JAK inhibitors for the treatment of vitiligo

Efficacy and Safety of JAK Inhibitors in the Management of Vitiligo: A Systematic Review and Meta-analysis

INTRODUCTION

Vitiligo, a chronic skin disease affecting 1-2% of the global population, is associated with significant impairment in quality of life. Current pharmacological treatment options have limited efficacy and considerable side effects. Recent studies have shown promising results when using Janus kinase inhibitors (JAKis). Despite these favourable findings, there remains a critical need for comprehensive data on the efficacy and safety of JAKi in the treatment of vitiligo.

METHODS

Three databases were searched for studies on patients with vitiligo treated with oral or topical JAKi, with or without conventional therapy. Placebo or vehicle cream were comparators in randomised controlled trials (RCTs). Outcomes included a 75% improvement in Facial-Vitiligo Area Scoring Index (F-VASI), mean Vitiligo Area Scoring Index (VASI) improvement, repigmentation percentage and adverse events. We performed three analyses: one using RCT data, one from case reports and a novel cohort of JAKi-treated patients from case reports. The protocol is registered with PROSPERO (CRD42023445503).

RESULTS

Among the 35 articles identified, 19 were included in the statistical analyses. A meta-analysis of three randomised controlled trials (RCTs) on topical Janus kinase inhibitors (JAKis) suggested that patients treated with JAKi were more likely to achieve Facial Vitiligo Area Scoring Index 75 (F-VASI75) than those using vehicle cream (risk ratio (RR) 3.47, 95% confidence interval (CI) 0.98-12.22), with no significant difference in adverse events between groups (RR 1.27; 95% CI 0.88-1.82). A meta-analysis of four single-arm trials showed a 43.8% mean Vitiligo Area Scoring Index (VASI) improvement (95% CI 0.71-0.93). A cohort (n = 28) from case reports and series revealed significant repigmentation increases of 48.7% and 63.7% (p = 0.0018; p < 0.001) in patients treated with JAKi alone or with narrowband ultraviolet B (UVB). However, data were insufficient to determine if combination treatments were superior to JAKi alone.

CONCLUSION

Our systematic review evaluated the efficacy and safety of JAKi for vitiligo using data from RCTs, single-arm trials and case reports. While topical ruxolitinib showed promising but non-significant results in RCTs, single-arm trials and case studies highlighted significant repigmentation, particularly with oral JAKis combined with other therapies. Oral JAKis showed effectiveness but require caution due to potential adverse effects such as immune suppression and cardiovascular risks. Furthermore, it is important to acknowledge that a considerable proportion of patients do not respond to these therapies. Additional RCTs are needed to address long-term safety, optimise application strategies and establish standardised endpoints for combination therapies.

Potential future biologic therapies for the treatment of vitiligo: focus on phase 2 and 3

INTRODUCTION

Vitiligo is a chronic autoimmune skin disorder characterized by the loss of melanocytes, leading to depigmented patches on the skin and mucous membranes. Its increasing prevalence and impact on patients' quality of life highlight the need for updated therapeutic strategies.

AREAS COVERED

This review discusses recent advances in the understanding of vitiligo pathogenesis, focusing on genetic predisposition, environmental triggers, and immune dysregulation-particularly the role of autoreactive CD8+ T cells and inflammatory cytokines such as IFN-γ. The literature search included recent clinical trials and emerging therapies. Novel approaches, including JAK inhibitors (e.g. povorcitinib, upadacitinib) and monoclonal antibodies (e.g. anifrolumab), are evaluated for their efficacy and safety based on phase II and III clinical trial data.

EXPERT OPINION

Targeted therapies that address immune mechanisms and oxidative stress represent promising advances in vitiligo management and may substantially improve patient outcomes in the near future.

A randomized interventional study that compares treatments for vitiligo and anti-vitiligo cream

This study aimed to evaluate the efficacy of a novel combination therapy, AVC (Anti-Vitiligo Cream), compared to common treatments for vitiligo. A randomized interventional study was conducted on 1,000 patients with confirmed vitiligo, aged 7-70 years. Participants were divided into five groups (200 patients each): oral prednisolone, Tofacitinib, Ruxolitinib, AVC (Anti-Vitiligo Cream), and AVC combined with Tofacitinib. Outcomes were assessed over two years using the Vitiligo Area Scoring Index (VASI), patient satisfaction scores, and clinical observations. AVC-based therapies (Groups 4 and 5) demonstrated superior efficacy and patient satisfaction compared to other treatments. Group 5 (AVC + Tofacitinib) achieved the highest outcomes, with a mean satisfaction score of 90 (IQR: 85-95) and treatment efficacy significantly higher than Group 1 (p < 0.001). Regression analysis identified treatment outcomes and therapy type as significant predictors of satisfaction. AVC (Anti-Vitiligo Cream), particularly in combination with Tofacitinib, represents a groundbreaking approach for managing vitiligo, providing enhanced efficacy and patient satisfaction. These findings support the potential of AVC-based therapies as a standard treatment option.

