Hypopigmentary Skin Disorders

Microneedling in Localized Acquired Hypomelanosis: A Randomized Controlled Trial

BACKGROUND

Several insults can cause acquired localized hypomelanosis which can be a therapeutic challenge. Microneedling is a minimally invasive procedure that stimulates melanogenesis with the benefit of short downtime and a low risk of scarring.

OBJECTIVE

To determine the efficacy and safety of microneedling in localized acquired hypomelanosis.

MATERIALS AND METHODS

This is a randomized controlled trial. Twenty patients aged 18 years and older had their lesions randomized into either a single session of microneedling with 1.5-mm needles or no treatment. Three months later, peripheral tanning, patient satisfaction, surface tanning grade of improvement, Vitiligo Extent Score for a Target Area (VESTA), patient and physician global assessment of improvement (GAI) were evaluated.

RESULTS

Median peripheral tanning was observed in 80% of lesions in the microneedling arm versus 85% in the no-treatment arm. Median physician GAI was 37.5% versus 33.33%, respectively. Median VESTA was 37.5% versus 29%, respectively. Median Patient GAI was 50% in both arms. Surface tanning showed a median increase of +3 grades in both arms.

CONCLUSION

Medium-depth microneedling deserves a place in the armamentarium of therapeutic tools for localized acquired hypomelanosis in normal-texture and scarred skin. The authors suggest repetitive sessions at intervals of 1 to 2 months to offer better coverage. Interestingly, a possible systemic effect of microneedling deserves further investigation.

Screening of Glaucoma or Cataract Prevalence in Vitiligo Patients and Its Relationship With Periorbital Steroid Use

Background/Aim:

There is scarce literature connecting vitiligo and primary open angle glaucoma (POAG). Most literature reports that secondary complications are a direct consequence of corticosteroid treatment of vitiligo. In this study, we aimed to investigate the prevalence of ocular problems in patients with vitiligo and to determine its association with periorbital topical corticosteroid use.

Method:

A cross-sectional study was carried out on 90 patients with vitiligo. The Vitiligo European Task Force questionnaire was completed for each patient. A control group comprising 90 healthy individuals who did not have vitiligo and who were matched on age and gender was used for comparison. A complete ophthalmologic examination was performed. A family history of glaucoma and the use of topical steroids were recorded.

Results:

Two (2/90, 2.2%) of the patients with vitiligo had glaucoma compared with none of the individuals in the control group ( P = .25). Nineteen of the 90 patients with vitiligo used periorbital steroids, and of these patients, 10.5% (2/19) developed glaucoma. The duration of periorbital corticosteroid use was 4.50 ± 2.1 years. Eighty-nine percent (17/19) of the vitiligo patients who applied the potent topical corticosteroid (class I) clobetasol propionate to the periorbital area did not develop glaucoma. In contrast, glaucoma was not observed in 79% (71/90) of the vitiligo patients who did not use steroids. Cataract, uveitis, or fundus problems were not observed in either group.

Conclusion:

The study suggests that patients who have vitiligo and use topical steroids periorbitally do not have an increased risk of glaucoma or cataracts. Future studies that have a larger sample size and use a detailed steroid use protocol are needed.

Public perceptions and attitudes toward vitiligo

BACKGROUND

Previous studies have discussed attitudes of vitiligo patients toward their disease. However, no studies have addressed this issue from the public's point of view.

OBJECTIVE

To explore the perceptions, attitudes, and misconceptions of the public toward vitiligo.

METHODS

A self-administered questionnaire was distributed to attendees of primary health care centers in Riyadh, Saudi Arabia, between January and August 2010.

RESULTS

Overall, 924 of the 1,000 distributed questionnaires were returned, and 429 were males (46.8%). Moreover, 33.1% (303 of 916) believed that vitiligo is contagious or did not know that it is not. The cause of vitiligo was thought to be infectious by 20.4% of respondents (182 of 894), inherited by 40.5% (365 of 902), autoimmune by 41.2% (370 of 899), and due to a lack of hygiene by 22.5% (199 of 883). Unmarried individuals and those with less education were more likely to state that vitiligo is caused by an infection (.  =  .02, .  =  .03, respectively). Younger individuals and those with less education were more likely to think that vitiligo is caused by a lack of hygiene (.  =  .01, .  =  .001, respectively). More than half of the participants (56.1%, 504 of 898) would be unwilling to marry a vitiligo patient. Younger individuals and males were less likely to marry a vitiligo patient (.  =  .01, .  =  .05, respectively), whereas those of lower income were more likely to accept it (.  =  .002).

