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1.  Disease Severity Indexes and Treatment Evaluation Criteria in Vitiligo 
There is a current lack of consensus regarding methods of assessment of vitiligo. Recently, the Vitiligo Area Scoring Index (VASI) and the Vitiligo European Task Force (VETF) were proposed to offer more accurate measures of disease severity indexes and treatment evaluation criteria. It would make sense to combine the VASI with the VETF system. We proposed an original scale for treatment evaluation criteria in vitiligo based on VASI. We plan to add the digital image analysis system, health-related quality of life questionnaire, affected skin location, and skin color in the original scale.
PMCID: PMC3130989  PMID: 21747840
2.  Correlation of Vitamin D Levels with Pigmentation in Vitiligo Patients Treated with NBUVB Therapy 
ISRN Dermatology  2014;2014:493213.
Cholecalciferol (vitamin D) might play a physiological role in photo-induced melanogenesis in human skin. We estimated the levels of 25-hydroxy vitamin D [25(OH)D] before, during, and after Narrow Band Ultraviolet B (NBUVB) radiation in patients of vitiligo and their correlation with NBUVB induced pigmentation. Thirty patients of vitiligo and equal number of age and sex matched controls were recruited for the study. Vitiligo patients were treated with NBUVB thrice weekly for 12 weeks. [25(OH)D] levels and Vitiligo Area and Severity Index (VASI) were calculated at 0 (baseline), 6, and 12 weeks. Baseline [25(OH)D] levels were measured in controls. Significant reduction in VASI score was observed after 12 weeks of therapy. Comparison and correlation between mean improvement in VASI and [25(OH)D] levels at 12 weeks showed moderate correlation, and the results were statistically insignificant. Mean reduction in VASI and increase in [25(OH)D] levels after 12 weeks of NBUVB showed moderate correlation. Thus, vitamin D might play a significant role in photo-induced melanogenesis. However, there might be additional effects of the phototherapy on melanogenesis. The complete mechanism of NBUVB induced pigmentation in vitiligo needs to be elucidated.
PMCID: PMC4005019
3.  Investigation of herb-drug interactions with ginkgo biloba in women receiving hormonal treatment for early breast cancer 
SpringerPlus  2013;2:126.
Women receiving treatment for breast cancer commonly ingest herbal medicines. Little is known about the potential for herb-drug interactions in this population. The aim of this study is to investigate the effect of ginkgo biloba co-administration on the pharmacokinetics of tamoxifen, anastrozole and letrozole. This was a prospective open-label cross-over study in 60 women with early stage breast cancer taking either tamoxifen, anastrozole or letrozole (n=20/group). Participants received ginkgo biloba (EGb 761) for 3 weeks (120 mg twice daily). Trough concentrations of drugs were measured before and after ginkgo biloba treatment using LC-MS/MS. Toxicities were graded according to National Cancer Institute Common Terminology Criteria for Adverse Events. Trough concentrations before and after treatment with ginkgo biloba were not significantly different for tamoxifen (93.5 ± 29.0, 86.5 ± 25.3 ng/mL; p=0.16), letrozole (91.1 ± 50.4, 89.6 ± 52.14 ng/mL; p=0.60) or anastrozole (29.1 ± 8.6, 29.1 ± 7.6 ng/mL; p=0.97). Ginkgo biloba was well tolerated, with no difference in toxicity during ginkgo biloba. Co-administration of ginkgo biloba does not significantly affect the pharmacokinetics of tamoxifen, anastrozole or letrozole. There was no difference in the toxicity profile of hormone therapy with ginkgo biloba use in women with early stage breast cancer.
PMCID: PMC3625417  PMID: 23596562
Anastrozole; Ginkgo biloba; Herb-drug interaction; Letrozole; Tamoxifen
4.  Depigmentation Therapy with Q-Switched Nd: YAG Laser in Universal Vitiligo 
Any residual pigment left in patients of universal vitiligo is managed with topical treatments, cryotherapy, and lasers.
The study aims to assess the efficacy and safety of Q-switched Nd: YAG laser in treating the residual pigmentation in patients with universal vitiligo.
Materials and Methods:
Fifteen patients of universal vitiligo with residual pigmentation on the face, hands, or feet, resistant to topical treatments, were treated with single or multiple sessions of Q-switched Nd: YAG laser treatment. Topical treatments were continued in between the laser sessions and the depigmentation achieved was monitored by clinical examination and repeat digital photographs. Response to the treatment was labelled as excellent if the residual pigment could be reduced by at least 90% while 50–90% resolution of pigmentation was labelled as a partial response. Adverse effects to the treatment offered were also monitored.
