Vitiligo treatments

vitiligo phototherapy: effectiveness of UVB for vitiligo treatment

American Academy of Dermatology. Study Confirms Effectiveness of Revolutionary Vitiligo Treatment SCHAUMBURG, IL (July 12, 2001) Imagine feeling perfectly healthy on the inside, but on the outside something looks wrong.

For millions of people who suffer from vitiligo, a disease in which patients experience a complete loss of pigment in localized areas of the skin, this feeling is one they know all too well. In a new study by dermatologist Henry W. Lim, MD, chairman of the department of dermatology at Henry Ford Hospital, Detroit, Mich., the effectiveness of narrow-band UVB (NB-UVB) phototherapy as treatment for vitiligo was examined in a small sampling of patients. The results of the study are promising for this often hard-to-treat skin condition. After completing an average of 19 treatments with NB-UVB phototherapy, five of the seven vitiligo patients that participated in the study showed greater than 75 percent repigmentation. Additionally, one patient has remained repigmented 11 months after phototherapy was discontinued. "The successful repigmentation that these patients experienced is quite remarkable," explained Dr. Lim, co-author of "Narrow-Band Ultraviolet B is a Useful and Well-Tolerated Treatment for Vitiligo" published in the June 2001 issue of the Journal of the American Academy of Dermatology. "Vitiligo is a difficult skin condition to treat, and patients are often frustrated because results from some of the other current treatments are not nearly as favourable."

Vitiligo is a disease in which patients have a complete loss of pigment in localized areas of the skin. These areas, often around the mouth and eyes, become completely white. As a result, vitiligo can be cosmetically disfiguring, especially for dark-skinned people. Vitiligo affects 1 percent to 2 percent of the worldwide population and about half of the people who develop it do so before the age of 20. About one fifth of those with vitiligo have a family member with this condition. Vitiligo usually affects both sides of the body, and although the cause is generally not known, it is believed to be an autoimmune process. During the twelve-month trial period, 11 patients participated in Dr. Lim s study. Therapy was administered three times a week and affected segments of the body were treated with NB-UVB, a light source that emits a very narrow spectrum of UVB, the portion of sunlight that causes sunburn. The dose of radiation was increased by 15 percent for each treatment. If mild burning, pain or blistering developed, the irradiation dose was decreased. Once the desirable 75 percent repigmentation was achieved, the frequency of treatments was tapered to twice a week for four weeks, then weekly for an additional four weeks.

NB-UVB therapy has several advantages over other therapies for vitiligo. While topical corticosteroid therapy has a success rate of 56 percent, long-term use of corticosteroids can result in thinning of the skin, stretch marks, and dilation of blood vessels. Another treatment option is oral or topical psoralen plus UVA (PUVA), the latter which has a success rate of 51 percent. However, patients need to ingest or apply psoralen before getting the light treatment, and long term use of oral PUVA for another skin disease, psoriasis, has been associated with an increased incidence of skin cancer. Presently, there are only a few centres in the United States that have the capabilities for NB-UVB therapy; therefore patients undergoing this therapy have long distances to commute. While NB-UVB therapy has been used in Europe since the mid-1980s, there has not been any evidence that it causes an increase in skin cancer

 "Our findings confirmed that narrow-band UVB therapy is a useful and well-tolerated treatment option for patients with vitiligo," says Dr. Lim of the American Academy of Dermatology. "Although more research needs to be conducted, the successes thus far are promising to those who suffer from the psychological and physical effects of vitiligo."

cortisone steroid treatment for vitiligo still dangerous

Hydrocortisone steroids once used liberally in the 1980's often cause more problems than they address. Steroids may initially help for a very short time, however they have often dangerous and longer lasting side effects such thinning of the skin, dilated blood vessels, bruising, skin colour changes and hair loss. Vitiligo often flares up much worse after discontinuing steroids. Long term use of Hydrocortisone can cause liver and kidney disease and worsen psoriasis. Large amounts of Hydrocortisone are found in the Skin Cap and Blue Cap and other "zinc" sprays, hence these products can be very dangerous. Stop using the steroids and Vitiligo usually returns many times worse than it was prior to using steroids to treat the Vitiligo.

vitamins, drugs and diets for vitiligo

There is no CLINICAL evidence that exists anywhere that proves vitamins, homeopathic or a special diet can improve, treat or cure Vitiligo. If you are interested in Vitamins or moisturising lotions, you are best to see your pharmacist or Dermatologist than waste your money on expensive and "unique" home made products found on the internet. If only it were that simple. Vitiligo has been known about for at least five thousand years and if any particular nutrient had been proved to be beneficial surely we would all have heard about it by now! If you really want to spend money on vitamins, go to your pharmacist and buy quality products, not home made "cures" on the internet.

UVB narrow band phototherapy for vitiligo

UVB narrow band phototherapy is extremely efficient Vitiligo treatment. particularly Narrow Band UVB that promotes normal skin growth patterns. You can order our home Vitiligo phototherapy treatment here; online ordering.

