Apremilast in Combination with Narrowband UVB in the Treatment of Vitiligo: A 52-Week Monocentric Prospective Randomized Placebo-Controlled Study

Emerging role of regulatory T cells in the immunopathogenesis of vitiligo and implications for treatment

Vitiligo is an autoimmune skin disease that targets pigment-producing melanocytes and results in depigmentation. This disfiguring condition frequently affects visible areas of the body and therefore causes a heavy psychological burden and a decreased quality of life. Although it remains intractable, the ever-growing understanding of its immunopathogenesis has dramatically shaped the treatment paradigm for vitiligo. With the impact of autoreactive cytotoxic T cells explained extensively, accumulating evidence suggests the unique role of regulatory T cells (Tregs) in the immune microenvironment of vitiligo. We systematically reviewed Treg deficiency, instability, reduced vitality and dysfunction in people with vitiligo, combined with novel findings regarding Treg function modulation in autoimmune backgrounds, including metabolic alteration, post-translational modifications and interaction with other immune cells. We further summarized classic and advanced Treg-targeted therapeutics in vitiligo practice and research. Herein, we share up-to-date knowledge of Tregs in vitiligo, providing insights into novel Treg-based therapeutic strategies.

Emerging Therapeutic Innovations for Vitiligo Treatment

Vitiligo is a chronic autoimmune disorder with a multifactorial etiology, typically manifesting as localized or generalized hypopigmentation or depigmentation of the skin and mucous membranes. The pathogenesis of vitiligo is complex and significantly impacts patients' quality of life. Although traditional treatments such as hormone therapy, topical medications, and laser therapy can help control the disease to some extent, their outcomes remain unsatisfactory. Therefore, ongoing research is crucial to explore and develop novel treatment strategies while assessing their efficacy and safety. This review aims to classify and summarize various new candidate drugs for vitiligo currently undergoing clinical trials, providing a reference for clinical practice. Recent advancements in the understanding of the pathogenesis of vitiligo have facilitated the development of potential treatment strategies, such as Janus kinase inhibitors, cytokine blockers, and agents targeting tissue-resident memory or regulatory T cells. These emerging therapies offer hope to patients with vitiligo, though further investigation is needed to confirm their safety, efficacy, and optimal treatment regimens.

Utility of prostaglandin analogues and phosphodiesterase inhibitors as promising last resorts for the treatment of vitiligo: A systematic review, from mechanisms of action to mono-, combination and comparative therapies

BACKGROUND

The treatment of vitiligo is a persistent challenge in dermatology. New treatments are being offered and studied in this field for those resistant to or intolerant of classical therapies.

AIMS

In this systematic review, we study the use of prostaglandin analogues (PGAs) and phosphodiesterase inhibitors (PDEIs) in the treatment of vitiligo, as they are known for their pigmentation inducing effects through activating melanocytes.

METHODS

We searched four main online databases with the keywords "Vitiligo", "Prostaglandin analogue" and "Phosphodiesterase inhibitor".

RESULTS

A total of 42 articles were included, with 1027 cases, studying drugs like bimatoprost, latanoprost, travoprost, dinoprostone, apremilast, crisaborole, etc. Among the included studies, the treatment regimens are commonly once or twice daily for 12-48 weeks, with a mean of 20.61 weeks, and the routes of administration are mainly topical gels or ophthalmic solutions and oral tablets. Side effects are mild and tolerable, namely erythema, itching or burning sensations at application site for topicals, or gastrointestinal problems with apremilast. Repigmentation results are significant in both adult and pediatric patients and progressive or stable vitiligo. PGAs and PDEIs outperform many classical therapies, for example, narrowband ultraviolet B phototherapy (NB-UVB), tacrolimus, mometasone or methylprednisolone mini-pulse. PGAs or PDEIs are usually used in combination therapies to either cause synergism or increase drug delivery, and almost always enhance repigmentation, for example, with NB-UVB, fractional CO2 laser, microneedling, and mometasone.

CONCLUSION

Monotherapy or add-on PGAs and PDEIs can be considered effective treatments for vitiligo and promising last resorts for those resistant to other therapies.

