Introduction

Vitiligo

Last Updated: April 14, 2007

Synonyms and related keywords: white spot disease, acquired leukoderma, nonpigmented skin, depigmented skin, depigmentation, hypopigmentation, loss of melanin, hypomelanosis, HLA-DR4, HLA-B13, HLA-B35, leukotrichia, trichrome vitiligo, blue vitiligo

Definition of Vitiligo

Vitiligo is an autoimmune disease in which pigment cells (melanocytes) are destroyed, resulting in irregularly shaped white patches on the skin. Any part of the body may be affected. Common sites are exposed areas (face, neck, eyes, nostrils, nipples, navel, genitalia), body folds (armpits, groin), sites of injury (cuts, scrapes, burns) and around pigmented moles (halo naevi). The hair may also go grey early on the scalp, eyebrows, eyelashes and body. White hair is called ‘poliosis’. The retina may also be affected.

Mucosal vitiligo

Trichrome vitiligo

Poliosis

Halo moles

A halo mole (or halo naevus) is a mole with a white ring, or halo, around it. It is sometimes known as Sutton naevus or leukoderma acquisitum centrifugum.

Halo moles are not uncommon and are usually seen in children or young adults of either sex.

Halo naevi

More images of halo naevi ...

Why do they arise?

For reasons which are unknown, the body selects a particular mole or moles for destruction. This is presumably because the mole is recognised as being abnormal in some way. It is considered an autoimmune process.

The mole in the centre of a halo is rarely malignant (cancerous) although all halo moles need to be examined carefully by an appropriate medical practitioner. A malignant mole is called a melanoma, and these may sometimes develop white halos around them as well.

Sometimes halo moles are triggered by sunburn which damages the mole and causes it to be recognised by the body as foreign.

A circulating antibody and special white cells (T cells) attack the pigment cells in the mole. This causes the central mole to fade from dark brown to light brown to pink, eventually disappearing completely. Some of the reaction affects the normal skin around the mole, which also has pigment cells in it, causing the white halo. This is usually about 0.5 to 1.0 cm wide, usually on the trunk. They are less common on the head, and are rare on the limbs. They develop at intervals round one or several moles but not all.

Once the the mole in the centre of the halo disappears, repigmentation can occur. This can sometimes take several years.

Pathophysiologyof vitiligo

: Mechanisms by which the melanocytes are lost may be multiple but are not yet identified unequivocally.

Some observations seem to support autosomal dominant inheritance with variable expression and incomplete penetrance. The disease itself is not inherited, but the disposition to have vitiligo is inherited.

Human leukocyte antigens (HLAs) may be associated but not in a consistent manner: HLA-DR4 is increased in blacks, HLA-B13 is increased in Moroccan Jews, and HLA-B35 is increased in Yemenite Jews. An association with HLA-B13 is described in the presence of antithyroid antibodies.

Frequency:

Internationally: Vitiligo is relatively frequent, with a rate of 1-2%. About 30% of cases occur with a familial clustering of cases.

Sex: No sex-related difference in prevalence is reported. The age of onset is unlikely to vary between the sexes.

Age: Vitiligo may appear at any time from birth to senescence, though the onset is most commonly observed in persons aged 10-30 years.

• It rarely is seen in infancy or old age. Nearly all cases of vitiligo are acquired relatively early in life.

• The average age of onset is around 20 years. The age of onset is unlikely to vary between the sexes.

• Heightened concern about the appearance of the skin may contribute to an early awareness of the condition among women.

clinic

History:

• In early vitiligo, white areas are not distinct and may be pruritic.

• Vitiligo primarily progresses without any symptoms.

• In late vitiligo, the tendency of the disease to spread can be stopped.

Physical:

• Vitiligo appears as sharply circumscribed, cosmetically disturbing, white spots that stand out. The appearance is particularly noticeable when the

unaffected skin is tanned.

o At first, only a few, small, and sharply circumscribed foci are present. The borders of these foci are often hyperpigmented.

o Lesions increase in number and become confluent, taking on bizarre shapes.

o Vitiligo lesions may be localized or generalized, with the latter being more common than the former.

� Localized vitiligo is restricted to 1 general area with a segmental or quasidermatomal distribution.

� Generalized vitiligo implies more than 1 general area of involvement. In this situation, the macules are usually found on both sides of the trunk, either symmetrically or asymmetrically arrayed.

o Most common sites of involvement are the face, neck, and scalp.

o Many of the most common sites of occurrence are areas subjected to repeated trauma, including the following:

� Bony prominences � Extensor forearm � Ventral wrists � Dorsal hands � Digital phalanges

o Involvement of the mucus membrane is frequently observed in the setting of generalized vitiligo.

o Vitiligo often occurs around body orifices such as the lips, genitals, gingiva, areolas, and nipples.

o Depigmentation of body hair in vitiliginous macules may be present. � Vitiligo of the scalp usually appears as a localized patch of

white or gray hair, but total depigmentation of all scalp hair may occur.

� Scalp involvement is the most frequent, followed by involvement of the eyebrow, pubic, and axillary hair, respectively.

� Leukotrichia may indicate a poor prognosis in regard to repigmentation.

o Clinical variants � Trichrome vitiligo has an intermediate zone of hypochromia

located between the achromic center and the peripheral unaffected skin. This results in three shades of color-brown, tan, and white-in the same patient (see Image 1).

� Marginal inflammatory vitiligo results in a red, raised border, which are present from the onset of vitiligo (in rare cases) or which may appear several months or year after the initial onset. A mild pruritus may be present (see Image 2).

� Blue vitiligo results in blue coloration of vitiligo macules. This

type has been observed in a patient with postinflammatory hyperpigmentation who then developed vitiligo.

• Clinical classification of vitiligo: The classification system is important because of the special significance assigned by some authorities to each type of vitiligo. The widely used classification of vitiligo as localized, generalized, and universal types is based on the distribution, as follows:

o Localized � Focal - One or more macules in 1 area but not clearly in a

segmental or zosteriform distribution � Segmental - One or more macules in a quasidermatomal

pattern � Mucosal - Mucus membrane alone

o Generalized � Acrofacial - Distal extremities and face � Vulgaris - Scattered macules � Mixed - Acrofacial and vulgaris involvement, or segmental

and acrofacial and/or vulgaris involvement � Universal - Complete or nearly complete depigmentation

o When progression, prognosis, and treatment are considered, vitiligo can be classified into 2 major clinical types: segmental and nonsegmental.

� Segmental vitiligo usually has an onset early in life and rapidly spreads in the affected area.

� The course of segmental vitiligo can arrest and depigmented patches can persist unchanged for the life of the patient (see Image 3).

� The nonsegmental type includes all types of vitiligo except segmental vitiligo (see Image 4).

Causes:

Four pathogenic theories have been discussed, as follows:

• Immune hypothesis: Aberration of immune surveillance results in melanocyte dysfunction or destruction.

• Neural hypothesis: A neurochemical mediator destroys melanocytes or inhibits melanin production.

• Self-destruction hypothesis: An intermediate or metabolic product of melanin synthesis causes melanocyte destruction.

