Vitiligo Prevalence and Quality of Life Among Adults in Europe, Japan, and the United States

Background

Vitiligo, an autoimmune disorder characterised by skin depigmentation, is associated with reduced quality of life (QoL). Vitiligo may be under‐reported, in part because of misconceptions that it is a cosmetic disease.

Objectives

This survey sought to characterise vitiligo prevalence and explore the relationship between sociodemographic and clinical characteristics with QoL in a population‐based, multinational study.

Methods

Participants aged ≥18 years were recruited via an online panel in Europe, Japan and the USA to answer questions regarding skin disorders they may have experienced. Those reporting vitiligo (diagnosed or undiagnosed) or vitiligo signs (experiencing loss of skin colour but unaware of vitiligo and not diagnosed) were included in the analyses of vitiligo prevalence. Participants who self‐reported physician‐diagnosed vitiligo were given a broader survey to characterise disease progression, management and QoL (as measured with the Vitiligo‐specific QoL [VitiQoL] instrument).

Results

The total estimated vitiligo prevalence among 35 694 survey participants (Europe, n = 18 785; USA, n = 8517; Japan, n = 8392) was 1.3% (diagnosed, 0.6%; undiagnosed, 0.4%; vitiligo signs, 0.3%). Among 219 patients formally diagnosed with vitiligo (Europe, n = 150; USA, n = 48; Japan, n = 21), total VitiQoL scores were associated with age (P = 0.00017), disease extent (P < 0.0001), disease progression (P < 0.0001), disease management (P < 0.0001) and time since diagnosis (P = 0.0015). Behaviour scores varied based on skin phototype (P = 0.024) and ethnicity (P = 0.048). Higher total VitiQoL scores were reported in patients with head lesions (P = 0.027) and those with head and hand and/or wrist lesions (P = 0.018). Substantial high concern (rated 8–10 on an 11‐point Likert scale) for lesions was found across all body areas and varied with geographical region.

Conclusions

The vitiligo prevalence rate may be higher than previously reported, with a substantial proportion attributed to people who have not received a formal diagnosis. Among formally diagnosed patients with vitiligo, QoL was most severely impacted by more progressive and higher extent of disease.

International Initiative for Outcomes (INFO) for vitiligo: workshops with patients with vitiligo on repigmentation

BACKGROUND

There is no cure or firm clinical recommendations for the treatment of vitiligo. One of the main issues is the heterogeneity of outcome measures used in randomized controlled trials for vitiligo.

OBJECTIVES

To define successful repigmentation from the patients' point of view and to propose how and when repigmentation should be evaluated in clinical trials in vitiligo.

METHODS

We conducted three workshops with patients with vitiligo and their parents or caregivers. Workshop 1 was held at World Vitiligo Day (Detroit, MI), workshop 2 at the University of Texas Southwestern Medical Center and workshop 3 at the Vitiligo and Pigmentation Institute of Southern California, University of California.

RESULTS

Seventy-three participants were recruited. Consensus on the following questions was achieved unanimously: (i) the definition of 'successful repigmentation' was 80-100% of repigmentation of a target lesion and (ii) both an objective and a subjective scale to measure repigmentation should be used.

CONCLUSIONS

This was the largest patients' outcomes workshop. We followed the guidance from the CSG-COUSIN and the Vitiligo Global Issues Consensus Group. Our recommendations to use percentage of repigmentation quartiles (0-25%, 26-50%, 51-79%, 80-100%) and the Vitiligo Noticeability Scale are based on the best available current evidence. A limitation of the research is that the workshops were conducted only in the U.S.A., due to pre-existing organisational support and the availability of funding.

A comparative trial of two retinoids commonly used in the treatment of acne vulgaris

BACKGROUND

Topical retinoids are highly effective treatments for acne vulgaris. The various formulations and concentrations available allow physicians to tailor therapies to individual patient's needs and minimize the cutaneous irritation that is often observed with the use of these drugs.

OBJECTIVE

To compare the efficacy and safety of tretinoin gel microsphere 0.1% with adapalene gel 0.1% in the treatment of acne vulgaris.

METHODS

A 12-week double-blind study was conducted, and patients were evaluated at baseline and at weeks 2, 3, 4, 6, 8, 10, and 12.

