Treatment of vitiligo with NB-UVB: A systematic review

The efficacy of combined phototherapy with topical therapy in vitiligo: a network meta-analysis

BACKGROUND

The comparative effects of phototherapy and topical therapy in patients with vitiligo remain unclear. A network meta-analysis (NMA) was conducted to assess which combination therapy was more beneficial for patients with vitiligo.

METHODS

This study analyzed phototherapy, including narrowband ultraviolet B (NB-UVB) and 308-nm excimer laser/light (EL) combined with topical therapies. Randomized controlled trials were sourced from PubMed, Embase, and Cochrane Library. Data analysis was based on a random-effects model, and surface under the cumulative ranking (SUCRA) curves employed to assess the efficacy of the interventions.

RESULTS

This NMA included 27 trials, with a total of 2417 lesions (patches). According to the results of the SUCRA, for achieving ≥50% repigmentation, the top three combination therapies were phototherapy combined with antioxidants (SUCRA 87.7), corticosteroids (SUCRA 69.6), and calcineurin inhibitors (SUCRA 52.5), while for ≥75% repigmentation, the leading therapies were phototherapy combined with antioxidants (SUCRA 89.0), calcineurin inhibitors (SUCRA 70.3), and fractional CO2 laser (SUCRA 63.6).

CONCLUSIONS

This meta-analysis suggests that combining phototherapy with topical antioxidants, corticosteroids, or calcineurin inhibitors may offer superior outcomes for vitiligo patients. This study provides a reference for clinicians to develop personalized treatment plans for patients with vitiligo.

5,7-Dihydroxy-4-Methylcoumarin as a Functional Compound for Skin Pigmentation and Human Skin Safety

Background/Objectives: This study aims to investigate the effects of 5,7-dihydroxy-4-methylcoumarin (5,7D-4MC) on melanogenesis in B16F10 murine melanoma cells and to evaluate its safety as a potential ingredient for functional cosmetics and therapeutic agents targeting pigmentation-related disorders. Method: The cytotoxicity of 5,7D-4MC was assessed using an MTT assay, and melanin content and tyrosinase activity were measured at different concentrations (25, 50, 100 µM). Western blot analyses were conducted to evaluate the expression of key melanogenesis-related proteins (TYR, TRP-1, TRP-2, and MITF) and to investigate the regulation of major signaling pathways, including PKA/cAMP, GSK3β, and PI3K/AKT. Additionally, a human primary skin irritation test was performed on 32 participants to assess the dermatological safety of 5,7D-4MC. Results: 5,7D-4MC did not affect cell viability at concentrations below 100 µM and significantly promoted melanin production in a dose-dependent manner. Tyrosinase activity and the expression levels of melanogenic proteins increased significantly following 5,7D-4MC treatment. PKA and GSK3β pathways were activated, while the PI3K/AKT pathway was downregulated. The skin irritation test showed that 5,7D-4MC exhibited low irritation potential at concentrations of 50 µM and 100 µM. Conclusions: 5,7D-4MC enhances melanogenesis and demonstrates low skin irritation, making it a promising candidate for therapeutic applications in treating hypopigmentation disorders, such as vitiligo, as well as a functional cosmetic ingredient. However, further studies involving human melanocytes and clinical trials are required to validate their efficacy.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Study of Novel Furocoumarin Derivatives on Anti-Vitiligo Activity, Molecular Docking and Mechanism of Action

