Systemtherapie der Vitiligo

Systemic drug treatment of vitiligo is currently limited to predominantly adjuvant measures for increasing the effectiveness of UV light therapy. We here present new approaches for the systemic treatment of vitiligo currently under clinical investigation. These include the α?MSH-analogue afamelatonide and oral immunosuppressants such as the Janus kinase (JAK) inhibitors which target interferon-α-dependent autotoxic inflammatory reactions. In 2015 the first publications on the successful systemic use of Janus kinase (JAK) inhibitors in vitiligo appeared. The effectiveness was experimentally supported by animal models of vitiligo and by the characterization of new biomarkers in the serum of vitiligo patients. This may significantly expand the range of treatment options for vitiligo. Topical antiinflammatory and UV therapies are still the main components of vitiligo treatment, often in combination. The main outcome parameters include the extent and duration of repigmentation, cessation of spreading, avoidance of side effects and improvement in the quality of life of patients.     

A review of monochromatic excimer light in vitiligo

Phototherapy is a mainstay of vitiligo treatment and has varying rates of efficacy. Narrowband ultraviolet (UV) B (NB‐UVB) and UVA have been used for decades, but it is only recently that monochromatic excimer light (MEL) was developed for use in dermatology and adapted for the treatment of vitiligo. The specific 308‐nm radiation wavelength is delivered in a targeted form by the xenon‐chloride excimer laser and is also available in an incoherent form that is commonly referred to as the excimer lamp. MEL administered by both laser and lamp has shown efficacy superior to NB‐UVB for the treatment of vitiligo and induces more changes at the cellular level than conventional UVB modalities. The excimer laser is effective in adults and children with vitiligo in all skin types as monotherapy or in combination with other established vitiligo therapeutics. Treatment regimens studied included excimer laser two to three times weekly for up to 36 weeks. Patients commonly achieved > 75% repigmentation. The laser has also been used in combination with topical corticosteroids, calcineurin inhibitors and vitamin D analogues, as well as surgery, thus further expanding treatment options for patients with vitiligo. The excimer lamp has been used for treatments one to three times a week for up to 24 weeks and was found to be equal to excimer laser in a head‐to‐head comparison. It has also been used in combination with topical corticosteroids and oral vitamin E. Both MEL modalities have a limited adverse side‐effect profile. Long‐term effects are yet to be determined; however, based on available data on UVB phototherapy as well as the properties of MEL devices, there is probably only a minimal increased malignancy risk.     

Vitiligo Treatment in Childhood: A State of the Art Review

Abstract: Vitiligo is a common depigmenting disorder affecting about 1–2% of the world population. Approximately half of the affected individuals develop the disease before adulthood. Etiologic hypotheses for vitiligo include biochemical, neural and autoimmune mechanisms. The most compelling of these suggests a combination of genetic and immunologic factors that result in an autoimmune melanocyte destruction. We reviewed studies carried out on various treatment modalities used in childhood vitiligo. Topical corticosteroids were found to have excellent repigmentation rates, whereas calcineurin inhibitors have comparable efficacy and a better safety profile compared with topical corticosteroids. These two groups of topical medications are good first‐line treatment modalities for localized vitiligo. For the treatment of generalized vitiligo, phototherapy has excellent efficacy. Narrow‐band ultraviolet B (UVB) has better overall repigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA). Other treatment modalities may be considered depending on a patient’s specific condition, such as surgical options and depigmentation. With adequate sun protection, the option of no treatment with or without corrective camouflage, is an innocuous alternative to any of these treatment modalities.     