Up-and-Coming Drugs for the Treatment of Vitiligo

Vitiligo is a chronic autoimmune disease that causes depigmented patches on the skin. It affects 0.5%-2.0% of the global population. It goes beyond physical appearance, often leading to stigmatization, low self-esteem, and depression, burdening patients with psychosocial challenges. The pathogenesis of vitiligo involves the loss of melanocytes due to autoreactive CD8+ T cells, triggered by environmental stressors and exacerbated by cellular vulnerabilities and immune responses. The release of danger signals and pro-inflammatory factors initiates an immune cascade perpetuating melanocyte destruction, mainly driven by interferon-γ and the C-X-C motif chemokine ligand 9/10-chemokine receptor 3 axis. Long-lasting tissue-resident memory T cells (Trms) and cytokines contribute to lesion persistence. Current treatments focus on topical steroids and tacrolimus, systemic steroids, and phototherapies, but their efficacy remains suboptimal, necessitating the development of new therapeutic options. Building on recent advancements in understanding the immunological mechanisms in vitiligo pathogenesis, with the initiation of Food and Drug Administration approval of topical ruxolitinib, various potential treatment options such as JAK inhibitors, cytokine blockers, and Trm or regulatory T cell targeting agents are being clinically researched and anticipated for vitiligo based on both preclinical and clinical data. This review aims to categorize and summarize the diverse investigational drugs currently undergoing clinical trials for vitiligo. By examining clinical outcomes, it is anticipated that this review will bring hope to dermatologists and patients regarding vitiligo, a condition that has historically posed challenges and transform it into a realm of potential possibilities.

Phototherapy for vitiligo: A narrative review on the clinical and molecular aspects, and recent literature

BACKGROUND

Vitiligo is characterized by depigmented patches resulting from loss of melanocytes. Phototherapy has emerged as a prominent treatment option for vitiligo, utilizing various light modalities to induce disease stability and repigmentation.

AIMS AND METHODS

This narrative review aims to explore the clinical applications and molecular mechanisms of phototherapy in vitiligo.

RESULTS AND DISCUSSION

The review evaluates existing literature on phototherapy for vitiligo, analyzing studies on hospital-based and home-based phototherapy, as well as outcomes related to stabilization and repigmentation. Narrowband ultra-violet B, that is, NBUVB remains the most commonly employed, studied and effective phototherapy modality for vitiligo. Special attention is given to assessing different types of lamps, dosimetry, published guidelines, and the utilization of targeted phototherapy modalities. Additionally, the integration of phototherapy with other treatment modalities, including its use as a depigmenting therapy in generalized/universal vitiligo, is discussed. Screening for anti-nuclear antibodies and tailoring approaches for non-photo-adapters are also examined.

CONCLUSION

In conclusion, this review provides a comprehensive overview of phototherapy for vitiligo treatment. It underscores the evolving landscape of phototherapy and offers insights into optimizing therapeutic outcomes and addressing the challenges ahead. By integrating clinical evidence with molecular understanding, phototherapy emerges as a valuable therapeutic option for managing vitiligo, with potential for further advancements in the field.

Vitiligo non-responding lesions to narrow band UVB have intriguing cellular and molecular abnormalities that may prevent epidermal repigmentation

We have discovered that human vitiligo patients treated with narrow-band UVB (NBUVB) demonstrated localized resistance to repigmentation in skin sites characterized by distinct cellular and molecular pathways. Using immunostaining studies, discovery-stage RNA-Seq analysis, and confirmatory in situ hybridization, we analyzed paired biopsies collected from vitiligo lesions that did not repigment after 6 months of NBUVB treatment (non-responding) and compared them with repigmented (responding) lesions from the same patient. Non-responding lesions exhibited acanthotic epidermis, had low number of total, proliferative, and differentiated melanocyte (MC) populations, and increased number of senescent keratinocytes (KCs) and of cytotoxic CD8+ T cells as compared with responding lesions. The abnormal response in the non-responding lesions was driven by a dysregulated cAMP pathway and of upstream activator PDE4B, and of WNT/β-catenin repigmentation pathway. Vitiligo-responding lesions expressed high levels of WNT10B ligand, a molecule that may prevent epidermal senescence induced by NBUVB, and that in cultured melanoblasts prevented the pro-melanogenic effect of α-MSH. Understanding the pathways that govern lack of NBUVB-induced vitiligo repigmentation has a great promise in guiding the development of new therapeutic strategies for vitiligo.

A systematic review of case series and clinical trials investigating systemic oral or injectable therapies for the treatment of vitiligo

AIMS AND OBJECTIVES

The purpose of this study is to investigate the effectiveness and safety of oral and injectable systemic treatments, such as methotrexate, azathioprine, cyclosporine, tofacitinib, baricitinib, corticosteroids, statins, zinc, apremilast, etc., for treating vitiligo lesions.

