Comparison between the efficacy of microneedling combined with 5-fluorouracil vs microneedling with tacrolimus in the treatment of vitiligo

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.

Effect of Topical 5% 5-Fluorouracil with Microneedling in Vitiligo Patients as an Additional Modality to Standard Treatment at Tertiary Care Hospital

Background

Vitiligo is an inveterate disease of great aesthetic concern presenting with depigmented macules and patches. It is often incorrigible to medical treatment.

Aim

To study the clinical profile of vitiligo patients and evaluate the effect of 5% 5-fluorouracil (5-FU) cream with microneedling.

Materials and Methods

This observational analytical study was conducted from November 2019 to July 2021. A total of 33 adult vitiligo patients were treated with oral mini-pulse (dexamethasone) therapy and topical corticosteroid (clobetasol propionate 0.05%). Patient's total number of vitiligo lesions with <10-cm size were counted and half of the lesions were treated with 5-FU + microneedling (Group A), while a remaining number of lesions were not treated with 5-FU + microneedling (Group B). In the case of the odd number of lesions, the total number of lesions minus one was considered and then divided into equal numbers for treatment. The procedure was performed every 2 weeks for 3 months. Clinical improvement was assessed monthly till 6 months by serial clinical photographs and grading scores.

Results

Initiation of repigmentation started in the first month in Group A, whereas in Group B, it was seen in the second, which was statistically significant (P < 0.0001). Excellent improvement (>75% repigmentation) was noted in Group A as compared to Group B at the end of 6 months (P < 0.0001).

Conclusions

Needling with 5% 5-FU appears to be a simple, safe, and effective treatment in vitiligo. It can be used in poor responders to conventional therapy.

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.

Ophthalmic injuries from the beirut blast: Managing long-term consequences

The 2020 Beirut Port explosion was one of the largest non-nuclear urban explosions in history, and resulted in a plethora of oculofacial injuries. In this retrospective study, we present the two year follow up ophthalmic outcomes of the survivors of the blast. Only 16 out of 39 patients continued follow up at our center, with 13 having delayed complications and 7 requiring further surgery. The most common delayed complications related to the eyelid, lacrimal system, and orbit. Treatment of disfiguring facial and peri-ocular scarring with laser-assisted drug delivery of topical 5-fluorouracil showed great promise and significantly improved patients' functional and well as cosmetic outcomes.

Efficacy and safety of micro-needling combined with topical 5-fluorouracil and excimer light vs. excimer light alone in treatment of non-segmental vitiligo: A comparative study

BACKGROUND/PURPOSE

Vitiligo is one of the most challenging dermatological diseases with little improvement promises. Various modalities of treatment both medical and surgical have been used in the treatment of vitiligo. Some proved to be effective, others with controversial results and the rest were effective less. The aim of the present study was to evaluate the additional effect of topical 5-fluorouracil after micro-needling to excimer light (308 nm) in treatment of non-segmental vitiligo.

METHODS

Fifty patients were included in the present study, only 33 patients continued the treatment for 6 months. Two patches were selected in every patient to be treated, one patch with micro-needling then application of 5 FU and excimer (Group A), and the other with excimer only (Group B).

RESULTS

The treatment with the combination of micro-needling then application of 5 FU and excimer showed significant earlier response versus excimer alone. Also, the percentage of re-pigmentation was higher in the patches treated with the combination especially in the face and trunk. The combination of 5 FU after micro-needling and Excimer is more suitable for localized and focal vitiligo.

CONCLUSION

Topical 5 FU after micro-needling is a promising, rapid, and cost-effective therapeutic strategy for treatment of non-segmental vitiligo It had limited side effects, and the best response was reported for lesions affecting face and trunk.

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.

Efficacy of topical vitamin D combined with microneedling in the treatment of vitiligo: A comparative study

BACKGROUND

Vitiligo is a depigmenting disorder caused by the destruction of melanocytes by various mechanisms which affect melanocyte function and survival. Different therapeutic approaches for vitiligo include nonsurgical and surgical methods but effective therapy is still challenging. There are few studies that suggest the role of vitamin D analogs in the repigmentation process with encouraging results. To our knowledge, this is the first study to evaluate the effect of topical vitamin D (cholecalciferol) combined with microneedling in the treatment of depigmented patches of vitiligo.