Vitiligo is a common chronic dermatological abnormality that afflicts tens of millions of people. Furocoumarins isolated from Uygur traditional medicinal material Psoralen corylifolia L. have been proven to be highly effective for the treatment of vitiligo. Although many furocoumarin derivatives with anti-vitiligo activity have been synthesized, their targets with respect to the disease are still ambiguous. Fortunately, the JAKs were identified as potential targets for the disease and its inhibitors have been proved to be effective in the treatment of vitiligo in many clinical trials. Thus, sixty-five benzene sulfonate and benzoate derivatives of furocoumarins (7a–7ad, 8a–8ag) with superior anti-vitiligo activity targeting JAKs were designed and synthesized based on preliminary research. The SAR was characterized after the anti-vitiligo-activity evaluation in B16 cells. Twenty-two derivatives showed more potent effects on melanin synthesis in B16 cells than the positive control (8-MOP). Among them, compounds 7y and 8 not only could increase melanin content, but they also improved the catecholase activity of tyrosinase in a concentration-dependent manner. The docking studies indicated that they were able to interact with amino acid residues in JAK1 and JAK2 via hydrogen bonds. Furthermore, candidate 8 showed a moderate inhibition of CXCL−10, which plays an important role in JAK–STAT signaling. The RT-PCR and Western blotting analyses illustrated that compounds 7y and 8 promoted melanogenesis by activating the p38 MAPK and Akt/GSK-3β/β-catenin pathways, as well as increasing the expressions of the MITF and tyrosinase-family genes. Finally, furocoumarin derivative 8 was recognized as a promising candidate for the fight against the disease and worthy of further research in vivo.

Cosmeceutical Therapy: Engaging the Repercussions of UVR Photoaging on the Skin's Circadian Rhythm

Sunlight is an important factor in regulating the central circadian rhythm, including the modulation of our sleep/wake cycles. Sunlight had also been discovered to have a prominent influence on our skin's circadian rhythm. Overexposure or prolonged exposure to the sun can cause skin photodamage, such as the formation of irregular pigmentation, collagen degradation, DNA damage, and even skin cancer. Hence, this review will be looking into the detrimental effects of sunlight on our skin, not only at the aspect of photoaging but also at its impact on the skin's circadian rhythm. The growing market trend of natural-product-based cosmeceuticals as also caused us to question their potential to modulate the skin's circadian rhythm. Questions about how the skin's circadian rhythm could counteract photodamage and how best to maximize its biopotential will be discussed in this article. These discoveries regarding the skin's circadian rhythm have opened up a completely new level of understanding of our skin's molecular mechanism and may very well aid cosmeceutical companies, in the near future, to develop better products that not only suppress photoaging but remain effective and relevant throughout the day.

An Update on Narrowband Ultraviolet B Therapy for the Treatment of Skin Diseases

The objective of this review is to provide an update on narrowband ultraviolet B (NB-UVB) as a treatment for various skin conditions. NB-UVB works by suppressing the cutaneous cell-mediated immune response and has been shown to be an efficacious and clinically tolerable treatment for a range of inflammatory dermatoses. A literature search was conducted by advanced searches of PubMed for NB-UVB treatment of dermatologic skin diseases with a focus on reports from 2010 to 2021, including both office-based and home-based phototherapy (HBPT). Data were prioritized based on studies with a high level of evidence using the Oxford Evidence-Based Medicine guidance.

We found that NB-UVB continues to serve as an effective form of therapy for several cutaneous conditions, including vitiligo, psoriasis, atopic dermatitis, mycosis fungoides, and other inflammatory dermatoses. The recent introduction of Janus kinase inhibitors in combination with NB-UVB suggests future promise in the treatment of vitiligo. Despite its rise in popularity, a decline was seen in office-based NB-UVB treatment during the coronavirus disease 2019 pandemic. Options are available to deliver NB-UVB at home with comparable efficacy to office-based treatments. In conclusion, for a select group of patients and conditions, NB-UVB continues to serve as an effective treatment modality with minimal side effects, with HBPT serving as an option to improve patient compliance.