METHOD

Databases including PubMed, Scopus, and Web of Science were meticulously searched for studies spanning from 2010 to August 2023, focusing on systemic oral and injectable therapies for vitiligo, using comprehensive keywords and search syntaxes tailored to each database. Key data extracted included study design, treatment efficacy, patient outcomes, patient satisfaction, and safety profiles.

RESULTS

In a total of 42 included studies, oral mini-pulse corticosteroid therapy (OMP) was the subject of six studies (14.2%). Minocycline was the focus of five studies (11.9%), while methotrexate, apremilast, and tofacitinib each were examined in four studies (9.5%). Antioxidants and Afamelanotide were the subjects of three studies each (7.1%). Cyclosporine, simvastatin, oral zinc, oral corticosteroids (excluding OMP) and injections, and baricitinib were each explored in two studies (4.8%). Azathioprine, mycophenolate mofetil, and Alefacept were the subjects of one study each (2.4%).

CONCLUSION

Systemic treatments for vitiligo have been successful in controlling lesions without notable side effects. OMP, Methotrexate, Azathioprine, Cyclosporine, Mycophenolate mofetil, Simvastatin, Apremilast, Minocycline, Afamelanotide, Tofacitinib, Baricitinib, Antioxidants, and oral/injectable corticosteroids are effective treatment methods. However, oral zinc and alefacept did not show effectiveness.

Vitiligo: Pathogenesis and New and Emerging Treatments

Vitiligo is a complex disease with a multifactorial nature and a high impact on the quality of life of patients. Although there are multiple therapeutic alternatives, there is currently no fully effective treatment for this disease. In the current era, multiple drugs are being developed for the treatment of autoimmune diseases. This review assesses the available evidence on the pathogenesis of vitiligo, and a comprehensive review of treatments available for vitiligo now and in the near future is provided. This qualitative analysis spans 116 articles. We reviewed the mechanism of action, efficacy and safety data of phototherapy, afamelanotide, cyclosporine, phosphodiesterase 4 inhibitors, trichloroacetic acid, basic fibroblast growth factor, tumor necrosis factor (TNF) inhibitors, secukinumab, pseudocatalase and janus kinase (JAK) inhibitors. At the moment, there is no clearly outstanding option or fully satisfactory treatment for vitiligo, so it is necessary to keep up the development of new drugs as well as the publication of long-term effectiveness and safety data for existing treatments.

Implementation of the vitiligo area scoring index in clinical studies of patients with vitiligo: a scoping review

The vitiligo area scoring index (VASI) is a validated, reliable clinician-reported outcome measure widely used to assess the extent of skin depigmentation seen in patients with vitiligo and to measure patient responses to therapies for vitiligo in clinical trials. However, its implementation in studies is inconsistent and makes comparing results across different studies difficult. The aim of this scoping review is to summarize interventional clinical studies that applied the VASI to measure vitiligo and identify variability in VASI implementation. A systematic search of Ovid Medline, Embase, Web of Science, Cochrane, and ClinicalTrials.gov was performed. Interventional studies published between January 1946 and October 2020 that used the VASI as an outcome measure for assessing vitiligo response were reviewed for methodological approach. Great heterogeneity was found within the 55 included interventional studies that used VASI as an outcome measure. A total of 9 VASI subtypes were described by the authors within 10 intervention categories. VASI determined study eligibility in one study. Body surface area was most frequently established using inconsistent methods. We found unclear or ambiguously scaled assessments of depigmentation. Most VASI outcomes were reported as mean absolute difference, percentage VASI improvement, and percentage of patients who achieved the VASI endpoint. The VASI score was over 100 in one study. Our scoping review revealed many VASI methodology variations in interventional clinical studies of vitiligo. While VASI is a standard method to measure vitiligo changes, substantial heterogeneity in methodology limits reliable comparison and interpretation of findings from different clinical trials. Our findings may be used as a foundation to standardize the VASI outcome measure methodology, allowing for improved clinician training and rigorous data analysis across vitiligo research groups worldwide.

Combining network pharmacology, molecular docking, molecular dynamics simulation, and experimental verification to examine the efficacy and immunoregulation mechanism of FHB granules on vitiligo

Background

Fufang Honghua Buji (FHB) granules, have proven efficacy against vitiligo in long-term clinical practice. However, its major active chemical components and molecular mechanisms of action remain unknown. The purpose of this study was to confirm the molecular mechanism of FHB's therapeutic effect on vitiligo utilizing network pharmacology, molecular docking, and molecular dynamics simulation prediction, as well as experimental verification.

