Huma Khurrum

Worsening of vitiligo and onset of new psoriasiform dermatitis following treatment with infliximab.

Background: Vitiligo is a depigmentation disorder caused by melanocyte destruction that possibly results from an autoimmune mechanism. Psoriasis is an immune-mediated, chronic, inflammatory dermatosis. Although tumor necrosis factor α antagonists (anti-TNF-α), such as infliximab, are effective in treating psoriasis, many cases reported in the literature indicate that psoriasis might also be induced by treatment with infliximab. Some studies also suggest that TNF-α antagonists might be an effective treatment for vitiligo because the disorder is characterized by increased levels of TNF-α, indicating that it might play a role in the pathogenesis of this disease. Objective: We report a case of psoriasiform dermatitis with vacuolar interface reaction that occurred after infliximab therapy in a patient with vitiligo. Method: A 17-year-old male patient with vitiligo vulgaris was treated with an intravenous infusion of 5 mg/kg of infliximab at 0, 2, and 6 weeks and then once every 6 weeks over a span of 6 months. The patient was monitored both clinically and with laboratory investigations. He had no personal or family history of psoriasis. He tolerated the treatment well, without side effects. However, he developed a biopsy-proven psoriasiform lesion for the first time 4 months after he completed his sixth dose of infliximab. His vitiligo also worsened. Conclusion: This case report shows that infliximab given for vitiligo did not improve the disorder and that the vitiligo actually progressed. Moreover, psoriasiform lesions developed after this therapy. Further studies are needed to identify the effects of infliximab in patients with vitiligo.

The Relationship Between the Serum Level of Vitamin D and Vitiligo A Controlled Study on 300 Subjects

Background: Low vitamin D levels have been associated with several autoimmune diseases. Vitiligo could be associated with low vitamin D levels. Objective: To determine the level of serum vitamin D in vitiligo patients compared to controls and reveal the possible association of vitamin levels with the pathogenesis of vitiligo. Patients and Methods: A case-controlled study was conducted. After excluding factors that may affect serum vitamin D levels, blood samples were taken from vitiligo patients and controls. The association between vitamin D levels and various vitiligo subgroups (duration of vitiligo, site of onset, age, etc) was measured and correlated. Results: A total of 150 vitiligo patients, 90 (60%) males with a mean age of 30.6 ± 11.4 years, were recruited. The study also had 150 age- and gender-matched vitiligo-free control subjects. There was no significant difference in median serum vitamin D levels between the cases and the controls (P = .25). The serum levels of vitamin D of the vitiligo patients were found to be lower in males (P = .01), the younger age group (P = .01), and patients not treated with ultraviolet (UV) treatment (P = .01). Conclusion: There is no difference between the vitamin D levels of the vitiligo patients and the control subjects. However, deficiency of 25(OH)D levels within the vitiligo subgroups may be linked to younger age, male gender, short duration of vitiligo, and non-use of phototherapy.

Use of Complementary and Alternative Medicine Among Dermatology Outpatients Results From a National Survey

Background: Little is known about the prevalence and practice of complementary and alternative medicine (CAM) among dermatology patients in the Arab world. The aim of this study was to determine knowledge and attitudes about CAM, prevalence of its use, reasons for its use, and types of CAM used in dermatology patients in Saudi Arabia. Methods: This was a national survey of various regions of Saudi Arabia. In this cross-sectional study, dermatology outpatients were interviewed using a questionnaire. Sociodemographic characteristics, acceptability, utilization pattern, and reasons for CAM use were elicited. Dermatology life quality index (DLQI) was obtained. Results: Overall, 1901 patients returned complete questionnaires out of 2500 distributed (76% response rate). Of these, 808 (40%) were CAM users, and the majority were woman (55.1%), with a mean age of 31.6 ± 12 years. Most were literate (71.2%) and just over half were married (51.9%). Patients with acute skin diseases were found to be more likely to use CAM (P = .027). The mean DLQI score was higher (worse quality of life) among CAM users than among nonusers (P = .002). The results showed that 315 of 801 (40%) and 250 of 601 (30%) CAM users agreed that CAM methods are safer and more effective than modern medicine, respectively, and 83% will continue to use CAM in future. The most commonly used CAM modalities were vitamins, prayers, natural products, and herbs. Responses indicated that 379 of 803 (47.2%) CAM users did not consult their doctor before using CAM, and 219 of 743 (30%) did not obtain sufficient answers regarding CAM use from their dermatologists. Conclusions: There is a significant use of CAM among dermatology outpatients in Saudi Arabia. In view of the common belief that CAM has fewer side effects than conventional medicine, dermatologists need to increase their awareness of CAM.