Advances continue in vitiligo treatment

Jul 1, 2004
By: Cheryl Guttman
Dermatology Times

Washington - Treatment of vitiligo has advanced significantly recently, although older therapies still retain an important place in the management of this therapeutically challenging disease, says pearl E. Grimes, M.D.

Speaking at the annual meeting of the American Academy of Dermatology, Dr. Grimes reviewed information about roles for topical immunomodulators, targeted light therapy, and narrowband UVB phototherapy, and discussed new information on potential risks associated with use of dihydroxyacetone-containing self-tanners and depigmentation therapy with mono-benzone cream (Benoquin).

Efficacy of the topical immunomodulator tacrolimus ointment (protopic, Fujisawa Healthcare, Inc.) as a treatment for vitiligo was first reported by Dr. Grimes several years ago, and since that time other researchers have produced corroborating evidence of its benefits as a therapeutic modality for both adults and children. In addition, preliminary data suggest that pimecrolimus (Elidel, Novartis) offers similar efficacy, says Dr. Grimes, associate clinical professor of dermatology, David Geffen School of Medicine, University of California, Los Angeles, and director, Vitiligo and pigmentation Institute of Southern California.

tacrolimus most effective

Findings from initial studies showed that tacrolimus was most effective for inducing repigmentation on sun-exposed areas of skin. Subsequently, however, it has been shown that a synergistic benefit can be achieved using concomitant narrowband UVB phototherapy to treat anatomic regions normally covered by clothing.

Results of a recently published randomized, double-blind, split-side trial by Lepe et al. (Arch Dermatol 2003; 139:651-654) enrolling 20 children with vitiligo provided an excellent illustration of the efficacy of tacrolimus and its safety advantages. In that study, tacrolimus ointment 0.1 percent was almost as effective as clobetasol propionate 0.05 percent in inducing repigmentation. However, corticosteroid use was associated with development of skin atrophy in three patients and telangiectasia in two, while the only adverse effect associated with tacrolimus was a burning sensation in two patients.

"A major advantage of tacrolimus is that it is well-tolerated when used for extended periods, although there still remains a need for even longer term safety data," Dr. Grimes says.

The main limitations of tacrolimus relate to aesthetics and economics. Recognizing that patients may dislike the greasy ointment base of tacrolimus and in an effort to minimize treatment cost, Dr. Grimes says she often uses tacrolimus in combination regimens. For example, she may recommend that patients use pimecrolimus cream in the morning and tacrolimus ointment in the evening, or she may start treatment with a high potency corticosteroid used once daily in the morning with tacrolimus applied only in the evening, switching to twice-daily tacrolimus treatment after four to six weeks.

Since the first report describing narrowband UVB as a treatment for vitiligo by Westerhof and colleagues in 1997, several other studies have demonstrated its efficacy and safety.

"Narrowband UVB has become my treatment of choice for patients with moderate to severe vitiligo, defined as having more than 15 to 20 percent body surface area involvement," Dr. Grimes says.

She reported results from her own experience using narrowband UVB to treat 95 patients. The population was 40 percent Caucasian, 35 percent Hispanic, 13 percent African American, 9 percent Asian, and 3 percent were from other ethnic groups. The mean number of treatments administered was 41, but there was a relationship between response and number of treatments received. With 15 treatments, 43 percent of patients achieved >50 percent repigmentation whereas 71 percent of patients receiving more than 50 treatments repigmented more than 50 percent.

UVB phototherapy advanced for vitiligo treatment

"We have not abandoned PUVA, but narrowband UVB has the advantages of avoiding systemic side effects and the need for ocular protection while offering an excellent safety profile for use in children. However, it does require sessions three times per week to attain the maximum efficacy that can be achieved with PUVA," Dr. Grimes says.

For patients with less extensive disease, targeted phototherapy offers a safe and effective treatment alternative. A variety of light units emitting at different wavelengths are available, although Dr. Grimes indicated the number one system in her practice is a combination UVA/UVB device (TheraLight) that allows for both targeted UVB phototherapy and targeted UVA with psoralen.

Dr. Grimes' extensive experience treating vitiligo has also led to some clinically important observations regarding existing management modalities. For example, while depigmentation therapy with monobenzone cream continues to be an important alternative for patients who have greater than 50 percent pigment loss and who have either failed various repigmentation therapies or have no desire to undergo repigmentation, use of that modality can sometimes be associated with delayed repigmentation that is refractory to retreatment.

"It seems that monobenzone knocks out melanocytes in the epidermis, but does not affect the follicular reservoir. Consequently, while these patients depigment beautifully, one to two years later, they may repigment as the follicular melanocytes become activated. Retreatment with 20 percent monobenzone is ineffective, and the pigmentation has also proven refractory to depigmentation with 40 percent monobenzone combined with chemical peels. Ultimately, treatment involves repigmentation using PUVA or narrowband UVB," Dr. Grimes says.

Although treatment for vitiligo ideally produces permanent repigmentation, cosmetic camouflage remains an integral component in management. As a new caveat, however, years of experience indicate that regular use of dihydroxyacetone-containing self-tanners may lessen the response to repigmentation therapies, and new data may support that observation.