• Genetic hypothesis: Melanocytes have an inherent abnormality that impedes their growth and differentiation in conditions that support normal melanocytes.

• Because none of these theories alone is entirely satisfactory, some have suggested a composite hypothesis.

oxidative stress \ This is one theory about what may cause or contribute to the onset or exacerbation of vitiligo. Oxidative stress is an over-accumulation of hydrogen peroxide in the skin. Every person develops hydrogen peroxide in the skin, as a result of natural biological processes. An enzyme called "catalase" normally breaks down the hydrogen peroxide in the skin into water and oxygen. However, some people with vitiligo may have a problem manufacturing, using or delivering catalase to the skin.

differentials

Leprosy Piebaldism Tinea Versicolor Tuberous Sclerosis

Other Problems to be Considered:

Idiopathic guttate-form hypomelanosis Nevus anemicus Nevus depigmentosus

workup

Lab Studies:

• Although the diagnosis of vitiligo generally is made clinically, biopsy is occasionally helpful in differentiating vitiligo from other hypopigmentary disorders.

• Vitiligo may be associated with other autoimmune diseases, especially thyroid disease and diabetes mellitus. Other associated autoimmune diseases include pernicious anemia, Addison disease, and alopecia areata.

• Patients should be made aware of signs and symptoms that suggest onset of hypothyroidism, diabetes, or other autoimmune disease. If signs or symptoms occur, appropriate tests should be performed.

o Thyroid-stimulating hormone (TSH) test is the most cost-effective screening test for thyroid disease.

o Screening for diabetes can be accomplished with a fasting blood sugar or glycosylated hemoglobin.

Other Tests:

.Vitiligo is diagnosed by means of inspection with a Wood lamp - أ

Treatment

are good candidates for repigmentation?

All the patients are not good candidates. The ideal person for this treatment

must have the following requirements:

- Loss of pigment less than 5 years. It is possible to treat a vitiligo appeared

more than 5 years ago, but results are not so good.

- Patients should be at least 10 years old. Younger children can follow this

treatment, but it is long and better results are achieved when the child is

interested in the treatment. The process is long and requires much patience.

Furthermore, younger children still have not completed the development of the

crystalline, and therefore there is an increased cataracts risk for oral psoralens.

In these cases, treatment will have to be topical or with drugs that do not

produce phototoxic eye damage.

- Normally, children and young adults have better response than older persons

do. Patients should be healthy. Pregnant woman should not be treated because

treatment is dangerous for the fetus.

- The patient must have time to follow the treatment 3 times a week from 2 to 5

years. 85% of patients treated with PUVA will respond the treatment in greater or

minor degree, and just in a few cases total repigmentation will be achieved. We

have to indicate that, after the first 3 treatment weeks, patients can present a

worse aesthetic appearance. This is due to the contrast produced between the

tanned normal skin and the white areas with vitiligo. Soon after, small round

brownish spots begin to appear and tend to confluent, covering the white areas.

In some cases psoralen lotions may be applied on the spots, and 2 hours later the

skin is exposed to the sunlight. This treatment turns the skin very sensitive to the

sun, and also very susceptible to develop sunburns if sun exposure is excessive.

- It is accepted, as a rule, that for a vitiligo affecting less than 20% of the skin

surface, the treatment must be topical. In cases affecting 50% of the surface or

more, only the visible zones must be treated. Depigmenting the skin or

therapeutic abstention are other choices.

- Segmental and acrofacial vitiligo respond poorly to the treatment, as well as

vitiligo on areas such as palms and soles, folds, wrists, ankles, feet and eyelids.

- It is possible that associating several of the oral treatment modalities and/or

topical agents, the response could be better in percentage and/ or rapidity of

repigmentation.

medical treatment

The goal in treating vitiligo is to attempt to restore color (pigment) to your skin and improve your appearance. Depending on the type of therapy, treatment for vitiligo may take from six to 18 months. Treatment choices are based on the number of white patches you have and how widespread they are. Each person responds differently to treatment, and a particular therapy may not work for you.

Medical Therapies

• Topical corticosteroid therapy.

Corticosteroids may help return color to your skin (repigmenting), particularly if they're started early in the disease. These drugs, which include cortisone, are similar to the hormones produced by your adrenal glands. Your doctor may prescribe a mild topical corticosteroid cream or ointment for children younger than 10 years old or a stronger form for adults. You may need to apply the cream or ointment to the white patches on your skin for at least three months before you see any results. This treatment is simple and safe, but your doctor will monitor you closely for side effects, such as skin shrinkage and streaks or lines on your skin (skin striae). Calcipotriene (Dovonex), a vitamin D derivative, also may be used topically and is sometimes used with corticosteroids or ultraviolet light

Topical steroids

Topical steroids have revolutionized the practice of dermatology since they were introduced in the late 1950s.

Like all medications, topical (cortico)steroids are associated with potential adverse effects (side effects) especially if they are used incorrectly.

The topical steroids can be divided up into four groups according to their strength. As a general rule, use the weakest possible steroid that will do the job. However, sometimes it is appropriate to use a potent preparation for a short time to make sure the skin condition clears completely.

Topical steroids available in New Zealand

Note:

Topical steroids are prescription medicines regulated by Health Authorities. The products listed here are the generic (and trade) names of those available in New Zealand currently (July 2007). The products available in other countries may be different. For example, in the USA, the classification of topical steroids places them in seven potency classes. Seek the advice of a pharmacist or your own medical practitioner if you require more information.

Class 1

Very potent (up to 600 times as potent as hydrocortisone)

• Clobetasol propionate (Dermol™ Cream/Ointment • Betamethasone dipropionate (Diprosone™ OV Cream/Ointment)

Class 2

Potent (I50-100 times as potent as hydrocortisone)

• Betamethasone valerate (Beta™ Cream/Ointment/Scalp Application, Betnovate™ Lotion/C Cream/C Ointment, Daivobet™ 50/500 Ointment, Fucicort™)

• Betamethasone dipropionate (Diprosone™ Cream/Ointment) • Diflucortolone valerate (Nerisone™ C/Cream/Fatty Ointment/Ointment)

• Hydrocortisone 17-butyrate (Locoid™ C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion)

• Mometasone furoate (Elocon™ Cream/Lotion/Ointment) • Methylprednisolone aceponate (Advantan™ Cream/Ointment)

Class 3

Moderate (2-25 times as potent as hydrocortisone)

• Clobetasone butyrate (Eumovate™ Cream) • Triamcinolone acetonide (Aristocort™ Cream/Ointment, Viaderm KC™

Cream/Ointment, Kenacomb™ Ointment)

Class 4

Mild

• Hydrocortisone 0.5-2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment)

Topical steroids are also available in combination with salicylic acid to enhance penetration, and with antibacterial and antifungal agents.

Skin absorption of topical steroids

Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. But a potent steroid may cause side effects on the face. For example:

• Forearm absorbs 1% • Armpit absorbs 4% • Face absorbs 7% • Eyelids and genitals absorb 30% • Palm absorbs 0.1% • Sole absorbs 0.05%

Side effects of topical steroids

Internal side effects

If more than 50g of clobetasol propionate, or 500g of hydrocortisone is used per week, sufficient steroid may be absorbed through the skin to result in adrenal gland suppression and/or eventually Cushing's syndrome.

