Effectiveness of fractional erbium-YAG laser, microneedling, platelet-rich plasma in localized stable vitiligo patients: randomized clinical trial

Vitiligo is considered an autoimmune disease, and its treatment is challenging. We assessed and compared the effect of fractional erbium:yttrium-aluminum-garnet (Er:YAG) laser-assisted delivery of platelet-rich plasma versus microneedling (Mn) with platelet-rich plasma (PRP) in enhancing skin repigmentation in localized stable vitiligo patients. In total, 40 patients with localized stable vitiligo were selected in a random manner into two similar groups (20 each). Group (A) was subjected to fractional Er:YAG laser combined with platelet-rich plasma and Group (B) was subjected to microneedling combined with platelet-rich plasma. The procedure was repeated every 2 weeks for up to 6 months. Each individual was assessed clinically utilizing Vitiligo Area Scoring Index (VASI). Fractional Er:YAG + PRP group achieved better pigmentation100% (excellent 30%, very good 15%, good 30% and satisfactory 25%) which is comparable to Mn + PRP where 80% of cases demonstrate repigmentation (20% very good, 10% good and 50% mild). When comparing the VASI scores for both groups after therapy to the baseline VASI, there was a statistically significant decrease [p = 0.001 for group(A) and 0.003 for group(B)]. Regarding the treatment side effects, there was significantly (p = 0.048) side effects among cases treated with microneedling group(B) (25%) than those fractional Er:Yag laser therapy group(A) (5%). Both forms of therapy demonstrated induction of repigmentation of vitiligo, but fractional Er:YAG laser efficacy is greater when combined with platelet-rich plasma.Clinical trials.gov identifier: NCT05511493.

A Comparative Study on the Usefulness of Fractional CO2 and Fractional Er:YAG in Acne Scars: A Split-Face Trial

Background

Acne is a dermatologic condition with a high burden in terms of psychosocial consequences as a result of scars remaining on the skin. Its effects are severe in adolescence and finding treatments with short therapy courses, superior results, and fewer adverse effects are of high importance.

Materials and Methods

We included 30 individuals with acne vulgaris scars in Al-Zahra academic training hospital from June 2018 to Jan 2019. Each individual received both fractional CO₂ and fractional Er:YAG lasers on right and left sides of the face, respectively. Three sessions of laser treatment were applied to each side with one-month intervals. Results were evaluated by patients according to subjective satisfaction and physicians' assessment and photo evaluation by two blinded dermatologists. Improvement was graded by a quartile grading scale: less than 25%: mild, 25% to 50%: moderate, 51% to 75%: good, and 76% to 100%: excellent response. Assessments were obtained at baseline and one month after the last visit.

Results

Based on subjective satisfaction (p < 0.05) and physicians' assessment (p < 0.01), fractional CO₂ laser was significantly more effective than Erbium:YAG laser. Also, Post-treatment side effects were mild and transient in both groups.

Conclusion

Laser therapies are common in the treatment of scars and each modality has special advantages and disadvantages. Choosing among them should be based on various criteria. Fractional CO₂ lasers have been revealed favorable results in most reports. Large comprehensive trials could help experts in choosing among alternatives for different subgroups.

Research Progress of Small Molecules as Anti-vitiligo Agents

Vitiligo is a disease characterized by skin discoloration, and no safe and effective drugs have been developed until now. New drug research and development are imminent. This article reviews the research on small-molecule drugs for vitiligo from 1990 to 2021 at home and abroad. They are classified according to their structures and mechanisms of action, including natural products and derivatives, anti-oxidative stress drugs, immunosuppressants, prostaglandins, etc. The research on their anti-vitiligo activity, structural modification, new dosage forms, clinical trials, and the development trend in new anti-vitiligo drugs are reviewed, which provides important references for the development of new drugs.

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.

Efficacy and safety of combined fractional ablative CO2 laser and 5 fluorouracil in the treatment of acral vitiligo: An open, uncontrolled study

BACKGROUND

Acral lesions of vitiligo are most likely recalcitrant to the known lines of treatment. Ablative fractional CO₂ has shown efficacy in treatment of vitiligo in combination with other modalities.

METHODS

Thirty non-segmental vitiligo patients with acral lesion were included in the study. Each patient was subjected to fractional Carbon Dioxide Laser Treatment followed by application of 5 fluorouracil (5FU) cream for five consecutive days. Evaluation was done 3 weeks from the start of treatment and 12 weeks after the last treatment session using VESTA score, evaluation of patients' photos by blinded investigation in addition to patients' satisfaction scores.

RESULTS

Patients showed significant improvement of Vitiligo extent score for a target area (VESTA) score and developed considerable degree of repigmentation as assessed by blinded investigators.

CONCLUSION

The combination of fractional ablative CO₂ and 5FU is an effective and safe procedure for the treatment of acral vitiligo with promising results offering patients a new therapeutic window.

Treatment of stable nonsegmental vitiligo using transdermal delivery of 5-fluorouracil by fractional CO2 laser versus intralesional injection of 5-fluorouracil, both followed by narrow-band type ultraviolet B (UVB): A comparative study

BACKGROUND

Updates of treatment methods of stable vitiligo are needed to give better outcomes with a shorter duration of treatment.

OBJECTIVE

To test the effect of transdermal 5-fluorouracil (5-FU) delivery using fractional CO₂ (FrCO₂ ) laser versus intralesional 5-FU injection, with narrow-band type ultraviolet B (UVB) (NB-UVB) therapy after both, in the treatment of stable vitiligo.

