Clinical differences between segmental nevus depigmentosus and segmental vitiligo

Segmental nevus depigmentosus and segmental vitiligo can be difficult to differentiate from each other. Differential diagnosis of these two diseases is important because they have significantly different prognoses and psychological effects. The purpose of this study is to identify clinical clues that may be helpful in differentiating these two diseases. We enrolled 63 patients with segmental nevus depigmentosus and 149 patients with segmental vitiligo. Sex, age of onset, sites involved, dermatomal distribution, margin of lesion and presence of poliosis were evaluated in both groups. The age of onset was less than 10 years in 96.8% of segmental nevus depigmentosus and 28.9% of segmental vitiligo cases. Trunk (36.5%) and cervical (38.1%) dermatomes were the most commonly involved in segmental nevus depigmentosus and face (67.1%) and trigeminal (64.4%) dermatomes in segmental vitiligo. The average number of dermatomes involved in truncal lesions was different in segmental nevus depigmentosus and segmental vitiligo (2.71 vs 1.62, P = 0.001). Segmental vitiligo on the face, neck and trunk appeared closer to the axis than segmental nevus depigmentosus (P < 0.001). Segmental nevus depigmentosus and segmental vitiligo showed significantly different margins (90.5% and 41.6% serrated, respectively; P < 0.001). We observed clinical differences between patients with segmental nevus depigmentosus and those with segmental vitiligo. Distribution (site, distance to axis, dermatome), vertical width, margin of lesion and presence of poliosis can be helpful in differentiating segmental nevus depigmentosus and segmental vitiligo.     

Mixed vitiligo of Blaschko lines: a newly discovered presentation of vitiligo responsive to combination treatment

Vitiligo, depigmenting disorder of the skin and mucous membranes, affects up to 1% of the population worldwide. It is classified into four major types: segmental, non‐segmental, mixed, and unclassified type. Non‐segmental vitiligo refers to non‐dermatomal distribution of lesions, while dermatomal distribution of lesions is present in patients with segmental vitiligo. Segmental vitiligo can also follow Blaschko lines – pathways of epidermal cell migration and proliferation during the development of the fetus. Here, we present patient with segmental and non‐segmental vitiligo following Blaschko lines with excellent therapeutic response to combined therapy. Prior to our report, a case of segmental and non‐segmental vitiligo followed by Blaschko lines was never described, therefore we suggest the term “mixed vitiligo of Blaschko lines” to describe this entity. This is also a rare case in which 90% repigmentation was achieved in patient with segmental and nonsegmental vitiligo following Blaschko lines in only 2 months of combined therapy.     

Clinical course of 44 cases of localized type vitiligo

Vitiligo is often classified into three types, generalized, segmental, and localized, on the basis of their distribution pattern. It is also classified into type A (non-dermatomal or non-segmental) and type B (dermatomal or segmental) vitiligo on the basis of both the distribution pattern and physiological function. The natural courses of type A and type B vitiligo are characteristic and quite different from each other. Whereas type A vitiligo appears at any age and progresses throughout the patient's life span, type B vitiligo affects the young and stabilizes within a few years. Segmental type vitiligo corresponds to type B, and generalized type vitiligo is the late stage of type A. However, no one has observed the course and character of localized type vitiligo, and its nosological position in A/B classification is unclear. We followed 44 cases of localized type vitiligo for periods of 6 months to 8 years. In 3 of the 44 patients, new white patches developed within the same dermatome as their affected areas in the first 12 months and stabilized in a short period. Therefore, these patients were diagnosed as type B vitiligo. In 15 patients, vitiligo developed in other dermatomal areas; the earliest case at 9 months, and others later on. The new white patches continue to develop for a long period, so these patients were diagnosed with type A vitiligo. In 26 of the 44 patients, the vitiligo remained localized within the period of observation. It is concluded that most localized type vitiligo is the early stage of type A, but a small number of cases belong to the early stage of type B.     

