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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.
doi:10.1155/2011/750342
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.
doi:10.1155/2014/493213
PMCID: PMC4005019  PMID: 25006488
3.  Comparing Nigella sativa Oil and Fish Oil in Treatment of Vitiligo 
Background:
Vitiligo is one of the autoimmune skin diseases that destroy the melanocytes of the skin. Moreover, its prevalence varies in different countries and regions.
Objectives:
The aim of this study was to compare the effect of Nigella sativa and fish oil on vitiligo lesions of the patients referred to a dermatology clinic.
Materials and Methods:
This randomized, double blind clinical trial was conducted in the dermatology clinic of the Imam Khomeini Hospital Ahvaz, Iran, from June to December 2011. We used a randomized simple sampling. From 96 patients with vitiligo, 52 eligible patients were selected and allocated to two groups with equal size. The study medications were applied twice a day by patients on their lesions. After six months, the improvement rate of lesions was assessed by the Vitiligo Area Scoring Index (VASI). Data were analyzed using SPSS v. 15; P value < 0.05 was considered as statistically significant.
Results:
After six months, a mean score of VASI decreased from 4.98 to 3.75 in patients applying topical Nigella sativa and from 4.98 to 4.62 in those using topical fish oil. Most of the percent improvement observed in upper extremities, trunk, head, and neck of those who received Nigella sativa and head, neck, trunk, and feet of those who received fish oil. No adverse effect was reported by the patients.
Conclusions:
Nigella sativa oil and fish oil were effective in reduction the size of patient’s lesions; however, Nigella sativa was more effective in comparison to the fish oil. Therefore, using Nigella sativa with the major drugs in the treatment of vitiligo is recommended.
doi:10.5812/ircmj.4515
PMCID: PMC4102993  PMID: 25068060
Nigella sativa; Fish Oils; Vitiligo
4.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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
NCT01478945
doi:10.1186/1745-6215-15-51
PMCID: PMC3923442  PMID: 24507484
Hand-held phototherapy; Home phototherapy; Patient education; Randomised trial; Vitiligo
5.  Survey and online discussion groups to develop a patient-rated outcome measure on acceptability of treatment response in vitiligo 
BMC Dermatology  2014;14:10.
Background
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.
Method
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-5945-14-10
PMCID: PMC4075774  PMID: 24929563
Vitiligo; Outcome measure; Patient-reported outcome; Randomised controlled trial
6.  Dermatology Specific Quality of Life in Vitiligo Patients and Its Relation with Various Variables: A Hospital Based Cross-sectional Study 
Introduction: Vitiligo is an acquired, idiopathic skin disease characterized by progressive loss of the inherited skin color. Vitiligo has a special significance to patients in our country because depigmentation is obvious on dark skin and due to the enormous stigma that the disease carries.
Materials and Methods: One hundred vitiligo patients aged more than 18 years were included in our hospital based study depending on inclusion and exclusion criteria. All the patients were asked to fill a validated Hindi version of DLQI questionnaire. DLQI scores and its interpretation were recorded separately. correlation of DLQI Scores with different variables like age, body surface area, duration of disease and socioeconomic status were studied using Pearson’s correlations. Mean DLQI scores were also compared between different groups.
Results: Male and female patient were statistically similar in all variables, like their age, BSA of the involvement and DLQI score. DLQI interpretation showed that out of 100 patients of vitiligo, 16 felt no effect of vitiligo on their quality of life while 84 patients reported small to very large effect on their quality of life. Out of this 84, 37 felt small effects, 21 felt moderate effect and rest 26 felt very large effect on their quality of life. There was no significant difference among the different groups mentioned except very large effect on quality of life seen significantly more in unmarried patients compared to married one.
Conclusion: Vitiligo although a cosmetic disease without any symptoms, it carry a significant social stigma especially in Indian society. Data interpretation in this study indicates that vitiligo affects QOL in majority of vitiligo patients and such patients require more aggressive and empathic attitude from a dermatologist to cure/improve this so called chronic cosmetic disease.
doi:10.7860/JCDR/2014/8248.4508
PMCID: PMC4129253  PMID: 25121050
DLQI; Quality of life; India; Vitiligo
7.  A systematic review of natural health product treatment for vitiligo 
BMC Dermatology  2008;8:2.