Combination of carboxytherapy with narrowband-ultraviolet B in the treatment of recalcitrant areas of vitiligo: A randomized clinical trial

Carboxytherapy has been used in the treatment of autoimmune skin diseases such as psoriasis and morphea. Carboxytherapy has antioxidant effects, and leads to better tissue oxygenation, and release of growth factors. In this article, we decided to evaluate efficacy of combined carboxytherapy and narrowband-ultraviolet B (NB-UVB) compared to NB-UVB alone in the treatment of vitiligo. This is a prospective, split-body double-blind comparative study performed in patients with generalized stable vitiligo in acral areas and extremities referred to dermatology clinic of Afzalipour hospital in Kerman University of Medical Sciences. NB-UVB was performed three times a week in non-consecutive days for 4 months. In each patient, one lesion was randomly treated with carboxytherapy (weekly sessions for total of 16 sessions). Efficacy of treatment was evaluated by percentage of repigmentation of the lesions. Chi-square test and analysis of variance test (ANOVA) were used to compare efficacy of treatment based on demographic features of the patients and clinical features of the lesions, respectively. Twenty-eight patients with mean age of 32.35 ± 7.37 years old completed the study. At the end of the treatment, 37% of the patients in combination therapy group demonstrated more than 75% improvement compared to 0% in the monotherapy group (p = 0.001). There was no significant difference between either demographic features of the patients (age, sex, and skin phototypes) or duration of disease with efficacy of the treatment in both groups. Combination of carboxytherapy with NB-UVB leads to higher percentage of repigmentation and patients' satisfaction compared to monotherapy with NB-UVB.

Repigmentation by combined narrow‑band ultraviolet B/adipose‑derived stem cell transplantation in the mouse model: Role of Nrf2/HO‑1‑mediated Ca2+ homeostasis

Vitiligo is a depigmentation disease commonly seen in clinical practice, mainly involving loss of functional epidermal pigment cells and hair follicle melanocytes. Narrow‑band ultraviolet B (NB‑UVB) has emerged as the first choice of treatment for vitiligo, but long‑term exposure may have serious consequences. Recently, it was reported that adipose‑derived stem cells (ADSCs) improve melanocyte growth and the efficacy of melanocyte transplantation. The present study aimed to examine the efficacy of NB‑UVB/ADSC‑transplantation combined therapy on a mouse vitiligo model and explore the underlying mechanisms by focusing on endoplasmic reticulum stress and cellular calcium (Ca²⁺) homeostasis. Vitiligo mice models were established by applying 40% monobenzone (MBZ) cream twice daily and treated with NB‑UVB/ADSC combination therapy. Some treated mice were also given ML385, a nuclear factor erythroid 2 like 2 (Nr2) inhibitor. Histopathological changes were evaluated using a depigmentation evaluation score and observed with hematoxylin and eosin staining on skin tissues. ELISA was used to measure diagnostic markers in plasma. Flow cytometric assay was performed to quantify CD3⁺, CD4⁺ and CD8⁺ levels. Expression levels of associated proteins were detected with western blot and immunofluorescence. Treatment of mice with MBZ‑induced depigmentation patches on the skin was accompanied with loss of redox balance and disruption of cellular Ca²⁺ homeostasis. Oxidative stress and Ca²⁺ unbalancing were improved after the mice were treated by NB‑UVB/ADSCs transplantation combination therapy. ML385, strongly negated the protective effect of NB‑UVB/ADSC transplantation combination therapy, indicating the critical role of Nr2 signaling. The findings improved the understanding of the pathogenesis of vitiligo and will guide future development of therapeutic strategies against it.

Rational design of hollow mesoporous titania nanoparticles loaded with curcumin for UV-controlled release and targeted drug delivery

Curcumin (Cur), appeared to provide huge potential in biomedical application. However, its therapeutic efficacy was greatly limited as the result of poor solubility and instability. To address these limitations, we create a new type of hollow mesoporous titania nanoparticle (HMTN) to encapsulate Cur. HMTN was decorated with a layer of hydrophilic polyethylenimine (PEI), which controlled the release rate of Cur inside the pore due to its dendritic structure. Combined with the folic acid (FA) mediated targeting effect, the potential multifunctional Cur loaded titania nanoparticle (Cur-FA-PEI-HMTN) showed excellent biocompatibility and bioavailability, as well as the UV-responsive drug release properties. The operating parameters to prepare hollow structure were studied and the Cur-FA-PEI-HMTN nanosystem had been fully characterized by Brunauer-Emmet-Teller, Fourier transform infrared spectroscopy, transmission electron microscope, thermal gravity analysis, differential thermal analysis, x-ray diffraction, dynamic light scattering and zeta potential. In addition, the hemolytic test, as well as CCK8, flow cytometry, Hoechst 33342 staining experiment, were carried out to confirm the low cytotoxity and high biocompatibility. The confocal microscopy analysis results also revealed the increasing uptake of Cur@FA-PEI-HMTN by MCF-7 cells. The synthesized nanoparticles displayed great potential as drug nanovehicles with high biocompatibility.