Methods

Traditional Chinese Medicine Systems Pharmacology (TCMSP) and HERB databases were used to obtain the chemical composition and action targets of FHB. Online Mendelian Inheritance in Man (OMIM), DrugBank, DisGeNET, GeneCards, and Therapeutic Target Database (TTD) databases were applied to screen for vitiligo-related targets. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed through the Matascape database. Molecular docking and dynamics simulation methods were for the analysis of the binding sites and binding energies between the FHB's active components and the targets. Finally, a vitiligo mouse model was created, and the therapeutic effect and molecular mechanism of action of FHB were validated using enzyme linked immunosorbent assay (ELISA), western blot (WB), and quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Additionally, hematoxylin-eosin staining (HE) and blood biochemical assays were conducted to assess the biosafety of FHB.

Result

The screening of chemical composition and targets suggested that 94 genetic targets of FHB were associated with vitiligo. The bioinformatics analysis suggested that luteolin, quercetin, and wogonin may be major active components, and nuclear factor-kappa B p65 subunit (RELA), signal transducer, and activator of transcription (STAT) 3 and RAC-alpha serine/threonine-protein kinase (AKT) 1 may be potential targets of FHB-vitiligo therapy. Molecular docking and dynamics simulation further demonstrated that luteolin, quercetin, and wogonin all bound best to STAT3. Through experimental verification, FHB has been demonstrated to alleviate the pathogenic characteristics of vitiligo mice, suppress the JAK-STAT signaling pathway, reduce inflammation, and increase melanogenesis. The in vivo safety evaluation experiments also demonstrated the non-toxicity of FHB.

Conclusions

FHB exerts anti-inflammatory and melanogenesis-promoting effects via the effect of multi-component on multi-target, among which the JAK-STAT pathway is a validated FHB-vitiligo target, providing new ideas and clues for the development of vitiligo therapy.

Apremilast Add-On Benefits Over Conventional Drugs (ABCD) in Unstable Non-segmental Vitiligo: A 12-Week Single-Center Randomized Controlled Trial

Background Apremilast is an oral phosphodiesterase-4 enzyme inhibitor that modulates the immune system by increasing intracellular cyclic adenosine monophosphate levels and inhibiting inflammatory cytokines synthesis. We aimed to compare the efficacy and safety of add-on apremilast in combination therapy with standard treatment in patients with unstable, non-segmental vitiligo. Methods The study was a 12-week randomized, controlled, parallel-group, open-labeled trial. The control group received standard treatment (n=15), and the intervention group received 30 mg apremilast twice daily in addition to standard treatment (n= 16). Time to the first sign of re-pigmentation, halt in progression, and change in vitiligo area scoring index (VASI) score is the primary outcomes. Normality was assessed, and appropriate parametric and nonparametric tests were undertaken. Results Thirty-seven participants were randomized into two groups, and analysis was done on thirty-one participants. Over the treatment duration of 12 weeks, the median time to observe the first sign of re-pigmentation was four weeks in the add-on apremilast group compared to seven weeks in the control group (p=0.018). The halt in progression was observed more in the add-on Apremilast group (93.75%) compared to the control group (66.66%) (p=0.08). The VASI score decreased by 1.24 in the add-on apremilast group and 0.05 in the control group (p= 0.754). Parameters including body surface area, dermatology life quality index, and body mass index reduced significantly, while the visual analog scale increased significantly in the add-on apremilast group. However, results were comparable between groups. Conclusions Treatment with add-on apremilast accelerated clinical improvement. It also reduced disease progression and improved the disease index among participants. However, add-on apremilast had a lower tolerability profile than the control group.

Roflumilast enhances the melanogenesis and attenuates oxidative stress-triggered damage in melanocytes

BACKGROUND

The management of vitiligo is challenging due to limited treatment options, and therapeutic strategy varies according to the active or stable stage of vitiligo. PDE4 inhibitor has been used to treat various skin diseases, but the efficacy in vitiligo treatment is mixed.

OBJECTIVE

In this study, we aimed to investigate whether roflumilast, a PDE4 inhibitor, induces melanogenesis and attenuates oxidative stress-triggered damage in melanocytes, and if so, what is the mechanism.

