood samples were collected, and the samples were used for measurement of free triiodothyronine (fT₃), free thyroxine (fT₄), thyroid-stimulating hormone (TSH), adrenocorticotrophic hormone (ACTH), cortisol, estrogen, testosterone, melatonin, and prolactin levels by ELISA, while norepinephrine (NE), epinephrine (Epi), dopamine (DA), homo-vanillic acid (HVA), serotonin, and 5-hydroxyindoleacetic acid (5-HIAA) by high-pressure liquid chromatography. The current results showed a significant increase in plasma levels of Epi, NE, DA, HVA, serotonin, 5-HIAA, melatonin, and in serum level of TSH and prolactin either in SVP or AVP groups than the control group and in AVP than SVP group. The serum levels of fT₃ and fT₄ were significantly decreased either in SVP or AVP groups than the control group. A significant increase in estradiol levels was observed in females within AVP than females in either SVP or control groups. There was a significant increase in serum level of cortisol in AVP than either SVP or control group. There was a significant decrease in serum level of ACTH in either AVP or SVP than control and in AVP than SVP group. In conclusion, there are some neural and endocrine markers that play a pivotal role in pathogenesis and/or consequences of vitiligo. The abnormally disturbed levels of theses markers lead to melanocyte destruction and/or depigmentation.

Network pharmacological mechanisms of Vernonia anthelmintica (L.) in the treatment of vitiligo: Isorhamnetin induction of melanogenesis via up-regulation of melanin-biosynthetic genes

Background

Vitiligo is a long-term skin disease characterized by the loss of pigment in the skin. The current therapeutic approaches are limited. Although the anti-vitiligo mechanisms of Vernonia anthelmintica (L.) remain ambiguous, the herb has been broadly used in Uyghur hospitals to treat vitiligo. The overall objective of the present study aims to identify the potential lead compounds from Vernonia anthelmintica (L.) in the treatment of vitiligo via an oral route as well as the melanogenic mechanisms in the systematic approaches in silico of admetSAR and substructure-drug-target network-based inference (SDTNBI).

Results

The results showed that the top 5 active compounds with a relatively higher bioavailability that interacted with 23 therapeutic targets were identified in Vernonia anthelmintica (L.) using admetSAR and SDTNBI methods. Among these compounds, Isorhamnetin and Kaempferide, which are methyl-flavonoids, performed 1st and 2nd. Isorhamnetin and Kaempferide significantly increased the expression of melanin-biosynthetic genes (MC1R, MITF, TYR, TYRP1 and DCT) and the tyrosinase activity in B16F10 cells. Isorhamnetin and Kaempferide significantly increased the mRNA-expression of melanin-biosynthetic genes (MC1R, MITF, TYR, TYRP1 and DCT), the protein level of MITF and the tyrosinase activity. Based on the SDTNBI method and experimental verification, Isorhamnetin and Kaempferide effectively increased melanogenesis by targeting the MC1R-MITF signaling pathway, MAPK signaling pathway, PPAR signaling pathway (PPARA, PPARD, PPARG), arachidonic acid metabolism pathway (ALOX12, ALOX15, CBR1) and serotonergic synapses (ALOX12, ALOX15) in the treatment of vitiligo from a network perspective.

Conclusion

We identified the melanogenic activity of the methyl-flavonoids Isorhamnetin and Kaempferide, which were successfully predicted in a network pharmacological analysis of Vernonia anthelmintica (L.) by admetSAR and SDTNBI methods.

Electronic supplementary material

The online version of this article (10.1186/s12918-017-0486-1) contains supplementary material, which is available to authorized users.

Chronic diseases among vitiligo patients. A case control study

OBJECTIVES

To identify the proportion and risk of chronic diseases in vitiligo patients in a tertiary hospital in Riyadh, Kingdom of Saudi Arabia (KSA). Methods: A retrospective case-control study included 61 vitiligo patients and 61 normal non-dermatology controls in King Abdulaziz Medical City, Riyadh, KSA between January and September 2016. Age, gender and  co-morbid diseases including hypertension, diabetes, dyslipidemia, obesity and hypothyroidism were retrieved from participants' charts and medical records. Proportion and mean were used to describe the variables, and odds ratio (OR) was used to test the data. Results: A total of 122 participants (34 males, 88 females) equally divided in cases and controls. The mean age was 45±19 years for the case and 40±17 years for the control group. The proportion of diabetes (51%) was higher in the case group than the control (33%) (OR: 0.47; 95% confidence interval [CI]: 0.23-0.98; p=0.04). Dyslipidemia was significantly associated with vitiligo (67%) compared with the control group (48%) (OR: 0.44; 95% CI: 0.21-0.92; p=0.03). Vitiligo participants had a significantly increased risk of having hypothyroidism (26%) compared with the control group (10%) (OR: 0.31; 95% CI: 0.11-0.85; p=0.02). Conclusion: There is an increased risk of chronic diseases among vitiligo patients including diabetes, dyslipidemia, hypothyroidism, renal injuries, and obesity.

Assessment of auditory and vestibular functions in vitiligo patients

Objectives

To evaluate audiological and vestibular functions via basic audiological evaluation, otoacoustic emissions and videonystagmography (VNG) in vitiligo patients.

Material and methods

30 vitiligo patients (8 acrofacial and 22 mixed types) as the study group and 30 normal healthy adults as the control group were included in the study. All participants were submitted to basic audiological evaluation, transient and distortion product otoacoustic emmisions (TEOAEs and DPOAEs), vestibular assessment including history taking, office tests and videonystagmography (VNG) and dermatological assessment to determine type, percent of body surface area involvement and duration of vitiligo.