Efficacy and safety of noncultured melanocyte‐keratinocyte transplant procedure for vitiligo and other leukodermas: a critical analysis of the evidence

Vitiligo is an acquired pigmentary skin of depigmentation occurring secondary to melanocyte destruction. Vitiligo and other leukodermas have a profound impact on quality of life. Current therapies include medical options, such as phototherapy, topical and systemic corticosteroids, topical calcineurin inhibitors, immunomodulators, and antioxidiants, and surgical options. Surgical options provide melanocytic cells to previously depigmented areas and use either tissue grafting or cellular grafting methods. Topical treatments are often insufficient, and many of the current surgical procedures have shown variable response rates. In this review, we discuss the process of the cellular grafting melanocyte‐keratinocyte transplantation procedure (MKTP) and critically analyze its efficacy and safety in the treatment of vitiligo and other leukodermas. PubMed was searched for studies (2001–2017) describing the use of MKTP in patients with vitiligo or other leukodermas. Articles or trials discussing the use of MKTP for these patients were selected for in‐depth review. Clinically relevant results regarding efficacy and safety of MKTP in vitiligo and leukoderma patients were analyzed. Numerous trials and case series/reports have demonstrated tolerability and efficacy of MKTP with repigmentation for patients with refractory, stable vitiligo. However, the response rates have been variable, likely influenced by vitiligo type and affected areas. Future research and clinical reporting will provide more insight on which phenotypes may benefit from MKTP.     

Treatment of vitiligo with the 308-nm excimer laser: a pilot study

BACKGROUND: Present vitiligo therapies require many months of treatment and often result in disappointing outcomes. Common therapeutic options include phototherapy with psoralens plus ultraviolet A (UVA) radiation and broadband or narrowband UVB radiation phototherapy. Some of these modalities require regular phototherapy sessions several times a week for up to a year to achieve a therapeutic response. Targeted phototherapy with single-wavelength laser light is a treatment alternative that may prove to be a time-efficient and effective therapeutic option for the management of vitiligo. METHODS: This intervention study was designed as a before and after trial with a single arm. Twenty-nine patches of vitiligo from 18 patients (6 males and 12 females) were treated at the start of the study. Vitiligo patches were treated by using a 308-nm xenon-chloride excimer laser. Lesions were treated 3 times a week for a maximum of 12 treatments. Treatment was withheld if sunburn was observed and held until resolution. All patients had untreated vitiligo patches that served as control sites. RESULTS: Twenty-three vitiligo patches from 12 patients received at least 6 treatments and resulted in some repigmentation in 57% of the treated patches. Eleven vitiligo patches from 6 patients received all 12 treatments and resulted in some repigmentation in 82% of the treated patches. Untreated control patches remained unchanged. CONCLUSION: This degree of repigmentation in a period of 2 to 4 weeks is much higher than that achieved with any other present vitiligo therapy. The xenon-chloride excimer laser may represent a new treatment modality for the management of stable vitiligo.     

Cosmetic camouflage in vitiligo

Vitiligo is not a life-threatening nor a contagious disease. But the disfigurement of vitiligo can be devastating to its sufferers, especially dark-skinned individuals. Available treatment options are disappointing and sufferers often use various forms of camouflage. Remedial cosmetic cover creams help conceal the blemish of vitiligo at least temporarily. A high concentration of pigment is incorporated into water-free or anhydrous foundations to give a color that matches the patient's skin, thereby concealing vitiligo patches. The article highlights the content and technique of application of these creams.     

系统应用糖皮质激素治疗白癜风

白癜风是一种常见的色素脱失性皮肤病,发病机制复杂且不完全清楚,治疗方式多样但疗效欠佳。研究表明,系统应用糖皮质激素通过其抗炎、免疫抑制等作用可以控制白癜风的进展、促进皮损复色,其治疗方法包括低剂量每日口服疗法、间歇疗法、冲击疗法,以及联合外用药、光疗、外科治疗等。系统应用糖皮质激素需根据白癜风类型、发展时期选择适宜的治疗方法,才能达到最佳疗效、减少不良反应。     

The efficacy and safety of tacrolimus as mono- and adjunctive therapy for vitiligo: A systematic review of randomised clinical trials