Systemic CXCL10 is a predictive biomarker of vitiligo lesional skin infiltration, PUVA, NB-UVB and corticosteroid treatment response and outcome

Vitiligo is an acquired pigmentary skin disorder that currently lacks standardized treatment and validated biomarkers to objectively evaluate disease state or therapeutic response. Although prior studies have linked vitiligo autoimmunity with CXCL10/CXCL9-mediated recruitment of leukocytes to the skin, only limited clinical data are available regarding CXCL10 as vitiligo biomarker. To evaluate the utility of systemic CXCL10 as a predictor of disease progression and treatment response on a large cohort of vitiligo patients. CXCL10 levels in lesional, perilesional, and unaffected skin of vitiligo patient (n = 30) and in the serum (n = 51) were measured by quantitative ELISA. CXCL10 expression, recruitment of leukocytes, and inflammatory infiltrates were evaluated by histochemical (n = 32) and immunofluorescence (n = 10) staining. Rigorous cross-sectional and longitudinal biostatistical analysis were employed to correlate CXCL10 levels with disease variables, treatment response, and outcome. We demonstrated that elevated CXCL10 level (2 pg/mm² and higher) in lesional skin correlates with increased leukocytic infiltrate, disease duration (< 2 year), and its higher level in the serum (50 pg/ml and higher). Changes in CXCL10 serum levels in patients treated with psoralen plus UVA (PUVA) phototherapy, narrowband UVB (NB-UVB) phototherapy, and systemic steroids (SS) correlated with changes in the intralesional CXCL10 levels in repigmented skin. NB-UVB and SS regimens provided most consistent CXCL10 mean change, suggesting that these regimens are most effective in harnessing CXCR3-mediated inflammatory response. Serum CXCL10 is a useful vitiligo biomarker, which predicts lesional skin leukocytic infiltration, and vitiligo treatment response and outcome.

Vitiligo: An Updated Narrative Review

BACKGROUND

Vitiligo is a relatively common acquired pigmentation disorder that can cause significant psychological stress and stigmatism.

OBJECTIVE

This article aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis, and management of vitiligo.

METHODS

A Pubmed search was conducted in Clinical Queries using the key term "vitiligo". The search included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English language. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Approximately one quarter of patients with vitiligo have the onset before 10 years of age. Genetic, immunological, neurogenic and environmental factors may have a role to play in the pathogenesis. Vitiligo typically presents as acquired depigmented, well-demarcated macules/patches that appear milk- or chalk-white in color. Lesions tend to increase in number and enlarge centrifugally in size with time. Sites of predilection include the face, followed by the neck, lower limbs, trunk, and upper limbs. The clinical course is generally unpredictable. In children with fair skin, no active treatment is usually necessary other than the use of sunscreens and camouflage cosmetics. If treatment is preferred for cosmesis, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the mainstays of treatment.

CONCLUSION

The therapeutic effect of all the treatment modalities varies considerably from individual to individual. As such, treatment must be individualized. In general, the best treatment response is seen in younger patients, recent disease onset, darker skin types, and head and neck lesions. Topical corticosteroids and calcineurin inhibitors are the treatment choice for those with localized disease. Topical calcineurin inhibitors are generally preferred for lesions on genitalia, intertriginous areas, face, and neck. Narrowband ultraviolet B phototherapy should be considered in patients who have widespread vitiligo or those with localized vitiligo associated with a significant impact on the quality of life who do not respond to treatment with topical corticosteroids and calcineurin inhibitors.