METHODS

Melanin content assay, qRT-PCR, western blotting, ELISA, immunofluorescence assays, immunohistochemistry, small interfering RNA, flow cytometry, and transmission electron microscopy were employed.

RESULTS

Our results demonstrated that roflumilast alone only slightly increased melanogenesis, however, the combination of roflumilast and forskolin could boost cAMP levels, hence promoting melanogenesis more significantly. Moreover, roflumilast attenuated H₂O₂-induced apoptosis and mitochondrial morphological changes in melanocytes by reducing ROS levels. Furthermore, roflumilast activated AhR/Nrf2 pathway via cAMP whereas AhR silencing blocked roflumilast-induced Nrf2 nuclear translocation and reversed the inhibitory effect of roflumilast on H₂O₂-induced ROS production. Finally, we observed that the lesional skin of active vitiligo patients exhibited higher PDE4 expression levels.

CONCLUSION

roflumilast enhances the melanogenesis effect of forskolin and protects melanocytes from H₂O₂-induced apoptosis by cAMP/AhR/Nrf2-activated ROS inhibition, highlighting its therapeutic potential in vitiligo treatment.

Apremilast and narrowband ultraviolet B combination therapy suppresses Th17 axis and promotes melanogenesis in vitiligo skin: a randomized, split-body, pilot study in skin types IV-VI

Improved repigmentation of generalized vitiligo in skin types IV-VI has been reported in clinical response to combined therapy with apremilast and narrowband (NB)-UVB; however, tissue responses to combined therapy versus NB-UVB monotherapy have not been elucidated. We compared the change from baseline in cellular and molecular markers in vitiligo skin after combined therapy versus NB-UVB monotherapy. We assessed lesional and nonlesional skin samples from enrolled subjects and evaluated for immune infiltrates, inflammatory, and melanogenesis-related markers which were compared across different treatment groups. Combined therapy resulted in significant reduction of CD8⁺T cells and CD11c⁺ dendritic cells, downregulation of PDE4B and Th17-related markers, and upregulation of melanogenesis markers. This study was limited to small sample size, skin types IV-VI, and high dropout rate. Our molecular findings support the clinical analysis that apremilast may potentiate NB-UVB in repigmentation of generalized vitiligo in skin types IV-VI.

Vitiligo Treatments: Review of Current Therapeutic Modalities and JAK Inhibitors

Vitiligo is a chronic autoimmune disease characterized by loss of pigment of the skin, affecting 0.5-2% of the population worldwide. It can have a significant impact on patients' quality of life. In recent years, there has been significant progress in our understanding of the pathogenesis of vitiligo. It is believed that vitiligo develops due to a complex combination of genetics, oxidative stress, inflammation, and environmental triggers. Conventional treatments include camouflage, topical corticosteroids, topical calcineurin inhibitors, oral corticosteroids, phototherapy, and surgical procedures, with the treatment regimen dependent on the patient's preferences and characteristics. With increased understanding of the importance of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway in the pathogenesis of vitiligo, treatment has expanded to include the first US FDA-approved cream to repigment patients with vitiligo. This review summarizes our understanding of the major mechanisms involved in the pathogenesis of vitiligo and its most common available treatments.

Successful treatment of vitiligo with crisaborole ointment: a report of two cases

As selective PDE-4 small molecule inhibitor, Crisaborole has been used with success in atopic dermatitis and psoriasis. Here we report two vitiligo patients successfully treated with crisaborole ointment.

Has the core outcome (domain) set for vitiligo been implemented? An updated systematic review on outcomes and outcome measures in vitiligo randomized clinical trials

BACKGROUND

In 2015, a major achievement in vitiligo research was the development of an internationally agreed upon core outcome domain set for randomized clinical trials (RCTs). Three outcomes were identified as being essential: repigmentation, side-effects/harms and maintenance of gained repigmentation. Four items were further recommended for inclusion. The following recommendations then followed: repigmentation should be assessed by measuring the percentage of repigmentation in quartiles (0-25%, 26-50%, 51-79%, 80-100%) and cosmetic acceptability of the results should be assessed using the Vitiligo Noticeability Scale.

OBJECTIVES

The primary objective of this study was to assess uptake of the core outcome domain set for RCTs in vitiligo. Secondary objectives were to update the systematic review on outcomes reported in vitiligo RCTs, and to assess whether repigmentation and cosmetic acceptability of the results were measured using the above-mentioned recommended scales.