Background
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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1186/1471-5945-8-2
PMCID: PMC2432048  PMID: 18498646
8.  Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference 
Summary
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.
doi:10.1111/j.1755-148X.2012.00997.x
PMCID: PMC3511780  PMID: 22417114
vitiligo; consensus conference
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.
Background
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.
Objectives
To stimulate and steer future research in the field of vitiligo treatment, by identifying the 10 most important research areas for patients and clinicians.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1111/j.1365-2133.2010.10160.x
PMCID: PMC3084501  PMID: 21128908
10.  Epidermal Permeability Barrier Recovery Is Delayed in Vitiligo-Involved Sites 
Skin Pharmacology and Physiology  2010;23(4):193-200.
Background/Objectives
Prior studies have demonstrated that both the skin surface pH and epidermal permeability barrier function vary with skin pigmentation types. Although melanin deficiency is the main feature of vitiligo, alterations in cutaneous biophysical properties in vitiligo have not yet been well defined. In the present study, stratum corneum (SC) hydration, the skin surface pH and epidermal permeability barrier function in vitiligo were evaluated.
Methods
A total of 30 volunteers with vitiligo comprising 19 males and 11 females aged 13–51 years (mean age: 27.91 ± 2.06 years) were enrolled in this study. The skin surface pH, SC hydration, melanin/erythema index and transepidermal water loss (TEWL) were measured by respective probes connected to a Courage-Khazaka MPA5. SC integrity was determined by measuring the TEWL following each D-Squame application. The barrier recovery rate was assessed at 5 h following barrier disruption by repeated tape stripping.
Results
In addition to SC hydration, both melanin and erythema index were significantly lower in vitiligo lesions than in contralateral, nonlesional sites, while no difference in skin surface pH between vitiligo-involved and uninvolved areas was observed. In addition, neither the basal TEWL nor SC integrity in the involved areas differed significantly from that in the uninvolved areas. However, barrier recovery in vitiligo-involved sites was significantly delayed in comparison with uninvolved sites (40.83 ± 5.39% vs. 58.30 ± 4.71%; t = 2.441; p < 0.02).
Conclusion
Barrier recovery following tape stripping of the SC is delayed in vitiligo. Therefore, improvement in epidermal permeability barrier function may be an important unrecognized factor to be considered in treating patients with vitiligo.
doi:10.1159/000288166
PMCID: PMC2883831  PMID: 20185976
Vitiligo; Stratum corneum; Barrier function; Hydration
11.  Treatment of segmental vitiligo with normal-hair follicle autograft 
Background
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.
Methods
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.
Results
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.
Conclusion
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
12.  Effects of Ginkgo biloba in dementia: systematic review and meta-analysis 
BMC Geriatrics  2010;10:14.
Background
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.
Methods
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.
Results
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.
Conclusions
Ginkgo biloba appears more effective than placebo. Effect sizes were moderate, while clinical relevance is, similar to other dementia drugs, difficult to determine.
doi:10.1186/1471-2318-10-14
PMCID: PMC2846949  PMID: 20236541
13.  A pilot study assessing the effect of prolonged administration of high daily doses of vitamin D on the clinical course of vitiligo and psoriasis 
Dermato-endocrinology  2013;5(1):222-234.
Autoimmunity has been associated with vitamin D deficiency and resistance, with gene polymorphisms related to vitamin D metabolism frequently described in affected patients. High doses of vitamin D3 may conceivably compensate for inherited resistance to its biological effects. This study aimed to assess the efficacy and safety of prolonged high-dose vitamin D3 treatment of patients with psoriasis and vitiligo. Nine patients with psoriasis and 16 patients with vitiligo received vitamin D3 35,000 IU once daily for six months in association with a low-calcium diet (avoiding dairy products and calcium-enriched foods like oat, rice or soya “milk”) and hydration (minimum 2.5 L daily). All psoriasis patients were scored according to “Psoriasis Area and Severity Index” (PASI) at baseline and after treatment. Evaluation of clinical response of vitiligo patients required a quartile grading scale. All patients presented low vitamin D status (serum 25(OH)D3 ≤ 30 ng/mL) at baseline. After treatment 25(OH)D3 levels significantly increased (from 14.9 ± 7.4 to 106.3 ± 31.9 ng/mL and from 18.4 ± 8.9 to 132.5 ± 37.0 ng/mL) and PTH levels significantly decreased (from 57.8 ± 16.7 to 28.9 ± 8.2 pg/mL and from 55.3 ± 25.0 to 25.4 ± 10.7 pg/mL) in patients with psoriasis and vitiligo respectively. PTH and 25(OH)D3 serum concentrations correlated inversely. The PASI score significantly improved in all nine patients with psoriasis. Fourteen of 16 patients with vitiligo had 25–75% repigmentation. Serum urea, creatinine and calcium (total and ionized) did not change and urinary calcium excretion increased within the normal range. High-dose vitamin D3 therapy may be effective and safe for vitiligo and psoriasis patients.
