Vitiligo Research: 2002-2006
  
Ned Tijdschr Geneeskd. 2006 Sep 9;150(36):1976-81.
[The practice guideline 'vitiligo']
[Article in Dutch]
Menke HE, van Everdingen JJ.
Sint Franciscus Gasthuis, afd. Dermatologie, Rotterdam.

A working group of the Dutch Society for Dermatology and Venereology (NVDV), in collaboration with the Dutch Institute for Health Care Improvement (CBO), has written an evidence-based guideline for the treatment of vitiligo. A distinction is made between generalised or non-segmental vitiligo and localised, including segmental, vitiligo. In patients with generalised vitiligo phototherapy (especially narrow-band ultraviolet B) is the treatment of first choice while in localised vitiligo, this is surgery, particularly autologous skin transplantation (Thiersch grafting, the use of blister epidermis and cell suspensions). However, on the basis of the results of the treatments proposed in the guideline, the working group cannot advise dermatologists to propose a particular treatment to each vitiligo patient they see. On the other hand, the working group is of the opinion that, based on a proper medical examination and an assessment of the disease burden, well-considered advice--and in some cases therapy--should be given to every vitiligo patient who requests it. The benefit of the guideline is that it provides clarity to dermatologists, general practitioners and patients regarding the therapeutic possibilities and limitations.

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Tidsskr Nor Laegeforen. 2006 Sep 21;126(18):2370-2.
[Vitiligo—loss of cutaneous pigmentation]
[Article in Norwegian]
Sitek JC.
Hudavdelingen, Rikshospitalet-Radiumhospitalet, 0027 Oslo. jsitek@rikshospitalet.no

BACKGROUND: Vitiligo is an acquired pigmentary skin disorder that affects 0.5-2% of the population. Many patients contact their physician and alternative therapists for help. This review article presents an update of knowledge about vitiligo and is aimed at physicians that treat this patient group. METHOD: The article is based on literature identified on PubMed, textbooks in Dermatology and supplemented by clinical experience. RESULTS AND INTERPRETATION: Vitiligo is characterized by the absence of melanocytes in skin and hair follicles. The pathogenesis is complex with genetic, autoimmune and toxic contributors. Clinically well-defined milk-white maculae are seen in the skin, with a wide variety of spread and distribution. The debut of vitiligo is often in childhood and adolescence. Investigations indicate that vitiligo affects quality in life for both children and adults. Treatment of vitiligo is a challenge. Phototherapy with narrowband UVB or topical therapy with tacrolimus ointment or potent steroids may be indicated in some cases, but the effect is not well documented.

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Harefuah. 2006 Jul;145(7):483-5, 552, 551.
[Long-term effects of PUVA therapy on Israeli patients with vitiligo]
[Article in Hebrew]
Vussuki E, Ziv M, Rosenman D, David M.
Department of Dermatology, Rabin Medical Center, Petah Tikva, Israel. evusuki@clalit.org.il

BACKGROUND: Long-term treatment of psoriasis patients with PUVA (psoralen and ultraviolet A) is associated with an increased risk of photoaging and non-melanomic skin cancer, and perhaps of melanoma as well. Very little information is available on the long-term effects of PUVA treatment on vitiligo patients in general, and specifically on the risk of developing skin tumors. Among vitiligo patients treated with PUVA or heliotherapy, only a few cases of squamous cell carcinoma (SCC) have been described. OBJECTIVE: The objective of this research is to examine the long-term effects of PUVA treatment among vitiligo patients and the incidence of long-term side effects, including various types of skin cancers. PATIENTS AND METHODS: The medical files of all patients treated with PUVA at the Rabin Medical Center and the Emek Medical Center between 1982 and 1996 were surveyed. Each patient was interviewed by telephone and then invited to come in for a medical examination. RESULTS: A total of 28 out of 31 patients completed the questionnaire, and 12 of them were also examined. The average age of the patients was 47 years (range 25-84). The average amount of radiation to which each patient was exposed was 546.8 J/cm2 (range 26.5-1561), with a median of 336.8 J/cm2. The average number of treatments per patient was 84.2 (median 77). The average time that elapsed since beginning the treatment was 11 years (range 7-20), and the average time since treatment ended was 9.4 years (range 2-23). Partial or total repigmentation was experienced by 60% of the patients. In 18% of the patients, total or almost total repigmentation was seen, which lasted an average of 46 months. No skin cancer of any kind was seen in any of the patients. CONCLUSION: A recurrence of the illness was seen in all the vitiligo patients who had responded to PUVA treatment. Long-term treatment with PUVA for vitiligo patients does not entail photoaging damages or increased risk of skin cancer.

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Photomed Laser Surg. 2006 Jun;24(3):354-7.
Treatment of vitiligo using the 308-nm excimer laser.
Hadi S, Tinio P, Al-Ghaithi K, Al-Qari H, Al-Helalat M, Lebwohl M, Spencer J.
Department of Dermatology, Mount Sinai School of Medicine, New York, New York 10029, USA. Suhail.Hadi@mssm.edu

OBJECTIVE: The aim of this study was to study the effectiveness of the 308-nm xenon chloride excimer laser in the treatment of vitiligo and to determine factors that favor a good response to treatment. BACKGROUND DATA: Targeted phototherapy using the 308-nm xenon chloride excimer laser represents an effective therapy for the management of vitiligo. However, studies on a large number of patients are few despite the increasing use of the excimer laser to treat patients with vitiligo. METHODS: A retrospective chart review of 97 patients with chronic stable vitiligo was done with a total of 221 vitiligo patches treated. RESULTS: Out of 221 vitiligo patches treated, 50.6% showed 75% pigmentation or more, 25.5% achieved 100% pigmentation of their patches, and 64.3% showed 50% pigmentation or more. Lesions on the face responded better than lesions elsewhere. CONCLUSION: The 308-nm xenon chloride excimer laser is an effective and safe modality for the treatment of vitiligo, with good results achieved in a relatively short duration of time.

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Int J Dermatol. 2006 Jun;45(6):747-50.
Autologous melanocyte transfer via epidermal grafts for lip vitiligo.
Gupta S, Goel A, Kanwar AJ, Kumar B.
>From the Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background Vitiligo of the lips is a common concern of great psychologic consequence. Medical therapies are often ineffective due mainly to the absence of hair follicles. The transfer of melanocytes or melanocyte-bearing skin by a surgical procedure may repigment this condition. Only a few surgical modalities have been successful in this "difficult to treat" site. Objective To assess the effectiveness of autologous melanocyte transfer by epidermal grafts for lip vitiligo and to review the literature on the surgical correction of lip vitiligo. Methods Twenty-six vitiligo patients (20 women and six men; age range, 13-43 years; mean, 26.8 years) having 31 affected lips with stable disease were included in the study. The suction blisters were raised using our own modified device on the lateral aspect of the thigh. The roofs of the blisters were transferred to the dermabraded recipient area. The dressing, together with the grafts, was removed on day 8. Patients were given photochemotherapy for 6 weeks. In addition, meta-analysis of the published literature on the surgical management of lip vitiligo was also performed. Results Complete repigmentation was observed in 27 of the 31 lip areas (87%) in 23 of 25 patients (92%) in whom a follow-up for 6 months or more was available. Complications observed were persistent hyperpigmentation in 12 lips and reactivation of herpes in one patient. Minimal hyperpigmentation was seen in most of the remaining lips. The results of the meta-analysis revealed that the success rate varies from 32.5% to 100% with various surgical procedures. Conclusion Autologous melanocyte transfer is an effective and safe therapeutic option for stable vitiligo of the lips. It is cosmetically more acceptable, as there is no abnormal keratinization, which is a problem associated with dermo-epidermal grafts.

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Int J Dermatol. 2006 Jun;45(6):649-55.
Repigmentation of vitiligo with punch grafting and narrow-band UV-B (311 nm)—a prospective study.
Lahiri K, Malakar S, Sarma N, Banerjee U.
>From the Pigmentary Disorder Unit, Rita Skin Foundation, Calcutta, India.

Background Phototherapy is already established as an effective mode of therapy in vitiligo. An evidence-based study was carried out of the effect of narrow-band (311 nm) ultraviolet-B (NB-UV-B) radiation in 66 surgically treated patients with recalcitrant vitiligo in whom autologous mini-punch grafting was deployed. Methods A total of 2613 grafts were placed over 108 lesions on 17 regions in 66 individuals (39 females and 27 males) with stable, refractory vitiligo. The age range was 21-48 years. Postsurgically, they were exposed to a suberythemal dose of NB-UV-B (311 nm). Different parameters of surgical repigmentation were documented. Results Successful repigmentation was achieved in 57 (86.36%) cases. The appearance of repigmentation (AOR) time in different regions varied between 14 and 32 days, with an overall average of approximately 20.6 days. Maximum pigment spread (MPS) reached 12 mm with an average of 6.5 mm. The relationship between the donor graft area and area of surgical repigmentation was also calculated. Cobblestoning was the most common (31.8%) complication, but improved with time and/or interference. Conclusions Punch grafting in combination with phototherapy (NB-UV-B, 311 nm) was found to be an easy, safe, inexpensive, and effective method of repigmenting static and stubborn vitiligo. Different facets of punch grafting-induced and phototherapy-aided surgical repigmentation were taken into consideration. The area of repigmentation, MPS, and relationship between the donor graft area and area of surgical repigmentation were documented.