Inflammatory Skin Diseases: The Importance of Immunological Signatures

BACKGROUND

The understanding and classification of inflammatory skin diseases is shifting from a historical-descriptive perspective to a molecular-pathophysiological one based on immune response patterns. These are derived from a few key immunological mediators, each of which induces its own characteristic clinical, histopathological, and molecular patterns in the skin.

METHODS

This discussion of the definition of the immune response patterns of inflammatory skin diseases is based on information from pertinent publications retrieved by a selective literature search. A systematic literature search was also conducted on the response of inflammatory skin diseases to treatment with specific biologic agents.

RESULTS

The described immune response patterns are: autoinflammation; type 1, cytotoxic; type 2a, eczematous; type 2b, blistering; type 3, psoriasiform; type 4a, fibrosing; and type 4b, granulomatous. Each signature can usually be treated in a targeted manner. In general, each therapeutic target structure is associated with an adequate treatment response if and only if the skin disease under treatment has the relevant signature type. Hardly any biomarkers are currently available for the determination of immune response patterns in routine clinical practice.

CONCLUSION

The classification of inflammatory skin diseases by their immune response patterns opens up the prospect of specifically targeted immunotherapy for each immune response pattern regardless of the historical-descriptive disease entity. Targeting is intended to improve response rates. Initial findings suggest that this strategy is likely to succeed.

Comprehensive Overview of Cytokine Interplay in Vitiligo: A Decade of Meta-Analyses Systematically Reviewed

(1) Background: Vitiligo is an autoimmune skin disorder characterized by melanocyte destruction. Despite metabolic disturbances and oxidative stress also playing a key role in its pathogenesis, accumulating evidence highlights a prominent role for cytokine dysregulation. (2) Methods: A systematic search was conducted to identify meta-analyses published in the last decade that investigated cytokine involvement in vitiligo. (3) Results: Based on predefined inclusion criteria, nine meta-analyses were retrieved and reviewed. The findings confirm a central role for interferon-gamma (IFN-γ) in vitiligo pathogenesis, although recent meta-analyses suggest that IFN-γ gene polymorphisms are more broadly associated with autoimmunity rather than being vitiligo-specific. Elevated interleukin-17 (IL-17) levels have been consistently reported in vitiligo patients, supporting its contribution to immune-mediated melanocyte destruction. Regulatory T cell dysfunction appears to play a crucial role in disease progression. Additionally, TNF-α-308 G/A polymorphism has been linked to a genetic susceptibility to vitiligo, particularly in specific populations, reinforcing the role of TNF-α in immune dysregulation. Lastly, chemokines involved in immune cell recruitment to melanocytes further illustrate the complex inflammatory network underlying the disease. (4) Conclusions: This systematic review consolidates evidence from a decade of meta-analyses, underscoring the significance of cytokine dysregulation in vitiligo and highlighting potential therapeutic targets.

Effectiveness and Safety of Oral Compound Glycyrrhizin Followed by Phototherapy for the Treatment of Progressive Vitiligo in Children

Childhood vitiligo, distinct from its adult counterpart, presents unique treatment challenges. Glycyrrhizin inhibits the release of high-mobility group box 1 (HMGB1) protein from keratinocytes, preventing melanocyte apoptosis and autophagy. Furthermore, the orally administered compound glycyrrhizin (OCG) effectively treats various autoimmune disorders, demonstrating long-term efficacy, safety, and tolerability. This study compared the efficacy of OCG and oral prednisone (OP), followed by phototherapy, in patients with progressive childhood vitiligo at 52 weeks' follow-up. Fifty children with vitiligo were randomized into two groups according to treatment: OCG (50-150 mg/day) followed by phototherapy (n = 25) and OP (5-10 mg/day) followed by phototherapy (n = 25). At Week 24, a halt in disease progression (HDP) was observed in 20 (80%) patients in the OCG group and 21 (84%) in the OP group, with no significant difference (p > 0.99). However, the mean time to achieve HDP was significantly shorter in the OP group than in the OCG group (14.73 ± 4.84 vs. 19.13 ± 4.82 weeks; p < 0.01). In addition, serum HMGB1 concentrations were significantly reduced after treatment with OCG at Week 24 (3.02 ± 0.83 vs. 0.95 ± 0.36 ng/mL [p < 0.01]; OP, 2.79 ± 0.16 vs. 1.03 ± 0.34 ng/mL [p < 0.01]). The decline in Vitiligo Area Scoring Index (VASI) score at the end of follow-up (i.e., Week 52) did not show a statistically significant difference between the OCG and OP groups (52.31% ± 14.86% vs. 55.71% ± 21.23%; p = 0.55). The therapeutic response of the clinical markers of progression was good and comparable between the OCG and OP groups. OCG demonstrated similar efficacy to OP followed by phototherapy in controlling disease activity and promoting repigmentation in children with vitiligo at 52 weeks of follow-up. Trial Registration: ChiCTR2400086844.