• Adrenal Gland Suppression. Topical steroids can suppress the production of natural steroids, which are essential for healthy living. Stopping the steroids suddenly may then result in illness.

• Cushing's Syndrome If large amounts of steroid are absorbed through the skin, fluid retention, raised blood pressure, diabetes etc. may result.

Skin side effects

Local side effects of topical steroids include:

• Skin thinning (atrophy) and stretch marks (striae). • Easy bruising and tearing of the skin. • Perioral dermatitis (rash around the mouth). • Enlarged blood vessels (telangiectasia). • Susceptibility to skin infections. • Disguising infection e.g. tinea incognito. • Allergy to the steroid cream.

The risk of these side effects depends on the strength of the steroid, the length of application, the site treated, and the nature of the skin problem. If you use a potent steroid cream on your face as a moisturiser, you will develop the side effects within a few weeks. If you use 1% hydrocortisone cream on your hands for 25 years, you will have done no harm at all (except for having wasted a lot of money!)

Adverse effects of topical steroids

Bruising

Skin thinning

Prominent capillaries

Stretch marks

How to use topical steroids

Ask for specific instructions how to use your topical steroid(s). See DermNet's information about fingertip units. Which one, where, when, how often and for how long? Cream, ointment or lotion? This is particularly important if:

• You are using strong steroids over large areas of your body. • You have been asked to use plastic to cover treated areas (occlusion). • Your skin condition persists for more than two or three weeks. • You are a child.

Topical steroids are very effective medications. They work by reducing inflammation, and when used correctly are very safe.

Apply topical steroids only to the areas affected by the skin disease, and generally only once or twice daily. If your skin is dry, apply an emollient frequently.

• Topical psoralen plus ultraviolet A (PUVA).

Topical PUVA may be a treatment option if you have a small number of depigmented patches (affecting less than 20 percent of your body). PUVA, also called photochemotherapy, is performed under artificial UVA light once or twice a week in your doctor's office. Your doctor or a nurse will apply a thin coating of psoralen to the depigmented patches of your skin about 30 minutes before UVA light exposure. You're then exposed to an amount of UVA light that turns the affected area of your skin pink. Your doctor may slowly increase the dose of UVA light over many weeks. Eventually, the pink areas of your skin fade and a more normal skin color appears.

Potential short-term side effects of topical PUVA therapy include severe sunburn and blistering and too much repigmentation or darkening of the treated patches or the normal surrounding skin (hyperpigmentation). You can minimize your chances of sunburn by avoiding exposure to direct sunlight after each treatment. Hyperpigmentation is usually a temporary problem and eventually disappears when treatment stops.

• Oral psoralen photochemotherapy (PUVA).

Oral PUVA therapy may be used if you have extensive vitiligo (affecting more than 20 percent of your body) or if you haven't responded to topical PUVA therapy. Oral PUVA isn't recommended for children younger than 10 years of age because of an increased risk of damage to the eyes, such as cataracts. For oral PUVA therapy, you take a prescribed dose of psoralen by mouth about two hours before exposure to artificial UVA light or sunlight. Your doctor adjusts the dose of light until the skin areas being treated become pink. Treatments are usually given two or three times a week, with at least one day in between.

If you don't have access to a PUVA facility, your doctor may prescribe psoralen to be used with natural sunlight exposure. Your doctor will give you careful instructions on carrying out treatment at home and monitor your progress with frequent office visits.

Short-term side effects of oral PUVA may include sunburn, nausea and vomiting, itching, abnormal hair growth, and too much repigmentation or darkening of the treated patches or the normal surrounding skin (hyperpigmentation). If received for longer periods of time, this type of treatment may increase your risk of skin cancer. To avoid sunburn and reduce your risk of skin cancer, you'll need to apply sunscreen

and avoid direct sunlight for 24 to 48 hours after each treatment. Wear protective UVA sunglasses for 18 to 24 hours after each treatment to avoid eye damage, particularly cataracts.

• Depigmentation. Depigmentation involves fading the rest of the skin on your body to match the already-white areas. If you have vitiligo on more than 50 percent of your body, depigmentation may be the best treatment option. In this procedure, the drug monobenzone (Benoquin) is applied twice a day to the pigmented areas of your skin until they match the already-depigmented areas. Avoid direct skin-to-skin contact with others for at least two hours after applying the drug.

The major side effect of depigmentation therapy is redness and swelling (inflammation) of the skin. You may experience itching, dry skin or abnormal darkening of the membrane that covers the white of your eyes. Depigmentation is permanent and cannot be reversed. In addition, if you undergo depigmentation you will always be extremely sensitive to sunlight.

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- homeopathy

What is homeopathy? Homeopathy is a branch of medicine originated in Germany in 1794, which is based on the principle of The

Law of Similars. In a way, it is an advanced form of vaccination; whereby a substance which is capable of

producing a disease like state is administered to the patient, but in a very minute dose, to cure the similar

disease.

Homeopathy works much beyond vaccination. Here, the dose administered is unbelievably miniscule, which

renders if absolutely harmless yet very powerful.

Contrary to the conventional medicine, the action of homeopathy is much safer, deeper acting, somewhat

slower, and results much longer lasting by energizing the body's curative powers.

Homeopathy is amongst the youngest and latest medicines calling for more research and promotion.

How does it work? There are theories on how exactly homeopathic medicine works. As supported in major clinical trials and in

practice, it is believed to be working by stimulating body's own healing mechanisms.

For example, in case of diseases which are caused by infection, it seems to be working by stimulating the

production of antibodies, defense blood cells, etc.

In cases of immune diseases, it seems to be working by correcting the immune mechanism.

In case of painful conditions, by activating body's anti-pain mechanisms.

Similarly, its action must be on the lines of being antispasmodic, anti-allergic, immuno-modulatory, anti-

inflammatory, hormone stimulatory, anti-carcinogenic, etc.

Large scale studies alone will allow full exploration of this young science.

What can it do? Homeopathy boasts of tremendous powers as a system of medicine.

Especially in case of chronic, long standing and recurring diseases like allergies, bronchitis, Chron's diseases, …..Psoriasis,

Rheumatism, Sinusitis, Trigeminal Neuralgia, Ulcerative Colitis, Vitiligo, etc, homeopathy offers results which can change

the life of patients.

In the cases of allergic diseases like Asthma, urticaria, and the like, it can enhance body's immune mechanism is such as

way that the body no more reacts in abnormal way by producing constricted bronchial tubes, abnormal release of

histamine, spasm, inflammation, etc.

In cases of ulcerative diseases (like Ulcerative colitis), it leads the immune mechanism to enhance ulcer healing

mechanism.

In cases of chronic infections (e.g. Hepatitis C ) it reduces the count and activities of viral.

This goes true for most chronic diseases.

Phototherapy Treatment can effectively treat Vitiligo

UV light, or phototherapy vitiligo treatment can help create repigmentation. This process is slow, working from the outer edges of

each patch inward, so regular phototherapy vitiligo treatment is prescribed. Phototherapy vitiligo treatment may continue twice a week

for a year or more. Phototherapy equipment has been well-studied and has been proven to be an effective treatment for vitiligo.