doi:10.4161/derm.24808
PMCID: PMC3897595  PMID: 24494059
vitiligo; psoriasis; vitamin D; 25(OH)D3; high dose; calcium; treatment; toxicity; autoimmunity
14.  CXCL10 is critical for the progression and maintenance of depigmentation in a mouse model of vitiligo 
Science translational medicine  2014;6(223):223ra23.
Vitiligo is an autoimmune disease of the skin that results in disfiguring white spots. There are no FDA-approved treatments for vitiligo, and most off-label treatments yield unsatisfactory results. Vitiligo patients have increased numbers of autoreactive, melanocyte-specific CD8+ T cells in the skin and blood, which are directly responsible for melanocyte destruction. Here we report that gene expression in lesional skin from vitiligo patients reveals an IFN-γ-specific signature, including the chemokine CXCL10. CXCL10 is elevated in both vitiligo patient skin and serum and CXCR3, its receptor, is expressed on pathogenic T cells. To address the function of CXCL10 in vitiligo, we employed a mouse model of disease that also exhibits an IFN-γ-specific gene signature, expression of CXCL10 in the skin, and upregulation of CXCR3 on antigen-specific T cells. Mice that receive Cxcr3−/− T cells develop minimal depigmentation, as do mice lacking Cxcl10 or treated with CXCL10 neutralizing antibody. CXCL9 promotes autoreactive T cell global recruitment to the skin but not effector function while, in contrast, CXCL10 is required for effector function and localization within the skin. Surprisingly, CXCL10 neutralization in mice with established, widespread depigmentation induces reversal of disease, evidenced by repigmentation. These data identify a critical role for CXCL10 in both the progression and maintenance of vitiligo, and thereby support inhibiting CXCL10 as a targeted treatment strategy.
doi:10.1126/scitranslmed.3007811
PMCID: PMC4086941  PMID: 24523323
15.  A Multicenter Collaborative Study by the Korean Society of Vitiligo about Patients' Occupations and the Provoking Factors of Vitiligo 
Annals of Dermatology  2014;26(3):349-356.
Background
It was previously thought that persons with genetic predispositions to vitiligo develop the condition after exposure to various precipitating environmental factors. However, in many cases, the aggravating factors of vitiligo have not been clearly identified.
Objective
To identify the aggravating factors of vitiligo in the working environment and daily life.
Methods
A total of 489 vitiligo patients were recruited from 10 institutions in South Korea; patients were provided with a questionnaire about environmental factors and behavior patterns in the workplace and in daily life, and their association with vitiligo.
Results
Ninety-five of the 470 enrolled patients (20.2%) answered that environmental risk factors in daily life and in the workplace affected the development of vitiligo. The most frequently attributed causes were trauma and burn (13.6%), followed by sunlight (12.8%), stress (12.8%), cleaning products/disinfectant/chemicals (4.9%), and hair dye (2.1%).
Conclusion
Vitiligo of the hand and foot was associated with frequent exposure to aggravating materials and overexposure to sunlight, along with frequent trauma of these areas, all of which could be considered important risk factors of vitiligo. The development of vitiligo could potentially be controlled through the early detection of aggravating factors.
doi:10.5021/ad.2014.26.3.349
PMCID: PMC4069646  PMID: 24966635
Environment; Occupations; Provoking factor; Risk factors; Vitiligo
16.  Comparison of the Psychological Impacts of Asymptomatic and Symptomatic Cutaneous Diseases: Vitiligo and Atopic Dermatitis 
Annals of Dermatology  2013;25(4):454-461.
