A Patient-Centric Approach of Ayurveda in the Management of Vitiligo: A Case Report

Background: Recent studies have confirmed that both hereditary and environmental influences contribute to the onset of vitiligo. Among the key immune elements involved are CD8+ T cells and Interferon-Gamma (IFN-γ), which play a critical role in melanocyte destruction. Immunomodulatory drugs like azathioprine, an oral agent with established suppressive effects on T-cell activity, have been introduced to help slow the progression of the disease. Another promising addition to the therapeutic options is tofacitinib, a Janus Kinase (JAK) inhibitor that works by blocking IFN-γ-driven inflammation-one of the central mechanisms in the formation of vitiligo patches. These developments offer new avenues for controlling immune-mediated skin damage in affected individuals. The purpose of this study was to compare the therapeutic efficacy of tofacitinib with azathioprine pulse therapy in reducing disease activity among patients with vitiligo. Aims and objectives: The aim of this study was to compare the therapeutic efficacy of tofacitinib with azathioprine pulse therapy in reducing disease activity among patients with vitiligo, as measured by changes in the Vitiligo Area Severity Index (VASI) and Body Surface Area (BSA) involvement. The primary objective was to evaluate whether tofacitinib demonstrates superior clinical outcomes compared to azathioprine. The secondary objective was to assess the safety and tolerability of tofacitinib in the treatment of vitiligo. Methodology: All patients aged above 12 years with a clinical diagnosis of vitiligo, attending the dermatology outpatient department of our institution and providing written informed consent, were enrolled in the study. Participants were randomly allocated into two groups: Group A received azathioprine at a dose of 50 mg on two non-consecutive days per week, while Group B was administered tofacitinib 5 mg twice daily. Both groups were advised to follow each dose with controlled sun exposure. Standardized clinical photographs were obtained at each monthly follow-up to monitor treatment response. Results: The mean reduction in both VASI and BSA scores was consistently greater in the tofacitinib group compared to the azathioprine group at all follow-up visits. In the azathioprine group, the average VASI scores at baseline and at the 1st, 2nd and 3rd monthly visits were 13.82, 12.25, 10.43 and 7.56, respectively. Corresponding mean BSA values were 10.65, 9.58, 8.20 and 7.61. In contrast, the tofacitinib group demonstrated a more pronounced reduction, with mean VASI scores of 14.86, 12.30, 9.32 and 6.94 across the same time points and BSA values declining from 11.35 at baseline to 9.20, 7.10 and 5.10 by the third visit. As illustrated in Fig. 1,2, the average change in both VASI and BSA from baseline was significantly higher in the tofacitinib group at each visit. Importantly, no adverse effects were reported in either treatment arm throughout the study period. Conclusion: Tofacitinib, when used in conjunction with controlled sun exposure, appears to induce more rapid repigmentation and better disease control compared to oral azathioprine pulse therapy in patients with vitiligo, as evidenced by the greater improvements in VASI and BSA scores over time.

Phototherapy is the most commonly used treatment for vitiligo, with initial pigment appearing at the perifollicular site, eventually coalescing into uniform pigmentation due to melanocyte migration from hair follicles. Melanocyte activity is higher during the anagen phase of the hair cycle, which is prolonged by minoxidil. To assess if topical minoxidil enhances the rate of pigmentation during phototherapy for the treatment of vitiligo. In this double-blinded, randomized control study, the efficacy of minoxidil in inducing repigmentation was compared with the vehicle used as a placebo. Thirty vitiligo patients with a minimum of 2 patches were included and randomized into 2 groups and treated with phototherapy. Minoxidil 5% solution was randomly applied on one patch and vehicle on the other patch. The vitiligo area severity index (VASI) score of the lesion was measured at baseline and then at 4, 8, and 12 weeks for each lesion. Physician and patient global assessment scores were recorded at week 12. In minoxidil group, the baseline VASI score of 94 ± 9.68% reduced to 47.76 ± 17.25% at 12 weeks. In the placebo group, the VASI score reduced from 94 ± 9.68% to 67.93 ± 16.88%. Reduction in VASI was found to be greater in minoxidil group as compared with the placebo group ( P value = <0.001). The difference in the physician and patient's global assessment scores in both minoxidil and placebo groups was also statistically significant. The study had a small sample size and a short follow-up period. Concomitant use of phototherapy and minoxidil increases the rate of pigmentation with reduction in VASI score.

