Actinic keratoses and squamous cell carcinoma limited to photo-exposed skin in vitiligo vulgaris in pigmented skin type.

Vitiligo skin has a lesser number of photoprotective melanocytes-theoretically, there is a higher risk of development of non-melanoma skin cancers in such patients. But most studies in Caucasian patients have shown decreased incidence of non-melanoma skin cancers in patients with vitiligo. In Indian patients, there is a paucity of literature on such adverse events. We report a case of actinic keratoses, cutaneous horn with dysplasia and squamous cell carcinoma developing exclusively over photo-exposed vitiligo lesions in an Indian woman in her 60s (housewife, Fitzpatrick skin type V and average daily photo-exposure time 2-4 hours) of long-standing vitiligo vulgaris without any history of phototherapy. The photoprotected lesional skin was completely normal with no clinically appreciable enlarged regional lymph nodes. Shave and elliptical excision of the suspicious lesions were done, and histopathology showed various degrees of malignant transformation in various lesions. The patient was started on topical imiquimod for the lesions of actinic keratoses and was referred for staging and wide excision of squamous cell carcinoma lesion. We report this case for its rarity and to emphasise the fact that there is a need for counselling for lifestyle modification in patients with vitiligo as the use of sunscreens is often not practised by Indian patients due to financial constraints and physical measures such as using full sleeves, high-collared dresses and scarves should be encouraged.

Association between three autoimmune diseases: vitiligo, primary biliary cirrhosis, and Sjögren's syndrome.

Although the association of multiple autoimmune diseases has already been widely described, no reports of the association between vitiligo, primary biliary cirrhosis and Sjogren's syndrome were retrieved in the SciELO and PubMed databases. The authors describe the case of a female patient who was diagnosed with primary biliary cirrhosis and Sjogren's syndrome at age 54. At age 58, she developed vitiligo restricted to the face, associated with significant impairment of self-esteem and quality of life. Antinuclear antibody was negative at the onset of the condition, but became positive after phototherapy initiation. In general, the occurrence of multiple autoimmune diseases in the same patient is known as a mosaic of autoimmunity. However, specific mechanisms appear to interconnect primary biliary cirrhosis and Sjogren's syndrome, such as PDC-E2-mediated generalized epithelitis.

Association between three autoimmune diseases: vitiligo, primary biliary cirrhosis, and Sjögren's syndrome

Abstract Although the association of multiple autoimmune diseases has already been widely described, no reports of the association between vitiligo, primary biliary cirrhosis and Sjogren's syndrome were retrieved in the SciELO and PubMed databases. The authors describe the case of a female patient who was diagnosed with primary biliary cirrhosis and Sjogren's syndrome at age 54. At age 58, she developed vitiligo restricted to the face, associated with significant impairment of self-esteem and quality of life. Antinuclear antibody was negative at the onset of the condition, but became positive after phototherapy initiation. In general, the occurrence of multiple autoimmune diseases in the same patient is known as a mosaic of autoimmunity. However, specific mechanisms appear to interconnect primary biliary cirrhosis and Sjogren's syndrome, such as PDC-E2-mediated generalized epithelitis.

New insights into leukotrichia in nonsegmental vitiligo: A cross-sectional study.

BACKGROUND: Leukotrichia has been considered a predictor of poor outcome in vitiligo. However, studies considering the different clinical aspects of leukotrichia in vitiligo patients are few. AIM: Our aim was to conduct a detailed clinical study to provide insights into the relevance and associations of leukotrichia in non-segmental vitiligo. METHODS: In this cross-sectional study, vitiligo patients attending the dermatology outpatient clinic and phototherapy unit at Cairo University Hospital over a period of 6 months (April-September 2016) were included. Family history, clinical details, the Vitiligo Global Issues Consensus Conference classification, the Dermatology Life Quality Index, Vitiligo Area and Severity Index, Vitiligo Extent Score, Vitiligo Disease Activity Score and Vellus Score were determined and these measurements were correlated to leukotrichia. RESULTS: Out of the 101 patients studied, leukotrichia was found in 47 (46.5%) patients, with vellus hair involved in 37 (78.7%), terminal hairs in 30 (63.8%) and both in 20 (42.5%) patients. Vellus hair involvement was significantly higher in generalized bilaterally symmetrical vitiligo than in acrofacial or unclassified vitiligo. The incidence of scalp leukotrichia also was higher in generalized symmetrical vitiligo than in acrofacial vitiligo. The Vellus Score showed significant associations with Vitiligo Area and Severity Index, Vitiligo Extent Score and the Dermatology Life Quality Index. LIMITATIONS: This was a short-term study with a small sample size. Prognostic and therapeutic correlations were not studied; prospective longitudinal studies are needed for further evaluation. CONCLUSION: Leukotrichia was found in almost half of the studied sample and its frequency varied among the different types of vitiligo.