Evaluation of the effects of NB-UVB in both segmental and non-segmental vitiligo affecting different body sites

BACKGROUND: Narrow band (NB)-UVB has been used in the treatment of vitiligo for years but statistical evaluation of the clinical response in both segmental and non-segmental vitiligo patients has yet to be assessed. OBJECTIVES: Statistical evaluation of the clinical response of vitiligo patients to NB-UVB in both segmental and non-segmental types affecting different body sites. METHODS: This study included 150 patients with vitiligo either segmental (10%) or non-segmental (90%). NB-UVB therapy was given twice weekly till reaching our end point of 100% re-pigmentation or a cut point in unresponsive cases. Evaluation of the percentage of re-pigmentation was performed by total body photography and planimetry every 8 weeks. RESULTS: The overall response to therapy in the non-segmental vitiligo group demonstrated that 48% of the patients showed marked response, 27% showed moderate response and 25% showed mild response after UVB therapy. The patients showed marked response in 76.3% in face lesions, 41.9% in trunk lesions and 37.6% in limbs lesions. None of the patients in the acral areas achieved marked response. The mean duration of therapy was 7.8 months. Moreover, the results demonstrated that the earlier the patient was treated, the better the response was especially for lesions on the face, trunk and limbs. On the other hand, in the segmental vitiligo group, patients showed no more than mild response to NB-UVB whatever the site of the lesion was. No side effects were encountered with NB-UVB therapy except for aggravation of the disease in two cases and erythema in one patient who was an outdoor worker and was skin type II. CONCLUSION: The type of vitiligo, the affected anatomical area and the disease duration are important factors that influence potential re-pigmentation.     

Transplant of cultured autologous pure melanocytes after laser-abrasion for the treatment of segmental vitiligo

Segmental vitiligo is a special type of vitiligo with unilateral distribution of lesions and has a stable course. Clinically, many patients with segmental vitiligo have unsatisfactory responses to topical corticosteroid or UV phototherapy. We have developed a technique for the isolation of melanocytes from a small specimen of normally pigmented skin obtained via a suction blister. The melanocytes can be proliferated in culture and then replanted onto laser-abrased vitiliginous areas. We used this procedure to treat 25 patients with segmental vitiligo that were refractory to medical therapy. The repigmented portion of the total treated area amounted to 95-100% in 21 patients and 65 to 94% in 4 patients. The response rate to treatment was 100% in this study. No scarring or other side-effects developed. The results of this study demonstrate that this method is a valuable tool for the treatment of patients with segmental vitiligo.     

Simultaneous improvement and worsening of vitiligo lesions during the course of NB‐UVB phototherapy; vitiligo may not act as one unit

Re‐pigmentation and stabilization are the two ultimate goals of any re‐pigmenting plan designed for vitiligo management. Furthermore, whether the improvement of some vitiligo lesions could be considered a guarantee for a similar response and/or stabilization of the rest of the lesions or not, remains to be clarified. To evaluate the behavior of non‐segmental vitiligo (NSV), while on narrow band‐ultraviolet B (NB‐UVB) phototherapy. 25 patients with stable generalized NSV were included and received NB‐UVB twice weekly. For the sake of ensuring accuracy of follow up, up to four lesions were randomly chosen in each patient and regularly measured using the point counting technique. The over‐all point counting technique of all included patients showed a significant reduction (18.5 ± 8.4 cm² to 8.2± 3.1 cm²) after 6 months of therapy (p < .001). Nine patients (36%), showed mixed response in the different lesions. Improvement was documented in some lesions, while other lesions showed no response or even worsening. No significant correlations were detected between the behavior of vitiligo during NB‐UVB and any of the demographic or clinical data of the patients. NB‐UVB is a pillar in the management of vitiligo, however close follow‐up of the patient as a whole and his lesions, by both subjective and objective measures are mandatory to detect activity as early as possible, as vitiligo at many times may not act as one unit. This early detection of activity and the subsequent change in the treatment policy may ultimately change the final outcome of treatment.     

Reduction of skin-homing cytotoxic T cells (CD8+ -CLA+) in patients with vitiligo

Background: Vitiligo is a frequently acquired, hereditary disease, characterized by achromic macules due to the absence of melanocytes. In contrast with earlier studies, in which the main pathogenic role was attributed to anti‐melanocyte antibodies, recent papers have emphasized a role for CD8⁺ cytotoxic T lymphocytes in melanocyte destruction. Fifteen percent of peripheral T cell express cutaneous lymphocyte‐associated antigen (CLA), responsible for skin‐homing T cell. Phototherapy is used to treat patients with generalized vitiligo and it has been shown to interfere with CLA⁺ T cells in other skin diseases. Objective: To describe peripheral blood T cell subpopulations' frequency and ability to express the skin‐homing molecule (CLA) in patients with non‐segmental vitiligo, before and after photochemotherapy (PUVA). Patients and Methods: Twenty‐two patients with generalized and active spreading vitiligo were submitted to 30 PUVA‐8MOP sessions. Lymphocyte immunophenotyping was performed by flow cytometry using anti‐CD3, anti‐CD8 and anti‐CLA monoclonal antibodies. Fifteen healthy volunteers, sex‐ and age‐matched, were included as a control group. Results: CD8⁺–CLA⁺ T cells were significantly reduced in number in untreated vitiligo patients (P=0.008) when compared with control individuals, albeit with a more intense CLA expression (P=0.028). These findings were not altered after PUVA. No significant difference was noticed in CD4/CD8 ratios nor in CD4–CLA⁺ T cell numbers between vitiligo patients and controls, both before and after PUVA. Conclusions: CD8–CLA⁺ T cells are reduced in peripheral blood of patients with non‐segmental vitiligo. This finding may be related to the previously reported increase of CD8⁺ cells in both lesions and perilesional skin of these patients.     