A Simple Drug Delivery System for Platelet-Derived Bioactive Molecules, to Improve Melanocyte Stimulation in Vitiligo Treatment

Vitiligo is the most common depigmentation disorder of the skin. Currently, its therapy focuses on the halting of the immune response and stimulation of the regenerative processes, leading to the restoration of normal melanocyte function. Platelet-rich plasma (PRP) represents a safe and cheap regenerative therapy option, as it delivers a wide spectrum of native growth factors, cytokines and other bioactive molecules. The aim of this study was to develop a simple delivery system to prolong the effects of the bioactive molecules released from platelets. The surface of electrospun and centrifugally spun poly-ε-caprolactone (PCL) fibrous scaffolds was functionalized with various concentrations of platelets; the influence of the morphology of the scaffolds and the concentration of the released platelet-derived bioactive molecules on melanocytes, was then assessed. An almost two-fold increase in the amount of the released bioactive molecules was detected on the centrifugally spun vs. electrospun scaffolds, and a sustained 14-day release of the bioactive molecules was demonstrated. A strong concentration-dependent response of melanocyte to the bioactive molecules was observed; higher concentrations of bioactive molecules resulted in improved metabolic activity and proliferation of melanocytes. This simple system improves melanocyte viability, offers on-site preparation and is suitable for prolonged topical PRP administration.

Beyond the Booth: Excimer Laser for Cutaneous Conditions

The excimer laser has emerged as an efficacious treatment modality for many dermatologic diseases. The excimer laser is an alternative to standard narrowband ultraviolet B (NBUVB) phototherapy treatment in patients with limited disease. In comparison to standard NBUVB, the excimer laser requires fewer treatment sessions, has reduced treatment duration, requires a lower cumulative UVB dose, and limits UVB exposure to lesional skin. This review addresses the mechanism, safety, application, and efficacy of the excimer laser for the treatment of these conditions.

The color of skin: white diseases of the skin, nails, and mucosa

White diseases are a heterogenous group characterized by hypopigmentation or depigmentation. Skin and eye color are determined by the number and size of melanosomes present. Melanin is produced by melanosomes in the melanocytes present within the epidermis of the skin, uvea, and retinal pigmented epithelium (RPE). Conditions altering the number of melanocytes or concentration of melanin result in a lack of pigmentation, appearing as "white diseases" ranging from the well-known albinism and vitiligo to more esoteric white hand syndrome and Degos disease.

The effect of topical piperine combined with narrowband UVB on vitiligo treatment: A clinical trial study

Vitiligo is the most common acquired hypopigmentary disease in the community. Piperine as an herbal extract derived from black pepper has strong impact on the melanocyte proliferation and adverse side effects less than synthetic drugs such as corticosteroids. For the first time, this study was aimed to evaluate the effect of topical piperine combined with narrowband ultraviolet B (NB-UVB) on vitiligo treatment. In this double-blind clinical trial, 63 patients with facial vitiligo were randomly divided into 2 groups: treated with piperine (case) and placebo (control). Also, both groups received NB-UVB phototherapy every other day for 3 months. In the case group, 10 patients have burning sensation on their skin areas (p value = .002). Also, redness of the treated areas was observed in 6 patients (p value = .028). Both side effects were temporary. Regarding repigmentation at time intervals of 1, 2, and 3 months after treatment, its level in the case group was significantly higher than the control group (p value < .001). Based on our findings, the combination therapy with NB-UVB/topical piperine has more influence on facial vitiligo than that of NB-UVB alone. It could be concluded that the simultaneous use of NB-UVB and topical piperine has a remarkable effect on treatment of vitiligo.

