Efficacy of narrow band UVB with or without OMP in stabilization of vitiligo activity in skin photo-types (III-V): A double-blind, randomized, placebo-controlled, prospective, multicenter study.

BACKGROUND: NB-UVB has long been the vitiligo management pillar with capability of achieving the main treatment outcomes; repigmentation and stabilization. Its stabilizing effect in dark skin has been debatable. However, randomized controlled trials regarding NB-UVB ability to control disease activity are lacking. PURPOSE: To assess stabilizing effect of NB-UVB in comparison to systemic corticosteroids, the mainstay in vitiligo stabilization, in skin photo-types (III-V). METHODS: This is a multicenter, placebo-controlled, randomized, prospective study. Eighty patients with active nonsegmental vitiligo (NSV) (Vitiligo disease activity (VIDA) ≥2) were randomized to either NB-UVB and placebo (NB-placebo) or NB-UVB and dexamethasone oral mini-pulse (OMP) therapy (NB-OMP) for 6 months. Sixty four patients completed the study, 34 in the NB-OMP group and 30 in the NB-placebo group. Patients were evaluated fortnightly according to presence or absence of symptoms/signs of activity. RESULTS: In spite of earlier control of disease activity observed in the NB-OMP group, it was comparable in both groups by the end of the study period. Disease activity prior to therapy, but not extent, was found to influence control of activity in both groups. Thus, NB-UVB is a safe sole therapeutic tool in vitiligo management. Not only does it efficiently achieve repigmentation, but also it is a comparable stabilizing tool for systemic corticosteroids in spite of slightly delayed control. CONCLUSION: NB-UVB is the only well-established vitiligo therapy that can be used solely whenever corticosteroids are contraindicated or immune-suppression is unjustified. Nonetheless, its combination with corticosteroids expedites response and improves compliance.

Site-oriented depigmentation in vitiligo patients using Q-switched Nd:YAG laser (1,064/532 nm), cryotherapy and chemical peels: A comparative study.

Depigmentation emerges as a feasible solution for vitiligo universalis and refractory cases of vitiligo vulgaris that hinder patients' quality of life. A range of depigmenting modalities has previously been developed. However, each has its own limitations. Based on skin sensitivity, this study sets out to compare the efficacy and tolerability of "trichloroacetic acid (TCA) peels 25% and 50% and Qs Nd:YAG laser (1,064/532 nm)" for facial depigmentation and "cryotherapy, phenol 88% and Qs Nd:YAG (1,064/532 nm)" for extrafacial skin depigmentation. Forty vitiligo patients were examined and equally divided into facial & extrafacial groups. Regular sessions were performed. Patients' responses were assessed after 3 months or when excellent/complete depigmentation was attained through assessing "depigmentation grade", "extent of depigmented skin", "patient satisfaction" and "overall response". Patients were observed for a six-month follow-up period. In facial depigmentation, Qs Nd:YAG showed the highest significant response followed by TCA 50% and 25%. In extrafacial depigmentation cryotherapy, phenol 88% and Qs Nd:YAG laser displayed positive outcomes without significant difference. Among the modalities tested Qs Nd:YAG yielded superior results in facial residual pigmentation in vitiligo when compared to TCA 50% and 25%, whereas in extrafacial sites Qs Nd:YAG, cryotherapy and phenol were equally effective.

A clinical and immunological study of phototoxic regimen of ultraviolet A for treatment of alopecia areata: a randomized controlled clinical trial.

Background: Various therapeutic agents have been described for alopecia areata but none is satisfactory. The use of ultraviolet A phototherapy in phototoxic regimens has emerged lately with promising results. Objective: To determine the efficacy and safety of phototoxic regimen of psoralen ultraviolet A (PUVA) in comparison to conventional therapy with intralesional corticosteroids in patients with alopecia areata. Methods: In this randomized controlled clinical trial, 40 patients were randomized to either phototoxic regimen of psoralen ultraviolet A group or potent intralesional corticosteroids group for three months. Study ended at six months. The primary outcome was treatment success: sustained regrowth of hair in ≥80% of the affected areas at six months. Tissue cytokines were assessed at zero and three months. Results: At six months, treatment success was achieved by 45% of patients, similarly in both groups. Tissue cytokine expression correlated well with clinical response. Conclusion: Phototoxic regimen of topical PUVA deserves a place among therapeutic tools used in management of alopecia areata especially in more extensive conditions where intralesional corticosteroids would not be suitable. Trial registration: https://clinicaltrials.gov/ct2/show/record/NCT01559584.