Liquen nitidus sobre vitíligo: nueva variante del fenómeno de co-respuesta isotópica / Lichen nitidus arising on vitiligo: a new variant of the isotopic coresponse

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Vitamin D status and the effects of oral vitamin D treatment in children with vitiligo: A prospective study.

BACKGROUND & AIMS: Vitiligo is a pigmentary disorder and autoimmune pathogenesis seems most likely. Decreased vitamin D levels have been related to several autoimmune diseases. Little is known about the association of vitiligo and vitamin D. We aimed to evaluate serum 25-hydroxyvitamin D [25(OH)D] levels in children with vitiligo and to determine the efficacy of oral vitamin D therapy on the repigmentation of vitamin D deficient patients. METHODS: Thirty patients aged 6-17 years with vitiligo and 30 sex- and age-matched apparently healthy controls were included in this prospective study. Size of the vitiligo representative area was estimated using the point counting method and blood samples were obtained at the beginning and month six. By the end of the study, all patients treated with topical tacrolimus for six months and the patients who were vitamin D deficient (n = 14) had been on combination treatment of oral vitamin D and topical tacrolimus. A dose of 1500 IU/day vitamin D was given if the serum 25(OH)D levels <20 ng/ml and 3000 IU/day was given if the levels <10 ng/ml for six months. Serum 25(OH)D levels were measured by high-performance liquid chromatography. RESULTS: Serum 25(OH)D levels of patients and controls were not significantly different (p > 0.05). Lesion size decreased from 66.1 ± 58.3 cm2 to 48.0 ± 52.6 cm2 after six months of treatment in patients who received combination treatment (p < 0.001) and increased in patients who received only topical therapy from 34.8 ± 48.1 cm2 to 53.5 ± 64.9 cm2 (p < 0.01). CONCLUSIONS: Although we did not determine decreased serum 25(OH)D levels in children with vitiligo, we showed that combination treatment with oral vitamin D and topical tacrolimus is more effective in reaching repigmentation than topical tacrolimus alone. Oral vitamin D supplementation might be useful for children with vitiligo who are also deficient in vitamin D.

Vitiligo induced by specific immunotherapy with grass pollen: the Koebner phenomenon

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Vitiligo, NB-UVB and tacrolimus: our experience in Naples.

AIM: The aim of the present study was to evaluate the efficacy and safety of narrowband UVB (NB-UVB) compared with tacrolimus ointment 0.1% in patients with bilateral vitiligo. METHODS: In this comparative study, four groups of patients were randomized. Each group was composed by 12 patients with bilateral vitiligo; in each group, every patient was irradiated with NB-UVB (length: 311 nm) twice a week for 9 months and applied tacrolimus ointment 0.1% twice a day on the other area in the same period. Before starting therapy and after 3, 6 and 9 months of therapy, a clinical and photographic evaluation of percentage of repigmentation was performed and Dermatology Life Quality Index Questionnaire was fulfilled. RESULTS: A repigmentation at least partial occurred in 71% of patients after 36 weeks of treatment with tacrolimus ointment 0.1%; in the whole sample, 14 patients (29%) showed no repigmentation at all, with 2 of them discontinuing the therapy because of side effects (erythema and folliculitis-like manifestations). A homogeneous repigmentation at least partial occurred in 69% of patients after 36 weeks of treatment with NB-UVB; in the whole sample 15 patients (31%) showed no repigmentation at all, with 1 of them discontinuing the therapy because of side effects. CONCLUSION: The present study confirmed that the efficacy of NB-UVB phototherapy in vitiligo is comparable to tacrolimus ointment 0.1% therapy. On the basis of our study, we may suggest tacrolimus ointment 0.1% as an alternative to NB-UVB therapy for treating vitiligo.