"Dihydroxyacetone may inhibit repigmentation by increasing hydrogen peroxide and oxidative stress. ... We are now recommending that patients use cosmetics to camouflage areas of depigmentation," Dr. Grimes says.

Dr. Grimes has no financial interest in any of the modalities she mentioned

UVB spars with PUVA for tough vitiligo

Feb 1, 2004
By: Cheryl Guttman
Dermatology Times

Bangkok, Thailand - Narrow band ultraviolet B (NBUVB) phototherapy can offer a well-tolerated and effective modality for achieving repigmentation of vitiligo in Pediatric and adult Asian patients, said Natta Rajatanavin, M.D.

In a recent publication [J Am Acad Dermatol 2003;49:473-6], Dr. Rajatanavin, associate professor of medicine and head of the phototherapy unit, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, and colleagues reported their experience using NBUVB as monotherapy to treat vitiligo in a series of 60 Thai patients. The subjects in their three-year retrospective study ranged in age from 11 to 61, and all were selected for NBUVB because they had failed previous topical therapy or responded insufficiently to or could not tolerate PUVA.

"Based on our analyses, we consider NBUVB the treatment of choice for progressive, symmetrical vitiligo, particularly when lesions are present on the face, trunk, arms, and legs. Compared with PUVA, NBUVB seems to offer comparable efficacy and has the additional advantages of causing less hyperpigmentation of normal skin and avoiding hyperkeratosis of vitiliginous skin. For those reasons, the majority of our patients who had received prior PUVA indicated a preference for NBUVB," Dr. Rajatanavin said.

"However, our experience indicates that patients whose vitiligo has already failed to respond to PUVA probably represent a pre-selected group with treatment-resistant disease," she added.

Of the 60 patients included in the study, two were skin type V and the rest were skin types III (25 patients) and IV (33 patients). Vitiligo was generalized in 53 individuals and localized in seven, and the body surface area of involvement ranged from <5 percent to 50 percent. Duration of disease averaged 8.2 years and varied from six months to 22 years.

NBUVB sessions were scheduled twice a week on non-consecutive days and involved total body exposure using a standard dosing protocol that began with a 100 mJ/cm2 dose in all patients. The dose was raised incrementally thereafter and treatment was continued to achieve maximum repigmentation unless the patient was satisfied or failed to achieve 25 percent improvement after 40 to 50 sessions. Treatment duration ranged from five months to two years and patients received between 36 and 175 treatments.

Treatment response, defined as >50 percent repigmentation, was achieved in 25 (42 percent) of the 60 patients with 20 patients (33 percent) achieving >75 percent repigmentation. Five patients had no response and disease progressed in three individuals.

Analyses of factors predicting response showed that good responses were achieved in patients with symmetrical vitiligo on the face, trunk, arms, and legs.

"Lesions of the face and body responded fairly quickly with progression halting within the first 10 treatments. However, many additional exposures were needed to achieve cosmetically acceptable repigmentation," Dr. Rajatanavin said.

Lesions of the hands and feet rarely repigmented more than 25 percent. In addition, the rate of responders was significantly lower among the subgroup of patients who had previously failed PUVA relative to those who had received topical therapy only. Among 24 patients without a history of PUVA treatment, 16 (67 percent) responded compared with only nine (25 percent) of the 36 patients who had received PUVA. The proportion of patients who had received prior PUVA was 36 percent among responders and 77 percent among no responders.

Other variables examined as potential predictors of response included disease duration, patient age, gender, and skin type, but none of those features differed significantly between responders and no responders.

The dosing protocol used at Ramathibodi Hospital involved dose increases of 20 percent per treatment over the first 10 treatments followed by 10 percent increases until session 20. Thereafter, the increments per treatment were reduced to five percent, and the dose continued to be raised until 50 percent repigmentation was achieved or the patient was satisfied.

"In a limited number of other reports on NBUVB phototherapy for vitiligo, the protocols have varied with starting doses ranging anywhere between 75 and 280 J/cm2. In initiating treatment with 100 mJ/cm2, we encountered a mild phototoxic reaction, but that was restricted to persons with disease involving more than 10 percent of body surface area. Based on the safety observed in patients with less extensive disease, we now use a starting dose of 200 mJ/cm2 if the lesion is less than 10 percent of body surface area and follow our same protocol for dose increments," Dr. Rajatanavin said. The NBUVB phototherapy was generally well tolerated using that approach. No patient discontinued treatment because of adverse events, and only 10 percent of patients experienced more than mild erythema or pruritus.

Nine responders continued to be seen after treatment cessation, and during follow-up extending up to two years, vitiligo remained in remission in only five patients. Among the other four individuals, vitiligo either recurred or new lesions developed between three and 24 months after NBUVB ended. Three of those patients responded to NBUVB retreatment, although more slowly than they did during the first course.

There are several treatments for Vitiligo, but there is still no vitiligo cure.   Treatments include steroids, vitamins cosmetic creams, skin grafts and the modern treatment of choice is narrow band UVB phototherapy.

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