Results

This study showed statistically significant difference between control and study groups in pure tone audiometry (PTA) and otoacoustic emissions results. Fifty percent of vitiligo patients had peripheral vestibular disorders (10 vestibular neuritis and 5 posterior canal benign paroxysmal positional vertigo.

Conclusion

The results in this study showed that 50% of vitiligo patients suffered from peripheral vestibular disorders in addition to auditory affection. Vitiligo patients require routine monitoring for auditory and vestibular functions for early identification and monitoring of changes as the disease progress.

A case-control study on association of proteasome subunit beta 8 (PSMB8) and transporter associated with antigen processing 1 (TAP1) polymorphisms and their transcript levels in vitiligo from Gujarat

BACKGROUND

Autoimmunity has been implicated in the destruction of melanocytes from vitiligo skin. Major histocompatibility complex (MHC) class-II linked genes proteasome subunit beta 8 (PSMB8) and transporter associated with antigen processing 1 (TAP1), involved in antigen processing and presentation have been reported to be associated with several autoimmune diseases including vitiligo.

OBJECTIVES

To explore PSMB8 rs2071464 and TAP1 rs1135216 single nucleotide polymorphisms and to estimate the expression of PSMB8 and TAP1 in patients with vitiligo and unaffected controls from Gujarat.

METHODS

PSMB8 rs2071464 polymorphism was genotyped using polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP) and TAP1 rs1135216 polymorphism was genotyped by amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) in 378 patients with vitiligo and 509 controls. Transcript levels of PSMB8 and TAP1 were measured in the PBMCs of 91 patients and 96 controls by using qPCR. Protein levels of PSMB8 were also determined by Western blot analysis.

RESULTS

The frequency of 'TT' genotype of PSMB8 polymorphism was significantly lowered in patients with generalized and active vitiligo (p = 0.019 and p = 0.005) as compared to controls suggesting its association with the activity of the disease. However, TAP1 polymorphism was not associated with vitiligo susceptibility. A significant decrease in expression of PSMB8 at both transcript level (p = 0.002) as well as protein level (p = 0.0460) was observed in vitiligo patients as compared to controls. No significant difference was observed between patients and controls for TAP1 transcripts (p = 0.553). Interestingly, individuals with the susceptible CC genotype of PSMB8 polymorphism showed significantly reduced PSMB8 transcript level as compared to that of CT and TT genotypes (p = 0.009 and p = 0.003 respectively).

CONCLUSIONS

PSMB8 rs2071464 was associated with generalized and active vitiligo from Gujarat whereas TAP1 rs1135216 showed no association. The down-regulation of PSMB8 in patients with risk genotype 'CC' advocates the vital role of PSMB8 in the autoimmune basis of vitiligo.

Impact of Vitiligo on Quality of Life

INTRODUCTION AND OBJECTIVE

Vitiligo is a chronic autoimmune skin disease caused by the destruction of melanocytes. Although quality of life (QOL) in vitiligo has been studied in different countries, it has not yet been investigated in Mexico. The aim of this study was to assess the QOL of Mexican patients with vitiligo.

MATERIAL AND METHOD

We conducted a cross-sectional study at the research unit of Centro Dermatológico Dr. Ladislao de la Pascua in Mexico City. We included adults with vitiligo and excluded those with other pigmentation disorders or a neurological or psychiatric disorder. Patients on psychoactive medications were also excluded. All the patients were administered the Dermatology Life Quality Index (DLQI), a vitiligo-specific quality of life instrument (the VitiQoL), and the Beck Depression and Anxiety Inventories.

RESULTS

We studied 150 patients with vitiligo (103 women [68.7%] and 47 men [31.3%]). The median (interquartile range) age was 38 (20) years. The mean (SD) scores on the DLQI and VitiQoL were 5.2 (5.4) and 32.1 (22.7) out of total possible scores of 30 and 90, respectively. The correlation between questionnaire scores was 0.675 (P<.001). Patients with genital involvement scored significantly worse on the VitiQoL than those without lesions in this area (43.95 [28.4]) vs. 28.98 [20.08], P<.001). The prevalence of depression and anxiety was 34% and 60%, respectively.

CONCLUSION

Vitiligo has a minimal impact on the QOL of our patients. QOL was worse in patients with genital lesions.

Pigmentation Traits, Sun Exposure, and Risk of Incident Vitiligo in Women

Vitiligo is the most common cutaneous depigmentation disorder worldwide, yet little is known about specific risk factors for disease development. Using data from the Nurses' Health Study, a prospective cohort study of 51,337 white women, we examined the associations between (i) pigmentary traits and (ii) reactions to sun exposure and risk of incident vitiligo. Nurses' Health Study participants responded to a question about clinician-diagnosed vitiligo and year of diagnosis (2001 or before, 2002-2005, 2006-2009, 2010-2011, or 2012+). We used Cox proportional hazards regression models to estimate the multivariate-adjusted hazard ratios and 95% confidence intervals of incident vitiligo associated with exposures variables, adjusting for potential confounders. We documented 271 cases of incident vitiligo over 835,594 person-years. Vitiligo risk was higher in women who had at least one mole larger than 3 mm in diameter on their left arms (hazard ratio = 1.37, 95% confidence interval = 1.02-1.83). Additionally, vitiligo risk was higher among women with better tanning ability (hazard ratio = 2.59, 95% confidence interval = 1.21-5.54) and in women who experienced at least one blistering sunburn (hazard ratio = 2.17, 95% confidence interval = 1.15-4.10). In this study, upper extremity moles, a higher ability to achieve a tan, and history of a blistering sunburn were associated with a higher risk of developing vitiligo in a population of white women.