AIM OF THE WORK

Evaluate the effect of microneedling alone versus microneedling with topical vitamin D in the treatment of vitiligo.

PATIENTS AND METHODS

A prospective comparative clinical trial was carried out on 25 patients with stable vitiligo; every patient had at least two patches; the first patch was treated with microneedling alone. The other patch was treated with microneedling combined with topical cholecalciferol.

RESULTS

Good-to-excellent response was detected in 52% of the patches treated with microneedling topical cholecalciferol, while only in 40% of the patches treated with microneedling alone. The improvement was higher in combined treatment with no significant difference between both groups.

CONCLUSION

Topical cholecalciferol is a relatively effective and safe alternative in the treatment of stable vitiligo and its combination with microneedling increases its efficacy.

The efficacy of adding topical 5-fluorouracil to micro-needling in the treatment of vitiligo: A randomized controlled trial

BACKGROUND AND AIM

Vitiligo is an autoimmune skin disorder characterized by circumscribed depigmented macules and patches caused by the loss of functional melanocytes. Although there is no definitive treatment for vitiligo, several treatment options have been associated with relative satisfactory outcomes. The purpose of this study was to compare the efficacy of micro-needling in conjunction with topical 5-fluorouracil (5-FU) versus topical tacrolimus ointment in treating vitiligo patches.

PATIENTS AND METHODS

This study included nineteen participants, each of whom received both treatments on two randomly selected vitiligo patches of approximately the same size and location. On one patch, a combination of weekly micro-needling and topical application of 5-FU solution was used every other day, while on the other, 0.1% tacrolimus topical ointment was applied twice daily. The G-score was used to compare treatment outcomes after 3 months.

RESULTS

The median duration of the disease in our population was 7 years. Six patients (32%) in the micro-needling plus topical 5-FU treated group showed a moderate to excellent response, indicating a significant improvement between both treatments (p-value = 0.019). In contrast, all other patches treated with topical tacrolimus showed poor improvement. Lower extremity and trunk responded more to treatment with micro-needling plus topical 5-FU than upper extremity and acral areas. Moreover, none of those who have had the disease for more than ten years have responded to treatment. Mild erythema, pinpoint bleeding, and irritation were detected only in the micro-needling treated group.

CONCLUSION

The current study showed that using micro-needling in conjunction with 5-FU could treat vitiligo patients more efficiently than tacrolimus monotherapy. Despite showing moderate to excellent improvement in patches treated with micro-needling and 5-FU, this well-tolerated office-based modality still requires additional research.

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.

5-Fluorouracil With Microneedling Modulates Wound Healing in a Murine Model: An Immunohistochemical Analysis of Mechanism and Dose Efficacy

PURPOSE

The purpose of this study is to assess the dose-dependent immunohistopathological effects of intradermal microneedle-delivered 5-fluorouracil (5-FU) for postincisional wound healing in a murine model.

METHODS

A prospective experimental study was performed. Twelve hairless mice were randomized into 4 treatment groups for postincisional wound treatment: microneedling with topical saline, or microneeding with topically-applied 5-FU at concentrations of 25 mg/ml, 50 mg/ml, or 100 mg/ml. Two surgical wounds were created on each animal. Combination wound treatments were performed on postoperative days 14 and 28, and cutaneous biopsies were obtained on day 56. Specimens were analyzed by a dermatopathologist, blinded to the treatment group, for collagen thickness, lymphocytic infiltration, histiocytic response, sub-epidermal basement membrane zone thickness, and myofibroblast density.

RESULTS

Histopathologic evaluation showed increased collagen thickness, lymphocyte infiltration, and granuloma density in the groups undergoing microneedling treatment with 5-FU, compared to saline. Immunohistochemical analysis revealed a trend toward thicker basement membranes with higher concentrations of 5-FU used, reaching statistical significance between controls and those treated with 100 mg/ml 5-FU ( p = 0.0493). A trend toward decreasing myofibroblast density with increasing doses of 5-FU was noted. No postincisional or treatment complications were observed.

CONCLUSIONS

Our results demonstrate that microneedling is an effective topical subepithelial drug delivery system, and further suggest a beneficial dose-dependent immunomodulatory effect of 5-FU on intermediate wound healing when used in combination with microneedling. We recommend a 5-FU dose at the mid-range 50 mg/ml concentration to simultaneously maximize efficacy and minimize complication risk.