There is currently no definitive treatment for vitiligo; various modalities include immune modulators phototherapy and skin camouflage. We investigated the efficacy and safety of topical tacrolimus either as monotherapy or combined therapy in the treatment of vitiligo. Electronic systematic search of the literature was carried out using four major databases. Randomised clinical trials (RCTs) that reported the use of topical tacrolimus in the treatment of human vitiligo have been included in a systematic review and meta-analysis. Meta-analysis was conducted via RevMan, and risk of bias was assessed through the Cochrane quality assessment tool. The protocol was published through PROSPERO (CRD42018112430). A total of 19 studies including 814 patients were included in our systematic review. The random-effects-model meta-analysis of two studies revealed that the tacrolimus and narrowband ultraviolet B (NB-UVB) combination therapy rates is better than NB-UVB alone in inducing >75% repigmentation [RR 1.34 (95% CI: 01.05–1.71), P = 0.02]. Tacrolimus and steroids had similar potency in acheiving >75% repigmentation [RR 1.02 (95% CI: 0.19–5.51), P = 0.98]. Meta-analysis of two studies revealed that the fractional laser and tacrolimus combination therapy is no better than tacrolimus alone in causing >75% repigmentation [RR 2.11 (95% CI: 0.87–5.09), P = 0.10]. Further investigating tacrolimus as mono- or adjuvant therapy for vitiligo is highly recommended. Combining tacrolimus to other treatment options such as steroids, phototherapy and laser may be superior to using tacrolimus alone.     

Therapeutic options in vitiligo with special emphasis on immunomodulators: A comprehensive update with review of literature

Vitiligo is a relatively common disorder characterized by areas of depigmented skin. It may be associated with social stigma and adversely affects the quality of life. Although many treatment options are available, none is curable. The search continues for an effective therapeutic option. New targeted options include biologics and other immunomodulatory agents, with varying degrees of evidence. We have discussed briefly the therapeutic options with special emphasis on the newer immunomodulatory agents. We undertook a comprehensive English literature search across multiple databases such as PubMed, SCOPUS, EMBASE, MEDLINE, and Cochrane using keywords (alone and in combination) and MeSH items such as “vitiligo,” “treatment,” “recent,” and “immunomodulators” to obtain several relevant articles, priority being given to prospective randomized controlled trials. We scanned all the relevant articles and summarized them to obtain the latest information about the treatment of this condition to prepare the current article.     

Pimecrolimus cream in repigmentation of vitiligo

BACKGROUND: Vitiligo is a chronic disease that mostly affects children and young adults. Nowadays many treatment options are available; however, most of them have limited efficacy and in most cases would result in undesirable complications. OBJECTIVE: To determine the extent of repigmentation according to the location of the lesions after applying topical cream pimecrolimus 1% in vitiligo patients. MATERIALS AND METHODS: Thirty consecutive patients with vitiligo lesions affecting less than 20% of body surface area without any previous history of spontaneous repigmentation were treated with pimecrolimus cream 1% twice daily for 12 weeks. The extent of repigmentation in vitiligo lesions was determined in each patient after 6 and 12 weeks. RESULTS: Moderate to excellent response (repigmentation >26%) was observed in 6.6 and 25.9% of vitiligo lesions 6 and 12 weeks after treatment, respectively. More responsive lesions were located on the trunk, face and elbow (85.7, 75 and 70%). CONCLUSION: Pimecrolimus cream 1% results in repigmentation in vitiligo in different extents according to the location of the lesion; however, to clearly prove its efficacy as monotherapy or in combination with other available treatment options, double-blind placebo-controlled studies are essential.     

Fototerapia y fotoquimioterapia

—Despite the noteworthy advances that have taken place in therapeutics during recent years, phototherapy and photochemotherapy still represent a first-choice alternative in widely prevalent dermatoses such as psoriasis and vitiligo, or the initial stages of cutaneous T-cell lymphoma. In addition, they are a valuable option in atopic dermatitis, prurigo nodularis, localized scleroderma or in preventing photodermatoses.Furthermore, due to their versatility and limited side effects, they are often tried in nearly all cutaneous processes of presumed inflammatory pathogenesis in which other alternatives have failed.PUVA therapy still represents the benchmark with regard to its efficacy in the treatment of psoriasis and cutaneous T-cell lymphoma, although it is also the type of phototherapy associated with more short- and long-term side effects. This circumstance probably explains the increasing use of PUVA baths in recent years, which would partially reduce these drawbacks.In UVB phototherapy, the main innovation is the fact that narrow- band UVB therapy, associated with greater convenience and safety compared to PUVA therapy, has burst onto the scene; it is currently considered one of the treatments of choice for plaque-type psoriasis. It is also a versatile source of radiation which has been successfully applied in the treatment of other dermatoses, such as vitiligo or atopic dermatitis.Other types of phototherapy whose use is increasing in recent years include UVA1 therapy, microphototherapy or excimer lasers.     