Dietary Interventions, Supplements, and Plant-Derived Compounds for Adjunct Vitiligo Management: A Review of the Literature

Vitiligo is a chronic autoimmune pigmentation disorder shaped by a complex interplay of genetic predispositions and environmental triggers. While conventional therapies-phototherapy, corticosteroids, and immunosuppressants-can be effective, their benefits are often partial and temporary, with recurrence common once treatment stops. As such, there is increasing interest in exploring complementary approaches that may offer a more sustainable impact. Emerging evidence suggests that macronutrient and micronutrient-level changes could be beneficial for managing progression and, in some cases, facilitating repigmentation. Antioxidant-rich foods, such as apples, green tea, Indian gooseberry, onions, and peppers, may help mitigate oxidative stress, while inflammatory foods, such as gluten and high-phenol nuts and berries, may exacerbate the condition. Certain supplements, including high-dose vitamin D, vitamin C, vitamin E, and selenium, may enhance phototherapy outcomes. Omega-3 and other unsaturated fatty acids, in addition to prebiotics and probiotics, are under active investigation for their roles in gut health and immune regulation. Notably, plant-derived compounds, i.e., Ginkgo biloba, have demonstrated promise in promoting repigmentation and managing disease progression. However, it must be emphasized that these nutritional interventions remain exploratory, and more research is needed to establish their efficacy, safety, and optimal usage before they can be recommended as part of a standard treatment regimen.

Mechanistic Insights into the Stimulatory Effect of Melanogenesis of 4-Methylcoumarin Derivatives in B16F10 Melanoma Cells

Vitiligo is a skin condition characterized by the loss of pigment, resulting in white patches on various parts of the body. It occurs when melanocytes, the cells that are responsible for producing skin pigment, are destroyed or stop functioning. This study aimed to investigate the melanogenic potential of various 4-methylcoumarin (4MC) derivatives, including 6-methoxy-4-methylcoumarin (6M-4MC), 7-methoxy-4-methylcoumarin (7M-4MC), 7-amino-4-methylcoumarin (7A-4MC), 6,7-dihydroxy-4-methylcoumarin (6,7DH-4MC), 7,8-dihydroxy-4-methylcoumarin (7,8DH-4MC), and 6,7-dimethoxy-4-methylcoumarin (6,7DM-4MC), in B16F10 melanoma cells. Our findings revealed that, while 4MC, 7A-4MC, 6,7DH-4MC, and 7,8DH-4MC did not exhibit any effect on melanin production, significant stimulation of melanogenesis was observed with 6M-4MC, 7M-4MC, and 6,7DM-4MC, with 6M-4MC demonstrating the most pronounced effect. 6M-4MC significantly stimulated melanin production and tyrosinase activity in a concentration-dependent manner in B16F10 cells. A Western blot analysis revealed that 6M-4MC increased the expression levels of microphthalmia-associated transcription factor (MITF), tyrosinase, tyrosinase-related protein-1 (TRP-1), and tyrosinase-related protein-2 (TRP-2). Further mechanistic studies showed that 6M-4MC inhibited extracellular signal-regulated kinase (ERK) and protein kinase B (AKT), which led to the upregulation of MITF and TRP proteins and subsequent activation of melanin synthesis. Additionally, 6M-4MC activated GSK3β phosphorylation, reduced β-catenin phosphorylation, and stimulated melanogenesis via the GSK3β/β-catenin pathway. Moreover, a primary skin irritation test was conducted on the upper backs of 32 healthy female volunteers to assess the potential irritation or sensitization from 6M-4MC when applied topically at concentrations of 50 µM and 100 µM. The test results showed no adverse effects on the skin. Collectively, these findings suggest that 6M-4MC may be a promising pigmentation stimulator for use in cosmetics and in the medical treatment of hypopigmentation disorders, particularly in the treatment of skin conditions such as vitiligo.