RESULTS

Although the two drugs displayed similar efficacy in the resolution of acne lesions at 12 weeks, a significantly greater reduction in the number of comedones was seen at week 4 among patients treated with tretinoin gel microsphere (p = 0.047). Patients receiving tretinoin gel microsphere had an increased incidence of dryness (weeks 8 and 10) and peeling (weeks 3, 6, 8, and 10) compared with those patients treated with adapalene gel, but the two groups were comparable with respect to erythema, burning/stinging, and itching.

CONCLUSION

Both drugs have similar efficacy in the resolution of acne lesions but tretinoin gel microsphere may result in a faster onset of action in the reduction of comedones compared to adapalene.

Minocycline effect on meibomian gland lipids in meibomianitis patients

The objective of this research was to determine the effect of oral minocycline on the meibomian gland nonpolar and free fatty acid lipids of chronic blepharitis patients. Patients--seborrheic blepharitis (SBBL), acne rosacea (AR) without ocular involvement, and acne rosacea with meibomianitis (AR-MKC). Minocycline treatment--50mg orally for 2 weeks followed by 100mg to the end of 3 months; this was followed by 3 more months with no treatment. Meibomian gland secretions (meibum) were collected before treatment, at the end of the 3 months on treatment, and 3 months after stopping treatment. Lipids were separated and analyzed for wax and sterol esters, triglycerides, diglycerides, free cholesterol and free fatty acids. Data were analyzed statistically by ANOVA. Minocycline treatment resulted in decreased diglycerides and free fatty acids in the group AR-MKC, which continued into the second 3 months (off treatment) and was significant. Cholesterol decreased, but triglycerides initially decreased with treatment and then increased when treatment in the group was discontinued (second 3 months); these results, however, were not significant. Thus, minocycline has its greatest effect on lipid types, which result from degradation (lipase) reactions, suggesting a lipase inhibition effect and/or direct effect on ocular flora. This minocycline effect continues even after treatment is discontinued, suggesting a more lasting effect on ocular microflora. Minocycline may be most effective when the treatment period is longer than 3 months. These results give insight into disease mechanisms associated with chronic blepharitis.

Hypopigmented mycosis fungoides: a report of 7 cases and review of the literature

Over the last 2 decades, hypopigmented macules have been reported with increasing frequency as an initial presentation of mycosis fungoides (MF). We retrospectively reviewed 7 patients with hypopigmented MF. The mean age was 35 years at disease onset, with a mean of 5.5 years' duration of illness before presentation. All of our patients were Fitzpatrick skin type IV or V, and most reported pruritus. Histologic findings in all cases were consistent with MF. Treatment with topical nitrogen mustard produced repigmentation in 4 of 6 patients.

Pulse intravenous cyclophosphamide therapy for dermatologic disorders

Cyclophosphamide is a potent immunosuppressive agent that has an important role in the treatment of autoimmune, neoplastic, granulomatous, and neutrophilic disorders. Pulse intravenous cyclophosphamide has been shown to be efficacious for several dermatologic disorders, particularly pemphigus vulgaris, with a low incidence of toxicity reported. As reported earlier, studies performed on the use of pulse intravenous cyclophosphamide in the treatment of a variety of dermatology-related diseases strongly suggest that the toxicities frequently noted with the use of oral cyclophosphamide therapy may be significantly less common with pulse intravenous administration of cyclophosphamide. The short follow-up period of patients treated with this modality so far, however, requires constant vigilance for the development of side effects, particularly secondary malignancy. At this time, pulse intravenous cyclophosphamide is a promising treatment modality with an acceptable risk profile for moderate-to-severe dermatologic diseases recalcitrant to standard therapy. Prospective comparative trials are needed to assess further the efficacy and toxicity of this therapy.

Nontuberculous mycobacterial infections of the skin

Nontuberculous mycobacteria are playing an increasingly important role in human disease owing to higher prevalence of antibiotic resistance and immunodeficiency. These organisms cause a variety of cutaneous findings which are often misdiagnosed by the clinician. Compounding this problem is the fact that most mycobacteria require special culture conditions, which if not specifically requested, are frequently not used. Recognition of susceptible patients is imperative and is not limited to the immunocompromised. Successful treatment of mycobacterial infections requires knowledge of currently available and recommended antibiotics followed by tailoring of the antimicrobial regimen after sensitivity testing is performed.