Tofacitinib cream plus narrowband ultraviolet B phototherapy for segmental vitiligo in a child

Segmental vitiligo often presents in childhood and tends to be more recalcitrant to therapy than generalized vitiligo. Recently, Janus kinase inhibitors have emerged as a promising treatment option, with some reports suggesting that concomitant ultraviolet light exposure may enhance therapeutic response. Here, we present a child with segmental vitiligo who responded rapidly and completely to treatment with tofacitinib cream plus phototherapy.     

Long-term results of 2-mm punch grafting in patients with vitiligo vulgaris and segmental vitiligo: effect of disease activity

Background Punch grafting is a simple and frequently used technique for the treatment of stable vitiligo, resistant to medical therapy. However, studies reporting long‐term results are exceptional. Objectives To evaluate the long‐term results of 2‐mm punch grafting in patients with vitiligo vulgaris and segmental vitiligo. Methods We studied a prospective cohort study involving 61 patients (25 male, 36 female) with vitiligo vulgaris and nine patients (all male) with segmental vitiligo who underwent 2‐mm punch grafting more than 3 years ago. The main outcome measure was the degree of repigmentation of a single transplanted lesion as measured with a digital image analysis system with a mean follow‐up of 5·2 years. Results In patients with vitiligo vulgaris, 17 lesions (28%) showed excellent, 14 lesions (23%) showed good, 14 lesions (23%) showed fair and 16 lesions (26%) showed poor repigmentation. In patients with segmental vitiligo, seven of nine lesions (78%) showed excellent repigmentation. A cobblestone‐like effect was observed in 19 of 70 patients (27%). Disease activity after punch grafting was reported in 94% of patients with poor repigmentation but in only 18% of patients with excellent repigmentation (χ² test, P < 0·0005). Patients who reported disease activity after transplantation had a lower mean repigmentation than those who did not report disease activity (77% vs. 39%, P < 0·05). Conclusions Two‐millimetre punch grafting in vitiligo is an effective surgical procedure with long‐lasting effect. To prevent a cobblestone‐like effect, we advise the use of smaller grafts (1–1·2 mm). Disease activity after grafting, localization and type of vitiligo, prior ultraviolet B treatment and a Koebnerized donor site influence the long‐term outcome of punch grafting and should be taken into account in the selection of patients eligible for this treatment.     

The distribution pattern of segmental vitiligo: clues for somatic mosaicism

Background Segmental vitiligo is characterized by a unilateral and localized distribution. So far, the underlying mechanism is still an enigma. Objectives To get an insight into the aetiopathogenesis of segmental vitiligo by comparison with the distribution pattern of dermatoses with a possible mosaic or neurogenic background. Methods In this retrospective observational study the distribution pattern of 724 unilateral, linear or band‐shaped control lesions was compared with 181 segmental vitiligo lesions. Clinical photographs were used to score similarities according to a defined grading system (scale ranging from 0 for no similarities to 4 for complete similarity). Control lesions were evaluated both individually and after grouping into different cell types. Results In general, only a minority of cases (36·9%), showed similarities (grade 1–4) between control lesions and segmental vitiligo. Grade 2–4 similarities were seen mainly in segmental lentiginosis (73·7%, P < 0·001). The best grade for correspondence (grade 3–4) was observed significantly more only in segmental lentiginosis (36·8% vs. 3·5%, P < 0·001) and epidermal naevus verrucosus (12·5% vs. 3·7%, P = 0·008) compared with the other control lesions. The distribution pattern of segmental vitiligo significantly overlapped those of other disorders originating from melanocytes. Conclusions Our results demonstrate that the distribution pattern of segmental vitiligo is not entirely similar to any other skin disease, although some mosaic skin disorders have more overlap with segmental vitiligo than others. The remarkable clinical similarity with several cases of mosaic diseases involving melanocytes supports the hypothesis that cutaneous mosaicism may be involved in segmental vitiligo.     