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J Dermatol. 2006 May;33(5):338-43.
Narrow-band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of vitiligo.
Arca E, Tastan HB, Erbil AH, Sezer E, Koc E, Kurumlu Z.
Department of Dermatology, Gulhane Military Medical Academy, School of Medicine Etlik, Ankara, Turkey. earca@gata.edu.tr

Vitiligo is a common, idiopathic, acquired, depigmenting disease characterized by loss of normal melanin pigments in the skin. The most interesting treatment methods for extensive vitiligo involve psoralen plus ultraviolet A (PUVA) therapy and ultraviolet (UV)-B phototherapy, particularly narrow-band UV-B. In this randomized and comparative study, we investigated the safety and efficacy of narrow band ultraviolet B as monotherapy and in combination with topical calcipotriol in the treatment of generalized vitiligo. Of the 40 vitiligo patients enrolled in the study, 15 were treated with the calcipotriol plus narrow-band UV-B (NBUVB) and 25 with narrow band UV-B alone. The patients were randomized into two NBUVB treatment groups. The first group, consisting of 24 patients (all male), received only NBUVB treatment; the second group, consisting of 13 patients (all male) applied 0.05% topical calcipotriol ointments twice daily. Both groups were irradiated with NBUVB (311 nm). In the NBUVB group, the percentage of the body surface affected was reduced from 27.21 +/- 10.41% to 16.25 +/- 8.54% after a mean of 30 treatment sessions. The mean repigmentation percentage was 41.6 +/- 19.4%. In clinical evaluation (moderate and marked/complete response was accepted as an effective treatment), 19 patients (19/24; 79.17%) had clinically good results. In the NBUVB plus calcipotriol group, the percentage of the body surface affected was reduced from 23.35 +/- 6.5% to 13.23 +/- 7.05% after a mean of 30 treatment sessions. The mean repigmentation percentage was 45.01 +/- 19.15%. In clinical evaluation (moderate and marked/complete response was accepted as an effective treatment), 10 patients (10/13; 76.92%) had clinically good results. Statistically significant intragroup reductions from the baseline percentage of the body surface affected were seen at the endpoint of treatment for the two treatment groups (P < 0.001). However, there was no statistically significant difference between the two treatment groups at the end of therapy with respect to the reduction of repigmentation rates (P > 0.05). The present study reconfirmed the efficacy of NBUVB phototherapy in vitiligo. It can be a therapeutic option considered in the management of patients with vitiligo. However, addition of topical calcipotriol to NBUVB did not show any advantage.

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J Eur Acad Dermatol Venereol. 2006 May;20(5):558-64.
The efficacy of excimer laser (308 nm) for vitiligo at different body sites.
Hofer A, Hassan AS, Legat FJ, Kerl H, Wolf P.
Medical University of Graz, Department of Dermatology, Graz, Austria. angelika.hofer@meduni-graz.at

BACKGROUND: The treatment with XeCl-excimer laser generated 308-nm UVB radiation has shown promising results in patients with vitiligo. OBJECTIVE: In this controlled, prospective trial we studied the primary efficacy (start and grade of repigmentation) and patient's satisfaction of XeCl-excimer laser for treatment of vitiligo patches at different body sites and re-evaluated the achieved repigmentation 12 months after the end of therapy. METHODS: Twenty-five patients with generalized or localized vitiligo with a total of 85 lesions at different body sites were enrolled in this study. Vitiligo patches were treated with 308-nm XeCl-excimer laser 3 times a week for 6 to 10 weeks. The overall repigmentation grade of each treated lesion was evaluated once a week on a 5 point scale rating from 0 (no repigmentation), 1 (1-5%), 2 (6-25%), 3 (26-50%), 4 (51-75%), to 5 (76-100%). RESULTS: Twenty-four patients completed the study. Within 6 to 10 weeks of treatment 67% of the patients (16/24) developed follicular repigmentation of at least one of their vitiligo lesions. Lesion repigmentation started after a mean of 13 treatments in lesions located on the face, trunk, arm, and/or leg (high-responder location), and after a mean of 22 treatments in lesions located on the elbow, wrist, dorsum of the hand, knee, and/or dorsum of the foot (low-responder location). Untreated control lesions and lesions located on the fingers did not achieve any repigmentation. After 10 weeks of treatment repigmentation of more than 75% was found in 25% (7/28) of lesions of the high-responder location group versus 2% (1/43) of lesions of the low-responder location group. In most cases, laser-induced repigmentation was persistent, as determined 12 months after the end of treatment. CONCLUSIONS: 308-nm excimer laser is an effective modality for the treatment of vitiligo. However, similar to other non-surgical treatment modalities, the therapeutic effect is mainly dependent on the location of vitiligo lesions.

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Int J Dermatol. 2006 Apr;45(4):411-7.
Dermatosurgical techniques for repigmentation of vitiligo.
Rusfianti M, Wirohadidjodjo YW.
Dermatovenereology Department, School of Medicine, Gadjah Mada University, Sardjito Hospital, Yogyakarta, Indonesia.

There are a number of dermatosurgery techniques available to achieve repigmentation of vitiligo, such as suction blister grafting, split-thickness skin grafting, punch grafting, follicular grafting, cultured-melanocytes transplantation, and noncultured-melanocytes transplantation. Each method has advantages and disadvantages. As there are no specific data available from the prospective studies in this field it is uneasy to recommend which surgical approach to vitiligo offers the best result. According to a systematic review by Njoo et al.,(17) suction blister and split-thickness skin grafting have the highest rates of success (87%), while the average success rates for other methods varied from 13% to 53%. Punch grafting has the highest rate of adverse effects, including cobblestoning appearance (27%) and scar formation (40%) in the donor site. Accordingly, it is also mandatory to appropriately select vitiligo patients in order to achieve a complete and permanent repigmentation.

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J Eur Acad Dermatol Venereol. 2006 Mar;20(3):269-73.
Effect of topical calcipotriol, betamethasone dipropionate and their combination in the treatment of localized vitiligo.
Kumaran M, Kaur I, Kumar B.
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background Treatment of vitiligo is a challenge. Steroids are known to be effective but are associated with serious adverse effects. Many uncontrolled studies have shown calcipotriol to be a promising therapeutic modality in vitiligo. Objective To conduct a randomized trial to evaluate the effect of topical calcipotriol ointment (0.005%) and betamethasone dipropionate (0.05%) cream, given alone or in combination, in treatment of localized vitiligo. Methods Forty-nine patients with vitiligo affecting 5% of their skin were recruited. Patients were randomized into three groups. Group I patients were treated with betamethasone dipropionate (0.05%) cream twice daily. Group II patients were treated with calcipotriol ointment (0.005%) twice daily, and group III with betamethasone dipropionate (0.05%) in the morning and calcipotriol (0.005%) in the evening. Results Forty-five patients completed the study period of 3 months with 15 patients in each group. No patient achieved excellent (> 75%) pigmentation. Marked (50% to 75%) repigmentation was observed in 2 (13.3%), 1 (6.7%) and 4 (26.7%) patients in groups I, II and III, respectively. Moderate (25-50%) repigmentation was observed in 7 (46.7%), 5 (33.3%) and 7 (46.7%) patients in groups I, II and III, respectively. Patients with < 25% pigmentation were termed as minimal pigmentation or no response. The mean time for initial pigmentation to appear was 9.04 +/- 2.0 weeks in group I, 10.18 +/- 1.6 weeks in group II and 5.17 +/- 2.4 weeks in group III (P < 0.01). The acquired pigmentation in the lesions was more stable in group III as compared with patients in groups II and I (P < 0.01). Side-effects in the form of atrophy and lesional burning sensations were more common in group I when compared with groups II and III (P < 0.05). Conclusion Combined therapy appeared to give a significantly faster onset of repigmentation along with better stability of the achieved pigmentation and with lesser number of side-effects.

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Clin Exp Dermatol. 2006 Mar;31(2):200-5.
Tacalcitol and narrow-band phototherapy in patients with vitiligo.
Leone G, Pacifico A, Iacovelli P, Vidolin AP, Picardo M.
Phototherapy Unit, S. Gallicano Dermatological Institute, IRCCS, Rome, Italy.

Background. Vitiligo is a skin disease characterized by loss of normal pigmentation in the skin. Several treatments exist but none is really effective. Recently, perturbations of calcium homeostasis in vitiliginous epidermis have been described. Aim. Based on these findings, the aim of this prospective, randomized, open-label study was to compare the effectiveness of narrow-band ultraviolet B (NB-UVB) phototherapy alone and the combination of NB-UVB and topical application of the vitamin D(3) analogue tacalcitol in the treatment of vitiligo. Methods. In total, 32 subjects with generalized vitiligo and symmetrical lesions were enrolled in the study. Subjects were instructed to apply tacalcitol ointment daily to the lesion on the side randomly selected to receive combination therapy. All subjects received NB-UVB phototherapy on a twice-weekly schedule. Results. Addition of topical tacalcitol to NB-UVB treatment improved the extent of repigmentation and increased the response rate in patients with vitiligo compared with NB-UVB treatment alone. Conclusion. Application of tacalcitol ointment in combination with twice-weekly NB-UVB phototherapy is an effective alternative treatment for patients with generalized vitiligo.

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Am J Clin Dermatol. 2006;7(1):7-12.
Topical macrolide immunomodulators : a role in the treatment of vitiligo?
Tjioe M, Vissers WH, Gerritsen MJ.
Department of Dermatology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands.

Recently, topical macrolide immunomodulators have been successfully introduced in the treatment of atopic dermatitis. With the growing interest in this new line of topical immunosuppressants, research into the efficacy of these medicines in other T-cell-mediated skin diseases, such as psoriasis, lichen planus, and even vitiligo, is expanding rapidly. It is generally accepted that autoimmune factors play an important role in vitiligo. In this article, the possible use and mechanism of topical macrolide immunomodulators in the treatment of vitiligo are discussed, together with the current state of clinical studies and case reports. These limited reports indicate that topical macrolide immunomodulators may play a role in the treatment of vitiligo, particularly in areas where use of potent corticosteroids is contraindicated.

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J Eur Acad Dermatol Venereol. 2006 Feb;20(2):175-7.
Psoralen-ultraviolet A vs. narrow-band ultraviolet B phototherapy for the treatment of vitiligo.
Parsad D, Kanwar AJ, Kumar B.
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Background Although many treatment modalities have been tried for the treatment of vitiligo, none is uniformly effective. Psoralen phototherapy (psoralen ultraviolet A (PUVA)) is established as efficacious treatment for vitiligo. Recently, narrow-band UVB (NBUVB) has been reported to be an effective and safe therapeutic option in patients with vitiligo. Objective To compare the efficacy of PUVA and NBUVB in the treatment of vitiligo. Design and setting Retrospective analysis of 69 patients with vitiligo who were treated either with PUVA or NBUVB at the pigmentary clinic of the Dermatology Department of the Postgraduate Institute of Medical Education and Research, Chandigarh, India. Outcome measures The following variables were compared between the two groups of patients: repigmentation status, number of treatments for marked to complete repigmentation in existing lesions, appearance of new lesions or increase in size of existing lesions, adverse effect of therapy, stability of repigmentation and colour match. Results In PUVA-treated group, 9 patients showed marked to complete repigmentation (23.6%) and 14 patients showed moderate improvement (36.8%), whereas in NBUVB-treated group, 13 patients showed marked to complete repigmentation (41.9%) and 10 patients showed moderate improvement (32.2%). A statistically significantly better stability and colour match of repigmentation with surrounding skin was seen in NBUVB-treated patients. Conclusion We showed that NBUVB is more effective than PUVA and repigmentation induced with NBUVB is statistically significantly more stable.

