Carbon dioxide laser resurfacing and thin skin grafting in the treatment of "stable and recalcitrant" vitiligo

Various surgical methods have been used in the treatment of small stable vitiliginous areas, but there is no established surgical approach for larger vitiligo areas and therapy-resistant anatomic sites, such as the hands. Two years ago, we successfully treated large burn scar depigmentation areas at different anatomic sites using carbon dioxide laser resurfacing and thin (0.2 to 0.3 mm) skin grafting. The purpose of this study was to investigate the effectiveness of our method in treating large, stable, and recalcitrant vitiligo areas. Thirteen anatomic sites of seven male patients, whose ages ranged from 20 to 22 years, were treated. The locations of the treated areas were as follows: seven areas on the dorsum of the hands, two areas on the forearms, two areas in the pretibial region, one area on the lateral thigh, and one area in the presternal region. The surface area of treated vitiligo sites ranged from 0.5 to 6 percent of total body surface area (mean, 2.5 percent). Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 6 to 18 months, with an average follow-up period of 14 months. Early and complete repigmentation was achieved and the color match was good or excellent in all patients. No depigmentation occurred again in the treated areas or graft donor sites. In conclusion, with careful patient selection and delicate surgical technique, our method was effective in treating large areas of vitiligo over the extremities and dorsum of hands, which were refractory to other therapies and could not be hidden.     

Modulation of melanocytic activity by acetylcholine

Acetylcholine esterase (AChE) activity is lowered in vitiliginous skin. The AChE activity in 52 cases of vitiligo during repigmentation and depigmentation has been observed in this study. The cases with marginal dendritic melanocytes show that AChE is negative in these cells during depigmentation but positive on repigmentation. There is little variation in activity in the cases showing nondendritic marginal melanocytes. Acetylcholine (ACh) has an inhibitory effect on dopa oxidase activity in both types of marginal melanocytes in vitiligo. ACh modulates pigment production by the melanocytes, its role being inhibitory. From the present results, it is evident that a fall in AChE activity in the melanocytes leads to greater inhibition by ACh aggravating the process of depigmentation in vitiligo.     

A prospective observational study to sequentially determine the dermoscopic features of vitiligo and its association with disease activity in patients on medical treatment

Prospective data on correlation between dermoscopic features of vitiligo and disease activity are scarce. This study was conducted to sequentially determine the dermoscopic features of vitiligo and to evaluate their association with disease activity. A cohort of 30 patients with 60 active vitiligo patches on medical therapy was subjected to sequential clinical and dermoscopic examination at four weekly intervals till 16 weeks. Disease activity at each visit was assessed using serial clinical photographs and modified vitiligo activity severity index. The dermoscopic images were merged and analysed for a predefined set of dermoscopic parameters by two blinded dermatologists. Paired analysis of dermoscopic features was done between baseline, and stabilized vitiligo patches at 12 and 16 weeks. Pigment network changes (absent and reduced pigment network, p < .001), perifollicular depigmentation (p = .02), ill-defined margins (p = .04) and satellite lesions and micro-Koebner phenomenon (p < .001) were associated with active vitiligo while perifollicular repigmentation (p < .001) was associated with stabilizing and repigmenting vitiligo. Satellite lesions and micro-Koebner's phenomena were suggestive of unstable disease irrespective of site of target lesion, while perifollicular repigmentation was suggestive of stabilized/repigmenting disease only at non-acral sites. We found sequential dermoscopy to be useful to assess disease activity and potential for repigmentation in localized vitiligo.     