Screening of Glaucoma or Cataract Prevalence in Vitiligo Patients and Its Relationship With Periorbital Steroid Use

Background/Aim: There is scarce literature connecting vitiligo and primary open angle glaucoma (POAG). Most literature reports that secondary complications are a direct consequence of corticosteroid treatment of vitiligo. In this study, we aimed to investigate the prevalence of ocular problems in patients with vitiligo and to determine its association with periorbital topical corticosteroid use. Method: A cross-sectional study was carried out on 90 patients with vitiligo. The Vitiligo European Task Force questionnaire was completed for each patient. A control group comprising 90 healthy individuals who did not have vitiligo and who were matched on age and gender was used for comparison. A complete ophthalmologic examination was performed. A family history of glaucoma and the use of topical steroids were recorded. Results: Two (2/90, 2.2%) of the patients with vitiligo had glaucoma compared with none of the individuals in the control group (P = .25). Nineteen of the 90 patients with vitiligo used periorbital steroids, and of these patients, 10.5% (2/19) developed glaucoma. The duration of periorbital corticosteroid use was 4.50 ± 2.1 years. Eighty-nine percent (17/19) of the vitiligo patients who applied the potent topical corticosteroid (class I) clobetasol propionate to the periorbital area did not develop glaucoma. In contrast, glaucoma was not observed in 79% (71/90) of the vitiligo patients who did not use steroids. Cataract, uveitis, or fundus problems were not observed in either group. Conclusion: The study suggests that patients who have vitiligo and use topical steroids periorbitally do not have an increased risk of glaucoma or cataracts. Future studies that have a larger sample size and use a detailed steroid use protocol are needed.

Is there a real relationship between serum level of homocysteine and vitiligo? A controlled study on 306 subjects.

To the Editor: Vitiligo is a skin disease characterized by the development of white macules and patches. The etiology of vitiligo is complex; there appears to be a certain genetic predisposition and a number of potential precipitating causes. Reduced serum levels of folic acid (FA) and vitamin B12 have been found in patients with vitiligo. It has been reported that vitiligo improves after treatment with FA and vitamin B12. 6 Both FA and vitamin B12 are required as cofactors by the enzyme homocysteine methyltransferase for the regeneration of methionine from homocysteine (Hcy) in the activated methyl cycle. Consequently, a nutritional deficiency in either of these two vitamins results in an increase in Hcy and a decrease in methionine levels in the circulation. It was also suggested that Hcy has an inhibitory action on histidase and tyrosinase activity of the skin. Therefore, it is possible that an increase in local Hcy interferes with normal melanogenesis and plays a role in the pathogenesis of vitiligo. Our study included 153 vitiligo patients and 153 ageand sex-matched controls. The duration of vitiligo, activity of the disease, and family history for vitiligo were noted, and the percentage of the area of the vitiligo lesions was measured. The exclusion criteria included intake of FA, vitamin B12, or vitamin B6 or hormonal therapy; pregnancy; cigarette smoking; having diseases known to affect Hcy levels, including genetic disorders of amino acid metabolism; and any comorbid disease. A fasting 3 mL blood sample was drawn and centrifuged at 3,000g after clotting for 10 minutes. Serum Hcy was measured using the Axis Homocysteine Enzyme Immunoassay kit (Axis-Shield Diagnostics Ltd., Dundee, UK). This kit is an enzyme immunoassay for the determination of Hcy in blood. Serum levels of FA and vitamin B12 were assessed by immunoassay using an autoanalyzer (Unicel DxI 800, Access Immunoassay System, Beckman Coulter, Inc., Fullerton, CA). FA levels of , 2.5 ng/mL ( normal range 2.7–17.0 ng/mL), vitamin B12 levels of , 190 pg/mL (normal range 200–800 pg/mL), and Hcy levels of . 20 mmol/L were considered abnormal (normal range 5.7–19.6). The median age of the patients was 28 years (range 22– 34.5 years). Eighty-seven patients were male and 66 were female. The mean duration of vitiligo was 8.5 years (range 4–15 years). The body surface area ranged between 0.1 and 23%. The median serum Hcy level in cases and controls was 12.73 mmol/L and 12.94 mmol/L, respectively (p 5 .94). The median FA level was 10.0 ng/mL in patients and 7.60 ng/mL in controls (p 5 .001). The median vitamin B12 level was 351.6 pg/mL in patients and 356.85 pg/mL in controls (p 5 .76) (Table 1). The median levels of Hcy, FA, and vitamin B12 were not affected by the type of vitiligo and activity (p 5 .08) (Table 2 and Table 3). The results of our study revealed that there was no association between serum levels of Hcy and vitamin B12 and vitiligo (see Table 1). FA was higher in patients than in controls, which is contrary to a previous study. It is unclear whether this may be attributable to genetic or nutritional factors. In a study by Karadag and colleagues, subjects with vitiligo had significantly higher homocysteine levels than controls but lower vitamin B12 and holotranscobalamine levels. A study by Shaker and El-Tahlawi revealed that the mean serum Hcy level was significantly higher in patients with progressive disease. However, the sample size was extremely small (26 patients only), which was not enough to make viable statistical decisions, and no controls were used. Another recent study by Silverberg and Silverberg demonstrated the association between serum Hcy and extent of vitiligo, suggesting Hcy as a new biomarker of vitiligo extent. Another conflicting study by Balci and colleagues on the same issue revealed that there was no relationship between serum Hcy, FA, and vitamin B12 levels and vitiligo. 13 Singh and colleagues reported higher levels of Hcy in male vitiligo patients compared to healthy controls. The Hcy level in vegetarian patients was significantly higher compared to that in nonvegetarian patients. Our results are somewhat different from those of previous studies, which reported no significant differences in FA levels in vitiligo patients compared to healthy controls. This might help resolve the conflict in the DOI 10.2310/7750.2013.13050