Thirteen of the 15 patients enrolled for the study showed an excellent response to the treatment offered. Two other patients showed a poor response with less than 50% resolution of pigmentation. The number of laser sessions needed at a particular site ranged from 1 to 3 and no patient was offered more than three sessions of laser treatment at any site. No significant adverse events were reported by any patient.
Residual pigmentation in patients with universal vitiligo that does not respond to topical treatment options alone can be managed quite effectively with Q-switched Nd: YAG laser without any significant adverse effects.
PMCID: PMC3764769  PMID: 24023431
Depigmentation; lasers; Q-switched Nd: YAG laser; treatment; vitiligo
5.  Tumor necrosis factor-α -308G/A polymorphism is associated with active vitiligo vulgaris in a northeastern Mexican population 
Vitiligo is a skin disease characterized by depigmentation. Its etiopathogenesis is unclear, but it has been associated with autoimmune processes. Gene polymorphisms in the tumor necrosis factor-α (TNF-α) have been associated with several imflammatory diseases. In particular, the -308G/A polymorphism in the gene promoter region has been reported to be associated with increased plasma levels of TNF-α and with an increased risk to develop autoimmune diseases. To date, this polymorphism has not been associated with vitiligo. To assess a possible association between the TNF-α -308G/A and vitiligo vulgaris (VV), 198 vitiligo patients and 395 control subjects were recruited for the study. A complete demographic and clinical profile of each case was registered to analyze the possible risk factors of vitiligo. Genomic DNA isolated from peri pheral blood was subjected to PCR-RFLP for genotyping of the TNF-α -308G/A polymorphism. Causal associations were determined by χ2 test and their respective OR was assessed in a 2×2 contingency table. When population variables of type of vitiligo, gender, age of disease onset, and active disease status were considered, an association between active VV and the TNF-α GA genotype was found (P=0.0295, OR=2.0; 95% CI 1.01-3.93). All other variables were irrelevant to vitiligo. Our data suggest a possible association between the TNF-α -308 GA genotype and the active form of VV in a Mexican population.
PMCID: PMC3438838  PMID: 22969989
tumor necrosis factor-α -308G/A polymorphism; active vitiligo vulgaris; autoimmune diseases; PCR-RFLP; northeastern Mexican population
6.  Feasibility, double-blind, randomised, placebo-controlled, multi-centre trial of hand-held NB-UVB phototherapy for the treatment of vitiligo at home (HI-Light trial: Home Intervention of Light therapy) 
Trials  2014;15:51.
Hand-held NB-UVB units are lightweight devices that may overcome the need to treat vitiligo in hospital-based phototherapy cabinets, allowing early treatment at home that may enhance the likelihood of successful repigmentation. The pilot Hi-Light trial examined the feasibility of conducting a large multi-centre randomised controlled trial (RCT) on the use of such devices by exploring recruitment, adherence, acceptability, and patient education.
This was a feasibility, double-blind, multi-centre, parallel group randomised placebo-controlled trial of hand-held NB-UVB phototherapy for the treatment of vitiligo at home. The overall duration of the trial was seven months; three months recruitment and four months treatment. Participants were randomly allocated to active or placebo groups (2:1 ratio). The primary outcome measure was the proportion of eligible participants who were willing to be randomised. The secondary outcomes included proportion of participants expressing interest in the trial and fulfilling eligibility criteria, withdrawal rates and missing data, proportion of participants adhering to and satisfied with the treatment, and incidence of NB-UVB short-term adverse events.
Eighty-three percent (45/54) of vitiligo patients who expressed interest in the trial were willing to be randomised. Due to time and financial constraints, only 29/45 potential participants were booked to attend a baseline hospital visit. All 29 (100%) potential participants were confirmed as being eligible and were subsequently randomised. Willingness to participate in the study for General Practice (family physicians) surgeries and hospitals were 40% and 79%, respectively; 86% (25/29) of patients adhered to the treatment and 65% (7/11) of patients in the active group had some degree of repigmentation. Only one patient in the active group reported erythema grade 3 (3%). Both devices (Dermfix 1000 NB-UVB and Waldmann NB-UVB 109) were acceptable to participants.
Hand-held NB-UVB devices need evaluation in a large, pragmatic RCT. This pilot trial has explored many of the uncertainties that need to be overcome before embarking on a full scale trial, including the development of a comprehensive training package and treatment protocol. The study has shown strong willingness of participants to be randomised, very good treatment adherence and repigmentation rates, and provided evidence of feasibility for a definitive trial.
Trial registration
PMCID: PMC3923442  PMID: 24507484
Hand-held phototherapy; Home phototherapy; Patient education; Randomised trial; Vitiligo
7.  Survey and online discussion groups to develop a patient-rated outcome measure on acceptability of treatment response in vitiligo 
BMC Dermatology  2014;14:10.