CXCL-10 and Interleukin-6 are reliable serum markers for vitiligo activity: A multicenter cross-sectional study.

This cross-sectional multicenter study aimed to evaluate serum CXCL-10, as an activity marker for vitiligo, and compare it with other putative serum and tissue markers. Serum CXCL-10 was compared to interferon gamma (IFN-γ), interleukin 6 (IL-6), and IL-17 using ELISA in 55 non-segmental vitiligo patients (30 active and 25 stable) and 30 healthy controls. Marginal skin biopsy was taken for immunohistochemical evaluation of CD8+T cells and CXCL-10+ve cells. Serum levels of CXCL-10, IL-17, and IL-6 were elevated in all vitiligo patients compared to controls (p < .05). All investigated serum markers were higher in active versus stable vitiligo. Tissue expression of CXCL-10+ve cells and CD8+ve T cells was stronger in vitiligo patients compared to controls, and tissue CXCL-10+ve cell expression was stronger in active versus stable cases. Positive correlations were noted between the different serum and tissue markers. CXCL-10 was the most specific, whereas IL-6 was the most sensitive serum marker to distinguish active from stable disease.

Effect of different types of therapeutic trauma on vitiligo lesions.

New treatment modalities for vitiligo acting by changing certain cytokines and metalloproteinases are newly emerging. The aim of this work is to To assess the efficacy of trichloroacetic acid (TCA) chemical peel, dermapen, and fractional CO2 laser in treatment of stable non-segmental vitiligo and to detect their effects on IL-17 and MMP-9 levels. Thirty patients with stable vitiligo were recruited in a randomized controlled study. They were randomly categorized into three equal groups. Group 1: TCA peel, Group 2: dermapen machine, and Group 3: Fractional CO2 laser. Skin biopsies were taken from treated areas and from control areas for which MMP-9 and IL-17 tissue levels were measured using ELISA. The 30 vitiligo patients had low basal tissue MMP-9 levels and high baseline IL-17 tissue levels. As regards the three different used modalities, all of them caused rise in MMP-9 as well as IL-17 levels and almost their levels were much more elevated with repetition of the previously mentioned traumatic procedures. TCA 25% peel proved to be the most effective modality both clinically and laboratory and it can be used prior or with other conventional therapies in the treatment of vitiligo.

Phototherapy: The vitiligo management pillar.

Phototherapy has been the mainstay of vitiligo therapy for several decades. A variety of wavelengths and modalities are available, but narrowband ultraviolet B remains the safest and most commonly used treatment. Acting on multiple steps in vitiligo pathogenesis, narrowband ultraviolet B is one of the few therapies that can effectively induce stabilization and stimulate repigmentation. Achievement of optimal results involves using a combination of appropriate treatment protocols, careful patient selection, and patient education to set expectations. Individual patient characteristics, including disease activity, vitiligo phenotype, lesion location, and skin phototype, should all be considered, along with combination therapies.

The role of systemic steroids and phototherapy in the treatment of stable vitiligo: a randomized controlled trial.

