There are many types of vitiligo treatment methods and drugs, and although some progress has been made in recent years in photochemotherapy, medium wave ultraviolet therapy, Chinese medicine therapy, immunosuppressant and other drug treatments, there is no cure yet. The hotspot for vitiligo treatment is how long the re-coloring induction therapy should last and the trade-off between the pros and cons of applying different treatment options for a long period of time. The aims of treatment are to.
(i) stimulate the local abnormal melanocytes and promote their development and regeneration to produce more melanin;
(2) To inhibit the progression of the disease so that the lesions do not continue to expand;
(3) to make the pigmented area around the lesion lighter and the edges less distinguishable.
Njoo et al. (1999) established guidelines for the selection of treatment methods based on a comprehensive analysis of literature and clinical questionnaires based on an evidence-based approach, which has some reference value for clinical application.
Table Selection of vitiligo treatment methods
Target group
Clinical type
Preferred option
Alternative
80 %
Topical bleaching cream and/or laser
None
Note: s is the percentage of skin lesion area to body surface area
1. Photochemotherapy (PUVA)
The mechanism may be to act on the residual melanocytes and activate tyrosinase to produce a growth factor in the serum or to affect the melanocytes through the immune system. PUVA not only has a long duration and rebound at the end of treatment, but can also cause adverse reactions caused by methoxyphenidate. The majority of patients have skin pigmentation after long-term irradiation, which can slowly fade 2-3 months after discontinuing treatment. Special eye protection must be worn when irradiated to prevent cataract formation; avoid direct sunlight when going out; doses exceeding 1500 J/cm2 can cause skin aging or even cancer. It is not suitable for children under 10 years old, pregnant women and lactating women.
For limited vitiligo can be topical PUVA therapy, that is, local topical 0.1% 8-MOP and then irradiation UVA, this method without systemic adverse reactions. In addition, PUVA therapy can also be used in the bath.
2.Medium wave ultraviolet (UVB) therapy
In 1997, Westerhof and Nieuweboer-Krobotova first reported the treatment of vitiligo with NB-UVB, and got similar efficacy with local PUVA treatment, and the adverse effects are less than PUVA. In addition, pregnant women and children can also be applied. The treatment of vitiligo is irradiated 2 to 3 times a week, requiring 30 to 50 or more treatments, with a total efficiency of more than 80%.
Najoo et al. used 311 nm UVB irradiation twice a week to treat 51 cases of childhood generalized vitiligo, resulting in 53% of patients with >75% pigment regeneration, and the better the pigment regeneration, the better the quality of life index (CDLQ I, an indicator of the psychosocial role of disease and treatment). Lotti et al. reported that after six months of treatment in eight patients with segmental disease, five of them had >75% pigment recovery, two had 100%, and two had 50-75%, while only one of the control group had pigment recovery and the area was <50%.
3. Drug treatment
3.1 Corticosteroids The development of vitiligo is related to autoimmunity. The application of corticosteroids may be the treatment of vitiligo by suppressing immunity. Generally, strong corticosteroids are used topically, such as sicorten. If combined with PU VA irradiation, the efficacy is superior to that of the drug or irradiation alone. Acne, skin atrophy, and capillary dilation may occur with long-term topical use. Use in children is recommended for up to 3 months.
For patients with extensive lesions and no contraindications to hormones, prednisone can be given orally 15-30 mg daily for 1.5-2 months, and then reduced by 1 tablet (5 mg) every 2-4 weeks to 1 tablet taken every other day for 3-6 months. The effect is usually seen within 1 month, and the medication is discontinued if it is not effective for 2 months. A 5-month observation showed that small doses of oral corticosteroids stopped the development of lesions and restored pigmentation without significant adverse effects in those with poor topical efficacy; the effect was more pronounced in men aged ≤15 years and with a disease duration ≤2 years. Seiter et al. used methylprednisolone shock therapy to treat progressive pancytopenia effectively. However, Radakovic-Fijan et al. reported that high-dose intermittent oral dexamethasone, after an average of 18 weeks of treatment, stopped the progression of the disease in most patients, but the recovery of pigmentation was not satisfactory and there were adverse effects such as weight gain, insomnia, menstrual disorders and acne.
The IPD inhibits the production of interleukin-4 (IL-4) by Th2 cells, which causes B cells to produce antibodies against their own melanocytes and has a destructive effect on melanocytes. The effect of IPD on melanocytes. The use of immune agents such as transfer factor, cyclosporine A, and Anapsos has been reported for the treatment of vitiligo. If we can further understand the immune basis of vitiligo and the therapeutic mechanism of immune agents, it is expected to find a better treatment method.
