Effect of different types of therapeutic trauma on vitiligo lesions

Application of clitoris exposure + episioplasty + dermabrasion + platelet-rich plasma injection + chemexfoliation in vulvar lichen sclerosus

Introduction

To investigate the therapeutic effect of clitoris exposure + episioplasty + dermabrasion + platelet-rich plasma (PRP) injection + chemexfoliation on vulvar lichen sclerosus (VLS).

Methods

Twenty children with VLS (under 14 years old) at our hospital from July 2020 to November 2022 were enrolled and treated with clitoris exposure + episioplasty + dermabrasion + PRP injection + chemexfoliation. Additionally, symptomatic changes and improvements in signs were recorded.

Results

Significant therapeutic effects were achieved in all children enrolled in this study. The Cattanco score was 8.02 ± 1.22 points before surgery, 2.21 ± 0.70 points 3 months after surgery, and 2.61 ± 0.59 points 6 months after surgery, demonstrating that the score after surgery was significantly lower than that before surgery (p < 0.05). Mild complications (one case of mild vulvar swelling, one case of minor bleeding, and one case of superficial ulcer) were observed in three children after surgery, with an overall complication incidence of 15%; all complications were improved after the intervention, and no severe adverse reactions were observed. Recurrence was observed in one child (5%) 6 months after surgery.

Conclusion

Clitoris exposure + episioplasty + dermabrasion + PRP injection + chemexfoliation is an effective approach for the treatment of VLS.

Systematic Review Registration

https://www.chictr.org.cn/searchproj.html, identifier: ChiCTR2100054787.

An Updated Review of Hypertrophic Scarring

Hypertrophic scarring (HTS) is an aberrant form of wound healing that is associated with excessive deposition of extracellular matrix and connective tissue at the site of injury. In this review article, we provide an overview of normal (acute) wound healing phases (hemostasis, inflammation, proliferation, and remodeling). We next discuss the dysregulated and/or impaired mechanisms in wound healing phases that are associated with HTS development. We next discuss the animal models of HTS and their limitations, and review the current and emerging treatments of HTS.

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.

Pharmaceutical based cosmetic serums

The growth and demand for cosmeceuticals (cosmetic products that have medicinal or drug-like benefits) have been enhanced for the last few decades. Lately, the newly invented dosage form, i.e., the pharmaceutical-based cosmetic serum has been developed and widely employed in various non-invasive cosmetic procedures. Many pharmaceutical-based cosmetic serums contain natural active components that claim to have a medical or drug-like effect on the skin, hair, and nails, including anti-aging, anti-wrinkle, anti-acne, hydrating, moisturizing, repairing, brightening and lightening skin, anti-hair fall, anti-fungal, and nail growth effect, etc. In comparison with other pharmaceutical-related cosmetic products (creams, gels, foams, and lotions, etc.), pharmaceutical-based cosmetic serums produce more rapid and incredible effects on the skin. This chapter provides detailed knowledge about the different marketed pharmaceutical-based cosmetic serums and their several types such as facial serums, hair serums, nail serums, under the eye serum, lip serum, hand, and foot serum, respectively. Moreover, some valuable procedures have also been discussed which provide prolong effects with desired results in the minimum duration of time after the few sessions of the serum treatment.

Evaluation of needling/microneedling as an adjunct to phototherapy in the treatment of stable acral vitiligo: a comparative clinical and immunohistochemical study

OBJECTIVES

To evaluate the efficacy and tolerability of needling/microneedling as an adjunct to NB-UVB phototherapy in the treatment of stable refractory patches of acral vitiligo, based upon clinical and immunohistochemical assessment of melanocyte count and distribution in response to needling/microneedling.

MATERIALS AND METHODS

Twenty patients with stable acral vitiligo (≥2 patches) were enrolled. One of the two index patches was randomized to receive needling or microneedling in conjunction with NB-UVB. Patients received phototherapy sessions 3 times weekly, while needling was carried out on biweekly basis for 6 months. Assessment was done clinically using point counting method, VESTA, and global patients' satisfaction, and immunohistochemically by quantitative assessment of melanocyte count by Melan-A.

RESULTS

No statistically significant difference was observed between NB-UVB monotherapy and either of the combined therapy regimens as regards the mean percentage change in vitiligo surface area (p = .451), mean change in absolute melanocyte count from baseline (p = .589), and mean VESTA (p = .916). Patches subjected to adjuvant microneedling/needling were afflicted by koebnerization in 50% and 20% of cases, respectively.

CONCLUSION

Neither microneedling nor needling appear to confer an added therapeutic value to NB-UVB phototherapy in the treatment of stable acral vitiligo. Moreover, both carry the risk of koebnerization.

Microneedling combined with pimecrolimus, 5-fluorouracil and trichloroacetic acid in the treatment of vitiligo: A comparative study

BACKGROUND

Treatment of vitiligo represents a highly therapeutic challenge in spite of the continuous development of new modalities. Combination therapies of vitiligo can help improve treatment response, and reduce recurrence potential.

OBJECTIVE

To compare the efficacy and adverse effects of microneedling combined with 5-fluorouracil, pimecrolimus, and TCA in the treatment of localized, stable vitiligo.