Vitiligo is a chronic depigmenting skin disorder which affects around 0.5-1% of the world’s population. The outcome measures used most commonly in trials to judge treatment success focus on repigmentation. Patient-reported outcome measures of treatment success are rarely used, although recommendations have been made for their inclusion in vitiligo trials. This study aimed to evaluate the face validity of a new patient-reported outcome measure of treatment response, for use in future trials and clinical practice.
An online survey to gather initial views on what constitutes treatment success for people with vitiligo or their parents/carers, followed by online discussion groups with patients to reach consensus on what constitutes treatment success for individuals with vitiligo, and how this can be assessed in the context of trials. Participants were recruited from an existing database of vitiligo patients and through posts on the social network sites Facebook and Twitter.
A total of 202 survey responses were received, of which 37 were excluded and 165 analysed. Three main themes emerged as important in assessing treatment response: a) the match between vitiligo and normal skin (how well it blends in); b) how noticeable the vitiligo is and c) a reduction in the size of the white patches. The majority of respondents said they would consider 80% or more repigmentation to be a worthwhile treatment response after 9 months of treatment. Three online discussion groups involving 12 participants led to consensus that treatment success is best measured by asking patients how noticeable their vitiligo is after treatment. This was judged to be best answered using a 5-point Likert scale, on which a score of 4 or 5 represents treatment success.
This study represents the first step in developing a patient reported measure of treatment success in vitiligo trials. Further work is now needed to assess its construct validity and responsiveness to change.
PMCID: PMC4075774  PMID: 24929563
Vitiligo; Outcome measure; Patient-reported outcome; Randomised controlled trial
8.  Effects of Ginkgo biloba in dementia: systematic review and meta-analysis 
BMC Geriatrics  2010;10:14.
The benefit of Ginkgo biloba has been discussed controversially. The aim of this review was to assess the effects of Ginkgo biloba in Alzheimer's disease as well as vascular and mixed dementia covering a variety of outcome domains.
We searched MEDLINE, EMBASE, the Cochrane databases, CINAHL and PsycINFO for controlled trials of ginkgo for Alzheimer's, vascular or mixed dementia. Studies had to be of a minimum of 12 weeks duration with at least ten participants per group. Clinical characteristics and outcomes were extracted. Meta-analysis results were expressed as risk ratios or standardized mean differences (SMD) in scores.
Nine trials using the standardized extract EGb761® met our inclusion criteria. Trials were of 12 to 52 weeks duration and included 2372 patients in total. In the meta-analysis, the SMDs in change scores for cognition were in favor of ginkgo compared to placebo (-0.58, 95% confidence interval [CI] -1.14; -0.01, p = 0.04), but did not show a statistically significant difference from placebo for activities in daily living (ADLs) (SMD = -0.32, 95% CI -0.66; 0.03, p = 0.08). Heterogeneity among studies was high. For the Alzheimer subgroup, the SMDs for ADLs and cognition outcomes were larger than for the whole group of dementias with statistical superiority for ginkgo also for ADL outcomes (SMD = -0.44, 95% CI -0.77; -0.12, p = 0.008). Drop-out rates and side effects did not differ between ginkgo and placebo. No consistent results were available for quality of life and neuropsychiatric symptoms, possibly due to the heterogeneity of the study populations.
Ginkgo biloba appears more effective than placebo. Effect sizes were moderate, while clinical relevance is, similar to other dementia drugs, difficult to determine.
PMCID: PMC2846949  PMID: 20236541
9.  Future research into the treatment of vitiligo: where should our priorities lie? Results of the vitiligo priority setting partnership 
The British Journal of Dermatology  2011;164(3):530-536.
Vitiligo is the most frequent depigmentation disorder of the skin and is cosmetically and psychologically devastating. A recently updated Cochrane systematic review ‘Interventions for vitiligo’ showed that the research evidence for treatment of vitiligo is poor, making it difficult to make firm recommendations for clinical practice.
To stimulate and steer future research in the field of vitiligo treatment, by identifying the 10 most important research areas for patients and clinicians.
A vitiligo priority setting partnership was established including patients, healthcare professionals and researchers with an interest in vitiligo. Vitiligo treatment uncertainties were gathered from patients and clinicians, and then prioritized in a transparent process, using a methodology advocated by the James Lind Alliance.
In total, 660 treatment uncertainties were submitted by 461 participants. These were reduced to a list of the 23 most popular topics through an online/paper voting process. The 23 were then prioritized at a face-to-face workshop in London. The final list of the top 10 treatment uncertainties included interventions such as systemic immunosuppressants, topical treatments, light therapy, melanocyte-stimulating hormone analogues, gene therapy, and the impact of psychological interventions on the quality of life of patients with vitiligo.
The top 10 research areas for the treatment of vitiligo provide guidance for researchers and funding bodies, to ensure that future research answers questions that are important both to clinicians and to patients.