Background
Vitiligo and atopic dermatitis (AD) are common dermatological disorders which may cause significant psychological and social distress leading to impaired quality of life (QoL) in patients.
Objective
We evaluated the degree of psychological stress and impairment of QoL in vitiligo patients as compared with AD patients and normal controls (NCs).
Methods
A total of 60 patients from each group and 60 NCs were enrolled. Five questionnaires on depression (Beck depression inventory, BDI), state anxiety (SA) and trait anxiety (TA), interaction anxiousness (IAS), private body consciousness (PBC) and dermatologic QoL were used.
Results
The vitiligo patients had a significantly higher level of TA (p<0.01), PBC (p<0.001) and impaired QoL (p<0.001) than NCs, but not BDI, SA and IAS. The AD patients had significantly higher scores for all five questionnaire items compared with NCs. In the comparison between the AD and vitiligo groups, all of the indexes except body consciousness were higher in AD patients than in vitiligo patients: BDI (p<0.01), SA (p<0.05), TA (p<0.001), IAS (p<0.01) and impaired QoL (p<0.001). Exposure of vitiligo lesions was not a significant variable in the analysis of the contribution of clinical variables of vitiligo on psychological stress and QoL.
Conclusion
Vitiligo, which is not accompanied by any symptoms, involves less psychological impact than AD, which is accompanied by itching. Compared to NCs, however, the elevated general anxiety and body consciousness in patients with vitiligo suggests that they may be more concerned with the aggravation of hypopigmented patches than difficulties in social interactions.
doi:10.5021/ad.2013.25.4.454
PMCID: PMC3870214  PMID: 24371393
Atopic dermatitis; Psychological impacts; Vitiligo
17.  Efficacy of Targeted Narrowband Ultraviolet B Therapy in Vitiligo 
Indian Journal of Dermatology  2014;59(5):485-489.
Background:
Phototherapy is one of the most effective treatment options in vitiligo. Targeted phototherapy devices are becoming more popular as they offer a lot of advantages over the conventional whole-body phototherapy units.
Aims and Objectives:
The present study was conducted to assess the efficacy and safety of a targeted narrowband ultraviolet B (NBUVB) device in vitiligo.
Materials and Methods:
A total of 40 patients of vitiligo were treated with a targeted NBUVB device twice-weekly for a maximum of 30 sessions or until 100% repigmentation, whichever was reached first. The extent of repigmentation achieved was assessed and adverse effects, if any, were also noted down.
Results:
There were 31 responders (77.5%) who achieved repigmentation ranging from 50% to 100%. The onset of repigmentation was seen as early as the 3rd dose in some cases and by the 10th dose in all responders. A total of 97 lesions were treated out of which 45 lesions (46.6%) achieved 90-100% repigmentation. Lesions showing 75% and 50% repigmentation were 14 and 15 in number respectively. 23 lesions failed to show any significant repigmentation at the end of 30 doses. Best response was seen on the face and neck with 20 of the 31 lesions achieving 90-100% repigmentation in this area. Duration of vitiligo was seen to have no statistically significant impact on the repigmentation achieved.
Conclusion:
Targeted NBUVB phototherapy seems to be an effective treatment option in localized vitiligo with a rapid onset of repigmentation seen as early as 2nd week of treatment.
doi:10.4103/0019-5154.139892
PMCID: PMC4171919  PMID: 25284856
Phototherapy; treatment; targeted narrowband ultraviolet B phototherapy; vitiligo
18.  Evaluation of the Efficacy of Topical Tetracycline in Enhancing the Effect of Narrow Band UVB against Vitiligo: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial 
ISRN Dermatology  2014;2014:472546.