Home Phototherapy Equipment to treat vitiligo

Vitiligo treatments at home or at your doctor's office is a decision between you and your doctor. Home phototherapy units are usually reimbursed by

insurance. The right phototherapy equipment is based on the size of the area affected by vitiligo. The most often used phototherapy units for vitiligo are:

• Foldalite III - full-sized folding home phototherapy booth

Extra-large treatment area, yet folds to only 9” deep

• Panosol II - 2-foot & 6-foot phototherapy light panels; optional foldable wings

• Dermalight-80 handheld model is ideal for smaller areas of vitilig

PHOTOTHERAPY SYSTEMS

Houva II Houva III - NEW!

Foldalite 32 - NEW!

Clinical Starter Kit - NEW! Compare Phototherapy Booths

Hand/Foot II Foot Phototherapy- NEW! Dermawand - wound care

Excilite - Rapid Spot Treatment REQUEST A BROCHURE

Phototherapy Booths for Clinical Settings

Houva II

full body phototherapy booth

Houva III

low maintenance phototherapy booth

with removable

sensors

Foldalite 32

"The Space-Saver" folding phototherapy

booth

32 narrowband UVB lamps

Full-Body Phototherapy for Patients at Home

Foldalite-III similar to clinical

version (Foldalite-32, above)

now available for

home use with 16 narrowband lamps

Panosol-II home light panels

now available with optional wings

Houva II™

High output phototherapy device with PhotoSense™ Exposure Control–the ultimate in

phototherapy technology.

Features

• Utilizes “watchdog” circuitry which automatically shuts off the device if it

senses a potential malfunction • Designed to never fail in the “ON”

position • ON/OFF safety key switches • Non-UV-transmitting viewing window to

monitor patient • Exclusive perimeter flow ventilation for patient comfort

• Full reflector panels to maximize lamp output • Lamp hour clocks(s) to monitor lamp life • Raised floor for proper treatment of lower leg

• Hand rails and non-skid floor mat for patient safety • Sturdy screen protection for lamps

PhotoSense™ Exposure Control

• For precise treatment management

• Preset a maximum exposure time • Minimize the chance for overexposure

Treatments are covered by most insurers.

Six Configuration Options

Option Description UVA Lamps

Broad Band

UVB Lamps

Narrow Band

UVB Lamps

Measuring Devices

Included

1 Combination

Unit 36 12 UVA & UVB

2 UVA-Only 48 UVA

3 Broad Band UVB-Only

18 UVB

4 Combination

Unit 12 36 UVB

5 Narrow Band

UVB-Only 48 UVB

6 Combination

Unit 24 24 UVA & UVB

UVA phototherapy lamps: # F72T12 BL/HO BB UVB phototherapy lamps: # FSX72T12/HO

NB UVB phototherapy lamps: # TL100W/01

Houva II Specifications:

Electrical Rating: • 120/240 volt, 3 wire, single phase,

solid neutral, 50/60 hertz. A fourth wire (green) is required to be

attached to an isolated ground. • 30 amperes per leg for NB UVB units • 10-foot, 4 conductor #10 AWG power

cable supplied

Dimensions: • 46”W x 49”D x 87”H

International Product

Specifications:

• For countries with electrical current other than U.S. standard, the device will be delivered with an international

base.

CAUTION: Federal law restricts this device to sale by or on the order of a physician.

Houva II 5-Year/3-Year Total Support Warranty

• All parts (excluding lamps) carry a 5-year free replacement warranty.

• All labor carries a 3-year no charge warranty from date of installation

• Lamps carry a 90 day warranty

Houva III Specifications:

Electrical Rating: • 120/240 volt, 3 wire, single phase, solid neutral, 50/60 hertz

• 30 amperes per leg all units • 10-foot, 4 conductor #10 AWG power

cable included

• Optional international base 220-240 volts, 50/60 hertz

Electrical Certification:

• Listed with ETL laboratories, Inc. • Certified to Canadian Standards

Association and CMDCAS

• Pending certifications CE

System

Dimensions:

• 46”W x 49”D x 82”H

CAUTION: Federal law restricts this device to sale by or on the

order of a physician.

Houva III Warranty

• All parts (excluding lamps) carry a 5-year, free replacement warranty.

• All labor carries a 5-year, “NO CHARGE” warranty from date of installation.

• Extended warranties available

• Lamps warranted for 90 days.

We are the only company certified to ship phototherapy units to Canada.

HOUVA III

clinical phototherapy system is most effective way to treat a large number of patients with psoriasis or vitiligo covering much of their

body. With 48 lamps and numerous features for more effective, safer, and faster treatment of patients, HOUVA III clinical

phototherapy system will improve your practice. Houva III is available in Narrowband UVB or UVA/UVA options. Choose Houva III as your clinical phototherapy system. Phototherapy system

treatments are generally covered by insurers. With

all Houva III units built on premises, your satisfaction is assured.

Contact National

Biological about Houva III clinical phototherapy system today!

Foldalite 32™ - THE SPACE_SAVER Full-Body UVB Clinical Phototherapy Booth PART OF THE

Roomy, compact, and economical booth

Foldalite-32™ is … Fast and easy

• Rapid treatments with 32 narrowband UVB lamps

• Simple push button operation

Foldalite-32™ has … Large interior treatment area

• At 5.4 sq ft, it’s roomy enough for most patients

• Easily treat entire body with single session • Adjustable doors can expand treatment area

further

Foldalite-32™ is … Economical

• Less expensive option with fewer lamps and features than our Houva III phototherapy

system • Less expensive than competitive models • Treatments usually covered by insurers

Foldalite-32™ has … Space-saving design

• Ultrathin Foldalite-32 UVB clinical phototherapy unit is only 9” deep when closed

• Easy open doors and adjustable wheels designed for any floor surface

Foldalite-32™ is … Safe for any clinical setting

• Calculating timer to ensure exact dosage

Specifications:

Folding UV Clinical

Phototherapy Unit Dimensions:

• CLOSED footprint: 76”H x 56”W x 9”D

• OPEN footprint: 76” x 38”W x 38”D • OPEN treatment area: 5.4 square feet

Lamps: • 32 TL 100W UVB narrowband lamps

Electrical Rating: • 120-240V AC hardwired • 50/60 Hz

• 15 Amps per leg - Risk class 1

CAUTION: Federal law restricts this device to sale by or on the order of a physician.

Warranty

• 3 year limited (excluding lamps) • Lamps carry a 90 day warranty

Safety Features

• Safety key lock switch prevents unauthorized use • Internal switch allows patient to stop treatment in

emergency • Calculating timer to ensure exact dosage

Support Comes Standard

• Unlimited Customer Service • Most insurance carriers reimburse phototherapy treatment in

offices

• Financing options available • All major credit cards accepted

Foldalite is Foldalite-32™. Foldalite-32™ is 50% larger than any

folding UV clinical phototherapy unit available today. Yet, Foldalite-32™ easily folds to only 9” of wall space. Attractive and durable

powder coated aluminum finish will look as good today as in years to come. Foldalite-32™ UV clinical phototherapy unit has our exclusive

watch dog circuitry. Foldalite-32™ is the most safe, convenient and economical UVB clinical phototherapy unit available. A compact and economical UVB clinical phototherapy unit!