PMCID: PMC3084501  PMID: 21128908
10.  The effect of pseudocatalase/superoxide dismutase in the treatment of vitiligo: A pilot study 
Pseudocatalase/superoxide dismutase (PSD) is a topical gel considered having therapeutic effects in vitiligo. This study was designed to evaluate the efficacy of this combination in vitiligo.
This was a pilot randomized, double-blind, placebo-controlled trial on 46 symmetrical vitiligo lesions of limbs in 23 patients referring to dermatology clinics, Isfahan, Iran in 2010. Patients were received this formula or placebo gels for the right and left lesions. Lesion area and degree of pigmentation were assessed at baseline, 2, 4, and 6 months.
There were no significant changes in lesion area and perifollicular pigmentation in each group (P > 0.05).
The results indicated no significant therapeutic effect for PSD in vitiligo.
PMCID: PMC4076862
Pseudocatalase/superoxide dismutase; efficacy; vitiligo
11.  Effect of Ginkgo Biloba on the Pharmacokinetics of Raltegravir in Healthy Volunteers 
Antimicrobial Agents and Chemotherapy  2012;56(10):5070-5075.
Medicinal herbs may cause clinically relevant drug interactions with antiretroviral agents. Ginkgo biloba extract is a popular herbal product among HIV-infected patients because of its positive effects on cognitive function. Raltegravir, an HIV integrase inhibitor, is increasingly being used as part of combined antiretroviral therapy. Clinical data on the potential inhibitory or inductive effect of ginkgo biloba on the pharmacokinetics of raltegravir were lacking, and concomitant use was not recommended. We studied the effect of ginkgo biloba extract on the pharmacokinetics of raltegravir in an open-label, randomized, two-period, crossover phase I trial in 18 healthy volunteers. Subjects were randomly assigned to a regimen of 120 mg of ginkgo biloba twice daily for 15 days plus a single dose of raltegravir (400 mg) on day 15, a washout period, and 400 mg of raltegravir on day 36 or the test and reference treatments in reverse order. Pharmacokinetic sampling of raltegravir was performed up to 12 h after intake on an empty stomach. All subjects (9 male) completed the trial, and no serious adverse events were reported. Geometric mean ratios (90% confidence intervals) of the area under the plasma concentration-time curve from dosing to infinity (AUC0-∞) and the maximum plasma concentration (Cmax) of raltegravir with ginkgo biloba versus raltegravir alone were 1.21 (0.93 to 1.58) and 1.44 (1.03 to 2.02). Ginkgo biloba did not reduce raltegravir exposure. The potential increase in the Cmax of raltegravir is probably of minor importance, given the large intersubject variability of raltegravir pharmacokinetics and its reported safety profile.
PMCID: PMC3457394  PMID: 22802250
12.  Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference 
During the 2011 International Pigment Cell Conference (IPCC), the Vitiligo European Taskforce (VETF) convened a consensus conference on issues of global importance for vitiligo clinical research. As suggested by an international panel of experts, the conference focused on four topics: classification and nomenclature; definition of stable disease; definition of Koebner’s phenomenon (KP); and ‘autoimmune vitiligo’. These topics were discussed in seven working groups representing different geographical regions. A consensus emerged that segmental vitiligo be classified separately from all other forms of vitiligo and that the term ‘vitiligo’ be used as an umbrella term for all non-segmental forms of vitiligo, including ‘mixed vitiligo’ in which segmental and non-segmental vitiligo are combined and which is considered a subgroup of vitiligo. Further, the conference recommends that disease stability be best assessed based on the stability of individual lesions rather than the overall stability of the disease as the latter is difficult to define precisely and reliably. The conference also endorsed the classification of KP for vitiligo as proposed by the VETF (history based, clinical observation based, or experimentally induced). Lastly, the conference agreed that ‘autoimmune vitiligo’ should not be used as a separate classification as published evidence indicates that the pathophysiology of all forms of vitiligo likely involves autoimmune or inflammatory mechanisms.
PMCID: PMC3511780  PMID: 22417114
vitiligo; consensus conference
13.  A case of vitiligo vulgaris showing a pronounced improvement after treatment for myasthenia gravis 
BMJ Case Reports  2009;2009:bcr07.2009.2091.
This is a report of a 64 year-old male patient whose myasthenia gravis (MG) was accompanied by vitiligo vulgaris. Depigmentation of the face, trunk, and hands was noted. He was diagnosed with vitiligo vulgaris according to macroscopic findings and a skin biopsy. He was also found to have blepharoptosis, and proximal dominant muscle weakness of the extremities. He was anti-acetylcholine receptor antibody-positive, with repetitive nerve stimulation showing a waning phenomenon and chest computed tomography showing invasive thymoma, which led to the diagnosis of generalised MG. His myasthenic symptoms were relieved by the use of steroids and the removal of the thymoma. His vitiligo vulgaris began to improve a month after the relief of myasthenic symptoms. Such improvement was pronounced during the next several months. The clinical or immunological relationship between MG and vitiligo vulgaris is still not known, but these findings might indicate clinical correlation between MG and vitiligo vulgaris.