Background. Vitiligo is a pigmentary disorder characterized by depigmented macules due to absence of melanocytes. Increased levels of tumor necrosis factor alpha and interleukin-1 in the epidermis of lesions may play a role in keratinocyte apoptosis and less production of melanogenic cytokines. Tetracyclines reduce production of tumor necrosis factor alpha and interleukin-1. Objective. To evaluate the effect of topical tetracycline on vitiligo patients on phototherapy. Methods. Thirty cases of generalized stable vitiligo were chosen randomly and pigmentation of two assigned lesions on right and left sides (same size and location) was determined by vitiligo area severity index, and medication and placebo were randomly assigned to be applied twice daily on either right or left side, respectively. Images were taken of the lesions at the end of the 4th, 8th, and 12th weeks and pigmentations were compared to baseline using aforementioned index. The patients also took narrow band ultraviolet B two to three times a week. Results. Mean pigmentation, based on vitiligo area severity index, changed significantly from 90.1667 to 86.6667 (P = 0.026) and on placebo side from 89.6667 to 86.8333 (P = 0.026). There was no significant difference between medication and placebo sides in terms of pigmentation (P = 0.566). Conclusions. No significant difference in improving repigmentation between medication and placebo sides was seen.
doi:10.1155/2014/472546
PMCID: PMC3934486  PMID: 24665368
19.  Role of In Vivo Reflectance Confocal Microscopy in Determining Stability in Vitiligo: A Preliminary Study 
Indian Journal of Dermatology  2013;58(6):429-432.
Background:
Vitiligo is an acquired pigmentary disorder. In vivo reflectance confocal microscopy (RCM) reproducible imaging technique has already been reported to be useful in the diagnosis of other skin diseases.
Objective:
To define RCM features of vitiligo on different clinical stages.
Materials and Methods:
A total of 125 patients with a clinical diagnosis of vitiligo were included in this study. After informed consent, lesional skins of those vitiligo patients were characterized by using RCM. Five patients with inflammatory cell infiltration observed at the edge of skin lesions and another 5 patients without inflammatory cell infiltration were selected. Biopsies were performed at same sites of the RCM examination areas for histological and immune-histological analysis.
Results:
In the active stage of vitiligo, the RCM examination revealed that the bright dermal papillary rings presented at the dermoepidermal junction level in normal skin lost their integrity or totally disappeared, border between vitiligo lesion and normal skin became unclear, and highly refractile cells that referred to infiltrated inflammatory cells could be seen within the papillary dermis at the edge of the lesions. In the stable stage of vitiligo, the RCM showed a complete loss of melanin in lesional skin and a clear border between lesional and normal skin.
Conclusion:
A simple clinical examination with RCM may reliably and efficiently allow evaluation of the stability status of vitiligo lesions.
doi:10.4103/0019-5154.119948
PMCID: PMC3827512  PMID: 24249892
Histopathology; immunohistological; reflectance confocal microscopy; vitiligo
20.  Relationship of macrophage migration inhibitory factor levels in PBMCs, lesional skin and serum with disease severity and activity in vitiligo vulgaris 
Melanocyte loss in vitiligo vulgaris is believed to be an autoimmune process. Macrophage migration inhibitory factor (MIF) is involved in many autoimmune skin diseases. We determined the possible role of MIF in the pathogenesis of vitiligo vulgaris, and describe the relationship between MIF expressions and disease severity and activity. Serum MIF concentrations and mRNA levels in PBMCs were measured in 44 vitiligo vulgaris patients and 32 normal controls, using ELISA and real-time RT-PCR. Skin biopsies from 15 patients and 6 controls were analyzed by real-time RT-PCR. Values are reported as median (25th-75th percentile). Serum MIF concentrations were significantly increased in patients [35.81 (10.98-43.66) ng/mL] compared to controls [7.69 (6.01-9.03) ng/mL]. MIF mRNA levels were significantly higher in PBMCs from patients [7.17 (3.59-8.87)] than controls [1.67 (1.23-2.42)]. There was also a significant difference in MIF mRNA levels in PBMCs between progressive and stable patients [7.86 (5.85-9.13) vs 4.33 (2.23-8.39)] and in serum MIF concentrations [40.47 (27.71-46.79) vs 26.80 (10.55-36.07) ng/mL]. In addition, the vitiligo area severity index scores of patients correlated positively with changes of both serum MIF concentrations (r = 0.488) and MIF mRNA levels in PBMCs (r = 0.426). MIF mRNA levels were significantly higher in lesional than in normal skin [2.43 (2.13-7.59) vs 1.18 (0.94-1.83)] and in patients in the progressive stage than in the stable stage [7.52 (2.43-8.84) vs 2.13 (1.98-2.64)]. These correlations suggest that MIF participates in the pathogenesis of vitiligo vulgaris and may be useful as an index of disease severity and activity.
doi:10.1590/S0100-879X2012007500152
PMCID: PMC3854402  PMID: 23797494
Migration inhibitory factor; Vitiligo vulgaris
21.  Diphencyprone Induced Vitiligo: A Case Report 
Case Reports in Medicine  2012;2012:356236.