Regenerative Medicine-Based Treatment for Vitiligo: An Overview

Vitiligo is a complex disorder with an important effect on the self-esteem and social life of patients. It is the commonest acquired depigmentation disorder characterized by the development of white macules resulting from the selective loss of epidermal melanocytes. The pathophysiology is complex and involves genetic predisposition, environmental factors, oxidative stress, intrinsic metabolic dysfunctions, and abnormal inflammatory/immune responses. Although several therapeutic options have been proposed to stabilize the disease by stopping the depigmentation process and inducing durable repigmentation, no specific cure has yet been defined, and the long-term persistence of repigmentation is unpredictable. Recently, due to the progressive loss of functional melanocytes associated with failure to spontaneously recover pigmentation, several different cell-based and cell-free regenerative approaches have been suggested to treat vitiligo. This review gives an overview of clinical and preclinical evidence for innovative regenerative approaches for vitiligo patients.

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 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.

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.

Applications of microneedling for various dermatologic indications with a special focus on pigmentary disorders: A comprehensive review study

Microneedling can accelerate skin repair through numerous complex processes triggered by micro-injuries it produces on the skin surface with very thin needles. The current growth in the application of microneedling in the treatment of cutaneous diseases can be explained by its numerous effects on the skin as reported in the literature. Despite the numerous studies conducted on the application of microneedling in the treatment of skin lesions, its effects on pigmented skin lesions have remained relatively unexplored. The present review comprises an examination of the evidence for the application of microneedling in skin diseases in general and a comprehensive review of the applications of microneedling in pigmentation disorders. The review involved a search of all clinical studies, including trials, case reports, and case series, in the databases MEDLINE/PubMed and Google Scholar using the following keywords: "microneedling," "dermal needling," "percutaneous collagen induction," "skin needling," "dermaroller," and "dermatology disorder." Pertinent data were extracted from all relevant articles published from 1990 to April 2021, and focused on the application of microneedling in the treatment of pigmented skin lesions. Despite the limited number of available studies, evidence suggests the effectiveness and safety of microneedling in treating vitiligo, melasma, and periorbital hypermelanosis. It is noteworthy that the combination of any type of non-aggressive needing technique with other effective therapies (especially topical agents and mesotherapy) yields more promising therapeutic results than single therapy for melasma, dark cycles, and vitiligo as the prototype of pigmentary disorders. However, single needling therapy is significantly effective, too.

Pro-pigmentary action of 5-fluorouracil through the stimulated secretion of CXCL12 by dermal fibroblasts

Background:

There is growing evidence that 5-fluorouracil (5-FU) combined with therapeutic trauma can effectively induce skin repigmentation in vitiligo patients who are unresponsive to conventional treatments. Previous studies have mainly focused on identifying the antimitotic activity of 5-FU for the treatment of skin cancer, but few studies have investigated its extra-genotoxic actions favoring melanocyte recruitment.

Methods:

We utilized the full thickness excisional skin wound model in Dct-LacZ transgenic mice to dynamically assess the migration of melanocytes in the margins of wounds treated with or without 5-FU. The in-situ expression of CXCL12 was examined in the wound beds using immunofluorescence staining. Quantitative real-time polymerase chain reaction and Western blotting analyses were performed to detect the expression levels of CXCL12 mRNA and protein in primary mouse dermal fibroblasts treated with or without 5-FU. Transwell assays and fluorescein isothiocyanate (FITC)-phalloidin staining were used to observe cell migration and filamentous actin (F-actin) changes of melan-a murine melanocytes.

Results:

Whole mount and cryosection X-gal staining showed that the cell numbers of LacZ-positive melanocytes were much higher in the margins of dorsal and tail skin wounds treated with 5-FU compared with the controls. Meanwhile, CXCL12 immunostaining was significantly increased in the dermal compartment of wounds treated with 5-FU (control vs. 5-FU, 22.47 ± 8.85 vs. 44.69 ± 5.97, P < 0.05). Moreover, 5-FU significantly upregulated the expression levels of CXCL12 mRNA (control vs. 5-FU, 1.00 ± 0.08 vs. 1.54 ± 0.06, P < 0.05) and protein (control vs. 5-FU, 1.00 ± 0.06 vs. 2.93 ± 0.10, P < 0.05) in cultured fibroblasts. Inhibition of the CXCL12/CXCR4 axis suppressed melanocyte migration in vitro using a CXCL12 small interfering RNA (siRNA) or a CXCR4 antagonist (AMD3100).