PMCID: PMC3029627  PMID: 22162736
Indian Journal of Dermatology  2009;54(3):221-224.
To evaluate whether oxidative stress is implicated in melanocyte damage in vitiligo.
Vitiligo is a complex disorder characterized by gradually enlarging areas of depigmentation. A new unifying hypothesis for the etiology of this pigment disorder is proposed, in which we postulate that the final destruction of melanocytes in vitiligo results from a cascade of reactions initiated by a disregulation of melanogenesis, as the result of a breakdown in free radical defense.
We evaluated 18 vitiligo mice and 12 controls that were age matched. Parameters of oxidative stress such as catalase (CAT), superoxide dismutase (SOD), and plasma malondialdehyde (MDA) were measured by spectrophotometry.
MDA levels in vitiligo mice were significantly higher than in controls (P < 0.001). CAT, SOD, and glutathione peroxidase (GPx) activities in mice were significantly lower than controls (P < 0.05 and P < 0.001, respectively).
Our results confirmed that oxidative stress plays an important role in the pathogenesis of vitiligo. Melanocyte damage in vitiligo might be linked to generalized oxidative stress. This study is the first report on antioxidant parameters in experimental vitiligo mice.
PMCID: PMC2810685  PMID: 20161850
Antioxidant status; catalase; glutathione peroxydase; malondialdehyde; oxidative stress; superoxide dismutase; vitiligo
15.  Vitiligo vulgaris and autoimmune diseases in Japan 
Dermato-endocrinology  2009;1(1):43-45.
We reviewed the causes of “loss of skin color” in 144 patients, who visited Vitiligo Clinic of Kyoto University Hospital between April 2005 and August 2008. The numbers of patients with generalized and segmental Vitiligo vulgaris were 98 (68.1%) and 26 (18.1%), respectively. Small numbers of the patients suffered from Vogt-Koyanagi-Harada disease, piebaldism, congenital albinism, Hypomelanosis of Ito, post-inflammatory hypopigmentation, white leaf-shaped macules associated with tuberous sclerosis and nevus hypopigmentosus. One forth of the patients with generalized vitiligo had complications, while no complications were found in the patients with segmental vitiligo. Among the complications, autoimmune diseases dominated 43% (10 of 23 cases). Autoimmune thyroid diseases explained for the most of the complicated autoimmune diseases and were associated with 7.4% of the patients with generalized vitiligo. Minor autoimmune complications include myasthenia gravis, Sjogren syndrome and autoimmune nephritis. Reflecting the condition that our clinic is located in a university hospital, vitiligo patients with end-stage non-melanoma cancers of internal organs accounted for 8.4% of the patients of generalized vitiligo.
PMCID: PMC2715204  PMID: 20046588
vitiligo; autoimmune disease; thyroid disease; Japanese
16.  Treatment of segmental vitiligo with normal-hair follicle autograft 
Segmental vitiligo is a small subset albeit persistent form of focal vitiligo with dermatomal distributionand resistant to medical therapy. In recent years, surgical therapy as hair follicle autograft transplantationhas been a hot topic in management of segmental vitiligo. In this study, we evaluated the efficacy of thismethod in segmental vitiligo lesions.
The study recruited 10 patients who suffered from resistant segmental vitiligo to evaluate the effectof transplantation of pigmented hair follicles on re-pigmentation of the affected area. In this method, one or twopunched-biopsy skin sample with a diameter of 5mm were harvested from occipital area of the scalps. Graftswere trimmed and divided into the follicular segments with at least one follicle in the interior and then insertedin the depigmented areas. Follow-up plan studies were scheduled to evaluate presence of pigmentation in theperifollicular areas.
After 2 weeks, re-pigmentation was detectable surrounding the grafted hair follicles in 60 % of thecases. After 6 months, all of the patients had detectable re-pigmented area of about 2-9 mm.
giving the surprising result of the study, hair follicle autograft transplant is an effective treatmentoption in the persistent segmental vitiligo.
PMCID: PMC4011411  PMID: 24926182
Vitiligo; Surgical therapy; Hair follicle; Autologous transplantation
17.  Vitiligo at Injection Site of PEG-IFN-α 2a in Two Patients with Chronic Hepatitis C: Case Report and Literature Review 
Case Reports in Dermatology  2010;2(2):156-164.