CONCLUSIONS

Various misconceptions and negative attitudes about vitiligo among the public are prevalent. Educating the public about vitiligo could ultimately lead to better psychosocial well-being of vitiligo patients.

Breaking immunological tolerance to melanocyte differentiation antigens by hypopigmenting agents: a new means for melanoma immunotherapy?

The hypopigmenting agent monobenzone induces inflammatory responses only in pigmented skin as well as depigmentation in areas not directly exposed to the drug. Both observations have been ascribed to the possible induction of adaptive immune responses against melanocytes. In this issue, van den Boorn et al. provide direct evidence confirming this hypothesis. Since the monobenzone-induced immune responses target melanocyte-differentiation antigens, this report opens the opportunity for a simple and instantaneous deployable immunotherapy of melanoma.

Response of vitiligo to narrowband ultraviolet B and oral antioxidants

Narrowband ultraviolet B phototherapy (NB-UVB) is the most widely and effective therapeutic option in vitiligo. Antioxidant supplementation has also been reported to be useful. The purpose of this study was to determine the efficacy of oral antioxidants with NB-UVB in the treatment of vitiligo. Twenty-four patients with stable vitiligo were recruited and divided randomly into 2 groups. They were treated with NB-UVB plus oral vitamin E in group A and with NB-UVB only in group B. Improvement was recorded according to the extent of repigmentation in the existing lesions. Both plasma malondialdehyde (MDA; product of lipid peroxidation) and reduced glutathione (GSH) were measured before and after treatment. Twenty patients completed the study. Marked to excellent repigmentation was noted in 72.7% and 55.6% of the patients in group A and group B, respectively. Of the patients, 70% in group A and 85% in group B experienced mild erythema. After treatment, there was a significant reduction in plasma MDA in group A than in group B, but the increase in plasma GSH was not significant. In conclusion, oral vitamin E may represent a valuable adjuvant therapy, preventing lipid peroxidation in the cellular membrane of melanocytes and increasing the effectiveness of NB-UVB.

Vitiligo and melanoma-associated hypopigmentation (MAH): shared and discriminative features

BACKGROUND

It is unclear if differences between melanoma-associated hypopigmentation (MAH) and classical vitiligo exist.

PATIENTS AND METHODS

Hypopigmented areas and associated lesions (halo nevi, hypopigmented scars) in 15 melanoma patients and 31 patients with classical vitiligo were analyzed by digital photography. The activity of the respective lesions was assessed by the vitiligo disease activity (VIDA) score. Associated diseases were recorded by history and serological tests;genotyping of HLA class I antigens as well as histology/immunohistology were performed.

RESULTS

MAH were diagnosed in 12 of 15 melanoma patients; mean onset was 4.8 years after the primary diagnosis of the melanoma. Three melanoma patients reported hypopigmentation more than 15 years before diagnosis of melanoma. In the history and family history of vitiligo patients, autoimmune diseases were much more frequent and haplotype HLA-A2 was twice as common compared to MAH patients. MAH lesions were most often distributed in a bilateral symmetrical pattern, corresponding to vitiligo. MAH was less progressive compared to classical vitiligo; however, it was more often associated with other acquired leukodermas. In both groups hypopigmentation spread centripetally to the trunk. Histological and immunohistological differences were not found.

CONCLUSIONS

Whereas differences exist concerning associated autoimmune diseases, MAH and vitiligo shared many common clinical and histological features. Further studies are needed to assess the clinical relevance of vitiligo-like alterations in melanoma patients.