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Clin Dermatol. 2006 Jan-Feb;24(1):33-42.
Use of the 308-nm excimer laser for psoriasis and vitiligo.
Passeron T, Ortonne JP.
Department of Dermatology. Archet 2 Hospital, 06202 NICE Cedex 3, France.

The 308-nm excimer laser represents the latest advance in the concept of selective phototherapy. It emits a wavelength in the UV-B spectrum and thus shares the same indications as conventional phototherapy. Like other laser devices, the 308-nm excimer laser emits a monochromatic and coherent beam of light, can selectively treat a lesion while sparing surrounding healthy skin, and can deliver high fluencies. Clinicians have taken advantage of these properties to treat dermatologic disorders since 1997, with psoriasis and vitiligo attracting most attention. Initially, high fluencies (minimal erythemal dose, 8-16) were used, with excellent clinical results, to treat psoriasis vulgaris. The significance of side effects and the potential long-term carcinogenic risk associated with such fluencies have resulted in medium doses (about 3 minimal erythemal dose) being recommended, however. Interestingly, taking advantage of the selectivity of the laser, newer treatment protocols adapt the dose to the lesion and not to the minimal erythemal dose, as is the case for conventional phototherapies. Many prospective study series have also shown the efficacy and the good tolerance of the 308-nm excimer laser in the treatment of localized vitiligo. Induced rates of repigmentation seem to be higher than with narrowband UV-B. Moreover, the selectivity of the treatment prevents irradiation of healthy skin and limits unsightly tanning of surrounding skin. Aesthetically pleasing results are usually not achieved in extremities and bony prominences, which are not good indications for this technique. Combining the 308-nm excimer laser with 0.1% tacrolimus ointment has provided very interesting results, which need to be confirmed in larger series. The absence of actual data concerning the long-term risk for skin cancer after this treatment means that it should be considered with caution. Combination with topical steroids appears to be synergistic and potentially reduces long-term side effects; again, prospective data are lacking.

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Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003263.
Interventions for vitiligo.
Whitton M, Ashcroft D, Barrett CW, Gonzalez U.

BACKGROUND: Around 1% of the world's population has vitiligo, which causes a loss of skin colour in patches. The methods currently available to treat vitiligo are largely unsatisfactory and vary widely between cultures and within health systems. OBJECTIVES: To assess the effects of interventions used to manage vitiligo. SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED and other databases (last searched September 2004). Reference lists of articles and conference proceedings were searched. Authors of reviews were contacted. SELECTION CRITERIA: Randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: At least two reviewers independently assessed study eligibility and methodological quality and carried out data extraction. The included studies compared different interventions and used different outcome measures so we considered it inappropriate to combine their results. MAIN RESULTS: Nineteen trials with a total of 1350 participants were included. The RCTs generally had low numbers of participants and only RCTs of repigmentation and not other methods of managing vitiligo were able to be included.In one study, potent topical steroids resulted in better repigmentation than placebo and they were also better than oral psoralens plus sunlight in another study (RR 4.70 95% CI 1.14 to 19.39) although their long-term use is limited by adverse effects. Two studies suggested that topical calcipotriol enhanced repigmentation rates from PUVAsol and PUVA when compared with placebo. Another two studies showed higher repigmentation rates with oral PUVAsol versus placebo plus sunlight (RR 19.20 95% CI 1.21 to 304.50 in 79 adults and RR 2.29 95% CI 1.14 to 4.58 in a study of 50 children). The safety of these interventions was poorly described and none of the studies was able to demonstrate long term benefits. Very few studies were carried out on children or included segmental vitiligo. No trials evaluating micropigmentation, melanocyte transplantation, depigmentation or cosmetic camouflage could be found. Despite the fact that the main impact of vitiligo is psychosocial only one study on psychological therapy was found and it is awaiting assessment. AUTHORS' CONCLUSIONS: This review has found some evidence to support existing therapies for vitiligo, but the different designs and outcome measurements, lack of quality of life measures and adverse effect reporting in the studies limit the usefulness of their findings. There is a pressing need for high quality randomised trials using standardised measures of repigmentation and which address relevant clinical outcomes including quality of life.

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Int J Dermatol. 2006 Jan;45(1):63-5.
Treatment of vitiligo with broadband ultraviolet B and vitamins.
Don P, Iuga A, Dacko A, Hardick K.
Department of Dermatology, Metropolitan Hospital Campus of New York Medical College, NY, USA.

BACKGROUND: While oral psoralen plus ultraviolet A (PUVA) remains the most popular therapeutic modality for vitiligo, recent reports have shown that narrowband ultraviolet B (UVB) also induces significant repigmentation. In this study we evaluated the efficacy of broadband UVB on actively spreading, progressive vitiligo in patients who had been followed for many months (12 or more) in our practice, who continued to depigment despite treatment. METHODS: Nine patients with actively spreading vitiligo were exposed to broadband UVB 2-3 times per week at a starting dose of 20-30 mJ/cm(2). Radiation was increased by 10-20 mJ/cm(2) per session with adjustments for symptomatic erythema or missed visits. In addition, patients took vitamin C 500 mg twice a day (BID), vitamin B(12) 1000 microg BID and folic acid 5 mg BID. The response to treatment and side-effects were assessed at each visit. The patient's response to treatment and progress were assessed by photographs and by physician evaluation of body surface area (BSA) (using the Rule of 9s) involved at monthly intervals. Photographs were taken and estimations of BSA by physical examination made at the start and finish of the trial and then compared by the physicians involved in the study. RESULTS: Broadband UVB halted the progression of vitiligo in all nine patients and in general induced repigmentation early after 8-12 treatments (6-8 weeks). After 2-8 months of treatment, nine of nine patients achieved good (51-75%) or excellent response (76-100%). The percentage of repigmentation varied with length of treatment and anatomic site. CONCLUSIONS: This study confirms the only published report that broadband UVB is effective on actively spreading vitiligo. Since it is more cost effective than narrowband UVB and has numerous advantages compared to oral PUVA, broadband UVB may offer an alternative for future treatment of vitiligo. The role of vitamins in this therapy remains to be determined.

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Indian J Dermatol Venereol Leprol. 2005 Nov-Dec;71(6):393-7.
A study of autologous melanocyte transfer in treatment of stable vitiligo.
Pandya V, Parmar KS, Shah BJ, Bilimoria FE.
Department of Dermatology, Civil Hospital and BJ Medical College, Ahmedabad, India. vbpandya@rediffmail.com

BACKGROUND: Replenishing melanocytes selectively in vitiliginous macules by autologous melanocytes is a promising treatment. With expertise in culturing melanocytes, it has now become possible to treat larger recipient areas with smaller skin samples. AIM: To study the extent of repigmentation after autologous melanocyte transplantation in patients with stable vitiligo. METHODS: The melanocytes were harvested as an autologous melanocyte rich cell suspension from a donor split thickness graft. Melanocyte culture was performed in selected cases where the melanocyte cell count was insufficient to meet the requirement of the recipient area. These cells were then transplanted to the recipient area that had been superficially dermabraded. RESULTS: An excellent response was seen in 52.17% cases with the autologous melanocyte rich cell suspension (AMRCS) technique and in 50% with the melanocyte culture (MC) technique. CONCLUSION: Autologous melanocyte transplantation can be an effective form of surgical treatment in stable but recalcitrant lesions of vitiligo.

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J Autoimmune Dis. 2005 Nov 22;2(1):11 [Epub ahead of print]
Phenytoin as a novel anti-vitiligo weapon.
Namazi MR.

Vitiligo is a psychologically devastating clinical conundrum which affects approximately 1% of the general population. The exact cause of the illness is an enigma, but several hypotheses about its pathogenesis are advanced. The autoimmune hypothesis proposes an autoimmune attack against melanocytes. Although anti-melanocyte autoantibodies have been demonstrated in vitiligo, recent research casts doubt on their pathogenic role and instead supports the involvement of cell-mediated autoimmune response in the pathobiology of this disorder, which is characterized by increase of suppressor T-cells and decrease of the helper/suppressor ratio in association with the presence of type-1 cytokine secreting cytotoxic T cells in the vicinity of disappearing melanocytes, The neural hypothesis proposes that increased release of norepinephrine, a melanocytotoxin, from the autonomic nerve endings in the microenvironment of melanocytes injures these cells. Moreover, norepinephrine induces the catecholamine degrading enzyme monoamine oxidase (MAO), which favors the formation of toxic levels of hydrogen peroxide in the vicinity of melanocytes. Another theory suggests that abnormal permeability of melanosome membrane, which normally prevents the diffusion of toxic melanin precursors into the cytoplasm, may cause melanocyte damage. Phenytoin, the widely-used anticonvulsant, has been employed both topically and systemically in the treatment of some dermatological disorders. The drug has been shown to significantly suppress mitogen-induced activation of lymphocytes and cytotoxic T lymphocyte activity and to polarize the immune response toward the type-2 pathway. It also significantly decreases suppressor T cells and increases the helper/suppressor ratio. At high concentrations, the drug inhibits the release of norepinephrine and the activity of MAO. Moreover, phenytoin is suggested to interact with membrane lipids, which may promote stabilization of the membranes. The hydantoin moiety of phenytoin exerts a direct stimulatory action on melanocytes; facial hyperpigmentation is a recognized side effect of orally administered phenytoin. Altogether, the above evidence suggests that phenytoin could be therapeutically effective against vitiligo. As phenytoin stimulates collagen production and inhibits its breakdown, its concomitant use with topical steroids could prevent steroid-induced skin atrophy while potentiating the anti-vitiligo effect of these agents.

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J Dtsch Dermatol Ges. 2005 Nov;3(11):874-82.
[New and established indications for phototherapy with narrowband UVB]
[Article in German]
Berneburg M, Brod C, Benedix F, Rocken M.
Universitats-Hautklinik, Eberhard-Karls-Universitat Tubingen, Liebermeisterstrasse 25, D-72076 Tubingen, Germany. Mark.Berneburg@med.uni-tuebingen.de

Phototherapy with ultraviolet (UV) irradiation of wavelengths between 280 and 320 nm (UV-B) is a safe and effective treatment for a variety of inflammatory skin diseases. In addition to standard broad band UVB, narrow band phototherapy with fluorescent bulbs emitting near monochromatic UV between 310-315 nm has become an important treatment for diseases such as psoriasis, atopic dermatitis or vitiligo. Other diseases respond favorably to narrow band UV-B phototherapy, the number of potential indications for such phototherapy is continuously growing. The differential effects of narrow band UV-B phototherapy in comparison to other UV phototherapies, as well as new and established indications for this treatment modality are reviewed.