Vitiligo is a common chronic hypomelanotic skin disorder. An intricate pool of markers associated with a complex combination of biological and environmental factors is thought to be implicated in etiology. This study aims to investigate the most important markers associated with vitiligo pathogenesis, including redox status, inflammation, and immune profile, in patients with vitiligo. The study included a total of 96 subjects: 30 patients with active non-segmental vitiligo, 30 patients with stable non-segmental vitiligo, and 36 controls. The vitiligo area severity index (VASI) and vitiligo disease activity score (VIDA) were determined. The following serum parameters were assessed: antioxidant status (TAS), superoxide dismutase activity (SOD), catalase activity (CAT), glutathione peroxidase activity (GPx), glutathione-S-transferase activity (GST), malondialdehyde (MDA), advanced oxidation protein products (AOPP), C reactive protein (CRP), interleukin-15 (IL-15), and chemokines (CXCL9, CXCL10). The VASI score was not significantly different between active and stable vitiligo patients, as it was approximately 0.1. TAS, CAT, GPx, and GST were significantly lower in vitiligo patients compared to controls (p < 0.05). They were also significantly lower in active vitiligo when compared to stable vitiligo (p < 0.05). However, SOD levels were significantly higher in vitiligo patients than in controls and in the active vitiligo group than in the stable vitiligo group (p < 0.05). MDA and AOPP levels were significantly higher in patients with active and stable vitiligo compared to controls (p < 0.05). However, they did not significantly differ between active and stable vitiligo patients (p < 0.05). In both active and stable vitiligo, CRP and IL-15 were significantly higher than controls (p < 0.05). Whereas CRP was significantly higher in active (range = 2.0-7.2, mean = 4.46 ± 1.09) than in stable vitiligo (range = 1.6-6.7, mean = 3.75 ± 1.08) (p < 0.05). There was no significant difference in IL-15 levels between active and stable vitiligo. In both active and stable vitiligo, CXCL9 and CXCL10 were significantly higher than controls (p < 0.05), and they were significantly higher in active than stable vitiligo (p < 0.05). In vitiligo, oxidative damage induces an increase in pro-inflammatory IL-15, which in turn promotes IFN-γ-inducible chemokines such as CXCL9 and CXCL10. Further, there seems to be a link between the VASI score and IL-15 levels. These data imply that inhibiting IL-15 could be a promising method for developing a potentially targeted treatment that suppresses the early interplay between oxidant stress and IL-15 keratinocyte production, as well as between resident and recirculating memory T cells.

Vitiligo is an acquired autoimmune depigmenting disorder that is the result of white macules formation in the skin and mucous membranes, caused by the loss of melanocytes. It has affected 0.4 to 2.0% of world’s population. It has been hypothesized that Vitamin D is important for skin pigmentation, but the correlation between vitamin D and vitiligo treatment response needs to be evaluated. To evaluate vitamin D supplementation effect on the vitiligo area severity index in patients treated with narrow band UVB (NB UVB). This clinical pilot randomized study was carried out on 48 vitiligo patients who admitted to the Department of Dermatology at Imam Khomeini Hospital. Patients were randomly divided into two groups: intervention group which received vitamin D supplementation with a dose of 50,000 units once every 2 weeks, for 8 weeks. The rest of the patients were put in control group and consumed placebo. Treatment with NB UVB irradiation with a starting dose of 0.3 j/CM2 was carried out twice a week for all patients. Our study included 21 males and 27 females. The mean age of patients was 28.08 years old. The disease’s duration ranged from 1 to 15 years, with the mean of 4.52 ± 4.2 years. Sex distribution and mean age were not significantly different in either groups. Vitamin D deficiency was seen in 32 (66.7%) of the patients. Vitiligo area severity index (VASI) score significantly decreased from 27.14 to 4.4 in intervention group and from 7.7 to 3.28 in control group. The correlation between mean 25(OH)D serum levels and VASI before and after intervention was statistically insignificant. NB UVB could significantly improve regimentation in vitiligo patients. Moreover, it significantly increased the serum level of vitamin D. But we have failed to demonstrate any significant correlation between serum level of vitamin D and VASI score in vitiligo patients.