Diphencyprone (DCP) is a contact sensitizer which is used to treat dermatological disorders with an immunological origin, such as extensive alopecia areata (AA). Vitiligo is a rare but known side effect of DPCP therapy which is formed in the treatment site or remote areas. In this paper a 37-year-old man developed alopecia totalis with loss of eyebrows and eyelashes who presented some vitiligo patches on his scalp and arm distant from the location of DPCP application and a 42-year-old woman with 25 years history of hair loss and 3 months DPCP application who revealed some vitiligo patches on the scalp with distant to the site of application at the 6th week are reported. Considering the absence of personal and family history of Vitiligo in our two cases, the hypothesis of latent Vitiligo is not proved. The positive patch test in left arm of one of the patients also suggests the direct role of DPCP as the cause of Vitiligo occurrence. As the development of vitiligo by DCP is unpredictable and the depigmentation may persist indefinitely, it is important to inform all patients about this potential adverse effect before starting the treatment.
doi:10.1155/2012/356236
PMCID: PMC3395361  PMID: 22811720
22.  Transcriptome Analysis Reveals Markers of Aberrantly Activated Innate Immunity in Vitiligo Lesional and Non-Lesional Skin 
PLoS ONE  2012;7(12):e51040.
Background
Vitiligo is characterized by the death of melanocytes in the skin. This is associated with the presence of T cell infiltrates in the lesional borders. However, at present, there is no detailed and systematic characterization on whether additional cellular or molecular changes are present inside vitiligo lesions. Further, it is unknown if the normal appearing non-lesional skin of vitiligo patients is in fact normal. The purpose of this study is to systematically characterize the molecular and cellular characteristics of the lesional and non-lesional skin of vitiligo patients.
Methods and Materials
Paired lesional and non-lesional skin biopsies from twenty-three vitiligo patients and normal skin biopsies from sixteen healthy volunteers were obtained with informed consent. The following aspects were analyzed: (1) transcriptome changes present in vitiligo skin using DNA microarrays and qRT-PCR; (2) abnormal cellular infiltrates in vitiligo skin explant cultures using flow cytometry; and (3) distribution of the abnormal cellular infiltrates in vitiligo skin using immunofluorescence microscopy.
Results
Compared with normal skin, vitiligo lesional skin contained 17 genes (mostly melanocyte-specific genes) whose expression was decreased or absent. In contrast, the relative expression of 13 genes was up-regulated. The up-regulated genes point to aberrant activity of the innate immune system, especially natural killer cells in vitiligo. Strikingly, the markers of heightened innate immune responses were also found to be up-regulated in the non-lesional skin of vitiligo patients.
Conclusions and Clinical Implications
As the first systematic transcriptome characterization of the skin in vitiligo patients, this study revealed previously unknown molecular markers that strongly suggest aberrant innate immune activation in the microenvironment of vitiligo skin. Since these changes involve both lesional and non-lesional skin, our results suggest that therapies targeting the entire skin surface may improve treatment outcomes. Finally, this study revealed novel mediators that may facilitate future development of vitiligo therapies.
doi:10.1371/journal.pone.0051040
PMCID: PMC3519491  PMID: 23251420
23.  The effect of pseudocatalase/superoxide dismutase in the treatment of vitiligo: A pilot study 
Objective:
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.
Methods:
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.
Findings:
There were no significant changes in lesion area and perifollicular pigmentation in each group (P > 0.05).
Conclusion:
The results indicated no significant therapeutic effect for PSD in vitiligo.
doi:10.4103/2279-042X.108375
PMCID: PMC4076862  PMID: 24991594
Pseudocatalase/superoxide dismutase; efficacy; vitiligo
24.  Vitiligo in adults and children 
Clinical Evidence  2008;2008:1717.