他克莫司乳膏联合治疗白癜风的疗效评价

目的:通过比较自体表皮移植术联合他克莫司和传统自体表皮移植术治疗白癜风的疗效,明确他克莫司乳膏对白癜风复色率的影响。方法:回顾性分析自体表皮移植术联合他克莫司和传统自体表皮移植术治疗的稳定期白癜风患者共90例,比较其均匀复色时间和疗效。结果:表皮移植术联合他克莫司组起效时间显著性短于单一表皮移植术组(P<0.05),1月、3月的显效率和痊愈率均明显高于单一表皮移植术组(P<0.05)。单一表皮移植术组颈部的疗效相比于头面部、躯干部、四肢更佳(P<0.05),表皮移植术联合0.1%他克莫司软膏外用治疗(相对于单一表皮移植术)可显著性提高位于四肢的皮损的疗效(P<0.05)。相较于单一表皮移植术而言,表皮移植术联合他克莫司对提高节段型和局限型白癜风疗效显著(P<0.05)。然而,他克莫司联合治疗可提高散发型和肢端型白癜风的疗效,但无统计学意义(P>0.05)。表皮移植术联合他克莫司组和单一表皮移植术组中,男性疗效均高于女性,但无显著性差异(P>0.05)。结论:自体表皮移植术联合0.1%他克莫司软膏治疗白癜风的疗效优于单一自体表皮移植术,他克莫司可有效提高白癜风复色。     

Repigmentation in vitiligo: position paper of the Vitiligo Global Issues Consensus Conference

The Vitiligo Global Issues Consensus Conference (VGICC), through an international e‐Delphi consensus, concluded that ‘repigmentation’ and ‘maintenance of gained repigmentation’ are essential core outcome measures in future vitiligo trials. This VGICC position paper addresses these core topics in two sections and includes an atlas depicting vitiligo repigmentation patterns and color match. The first section delineates mechanisms and characteristics of vitiligo repigmentation, and the second section summarizes the outcomes of international meeting discussions and two e‐surveys on vitiligo repigmentation, which had been carried out over 3 yr. Treatment is defined as successful if repigmentation exceeds 80% and at least 80% of the gained repigmentation is maintained for over 6 months. No agreement was found on the best outcome measure for assessing target or global repigmentation, therefore highlighting the limitations of e‐surveys in addressing clinical measurements. Until there is a clear consensus, existing tools should be selected according to the specific needs of each study. A workshop will be conducted to address the remaining issues so as to achieve a consensus.     

Ginkgo biloba extract protects human melanocytes from H2O2‐induced oxidative stress by activating Nrf2

Vitiligo is a common skin depigmenting disorder characterized by the loss of functional melanocytes. Its pathogenesis is complicated and oxidative stress plays a critical role in the development of vitiligo. Thus, antioxidant therapy is a promising therapeutic strategy to prevent or even reverse the progression of depigmentation. Ginkgo biloba extract EGb761 has been confirmed to have protective effects on neurons against oxidative stress. Notably, several clinical trials have shown that patients with stable vitiligo achieved repigmentation after taking EGb761. However, the exact mechanism underlying the protective effects of EGb761 on melanocytes against oxidative stress has not been fully elucidated. In the present study, we found that EGb761 effectively protected melanocytes against oxidative stress‐induced apoptosis and alleviated the excessive accumulation of reactive oxygen species (ROS) and lipid peroxidation by enhancing the activity of antioxidative enzymes. Furthermore, the antioxidative effect of EGb761 was achieved by activating Nrf2 and its downstream antioxidative genes. In addition, interfering Nrf2 with siRNA abolished the protective effects of EGb761 on melanocytes against oxidative damage. In conclusion, our study proves that EGb761 could protect melanocytes from H₂O₂‐induced oxidative stress by activating Nrf2. Therefore, EGb761 is supposed to be a potential therapeutic agent for vitiligo.     

自体吸疱表皮移植术结合搔刮术治疗白癜风的临床评价

目的:观察和比较搔刮术结合负压吸疱术和传统负压吸疱术对白癜风复色的疗效。方法:将90例稳定期白癜风患者随机分成搔刮术结合负压吸疱术组(45例)和传统负压吸疱术组(45例),分别给予搔刮术结合负压吸疱术和传统负压吸疱术治疗。治疗后,比较两组的复色情况,是否留有白斑缝隙,并进行白癜风疗效评价。进一步分析皮损部位、性别、临床类型对搔刮术结合负压吸疱术和传统负压吸疱术临床疗效的影响。结果:治疗后,搔刮术结合负压吸疱术组和传统负压吸疱术组在整体疗效无显著性差异(P0.05)。搔刮术结合负压吸疱术组术后获得成片复色比例显著高于传统负压吸疱术组(88.9%vs. 4.4%,P0.001)。不同性别患者接受搔刮术结合负压吸疱术和传统负压吸疱术的疗效比较均无统计学差异(P0.05)。表皮移植术结合搔抓术组和单一表皮移植术组中,皮损发生在颈部、面部相比于躯干部、四肢、手足部的疗效明显更佳,局限型和节段型相比于散发型、肢端型的疗效更佳。结论:自体吸疱表皮移植术结合搔刮术用于稳定期白癜风的复色效果相比于传统自体吸疱表皮移植术疗效更佳。     