Disorders of hyperpigmentation

Hyperpigmentation is a common disorder of the skin, particularly in brown-skinned patients. Melasma is a common cause of facial hyperpigmentation and can be resistant to treatment. A combination of topical creams and gels, chemical peels, and sunscreens may be necessary for significant improvement. Erythema dyschromicum perstans is a dermal pigmentation seen on the trunk and proximal extremities, most commonly presenting in dark-skinned Hispanics. Drug-induced and postinflammatory hyperpigmentation may last for many months after the offending drug or dermatitis has been eliminated. These disorders, including their management, is reviewed in this article.

Pulse intravenous cyclophosphamide therapy in pemphigus

BACKGROUND

Adjuvant therapy is commonly used in pemphigus to mitigate the high morbidity and mortality associated with the use of corticosteroids and improve disease control. However, these adjuvant agents are not without adverse effects of their own, including an increased risk of malignancy with the use of oral immunosuppressives. Intravenous pulse cyclophosphamide, which may be more efficacious and less toxic than oral immunosuppressives, has been used successfully in the treatment of pemphigus.

OBJECTIVE

To review 9 patients with severe or previously recalcitrant pemphigus who were treated with intravenous pulse cyclophosphamide therapy.

RESULTS

Six of the 9 patients responded to therapy, with 2 patients achieving remission from skin lesions. Five patients were able to decrease their daily dose of prednisone, and 1 was able to discontinue the use of prednisone completely. Most patients experienced minimal or no adverse effects.

CONCLUSIONS

Intravenous pulse cyclophosphamide may be an alternative treatment option in patients with pemphigus recalcitrant to standard therapy. The decreased cumulative dose of cyclophosphamide observed with monthly pulse doses may reduce the incidence of secondary malignancies when compared with continuous oral therapy. Controlled trials are needed to further evaluate the efficacy of this mode of therapy.

Combination therapy of resistant warts in a patient with AIDS

BACKGROUND

An AIDS patient on anti-HIV therapy consisting of two reverse transcriptase inhibitors had a low CD4+ lymphocyte count, a high HIV viral RNA load, and facial warts that were resistant to ablative therapy.

OBJECTIVE

To find a regimen to treat resistant warts in an AIDS patient with a depressed CD4 count and high HIV viral load.

METHODS

A protease inhibitor was added to his regimen and he was treated with ablative therapy using a 585 nm flashlamp-pumped pulsed dye laser (FPPDL).

RESULTS

Observed resolution of the warts one month later, with no recurrence at seven-month follow-up.

CONCLUSIONS

Treatment of resistant warts in patients with AIDS may be enhanced by triple-drug therapy which includes a protease inhibitor, used in combination with ablative therapy, such as the FPPDL.

Pigmentary diseases

Abnormalities of pigmentation are common and frequently produce great concern in patients presenting to primary care physicians. Although many pigmentary changes arise as a consequence of inflammatory skin disorders, it is important to differentiate a primary skin disease from postinflammatory changes. Early recognition of a pigmentary disease allows the clinician to begin appropriate therapy at a stage when medical intervention may be more effective. Although many skin disorders are mainly of cosmetic concern, the condition may be devastating psychologically, requiring the clinician to be sensitive to the overall impact of the disorder and treat it accordingly.

Treatment of pemphigus with gold

BACKGROUND

Although gold has been reported to be useful in treating pemphigus vulgaris, its use has waned in recent years because of concerns regarding efficacy and toxicity.

OBJECTIVE

To review 26 patients with pemphigus who were treated with intramuscular gold over a 10-year period.

RESULTS

Gold was effective in 62% of patients as a primary treatment for pemphigus or as a steroid-sparing agent. An average of 3 months of therapy was required before the daily prednisone dosage could be halved. Four patients were free of disease and stopped receiving all therapy at the conclusion of the study. Toxic effects due to gold therapy developed in 42% of patients and all adverse effects resolved with its cessation.