Pathogenesis of vitiligo is believed to be multifactorial disease with a wide variety of therapeutic modalities. The aim of this work is to assess the efficacy of oral mini-pulse steroids (OMP) plus Nb-U.V.B in comparison to OMP alone and Nb-U.V.B alone in treating stable vitiligo. A prospective randomized controlled study including 45 patients categorized into three groups receiving therapy for 3 months; Group A received Nb-U.V.B plus OMP, Group B received OMP alone while Group C received Nb-U.V.B alone. Clinical assessment and PCR evaluation of bFGF, ICAM1, and ELISA for AMA were done. Patients receiving Nb-U.V.B plus OMP and using Nb-U.V.B alone gave statistically significant clinical response than those treated with OMP alone. Statistically significant rise of BFGF was noticed after treatment with Nb-U.V.B plus OMP and with Nb-U.V.B alone. Patients treated with OMP alone and with Nb-U.V.B alone showed statistically significant drop of ICAM-1 after therapy. NB-U.V.B plus OMP and Nb-U.V.B alone were found to be clinically superior over OMP alone in treating stable vitiligo patients, hence suggesting that adding OMP to Nb-U.V.B can maintain clinical and laboratory success for a longer period of time and with less relapse.

Phototherapeutic modalities pose no significantly increased risk of oxidative damage to DNA in dark skinned individuals.

BACKGROUND: 8-oxoguanine, a major product of DNA oxidation, is considered a key parameter in measuring the carcinogenic effects of ultraviolet radiation. OBJECTIVE: To assess and compare the carcinogenic potential of different photo (chemo) therapeutic modalities in photoresponsive skin diseases by measuring the levels of 8-oxoguanine in dark-skinned individuals before and after photo (chemo) therapy. METHODS: A prospective, randomized controlled pilot study was conducted in 63 patients of skin types III-V with photo-responsive dermatoses including vitiligo, psoriasis and mycosis fungoides. Patients were divided into three groups; Group 1 (received narrowband ultraviolet-B), Group 2 (received psoralen plus ultraviolet-A) and Group 3 (received broadband ultraviolet-A). Biopsies were taken before and after phototherapy to measure 8-oxoguanine levels using enzyme-linked immunosorbent assay. Biopsies were also taken from the sun-protected skin in 21 controls subjects who had no dermatological disease. RESULTS: Regardless of the disease, a significantly higher level of 8-oxoguanine was found after treatment when compared to the pre-treatment baseline levels; however, these levels were comparable to those in control subjects. A weakly significant positive correlation was found between cumulative dose and 8-oxoguanine levels following psoralen plus ultraviolet-A therapy. In controls, comparing the 8-oxoguanine levels between skin types III and IV showed significantly lower 8-oxoguanine in skin type IV. CONCLUSION: Therapeutic doses of ultraviolet radiation are relatively safe in dark skinned patients; however, minimizing the cumulative dose of phototherapeutic modalities (particularly psoralen plus ultraviolet-A) is recommended.

Broadband ultraviolet A in the treatment of psoriasis vulgaris: a randomized controlled trial.

BACKGROUND: Broadband ultraviolet A (BB-UVA) has been successfully used in the treatment of scleroderma, a UVA1-responsive dermatosis. OBJECTIVE: To compare the efficacy of BB-UVA versus psoralen + UVA (PUVA) in psoriasis treatment and assess apoptosis as an effector mechanism. PATIENTS AND METHODS: This randomized controlled trial included 61 patients with chronic plaque psoriasis randomly divided into group I or II. Group I were further randomized to either IA or IB who received UVA 10 or 15 J/cm(2) per session, respectively, while group II received PUVA. Therapy was delivered thrice weekly until clearance or 48 treatments at most. The primary outcome measured was clearance of psoriasis. Dermal lymphocytic counts and bcl-2 expression were measured in 20 patients from each group. RESULTS: Final Psoriasis Area Severity Index scores were reduced within each group. The UVA group achieved results comparable to PUVA until session 24 but failed to match it at final evaluation, with significantly better clinical, immunohistochemical, and histopathological results achieved by PUVA (P ≤ 0.05). Both modalities caused a reduction in dermal lymphocytic counts and epidermal bcl-2 expression. CONCLUSION: BB-UVA appears to be safe and acceptable for the treatment of chronic plaque psoriasis possibly through bcl-2-mediated apoptosis of keratinocytes and epidermal lymphocytes.

BB-UVA vs. NB-UVB in the treatment of vitiligo: a randomized controlled clinical study (single blinded).