Contact us to learn how a Foldalite-32™ phototherapy system can improve your practice

Pricing and availability information available.

Foot Phototherapy™ High output lights for quick, effective treatment

Foot Phototherapy Features:

• UVA, UVB, or narrowband UVB lights • Targeted phototherapy is effortless

and safe

• Ideal for office use. • Key Lock to prevent unauthorized use

• Electronic Timer ensures accurate treatment times

• Sturdy protective lamp shield

• Full reflector backing to maximize output

• Goggles and operating manual included • Ventilating Fan (100 c.f.m.) • Weight 68 lb (74 lb shipping weight)

• Device shipped fully assembled, ready for immediate use.

Optional Stand

• Heavy duty casters for easy movement. • Positions unit at ideal treatment height

• Size: 29" W x 32" H x 17" D (Upper) and 21.5" D (Lower)

Treatments are covered by most insurers.

Specifications:

Electrical Rating: • 110-120 Volt AC 60H • 3.0 Amps with grounded plug

Dimensions: • 24”W x 12 ¾”H x 20”D

Optional Cart: • 29”W x 32”H x17”D (upper) / 21.5”D

(lower)

Lamps: • UVA - 8 high output UVA lamps • UVB - 8 high output UVB lamps

• NB UVB - 8 narrowband UVB lamps

International

Product Specification:

• For countries with electrical current

other than U.S standard, the device will require a step down transformer.

CAUTION: Federal law restricts this device to sale by or on the order of a physician.

We are the only company certified to ship phototherapy units to Canada.

National Biological makes all of our phototherapy units on premises in our production facility.

Warranty

• All parts (excluding lamps) and labor carry a 3-year full replacement warranty.

• Lamps carry a 90 day warranty.

Dermalight® 80

Handheld Narrow Band UVB Phototherapy Device for spot treatment or scalp psoriasis treatment

Scalp psoriasis treatment UVB narrowband light!

Dermalight 80 Features Dermalight 80 Features

• No need for drugs! Dermalight 80 is effective spot or scalp psoriasis treatment

• Effective! Dermalight 80 works for psoriasis spot treatment,

psoriasis scalp treatment, vitiligo spot treatment and treatment of other localized skin conditions

• Convenient! Portable and lightweight, Dermalight 80 is ideal for localized treatment of spots or scalp psoriasis treatment

• Precise scalp psoriasis treatment! Comb attachment (included

with Dermalight 80) separates hairs to allow precise scalp psoriasis treatment

• Safe for skin! Dermalight 80 comb attachment may be used as a distance guard to treat areas other than the scalp. Uses NB UVB light.

• Arrives ready for use! Dermalight 80 is shipped fully assembled

• We are the exclusive U.S. Distributor of Dermalight-80

Covered by most insurance carriers. Let us help.

Specifications:

Electrical: • 110-120V plug-in • 60 Hz AC .5 Amps

Lamps: • Narrowband UVB (NB UVB) PL-F 9W/01 lamp

International

Product Specifications:

• For countries with electrical current

other than U.S. standard, the Dermalight 80 device will require a

step down transformer.

CAUTION: Federal law restricts this device to sale by or on the order of a physician.

Warranty

• Dermalight 80 wand carries a 1 year on parts (excluding lamps) and labor.

• Lamps carry a 90 day warranty

Comb attachment, goggles and timer included.

Dermalight 80, also known as Dermalight, is a

handheld phototherapy tool for spot treatment of psoriasis and vitiligo. Dermalight 80 is portable and convenient for local areas or as scalp psoriasis treatment.

Dermalight-80 is a highly effective scalp psoriasis treatment. Dermalight 80 and Dermalight are the same product.

Dermalight 80 uses NB-311 narrowband UVB (NB UVB) lamps. Narrow

band UVB (NB UVB) lamps are highly effective for scalp psoriasis treatment without need for drugs. A separate timer is included to monitor spot or scalp psoriasis treatment with Dermalight 80. Now

there's a safe, effective, and economical scalp psoriasis treatment. While spot and scalp psoriasis treatment is the most common use of

Dermalight-80, UV phototherapy effectively treats vitiligo, eczema and many other conditions. Dermalight-80 is generally covered by insurance.

Excilite-µµµµ™ Non-laser excimer psoriasis light source

NEW Shared Revenue Model --

Excilite-µµµµ™ has TEN TIMES the coverage area vs psoriasis excimer

laser

• Universally reimbursed by health insurers

• Small footprint for tight spaces • High output 308nm narrowband UVB

• Very simple to use. Just fit aperture and settings for excimer treatment.

• Fast! Treat in seconds and adjust settings for next patient just as

fast. • Safer than laser! No dangerous gasses to fill

• Portable psoriasis excimer laser targetted light

Main Applications:

• Psoriasis • Alopecia Areata

• Vitiligo • Atopic Dermatitis

The Excilite-µµµµ™ 308nm excimer technology offers the physician or phototherapy technician all the advantages of a psoriasis excimer

laser source, while eliminating many of the negative aspects of an

excimer laser psoriasis system. The Excilite-µ offers high energy

excimer output with a 308nm narrowband wavelength, without requiring long treatment times or the use of dangerous bottles of chlorine acid of a laser. The wide coverage area enables the

operator to treat the targeted area very quickly. The excilite-µ non-

laser psoriasis excimer light does not involve costly maintenance like the frequent replacement of filters, aligning, cleaning and tuning of

other psoriasis excimer laser treatments

Excilite-µµµµ™ is portable, compact and lightweight. The non-laser

psoriasis excimer system is fitted with additional apertures and screens to allow for different treatment areas that can range from one centimeter in diameter to 30 square centimeters. This serves to

protect the surrounding uninvolved regions.

Excilite-µµµµ Advantages:

• Short treatment times, both in duration (ten to twenty seconds), and number of sessions.

• Completely sealed excimer light source which eliminates the need for bottles containing chlorine.

• Ergonomic, user-friendly, and safe. • Large treatment surfaces (5 x 6 cm² ) with high intensity

non-laser output, narrowband wavelength (308 nm).

Spot The Difference?

308 Excimer Excilite

µ Feature

Psoriasis Excimer

Laser

Extensive Insurance Coverage

Limited

Limited Maintenance Frequent

Water Consumable XeCl Gas

30 cm² Treatment Area 4 cm²

9" x 15" x 19" 42 lbs.

Size 34" x 39" x 18" 220 lbs.

Technical Data:

Type of Source: • Monochromatic Excimer Light

Wavelength: • 308 nm

Power Density: • 50 mW/cm²

Treatment Surfaces

Rectangular:

• 30 cm² (5x6) Max

Electrical Requirements:

• 110 V

Dimensions: • 9 in. (H), 15 in (D), 19 in (W)

Weight: • 42 lbs.

CAUTION: Federal law restricts this device to sale by or on the order of a physician.