CONCLUSIONS

While toxic effects limit the use of gold in many patients with pemphigus, it may be effective in treating a large percentage of patients who otherwise are unable to reduce their steroid requirement. Because of its delayed onset of action, patients treated with gold usually require systemic steroids when therapy is initiated. Controlled, prospective trials are needed to further evaluate the efficacy of gold and its potential steroid-sparing effects.

Fatal scleromyxedema: report of a case and review of the literature

Scleromyxedema is a rare fibromucinous connective tissue that can be associated with systemic changes, such as myopathy, neurologic defects, esophageal dysmotility, paraproteinemia, and restrictive lung disease. We describe a fatal case of scleromyxedema in which neurologic, cardiac, gastrointestinal, and muscle changes were present. At autopsy, mucin was found in the papillary dermis of skin and in coronary and pulmonary vessels, but was absent from the brain, kidneys, heart, gastrointestinal tract, esophagus, liver, thyroid, lymph nodes, bone marrow, and pancreas. Because the pathogenesis of scleromyxedema may not always be attributable to mucin deposition, the role of circulating factors in the development of systemic manifestations warrants further investigation.

Radiation dermatitis after spinal arteriovenous malformation embolization: case report

Few cases of radiation injury related to lengthy interventional neuroradiologic procedures have been reported, although concern has been heightened, as evidence by a 1994 FDA Public Health Advisory. We report a case of radiation-induced dermatitis in a patient undergoing multiple diagnostic and embolization procedures for treatment of a spinal arteriovenous malformation.

Treatment of dermatomyositis with methotrexate

BACKGROUND

No published data exist on the incidence of liver fibrosis in patients with dermatomyositis treated with methotrexate.

OBJECTIVE

Our purpose was to examine the efficacy, steroid-sparing potential, and side effects of methotrexate in patients with dermatomyositis and to report liver biopsy results in four patients.

METHODS

A retrospective review of all cases of dermatomyositis treated with methotrexate in a dermatology and rheumatology referral practice was conducted.

RESULTS

Of the 10 cases reviewed, seven were of dermatomyositis whereas three were of amyopathic dermatomyositis (ADM). Nine patients received oral methotrexate. One patient received intravenous methotrexate. Improvement of cutaneous disease occurred in seven (100%) of the patients with dermatomyositis and in two (66%) of those with ADM; myositis improved in four (57%) of the patients with dermatomyositis. The initial prednisone dose was halved after an average of 18 weeks of methotrexate therapy in the patients with dermatomyositis and 13 weeks in the patients with ADM. Methotrexate-related side effects occurred in six (86%) of the patients with dermatomyositis and in one (33%) of the patients with ADM. Of the four patients who had liver biopsies, two (50%) showed mild hepatic fibrosis, resulting in discontinuation of the drug. Both patients in whom fibrosis developed had preexisting steroid-induced diabetes mellitus.

CONCLUSION

Although methotrexate is an effective treatment for dermatomyositis, side effects are common. Patients with diabetes mellitus should be closely monitored for toxic effects on the liver.

Papulonodular mucinosis associated with systemic lupus erythematosus: possible mechanisms of increased glycosaminoglycan accumulation

BACKGROUND

The mechanism for the production of papulonodular mucinosis in patients with lupus erythematosus (LE) is not known.

OBJECTIVE

Our purpose was to determine whether fibroblasts in a patient with LE and papulonodular mucinosis produced more mucin than normal fibroblasts and whether this mucin production could be stimulated by the patient's serum.

METHODS

Skin fibroblasts from a patient with systemic LE and massive papulonodular mucin deposition, as well as normal fibroblasts, were incubated in the presence of serum from the patient or from a healthy volunteer. The production of glycosaminoglycan by fibroblasts was analyzed.

RESULTS

Fibroblasts from the patient produced more glycosaminoglycan than did normal fibroblasts. Glycosaminoglycan production was increased in all cells when incubated in the presence of the patient's serum.

CONCLUSION

Cutaneous mucin deposition in patients with papulonodular LE skin lesions is associated with increased glycosaminoglycan production by dermal fibroblasts. Our preliminary observations suggest glycosaminoglycan production by these fibroblasts appears to be stimulated by a factor, (or factors) in the patient's serum that is yet to be identified.