METHODS

The study included 75 patients with non-segmental, stable vitiligo who were randomly assigned to three equal groups: group 1 received a combination of microneedling and 5-FU, group 2 received microneedling and pimecrolimus, and group 3 received microneedling and TCA. The procedure was done every 2 weeks for a maximum of 6 sessions.

RESULTS

Combined microneedling and TCA was associated with the highest degree of repigmentation followed by combined microneedling + 5-fluorouracil, and lastly combined microneedling + pimecrolimus. The difference between the three groups was statistically significant in favor of the combined microneedling and TCA. Pain, erythema, post-inflammatory hyperpigmentation, infection, and scarring were variably reported adverse effects in the 3 groups.

CONCLUSION

Combination therapy seems to be a promising modality for the treatment of vitiligo. Combined microneedling and TCA is superior to combined microneedling with either 5-fluorouracil or pimecrolimus.

Automated Microneedling Versus Fractional CO2 Laser in Treatment of Traumatic Scars: A Clinical and Histochemical Study

BACKGROUND/OBJECTIVES

Microneedling has shown satisfactory effects in scar rejuvenation. Comparisons of its results with fractional laser are limited. This study aims to compare the efficacy and safety of automated microneedling versus fractional carbon dioxide (CO2) laser in treatment of traumatic scars on clinical and histochemical bases.

MATERIALS AND METHODS

Thirty patients with traumatic facial scars were randomized to treatment with 4 monthly sessions of either automated microneedling or fractional CO2 laser. Assessment of scars was performed at baseline and 3 months after the last treatment session, clinically by the modified Vancouver Scar Scale (mVSS) and histochemically by quantitative assessment of collagen and elastic fibers.

RESULTS

Both groups showed improvement in mVSS, collagen, and elastin contents after treatment. Percentage improvement of collagen and elastin content was higher after treatment by a laser compared with microneedling, in case of the collagen content. Percentage increase in the collagen content after treatment was higher in atrophic scars of the laser group than those of the microneedling group.

CONCLUSION

In this small study, microneedling was as safe as fractional CO2 laser for rejuvenation of traumatic scars with comparable clinical effects. Fractional CO2 laser is more powerful in stimulating neocollagenesis. Automated microneedling is effective for treatment of hypertrophic scars.

Trichloroacetic Acid in Different Concentrations: A Promising Treatment Modality for Vitiligo

BACKGROUND

Despite the recent advances in the treatment of vitiligo, results are still largely unsatisfactory and many patients show either weak or no response to treatment. Few clinical trials have investigated the use of trichloroacetic acid (TCA) to induce repigmentation in stable vitiligo.

OBJECTIVE

To evaluate the efficacy and safety of TCA, in different concentrations, for the treatment of stable localized vitiligo.

METHODS

The study included 100 patients with acral/nonacral stable vitiligo. Trichloroacetic acid was applied, as a monotherapy, to the vitiliginous patches at different concentrations according to the treated site every 2 weeks until complete repigmentation or for a maximum of 6 treatment sessions. Follow-up was done every month for 6 months to detect any recurrence.

RESULTS

Eyelid vitiligo showed the highest response to TCA treatment (excellent response in 80% of cases), followed by the face, trunk, and extremities. Lower response rates were noticed in the hands and feet vitiligo. Adverse effects were transient and insignificant in few patients.

CONCLUSION

Trichloroacetic acid seems to be a potential, cost-effective, well-tolerated therapeutic option for the treatment of vitiligo in the adults and pediatric populations.

Follicular Transplantation, Microneedling, and Adjuvant Narrow-band Ultraviolet-B Irradiation as Cost-Effective Regimens for Palmar-Plantar Vitiligo: A Pilot Study

Treatment of refractory palmar-plantar vitiligo is particularly challenging because the skin in these regions has a limited supply of follicle-derived melanocytic stem cells. Autologous hair transplantation monotherapy is effective in some forms of vitiligo through the provision of melanocytic stem cells. CO₂ laser followed by exposure to light (i.e., sunlight or narrow-band ultraviolet-B [nbUVB]) has independently shown to be an effective treatment strategy. Recently, it was found that the combination of hair transplantation and CO₂ laser followed by nbUVB exposure had superior efficacy to either modality as monotherapy. Similar to CO₂ laser, microneedling produces skin cell proliferation and releases pro-pigmentary cytokines. Given the important role of the cytokines in vitiliginous skin, microneedling may also be an effective therapeutic modality for refractory vitiligo. Herein, we conducted a pilot study to evaluate the efficacy of hair transplantation and CO₂ laser or microneedling followed by nbUVB. Microneedling and fractional CO₂ laser in combination with hair transplantation and nbUVB both demonstrated utility in the induction of repigmentation in refractory palmar-plantar vitiligo; however, a larger trial would be needed to determine a difference in treatment efficacy. Nonetheless, microneedling is cost-effective and requires minimal training; therefore, microneedling can be easily incorporated into standard dermatological practice.