Conclusion:

5-FU possesses a pro-pigmentary activity through activation of the CXCL12/CXCR4 axis to drive the chemotactic migration of melanocytes.

Safety Profile for Microneedling: A Systematic Review

BACKGROUND

Microneedling is a minimally invasive procedure that stimulates collagen and elastin proliferation. It is used in the treatment of various skin pathologies, that is, scarring, photodamage, and hair loss; however, its safety profile has yet to be comprehensively reviewed.

OBJECTIVE

This review will discuss the reported side effects of microneedling in the current literature and delineate factors that increase the risk of complications.

MATERIALS AND METHODS

A literature search in August 2019 was conducted using the PubMed database to identify studies reporting adverse events (AEs) after microneedling therapy.

RESULTS

Eighty-five articles were included in this systematic review. The most common reported AEs are transient procedural events that are expected postprocedure lasting up to 7 days, such as transient erythema/edema and pain, postinflammatory hyperpigmentation (PIH), dry skin/exfoliation, lymphadenopathy, and irritant contact dermatitis. Persistent serious adverse effects included PIH, tram-track scarring, and granulomatous reactions. Factors that increase the risk of events are active infections, darker skin, and metal allergies.

CONCLUSION

Microneedling is a relatively safe therapy. Most reported AEs are minimal, resolving quickly and spontaneously. Caution should be taken in patients with active infection, darker skin types, metal allergies, and when used in conjunction with products not approved for intradermal use.

The clinical and pathological effectiveness of microneedling and topical 5-fluorouracil in vitiligo treatment: An association with matrix metalloproteinase 2 immunohistochemical expression

BACKGROUND

The current therapies for vitiligo require long duration with often disappointing outcomes. 5-Fluorouracil (5-FU) is a chemotherapeutic agent approved for topical use in the treatment of several dermatologic conditions. Matrix metalloproteinase 2 (MMP2) is synthesized by keratinocytes during the epidermal remodeling process and has been found to help in melanocyte migration.

AIM

To investigate the efficacy and safety of flexible microneedling followed by application of 5-FU in vitiligo treatment and to evaluate the immunohistochemical expression of MMP2 in involved skin in vitiligo patients before and after treatment.

METHODS

Twenty patients presented with vitiligo were planned to receive one session every 2 weeks for 12 weeks of microneedling followed by 5-FU application. Clinical response to therapy was evaluated by VASI score. Pre- and post-treatment biopsies were taken from vitiliginous patches for MMP2 immunostaining.

RESULTS

Fifteen patients (75%) responded to therapy with observed side effects such as pain, erythema, and hyperpigmentation of margins. The clinical response was more in young patients and those who have short disease duration. MMP2 was significantly increased in post-treatment biopsy compared with the pretreatment one.

CONCLUSIONS

5-Fluorouracil application after microneedling is effective in the treatment of vitiligo with 75% response, 60% patient satisfaction, and tolerable side effects. The improvement in vitiligo patients by microneedling and 5-fluorouracil could be due to upregulation of MMP2 in affected vitiligo specimens.

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.

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.

Different methods of enhancing the efficacy of topical tacrolimus in extra-facial vitiligo: A comparative study

BACKGROUND

Vitiligo is an acquired pigmentation disorder due to loss of melanocytes. Topical tacrolimus is effective in vitiligo treatment with minimal effect on extra-facial lesions.

OBJECTIVE

To assess different methods of enhancing the absorption of topical tacrolimus in extra-facial vitiligo sites using microneedling and occlusion.

METHODS

This study included 20 adult patients of both sexes with non-segmental vitiligo. Four extra-facial vitiligo lesions in each patient were randomly labeled A, B, C, and D and treated as follows: area A: tacrolimus ointment (0.03%) application twice/day, area B: microneedling once/week and tacrolimus ointment application directly after microneedling and twice/day the rest of the week, area C: microneedling once/week alone, and area D: tacrolimus ointment application twice/day under occlusion by polyethylene foil. The evaluation was done clinically by calculating the re-pigmentation percent after 6 months of treatment.

RESULTS

Responders in area B were 45%, and 35% in area C, and 25% in both areas A and D. No statistically significant difference was detected regarding the re-pigmentation percent between the four areas (p > 0.05). No correlations were detected between re-pigmentation percent and patients' data.