PATIENTS AND METHODS

The present study comprised 40 patients with nearly symmetrical stable vitiligo lesions. The left side was treated with FrCO₂  laser followed by topical 5-FU (FrCO₂  + 5-FU), while the right side was treated with 5-FU intradermal injection. Both procedures were done at 2-week intervals for 3 sessions followed by 24 sessions of narrow-band UVB for both sides.

RESULTS

Repigmentation was demonstrated on the left side of 90% of patients and the right side of 85% of patients. As much as >50% improvement was demonstrated on the left side of 50% of patients, and the right side of 55% of patients. Intralesional 5-FU showed a statistically significant difference in repigmentation compared to FrCO₂  + 5-FU.

CONCLUSION

Both 5-FU injection and FrCO₂  + 5-FU were effective therapeutic modalities for vitiligo. Patients were more compliant with FrCO₂  + 5-FU.

Microneedling in Combination with Topical Pimecrolimus 1% versus Topical Pimecrolimus 1% for the Treatment of Refractory Stable Vitiligo: A Randomized Clinical Trial

Objective

Vitiligo is a common, autoimmune disease that results in the destruction of the melanocytes and manifests as depigmented macules on various areas of the skin. Numerous treatment options have been proposed for vitiligo. The purpose of this study was to compare the efficacy of microneedling plus topical pimecrolimus 1% versus the sole use of topical pimecrolimus 1% for the treatment of vitiligo.

Methods

This clinical trial was conducted on 30 skin lesions on 15 Al-Zahra hospital patients. Each patient had two similar lesions in the limb area, and each lesion was considered a separate treatment group. The left or right side of the patient's lesion was randomly assigned to receive microneedling plus topical pimecrolimus for three months, while the other side received only topical pimecrolimus 1%. As part of the follow-up, digital photography was taken at the baseline and biweekly for three months after treatment and six months' follow-up. The following methods were used to evaluate the results: DLQI questionnaires, patient satisfaction questionnaires, and two independent dermatologists comparing the improvement rate for each group.

Results

Topical pimecrolimus 1% treatment led to unsatisfactory results, whereas the combination of microneedling and topical pimecrolimus1% treatment produced a more favorable overall outcome (P < 0.001).

Conclusion

This study established that combination therapy results in more significant patient improvement. Additionally, one patient experienced mild skin irritation as a side effect of topical pimecrolimus.

Safety and Efficacy of High-Dose Fractional Erbium: Yttrium Aluminium Garnet Laser in Stable Vitiligo

Objective: Evaluate the treatment outcome of vitiligo patients receiving a standard regimen of high-dose biweekly fractional 2940 nm erbium:yttrium aluminium garnet (YAG) laser applications as an add-on to various treatment modalities. Materials and methods: The authors extracted the study population's clinical images before treatment and 3rd-month control from their clinical archive and used the medical records. The primary outcome measure was 50% repigmentation at 3rd-month follow-up. Institutional ethical committee approved the study. Results: Of the evaluated 28 patients, 18 were eligible with 31 treatment regions. All patients received at least one topical agent [steroids, calcineurin inhibitors, or 5-fluorouracil (5-FU)] and 11 patients received either targeted ultraviolet B (UVB) or narrow-band UVB. Of the 31 study regions, 88.8% (8/9) of facial; 77.7% (7/9) of dorsal hand; 75% (3/4) of limb; and 25% (2/8) of finger lesions achieved 50% repigmentation at 3rd-month control. The facial and dorsal hand lesions' treatment responses were higher than finger lesions (p = 0.008 and 0.03, respectively). Upon evaluating adjuvant treatment modalities, all of the treatment regions receiving targeted UVB (n = 4) or topical 5-FU (n = 5) achieved the primary endpoint, whereas severe irritation limited the topical use of 5-FU. The most common adverse effects were mild oozing and crusting related to laser treatments. Conclusions: Even with high-energy settings, fractional erbium: YAG laser does not induce the Koebner phenomenon. Although controlled trials are required to make firm conclusions, fractional erbium: YAG laser was an effective and safe adjunctive option for stable vitiligo in a real-life setting.

5-Fluorouracil in Dermatology: The Diverse Uses Beyond Malignant and Premalignant Skin Disease

BACKGROUND

5-fluorouracil (5-FU) is widely used for treatment of malignant and premalignant skin cancers; however, its use in other common cutaneous conditions has been less widely reported.

OBJECTIVE

We investigated the off-label uses of 5-FU beyond malignant and premalignant skin disease.

METHODS

We conducted a literature review searching multiple databases to evaluate the evidence for the off-label uses of 5-FU. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Centre of Evidence-Based Medicine 2011 guidance.

RESULTS

We found underlying evidence to support the use of 5-FU for a wide range of noncancerous cutaneous indications including scarring (keloid, hypertrophic), pigmentary disorders (vitiligo, idiopathic guttate hypomelanosis), cutaneous infections (viral warts, molluscum contagiosum), inflammatory dermatoses (Darier's disease, Hailey-Hailey disease and sarcoidosis), and cosmetic indications (photoaging, treatment of filler nodules and granulomas).

CONCLUSION

In selected patients, 5-FU can be as effective as more established treatments, with fewer side-effects.

Management of recalcitrant vitiligo in Vogt-Koyanagi-Harada syndrome: Adjuvant ablative fractional laser

The course of dermatologic findings in Vogt-Koyanagi-Harada disease is variable. Herein, we report the remarkable repigmentation of widespread facial vitiligo lesions in an adolescent girl with Vogt-Koyanagi-Harada disease. The patient was treated with a combination of fractional erbium:YAG laser, topical tacrolimus, and phototherapy.