Value of silicone gel in prevention of cobblestoning following punch minigrafting in vitiligo

Background: Cobblestoning is the most common complication of minipunch grafting.Objective: To assess the value of silicone gel application following minipunch grafting and the histopathological and immunohistochemical changes in cases with cobblestoning.Methods: Minipunch grafting was performed in two similar vitiligo lesions in 27 cases with stable vitiligo. After healing, silicone gel was applied twice daily on one lesion while zinc oxide ointment was applied to the other lesion serving as a control. Four biopsies were taken from each case; normal, vitiliginous skin before treatment and the two treated lesions 3 months after therapy, for histopathology and immunohistochemical staining for MMP9 & tenascin-C.Results: Repigmentation occurred in 19 cases (70.7%). The number of lesions showing excellent and good response was significantly higher on the silicone gel side (p < .001). In 20 cases, cobblestoning either occurred or was absent on both sides. Histopathologically, cobblestoning was similar to hypertrophic scarring. Both markers were elevated after therapy on both sides with no significant difference in percentage change between lesions showing positive and negative cobblestoning.Conclusion: Silicone gel application after minigrating improved the final response with no significant effect on the occurrence of cobblestoning. Cobblestoning resembled hypertrophic scarring histopathologically.

Combined microneedling with tacrolimus vs tacrolimus monotherapy for vitiligo treatment

Background: Miconeedling has been used to augment the transdermal drug delivery. Combination modalities may accelerate and improve the repigmentation in vitiligo.Objective: To determine the efficacy and tolerability of combined microneedling with tacrolimus vs tacrolimus 0.1% ointment for the treatment of vitiligo.Patients and Method: Forty-eight patients with vitiligo were randomized into two groups: group I applied tacrolimus once daily for 6 months. Group II received microneedling with topical tacrolimus at 2 weeks intervals for a maximum of 6 months. The assessment was based on the clinical improvement and immunohistochemical changes. Skin biopsies were taken at baseline and after the treatment for c-kit + expression.Results: After treatment, the repigmentation >75% was observed in 50% of the patients in group II compared to 29.2% in group I (p .02). There was an earlier response in group II than in group I (p .002). The improvement was significantly higher in the legs and extremities in group II than in group I (0.003). The immunohistochemical results showed significantly higher expression of c-kit in group II than group I (p .01). No severe side effects were reported.Conclusion: The results suggest the superiority of the combination regimen (tacrolimus and microneedling) for vitiligo treatment.

Platelet-rich plasma versus combined fractional carbon dioxide laser with platelet-rich plasma in the treatment of vitiligo: a comparative study

Purpose

The aim of this study was to assess the efficacy of platelet-rich plasma (PRP) vs combined fractional CO₂ (Fr: CO₂) laser with PRP in the treatment of stable nonsegmental vitiligo (NSV) lesions.

Patients and methods

This prospective, randomized, intrapatient, comparative controlled study was conducted between June 2014 and June 2016 at National Institute of Laser Enhanced Sciences (NILES), Cairo University, Cairo, Egypt. Thirty NSV patients were treated with PRP, Fr: CO₂ laser, and combined Fr: CO₂ laser with PRP. Intrapatient lesions were divide randomly into four groups. Each group was treated by one modality. The fourth group served as a control.Patients received six treatment sessions with 2-week interval for 3 months and were followed up after 3 months.

Results

A highly significant reduction was demonstrated through vitiligo analysis by computer-assisted grid (VACAG) in the combined Fr: CO₂ laser with PRP and in the PRP only groups than other groups. These results were confirmed by mean improvement score by physician (MISP) and by VAS with no statistical difference between them. The combined Fr: CO₂ laser with PRP group showed minimal side effects. Regardless of the modalities, better improvement was seen in the trunk than the face, extremities, and acral lesions with significant reduction in all regions. Face showed maximum response with combined Fr: CO₂ laser with PRP. Trunk showed higher response with PRP. Upper limbs showed highest response with combined Fr: CO₂ laser with PRP. Lower limbs showed the highest improvement with Fr: CO₂ laser.

Conclusion

According to our study, combined Fr: CO₂ laser with PRP achieved superior repigmentation than intradermal (ID) PRP. However, Fr: CO₂ alone showed poor improvement. Combined ablative Fr: CO₂ laser and PRP therapy followed by sun exposure could be used effectively and safely to treat refractory NSV.

Clinical and Molecular Aspects of Vitiligo Treatments

Vitiligo is an asymptomatic but cosmetically disfiguring disorder that results in the formation of depigmented patches on skin and/or mucosae. Vitiligo can be segmental or non-segmental depending upon the morphology of the clinical involvement. It can also be classified as progressing or stable based on the activity of the disease. Further, the extent of involvement can be limited (localized disease) or extensive (generalized disease). The treatment of vitiligo therefore depends on the clinical classification/characteristics of the disease and usually comprises of 2 strategies. The first involves arresting the progression of active disease (to provide stability) in order to limit the area involved by depigmentation. The second strategy aims at repigmentation of the depigmented area. It is also important to maintain the disease in a stable phase and to prevent relapse. Accordingly, a holistic treatment approach for vitiligo should be individualistic and should take care of all these considerations. In this review, we shall discuss the vitiligo treatments and their important clinical and molecular aspects.