Childhood vitiligo

Childhood vitiligo is often encountered in dermatological practice. When present in infancy or early childhood, various nevoid and hereditary disorders are to be differentiated. In many cases, familial aggregation of the disease is seen and other autoimmune disorders may be associated. Segmental presentation is more common, and limited body surface area involvement is usual in this age group. Children with vitiligo often suffer from anxiety and depression because of their unusual appearance. Management of vitiligo in children is difficult as therapeutic options are restricted when compared to that in adult patients. Selection of treatment should be careful in these patients with the aim to achieve best results with minimal side effects as well as relieving patients' and parents' anxiety.     

Heme oxygenase-1 expression protects melanocytes from stress-induced cell death: implications for vitiligo

To study protection of melanocytes from stress-induced cell death by heme oxygenases during depigmentation and repigmentation in vitiligo, expression of isoforms 1 and 2 was studied in cultured control and patient melanocytes and normal skin explants exposed to UV or bleaching agent 4-TBP. Similarly, expression of heme oxygenases was followed in skin from vitiligo patients before and after PUVA treatment. Single and double immunostainings were used in combination with light and confocal microscopic analysis and Western blotting. Melanocyte expression of heme oxygenase 1 is upregulated, whereas heme oxygenase 2 is reduced in response to UV and 4-TBP. Upregulation of inducible heme oxygenase 1 was also observed in UV-treated explant cultures, in skin of successfully PUVA-treated patients and in melanocytes cultured from vitiligo non-lesional skin. Heme oxygenase encoding genes were subsequently cloned to study consequences of either gene product on cell viability, demonstrating that HO-1 but not HO-2 overexpression offers protection from stress-induced cell death in MTT assays. HO-1 expression by melanocytes may contribute to beneficial effects of UV treatment for vitiligo patients.     

Targeted UV therapy in the treatment of psoriasis

Ultraviolet (UV) light is an effective treatment for extensive psoriasis and some other inflammatory skin conditions. Because the predominant effect of UV is a local one (as opposed to a systemic effect on immunity), localized delivery of ultraviolet B radiation (UVB) may be a useful treatment for localized variants of psoriasis and other conditions. The article reviews the literature regarding use of localized UV therapy. A theoretical benefit of localized UV therapy is reduced toxicity compared with whole-body therapy. Practical benefits in psoriasis treatment include higher efficacy and more appealing cosmesis compared with topicals. The 308-nm excimer laser is effective for psoriasis with fewer UVB treatments and lower total UVB exposure than needed for total body UV treatment. Other methods of localized UV delivery include quartz lamps, hand-held home UV devices, and non-laser intense photo sources. Other conditions treated with localized UV include vitiligo and lichen planus. Localized UV therapy is a useful modality for the treatment of localized variants of psoriasis with growing use for other dermatologic diseases.     

Vitiligo treatment demystified: a flowchart for stratified treatment approaches

The recent publication by Anbar et al. in the April issue of this journal, delineating and prioritizing treatment options for vitiligo, is both timely and significant. First and foremost, this work brings to the forefront the important message that vitiligo truly is a treatable disease. All too often, patients refrain from seeking treatment as public opinion dictates that vitiligo is not an important disease, there are no effective treatments available, and insurance will not cover attempts to treat. By providing clear guidelines of treatments to be considered, practicing physicians seeing an occasional vitiligo patient will be more readily inclined to explore the possibilities currently available for enhancing the quality of life of this patient group.     

Ultraviolet-based therapy for vitiligo: What's new?