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 dis‐eases,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.     

Effect of one session of ER:YAG laser ablation plus topical 5Fluorouracil on the outcome of short‐term NB‐UVB phototherapy in the treatment of non‐segmental vitiligo: a left–right comparative study

Background: NB‐UVB phototherapy is a very important modality in treating vitiligo but the treatment course usually exceeds 1 year. Skin ablation with mechanical dermabrasion with 5Fluorouracil (5FU) was introduced to treat vitiligo in 1983. This was modified replacing the mechanical dermabrasion by erbium‐YAG (ER:YAG) laser ablation and resulted in better prognosis in periungual vitiligo. Purpose: In the present study, we are exploring the effect of the use of ER:YAG laser skin ablation and application of 5FU on the outcome of short‐term NB‐UVB therapy for patients with non‐segmental vitiligo (NSV). Methods: This study included 50 adult patients with a total of 65‐paired symmetrical NSV lesions in different body parts. One side was treated with ER:YAG laser ablation, followed by 5FU application before simultaneous NB‐UVB therapy of both sides for a maximum period of 4 months. The outcome was then evaluated both qualitatively and quantitatively. Results: The overall response to therapy was better using the combination therapy. Fifty patients (78.1%) experienced a moderate‐marked repigmentation response in the combination group compared with 23.4% in the mono‐therapy group. The response was significantly higher when using the combination therapy in different body parts (P value is <0.05), except for feet lesions, which were better but not statistically significant (P value=0.15). Tolerable pain during ablation or at sites of 5FU application was reported in all cases. Transient hyperpigmentation occurred in 30% of cases and 3.1% of lesions healed by a transient slate blue color. Half of the treated periungual lesions showed a temporary tiny brownish spot on nail plates and Köebnerization was not detected in any patient. Conclusion: We concluded that prior use of ER:YAG laser skin ablation, followed by 5FU application before NB‐UVB phototherapy for vitiligo is a safe and tolerable technique that improves the outcome of short‐term NB‐UVB therapy and is expected to increase patient compliance.     

Therapeutic success of epidermal grafting in generalized vitiligo is limited by the Koebner phenomenon

Eighteen patients with vitiligo (two with localized type, five with segmental type, and 11 with generalized type) were treated with an epidermal graft using the roof of a suction blister. In all patients with localized and segmental lesions and in seven with generalized lesions, successful repigmentation without scarring was observed at the grafted sites approximately 2 to 3 weeks after grafting, and a subsequent two- to threefold expansion of the pigmented area occurred within 3 to 4 months. On the other hand, no repigmentation could be achieved in four patients with generalized vitiligo in whom depigmentation (i.e., the Koebner phenomenon) occurred at the donor sites. Our results suggest that the Koebner phenomenon occurs in an all-or-none pattern only in patients with generalized vitiligo. Thus, although epidermal grafting is a simple and useful method, successful repigmentation at the recipient sites depends on the selection of patients with localized lesions in whom the Koebner phenomenon does not develop.     

Halo naevi and leukotrichia are strong predictors of the passage to mixed vitiligo in a subgroup of segmental vitiligo

Background Until now, segmental vitiligo has been considered as a stable entity and mixed vitiligo, the association of segmental and nonsegmental vitiligo, has been reported rarely. Objectives The aim of this study was to search for factors associated with the generalization of vitiligo in patients with segmental vitiligo. Patients and methods This was a prospective observational study conducted in the vitiligo clinic of the Department of Dermatology of Bordeaux, France. The Vitiligo European Task Force questionnaire was completed for each patient attending the clinic with a confirmed diagnosis of segmental vitiligo after exclusion of other forms of vitiligo (focal, mucosal, not classifiable.) Thyroid function and antithyroid antibodies were screened if not obtained in the previous year. Results One hundred and twenty‐seven patients were recruited: 101 had segmental vitiligo and 26 had segmental vitiligo that evolved into mixed vitiligo; 56 were male and 71 were female. Most patients had onset of segmental vitiligo before the age of 18. When conducting multivariate analysis, we found the following to be independent factors associated with the evolution of patients’ disease from segmental vitiligo to mixed vitiligo: initial percentage of body surface involvement of the segment > 1% [odds ratio (OR) 15·14, P = 0·002], the presence of halo naevi (OR 24·82, P = 0·0001) and leukotrichia (OR 25·73, P = 0·0009). Conclusions Halo naevi association and leukotrichia at first consultation in segmental vitiligo are risk factors for the progression of segmental vitiligo to mixed vitiligo. In addition, this progression of segmental vitiligo to mixed vitiligo carries a stronger link if initial segmental involvement is situated on the trunk.     