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Int J Dermatol. 2005 Oct;44(10):841-5.
Long-term follow-up study of 142 patients with vitiligo vulgaris treated by autologous, non-cultured melanocyte-keratinocyte cell transplantation.
Mulekar SV.
Noble Clinic: Pune - India. dr_mulekar@vsnl.com

BACKGROUND: Vitiligo vulgaris patients are difficult to treat surgically owing to large area involvement. Larger areas can be treated with the help of in vitro cultured melanocytes. These techniques are complex. In most of the studies published to date the number of patients reported is low and follow-up period short. OBJECTIVE: To evaluate long-term efficacy and safety of melanocyte-keratinocyte cell transplantation in large number of vitiligo vulgaris patients. METHODS: A simpler and modified method based on that of Olsson and Juhlin has been used. It uses shave biopsy skin sample up to 1/10th the size of recipient area. Skin sample is incubated, cells mechanically separated using trypsin-EDTA solution, and then centrifuged to prepare a suspension. Cell suspension is then applied to a dermabraded de-pigmented skin area and collagen dressing given to keep it in place. RESULTS: One hundred and forty-two patients with vitiligo vulgaris were treated and observed for a period up to 6 years. Eighty (56%) patients showed excellent, 15 (11%) showed good, 13 (9%) showed fair and 34 (24%) showed poor repigmentation, which was retained till the end of the respective follow-up period.

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Dermatol Surg. 2005 Oct;31(10):1277-84.
Surgical approaches for stable vitiligo.
Falabella R.
Department of Dermatology, Universidad del Valle, Hospital Universitario del Valle, Centro Medico Imbanaco, Carrera 38A, No. 5A-100, Cali, Colombia. rafalabe@emcali.net.co

BACKGROUND: Vitiligo therapy is difficult. Depending on its clinical presentation, unilateral or bilateral vitiligo lesions respond well with different repigmentation rates, according to age, affected anatomic area, extension of lesions, time at onset, timing of depigmentation spread, and other associated factors. When stable and refractory to medical treatment, vitiligo lesions may be treated by implanting pigment cells on depigmented areas. OBJECTIVE: To describe the main events of depigmentation and the fundamentals of surgical techniques for repigmenting vitiligo by implanting noncultured cellular or tissue grafts, in vitro cultured epidermis-bearing pigment cells, or melanocyte suspensions. METHODS: A description of the available techniques for repigmentation of vitiligo is done, emphasizing the most important details of each procedure to obtain the best repigmentation and minimize side effects. RESULTS: With most of these techniques, adequate repigmentation is obtained, although there are limitations when applying some methods to clinical practice. CONCLUSIONS: Restoration of pigmentation may be accomplished with all available surgical procedures in most anatomic locations, but they are of little value for acral areas. Unilateral vitiligo responds well in a high proportion of patients, and bilateral disease may also respond when stable. Appropriate patient selection is important to achieve the best results.

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Int J Dermatol. 2005 Sep;44(9):736-42.
Narrow-band UVB vs. broad-band UVB therapy in combination with topical calcipotriol vs. placebo in vitiligo.
Hartmann A, Lurz C, Hamm H, Brocker EB, Hofmann UB.
>From the Department of Dermatology, University of Wurzburg, Germany.

Background Recently, it has been shown that UVB phototherapy may be more effective than UVA in the treatment of vitiligo. Currently, however, no studies have compared the efficacy of UVB(311 nm) and broad-band UVB therapy. Calcipotriol has recently been reported to be effective adjunctive treatment for vitiligo, enhancing the efficacy of 8-methoxypsoralen plus UVA (PUVA) therapy. Methods Ten patients were enrolled in the study; nine completed the 12 months of therapy. The upper part of the body was treated twice weekly with UVB(311 nm) and the lower part with broad-band UVB. Calcipotriol was applied onto the vitiligo lesions of the right side of the body and placebo on the left side. Repigmentation was documented by photography, planimetry, and Vitiligo Disease Activity (VIDA) score. The quality of life was measured by the Dermatology Life Quality Index (DLQI). Results After 7-16 weeks, six of the nine patients showed initial repigmentation on the side treated with UVB(311 nm). After 6 months of treatment, none of the patients showed repigmentation on the areas treated with broad-band UVB, which prompted us to apply UVB(311 nm) all over the body. At the end of 12 months, two patients showed > 75% repigmentation, two showed 51-75%, two showed 26-50%, and three showed 0-25%. In all patients with progressive vitiligo (seven of the nine patients), disease activity was stopped. Remarkably, vitiligo lesions treated with calcipotriol initially showed delayed repigmentation compared with control areas; however, there was no therapeutic difference between calcipotriol and placebo, both in combination with UVB(311 nm), by the end of the study. The DLQI score improved significantly by an average of 28%. Conclusion UVB(311 nm) therapy was effective in the treatment of vitiligo, whereas broad-band UVB had no effect. Combination with calcipotriol ointment was not superior to UVB(311 nm) monotherapy. The quality of life significantly improved with narrow-band UVB(311 nm) phototherapy.

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Dermatol Surg. 2005 Aug;31(8 Pt 1):928-31; discussion 931.
Micropigmentation: tattooing for medical purposes.
Garg G, Thami GP.
Department of Dermatology and Venerology, Government Medical College and Hospital, Chandigarh, India.

BACKGROUND: Micropigmentation, also known widely as tattooing, is being commonly used esthetically to camouflage various medical conditions related to dermatology and plastic surgery. OBJECTIVE: The aim was to review the procedure of tattooing and its various latest medical indications. METHODS: Peer review of the literature on micropigmentation through a MEDLINE search was done to enumerate its various medical indications. RESULTS: The literature review revealed widespread acceptance of micropigmentation for a spectrum of diseases of cosmetic importance, especially in mucosal vitiligo. Micropigmentation is also being used for various medical indications, such as burn scars, alopecia areata, and nipple-areola reconstruction. CONCLUSIONS: The procedure is relatively easy, provides permanent camouflage, and is generally devoid of any significant adverse effects. However, a number of infections can be transmitted from one patient to another if the universal precautions for sterilization of instruments used for micropigmentation are not adhered to.

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Clin Dermatol. 2005 Jul-Aug;23(4):424-9.
Autografts and cultured epidermis in the treatment of vitiligo.
Pianigiani E, Andreassi A, Andreassi L.
Department of Dermatologic Sciences, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy.

Skin transplants can be a useful and efficacious method to treat vitiligo. The aim is to repopulate areas lacking melanocytes with functional cells taken from normally pigmented areas. Several procedures have been devised and tested: some consist in the simple transfer of epidermis sampled and implanted as is, whereas others are based on the transplantation of disaggregated and manipulated cells. The therapeutic success of the former methods is partly determined by the ability and experience of the surgeon performing the operation, whereas the results of the latter methods mainly depend on the laboratory facilities and abilities of the personnel who manipulate the cells to be transplanted. The transplantation of cultured cells is the most fascinating and promising procedure but requires the observance of still not completely predictable procedures. The use of biological material of animal origin and the use of factors to stimulate cell proliferation, such as growth factors and promoting agents, are other points that require attention.

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Br J Dermatol. 2005 Jul;153(1):163-6.
A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo.
Agarwal S, Ramam M, Sharma VK, Khandpur S, Pal H, Pandey RM.
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi 110 029, India.

BACKGROUND: A previous uncontrolled, open trial of levamisole in patients with limited and slowly spreading vitiligo had shown that new lesions did not develop in 94% of patients after 2-4 months of treatment with the drug. OBJECTIVES: To assess the efficacy of levamisole in the treatment of slowly spreading, limited vitiligo. METHODS: In a randomized double-blind trial at the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India, 60 patients with vitiligo involving < 2% of the body surface area and with slowly spreading disease (defined as one to five new lesions in the previous month or six to 15 new lesions in the previous 3 months) were randomly allocated to receive oral levamisole 150 mg or placebo on two consecutive days in a week. Children received oral levamisole 100 mg. All patients applied mometasone furoate 0.1% cream on the depigmented macules once daily. Patients were evaluated monthly for 6 months. The main outcome measure was the occurrence of new lesions, counted at each monthly visit. The secondary outcome measures comprised: (i) a dermatology-specific instrument, the Dermatology Life Quality Index or Children's Dermatology Life Quality Index questionnaires, which were completed by the patients at baseline and at every visit, and (ii) a general health questionnaire, the World Health Organization Quality of Life Brief Questionnaire, which was completed at baseline and at the end of the study. RESULTS: Forty-three patients completed 6 months of follow-up. The mean +/- SD number of new lesions that developed during the study period of 6 months was 1.9 +/- 2.0 (range 0-8) in the levamisole group and 1.8 +/- 2.0 (range 0-7) in the placebo group (P = 0.92). The proportion of patients who did not develop any further new lesions for the remainder of the study period was higher in the levamisole group at all the monthly evaluation points, although it was statistically significant (P = 0.05) only at the fourth month. Improvement in quality of life was similar in both groups. CONCLUSIONS: The study indicates that levamisole is not as effective in arresting disease progression as was observed in a previous open study. A study with a larger sample size is necessary to determine if levamisole is truly superior to placebo in this respect.

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Clin Exp Dermatol. 2005 Jul;30(4):332-6.
Narrow-band UVB for the treatment of generalized vitiligo in children.
Kanwar AJ, Dogra S.
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. ajkanwar@sify.com

Vitiligo usually begins in childhood with approximately half of the patients manifesting onset of disease prior to the age of 20 years. Treatment options in this age group are few and have disappointing response rates. This study was designed to evaluate the role of narrow-band UVB in the treatment of generalized vitiligo in children. Twenty-six children (aged 5-14 years) with generalized vitiligo (minimal extent of depigmentation of 5% of the skin) were treated three times per week with narrow-band UVB therapy for a maximum period of 1 year. Of 26 patients, 6 were lost to follow up and 20 (7 males, 13 females) completed the study. At the end of 1 year of therapy, 15 (75%) patients developed marked to complete repigmentation. Moderate and mild repigmentation was noted in four (20%) and one (5%) patients, respectively. An average number of 34 (+/- 2) treatment visits was required to achieve 50% repigmentation. Adverse events were mild and transient. Narrow-band UVB is an effective and well-tolerated treatment option for childhood vitiligo.