Evaluation of serum 25-hydroxyvitamin D levels in vitiligo patients with and without autoimmune diseases.

BACKGROUND: Vitiligo is an autoimmune depigmentation disorder, commonly associated with systemic autoimmune diseases. Deficient serum 25-hydroxyvitamin D (25(OH)D) levels have been noted in some patients with autoimmune diseases. AIM: To evaluate serum 25(OH)D levels in vitiligo patients with and without systemic autoimmune diseases. METHODS: A case-control study was conducted on 40 vitiligo patients (20 patients with systemic autoimmune diseases and 20 patients without autoimmune diseases) and 40 age-, gender- and skin phototype-matched healthy controls. Serum 25(OH)D was measured in all subjects, divided into: normal or sufficient (≥ 30 ng/ml), insufficient (< 30-> 20 ng/ml) and deficient (≤ 20 ng/ml) levels. RESULTS: One patient with vitiligo (2.5%) versus 33 healthy controls (82.5%) have sufficient serum 25(OH)D levels while 39 patients (97.5%) versus 5 controls (12.5%) have deficient 25(OH)D levels with significantly lower serum 25(OH)D levels in patients compared to controls (P-value < 0.001). The other 2 healthy controls have insufficient 25(OH)D levels. Patients with vitiligo and autoimmune diseases have lower serum 25(OH)D levels than vitiligo patients without autoimmune diseases but with no significant difference. No significant correlations existed between age of the patients, duration of vitiligo, duration of associated autoimmune diseases, affected body surface area and serum 25(OH)D levels of patients. CONCLUSION: Deficient serum 25(OH)D levels are present in vitiligo patients with and without systemic autoimmune diseases. Accordingly, screening for vitamin D deficiency seems of value in vitiligo patients for the possibility of vitamin D supplementation.

Repigmentation of poliosis after epithelial grafting for vitiligo.

BACKGROUND: Vitiligo is a disease of color loss from skin and possibly also from hair. The presence of white hair follicles is known to be a bad prognostic sign. OBJECTIVES: To evaluate the possibility of repigmentation of white hair follicles after epithelial grafting. METHODS: Patients with recalcitrant vitiligo with loss of hair pigment were treated using Chinese cupping blisters or ultrathin Thiersch grafting after de-epithelialization of vitiliginous patches by dermabrasion. Phototherapy was used afterward to enhance success. RESULTS: Repigmentation of the skin surface was obtained with as little as 1 to 2 months of phototherapy, as expected, and further follow-up of cases revealed the re-coloring of hair follicles after 4 to 11 months. CONCLUSION: Re-coloring of poliosis with vitiligo is possible but was unexpected because of the difference in mechanism and signaling required between hair bulb melanization and the surface skin. One likely mechanism to explain this change is that melanocyte stem cells are stimulated and migrate to supply hair bulbs with new mature melanocytes. Epithelial grafting of vitiligo with poliosis in hairy areas should be a treatment of choice when white hair tufts cause cosmetic disfigurement.

Safety of repeated transcranial direct current stimulation in impaired skin: a case report.

Transcranial direct current stimulation (tDCS) is a neuromodulatory technique based on the application of a weak, direct electric current via 2 or more electrodes (anode and cathode) over the scalp. One concern when applying tDCS is skin burn. It has been suggested that skin lesions are related to changes in the local dermal homeostasis, and therefore, caution is warranted in patients with skin diseases (Loo et al [Int J Neuropsychopharmacol. 2011;14:425-426]). In this context, we believe that it would be useful for this emerging field of tDCS to report the preliminary safety of repeated application of tDCS in a patient with vitiligo, an autoimmune disorder characterized by depigmentation sites of the skin or mucous membranes. We report the case of a 31-year-old male patient with schizophrenia who underwent 10-daily tDCS sessions. He has had generalized vitiligo since childhood, and despite previous treatment, no current dermatologic follow-up was being carried out. Depigmentation sites were evident in different areas, particularly under the anodal area. We found that repeated anodal tDCS in 1 patient did not lead to skin lesions when applied over a vitiligo skin area. Some of the procedures that we used to buffer changes in skin temperature may have contributed to prevent tDCS-induced skin damage. Nevertheless, the exact conditions that lead to skin lesion are still unknown. Given the growing use and testing of tDCS, continuous assessment and reporting of local adverse effects are still warranted especially in conditions with increased risk of skin lesions such as in dermatologic conditions, skin burns, and previous skin damage.