A potent tyrosinase activator from Radix Polygoni multiflori and its melanogenesis stimulatory effect in B16 melanoma cells

Tyrosinase is a key enzyme in melanin biosynthesis. Activators of tyrosinase with stimulatory effects on melanogenesis are beneficial for the treatment of hypopigmentation diseases. In the present study, mushroom tyrosinase activity assay was performed to screen tyrosinase activators from traditional Chinese herbs. Four components from Radix Polygoni multiflori were tested. The most active compound, 2,3,5,4'-tetrahydroxystilbene-2-O-beta-D-glucoside (THSG), was found to be a significant tyrosinase activator. The maximal activation was 126% at a concentration of 75.0 microg/mL. The three anthraquinones slightly activated tyrosinase with effects in the range 7-31%. All the compounds were tested in B16 melanoma cells, the anthraquinones were found to inhibit cell proliferation at a concentration of 0.1-2.5 microg/mL, and THSG was found to be non-cytotoxic at a concentration of 0.1-12.5 microg/mL. THSG significantly increased the activity of murine tyrosinase and stimulated melanin biosynthesis in B16 melanoma cells. In conclusion, THSG is a potent tyrosinase activator and stimulator of melanogenesis with potential for the treatment of hypopigmentation disease.

Combination of 308-nm xenon chloride excimer laser and topical calcipotriol in vitiligo

BACKGROUND

A large variety of therapeutic agents are being used for the treatment of vitiligo, but treatment remains a challenge. Recently, monochromatic phototherapies such as 311-nm narrowband ultraviolet B therapy and 308-nm xenon chloride excimer laser have been reported to be an effective and safe therapeutic option in children and adult patients with vitiligo. Single reports stipulate that the addition of topically applied calcipotriol to phototherapy increases its effectiveness.

OBJECTIVE

The purpose of the present pilot study was to determine if the addition of topical calcipotriol increases the efficacy of the 308-nm xenon chloride excimer in the treatment of vitiligo.

METHODS

Ten patients with vitiligo with essentially bilateral symmetrical lesions were enrolled in this prospective right/left comparative, single-blinded trial conducted over a 15-month period. All patients received 308-nm XeCl excimer laser therapy three times weekly. Calcipotriol ointment (Daivonex) was applied to lesions on one side of the body twice daily.

RESULTS

After 24 treatments (8 weeks), nine patients were evaluated. Eight patients showed evidence of repigmentation on both body sides, with no significant difference between the body side treated with calcipotriol and excimer laser and the side treated with excimer laser alone. The mean repigmentation rate was 22.4% (1-37%).

CONCLUSION

The addition of calcipotriol ointment to 308-nm xenon chloride excimer laser phototherapy does not significantly enhance its efficacy. Small additive effects must be investigated in a larger trial.

Cytotoxic T cells

The immune system is a complex arrangement of cells and molecules that preserve the integrity of the organism by elimination of all elements judged dangerous. Within the immune system, a humoral and a cellular as well as an innate and an adaptive arm can be differentiated. The key players of adaptive cellular immune responses are T lymphocytes in general and, for the effector function, cytotoxic T lymphocytes (CTLs) in particular. T lymphocytes arise in the bone marrow and migrate to the thymus for maturation. During this process, T cells somatically rearrange gene segments, eventually leading to the expression of a unique antigen-binding molecule, the T-cell receptor (TCR). This receptor allows them to monitor all cells of the body, ready to destroy any cell posing a threat to the organism. Cytotoxicity is exerted directly through the Fas or perforin pathway and/or indirectly by the release of cytokines. Obviously, the activity of such a potent cell is tightly regulated. Indeed, a predominance of stimulatory over inhibitory signals is required for effective immune responses to pathogens, and a predominance of inhibitory over stimulatory signals is required for maintenance of self-tolerance. Still, several situations occur in which an inappropriate CTL response leads to either autoimmune disease or persistence of pathogens.

Melanin pigmentary disorders: treatment update

Most of the melanin pigmentary disorders are cosmetically important and have a strong impact on the quality of life of affected individuals. This article examines recent advances in the treatment of melanin pigmentary disorder including hypermelanosis and hypomelanosis. The development of laser technologies has completed the use of the increasing number of bleaching agents in treating hyperpigmented lesions. The treatment of hypomelanotic disorders is still often disappointing, but new therapeutic options provide encouraging results.