Davinder Parsad

Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference

During the 2011 International Pigment Cell Conference (IPCC), the Vitiligo European Taskforce (VETF) convened a consensus conference on issues of global importance for vitiligo clinical research. As suggested by an international panel of experts, the conference focused on four topics: classification and nomenclature; definition of stable disease; definition of Koebner’s phenomenon (KP); and ‘autoimmune vitiligo’. These topics were discussed in seven working groups representing different geographical regions. A consensus emerged that segmental vitiligo be classified separately from all other forms of vitiligo and that the term ‘vitiligo’ be used as an umbrella term for all non‐segmental forms of vitiligo, including ‘mixed vitiligo’ in which segmental and non‐segmental vitiligo are combined and which is considered a subgroup of vitiligo. Further, the conference recommends that disease stability be best assessed based on the stability of individual lesions rather than the overall stability of the disease as the latter is difficult to define precisely and reliably. The conference also endorsed the classification of KP for vitiligo as proposed by the VETF (history based, clinical observation based, or experimentally induced). Lastly, the conference agreed that ‘autoimmune vitiligo’ should not be used as a separate classification as published evidence indicates that the pathophysiology of all forms of vitiligo likely involves autoimmune or inflammatory mechanisms.

Guidelines for the management of vitiligo: the European Dermatology Forum consensus.

The aetiopathogenic mechanisms of vitiligo are still poorly understood, and this has held back progress in diagnosis and treatment. Up until now, treatment guidelines have existed at national levels, but no common European viewpoint has emerged. This guideline for the treatment of segmental and nonsegmental vitiligo has been developed by the members of the Vitiligo European Task Force and other colleagues. It summarizes evidence‐based and expert‐based recommendations (S1 level).

Quality of life in patients with vitiligo

Vitiligo is an important skin disease having major impact on quality of life of patients, many of whom feel distressed and stigmatized by their condition. Society greets vitiligo patients in much the same way as it does any one else who appears to be different. They are started at or subjected to whispered comments, antagonism, insult or isolation. The chronic nature of disease, long term treatment, lack of uniform effective therapy and unpredictable course of disease is usually very demoralizing for patients suffering from vitiligo. It is important to recognize and deal with psychological components of this disease to improve their quality of life and to obtain a better treatment response.

Dermatology Life Quality Index score in vitiligo and its impact on the treatment outcome

SIR, A 40-year-old man reported the slow progressive appearance, during the previous 6 years, of pruritic erythematous lesions on the trunk, buttock, abdomen, axilla, genital area and forearm (Fig. 1a). Lesions consisted of follicular papules, comedones, milia and cysts. Lesional areas were alopecic (Fig. 1b), and diffuse alopecia was also present on the scalp and beard area, along with comedones and cysts. The patient reported severe skin dryness, especially in the involved areas. No impairment of salivary or lacrimary function was noted. Serological and haematological tests were all normal or negative. Because of the diffuse presence of cysts and comedones, a diagnosis of chloracne had been made in another institution; the clinical diagnosis was confirmed histologically by the presence of infundibular cysts and a granulomatous foreign body reaction to keratin scales. A further biopsy was performed: the most striking histological feature was a lymphocytic infiltrate involving eccrine glands and coils along with a characteristic epithelial hyperplasia (Figs 1c,d). This picture fits perfectly with that reported in the literature as being characteristic of syringolymphoid hyperplasia, also known as syringotropic mycosis fungoides or syringotropic cutaneous T-cell lymphoma (CTCL). The hair follicles were involved by the lymphocytic infiltrate in a manner similar to that of the eccrine glands. Follicles were surrounded by a dense lymphocytic infiltrate, with extensive exocytosis. Occasional Pautrier microabscesses were evident in the follicular sheath. This pattern is that of pilotropic mycosis fungoides, a form of folliculotropic CTCL. Many follicles were entirely trans-

Clinical study of repigmentation patterns with different treatment modalities and their correlation with speed and stability of repigmentation in 352 vitiliginous patches

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.

Comparison of systemic PUVA and NB‐UVB in the treatment of vitiligo: an open prospective study

Background  Vitiligo is a common pigmentary disorder with great cosmetic and psychological morbidity. No treatment available is a definitive cure. Systemic psoralen and ultraviolet A (PUVA) has been the mainstay of treatment. Narrow‐band ultraviolet B (NB‐UVB) has been recently introduced. Although retrospective comparative study of systemic PUVA and NB‐UVB has been published from our centre, no prospective study has been reported to date.

Narrow-band UVB for the treatment of vitiligo: an emerging effective and well-tolerated therapy

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.

Psoralen–ultraviolet A vs. narrow‐band ultraviolet B phototherapy for the treatment of vitiligo

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.

Psoralen and ultraviolet A and narrow‐band ultraviolet B in inducing stability in vitiligo, assessed by vitiligo disease activity score: an open prospective comparative study

Background  Vitiligo is a common pigmentary disorder with great cosmetic and psychological morbidity and an unpredictable course. No treatment available is a definitive cure. Systemic psoralen and ultraviolet A (PUVA) has been the mainstay of treatment. Narrow‐band UVB (NBUVB) was later introduced. In this study, we have compared the phototherapy modalities PUVA and NBUVB in inducing stability in vitiligo, assessed by using vitiligo disease activity score (VIDA), for the first time.

Topical tacrolimus for treatment of childhood vitiligo in Asians.

Childhood vitiligo is a common disorder of pigmentation in India. Considering the lack of uniformly effective and safe treatment modalities for children with vitiligo, search for newer therapeutic agents continues. This study was designed to evaluate the role of topical tacrolimus in the treatment of childhood vitiligo. Twenty‐five children with vitiligo were treated with topical 0.03% tacrolimus ointment applied twice daily for 12 weeks. Response was noted as marked to complete (> 75% repigmentation), moderate (50–75% repigmentation) and mild (< 50% repigmentation). Twenty‐two children (9 boys and 13 girls) of mean age 7.2 ± 1.4 years completed the study. Twelve (54.5%) children had vitiligo vulgaris, nine (40.9%) had focal vitiligo and one (4.5%) had segmental vitiligo. The mean duration of disease was 8 ± 3 months. Nineteen (86.4%) children showed some repigmentation at the end of 3 months and other three had no response. Of these 19 children, repigmentation was marked to complete in 11 (57.9%), moderate in five (26.3%) and mild in three (15.7%) children. Side effects were minimal, such as the pruritus and burning noted in only three patients. Topical tacrolimus is an effective and well‐tolerated treatment modality in Asian children with vitiligo.