CONCLUSION

Combination of microneedling and topical tacrolimus has an edge over monotherapy in vitiligo, and further studies are needed to verify such results.

Fractional CO2 laser, platelet rich plasma and narrow band ultraviolet B in the treatment of Vitiligo (A randomized clinical trial)

Vitiligo is a chronic acquired disease. Various therapeutic strategies are available but with variable degrees of success. Fractional CO2 laser is claimed to be effective in the treatment of refractory non-segmental vitiligo. Platelet-rich plasma may help in stimulation of the proliferation of melanocytes and repigmentation within vitiliginous patches.Our aim was to evaluate and compare the efficacy and safety of fractional CO2 laser, PRP, and NB-UVB either alone or in combination in the treatment of vitiligo. This self-controlled randomized clinical trial included 20 patients with at least 6 patches of vitiligo (VIDA score 1 and 0). Each patch was randomly assigned to receive either, fractional CO2 laser, PRP, combined fractional CO2 with PRP, combined fractional CO2 with NB-UVB, combined fractional CO2 with PRP and NB-UVB or left as a control. There was a statistically significant improvement in all treatment groups on comparing the surface area of vitiligo patches before and after treatment. However on comparing the percentage of reduction in surface area in different treatment groups, there was no statistically significant difference (P = 0.122). Fr: CO2 laser and PRP may be adjuvant therapeutic options to NB-UVB especially in the treatment of refractory cases of non-segmental vitiligo.

Consensus on the treatment of vitiligo - Brazilian Society of Dermatology

Background

Vitiligo is a muco-cutaneous, autoimmune, localized, or disseminated disease, which manifests through hypochromic or achromic macules, with loss in quality of life. The prevalence of vitiligo in Brazil was determined to be 0.54%. There is no on-label medication for its treatment. To date, no Brazilian consensus on the treatment of vitiligo had been written.

Objectives

The objective of this group of Brazilian dermatologists with experience in the treatment of this disease was to reach a consensus on the clinical and surgical treatment of vitiligo, based on articles with the best scientific evidence.

Methods

Seven dermatologists were invited, and each was assigned two treatment modalities to review. Each treatment (topical, systemic, and phototherapy) was reviewed by three experts. Two experts reviewed the surgical treatment. Subsequently, the coordinator compiled the different versions and drafted a text about each type of treatment. The new version was returned to all experts, who expressed their opinions and made suggestions for clarity. The final text was written by the coordinator and sent to all participants to prepare the final consensus.

Results/Conclusion

The experts defined the following as standard treatments of vitiligo: the use of topical corticosteroids and calcineurin inhibitors for localized and unstable cases; corticosteroid minipulse in progressive generalized vitiligo; narrowband UVB phototherapy for extensive forms of the disease. Surgical modalities should be indicated for segmental and stable generalized vitiligo. Topical and systemic anti-JAK drugs are being tested, with promising results.

Efficacy of Topical 5% 5-Fluorouracil with Needling versus 5% 5-Fluorouracil Alone in Stable Vitiligo: A Randomized Controlled Study

Background:

Vitiligo is a chronic disease of great cosmetic concern presenting with depigmented macules and patches. It is often recalcitrant to medical treatment.

Aim:

The aim of the study was to study the efficacy and safety of topical 5% 5-fluorouracil with needling versus topical 5% 5-fluorouracil alone in stable vitiligo.

Materials and Methods:

This interventional prospective study was conducted from July 2018 to June 2019. Total of 60 patients, with stable vitiligo of age older than 10 years, were randomly assigned into two groups of 30 patients each. Group A was treated with needling followed by topical 5% 5-fluorouracil over vitiligo patches. The procedure was performed every 2 weeks for 3 months. Group B was treated with topical 5% 5-fluorouracil alone. Clinical improvement was assessed monthly till 6 months by serial clinical photographs and grading score.

Results:

Initiation of repigmentation started at 1 month in 76 patches (65%) in Group A, whereas in group B, it was seen in 45 patches (38.7%), which was statistically significant (P = 0.0001). Excellent improvement (>75% repigmentation) was noted in 55 patches (47%) in Group A as compared to 5 patches (4.3%) in group B at the end of 6 months (P = 0.03).