Excilite-µµµµ 308nm non-laser psoriasis excimer light will change the

way you treat psoriasis. It’s safe, targeted, high output light is more

effective than psoriasis excimer laser. Excilite-µ 308nm allows more

targeted treatment than psoriasis excimer laser. Excilite-µ is safer

for both patient and clinician than psoriasis excimer laser psoriasis

treatment. And, unlike psoriasis excimer laser, Excilite-µ is universally reimbursed, making it a solid source of income for your

practice. Excilte non-laser Psoriasis excimer light beats beats lasers and beats psoriasis.

Contact us about Excilite-µ non-laser psoriasis excimer treatment

today.

Lamps

Regular re-lamping saves valuable treatment

time.

Always in stock!

We carry replacement UVA phototherapy bulbs and UVB phototherapy bulbs for all your phototherapy needs.

• PUVA and UVB High Output Broad Band (BB) Lamps

• Slimline and Bi-Pin Lamps • UVA-1 High Output Lamp • UVB Narrow Band (NB) TL-01 311nm Lamps

UVB narrow band bulb – UVB narrowband lamps -

TL01 - TL-01

• TL01 lamps (TL-01 lamps) - narrowband lamp for Panosol and Foldalite phototherapy units!! - TL-01 lamp

• TL01 100W UVB 311 Narrow Band 6 ft. (Panosol II, Foldalite III, Foldalite 32)

• TL01 20W UVB 311 Narrow Band 2 ft. (Panosol II) • PL S9W101 – Narrow Band (Dermalight)

UVB broad band bulb – UVB broadband lamps

• FSX72T12/UVB/HO 6 ft.

• FX72T2/UVB/HO 6 ft.

• FS72T12/UVB/SL 6

ft. • FS40T12/UVB 4 ft.

• FSX24T12/UVB/HO 2 ft. • FS20T12/UVB 2 ft.

• F6T5/UVB (Handisol)

UVA bulb - UVA Lamps

• FR72T12/BL/HO

(UVA) 6 ft. • F72T12/BL/HO

(UVA) 6 ft. • F40/350 BL (UVA) 4

ft.

• F36T12/BL/HO (UVA) 3 ft.

• F24T12/BL/HO (UVA) 2ft.

• F20T12/BL/HO (UVA) 2 ft. • F6T5/350BL (Handisol)

UVA-01 bulb - UVA-01 Lamps • F72T12/BL9/HO UVA-1

Warranty

All lamps carry a 90 day warranty TL01 lamps / TL-01 lamps are replacement UVB phototherapy bulbs

for our narrowband phototherapy units!! Replace TL01 lamps / TL-01 lamps often enough so your Panosol or Foldalite III treatment

dosage remains at it’s best. For effective treatment, Panosol-II, Foldalite-III, and Foldalite-32 need a full compliment of TL01 lamps/TL-01 lamps. Narrowband lamp - TL01 lamp - TL-01 lamp -

NB lamp - uvb lamps - uva lamps - tl100w Keep enough TL-01/TL01 lamps on hand. Learn about Narrow band

UVB. Contact us and restock today.

Panosol II™ 6'foot Light Panels and 2-foot Light Panels for Home

Phototherapy UVA, UVB, and Narrowband UVB options

OPTIONAL WINGS ARE NOW AVAILABLE FOR PANOSOL II™!!

Panosol II home phototherapy light unit provides the benefits of physician-guided UVA or UVB

treatment in the comfort and privacy of your ow n home. Physician maintains control of the phototherapy treatment regimen through the use of Panosol II's exclusive CPT Timer™.

Panosol II light panel features:

• Home UVA/UVB phototherapy treatment for convenient,

economical light therapy in the privacy of your home • 2’ Panosol II™ light panels effectively treat small area

• 6' Panosol II™ lights treats entire side of body at once • OPTIONAL WINGS on 6' Panosol II extend treatment area and

close to store home phototherapy light unit discretely • CPT Timer (UVB models) assures accurate dosage • High-efficiency reflector design maximizes lamp output

• Operates on standard house current • Casters for easy moving and storage

• Goggles and user's manual included • Covered by most insurance carriers. Let us help!

Panosol II safety features:

• Failsafe feature disables unit in event of emergency

• Maximum 10-minute treatment setting on UVB timer

• Key-locked ON/OFF switch to prevent unauthorized use

Solar Shield Glasses

• Ultimate UV protection for PUVA and

other light-sensitive patients • For use after UVA or UVB light

treatments for patients or during treatment for medical professional

• Blocks 100% UVA/UVB • Meets or exceeds ANSI standards • Choose from two colors (clear, smoke)

Stock Code (Smoke) - 9PE-014

Stock Code (Clear) - 9PE-015

UVB/PUVA Goggles

• For use during phototherapy treatment • Blocks 100% UVB/UVB

• Yellow lenses permit viewing of all colored LED displays

• Soft rubber eye pieces and adjustable nose bridge for comfortable

fit

DEMYSTIFYING THE LIGHTS

Narrow band UVB Lights Narrowband UVB and UV lamps PUVA: Psoralen plus UVA

PUVA (photochemotherapy)

PUVA (photochemotherapy) is a type of ultraviolet radiation treatment (phototherapy) used for severe skin diseases.

PUVA is a combination treatment which consists of Psoralens (P) and then exposing the skin to long wave ultraviolet radiation (UVA). It has been available in its present form since 1976.

Psoralens are compounds found in many plants which make the skin temporarily sensitive to UVA. The ancient Egyptians were the first to use psoralens for the treatment of skin diseases thousands of years ago.

Methoxsalen capsules are taken two hours before exposure to UVA. Bulbs emitting different wavelengths are used for UVB (short wavelength radiation).

Those patients requiring treatment to small areas only may be treated using the smaller hand and foot unit. 'Bathwater' PUVA may be suitable. In this case the hands and/or feet are soaked in a dilute solution of methoxsalen

for 30 minutes, then immediately exposed to UVA.

A few patients may be treated with topical Tripsor PUVA - a lotion is painted on the affected areas 10 minutes before UVA exposure.

PUVA is useful for patients with various skin disorders, including psoriasis, dermatitis, polymorphic light eruption and mycosis fungoides. The number and the frequency of PUVA treatments will depend on the condition being treated and individual factors.

Side Effects

• Burning An overdose of PUVA results in a sunburn-like reaction called phototoxic erythema. It is more likely in fair skinned patients who sunburn easily. A burn is most likely 48 to 72 hours after the first two or three treatments. Sensitive areas such as breasts and buttocks may need to be covered for all or part of the treatment. Avoid photosensitizers such as certain medications, perfumed cosmetics and coal coal tar. If the treated skin becomes pink the dose of UVA will not be increased. One or more treatments may be missed. Unfortunately phototoxic erythema can persist for longer than sunburn from natural sunlight. Moisturizers and painkillers can reduce the discomfort.

• Itching Temporary mild pricking or itching of the skin is common after treatment. The skin is often rather dry. Apply moisturizing cream or lotion frequently. Antihistamine tablets may help.

• Nausea Nausea occurs in a quarter of those treated with psoralens. If it occurs, tell your phototherapy nurse or doctor. Nausea is less if the methoxsalen capsules are taken with food, or the dose is reduced. Antiemetic tablets can be prescribed.