3.3 Carboplatin triol Recent studies at the molecular level have shown that there is an imbalance in the internal environment of calcium in vitiligo lesions and that vitamin D3 receptors are involved in melanocyte expression. Therefore, Parsad observed the response of 21 cases of juvenile and pediatric vitiligo to topical carboplatin triol (50 μg/g), which was administered nightly with sunlight exposure for 10-15 min the next day, and most of them showed pigment regeneration after 6-12 weeks of treatment, and the rest did not develop new lesions. In order to improve the efficacy and shorten the course of treatment, topical carboplatin triol can be used in combination with PUVA treatment.
3.4 Khellin plus UVA The chemical structure of khellin (khellin) is similar to that of psoralen, and the mechanism of its oral administration plus UVA (KUVA) for the treatment of vitiligo is unknown, probably by stimulating keratinocytes to release certain inflammatory mediators, which in turn act as melanocyte growth stimulating factors to enhance the function of melanocytes. The most common recent adverse effect is mild nausea. The most common recent adverse effect is mild nausea. The topical preparation of Kelin is more effective in the treatment of vitiligo. However, there are negative evaluations on its efficacy, so further observation is needed.
3.4 Chinese medicine treatment
According to the identification of Chinese medicine, vitiligo can be divided into the types of Qi and blood disharmony, dampness and heat in the spleen, liver depression and qi stagnation. Therefore, the internal medication should be treated according to the evidence and can be combined with local external application. In recent years, some people collected herbal formulas for vitiligo and used computerized formula dismantling to screen out dozens of frequently used herbal medicines into ethanol extracts and observed their effects on tyrosinase in isolation experiments. The results showed that more than 10 herbs such as Radix Paeoniae, Rhizoma Chuanxiong and Scutellariae enhanced tyrosinase activity and showed positive correlation with melanin production. If we can further study the effect of these herbs on melanocytes in vivo, it will not only provide a theoretical basis for Chinese medicine treatment of vitiligo, but also make Chinese medicine treatment of vitiligo become an ideal treatment method.
3.5 Other drugs
L-phenylalanine plus UVA, folic acid and vitamin B12, pseudoperoxidase, nerve growth factor, melanopoietin and pulsed Nd:YA G laser have all been reported to be successful in the treatment of vitiligo. In addition, for the large area of generalized vitiligo where the above treatments are ineffective, in addition to the traditional depigmenting agent hydroquinone monophenyl ether, there are foreign countries that use 4-methoxyphenol with ruby laser for depigmentation in the pigmented remnants. Due to the racial skin color difference, this therapy is only applicable to white people.
4.Surgical treatment
It is suitable for patients with vitiligo in the stationary phase and small lesion area.
4.1 Dermabrasion Application of dermabrasion to treat limited lesions can be accompanied by topical application of 5-fluorouracil (5-FU).
4.2 Intravitiligo injection method Local injection of corticosteroids has some efficacy. Atropine can also be injected locally: 0.5 mg in the center of each lesion, 3 times a week, 10 times a course of treatment, with an interval of 5 days between each course.
6.6.3 Autologous small skin slice transplantation A hole is punched with a 1-1.5 mm borer with an inner distance of about 5 mm to allow natural hemostasis. The donor area is freed and the skin slice is implanted in the hole of the recipient area. They are bandaged with pressure for 15 days to become viable, restore pigmentation, and spread to the surrounding area until they fuse with each other.
4.3 Autologous suction epidermal transplantation Select the skin of the non-exposed area with normal pigmentation as the donor area; use negative pressure (40-80kPa) to suction both the white spot area and the donor area for 2-3 hours to produce blisters; cut off the blisters of the recipient area, then transplant the top of the donor area blisters on the recipient area wound, dressing and fixing, 7 days later the transplanted skin becomes viable, and the pigmentation is restored in half to one month; also add temperature during negative pressure suction of blisters, which can shorten the time of blister formation and improve the survival rate of transplantation.
4.4 Mixed epidermal cell transplantation or autologous melanocyte transplantation Mixed epidermal cell or melanocyte transplantation by cell culture method, but the required experimental conditions are high.
5.Laser therapy
The treatment of vitiligo with laser began in the early 1980’s. In 1981, Toshio Ojo of the Japan Laser Institute used argon laser with wavelength close to ultraviolet light to spot irradiate the vitiligo area and achieved certain efficacy. Since then, some people at home and abroad have reported the efficacy of laser treatment.