Vitiligo is an ancient disease in which depigmented and hypopigmented macules appear on the skin. It is a disfiguring condition that may lead to severe psychological trauma. Among the many treatment modalities available for use in vitiligo, those using light therapy, and in particular ultraviolet (UV) light, are some of the most effective treatments. UV-based therapy includes phototherapy (narrowband UVB), photochemotherapy (psoralens with UVA), and targeted phototherapy (excimer laser and excimer lamp). It is important for any practitioner of UV-based therapy to understand the efficacy of each treatment type, as well as their respective adverse effects. In order to take full advantage of UV-based therapy, location, dosing, and photoadaptation must also be taken into account. This review discusses the various UV-based therapeutic options, adjuvant therapies, optimal dosing guidelines, appropriate patient selection, future treatment options, and recommendations based upon the current evidence and the authors' experience with vitiligo.     

An update on new and emerging options for the treatment of vitiligo

Vitiligo is an acquired leukoderma that results from the loss of epidermal melanocytes, and is characterized by macules and patches of depigmented skin. With a relatively high rate of prevalence, vitiligo occurs in localized, generalized, or segmental patterns; it can run a rapidly progressive course or remain stationary. The pathogenesis of vitiligo is not yet fully understood, but the autoimmune hypothesis is the most commonly accepted one, based on which, many treatment modalities have been described. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist, as not all patients respond to available therapies. Variables that affect the choice of treatment include the extent, distribution, and progression rate of the lesions. Another challenge is the lack of a standardized scoring system, which hampers the production of level 1a evidence studies for the treatment of this condition.     

308 nm准分子激光治疗白癜风的现状

白癜风的治疗仍是皮肤科医生面临的一大难题。光疗作为有效、安全的治疗手段,在白癜风治疗中的应用正在逐步推广。308nm准分子激光治疗白癜风快速有效、不良反应少。联合其他治疗方法可提高紫外线抵抗区的疗效。为此,综述308nm准分子激光治疗白癜风的新进展,以供临床参考。     

Combined therapy for resistant vitiligo lesions: NB‐UVB,microneedling, and topical latanoprost,showed no enhanced efficacy compared to topical latanoprost and NB‐UVB

Vitiligo is depigmenting disorder of the skin and mucous membranes but despite various therapeutic options, complete and satisfactory treatment of vitiligo still remains a challenge. Therapeutic success also varies depending on the localization of lesions; hands and bony prominents are considered to be resistant to treatment. We investigated feasibility of treating resistant bilateral symmetrical vitiligo vulgaris and acrofacialis lesions with combination of narrowband UVB and topical prostaglandins (0.005% latanoprost solution) with or without Dermaroller 0.5 mm needle length‐assisted microneedling. Frequency of repigmentation onset was generally low (37.8%) and pronounced repigmentation was infrequently seen (26–50% repigmentation in 20.8%, and >50% repigmentation in only 8.8% of repigmenting lesions). Our study, however, showed that latanoprost can be used in combination with NB‐UVB phototherapy to induce repigmentation in some vitiligo lesions in resistant‐to‐treatment location, while addition of skin microneedling seems not to improve the treatment outcome and possibly needs modification.     

Bases inmunológicas de la hipopigmentación vitiligoide asociada a melanoma

Vitiligo is a skin condition characterized by white, hypopigmented macules. Melanocyte loss is a feature of the disease, and it has been hypothesized that an autoimmune mechanism could be responsible for the depigmentation. Melanoma is a malignancy that develops in melanocytes; if not detected and treated early, it is often deadly. Leukoderma, a condition characterized by depigmentation of the skin, is sometimes associated with malignant melanoma. An immune response against melanocyte antigens leading to destruction of either melanoma cells or melanocytes has been observed in both vitiligo and melanoma. Studies in animal models and humans have shown that humoral and cell-mediated immune responses are involved in modulating cytotoxic activity against tumor cells and normal melanocytes. The study of factors associated with anti-tumor immunopathogenic mechanisms —autoimmunity for example— may provide us with tools for the diagnosis and treatment of diseases such as vitiligo and malignant melanoma.