A 72-year-old female and a 57-year-old male with chronic hepatitis C were treated with a combination therapy of pegylated interferon (PEG-IFN)-α 2a (180 μg s.c. once a week) and ribavirin (1,000 mg orally daily). This resulted in the destruction of melanocytes at the injection site in both patients. In the male patient, the depigmentation progressed to the surrounding skin area. The dermatologist concurred with vitiligo as the diagnosis in both patients. Injection and surrounding site vitiligo associated with PEG-IFN-α 2b treatment for hepatitis C was noticed in previous case studies. For the first time, the case reports below highlight the same immunological adverse event secondary to PEG IFN-α 2a/ribavirin combination therapy and explain, in part, the complex interaction between host immune response and viral genotype. In addition, we systematically review drug-induced vitiligo and autoimmune diseases associated with the depigmentation disorder.
PMCID: PMC2978742  PMID: 21076689
Vitiligo; Injection site; PEG-IFN-α 2a; Chronic hepatitis C
18.  A systematic review of natural health product treatment for vitiligo 
BMC Dermatology  2008;8:2.
Vitiligo is a hypopigmentation disorder affecting 1 to 4% of the world population. Fifty percent of cases appear before the age of 20 years old, and the disfigurement results in psychiatric morbidity in 16 to 35% of those affected.
Our objective was to complete a comprehensive, systematic review of the published scientific literature to identify natural health products (NHP) such as vitamins, herbs and other supplements that may have efficacy in the treatment of vitiligo. We searched eight databases including MEDLINE and EMBASE for vitiligo, leucoderma, and various NHP terms. Prospective controlled clinical human trials were identified and assessed for quality.
Fifteen clinical trials were identified, and organized into four categories based on the NHP used for treatment. 1) L-phenylalanine monotherapy was assessed in one trial, and as an adjuvant to phototherapy in three trials. All reported beneficial effects. 2) Three clinical trials utilized different traditional Chinese medicine products. Although each traditional Chinese medicine trial reported benefit in the active groups, the quality of the trials was poor. 3) Six trials investigated the use of plants in the treatment of vitiligo, four using plants as photosensitizing agents. The studies provide weak evidence that photosensitizing plants can be effective in conjunction with phototherapy, and moderate evidence that Ginkgo biloba monotherapy can be useful for vitiligo. 4) Two clinical trials investigated the use of vitamins in the therapy of vitiligo. One tested oral cobalamin with folic acid, and found no significant improvement over control. Another trial combined vitamin E with phototherapy and reported significantly better repigmentation over phototherapy only. It was not possible to pool the data from any studies for meta-analytic purposes due to the wide difference in outcome measures and poor quality ofreporting.
Reports investigating the efficacy of NHPs for vitiligo exist, but are of poor methodological quality and contain significant reporting flaws. L-phenylalanine used with phototherapy, and oral Ginkgo biloba as monotherapy show promise and warrant further investigation.
PMCID: PMC2432048  PMID: 18498646
19.  Phase II Study of Ginkgo Biloba in Irradiated Brain Tumor Patients: Effect on Cognitive Function, Quality of Life, and Mood 
Journal of neuro-oncology  2012;109(2):357-363.
Ginkgo biloba has been reported to improve cognitive function in older adults and patients with Alzheimer’s disease and multi-infarct dementia. We conducted an open-label phase II study of this botanical product in symptomatic irradiated brain tumor survivors.
Eligibility criteria included: life expectancy ≥ 30 weeks, partial or whole brain radiation ≥ 6 months before enrollment, no imaging evidence of tumor progression in previous 3 months, or stable or decreasing steroid dose, and no brain tumor treatment planned while on study. The ginkgo biloba dose was 120 mg/day (40 mg t.i.d.) for 24 weeks followed by a 6-week washout period. Assessments performed at baseline, 12, 24 (end of treatment), and 30 weeks (end of washout) included KPS, Functional Assessment of Cancer Therapy-Brain (FACT-Br), Profile of Mood States (POMS), Mini-Mental Status Exam (MMSE), Trail Making Test Parts A (TMT-A) and B (TMT-B), Digit Span Test (DST), Modified Rey Osterrieth Complex Figure (ROCF), California Verbal Learning Test Part II (CVLT-II), and the F-A-S Test.
Of the 34 patients enrolled on study, 23 (68%) completed 12 weeks of treatment and 19 (56%) completed 24 weeks of treatment. There were significant improvements at 24 weeks in: executive function (TMT-B) (p=0.007), attention/concentration (TMT-A) (p=0.002), and non-verbal memory (ROCF – immediate/delayed recall) (p=0.001/0.002), mood (p=.002), FACT brain subscale (p=0.001), and the FACT physical subscale (p=.003).
Some improvement in quality of life and cognitive function were noted with ginkgo biloba. However, treatment with ginkgo biloba was associated with a high dropout rate.