METHODS

We searched PubMed, Cochrane Library (CENTRAL and Systematic Reviews) and ClinicalTrials.gov for vitiligo RCTs between November 2009 and March 2021. Screening and data extraction were independently performed on title and summary by two researchers. All outcomes and outcome measures reported in eligible RCTs were retrieved and collated.

RESULTS

In total, 174 RCTs were identified: 62 were published between 2009 and 2015, and 112 were published between 2016 and 2021.Thirty-eight different outcomes were reported. Repigmentation was the primary outcome in 89% of trials (150 of 169). Forty-nine different tools were used to measure repigmentation. Side-effects and harms were reported in 78% of trials (136 of 174). Maintenance of gained repigmentation was reported in only 11% of trials (20 of 174) and duration of follow-up varied greatly from 1 to 14 months. Cosmetic acceptability of the results and cessation of disease activity were assessed in only 2% of trials (four of 174). Quality of life of patients with vitiligo was assessed in 13% of trials (22 of 174). Finally, only 11 of 112 RCTs (10%) published between 2016 and 2021 reported all three essential core outcome domains (repigmentation, side-effects and maintenance of gained repigmentation) and none of the trials reported both essential and recommended core outcome domains.

CONCLUSIONS

Efforts are still needed to close the gap between set recommendations and RCT outcome reporting.

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.).

Research Progress on Targeted Antioxidant Therapy and Vitiligo

Vitiligo is a common acquired depigmenting disease characterized by the loss of functional melanocytes and epidermal melanin. Vitiligo has a long treatment cycle and slow results, which is one of the most difficult challenges for skin diseases. Oxidative stress plays an important role as an initiating and driving factor in the pathogenesis of vitiligo. Antioxidant therapy has recently become a research hotspot in vitiligo treatment. A series of antioxidants has been discovered and applied to the treatment of vitiligo, which has returned satisfactory results. This article briefly reviews the relationship between oxidative stress and vitiligo. We also describe the progress of targeted antioxidant therapy in vitiligo, with the aim of providing a reference for new drug development and treatment options for this condition.

Fototerapia – metoda wykorzystywana w leczeniu przewlekłych schorzeń dermatologicznych

Wykorzystanie energii świetlnej w terapii schorzeń o różnej etiologii towarzyszy człowiekowi od czasów starożytnych. Elementem decydującym o powodzeniu terapii jest dobranie odpowiedniej długości promieniowania (terapia NB-UVB, BB-UVB i UVA1) lub wystąpienie interakcji między substancją światłoczułą skumulowaną w zmienionej chorobowo tkance a zastosowanym promieniowaniem (terapia PUVA oraz terapia fotodynamiczna). Metody terapeutyczne wykorzystujące energię świetlną są klasyfikowane na podstawie wykorzystywanego zakresu promieniowania. Obecnie wyróżnia się fototerapię UV, wykorzystującą promieniowanie UVA lub UVB oraz terapię fotodynamiczną (PDT; photodynamic therapy), podczas której stosowane jest promieniowanie o długości fali 350-700 nm.

Fototerapia UV wykorzystywana jest do leczenia schorzeń dermatologicznych, takich jak łuszczyca, bielactwo oraz atopowe zapalenie skóry, ze względu na jej działanie immunosupresyjne i antyproliferacyjne. Jest dostępna w postaci terapii PUVA polegającej na wykorzystaniu synergicznego działania promieniowania ultrafioletowego (UVA) oraz związków o działaniu światłouczulającym (8-metoksypsolaren, 5-metoksypsolaren). Ponadto wyróżniono monoterapię promieniowaniem ultrafioletowym A1 (UVA1), szerokozakresowym UVB (BB-UVB) i wąskozakresowym UVB (NB-UVB). Terapia fotodynamiczna obok konwencjonalnych metod leczenia jest nowoczesną i nieinwazyjną alternatywą wykorzystywaną zarówno w diagnostyce, jak i terapii chorób o różnej etiologii. W 90% przypadków PDT jest stosowana w schorzeniach dermatologicznych, takich jak trądzik pospolity czy łuszczyca. Selektywna aktywność cytotoksyczna wykazywana w kierunku złośliwych komórek nowotworowych powoduje, że terapia fotodynamiczna stosowana jest także z powodzeniem w leczeniu zmian onkologicznych. Duży postęp, przejawiający się zarówno w opracowywaniu innowacyjnych substancji światłoczułych, jak i nowych źródeł promieniowania, sprawia, iż zakres stosowalności terapii fotodynamicznej ciągle się poszerza.