Glutathione maintenance is crucial for survival of melanocytes after exposure to rhododendrol

Rhododendrol is a phenolic compound that shows a tyrosinase‐dependent toxicity for melanocytes and occasionally induces a vitiligo‐like skin depigmentation. The post‐tyrosinase mechanisms determining melanocyte death or survival, however, are far from clear. Here, we find that rhododendrol treatment leads to a reduction in the levels of cellular glutathione but also induces a cellular antioxidant response that eventually increases glutathione levels. We further find that rhododendrol toxicity is enhanced when glutathione levels are experimentally reduced and alleviated when glutathione levels are increased. Hence, it appears that the size of the preexisting glutathione pool along with the capacity to supply glutathione via the antioxidant response determines whether melanocytes survive or die after rhododendrol exposure. It is conceivable, therefore, that rhododendrol‐induced leukoderma depends on the capacity to maintain appropriate glutathione levels and that enhancement of glutathione levels may preserve a patient's melanocytes and potentially help in repigmentation.     

Immune responses in a mouse model of vitiligo with spontaneous epidermal de‐ and repigmentation

To generate a mouse model of spontaneous epidermal depigmentation, parental h3TA2 mice, expressing both a human‐derived, tyrosinase‐reactive T‐cell receptor on T cells and the matching HLA‐A2 transgene, were crossed to keratin 14‐promoter driven, stem cell factor transgenic (K14‐SCF) mice with intra‐epidermal melanocytes. In resulting Vitesse mice, spontaneous skin depigmentation precedes symmetrical and sharply demarcated patches of graying hair. Whereas the SCF transgene alone dictates a greater retinoic acid receptor‐related orphan receptor gamma (RORγt)⁺ T‐cell compartment, these cells displayed markedly increased IL‐17 expression within Vitesse mice. Similar to patient skin, regulatory T cells were less abundant compared with K14‐SCF mice, with the exception of gradually appearing patches of repigmenting skin. The subtle repigmentation observed likely reflects resilient melanocytes that coexist with skin‐infiltrating, melanocyte‐reactive T cells. Similar repigmenting lesions were found in a different TCR transgenic model of vitiligo developed on an SCF transgenic background, supporting a role for SCF in repigmentation.     

Corticotropin Expression by Human Melanocytes in the Skin

Highly dendritic melanocytes have been observed in rapidly proliferating seborrheic keratosis, epidermis overlying melanomas, and in melanomas. On staining for the presence of POMC with monoclonal antibody against human ACTH, the melanocytes show cytoplasmic positivity. Short term organ cultures of whole skin from the marginal zone of vitiligo patients show that 22.7% of controls and 45.5% on dark incubation in adriamycin and 87.5% exposed to a pulse of UV on adriamycin treatment show melanocytes positive for ACTH. The surrounding keratinocytes in the epidermis and in the seborrheic keratosis are negative, whereas in melanomas, isolated groups of melanocytes are positive for ACTH. These findings indicate that ACTH is expressed by the melanocytes in the G₂-phase, the activity being enhanced on UV exposure. Thus UV dependent pigmentation is associated with POMC production in human skin. From this work it is evident that the melanocyte network varies the MSH/ACTH levels in correlation with repigmentation and depigmentation in the marginal zone in vitiligo by expressing POMC locally and is related to the UV-sensitivity of the melanocytes.     