Phototherapy and Combination Therapies for Vitiligo

Vitiligo is a disease characterized by disappearance of melanocytes from the skin. It can negatively influence the physical appearance of affected individuals, and may profoundly affect a person's psychosocial function and quality of life. Therefore, vitiligo should not be considered as merely a condition that affects a patient's appearance, but needs to be actively treated in patients who seek medical help. Phototherapy has been used as the main treatment modality for patients with vitiligo. Different forms of phototherapy for vitiligo include broadband UVB, narrowband UVB, excimer light and excimer laser, and psoralen plus UVA.

Phototherapy: The vitiligo management pillar

Phototherapy has been the mainstay of vitiligo therapy for several decades. A variety of wavelengths and modalities are available, but narrowband ultraviolet B remains the safest and most commonly used treatment. Acting on multiple steps in vitiligo pathogenesis, narrowband ultraviolet B is one of the few therapies that can effectively induce stabilization and stimulate repigmentation. Achievement of optimal results involves using a combination of appropriate treatment protocols, careful patient selection, and patient education to set expectations. Individual patient characteristics, including disease activity, vitiligo phenotype, lesion location, and skin phototype, should all be considered, along with combination therapies.

Phototherapy for alopecia areata

Phototherapy is a useful therapeutic method for various skin diseases due to its modulatory effect on the cutaneous immune system. Alopecia areata is a dermatosis characterized by partial or complete hair loss. Collapse of the immune privilege of the hair follicle, which induces noncicatricial alopecia, is an important factor in its etiology. Several forms of phototherapy are used in dermatology.

Efficacy and Safety of 308-nm Monochromatic Excimer Lamp Versus Other Phototherapy Devices for Vitiligo: A Systematic Review with Meta-Analysis

BACKGROUND

Various phototherapy methods are used to treat vitiligo; however, the recent emergence of new devices has heightened debate concerning the best treatment method.

OBJECTIVE

We aimed to systematically review and meta-analyze published data comparing the efficacy and adverse effects of monochromatic excimer lamps versus excimer laser and narrowband ultraviolet B (NB-UVB) in treating vitiligo.

METHODS

A systematic search of PubMed, EMBASE, LILACS, Cochrane Central Register of Controlled Trials (CENTRAL), and clinical trials registries identified randomized controlled trials that included vitiligo patients, regardless of age, sex, or study language. We evaluated studies comparing excimer lamps with excimer laser or NB-UVB phototherapy.

RESULTS

The review included six studies (411 patients, 764 lesions). No study found significantly different efficacy between excimer lamps and excimer laser using the outcomes of ≥50% repigmentation [risk ratio (RR) = 0.97, 95% confidence interval (CI) 0.84-1.11] and ≥75% repigmentation (RR = 0.96, 95% CI 0.71-1.30). Likewise, no study found significant differences between excimer lamps and NB-UVB (RR = 1.14, 95% CI 0.88-1.48 for ≥50% repigmentation; RR = 1.81, 95% CI 0.11-29.52 for ≥75% repigmentation). Adverse effects were mild, including pruritus, burning sensation, and dryness, none of which interrupted treatment.

CONCLUSIONS

To our knowledge, this is the first systematic review of the efficacy and safety of excimer lamp treatment for vitiligo. Excimer lamps, excimer laser, and NB-UVB are all safe and effective in repigmentation of vitiligo lesions. Safety, effectiveness, and cost are considerations when choosing treatment.

PROSPERO REGISTRATION NUMBER

CRD42014015237.

Alternative Systemic Treatments for Vitiligo: A Review

Vitiligo is a common, acquired disorder of skin pigmentation that can significantly impact quality of life. It often represents a therapeutic challenge, which has resulted in interest in alternative treatments such as herbal and vitamin supplements. In this review, we provide an overview of the most commonly studied complementary agents, describe proposed mechanisms of action, identify potential adverse effects, and discuss the primary evidence supporting their use. Our discussion focuses on L-phenylalanine, Polypodium leucotomos, khellin, Ginkgo biloba, and vitamins and minerals, including vitamins B12, C, and E, folic acid, and zinc used as monotherapy or in combination with other treatments for the management of vitiligo.