W artykule przedstawiono obecnie dostępne formy fototerapii poprzez opis mechanizmu ich działania, zastosowania oraz możliwości powstania skutków niepożądanych.

Autoimmunity in vitiligo: Therapeutic implications and opportunities

Vitiligo is an acquired chronic pigmentary disorder affecting the melanocytes, mainly in the skin and mucosae. It occurs due to the dynamic interaction between genetic and environmental factors leading to autoimmune destruction of melanocytes. Defects in melanocyte adhesion and increased oxidative stress further augment the immune response in vitiligo. It is a cosmetically disfiguring condition with a substantial psychological burden. Its autoimmune nature with resultant chronicity, variable responses to therapeutic modalities, and frequent recurrences have further diminished the quality of life. Hence, treatment should aim to provide more extended remission periods, prevent recurrences, provide good cosmetic outcomes and ensure patient satisfaction. These treatment goals seem plausible with the recent progress in our understanding of the complex pathogenic mechanisms underlying vitiligo at a molecular and genetic level. We provide a literature review of the pathogenic mechanisms and the therapies targeting these mechanisms.

Clinical Features, Immunopathogenesis, and Therapeutic Strategies in Vitiligo

Vitiligo is an autoimmune disease of the skin characterized by epidermal melanocyte loss resulting in white patches, with an approximate prevalence of 0.5-2% worldwide. Several precipitating factors by chemical exposure and skin injury present commonly in patients with vitiligo. Although the diagnosis appears to be straightforward for the distinct clinical phenotype and specific histological features, vitiligo provides many challenges including chronicity, treatment resistance, frequent relapse, associated profound psychosocial effect, and negative impact on quality of life. Multiple mechanisms are involved in melanocyte disappearance, including genetics, environmental factors, and immune-mediated inflammation. Compelling evidence supports the melanocyte intrinsic abnormalities with poor adaptation to stressors leading to instability and release of danger signals, which will activate dendritic cells, natural killer cells, and innate lymphoid cells to initiate innate immunity, ultimately resulting in T-cell mediated adaptive immune response and melanocyte destruction. Importantly, the cross- talk between keratinocytes, melanocytes, and immune cells, such as interferon (IFN)-γ signaling pathway, builds inflammatory loops that give rise to the disease deterioration. Improved understanding of the immune pathogenesis of vitiligo has led to the development of new therapeutic options including Janus kinase (JAK) inhibitors targeting IFN-γ signaling pathways, which can effectively reverse depigmentation. Furthermore, definition of treatment goals and integration of comorbid diseases into vitiligo management have revolutionized the way vitiligo is treated. In this review, we highlight recent developments in vitiligo clinical aspects and immune pathogenesis. Our key objective is to raise awareness of the complexity of this disease, the potential of prospective therapy strategies, and the need for early and comprehensive management.

Updates and new medical treatments for vitiligo (Review)

Vitiligo is a multifactorial disease characterized by the loss of skin pigment, which results in achromic macules and patches. There are currently several medical treatments available, which aim to arrest progression and induce skin repigmentation. These treatments alone or combined have exhibited varying degrees of pigmentation, and the majority are safe and effective. All therapies for vitiligo are limited, and no known treatment can consistently produce repigmentation in all patients. Individualized treatment is appropriate according to the location, clinical presentation and the presence of disease activity. The present review summarizes the medical treatments available for vitiligo: Systemic and topic pharmacological therapies, physical and depigmentation treatments. Several treatments are still underway and have not yet been approved. However, due to the promising preliminary results, these are also mentioned in the present review.

Oral gliadin-protected superoxide dismutase in addition to phototherapy for treating non-segmental vitiligo: A 24-week prospective randomized placebo-controlled study

Background

Despite a solid rationale, the usefulness of antioxidants in treating vitiligo has not been clearly demonstrated. Combining superoxide dismutase (SOD) with a wheat gliadin biopolymer protects it during the passage through the gastrointestinal tract.

Objective

To evaluate the efficacy of gliadin‐protected SOD (GP‐SOD), associated with narrowband ultraviolet B(NB‐UVB), for treating vitiligo.

Methods

We conducted a 24‐week monocentric interventional prospective randomized placebo‐controlled trial in the tertiary center for vitiligo care in the department of Dermatology of Nice University hospital, Nice, France.