Water Buffalo (Bubalus bubalis) as a spontaneous animal model of Vitiligo

Vitiligo is a multifactorial acquired depigmenting disorder. Recent insights into the molecular mechanisms driving the gradual destruction of melanocytes in vitiligo will likely lead to the discovery of novel therapies, which need to be evaluated in animal models that closely recapitulate the pathogenesis of human vitiligo. In humans, vitiligo is characterized by a spontaneous loss of functional melanocytes from the epidermis, but most animal models of vitiligo are either inducible or genetically programmed. Here, we report that acquired depigmentation in water buffalo recapitulates molecular, histological, immunohistochemical, and ultrastructural changes observed in human vitiligo and hence could be used as a model to study vitiligo pathogenesis and facilitate the discovery and evaluation of therapeutic interventions for vitiligo.     

Ammoidin (xanthotoxin) in the treatment of vitiligo

Eighteen patients with vitiligo were treated with two crystalline substances, xanthotoxin (Ammoidin) and imperatorin (Ammidin) from the plant Ammi majus. Four patients improved more than 50 per cent. One had complete cure, but depigmentation recurred after a few months. Six patients had moderate improvement (less than 50 per cent), three had slight repigmentation, and in five cases there was no improvement. These results are similar to those reported by other investigators.Pronounced local inflammatory reactions are to be expected after exposure to ultraviolet light in nearly all patients treated with xanthotoxin. In one case prolonged sensitivity to sunlight, manifest by vesiculating dermatitis, occurred.     

Neural differentiation as an expression of UV sensitivity of melanocytes.

The present work is to study neural differentiation in melanocytes in relation to the cell cycle and UV exposure. Whole skin organ cultures of vitiliginous skin were exposed to a pulse of UV with and without prior Adriamycin treatment. It was observed that the highly dendritic marginal melanocytes are destroyed on UV exposure during the depigmentation phase but not during repigmentation. The melanocytes are resistant to UV destruction during the G2 phase as seen on Adriamycin treatment. They show a prominent increase in dendricity as well as biphasic activity to produce increased melanin and noradrenaline. Thus, the melanocytes form a UV-sensitive neural network in the skin. These responses are reminiscent of the repigmentation and depigmentation of coat color in animals exposed to extreme variations in the day/night cycles as seen at the poles.     

Reduced skin homing by functional Treg in vitiligo

In human vitiligo, cutaneous depigmentation involves cytotoxic activity of autoreactive T cells. It was hypothesized that depigmentation can progress in the absence of regulatory T cells (Treg). The percentage of Treg among skin infiltrating T cells was evaluated by immunoenzymatic double staining for CD3 and FoxP3, revealing drastically reduced numbers of Treg in non-lesional, perilesional and lesional vitiligo skin. Assessment of the circulating Treg pool by FACS analysis of CD4, CD25, CD127 and FoxP3 expression, and mixed lymphocyte reactions in presence and absence of sorted Treg revealed no systemic drop in the abundance or activity of Treg in vitiligo patients. Expression of skin homing receptors CCR4, CCR5, CCR8 and CLA was comparable among circulating vitiligo and control Treg. Treg from either source were equally capable of migrating towards CCR4 ligand and skin homing chemokine CCL22, yet significantly reduced expression of CCL22 in vitiligo skin observed by immunohistochemistry may explain failure of circulating, functional Treg to home to the skin in vitiligo. The paucity of Treg in vitiligo skin is likely crucial for perpetual anti-melanocyte reactivity in progressive disease.     

The antibody response against MART‐1 differs in patients with melanoma‐associated leucoderma and vitiligo

Patients with melanoma may develop skin depigmentation spontaneously or following therapy, referred to as melanoma‐associated leucoderma (MAL). As clinical presentation of MAL may precede primary/metastatic melanoma detection, recognition of MAL is important to prevent its misdiagnosis as vitiligo and the subsequent application of immunosuppressive treatment. To reveal the immunity involved in MAL development, we investigated the presence of antibody and T‐cell immune responses directed against the melanocyte‐differentiation‐antigens MART‐1 (Melan‐A), tyrosinase and gp100 in patients with MAL, as compared to patients with vitiligo. Autoantibodies to gp100 and tyrosinase were commonly found in both diseases. Interestingly, MART‐1 antibodies were only present in patients with MAL. Melanocyte antigen‐specific T cells were found in all patients, with relatively more specific T cells in patients with active vitiligo. Although MAL and vitiligo may appear clinically similar, our results indicate that the humoral immune responses against MART‐1 differ between these diseases, which can help to differentiate MAL from vitiligo.     