Decreased risk of melanoma and nonmelanoma skin cancer in patients with vitiligo: a survey among 1307 patients and their partners.

BACKGROUND: Vitiligo is a common skin disease characterized by autoimmune melanocyte destruction. Recent genetic studies suggest a lower susceptibility to melanoma in patients with vitiligo; however, lifetime melanoma prevalence in patients with vitiligo has not previously been studied. Nonmelanoma skin cancer (NMSC) prevalence has been studied, but only in small studies and with contradictory results. OBJECTIVES: This retrospective, comparative cohort survey was designed to assess lifetime prevalences of melanoma and NMSC in patients with vitiligo compared with nonvitiligo controls. METHODS: Patients with nonsegmental vitiligo, who visited our clinic between January 1995 and September 2010, and were aged 50 years or older at the time of the study, were invited to participate in a postal survey. The questions regarded demographics, vitiligo characteristics, phototherapy history, skin cancer risk factors and the number of skin cancers experienced during the patient's lifetime. Patients were asked to have their partner fill in a control questionnaire. All skin cancers were validated by a pathology report. In total 2635 invitations were sent and 1307 eligible questionnaires were returned (50%). Multivariate logistic regression models were used to quantify adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for associations between vitiligo and lifetime prevalences of melanoma and NMSC. RESULTS: Adjusted for confounders, patients with vitiligo had a threefold lower probability of developing melanoma (adjusted OR 0·32; 95% CI 0·12-0·88) and NMSC (adjusted OR 0·28; 95% CI 0·16-0·50). Subgroup analyses of patients treated with narrowband ultraviolet (UV) B, and psoralen and UVA did not show dose-related trends of increased age-adjusted lifetime prevalence of melanoma or NMSC. CONCLUSIONS: Our findings suggest that patients with vitiligo have a decreased risk of both melanoma and NMSC.

Quality of life in vitiligo patients.

Quality of life is defined by the World Health Organization as "individuals' perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns." Often overlooked in the past, it is nowadays considered, in a more holistic view of medicine, a decisive factor to understand the impact of diseases and improve the quality of medical care. Such evaluation is particularly relevant for dermatological diseases, because visibility of the lesions can significantly affect self-esteem and social relationships. Vitiligo represents an emblematic case: often disfiguring and located in visible areas, confused in the past (and, in many world regions, even in the present) with leprosy, often perceived by physicians as a harmless, purely cosmetic problem, it significantly decreases the quality of life of affected persons. After a brief overview on definition, usefulness and methods for the assessment of quality of life, the authors examine the peculiarities of its relationship with skin diseases, particularly vitiligo. The state of the art of knowledge and research in this field is presented, together with data showing usefulness and positive results of a multidisciplinary approach, which adequately keeps into account perceived quality of life, on patient's satisfaction, adherence to treatment protocols and, ultimately, better outcome of treatments. In this context, an important role can be played by support communities, groups of patients and dedicated associations and societies, connected through modern communication networks like the Internet.

The effectiveness of therapeutic interventions on quality of life for vitiligo patients: a systematic review.

This paper reviews the effectiveness of therapeutic interventions on quality of life for adult patients with vitiligo. We systematically searched nine databases from 1990 to February 2010 and reviewed randomized controlled trials and quasi-experimental studies of current therapeutic interventions for vitiligo, including oral, topical, combination, camouflage, cognitive-behavioural therapy and grafting. Quality of life outcomes were collected. The Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument was used for quality assessment. Nine studies were included for this review, and all treatments were found to improve quality of life for vitiligo patients. Disease-altering interventions were effective in improving quality of life. Lifestyle-altering interventions were found to be selectively effective for patients with more severe quality of life impairment. Current interventions for vitiligo are effective in improving quality of life either by enhancing physical appearance of the patient or by addressing the psychological distress directly. Less effectiveness was achieved for the functional and social dimensions, which are more dependent on social and cultural norms. This suggests that current interventions alone are inadequate to address the holistic quality of life challenges associated with vitiligo.