Successful treatment of atrophic facial leishmaniasis scars by co2 fractional laser.

Background: A permanent, unpleasant atrophic leishmaniasis scar is a potentially disfiguring condition that causes social stigma with limited treatment choices. Fractionated carbon dioxide (CO2) laser resurfacing is expected to be a safe and effective treatment for leishmaniasis scars. Objective: To assess the safety and efficacy of ablative fractional resurfacing (AFR) with a CO2 laser for facial leishmaniasis atrophic scars. Methods: Eleven patients (five males, age 18–47 years) underwent the fractional CO2 laser procedure. The mean duration for scars was 18.3 years. Three to five treatment sessions with the fractional laser eCO2 (10,600 nm, Lutronic Corporation, Gyeonggi-do, Korea) were performed for each patient, at 2-month intervals, under topical anesthesia. Two passes (with tip type 120, density 150 spots/cm2 in static mode, and peak power of 30 watts) were performed on each leishmaniasis scar. Pulse energies ranged between 100 and 140 mJ. Posttreatment improvements in texture, atrophy, and overall satisfaction with appearance were graded on a quartile scale 1 month after the second session and 3 months after the final session. Scar improvement was graded using a 4-point score with a maximum score of 20. Results: At the 3-month posttreatment follow-up, all subjects were rated as having at least 50% improvement in texture, atrophy, borders, and overall appearance of scars. The median score of improvement was 18 of 20 (range 11–19). Mild postinflammatory hyperpigmentation was the only adverse effect, observed in 18% (2 of 11) of subjects. After the procedure, moderate to severe erythema and edema typically resolved within 24 to 48 hours. No additional adverse effects were observed. Conclusion: Fractional CO2 resurfacing represents a safe, effective, and well-tolerated potential treatment for atrophic facial leishmaniasis scars in ethnic skin.

Multivariate Analysis of Factors Associated with the Koebner Phenomenon in Vitiligo: An Observational Study of 381 Patients

Background The Koebner phenomenon (KP) is a common entity observed in dermatological disorders. The reported incidence of KP in vitiligo varies widely. Although the KP is frequently observed in patients with viltiligo, the associated factors with KP has not been established yet. Objective The aim is to estimate the prevalence of KP in vitiligo patients and to investigate the associated factors with KP among vitiligo characteristics. Methods A cross-sectional observational study was conducted using 381 vitiligo patients. Demographic and clinical information was obtained via the completion of Vitiligo European Task Force (VETF) questionnaires. Patients with positive history of KP were extracted from this vitiligo database. Multivariate analysis was performed to assess associations with KP. Results The median age of cases was 24 years (range, 0.6~76). In total, 237 of the patients were male (62.2%). Vitiligo vulgaris was the most common type observed (152/381, 39.9%). Seventy-two percent (274/381) patients did not exhibit KP, whereas 28.1% (107/381) of patients exhibited this condition. Multivariable analysis showed the following to be independent factors with KP in patients with vitiligo: the progressive disease (odds ratio [OR], 1.82; 95% confidence interval [95% CI], 1.17~2.92; p=0.041), disease duration longer than 5 years (OR, 1.92; 95% CI, 1.22~2.11; p=0.003), and body surface area more than 2% (OR, 2.20; 95% CI, 1.26~3.24; p<0.001). Conclusion Our results suggest that KP may be used to evaluate disease activity and investigate different associations between the clinical profile and course of vitiligo. Further studies are needed to predict the relationship between KP and responsiveness to therapy.