Vitiligo in children and adolescents: association with thyroid dysfunction

Background The clinical characteristics of vitiligo in children and adolescents with an emphasis on thyroid dysfunction have only been reported in a few studies. Objective The purpose of this study was to examine the characteristics of children and adolescents with vitiligo and compare the incidence of thyroid dysfunction between them and controls without vitiligo at the same age. Methods A retrospective analysis of 324 Korean children and adolescents with vitiligo was performed. The results of thyroid function screening tests in them (n = 254) were compared with controls (n = 122). Results Of the total 324 children and adolescents with vitiligo, vitiligo vulgaris was the most common type (42.3%) and the most commonly involved site was the face (54.6%). A total of 15 of 254 (5.9%) patients screened for thyroid function were diagnosed with thyroid disease (four had Hashimoto’s thyroiditis; two, Graves’ disease; seven, subclinical hypothyroidism; and two, subclinical hyperthyroidism). None of the 50 patients with segmental vitiligo showed any thyroid dysfunction (P = 0.047). There was no significant difference in the incidence of thyroid disease between children and adolescents with vitiligo and the control group, in which seven of 122 (5.7%) showed thyroid dysfunction. Conclusion In this study, we demonstrated the characteristics of children and adolescents with vitiligo and also observed no significant difference in the incidence of thyroid disease between children and adolescents with vitiligo and the control group.     

Repigmentation after autologous miniature punch grafting in segmental vitiligo in North Indian patients.

Segmental vitiligo is rather refractory to medical treatment. The paucity of literature on the results of autologous miniature punch grafting in segmental vitiligo in dark-skinned patients led us to conduct such a study in 15 dark-skinned patients of North Indian origin to observe the repigmentation response to this technique at different sites. The age range was 16-42 years (mean 23.08 years). There were four males and eleven females (M:F ratio being 1:2.75) who had the disease for 3-15 years. After autologous miniature punch grafting, a remarkable repigmentation was obtained in 12 (80%) cases with 90% to 100% improvement. About 40-60% repigmentation was observed within 3-6 months in the majority (66.6%) of cases and near total to total repigmentation was observed within 2 years. The maximum pigment spread was observed over the face (cheeks) and neck, and the minimum pigment spread was observed over the left arm and right upper eyelid. Complications were minimal. The present study demonstrates that autologous miniature punch grafting is a safe and easy technique, that produces good cosmetic results in the unsightly depigmenting lesions of segmental vitiligo, especially on the face and exposed areas, even in dark-skinned races if patients are selected carefully. This can be of great benefit to patients who are psychologically disturbed by their disease.     

Clinical study of psoriasis occurring over the age of 60 years: is elderly‐onset psoriasis a distinct subtype?

Background Previous studies demonstrated clinical differences of early‐ and late‐onset psoriasis. However, epidemiological data and clinical characteristics of psoriasis occurring in geriatric patients have been rarely studied. Objective Assessment of epidemiology and clinical features of psoriasis first occurring over the age of 60 years, so‐called elderly‐onset psoriasis, based on clinical data. Materials and methods Among 4049 patients visiting our psoriasis clinic for the last 27 years, patients were first divided into early‐ (onset age before 30 years) and late‐onset psoriasis (onset age after 30 years) based on our previous studies. Then, patients of late‐onset psoriasis were further divided into middle age‐onset group (onset age between 30 and 60 years) and elderly‐onset group (onset age over 60 years). Clinical characteristics of elderly‐onset psoriasis were compared with early‐ and middle age‐onset groups. We acquired the data both by physician’s assessments and patients’ responses. Results Elderly‐onset patients comprised 3.2% of total patients, 129 out of 4049. They have shown a lower incidence of family history (P < 0.05). The severity assessed by PASI score, body surface extent, and activity of individual lesions demonstrated that psoriasis of the elderly‐onset group was generally milder compared with early‐ and middle age‐onset groups (P < 0.05). In clinical phenotypes, the proportion of guttate type and generalized pustular psoriasis type decreased remarkably, while that of erythroderma type increased (P < 0.05). There was a significant change in the body part of origin comparing early‐ and middle age‐onset groups (P < 0.05). The proportion of scalp increased, while that of knee–elbow and trunk decreased significantly (P < 0.05). Patients’ subjective sensation of disease course improved statistically comparing early‐ and middle age‐onset groups (P < 0.05). There was no significant change in the degree of pruritus on psoriatic lesions and nail involvement (P > 0.05). Conclusion The elderly‐onset group demonstrated milder disease courses and some changes in clinical phenotypes and body part of origin compared with early‐ and middle age‐onset groups. Therefore, it seems that patients whose onset of psoriasis was over the age of 60 years might have distinct clinical features in some clinical aspects.     