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Pediatr Dermatol. 2005 May-Jun;22(3):257-61.
Useful treatment of vitiligo in 10 children with UV-B narrowband (311 nm).
Brazzelli V, Prestinari F, Castello M, Bellani E, Roveda E, Barbagallo T, Borroni G.
Department of Human and Hereditary Pathology, Institute of Dermatology, University of Pavia, Policlinico S. Matteo IRCCS, Pavia, Italy. vbrazzelli@libero.it

We report our experience with UV-B narrowband (UV-B-NB) therapy in children affected by vitiligo. We studied 10 Caucasian Italian children (six boys, four girls, mean age 9.7 years +/- 2.67). Treatment mean term was 5.6 months; frequency was three times a week on nonconsecutive days or only twice a week, because of school or family duties. The percentage of repigmentation was evaluated by comparing photographs taken before, during, and after the treatment, and showed a repigmentation level higher than 75% in five patients (5/10, 50%) and between 26% and 75% in three patients (3/10, 30%). Of our patients, 80% had a satisfactory response to phototherapy. Adverse events were limited and transient. No significant relationships between repigmentation grades and variables such as skin type, positive family history, and disease extension were observed. Some areas responded better than others; the best results were shown on the face and neck. Perhaps we studied too few patients to be conclusive, but the results obtained so far seem to indicate that children affected by recent vitiligo have a better response to the therapy. We feel that UV-B-NB therapy is a valuable and safe option for the treatment of pediatric vitiligo, and should be started as soon as possible.

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Br J Dermatol. 2005 May;152(5):981-5.
Optimal weekly frequency of 308-nm excimer laser treatment in vitiligo patients.
Hofer A, Hassan AS, Legat FJ, Kerl H, Wolf P.
Department of Photodermatology, Medical University Graz, Auenbruggerplatz 8, A-8036 Graz, Austria.

Summary Background Recently the beneficial effect of excimer laser treatment has been reported for patients with vitiligo. The influence of treatment frequency on this effect is not clear. Objectives To determine the optimal frequency of 308-nm excimer laser therapy for vitiligo. Methods In this prospective, university-based hospital study over 12 weeks we enrolled 14 patients. Each had at least three stable vitiligo lesions in the same body area. The three stable vitiligo lesions in each subject were randomly assigned to receive excimer laser treatment once (1 x), twice (2 x) and three times (3 x) weekly, respectively. The initial ultraviolet (UV) dose was 50 mJ cm(-2) less than the 308-nm minimal erythematous dose in vitiligo skin. The UV dose was increased at each treatment session according to the erythematous response to the previous treatment. Results Thirteen subjects were treated for at least 6 weeks; seven were treated for all 12 weeks. At 6 weeks, the repigmentation rates for treated lesions were 8% (1/13) after 1 x weekly treatment, 23% (3/13) after 2 x weekly treatment and 62% (8/13) after 3 x weekly treatment (P = 0.0134; 3 x vs. 1 x weekly); at 12 weeks, these rates were 46% (6/13), 62% (8/13) and 69% (9/13), respectively (P = NS; 3 x vs. 1 x weekly). Repigmentation initiation correlated with treatment number, regardless of frequency (P = NS). As shown by Kaplan-Meier analysis, repigmentation occurred earliest in the most frequently treated lesions (P = 0.0336). At 12 weeks, the projected repigmentation rates for 1 x, 2 x and 3 x weekly treatment approached each other (60%, 79% and 82%, respectively); the mean repigmentation grades (on a scale of 0-5) for 1 x, 2 x and 3 x weekly treatment were 1.7, 2.4 and 3.3, respectively (P = 0.018; 3 x vs. 1 x weekly). Laser-induced repigmentation persisted in most cases over the entire follow-up of 12 months after the end of treatment. Conclusions 308-nm excimer laser therapy is effective against vitiligo. Although repigmentation occurs fastest with 3 x weekly treatment, the ultimate repigmentation initiation seems to depend entirely on the total number of treatments, not their frequency. However, treatment periods of more than 12 weeks may be necessary to obtain a satisfactory clinical repigmentation, particularly when vitiligo lesions are treated only 1 x or 2 x compared with 3 x weekly.

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Dermatol Surg. 2005 Apr;31(4):436-41.
Comparison of Minipunch grafting versus split-skin grafting in chronic stable vitiligo.
Khandpur S, Sharma VK, Manchanda Y.
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India. shaifalikhandpur@eth.net

BACKGROUND: Minipunch grafting (MPG) and split-skin grafting (SSG) are common outpatient procedures for the surgical treatment of chronic stable vitiligo. However, there is a paucity of literature comparing the two procedures by the same group of investigators. OBJECTIVE: To compare the two techniques in patients with chronic stable localized vitiligo. METHODS: Sixty-four patients with stable vitiligo of 6 months duration were randomized into two groups to be taken up for MPG or SSG in a representative patch followed by PUVAsol therapy for 3 months. They were evaluated 3 months postoperatively for the degree of repigmentation and side effects. RESULTS: In the MPG group, 644 grafts, 2.5 mm in size, were placed on a total vitiliginous area of 521.25 cm2, whereas in the SSG group, 153 grafts covered a 1,489 cm2 recipient area. Three months postoperatively, in the first group, 15 cases (44.1%) showed very good to excellent (> 75%) repigmentation compared with 25 cases (83.3%) in group 2. Following MPG, 81 grafts (12.57%) were rejected. Cobblestoning was the main side effect, occurring in 13 cases (38.23%), and a variegated appearance was observed in 7 (20.58%) patients. The complications noted after SSG were achromic fissuring in four (13.3%) cases, graft contracture in four grafts (2.61%) in three patients, and rejection of seven grafts (4.57%) in one case; tire-pattern appearance in two patients (6.6%); milia formation in four (13.3%) patients; and depigmentation of the grafts in two (6.6%) cases. In both groups, superficial scarring was noted at the donor site in all cases, whereas hypertrophic scarring occurred in 3 (10%) patients after SSG. CONCLUSION: SSG carries a distinct advantage over MPG in producing excellent cosmetic matching over larger areas using fewer grafts, especially over the face and extremities.

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Photodermatol Photoimmunol Photomed. 2005 Apr;21(2):79-83.
No additional effect of topical calcipotriol on narrow-band UVB phototherapy in patients with generalized vitiligo.
Ada S, Sahin S, Boztepe G, Karaduman A, Kolemen F.
Department of Dermatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey. siminada@hotmail.com

BACKGROUND/PURPOSE: There is no definite cure for vitiligo; however, treatment responses with photobiological modalities are quite acceptable. Of all these, narrow-band UVB phototherapy was proposed rather recently. Calcipotriol has been shown to have stimulating activity on melanogenesis besides immunomodulatory and anti-inflammatory effects. This study was performed to determine whether adding topical calcipotriol to narrow-band UVB phototherapy enhances the efficacy of treatment. METHODS: In this prospective, single-blinded (investigator), right-left comparison clinical study, 20 patients with generalized vitiligo were enrolled. Symmetrical lesions with similar sizes, bilaterally distributed on arms, legs, hands, feet or trunk were selected as reference lesions. In addition to narrow-band UVB, totally 96 treatment sessions, received two or three times weekly, the patients were asked to apply 0.005% topical calcipotriol on the selected side of the reference lesions twice daily. Then, they were monitored at the end of every 24-session interval. RESULTS: Cosmetically acceptable repigmentation was observed in 55% (11/20) of the patients without taking calcipotriol into account. There was statistically significant better response on the side that calcipotriol was not applied at the 24th session (P < 0.05). No statistically significant difference was found between the calcipotriol-treated and non-treated sides at 48th, 72th, and 96th sessions (P > 0.05). CONCLUSION: Our data confirm that, narrow-band UVB phototherapy is effective by itself in vitiligo, and show that adding topical calcipotriol does not improve treatment outcome.

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Eur J Dermatol. 2005 Mar-Apr;15(2):88-91.
Topical 0.05% clobetasol propionate versus 1% pimecrolimus ointment in vitiligo.
Coskun B, Saral Y, Turgut D.
Firat University Faculty of Medicine, Department of Dermatology, Elazig-Turkey. basakkc@hotmail.com

Vitiligo is a common skin condition resulting from loss of normal melanin pigments in the skin which produces white patches. Topical corticosteroids are indicated for the treatment of limited areas of vitiligo. Pimecrolimus, which inhibits calcineurin, has recently been shown to be effective for the treatment of vitiligo. We performed a prospective study to evaluate the efficacy of the 0.05% clobetasol propionate and 1% pimecrolimus in the treatment of vitiligo. Ten patients with virtually bilateral symmetrical lesions of vitiligo were included. 0.05% clobetasol propionate was applied twice daily over the lesion on right side of the body, and topical 1% pimecrolimus was applied twice daily over the lesion on left side of the body. It was determined that both treatment modalities resulted in a comparable rate of repigmentation. Response to treatment was varied according to the anatomical location of the lesions where better results were seen on the trunk and extremities. Results from this pilot study indicate that topical 1% pimecrolimus is as effective as clobetasol propionate in restoring skin disfiguring due to vitiligo. For a better conclusive statement further studies involving larger groups of patients should be performed.

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Drugs. 2005;65(4):447-59.
New treatment modalities for vitiligo: focus on topical immunomodulators.
Kostovic K, Pasic A.
Department of Dermatology and Venerology, Zagreb University Hospital Center, Salata 4, Zagreb, HR-100000, Croatia. kreso.kostovic@zg.htnet.hr

The development of effective treatment modalities for vitiligo is dependent on an understanding of the events leading to depigmentation. However, the exact pathogenesis of vitiligo is still mostly unknown. Abnormalities in both humoral and cell-mediated immunity have been documented in vitiligo patients and they present a basis for using immunomodulating agents, such as corticosteroids and macrolide immunomodulators, in the treatment of vitiligo. Macrolide immunomodulators, such as tacrolimus and pimecrolimus, which can be used topically, are known as topical immunomodulators (TIMs). TIMs inhibit the action of calcineurin, and consequently inhibit T-cell activation and the production of various cytokines; this is considered the working mechanism of action of TIMs in vitiligo. Several small studies and case reports on the use of TIMs in vitiligo have been published so far. Tacrolimus achieves better results on the face and neck than on other body areas.Particular advantages of TIMs are safety in treating these areas because of lack of skin atrophy and good tolerability. The incidence of application site adverse events in vitiligo seems to be lower than in the treatment of atopic dermatitis. On the face and neck, TIMs may become a useful tool in the treatment of adults and children with vitiligo despite possibly lower efficacy than topical corticosteroids. Further, larger, controlled clinical studies are warranted to determine the definite role of TIMs as monotherapy or in combination with other modalities in the treatment of vitiligo.