Background: Vitiligo is a chronic progressive depigmented skin disorder, characterized by extensive melanocytes destruction. The explanation for the skin problem remains unknown. Human paraoxonase-1 (PON1) is a hepatic calcium-dependent esterase. PON1 is related to high-density lipoprotein (HDL). Reduction in serum PON1 activity has been recorded to be accompanied by certain pathological conditions under oxidative stress situations. Objective: To evaluate the serum PON1 activity as an indicator of oxidative stress in patients with non-segmental vitiligo (NSV). Patients and Methods: This case-control study included 2 groups, group (A) included 20 patients with NSV and group (B) included 20 age and sex matched healthy controls. The Vitiligo Area Severity Index (VASI) score was used to assess the disease severity. Serum PON1 level was measured using enzyme-linked immunosorbent assay (ELISA). Results: The mean VASI score was 9.86±15.61. The mean PON1 level demonstrated a statistically significant difference between both groups (p=0.002), suggesting that vitiligo cases may be associated with low PON1 levels. PON1 levels showed a significant negative correlation with the severity score measured by the VASI. Only PON1 was found to be a significant predictor of vitiligo severity. Conclusion: Vitiligo cases were associated with a reduction in PON1 level, which emphasizes the underlying theory of disease progression and could emphasize the effect of free radicals and leading oxidative damage in vitiligo. Low PON1 was found to be a significant predictor of a higher VASI score.

Objective To correlate between serum vitamin D levels and severity of vitiligo. Background Vitiligo is an acquired depigmentary disorder that affects more than 0.5–1% of the worldwide population. Vitamin D has been implicated in the pathogenesis of various autoimmune diseases. The correlation between vitiligo and vitamin D is discussed in this study. Patients and methods This case–control study was conducted on 60 patients with vitiligo and 60 age-matched and sex-matched healthy individuals. All patients were recruited from the Outpatient Clinic of Dermatology and Andrology Department of Shebeen El-Kom University Hospital between 1 May 2018 and 31 August 2018. Blood samples were taken, and serum levels of vitamin D were measured by enzyme-linked immunosorbent assay technique. Serum levels of vitamin D were statistically analyzed in relation to Vitiligo Area Severity Index (VASI) score using Spearman coefficient test. Results The patients had higher serum vitamin D levels than the controls with highly significant difference (P Conclusion There was no significant correlation between vitamin D levels and VASI score. Future larger controlled studies are required to obtain a wider assessment of the relationship between vitamin D level and vitiligo disease severity.

Background: Vitiligo is a type of autoimmune disease (AID) of the skin that is acquired and characterized by loss of melanocytes. The precise cause of vitiligo is still not well-identified. Autoimmune theory is the most supported by reliable laboratory and clinical data, particularly for non-segmental vitiligo (NSV). Objective: This study aimed to compare the levels of circulating autoantibodies namely anti-thyroperoxidase Ab (anti-TPO), anti-melanocyte Ab (AMA), anti-nuclear Ab (ANA), in the sera of vitiligo patients versus controls. Patients and Methods: This was a case-control study enrolled 50 vitiligo cases and40 healthy with matched age and sex as control group. The degree of vitiligo was assessed using the vitiligo area severity index (VASI) score. All patients and controls had laboratory test for measurement of anti-thyroperoxidase Ab, anti-melanocyte Ab and anti-nuclear Ab by ELISA kits. Results: There were significantly higher median levels of anti-TPO Ab, AMA and ANA compared to the control group. There were no significant differences in anti-TPO Ab levels, AMA levels and ANA levels based on gender, smoking status, and family history. There was a significant positive relationship between levels of anti-TPO Ab, AMA and ANA and the VASI score. Conclusion: There was a potential relationship between anti-TPO Ab levels, AMA levels & ANA levels and disease severity. These results suggest that higher levels of these antibodies are associated with increased disease severity (assessed by VASI) in vitiligo patients.