BACKGROUND: Vitiligo is an acquired pigmentary disorder that affects between 1% and 2% of the general population. Phototherapy remains the cornerstone of treatment, with NB-UVB being the most frequently used. BB-UVA can be a plausible alternative for darker population; skin photo type III and IV. PATIENTS AND METHODS: The study was a prospective, randomized, controlled, and single-blinded clinical trial, conducted on 40 patients with bilateral symmetrical vitiligo. The patients were randomly divided into two equal groups; group (A) received a fixed dose of 15 J/cm(2) BB-UVA, while group (B) received NB-UVB. The study was conducted for a period of 16 weeks (48 sessions). RESULTS: The final percentage of clinical improvement was significantly higher (P = 0.047) within the BB-UVA group (63.82% ± 27.42), than within the NB-UVB group (44.32% ± 29.78). CONCLUSION: BB-UVA can be considered as an alternative treatment line for vitiligo.

Broad band UVA: a possible reliable alternative to PUVA in the treatment of early-stage mycosis fungoides.

UVA1 phototherapy was found to induce marked improvement in skin lesions of patients with stages IA and IB mycosis fungoides (MF). Broad band UVA (BB-UVA) is composed of 80.1% UVA1, with similar mechanisms of action. Our aim was to evaluate the efficacy of BB-UVA in the treatment of early-stage MF. Thirty patients with early stage MF were included. They were divided into two equal groups receiving either BB-UVA at 20 J/cm2/ session or PUVA three times/week for 40 sessions. Clinical and histopathological evaluations were performed before and after therapy in addition to immunohistochemical measurement of CD4+ cells and Bcl-2. Patients were followed up for an average duration of 36 months. Comparable clinical and histopathological improvement was noted in MF patients in both groups. Clinical improvement graded 'Excellent' was achieved in 33% of patients in the BB-UVA versus 13.3% in the psoralen and UVA (PUVA) group. Long-term follow-up indicated superiority of BB-UVA over PUVA. BB-UVA group showed a more rapid clearance rate, shorter time to achieve complete clearance, a longer disease-free interval and lower relapse rate. The use of BB-UVA in the treatment of early-stage MF is comparable or even superior to PUVA regarding efficacy and remission periods.

Sulfasalazine and pentoxifylline in psoriasis: a possible safe alternative.

BACKGROUND: Conventional therapy of extensive psoriasis is effective but has complications. Biologics are safer but expensive. OBJECTIVE: To assess the efficacy of sulfasalazine and pentoxifylline, which have TNF antagonizing and anti-proliferative action in the treatment of psoriasis. METHODS: In this randomized controlled trial, 32 patients with extensive psoriasis were divided into four groups: group A received sulfasalazine; group B received pentoxifylline; group C received both drugs; and group D received methotrexate. The Psoriasis Area and Severity Index (PASI) score was done at weeks 0, 2, 4, 6 and 8. RESULTS: A significant reduction in PASI score occurred in groups C and D (p = 0.043 and 0.018, respectively). A significantly higher percentage of PASI score reduction occurred in group D compared with groups A, B and C (p = 0.006, 0.003 and 0.030, respectively). An excellent response occurred in one patient (14.3%) in group D. A very good response occurred in two patients (22.2%) in group C, and in five patients (71.4%) in group D. A moderate response occurred in three patients (37.5%) in group A, one patient (12.5%) in group B, and one patient (14.3%) in group D. CONCLUSION: Although incomparable to methotrexate, combined sulfasalazine and pentoxifylline produced a good response in cases of extensive psoriasis. Multicentre studies are needed to validate these results.

The use of synchrotron infrared microspectroscopy in the assessment of cutaneous T-cell lymphoma vs. pityriasis lichenoides chronica.