PMCID: PMC3752650  PMID: 22700031
ginkgo biloba; radiation; cognitive function; quality of life; brain tumors
20.  Profile of Vitiligo in Kumaun Region of Uttarakhand, India 
Vitiligo is a common, acquired, pigmentary disorder characterized by loss of melanocytes resulting in white spots. This disease carries a lot of social stigma in India.
To study the clinico-epidemiological profile of vitiligo patients in Kumaun region of Uttarakhand state in India.
Materials and Methods:
The clinical presentation of vitiligo was examined and analyzed in 762 vitiligo patients attending the Dermatology outdoor of Government Medical College, Haldwani, which is a referral centre for Kumaun region of Uttarakhand state in India.
Male and female patients were found to be affected almost equally. It was observed that onset of vitiligo was most common in 0-10 years age group, as evidenced by 336 cases out of 762 cases. Acrofacial type of vitiligo (339 cases out of 762) was most commonly observed, followed by vitiligo vulgaris, focal, segmental, mucosal, mixed, and universal vitiligo. The most common site of onset was the lower limbs followed by head and neck, upper limbs, trunk, genitalia, and mucasae. Leucotrichia was observed in 33.5%, Koebner's phenomenon in 26.3%, and a positive family history in 19% of the vitiligo patients. The other common conditions associated were thyroid disorders (8.9%), diabetes (5.3%), and atopic dermatitis (4.9%).
The study indicates that acrofacial vitiligo is the most common clinical type observed in Kumaun region of Uttarakhand in India. Onset of vitiligo is most common in first decade of life.
PMCID: PMC3969695  PMID: 24700953
Clinico-epidemiological profile; Uttarakhand; vitiligo
21.  Narrow Band-Ultraviolet B Versus Clobetasol Propionate Foam in the Treatment of Vitiligo: A Retrospective Study 
Dermatology and Therapy  2013;3(1):95-105.
Several therapeutic options are available for the treatment of vitiligo; among these phototherapy and topical steroids are the most widely documented. A topical formulation of 0.05% clobetasol propionate foam (CPF) has been introduced in the market, but no data are available about the efficacy and tolerability of this new formulation in the treatment of vitiligo. The aim of this study was to investigate the efficacy and tolerability of CPF in the treatment of vitiligo, in comparison with narrowband-ultraviolet B (NB-UVB) phototherapy.
The medical records of the first 60 vitiligo patients treated with NB-UVB phototherapy or with CPF were selected. Response to the treatment was determined for each anatomic site (neck, upper and lower limbs, trunk, hands/wrists, feet/ankles). Based on the area of repigmentation, treatment outcome was calculated according to a scale ranging from 0 (absent) to 4 (excellent). The incidence of adverse effects was also noted as a secondary endpoint. Significance level was set at P = 0.05.
For each anatomic site, statistical analyses demonstrated that the efficacy of CPF was significantly higher compared to NB-UVB. Side effects occurred in 4 patients (13.33%) in the CPF group compared to none in the NB-UVB group.
Clobetasol propionate has been used in vitiligo in different vehicles, but never in foam. The data showed that CPF is effective and seems to be superior to NB-UVB phototherapy, with furthermore a good safety profile.
This new foam formulation of clobetasol propionate may expand the options currently available for vitiligo therapy; however, further investigations are needed to confirm our preliminary observations.
PMCID: PMC3680636  PMID: 23888259
Clobetasol propionate foam; Narrowband-ultraviolet B phototherapy; VersaFoam; Vitiligo
22.  Narrow Band-Ultraviolet B Versus Clobetasol Propionate Foam in the Treatment of Vitiligo: A Retrospective Study 
Dermatology and Therapy  2013;3(1):95-105.
Several therapeutic options are available for the treatment of vitiligo; among these phototherapy and topical steroids are the most widely documented. A topical formulation of 0.05% clobetasol propionate foam (CPF) has been introduced in the market, but no data are available about the efficacy and tolerability of this new formulation in the treatment of vitiligo. The aim of this study was to investigate the efficacy and tolerability of CPF in the treatment of vitiligo, in comparison with narrowband-ultraviolet B (NB-UVB) phototherapy.
The medical records of the first 60 vitiligo patients treated with NB-UVB phototherapy or with CPF were selected. Response to the treatment was determined for each anatomic site (neck, upper and lower limbs, trunk, hands/wrists, feet/ankles). Based on the area of repigmentation, treatment outcome was calculated according to a scale ranging from 0 (absent) to 4 (excellent). The incidence of adverse effects was also noted as a secondary endpoint. Significance level was set at P = 0.05.
For each anatomic site, statistical analyses demonstrated that the efficacy of CPF was significantly higher compared to NB-UVB. Side effects occurred in 4 patients (13.33%) in the CPF group compared to none in the NB-UVB group.