Background: Interleukin 17 (IL-17) has recently been implicated in the pathogenesis of vitiligo by many studies but it is unclear whether it has any definitive role in causing depigmentation. IL-17 inhibitors have already been used in other inflammatory disorders with good results and may prove to be a valuable therapeutic modality in vitiligo. Thus, this study aims at adding to the existing data on the role of IL-17 in the pathogenesis of vitiligo. Objectives: (1) To determine the correlation between IL-17 and the extent of body surface area involvement. (2) To determine the correlation between IL-17 and the severity of disease activity. (3) To determine the correlation between IL-17 and serum vitamin D levels. Methodology: Thirty-two clinically diagnosed patients with vitiligo and 26 age- and sex-matched controls who fulfill the inclusion criteria were enrolled in the study. After obtaining a detailed history, a complete dermatologic examination was performed and vitiligo area severity index (VASI) and vitiligo disease activity score (VIDA) were assigned. The baseline serum IL-17 level was measured using Raybiotech serum IL-17 enzyme-linked immunosorbent assay kit. Serum vitamin D was measured for all cases and controls. Results: In our study, the mean VASI score of all the patients was 6.32 ± 10.14 and the mean VIDA score was 1.97 ± 0.999. The mean serum IL-17 levels were 155.72 ± 79.412 pg/mL in patients with vitiligo compared to 102.73 ± 56.478 pg/mL of the controls, with a mean difference of 52.99 pg/mL and the difference was statistically significant (P = 0.008). Although, there is no significant correlation between the serum IL-17 levels with the VASI score, our study noticed slightly higher levels of IL-17 in generalized vitiligo and lowest levels were noticed in localized vitiligo. Limitations: Our study was limited by the small sample size of 32. Conclusion: Although, serum IL-17 levels were significantly higher in the patient group than the controls, there was no correlation with the disease extent or activity. Thus, it is difficult to establish a causal role of serum IL-17 in vitiligo.

Genome-wide association study and gene editing reveals the causal gene responsible for abnormal red skin color in Yellow River carp

Objective To evaluate the efficacy of long-term treatment with tacrolimus ointment in patients with vitiligo. Methods A total of 156 patients with vitiligo (70 males and 86 females) were enrolled into this study, who were firstly diagnosed with vitiligo and continuously followed up in Department of Dermatology, Yiwu Dermatology Hospital and the Third People′s Hospital of Hangzhou between January 2016 and February 2018. Of the 156 patients, 114 were adults, and 42 were children aged 6 - 18 years. All the patients received 6-month treatment with tacrolimus ointment twice a day. They were followed up once a month, the time to initial repigmentation and vitiligo area severity index (VASI) were recorded, and VASI improvement rate was calculated. After 6-month treatment, the patients achieving marked improvement were divided into conventional treatment group and interval treatment group to be treated with tacrolimus ointment twice a day and once every 3 days respectively for another 6 months, and final efficacy of the 2 protocols was compared. Mauchly′s test of sphericity, randomized block analysis of variance and Bonferroni method were used to analyze differences among pre-treatment VASI scores, and 1- to 6-month post-treatment VASI scores. Results Among the 156 patients, the pre-treatment, and 1-, 2-, 3-, 4-, 5- and 6-month post-treatment VASI scores[M (P25, P75) ] were 2 (0.6, 5) , 2 (2, 5) , 1.6 (0.575, 4.5) , 1.2 (0.5, 4.0) , 0.4 (1.15, 3.5) , 0.75 (0.3, 2.575) , 0.6 (0.2, 2.2) respectively. Additionally, there was a significant difference in the VASI score among the above time points (F = 6.14, P 0.05) . Conclusions The initial 6-month topical tacrolimus therapy showed marked efficacy for vitiligo. After the marked improvement of skin lesions, good efficacy can be maintained by long-term treatment with topical tacrolimus once every 3 days or twice a day. Key words: Vitiligo; Therapy; Tacrolimus; Long-term treatment