Herpesvirus connection in the expression of autoimmune vitiligo in Smyth line chickens

The Smyth line (SL) chicken is an animal model for human vitiligo, a common acquired depigmentary disorder affecting about 1-2% of people worldwide. The vitiligo-like depigmentation in SL chickens typically develops when the birds are between 6 and 14 weeks of age and may affect 70-95% of hatch mates. The development of SL vitiligo is considered to depend on two interacting components, namely an inherent melanocyte defect and an autoimmune reaction to melanocytes. Recently, a role for an environmental factor in the expression of vitiligo was suggested by the observation that only 10% of SL chicks imported from the University of Massachusetts (UM) and reared in isolation at biosecurity level 2 (BSL 2) at the University of Arkansas (UA) exhibited vitiligo. Following further assessment of environmental differences between UA and UM SL chickens, three environmental factors that may have influenced the expression of SL vitiligo were identified. Included were housing condition, status of Mycoplasma synoviae infection, and turkey herpesvirus (HVT) vaccination status. Studies were subsequently conducted at UA and UM to assess the role of these environmental factors in the expression of SL vitiligo. M. synoviae infection was not found necessary for vitiligo expression in SL chickens. However, HVT emerged as a strong candidate for an important environmental factor in SL vitiligo. The connection between HVT and SL vitiligo was confirmed for both BSL 2 and conventional housing. Therefore, the observations reported here suggest a strong causative link between HVT infection and SL vitiligo.     

The first transepidermal transplantation of non‐cultured epidermal suspension using a dermarolling system in vitiligo: A sequential histological and clinical study

The current methods for melanocyte delivery to depigmented skin are invasive and often require sophisticated approaches. Here, we describe a promising simple and minimally invasive technique based on the dermarolling system. The technique involves preparation of a keratinocyte/melanocyte suspension prepared by trypsinization from a non‐lesioned part of a patient's scalp skin and transepidermal delivery using a dermaroller equipped with 0.2‐mm needles. Dermarolling leads to epidermal microinjuries without, however, causing pain or inflammation. The technique was applied to facial depigmented areas of five patients with stable vitiligo that were resistant to conventional UV/tacrolimus treatment. The efficacy of cell delivery was analysed histologically on punch biopsies, and repigmentation was evaluated photographically and by clinical assessment. We found that the transplanted keratinocytes rapidly degenerated, leading to keratinization, but melanocytes survived and integrated appropriately into the basal layer of the epidermis, leading to excellent repigmentation after 6 months in three cases and mild repigmentation in two cases. Although based on a small number of patients, we anticipate this technique to become a valid addition to the arsenal of therapeutic approaches to repigmentation in depigmenting disorders.     

Melanocyte destruction and repigmentation in vitiligo: A model for nerve cell damage and regrowth

Melanocytes (MCs) are melanin-producing cells of the skin that are derived from neural crest cells. Vitiligo vulgaris is a common depigmentation disorder resulting from the destruction of functional MCs in the affected skin. The three prevailing pathomechanisms of vitiligo are the immune hypothesis, the neural hypothesis and the autocytotoxic hypothesis. None of these mechanisms has been conclusively proven. Melanoblasts (MBs) in the outer root sheath of the hair follicles are the reservoir cells for repigmentation. Recovery from vitiligo is initiated by activation and proliferation of these MBs, followed by upward migration to the nearby epidermis that forms perifollicular pigmentation islands. Migration, proliferation and differentiation of MCs and MBs are regulated by keratinocyte-derived factors and some coat color genes. Any therapy for vitiligo must explain not only the repopulation of MCs but also their functional development. In patients with vitiligo, MCs are destroyed in the skin, the eyes, and possibly the ears. However, the concept of vitiligo as a systemic disease will be clearly established only when the mechanisms involved in vitiligo are identified. Recent advances in the fields of neural crest cell culture and molecular genetics have opened new perspectives in the understanding of vitiligo. Not only will this result in better treatments for vitiligo patients, but possibly will also provide a key to triggering nerve cell regrowth in other nervous diseases.