Comparisons of clinical features of HLA‐DRB1*07 positive and negative vitiligo patients in Chinese Han population

Background Human leucocyte antigen (HLA)‐II alleles have been found to be associated with vitiligo in different populations, and several studies also suggested that HLA class II alleles/haplotypes were associated with a different type vitiligo. Of HLA class II alleles, DRB1*07 has consistently shown a positive association with vitiligo in Chinese Han population. Objective To further explore the relationship between DRB1*07 and vitiligo and to evaluate the DRB1*07 effect on the clinical features of vitiligo in Chinese Han population. Methods This study investigated DRB1*07 allele distribution in 1178 unrelated Chinese vitiligo patients and 1743 healthy controls using polymerase chain reaction/sequence specific primer method and observed clinical differences between DRB1*07 positive and DRB1*07 negative patients. Results The analysis of the 1178 cases and 1743 controls revealed a highly association between DRB1*07 allele and vitiligo [odds ratio (OR) = 1.97, P = 2.13 × 10^?17]. DRB1*07 positive patients had early disease onset (OR = 1.49, P = 0.001), higher frequency of family history (OR = 1.44, P = 0.006) compared with DRB1*07 negative patients. Conclusions The DRB1*07 showed significant association with vitiligo in the study population. This study confirmed that DRB1*07 positive patients had some obvious clinical differences from DRB1*07 negative patients in the Chinese Han population.     

Mixed vitiligo

BACKGROUND: There are two commonly recognized forms of vitiligo-generalized and localized. This classification is important to understand the course of the disease and its prognosis. Most patients have generalized vitiligo; few patients have both segmented and generalized vitiligo. OBSERVATION: We report four more cases of mixed vtiligo, segmental with generalized type. This report is only the second to present a case of segmental with generalized vitiligo. CONCLUSION: Mixed vitiligo is not yet part of a standard classification. Its etiology is not yet fully defined. Further research is required to understand the course and prognosis of mixed vitiligo.     

Vitiligo expansion and extent correlate with durable response in anti-programmed death 1 antibody treatment for advanced melanoma: A multi-institutional retrospective study

Vitiligo is an autoimmune disorder resulting from the destruction of melanocytes. Several reports indicate the association between vitiligo and treatment response in advanced melanoma during immunotherapy. It has not been investigated, however, if an increase of vitiligo while on treatment with anti-programmed death 1 (PD-1) antibodies is associated with more durable responses. The aim of this study is to evaluate the correlation between the vitiligo dynamics and clinical efficacy of anti-PD-1 antibodies. This study included advanced melanoma patients who were treated with nivolumab or pembrolizumab and developed vitiligo thereafter. Correlation between vitiligo expansion (defined as an increase of lesion size at two separate time points at least 4 weeks apart) as well as vitiligo extent (body surface area [BSA] affected) and clinical efficacy based on response rate, progression-free survival and overall survival was assessed. We retrospectively reviewed 29 patients. The median time from the initiation of anti-PD-1 antibody to vitiligo onset was 4.3 months in patients who showed a response and 5.5 months in patients who showed no response (P = 0.31). Twelve patients showed vitiligo expansion, and in nine of these patients, vitiligo increased to grade 2 (covering ≥ 10% BSA). Vitiligo expansion and grade 2 vitiligo showed no improvement in treatment response (P = 0.59 and 0.25) but were associated with prolonged progression-free survival (P = 0.019 and 0.04). Grade 2 vitiligo also showed a trend for prolonged overall survival (P = 0.07). Trend of expansion and larger vitiligo extent may be predictive factors of prolonged survival during anti-PD-1 antibody in melanoma patients.