Vitiligo is a prevalent destructive melanocyte skin disease that negatively affects the patients' life in terms of self-esteem. Suction blister and dermabrasion plus 5-fluorouracil are effective treatments for vitiligo. The present study was conducted to compare the outcomes of these two techniques. The present clinical trial was conducted on 36 patients with persistent refractory vitiligo which defined as the lack of any new or progressed lesion during the previous year as well as no responding to conventional therapies of vitiligo including topical treatments and phototherapy. Individuals with two vitiligo patches, with similar baseline Vitiligo Area Severity Index (VASI) scores were randomly allocated to dermabrasion plus 5-fluorouracil or suction blister treatments. VASI and repigmentation scores were measured and compared at the baseline, four, and 12 weeks after performing the procedures. Both of the approaches accompanied with significant improvement in both entities of VASI and repigmentation scores (P value < .05) at the end of the study, besides the trend of VASI and repigmentation scores between the two groups revealed insignificant difference (P > .05). The short-term follow-up of the patients was the limitation of this study. The present findings suggested that both surgical techniques of dermabrasion plus 5-fluorouracil and suction blister posed acceptable outcomes within 12-week follow-up.

In vitiligo, there is a significant decrease in melanocytes and melanin. The decrease in melanin causes oxidative stress, with a chance of causing metabolic syndrome. Hence, there is a need to look for metabolic syndrome in vitiligo. To estimate the prevalence of metabolic syndrome in vitiligo patients and to evaluate the relationship between the severity and progression of vitiligo and metabolic syndrome. A hospital-based cross-sectional study was conducted on 178 vitiligo cases and 178 controls who were age- and sex-matched. The type of vitiligo, stability by vitiligo disease activity score (VIDA), and severity by vitiligo area severity index (VASI) were noted. The waist circumference, blood pressure, fasting lipid profile, and fasting blood sugar were measured for cases and controls. Metabolic syndrome was diagnosed based on Harmonization Asian criteria. The mean age in cases was 34.38 years, and in controls, it was 35.67 years. The majority were females in both cases (52.2%) and controls (55.6%). Most have a VIDA score of 2+ (41.6%). The mean VASI score was 2.54. The percentage of metabolic syndrome was higher in cases (36%) compared to controls (24.2%) (P = 0.015). The mean age was lower in vitiligo cases with metabolic syndrome (38.83 years) compared to controls with metabolic syndrome (43.14 years). Metabolic syndrome was more frequent in the vitiligo vulgaris type (48.9%) than in acral and segmental vitiligo. Metabolic syndrome was more common in patients with high VIDA (45%) and VASI (52.3%) scores compared to patients with low VIDA (25%) and VASI (27.3%) scores. It is a hospital-based study, so controls were not from the general population. The prevalence of metabolic syndrome was higher in vitiligo patients compared to controls, and it was higher in patients with active and severe disease. Screening and close monitoring of vitiligo patients help in the early diagnosis of metabolic syndrome and reduce the risk of cardiovascular disease.