• Tanning PUVA usually leads to tanning which lasts several months. Although the skin appears brown it may still burn easily on sun exposure.

• Eye damage If the eyes are not protected from UV radiation, keratitis may occur. This results in red sore gritty eyes. Damage to the lens in the eye leading to cacoal taracts is another possible risk.

• Skin aging and skin cancer Extensive PUVA treatment results in premature aging changes in the skin (i.e. increased dryness, freckling and wrinkling) and can increase the chance of skin cancer. Fair skinned individuals or those with previous sun or radiation damage are most at risk. This is not a concern for most patients, who receive PUVA therapy for two or three months only. Patients on long term maintenance therapy should have their skin checked by the specialist at least every 6 months. Bring any new moles or freckles, sores which are slow to heal, or growing lumps to the doctor's attention. It should be remembered that usually, but not always, skin cancers are readily curable. When ageing changes are evident or skin cancers occur, it becomes unwise to continue this form of treatment.

• Pregnancy There is no evidence to suggest that PUVA will damage a developing baby. However, should a patient become pregnant, or suspect she is pregnant, during a course of treatment, we advise our patients to stop PUVA treatment immediately.

Treatment of different skin conditions

• Psoriasis Psoriasis is a common inherited skin disorder, which may vary considerably in extent and severity. Neither phototherapy nor any other available treatment effects a permanent cure. PUVA is usually reserved for patients in older age groups, or for those whose psoriasis is either severe or not responding adequately to more conventional forms of treatment. In most cases (approximately 90%) PUVA is effective in clearing psoriasis, and can often control it as long as treatments are continued. Psoriasis in body areas shielded from light (e.g. scalp and body flexures) may not clear satisfactorily with PUVA. Initially most patients have their treatment two or three times a week. The first few exposures will be short (less than 5 minutes). The length of exposure is gradually increased, according to the patient's response, up to a maximum of 30 minutes per session. Few patients require such long exposures, most being controlled with shorter times. Most psoriasis patients will have their psoriasis cleared or much improved after 12 to 24 treatments. At this stage treatments may be reduced to once a week or less. Even without treatment, the skin may remain clear for some months. However, the psoriasis may later flare up again, and further PUVA treatments may be necessary. Those few cases of psoriasis which appear to be resistant to PUVA may still be helped by combining PUVA with other treatments (e.g. ointments or tablets).

• Eczema or dermatitis PUVA is occasionally used for severe cases of dermatitis. Frequency and dosage of treatment is similar to that used for psoriasis. However, a course of phototherapy may need to be more prolonged than that generally required for psoriasis.

• Mycosis fungoides For this rare skin form of cutaneous T-cell lymphoma, PUVA is usually given twice a week at first, using shorter exposures than for psoriasis. When the skin is clear, treatment is given less frequently. If PUVA is stopped, the condition sometimes relapses.

• PMLE Polymorphic light eruption (PMLE) is a common light sensitivity disorder. A six week course of PUVA in the spring or early summer usually gives patients good protection for the remainder of the summer. UVB may be recommended for those in whom PUVA is unsuitable. A further course of treatment will be necessary if protection is required in subsequent years.

• Vitiligo Patients with vitiligo have areas of completely white skin. PUVA can bring about some repigmentation, particularly for vitiligo of the face, and in dark-skinned patients. Results for other body sites and white-skinned patients are less encouraging. Treatment is usually twice a week for two years. Even then, complete repigmentation cannot be guaranteed and relapse is possible.

Instructions

If you are receiving PUVA therapy, follow the advice of the phototherapy nurse and that of your dermatologist. Some general advice:

• Keep all scheduled appointments. Allow time for changing. • Tell the staff about your health problems, including medications and eye disease. • Do not apply any ointments or cosmetics (especially perfumes and coal coal tar

products) except as directed by your doctor or phototherapist. • Schedule treatments at the same time of day whenever possible. • Always take the capsules at exactly the same interval before the UVA exposure. • Ideally, take the capsules two hours after a meal. • Alcohol consumption should be minimal. • Avoid sun exposure on treatment and non-treatment days. • Apply broad spectrum sunblock to face and hands before treatment. • Cover male genitalia - this area must not be exposed to UVA. • You must protect your skin and eyes from natural sunlight for twelve hours after

taking methoxsalen tablets. • During treatment, you must wear the special goggles provided. • Wear wrap-around ultraviolet-protective sunglasses both indoors and outdoors, from

the moment you take the methoxsalen tablets until nightfall on the treatment day. • After dark the glasses must still be worn under fluorescent lighting, but are not

necessary outside or with incandescent lamps. • Wear fully covering clothing outdoors and if near a window indoors, i.e. hats, long

sleeves and skirts or trousers. • Apply sunscreen to all uncovered skin after treatment. • In some circumstances polarized or prescription glasses may be suitable; they must

cut out all UV radiation however. You can use clear perspex glasses indoors. • Arrange to be seen regularly by your dermatologist

• Narrow-band ultraviolet B (NBUVB) therapy.

In recent years, NBUVB, a special form of ultraviolet B light, has been used as an alternative to PUVA. This type of therapy can be administered like PUVA and given up to three times a week. However, no pre-application of psoralen is required, thus simplifying the treatment process. NBUVB may be a safer long-term alternative to PUVA. However, more research is needed.

UVB Narrowband Phototherapy Lamp Technology

A UVB narrow band lamp emits light energy. Narrowband UVB phototherapy (UVB-NB) comprises a subset of the UVB wideband, or broadband, spectrum centered at roughly 311 nm. This is less than 1% of

total range of wavelengths from sunlight. Narrow band UVB has been shown to be the optimal part of the UV light spectrum which slows growth

of psoriasis lesions. Since the narrowband wavelength is shorter than braodband, exposure time to narrow band UVB phototherapy treatment lights can be increased. The result is powerful targeted phototherapy

treatment.

Another clear advantage of narrowband UVB is that skin is most sensitive to erythemic response, (sun burning) at 297 nm, so narrow band

phototherapy nearly eliminates this problem as shown in the chart below.

Narrow Band UVB lamp technology is available for nearly all home phototherapy products from National Biological, including the compact 2’

and full-sized 6’ Panosol II™ light panels, full-body folding Foldalite III™ booth, hand-held Dermalight 80™ wand, and Hand/Foot II™ unit.

• Psoriasis - Research shows that Narrow Band UVB lights have a

therapeutic advantage over traditional Broad Band UVB lights. This is because Narrowband UVB lights provide faster clearing, less sun

burning, and more complete disease resolution. • Vitiligo - Today Narrow Band UVB lights are proving to be very

useful in the treatment of Vitiligo. Narrowband UVB light treatment is replacing traditional PUVA phototherapy treatment. UVB Narrow Band for vitiligo requires no photo-sensitizing agents. Ask us or ask

your doctor.

The most recent medical methods in vitiligo treatment

AN ALL ITALIAN DISCOVERY, IT IS CALLED BIOSKIN® THE LATEST COLD-LIGHT MICROPHOTOTHERAPY FOR THE CARE AND THE TREATMENT OF

THE VITILIGO.

• FACE THE VITILIGO.