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Skin Pharmacol Physiol. 2005 Jan-Feb;18(1):3-11.
Safety and efficacy of fluticasone propionate in the topical treatment of skin diseases.
Roeder A, Schaller M, Schafer-Korting M, Korting HC.
Ludwig-Maximilians-Universitat Munchen, Klinik und Poliklinik fur Dermatologie und Allergologie, Frauenlobstrasse 9-11, DE-80337 Munich, Germany. Alexander.Roeder@lrz.uni-muenchen.de

Fluticasone propionate - the first carbothioate corticosteroid - has been classified as a potent anti-inflammatory drug for dermatological use. It is available as 0.05% cream and 0.005% ointment formulations for the acute and maintenance treatment of patients with dermatological disorders such as atopic dermatitis, psoriasis and vitiligo. This glucocorticoid is characterized by high lipophilicity, high glucocorticoid receptor binding and activation, and a rapid metabolic turnover in skin. Although skin blanching following fluticasone propionate exceeds that of corticosteroids of medium strength, several clinical trials demonstrate a low potential for cutaneous and systemic side-effects, even in difficult-to-treat areas like the face, the eyelids and intertriginous areas. Even among paediatric patients with atopic dermatitis, fluticasone propionate proved to be safe and effective. These pharmacological and clinical properties are reflected by the high therapeutic index of this glucocorticoid. Copyright 2005 S. Karger AG, Basel.

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Int J Dermatol. 2005 Jan;44(1):57-60.
Narrow-band UVB for the treatment of vitiligo: an emerging effective and well-tolerated therapy.
Kanwar AJ, Dogra S, Parsad D, Kumar B.
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. sundogra@hotmail.com

BACKGROUND: Vitiligo is an acquired depigmentation disorder of great cosmetic importance, affecting 1% of the general population. Photochemotherapy is the most commonly used treatment modality in extensive vitiligo, but is associated with many short- and long-term side-effects. Recently, narrow-band ultraviolet B (NBUVB) therapy has been reported to be an effective and safe therapeutic option in patients with vitiligo. We studied the efficacy and safety of NBUVB (311 nm) therapy in Indian patients with generalized vitiligo. METHODS: Fourteen patients (six males and eight females), aged 12-56 years, with generalized vitiligo, were treated thrice weekly with NBUVB radiation therapy for a maximum period of 1 year. RESULTS: At the end of 1 year, 10 patients (71.4%) had marked to complete repigmentation and two each (14.3%) had moderate or mild repigmentation. Repigmentation sites showed an excellent color match. The response to therapy was correlated with the sites of involvement, duration of disease, and compliance to therapy. Adverse events were limited and transient. CONCLUSION: NBUVB therapy is effective and safe in Indian patients with vitiligo. Long-term follow up is required, however, to establish the stability of repigmentation.

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J Eur Acad Dermatol Venereol. 2005 Jan;19(1):56-60.
Quality of life in vitiligo patients after treatment with long-term narrowband ultraviolet B phototherapy.
Tjioe M, Otero M, van de Kerkhof P, Gerritsen M.
Department of Dermatology, University Medical Centre St Radboud, Nijmegen, the Netherlands.

ABSTRACT Long-term treatments for chronic diseases such as vitiligo need to be evaluated for their clinical efficacy. Assessment of the quality of life (QOL), however, may provide the most relevant information on the actual benefit for these patients. In this study we evaluated QOL after long-term narrowband ultraviolet (UV) B for the treatment of vitiligo. All patients, with long-term stable vitiligo vulgaris, who were treated at our clinic during the last 4 years received specifically for this study a designed QOL questionnaire, which included questions about general well-being, camouflage and psychosocial aspects; 71.4% of the patients responded. Most patients indicated an improvement on a psychological level, but an increase in camouflaging. The present study shows that, after long-term narrowband UVB phototherapy, skin appearance does not play a major role in the life of vitiligo patients, while well being only improved in a minority of patients.

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Int J Clin Pharmacol Res. 2004;24(1):11-4.
Calcipotriol in the treatment of childhood vitiligo.
Gargoom AM, Duweb GA, Elzorghany AH, Benghazil M, Bugrein OO.
Dermatology Department, Jamahiriya Hospital, Benghazi, Libya.

Eighteen patients with a clinical diagnosis of vitiligo, aged between three and 12 years (mean 8.9 years), were enrolled in this study in order to evaluate the efficacy and tolerability of topical calcipotriol in the treatment of childhood vitiligo. Six patients (33.3%) were males and 12 were females (66.7%). Fourteen patients (77.8) had focal vitiligo, two (11.1%) had mucosal vitiligo and two (11.1%) had segmental vitiligo. The face was involved in 11 patients (61.1%). The treatment was applied twice daily as 50 microg/gm cream in nine patients and as ointment in the remaining patients. Treatment assessment was carried out clinically at 2 weeks, and then monthly for 4-6 months. Four patients (28.6%) were excluded from the study (one due to irritation and three due to lost contact in follow-up). Fourteen patients (71.4%) completed the treatment course (> 3 months). Of the treated patients, ten (77.8%) showed improvement and four patients (22.2%) had no response. Among responders, three patients (21.4%) showed complete resolution, four (28.6%) showed 50%-80% improvement and three patients (21.4%) showed 30% to < 50% improvement. Only one patient (5.5%) developed irritation. In conclusion, calcipotriol is an effective treatment in vitiligo. Better results are obtained with ointment than with cream. Calcipotriol can be helpful in children in whom potent steroids and PUVA are not advisable.

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J Am Acad Dermatol. 2004 Nov;51(5):760-6.
Tacrolimus ointment promotes repigmentation of vitiligo in children: a review of 57 cases.
Silverberg NB, Lin P, Travis L, Farley-Li J, Mancini AJ, Wagner AM, Chamlin SL, Paller AS.
Department of Dermatology, Division of Pediatric Dermatology, St Luke's-Roosevelt Hospital Center, New York, NY, USA.

BACKGROUND: Vitiligo is an autoimmune disorder characterized by loss of pigmentation. Phototherapy and application of topical corticosteroids are most commonly prescribed. However, these therapies are often not effective and use of corticosteroids on the face may lead to cutaneous atrophy, telangiectasia, and ocular complications. OBJECTIVE: We sought to assess the efficacy of topical tacrolimus ointment in the treatment of pediatric vitiligo. METHODS: A retrospective review was performed of 57 pediatric patients with vitiligo at two clinical sites. Patients were treated with tacrolimus ointment for at least 3 months. Clinical responses were documented during clinic visits, and by pretacrolimus and posttacrolimus photography. RESULTS: At least partial response was noted to tacrolimus ointment on the head and neck in 89%, and on the trunk and extremities in 63% of patients. Facial vitiligo of the segmental type showed the best response rate. Two patients initially experienced burning on application. CONCLUSIONS: Topical tacrolimus ointment is an effective alternative therapy for childhood vitiligo, particularly involving the head and neck.

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Photodermatol Photoimmunol Photomed. 2004 Oct;20(5):248-51.
Topical calcipotriene and narrowband ultraviolet B in the treatment of vitiligo.
Kullavanijaya P, Lim HW.
Department of Dermatology, Henry Ford Hospital, 2999 West Grand Boulevard, Detroit, MI 48202, USA.

BACKGROUND: Treatment of vitiligo, despite significant advances made in the past few years, remains to be a challenge. Narrowband ultraviolet (NB-UVB) has emerged as an important therapeutic option for this condition. OBJECTIVE: To evaluate whether the combination of calcipotriene ointment and NB-UVB could enhance the efficacy of NB-UVB alone. METHODS: An open, bilateral comparison study was performed in 20 patients with symmetrical vitiligo between August 2001 and October 2002. All patients received NB-UVB three times per week. Calcipotriene ointment was applied to lesions on the left side of the body. Response was graded visually as significant (66-100% repigmentation), moderate (26-65%), mild (10-25%), and minimal (< 10%). RESULTS: Seventeen patients (six females, 11 males) completed the study. Eight patients (8/17=47%) had significant repigmentation after 67-180 treatments, six patients (35%), one patient (6%), and two patients (12%) had moderate, mild, and minimal repigmentation after 40-160, 57, and 14-21 treatments, respectively. Nine of the 17 patients had an appreciably better improvement on the NB-UVB and calcipotriene side by 29-114 treatments. In six of these patients, differences were still observed at the end of the study period. No side effects were noted. CONCLUSION: Combination therapy of topical calcipotriene and NB-UVB is a therapeutic option that could be considered in the management of patients with vitiligo.

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Arch Dermatol. 2004 Oct;140(10):1211-5.
Long-term follow-up study of segmental and focal vitiligo treated by autologous, noncultured melanocyte-keratinocyte cell transplantation.
Mulekar SV.
Noble Clinic, Pune, India. dr_mulekar@vsnl.com

OBJECTIVE: To evaluate long-term efficacy and safety of melanocyte-keratinocyte cell transplantation in the management of segmental and focal vitiligo. DESIGN: A simpler and modified method based on that of Olsson and Juhlin was performed. This method uses a shaved biopsy skin sample up to one tenth the size of the recipient area. The skin sample is incubated, and the cells are mechanically separated using trypsin-EDTA solution and then centrifuged to prepare a suspension. Cell suspension is then applied to the dermabraded depigmented skin area, and a collagen dressing is applied to keep it in place. PATIENTS: Fifty patients with segmental and 17 with focal vitiligo were treated. One patient with segmental and 2 with focal vitiligo did not attend any follow-up visits. The remaining patients were observed for a period of up to 5 years. INTERVENTION: Autologous, noncultured melanocyte-keratinocyte cell transplantation. MAIN OUTCOME MEASURE: Repigmentation was graded as excellent with 95% to 100% pigmentation, good with 65% to 94%, fair with 25% to 64%, and poor with 0% to 24% of the treated area. RESULTS: In the segmental vitiligo group, 41 patients (84%) showed excellent, 3 (6%) good, and 5 (10%) poor pigmentation, which was retained until the end of the respective follow-up period. In the focal vitiligo group, 11 patients (73%) showed excellent, 1 (7%) fair, and 3 (20%) poor pigmentation, which was retained until the end of the respective follow-up period. CONCLUSIONS: Melanocyte-keratinocyte cell transplantation is a simple, safe, and effective surgical therapy. Patients with segmental and focal vitiligo can experience a prolonged disease-free period, which may extend through the rest of their lives.