Prepubertal and postpubertal vitiligo: a multivariate comparative study in 375 patients

Background The onset of vitiligo during childhood is common. Limited data exist that compare the clinical associations of prepubertal and postpubertal vitiligo in Arabs. Objective To compare the clinical profile of pre and postpubertal onset vitiligo. Methods A cross-sectional observational study was conducted. The Vitiligo European Task Force questionnaire was completed for each patient. Results A total of 375 patients were included; 199 had postpubertal vitiligo (>12 years), and 176 had prepubertal onset vitiligo (<12years). There were more females in the prepubertal group (49%) than in the postpubertal group (29%), p-value <0.001. The prepubertal group has had more involvement than the postpubertal group (45% vs 30%, p=0.004). Only 8 cases of segmental vitiligo were observed; five were observed in the prepubertal group of patients. Female gender (OR=2.3; 95% CI:1.5, 3.5), presence of halo nevus (OR=2.2; 95% CI:1.1, 4.4) and face involvement (OR=1.9; 95% CI:1.2, 2.9) were positively associated with prepubertal vitiligo. Stress, as an onset factor, was positively associated (OR=0.51; 95% CI:0.3, 0.8) with postpubertal onset vitiligo. Study limitations A possible selection bias toward more severe vitiligo cases can be a limitation, because the study was conducted in a clinic specialized in vitiligo. Moreover, a likelihood of false recall bias cannot be excluded. Conclusions Our data present clinical evidence that vitiligo behaves mostly the same way in the prepubertal group as in the postpubertal group. However, female over-representation, more face involvement and more halo nevi were observed in prepubertal vitiligo, while stress was more prevalent as an aggravating factor in postpubertal vitiligo patients.

Pilot trial evaluating the treatment of focal vitiligo with intralesional honeybee venom injection.

385 Exclusion criteria included allergy to BV or histamine, intake of chronic antihistamines, and use of any ~-blocker or systemic steroids within the last 2 months. Clinical assessment and photographs at baseline, 3 months, 6 months, and 9 months were done and evaluated according to visual repigmentation grading. The size and number of lesions were evaluated. Slight erythema and wheal formation was seen at the injection site. Repigmentation was recorded as absent (grade 0), moderate « 50%, grade l), good (between 50 and 75%, grade 2), and excellent (> 75%, grade 3) for each lesion. A multiple-dose vial of apitoxin (Apimeds, Inc., Korea & USA) contains 1.0 mg pure dried BV (which can make 10 standard doses). Each milligram of BV was diluted with 1 mL of normal saline. All patients were tested for allergy before the first treatment with apitoxin. A typical normal response appeared as a 0.5 to 1.0 em wheal and 2.5 to 3.8 cm eythematous changes surrounding the injection site. A patient was considered positive to the allergy test if he or she developed urticaria, facial or generalized angioedema, dyspnea, or anaphylactic shock. Allergic patients are not to be treated with apitoxin. The patient was regarded as negative to the test if he or she did not develop any systemic reactions 15 to 30 minutes after the intradermal injection of 0.05 mL of apitoxin. A single standard dose of 0.1 mLlcmz of vitiligo lesion was administered intradermally. Injections were spaced 1 em apart. A tuberculin syringe with a small-bore needle (25 gauge) was used for accuracy of dose measurement and ease of administration. Initial results with a concentration of I mg/l mL (BY with normal saline) once a week were inadequate. After 3 months, no change was noted in the lesions; therefore, we increased the concentration of injection to 2 mg/mL and frequency to twice weekly. This regimen was followed for 3 months. Therefore, the total duration of treatment was 6 months. At 6 months of treatment and for 3 more months of follow-up, we did not find any change, repigmentation, or aggravation in vitiligo lesions compared to control lesions in all patients. Lack of a response in our pilot clinical trial showed that BV probably has no role in vitiligo management. However, no patient experienced any significant side effect, such as infection, severe allergy, or systemic reaction. It seems that BY therapy is effective in in vitro