Introduction
Vitiligo is an acquired skin disorder characterised by white (depigmented) patches in the skin, due to the loss of functioning melanocytes. The extent and distribution of vitiligo often changes during the course of a person's lifetime and its progression is unpredictable.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of medical treatments, and of ultraviolet light treatments, for vitiligo in children and in adults? We searched: Medline, Embase, The Cochrane Library and other important databases up to March 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 25 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids, oral levamisole, topical immunomodulators, topical Vitamin D analogues, ultraviolet A plus psoralen (PUVA), and ultraviolet B (narrowband, and broadband).
Key Points
Vitiligo is an acquired skin disorder characterised by white (depigmented) patches in the skin, caused by the loss of functioning melanocytes. Vitiligo patches can appear anywhere on the skin, but common sites are usually around the orifices, the genitals, or sun-exposed areas such as the face and hands.The extent and distribution of vitiligo often changes during the course of a person's lifetime, and its progression is unpredictable.
Limited courses of potent topical corticosteroids are a safe and effective therapy for localised vitiligo and are often the first-choice treatment for this. The consensus is that adverse effects of oral corticosteroids outweigh the benefits in vitiligo. There is currently insufficient evidence available to assess their effectiveness.
Narrowband UVB is considered a safe and effective therapy for moderate to severe generalised vitiligo and is often the first-choice treatment for this.
Tacrolimus requires further evaluation, but is well tolerated in children and adults without the long-term adverse effects of topical corticosteroids. There is currently insufficient evidence available to assess other immunomodulators in vitiligo.
Vitiligo patches in certain body areas, such as the acral sites, palms and soles, lips, mucosa, and nipples, and segmental forms in any area are relatively resistant to all conventional treatment modalities. In these cases, counselling and cosmetic camouflage become a priority, and often no treatments are advocated.
There is insufficient evidence to assess topical vitamin D analogues, levamisole, and broadband UVB in vitiligo.
Consensus is that for the treatment of vitiligo in adults, oral PUVA is effective, whereas topical PUVA is unlikely to be effective. However, topical PUVA has fewer adverse effects than oral PUVA. PUVA is likely to be harmful in children.
PMCID: PMC2907927  PMID: 19450313
25.  Vitiligo in adults and children 
Clinical Evidence  2011;2011:1717.
Introduction
Vitiligo is an acquired skin disorder characterised by white (depigmented) patches in the skin, due to the loss of functioning melanocytes. The extent and distribution of vitiligo often changes during the course of a person's lifetime and its progression is unpredictable.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of medical treatments, and of ultraviolet light treatments, for vitiligo in adults and in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 25 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids (oral and topical), oral levamisole, topical immunomodulators, topical vitamin D analogues, ultraviolet A plus psoralen (PUVA [oral or topical]), and ultraviolet B (narrowband).
Key Points
Vitiligo is an acquired skin disorder characterised by white (depigmented) patches in the skin, caused by the loss of functioning melanocytes. Vitiligo patches can appear anywhere on the skin, but common sites are usually around the orifices, the genitals, or sun-exposed areas such as the face and hands.The extent and distribution of vitiligo often changes during the course of a person's lifetime, and its progression is unpredictable.
Limited courses of potent topical corticosteroids in adults and children are a safe and effective therapy for localised vitiligo and are often the first-choice treatment for this disorder. The consensus is that adverse effects of oral corticosteroids in adults and children outweigh the benefits in vitiligo. There is currently insufficient RCT evidence available to assess their effectiveness.
Narrowband ultraviolet B in adults and children is considered a safe and effective therapy for moderate to severe generalised vitiligo and is often the first-choice treatment for this disorder.
Tacrolimus requires further evaluation, but is well tolerated in children and adults without the long-term adverse effects of topical corticosteroids. There is currently insufficient RCT evidence available to assess other immunomodulators in vitiligo.
There is insufficient RCT evidence to fully assess levamisole or topical vitamin D analogues in vitiligo in children or in adults.
Consensus is that for the treatment of vitiligo in adults, oral psoralen plus ultraviolet A (PUVA) is effective, whereas topical PUVA is unlikely to be effective. However, topical PUVA has fewer adverse effects than oral PUVA. PUVA is likely to be harmful in children.
Vitiligo patches in certain body areas, such as the acral sites, palms and soles, lips, mucosa, and nipples, and segmental forms in any area are relatively resistant to all conventional treatment modalities. In these cases, counselling and cosmetic camouflage become a priority, and often no treatments are advocated.
PMCID: PMC3217714  PMID: 21439099

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