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Arch Dermatol. 2004 Oct;140(10):1203-8.
Double-blind placebo-controlled study of autologous transplanted epidermal cell suspensions for repigmenting vitiligo.
van Geel N, Ongenae K, De Mil M, Haeghen YV, Vervaet C, Naeyaert JM.
Department of Dermatology, Ghent University Hospital, 9000 Ghent, Belgium.

OBJECTIVES: To investigate the efficacy of epidermal noncultured cellular grafting in patients with vitiligo and the role of postinflammatory, spontaneous, or UV-induced pigmentation in obtaining repigmentation. DESIGN: A prospective, randomized, double-blind, placebo-controlled study. SETTING: Ambulatory patients in an institutional practice. Patients were followed up for 3 to 12 months. PATIENTS: A total of 33 paired, symmetrically distributed leukodermic lesions, all resistant to therapy, were observed in 28 patients. Nineteen patients appeared to have a stable vitiligo (group 1), whereas there was doubt about the stability of the disease in 9 patients (group 2). INTERVENTION: After laser ablation, a hyaluronic acid-enriched cellular graft was applied to 1 lesion while the paired lesion received placebo. Three weeks later all lesions were exposed to UV irradiation twice per week for approximately 2 months. MAIN OUTCOME MEASURES: Primarily, the percentage of repigmentation was assessed after 3, 6, and 12 months using a digital image analysis system. The repigmentation pattern was also evaluated after 1 and 3 months. RESULTS: A strongly significant difference between cellular grafts and placebo was observed after 3, 6, and 12 months (P<.001, P = .002, and P = .002, respectively). In group 1, repigmentation of at least 70% of the treated area was achieved in 55%, 57%, and 77% of the actively treated lesions 3, 6, and 12 months after treatment, whereas in group 2 repigmentation of at least 70% of the treated area was not observed at any time point. The repigmentation pattern was diffuse in 94% of the responding patients. CONCLUSIONS: After a strict preoperative selection for disease stability, transplantation resulted in repigmentation of at least 70% of the treated area in most actively treated vitiligo lesions. Repigmentation was primarily caused by the transplanted melanocytes.

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Arch Dermatol. 2004 Sep;140(9):1065-9.
Topical tacrolimus and the 308-nm excimer laser: a synergistic combination for the treatment of vitiligo.
Passeron T, Ostovari N, Zakaria W, Fontas E, Larrouy JC, Lacour JP, Ortonne JP.
Department of Dermatology, Hopital de l'Archet 2, Nice, France. t.passeron@free.fr

OBJECTIVE: To compare the efficacy of combined tacrolimus and 308-nm excimer laser therapy vs 308-nm excimer laser monotherapy in treating vitiligo. DESIGN: Comparative, prospective, randomized, intraindividual study. PATIENTS: Fourteen patients, aged 12 to 63 years, with Fitzpatrick skin types II to IV. INTERVENTION: For each patient, 4 to 10 target lesions were chosen. The treatment applied to each target lesion was randomized by drawing lots. Each lesion was treated twice a week by the 308-nm excimer laser, for a total of 24 sessions. Initial fluences were 12 mcal/cm(2) (50 mJ/cm(2)) less than the minimal erythemal dose in vitiliginous skin. Then, fluences were increased by 12 mcal/cm(2) every second session. Moreover, topical 0.1% tacrolimus ointment was applied twice daily on target lesions receiving the combined tacrolimus and excimer laser treatment (group A). Group B target lesions received only excimer laser monotherapy. For each treated lesion, the untreated lesion on the opposite side served as the control. Tolerance was evaluated by a visual analog scale, and secondary events were recorded at each session. MAIN OUTCOME MEASURE: Treatment efficacy, which was blindly evaluated by 2 independent physicians by direct and polarized light photographs taken before and after treatment. RESULTS: Forty-three lesions were treated (23 in group A and 20 in group B). All patients completed the study. Repigmentation was observed in all group A lesions (100%) and in 17 (85%) of the 20 group B lesions. Repigmentation was not observed in the untreated lesions (control group). A repigmentation rate of 75% or more was obtained in 16 (70%) of the 23 group A lesions and in 4 (20%) of the 20 group B lesions. In UV-sensitive areas (the face, neck, trunk, and limbs, with the exception of bony prominences and extremities), 10 (77%) of 13 group A lesions had a repigmentation rate of 75% or more vs 4 (57%) of 7 group B lesions. In classically UV-resistant areas, 6 (60%) of 10 group A lesions had a repigmentation rate of 75% or more vs 0 of the 13 group B lesions. The mean number of sessions necessary for an improvement of repigmentation was 10 in group A and 12 in group B. Adverse effects have been limited, and tolerance was excellent. CONCLUSIONS: The combination treatment of 0.1% tacrolimus ointment plus the 308-nm excimer laser is superior to 308-nm excimer laser monotherapy for the treatment of UV-resistant vitiliginous lesions (P<.002). The efficacy and the good tolerance of the 308-nm excimer laser in monotherapy for treating localized vitiligo were also confirmed, but this treatment regimen should be proposed only for UV-sensitive areas.

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Lasers Surg Med. 2004;35(2):152-6.
Treatment of vitiligo by 308-nm excimer laser: an evaluation of variables affecting treatment response.
Ostovari N, Passeron T, Zakaria W, Fontas E, Larouy JC, Blot JF, Lacour JP, Ortonne JP.
Department of Dermatology, Hopital de l'Archet 2, Nice, France.

BACKGROUND AND OBJECTIVES: To determine the true efficacy of the 308-nm excimer laser for the treatment of vitiligo, while taking into account confounding factors such as anatomic site of treatment, age, sex, skin type, MED, and duration of evolution of the vitiligo. STUDY DESIGN/MATERIALS AND METHODS: Thirty-five patients with vitiligo were included. Each lesion was treated twice a week by the 308-nm excimer laser for a maximum of 24 sessions. Efficacy was blindly evaluated by two independent physicians. RESULTS: Repigmentation was noted in 46 plaques/52 (88.5%). Repigmentation rate (75%) was obtained in 14 (26.9%). In "UV sensitive" areas (face, neck, trunk), 8/14 lesions (57.1%) had a repigmentation rate, 75% versus 6/38 (15.8%) in "UV resistant" areas (bony prominences and extremities) (P = 0.031). No relationship could be established between response to the treatment and the following variables: age, sex, skin type, MED, and duration of evolution of the vitiligo (respectively, P = 1, 0.666, 0.566, 0.628, 0.521). CONCLUSIONS: An aesthetically reasonable result is achieved essentially in "UV sensitive" areas, thus appearing to be the appropriate places of choice for this treatment.

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Pediatr Dermatol. 2004 Jul-Aug;21(4):495-8.  

Toxicol Appl Pharmacol. 2004 Mar 15;195(3):298-308.
Toxic effects of ultraviolet radiation on the skin.
Matsumura Y, Ananthaswamy HN.
Department of Dermatology, Kansai Medical University, Osaka 570-8507, Japan. matsumy@takii.kmu.ac.jp

Ultraviolet (UV) irradiation present in sunlight is an environmental human carcinogen. The toxic effects of UV from natural sunlight and therapeutic artificial lamps are a major concern for human health. The major acute effects of UV irradiation on normal human skin comprise sunburn inflammation (erythema), tanning, and local or systemic immunosuppression. At the molecular level, UV irradiation causes DNA damage such as cyclobutane pyrimidine dimers and (6-4) photoproducts, which are usually repaired by nucleotide excision repair (NER). Chronic exposure to UV irradiation leads to photoaging, immunosuppression, and ultimately photocarcinogenesis. Photocarcinogenesis involves the accumulation of genetic changes, as well as immune system modulation, and ultimately leads to the development of skin cancers. In the clinic, artificial lamps emitting UVB (280-320 nm) and UVA (320-400 nm) radiation in combination with chemical drugs are used in the therapy of many skin diseases including psoriasis and vitiligo. Although such therapy is beneficial, it is accompanied with undesirable side effects. Thus, UV radiation is like two sides of the same coin--on one side, it has detrimental effects, and on the other side, it has beneficial effects.

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Cutis. 2004 Mar;73(3):163-7.
The psychological aspects of vitiligo.
Silvan M.
Department of Dermatology, St. Luke's-Roosevelt Hospital Center, New York, New York 10025, USA. mes57@columbia.edu

Dermatologists are likely to be confronted with patients who present with a wide range of psychiatric issues and problems. Writers on psychocutaneous medicine have described a variety of conditions that represent the interplay between the psyche and the soma. Vitiligo is one such disease and will be the focus of this article. Specifically, 3 areas will be examined: (1) the psychological impact vitiligo has on patients, (2) how psychological factors contribute to the etiology and course of the illness, and (3) the benefits of offering adjunctive psychological treatment. By exploring these aspects of vitiligo in more detail, I hope to illustrate the profound importance psychological factors play in this disease and the value of incorporating a psychological approach in its treatment.

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Clin Exp Dermatol. 2004 Mar;29(2):180-4.
Treatment of vitiligo with local khellin and UVA: comparison with systemic PUVA.
Valkova S, Trashlieva M, Christova P.
Department of Dermatology and Venereology, Department of Public Health, Medical University, Pleven, Bulgaria.

Vitiligo is an idiopathic leukoderma often with a progressive course causing destruction of melanocytes. The best methods for achieving cosmetically acceptable re-pigmentation of affected skin appear to be both local and systemic PUVA. They may, however, cause serious side effects, which is an argument for conducting research into new, equally effective photo-chemotherapeutic agents. One of these agents is khellin. We conducted a pilot study in 33 patients to evaluate the effectiveness of local KUVA and systemic PUVA therapy for vitiligo and to compare them in terms of the degree of re-pigmentation, duration of treatment, number of procedures, total UVA dose and side effects. Local KUVA required longer duration of treatment and higher UVA doses. KUVA-induced re-pigmentation depended on the age of the patients (r = -0.61, P = 0.001), and better results were achieved with younger individuals [% re-pigmentation = 81.76 - (1.48 x age in years)]. No side effects were observed in cases of local KUVA treatment. Erythema, itching and gastro-intestinal disturbances occurred with some patients treated with PUVA. The results demonstrate that local KUVA may effectively induce re-pigmentation of vitiligo-affected skin areas to a degree comparable to that achieved when using systemic PUVA, provided that treatment duration is long enough.