Clobetasol propionate has been used in vitiligo in different vehicles, but never in foam. The data showed that CPF is effective and seems to be superior to NB-UVB phototherapy, with furthermore a good safety profile.
This new foam formulation of clobetasol propionate may expand the options currently available for vitiligo therapy; however, further investigations are needed to confirm our preliminary observations.
PMCID: PMC3680636  PMID: 23888259
Clobetasol propionate foam; Narrowband-ultraviolet B phototherapy; VersaFoam; Vitiligo
23.  Effect of the herbal extract combination Panax quinquefolium and Ginkgo biloba on attention-deficit hyperactivity disorder: a pilot study. 
OBJECTIVE: A combination herbal product containing American ginseng extract, Panax quinquefolium, (200 mg) and Ginkgo biloba extract (50 mg) (AD-FX; CV Technologies, Edmonton, Alta.) was tested for its ability to improve the symptoms of attention-deficit hyperactivity disorder (ADHD). DESIGN: Open study. PATIENTS: 36 children ranging in age from 3 to 17 years who fit the diagnostic criteria for ADHD. INTERVENTIONS: AD-FX capsules were taken twice a day on an empty stomach for 4 weeks. Patients were instructed not to change any other medications during the study. OUTCOME MEASURES: At the beginning of the study, after 2 weeks, and then at the end of the 4-week trial, parents completed the Conners' Parent Rating Scale--revised, long version, a questionnaire that assesses a broad range of problem behaviours (and was used as an indication of ADHD symptom severity). RESULTS: After 2 weeks of treatment, the proportion of the subjects exhibiting improvement (i.e., decrease in T-score of at least 5 points) ranged from 31% for the anxious-shy attribute to 67% for the psychosomatic attribute. After 4 weeks of treatment, the proportion of subjects exhibiting improvement ranged from 44% for the social problems attribute to 74% for the Conners' ADHD index and the DSM-IV hyperactive-impulsive attribute. Five (14%) of 36 subjects reported adverse events, only 2 of which were considered related to the study medication. CONCLUSIONS: These preliminary results suggest AD-FX treatment may improve symptoms of ADHD and should encourage further research on the use of ginseng and Ginkgo biloba extracts to treat ADHD symptoms.
PMCID: PMC1408291  PMID: 11394191
24.  Induction of vitiligo after imiquimod treatment of condylomata acuminata 
BMC Infectious Diseases  2014;14:329.
Condylomata acuminata (genital warts) is the most common sexually transmitted disease, and imiquimod is the sole FDA-approved medication for combating this condition. Vitiligo associated with imiquimod treatment of condylomata acuminata is rare.
Case presentation
A 28-year-old male with condylomata acuminata of the penis presented to our clinic. After removing his condylomata acuminata, we advised him to use imiquimod 5% cream to prevent relapse. When he presented to our clinic again about 12 weeks later, he complained of vitiligo patches on his penis and scrotum. Physical examination showed vitiligo patches involving the glans penis, shaft of the penis, and scrotum, and remaining pigmented areas within the plaques of vitiligo.
A skin biopsy of the dorsal surface of the penis showed a complete absence of melanocytes and melanin granules in the basal layer; the dermis was normal.
This is the first report of a case of imiquimod-induced vitiligo diagnosed by histopathological examination. This adverse effect should be considered when dermatologists prescribe this medication.
PMCID: PMC4084792  PMID: 24928346
Condylomata acuminata; Imiquimod; Vitiligo
25.  Genome-Wide Analysis Identifies a Quantitative Trait Locus in the MHC Class II Region Associated with Generalized Vitiligo Age of Onset 
Generalized vitiligo is a common autoimmune disease in which acquired patchy depigmentation of skin, hair, and mucous membranes results from loss of melanocytes from involved areas. Previous genetic analyses have focused on vitiligo susceptibility, and have identified a number of genes involved in disease risk. Age of onset of generalized vitiligo also involves a substantial genetic component, but has not previously been studied systematically. In this study, we report a genome-wide association study of vitiligo age of onset in 1,339 generalized vitiligo patients, with replication in an independent cohort of 677 cases. We identified a quantitative trait locus for vitiligo age of onset in the major histocompatibility complex (MHC) class II region, located near c6orf10-BTNL2 (rs7758128; P = 8.14×10−11), a region that is also associated with generalized vitiligo susceptibility. In contrast, there was no association of vitiligo age of onset with any other MHC or non-MHC loci that are associated with vitiligo susceptibility. These findings highlight the differing roles played by genes involved in vitiligo susceptibility versus vitiligo age of onset, and illustrate that genome-wide analyses can be used to identify genes involved in quantitative aspects of disease natural history, as well as disease susceptibility per se.
PMCID: PMC3172680  PMID: 21326295

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