BACKGROUND: The diagnosis of cutaneous lymphomas remains a challenge for both the clinician and dermatopathologist. OBJECTIVES: To differentiate between frank malignant and premalignant lymphocytes within the skin. METHODS: This study was performed on 20 patients with a mean age of 50 years. They were divided into two groups: mycosis fungoides (MF) (stage IA, IB and IIA) and pityriasis lichenoides chronica (PLC). Immunophenotyping using antibodies CD3, CD4, CD8, CD20 and CD30 was performed. Synchrotron Fourier transform infrared microspectroscopy (S-FTIRM) was performed on cell nuclei to assess chemical differences between MF and PLC cases as a potential complementary screening tool. Dermal spectra of both MF and PLC were compared using principal components analysis (PCA) of the S-FTIRM data. RESULTS: All PLC spectra was clustered together. However, the MF spectra formed two clusters, one that grouped with the PLC and the other grouped separately. Moreover, protein and nucleic acids showed highly significant differences between MF (IIA and IB), MF (IA) and PLC. CONCLUSIONS: The malignant transformation within lymphocytes was identifiable through the spectroscopic analysis of protein, RNA and DNA with S-FTIRM, making it a promising tool for classifying the progression of cutaneous T-cell lymphoma.

Different narrowband UVB dosage regimens in dark skinned psoriatics: a preliminary study.

BACKGROUND: Psoriasis is a common and relapsing disease, which is both physically and psychologically disabling. Narrowband UVB (NB-UVB) is used in fair-skinned population in suberythemogenic doses with good results; however, in the darker skin population (skin types III, IV, V) erythemogenic doses have not been thoroughly investigated. AIM: A left-right bilateral comparative trial was carried out to compare the suberythemogenic dose of NB-UVB vs. erythemogenic dose in the treatment of dark-skinned psoriatic patients. PATIENTS AND METHODS: The study was conducted on 20 patients with chronic plaque psoriasis. The left side was treated with the dose causing minimal erythema [100% of minimal erythema dose (MED)] while the right side received 70% of this MED (suberythemogenic side). RESULTS: Our results revealed no statistically significant difference in PASI final and in the percentage of reduction of PASI score between both sides as well as the total number of sessions (P-value>0.05), while the total cumulative UVB dose on the suberythemogenic side was significantly lower (P-value<0.001). CONCLUSION: Our study recommends reducing the dose regimen of NB-UVB and consequently the cumulative UVB dose by using the suberythemogenic dosing schedule even in dark skin population.

A comparative study of different treatment frequencies of psoralen and ultraviolet A in psoriatic patients with darker skin types (randomized-controlled study).

BACKGROUND: Photochemotherapy psoralen and ultraviolet A (PUVA) is a viable option for treatment of psoriasis. However, concerns about its side effects have raised the need to change current PUVA protocols. The aim of this study is to determine whether reducing the treatment frequency of PUVA to twice/week instead of three times/week would affect the efficacy of PUVA therapy. PATIENTS AND METHODS: The study included 20 psoriatic patients, randomized into two groups, 10 patients in each group. The first group received two weekly sessions, the second group received three. The study lasted until complete clearance or for 12 weeks (endpoint). Psoriasis area and severity index (PASI) score was done prior to therapy, at mid therapy and at end of therapy (PASI final). RESULTS: No significant different in PASI final and in the percentage of reduction of PASI score between both groups (P value >0.05) was found. However, a significant difference in the total number of sessions and the total cumulative UVA doses between both groups was found (P value <0.001). CONCLUSION: Our study suggests reducing PUVA frequency and the cumulative UVA dose does not compromise the efficacy of PUVA, but it may improve its benefit/risk ratio. RESTRICTIONS: Few number of cases.

Pigmentary disorders in the Mediterranean area.

The Mediterranean area represents the area of land that borders the Mediterranean basin. It is composed of several countries that share many geographic and racial characteristics. Although Mediterraneans seem to share common skin type and are subjected to similar enviromental factors, they still represent a genetic and socioeconomic diversity. True prevalence of pigmentary disorders in this area depends on large epidemiologic studies, including countries that are not available. This article, however, highlights and classifies the most important developmental (heritable-genetic) and acquired pigmentary disorders seen and reported in this important area of the world.