Subjects with non‐segmental vitiligo affecting more than 5% of the total body surface were included. The subjects received gliadin‐protected SOD (GP‐SOD; 1 g/day for 12 weeks followed by 0.5 g/day for 12 weeks) or placebo in combination with twice‐weekly sessions of NB‐UVB. The primary endpoint was the total repigmentation rate at 24 weeks, compared with baseline, as assessed by investigator‐assessed Vitiligo Extent Score (VES) on standardized pictures.

Results

A total of 50 patients were included. After 24 weeks, a greater improvement in VES was observed in the GP‐SOD group (19.85%; SE 4.63, P < 0.0001) compared with the placebo group (8.83%; SE 4.72, P = 0.0676). Tolerance was good in both groups. No related side‐effect was reported.

Conclusions

The use of GP‐SOD appears to be a useful add‐on to phototherapy in the treatment of vitiligo patients.

Vitiligo: Translational research and effective therapeutic strategies

This is an exciting phase of vitiligo research with the current understanding of vitiligo pathogenesis and its translation to successful treatment. The pathogenetic origin of vitiligo revolves around autoimmunity with supporting role from many other factors like oxidative stress, inherent melanocyte defects, or defective keratinocytes and fibroblasts. Vitiligo can be classified into segmental or non-segmental depending upon the clinical presentation, or it can be classified as progressing or stable based on the activity of the disease. Vitiligo treatments need to be stratified depending upon which type of vitiligo we are treating and at which phase the vitiligo patient presents to us. There are two different aims of treatment of vitiligo. The first involves rescuing the melanocytes from the damage to arrest the depigmentation. The second strategy focuses on replenishing the melanocytes so that successful repigmentation is achieved. It is also important to maintain the disease in a stable phase or prevent relapse. As stability in non-segmental vitiligo is a dynamic process, maintenance of the stability of repigmentation is also an important consideration in the management of vitiligo. In this review, we shall briefly discuss the current options and future insight into the management of vitiligo.

Translational Research in Vitiligo

Vitiligo is a disease of the skin characterized by the appearance of white spots. Significant progress has been made in understanding vitiligo pathogenesis over the past 30 years, but only through perseverance, collaboration, and open-minded discussion. Early hypotheses considered roles for innervation, microvascular anomalies, oxidative stress, defects in melanocyte adhesion, autoimmunity, somatic mosaicism, and genetics. Because theories about pathogenesis drive experimental design, focus, and even therapeutic approach, it is important to consider their impact on our current understanding about vitiligo. Animal models allow researchers to perform mechanistic studies, and the development of improved patient sample collection methods provides a platform for translational studies in vitiligo that can also be applied to understand other autoimmune diseases that are more difficult to study in human samples. Here we discuss the history of vitiligo translational research, recent advances, and their implications for new treatment approaches.

Therapeutic options and hot topics in vitiligo with special focus on pediatrics' vitiligo: A comprehensive review study

Vitiligo is a common skin disorder with an estimated worldwide prevalence to 2.28% which is connected with selective melanocytes loss which leads to depigmentation and chalky-white macules. Vitiligo may be dismissed as a cosmetic problem and may have psychologic impacts on patients. It is occurring in both children and adults and is considered as the most common depigmenting skin disorder in the world. There are still many unknown topics about this disease regarding to its treatment in pediatrics, curable drugs and manifestations. Therefore, we decided to evaluate the recent studies about its therapeutic strategies in pediatrics. Topical therapies should be considered as first line treatment in children, but phototherapy especially NBUVB may be used after topical treatment modalities failure or in extensive or rapidly progressive disease. Our suggestion for the treatment of this disease in children is to use combine treatment modalities with observing safety according to the patient's age.

Vitiligo, From Physiopathology to Emerging Treatments: A Review

Vitiligo is a chronic inflammatory skin disease leading to the loss of epidermal melanocytes. To date, treatment options for vitiligo patients are limited, lack sustained efficacy, and are mainly based on off-label use of immunosuppressive agents, such as systemic or topical steroids or topical calcineurin inhibitors, in association with the use of ultraviolet light. However, recent insights into the understanding of the immune pathogenesis of the disease have led to the identification of several therapeutic targets and the development of targeted therapies that are now being tested in clinical trials. In this review, based on the physiopathology of the disease, we summarize emerging targets that could be developed for the treatment of vitiligo and discuss recent and ongoing developments of drugs for the management of the disease.