Conclusion:

Needling with 5% 5-fluorouracil appears to be simple, safe, and effective treatment in vitiligo. It can be used in poor responders to conventional therapy.

Factors Affecting Depth of Penetration in Microneedling- and Laser-Assisted Drug Delivery: The Importance of Timing of Topical Application

BACKGROUND

Microneedling- and laser-assisted drug delivery are emerging techniques used to treat various conditions. However, key parameters affecting drug penetration remain unknown.

OBJECTIVE

This study aims to investigate the importance of timing of topical application, needle length, and device type for drug delivery.

MATERIALS AND METHODS

Skin harvested from cosmetic surgeries was treated with black ink applied before or after treatment with a microneedling pen (MP), roller, or fractional ablative CO2 laser, and incubated for different time intervals. Ink penetration was additionally tested using different needle lengths. Sandwich estimator was used for statistical analysis.

RESULTS

Ink applied before MP penetrated deeper compared to ink applied afterward at 1 and 3 hours, and roller microneedling in both the ink-before and -after scenarios at 1, 3, and 6 hours (p < .05). Microneedling demonstrated lateral extension of ink beyond microchannels with increased ink penetration over time. CO2 laser demonstrated ink localization within microthermal zones without time-dependent increases in depth after 30 minutes. Ink penetration increases by 0.06 mm per 1 mm increase in needle length.

CONCLUSION

Ink applied before MP results in the deepest penetration of ink. Microneedling offers unique advantages in transdermal delivery as its channels exhibit increasing penetration over time and lateral extension of product.

Safety of the current drug treatments for vitiligo

Introduction: Vitiligo is an acquired depigmenting skin disorder adversely affecting the patient's quality of life. Despite the presence of several treatment modalities, ranging from medical to physical to surgical options, none is curative. Each modality has its own drawbacks and side effects. Thus, the treatment modality needs to be tailored for each individual patient taking into consideration the disease characteristics and also its efficacy and safety to obtain a favorable risk-benefit ratio.Areas covered: This review highlights the different treatment modalities utilized in vitiligo up until 4 November 2019 along with their adverse effects and contraindications, if any.Expert opinion: All the medications have their own adverse effects and contraindications. We have included the most commonly used topical corticosteroids, which may result in striae, cutaneous atrophy, and tachyphylaxis, to the recently introduced biologics, which may induce hypersensitivity reactions, systemic toxicities, and even malignancies. However, more long-term studies are needed to assess the safety of these medications, especially the newer ones, to provide a safe and effective treatment for this disorder.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.

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.

Effect of Topical 5-Fluorouracil Alone versus Its Combination with Erbium:YAG (2940 nm) Laser in Treatment of Vitiligo

Purpose

To compare the efficacy of topical 5-FU as monotherapy to combined therapy of topical 5-FU and Er:YAG (2940 nm) laser in the treatment of non-segmental vitiligo (NSV).

Methods

This is a prospective randomized comparative study. Thirty patients diagnosed with NSV were recruited from the dermatology outpatient clinics of the Medical Research Centre of Excellence, the National Research Centre and the National Institute of Laser Enhanced Sciences. Our study group was divided into two subgroups, Group 1 was subjected to ablative Er:YAG and 5-FU cream and Group 2 applied topical 5-FU cream. Three treatment sessions were repeated every 4 to 6 weeks and patients were followed up to 9 months. Repigmentation was assessed by digital photography and subsequent computer based image analysis.

Results

Repigmentation of Group 1 patients ranged from 0 to 70% (mean 12±7%) whilst in Group 2 this ranged from 0 to 5% (mean 1.4±0.8%). In Group 1 repigmentation was mild in 22/30 (73.3%) and moderate to severe in 3/30 (10%) starting after 3 months and persisted or increased during the period of follow up to 9 months. Groups 1 and 2 were subdivided into A and B, vitiligo involving non-resistant and resistant areas respectively. Group 1A showed more repigmentation (mean 13.8±8.5%) than Group 1B (mean 9.8±4.5%) and Group 2A showed more repigmentation (mean 1.5±1%) than Group 2B (mean 1.3±0.5%).

Conclusion

The combination of Er:YAG with 5-FU is safe and effective in treating and improving outcome in vitiligo especially of non-resistant areas. Computer based image analysis of vitiliginous lesions and assessing post-therapy response is an easy, quick, and reliable method.

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