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Clin Exp Dermatol. 2004 Mar;29(2):133-7.
Treatment of vitiligo with the 308 nm excimer laser.
Esposito M, Soda R, Costanzo A, Chimenti S.
Department of Dermatology, University of Rome 'Tor Vergata', Italy.

Several therapeutic modalities have been proposed for the treatment of vitiligo either to achive repigmentation in the lesions or to stabilize the disease. Narrow-band UVB therapy has been shown to be effective and safe for use in the management of vitiligo; its wavelength is not so different from 308 nm XeCl excimer laser radiation. We present an open and uncontrolled pilot study of 24 patients (12 men, 12 women) in whom vitiligous patches were treated twice a week, for 9 months with 308 nm XeCl laser radiation. Seven of the 24 patients showed greater than 75% repigmentation, six patients showed repigmentation of between 25 and 75% and six patients showed less than 25% repigmentation. In five patients no signs of repigmentation were noted. The therapeutic benefit was stable during the 12-month follow-up period. Although these results are promising, treatment has so far been limited to small numbers of patients and a short follow-up period. Other prospective studies are needed to assess the efficacy of this treatment modality.

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Chin Med J (Engl). 2004 Feb;117(2):199-201.
Topical melagenine for repigmentation in twenty-two child patients with vitiligo on the scalp.
Xu AE, Wei XD.
Department of Dermatology, Third People's Hospital of Hangzhou, Hangzhou 310009, China.

BACKGROUND: The purpose of this study was to evaluate the efficacy of topical melagenine for repigmentation in child patients with vitiligo on the scalp. METHODS: Twenty-two child patients with vitiligo on the scalp were treated with 1.2 mg/ml aqueous melagenine in combination with 20 minutes of infrared exposure twice daily. RESULTS: In 4 patients (18.2%), melagenine treatment in combination with infrared exposure led to complete recovery; in 6 patients (27.3%), treatment was shown to be effective; in 8 patients (36.3%), treatment led to improvements in patient condition; and only 4 patients (18.2%) showed no response after 1 - 2 treatment sessions. The general effective rate of melagenine-infrared combination treatment was 45.5% for the children with vitiligo on the scalp, and treatment was accompanied by minimal side effects. CONCLUSION: Melagenine may be efficacious and a safe treatment option for childhood vitiligo affecting the scalp.

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Dermatol Surg. 2004 Feb;30(2):130-5.
Combined excimer laser and topical tacrolimus for the treatment of vitiligo: a pilot study.
Kawalek AZ, Spencer JM, Phelps RG.
Department of Dermatology Department of Pathology, Division of Dermatologic Surgery, Mount Sinai School of Medicine, New York, New York.

BACKGROUND. : Vitiligo is an acquired skin disorder that is characterized by well-defined, often symmetric white patches. Although current therapeutic modalities are directed toward increasing melanocyte melanin production, few treatment modalities address the immunologic nature of the disease. OBJECTIVE. : To determine whether excimer laser, a known therapeutic modality, in combination with tacrolimus, a topical immunomodulator, accelerate response time and/or improve the degree of response in patients with this disorder. METHODS. : Eight subjects diagnosed with vitiligo were recruited to participate in this institutional review board-approved double-blind, placebo-controlled study. Twenty-four symmetric vitiliginous patches (elbows, knees) from eight subjects received excimer laser treatment three times per week for 24 treatments or 10 weeks. Additionally, topical tacrolimus 0.1% ointment (Protopic) and placebo (Aquaphor) were applied to randomized patches (left or right) twice daily throughout the length of the trial. Vitiliginous patches were monitored with photographs at baseline, every 2 weeks, and 6 months after treatment. Biopsies were performed on subjects with significant results. RESULTS. : Twenty vitiliginous patches from six subjects qualified for evaluation. Fifty percent of patches treated with combination excimer laser and tacrolimus achieved a successful response (75% repigmentation) compared with 20% for the placebo group. Subjects who responded successfully repigmented faster (19%) with combination therapy compared with excimer laser alone. Additionally, three subjects experienced transient hyperpigmentation in lesions treated with combination therapy. CONCLUSION. : Combining topical immunomodulators with known phototherapeutic modalities may represent a key advancement in the treatment of disease.

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Drugs. 2004;64(1):89-107.
Hypopigmentary skin disorders: current treatment options and future directions.
Hartmann A, Brocker EB, Becker JC.
Department of Dermatology, University Hospital Wuerzburg, Wuerzburg, Germany.

Alterations of skin and hair pigmentation are important features that have warranted treatment from ancient history on up to modern time. In some cultures, even today patients with vitiligo are regarded as social outcasts and are affected considerably both emotionally and physically. This article presents current options and future directions for the treatment of hypopigmentary disorders. Whereas with congenital disorders, such as albinism and phenylketonuria, no causal therapy has been established up to now, several treatment options for acquired hypopigmentary disorders have been investigated. In particular, in vitiligo, one of the most prevalent hypopigmentary disorders, a number of treatment modalities have been employed in the past 30 years. However, most of them are only able to palliate, not cure, the disease. Depending on the distribution of the hypopigmented lesions (localised or generalised) and the state of the disease (active or stable), several therapeutic options, for example phototherapy, surgical skin grafts, autologous melanocyte transplantation and immunomodulators, can be applied alone or in combination. For phototherapy, because of unfavourable results and adverse effects, ultraviolet (UV) A has been largely replaced by narrow-band UVB for repigmentation of generalised vitiligo. Although immunomodulators, such as corticosteroids, have been used both topically and systemically over the past 3 decades for the treatment of disseminated vitiligo, they are only suitable for the treatment of acrofacial and localised forms because of adverse effects. Hence, new immunomodulatory agents, such as calcineurin antagonists, have recently been introduced as new promising tools to treat acquired hypopigmentary disorders. However, all therapeutic approaches are hampered by the fact that the pathophysiology of hypopigmentary disorders is still poorly understood.

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J Am Acad Dermatol. 2004 Jan;50(1):63-7.
Clinical study of repigmentation patterns with different treatment modalities and their correlation with speed and stability of repigmentation in 352 vitiliginous patches.
Parsad D, Pandhi R, Dogra S, Kumar B.
Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. dprs@satyam.net.in

Because the etiopathogenesis of depigmentation in vitiligo is still obscure, the source of pigmentation in the repigmentating lesion and its stability is also not fully known. Several authors have shown on histopathology and electron microscopy predominantly a perifollicular spread of pigment. The aim of this study was to clinically assess the types of repigmentation patterns obtained with different treatment modalities and their correlation with speed and stability of repigmentation. A total of 125 patients with vitiligo on treatment with psoralens (topical and systemic psoralen-UVA [PUVA]), steroids (both topical and systemic), and topical calcipotriol, alone or in combination were enrolled. Representative lesions of vitiligo excluding mucosal sites were selected in each patient and photographed at baseline. Repigmentation was assessed and labeled as marginal, perifollicular, diffuse, or combined. The preselected patches were evaluated at 3 months to assess the speed of repigmentation. Retention of pigment (stability) was noted at 6 months, after the stoppage of active treatment. Of the 352 vitiligo patches selected, 194 (55%) showed predominant perifollicular repigmentation, of which a majority (127; 65.5%) were on systemic PUVA and 35 (18%) were on topical PUVA. Diffuse pigmentation was observed in 98 patches (27.8%) of which 66 (67.3%) were on topical steroids. Marginal repigmentation was seen in 15, of which the majority (80%) were on systemic PUVA and topical calcipotriol. Of the 28 total lesions showing marked repigmentation at 3 months, 22 lesions pigmented in a diffuse manner, 2 in a perifollicular pattern, and 4 showed a combined type of repigmentation. On follow-up, marginal repigmentation was the most stable (93.3%), followed by perifollicular (91.7%) and combined type (84.4%). Diffuse repigmentation was the least stable (78.5%). Psoralens predominantly exhibit a perifollicular pattern of repigmentation and steroids (topical/systemic), a diffuse type. The speed of repigmentation is much faster when initial repigmentation is of the diffuse type as compared with follicular repigmentation. The marginal and perifollicular repigmentation is more stable than the diffuse type of repigmentation.

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Dermatol Surg. 2004 Jan;30(1):49-53.
A comparative study of punch grafting followed by topical corticosteroid versus punch grafting followed by PUVA therapy in stable vitiligo.
Barman KD, Khaitan BK, Verma KK.
Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND: Punch grafting followed by PUVA is an established therapy for stable vitiligo, but punch grafting followed by topical corticosteroid has never been evaluated. OBJECTIVE: The aim of this study was to evaluate the efficacy of topical corticosteroid in perigraft pigmentation and to compare it with perigraft pigmentation after PUVA in patients with stable vitiligo. METHODS: Fifty patients with stable vitiligo of various clinical types were subjected to punch grafting. In a randomized case study, these patients were divided into two groups: One group received post punch-grafting PUVA (group I) and the other group post punch-grafting topical application of fluocinolone acetonide 0.1% (group II). During the follow-up period of 6 months, six patients were lost to follow-up, and two patients were excluded from the study; 42 patients were evaluated for pigment spread and side effects. RESULTS: In group I, the average pigment spread was 6.38 mm, whereas in group II, it was 6.94 mm, showing a slightly higher pigment spread in group II, which was statistically not significant (P=0.301). There was no difference in response to therapy in patients having segmental vitiligo as compared with nonsegmental vitiligo. Cobblestoning, depigmentation of the grafts, infection, and graft displacement were the important side effects seen in some patients in both the groups. CONCLUSION: The study shows that the pigment spread with topical corticosteroid is comparable to that with PUVA. However, the studies with long-term follow-up are required to establish this. The advantages of topical corticosteroid are that its use is easy, less cumbersome, cheaper, and more cost effective than PUVA.

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Acta Dermatovenerol Croat. 2003;11(3):163-70.
Treatment of vitiligo: current methods and new approaches.
Kostovic K, Nola I, Bucan Z, Situm M.
Department of Dermatology and Venerology, Sisters of Mercy University Hospital, Vinogradska cesta 29, HR-10000 Zagreb, Croatia. kreso.kostovic@zg.hinet.hr

Vitiligo is an acquired idiopathic hypomelanotic disorder characterized by circumscribed depigmented maculae. It can be treated in many ways. The choice of therapy is individually adjusted depending on various factors, such as the patient age, type and stage of disease, and affected body site. Current treatment modalities include psoralen with exposure to ultraviolet A (PUVA) radiation t