Vitiligo and associated autoimmune disease: retrospective review of 300 patients.

BACKGROUND: Vitiligo, the most common cutaneous depigmentation disorder, has reported associations with other autoimmune diseases. However, literature on the strengths of the associations is conflicting, and no data on the subject exist from a Canadian population. OBJECTIVE: To determine autoimmune disease associations with vitiligo and which, if any, screening bloodwork is appropriate in vitiligo patients. METHODS: A retrospective review of vitiligo patients admitted to the Toronto Western Hospital phototherapy unit was conducted from January 1, 2000, to August 30, 2009. Data regarding patient characteristics, vitiligo clinical features (family history, age at onset, type, extent), associated diseases in the patient and family, and admission bloodwork (hemoglobin, vitamin B12, thyroid-stimulating hormone [TSH], antinuclear antibody) were recorded and compared, using the Fisher exact test where applicable. RESULTS: A total of 300 patient charts were reviewed (average age 41.5 ± 15.5 years; 47% male, 53% female). Hypothyroidism was present in 12.0% and pernicious anemia in 1.3% of patients-significant increases over the population prevalence. No other differences in prevalence were seen compared to the general population. TSH was increased in 3.7% of patients without a history of hypothyroidism. Hemoglobin and vitamin B12 were decreased in 0.3% of vitiligo patients without a history of pernicious anemia. CONCLUSION: We found a significantly higher prevalence of hypothyroidism and pernicious anemia in vitiligo patients.

[Vitiligo as an aesthetic problem. Noninvasive therapeutic methods in vitiligo]. / Bielactwo nabyte jako problem estetyczny. Nieinwazyjne metody leczenia bielactwa.

Vitiligo is an idiopathic chronic skin disease that is notable for depigmented macules forming by destruction of melanocytes mediated by cells of the immune system. Vitiligo occurs in 1-2% of the population irrespective of race and without predilection to gender or age. The dynamics and extent of the disease vary widely, ranging from stable cases with isolated minor foci to states showing rapid progression and occupying large areas of the skin. For many patients, the disease represents a serious cosmetic defect which limits their activities in various spheres of life. There are many noninvasive methods of treatment but none of them offers a guarantee of complete therapeutic success. PUVA- and UVB-therapy are recognized as the most effective and most commonly used methods. The management of vitiligo should also include education, cosmetic correction options, and psychotherapy in some cases.

Assessment of quality of life in Saudi patients with vitiligo in a medical school in Qassim province, Saudi Arabia.

OBJECTIVE: To determine the quality of life in Saudi patients with vitiligo and to detect the variables that could influence it by using the Dermatology Life Quality Index (DLQI). METHODS: One hundred and nine Saudi vitiligo patients were recruited from Qassim Medical College clinics between November 2004 and September 2006. We included 61 males, 48 females with an age range of 18 to 47 years, and a mean of 26.94 (SD +/- 9.73) years. Quality of life was evaluated using DLQI questionnaire and related to variables as age, gender, marital status, and extent of cutaneous involvement. RESULTS: Family history of vitiligo in first degree relatives was positive in 27.5%. The mean DLQI for all cases was 14.72 (SD +/-5.173) that showed no statistical difference between males and females. Patients on light therapy and with generalized vitiligo had significantly higher DLQI scores than patients on topical treatments and localized cutaneous involvement. Women are more embarrassed and self-conscious on the disease with more impairment of their social life, personal relationships, sexual activities, and more influenced in their choice of clothing than men. CONCLUSION: Vitiligo is associated with severe impairment of quality of life among Saudi patients. Dermatologists should pay careful attention to the psychosocial impact of vitiligo in the patients' life. Involvement of psychologist and even psychiatrist should be an essential part in the management of these cases.