Vitiligo is a chronic depigmentary skin disorder, characterised clinically by the development of white macules and or patches caused by loss of epidermal melanocytes. S100B is a dual function protein released from epidermal melanocytes in response to injury. It considered a possible marker of disease activity in both malignant melanoma and vitiligo. To estimate the serum level of S100B level in vitiligo patients and correlate its level with disease activity and various disease parameters. Sixty vitiligo patients and 60 healthy volunteers as controls were included in the study. Vitiligo Area Severity Index (VASI) and Vitiligo Disease Activity (VIDA) scores were estimated for each patient. Quantitative assessment of S100B level using ELISA technique was done for all participants. S100B level was significantly correlated with the presence of vitiligo (P=0.01), while it showed no correlation with the disease activity using VASI or VIDA scores. As regards the receiver operating characteristic (ROC) curve analysis of S100B for diagnosis and discrimination of vitiligo, serum S100B showed area under the curve (AUC) of 0.781 with 73.3% sensitivity and 80% specificity. The serum level of S100B was related to the presence of vitiligo, but its level did not show any relation to the disease activity using either VASI and VIDA scores or various disease parameters.

Background: Vitiligo is characterized depigmented macules and patches over the skin. It has a major impact on the quality of life (QoL) of patients, many of whom feel distressed and stigmatized by their condition. Aim: To assess QoL in vitiligo patients in terms of clinical severity and psychological burden. Materials and Methods: An observational study on 60 patients with age ≥16 years was conducted at an outpatient department of a tertiary care hospital. Data were collected in a predesigned pro forma. The QoL of patients and family members was assessed using Dermatology Life Quality Index (DLQI) and Family DLQI (FDLQI), respectively. The clinical severity was measured using Vitiligo Area Severity Index (VASI) and psychological burden by Vitiligo Impact Score-22 (VIS-22) questionnaire. Results: Sixty patients were included in the study. The mean age was 35.27 ± 2.24. Male-to-female ratio was 1.1:1. About 51.7% of patients were married. Majority of patients were students (30%). The time of presentation after disease onset was 5 years. About 20% of subjects had positive family history. The common sites were face (75%), lower limb (71.67%), and upper limb (60%), with leukotrichia in 11.7% of patients. The mean VASI score at baseline and at 1-month of follow-up after starting treatment was 4.11 ± 0.38 and 3.59 ± 0.58, respectively. The mean DLQI, FDLQI and VIS-22 score were 11.73 ± 0.80, 10.58 ± 0.71, and 37.32 ± 1.53, respectively. VIS-22 and VASI score correlated with changes in DLQI (P &lt; 0.059). Conclusion: Vitiligo largely impairs the QoL of patients. The more the clinical severity (high VASI score), the higher the psychological burden, impairing QoL of patients, and family members.

Objective: Vitiligo is an autoimmune disease marked by the presence of hypopigmented macules due to the reduction in the number and function of melanocytes. Besides its adverse cosmetic effect, vitiligo is also associated with other autoimmune diseases such as thyroid disorders. Ultraviolet irradiation, especially narrowband ultraviolet B (NB-UVB), has been widely used in treating vitiligo despite the unclear mechanism. However, such studies in Indonesian population are very limited. This study aims to examine the efficacy of NB-UVB in vitiligo treatment and its effect of thyroid function in Indonesian population.Material and Methods: Twenty-two vitiligo patients aged 4-54 years old were treated three times weekly with NB-UVB. The minimal erythema dose (MED) was determined and an initial dose of 50% MED dose was commenced three times per week. The dose was increased gradually while assessing for the treatment response. The change in depigmentation rate, vitiligo area severity index (VASI), and the level of thyroid stimulating hormone (TSH) were assessed before and after therapy using Wilcoxon test.Results: Depigmentation rate and VASI score were found to decrease after treatment, although the change was not statistically siginificant. Two patients showed an decrease in depigmentation rate of more than 75%. The TSH level significantly decreased after treatment (p&gt;0.05). The most common side effect found was the combination between erythema, soreness, and pruritus.Conclusion: Our study shows that NB-UVB therapy results in improved depigmentation, VASI score and a reduced TSH level in vitiligo patients.