The latest scientific knowledge on the vitiligo consider it as a dermatosis due to multiple factors and that it can have different

aspects according to the triggering cause. In fact, this is not simply a disorder of pure cosmetic interest, but would result from little defects

(probably genetic ones) that can cause thyroid unbalance and to other organs of autoimmune nature. In order to know the indicative

evaluation of the effectiveness of the BIOSKIN® therapy in your specific case, it is necessary to fill out the questionnaire following

which you will have an answer by e-mail. Besides, in order to be able to understand if these problems subsist for the individual patient, it is

necessary to carry out some blood tests to evaluate the possible involvement of the above mentioned organs. Once these

examinations are carried out, we will have a global vision of the patient and would be able then to begin a specific and personalized

therapy.

BIOSKIN® THERAPY.

In order to understand the BIOSKIN® therapy it is necessary to have some basic knowledge in dermatology.

The melanocytes are some cells located in the deeper layer of the epidermis (that it is not other than the most superficial thin veil of our skin and it has an average thickness of 0,4 mm) and that during the pathological process leading to the vitiligo are "inactivated" or "killed". The melanocytes being the cells, which contain (the main colour of the skin), their absence is revealed by the lack of colour in the affected zone: this is

the vitiligo. Yet the epidermis is not the only zone of the skin provided with melanocytes. In fact, the colour of the hair and of the hairs is precisely due to the

melanocytes being situated close to the hair bulb (in the zone known as perifollicular) placed much more in depth compared to the epidermis. These deep

melanocytes are very rarely interested by the process that causes the vitiligo and, if opportunely stimulated, they can multiply themselves, climb back in the epidermis and give rise to new pigmentation, and therefore to the cure of the

spots. This phenomenon, that sometimes is spontaneous or caused simply by the exposure to the sun, shows itself through the appearance of circular points of

pigmentation in the zones made achromic (that is without colour) by the vitiligo. In the illustration 1 (a and b) it may be noticed how the skin of the hands of a

subject before the therapy (a) and during (b) the treatment with BIOSKIN® is giving rise to these "tokens" of pigmentation that will increase of diameter and they will unite themselves, to give finally to the skin its normal pigmentation.

.

.

• Copyright© 1999-2008 BIOSKIN® all rights reserved •

The medical research and today's technologies have allowed to determine the wavelength (among all the ones of the solar spectrum) that stimulates more effectively the melanocytes to duplicate and to produce melanin (311 nm). BIOSKIN® allows us to be able to convey this wavelength exclusively on the vitiligo spot and in depth towards the perifollicular melanocytes without causing the damages due to all the other solar radiation of which mainly infrared and ultraviolet rays A.

• THE NEW THERAPY FOR THE CARE OF THE VITILIGO: BIOSKIN® THE LATEST COLD-LIGHT GENERATION MICROPHOTOTHERAPY A new and sophisticated emitting equipment of the ultraviolet B rays to 311 [nm] can eliminate the cutaneous dyschromias caused by the vitiligo. It is about THE LATEST GENERATION MICROPHOTOTHERAPY BIOSKIN® performed with an innovative equipment, which emits in a specific and selective way a bundle of ultraviolet light of type B able to stimulate the dormant melanocytes cells gradually, thus allowing to look after the disease in the least time possible and not to increase the contrast of colour between the healthy skin and the patched vitiligo. To obtain this result biomedical engineers supported by dermatologists researchers they have planned and built an electronic generator, protected by an international patent, with a very high percentage of UVB rays able to focus the light bundle exclusively on the vitiligo spots while using a particular optic fibre. The emitted UVB rays are the most effective ones in the therapy of the vitiligo because they stimulate in an optimal way the melanocytes and are active on the immune system of the skin. The bibliography in our web site lists the principal international scientific works documenting the effectiveness and lack of noteworthy negative side effects of the therapeutic UVB rays on the human skin for the dosages relating to the BIOSKIN® therapy. Otherwise from all therapeutic approaches which use ultraviolet radiation on full cutaneous surfaces, the BIOSKIN® therapy, because it only conveys microdoses of energy on the affected cutaneous zones, does not provoke the photo ageing of the skin. The BIOSKIN® therapy is adapted to the requirements of every individual patient, as

well with regards to some characteristics of emission of the ray as for the duration of each therapeutic treatment.

We are in any event able of providing a general model of the BIOSKIN® therapy. Every session, carried out exclusively by a doctor, it consists of an irradiation of the UVB rays on the spots concerned only, excluding any healthy part.

The ray, conveyed by optical fibre is applied for a maximum duration time of 10 seconds on every square centimetre of the spot. Thanks to the use of a diaphragm placed on the terminal of the optical fibre and which is modified according to the characters of the interested area, the doctor can modify the diameter of the area to be treated for any particular case.

Different to the other therapies based on the use of the UVB, this one doesn't provoke any pain, burn or other discomfort, neither during the treatment nor in the following days.

The therapy must be repeated once per month, effecting altogether 1-3 sessions in the same day in accordance with the therapeutic protocol determined by the dermatologist for each individual patient. The therapy has never highlighted any negative side effects. The treatment has a variable general duration in accordance with the extension of the affected zones and the reaction of the subject. There are conditions of relatively constant reaction for each patient. The face, the groin, the armpits, the genitals, the neck, the breast and the thighs are the areas which repigment first, while the terminal zones close to the fingernails of the hands and the feet require in general, a superior lapse of time.

Usually after 8-10 sessions it is possible to have an idea of the recovery speed of each spot of vitiligo for each individual patient.

IPL Guide

What is IPL?

IPL (Intense Pulsed Light) is a non-invasive skin treatment that emits powerful bursts of light energy to treat sun-damaged skin, wrinkles, and unwanted hair growth without damaging the surface of your skin. IPL is often marketed as a lunchtime treatment.

The idea is that after a short session you should be able to return to work, with no downtime, bruises, or special after-care. However, real experience of those who've tried IPL, including a testimonial by a RealSelf member, suggests that in some cases IPL can cause redness and scabs. Additionally, sun exposure is not a great idea after an IPL treatment.

Make sure you go to a highly reputable dermatologist or IPL operator. Poorly trained IPL device operators are more likely to make a mistake that can lead to burns or less satisfactory results.

IPL Treatment

The IPL device can generate light energy at various frequencies in order to treat these different skin problems. For this reason, many dermatologists indicate that they prefer IPL over laser therapy. Certain frequencies destroy dark skin regions, while other frequencies will increase the melanin in your skin to re-pigment skin.

IPL can encourage new collagen growth (that causes wrinkles to diminish in appearance), remove age spots or brown spots, and decrease skin redness. Researchers at Brown University found that IPL is also highly effective at removing visible signs of birthmarks and facial lesions.

Most IPL units have a hand-held wand so the dermatologist can deliver short energy pulses to a small area of skin. During your session you'll wear protective goggles as if you were headed to a tanning bed. The area of your skin that's being treated is then covered in a gel, and the wand will be pressed against your skin. The IPL unit emits light energy pulses that get absorbed by your skin without damaging nearby healthy skin tissue. Most treatments last less than 30 minutes.

IPL Options

Common names you'll see IPL advertised as include: Intense Pulsed Light, IPL Laser, FotoFacial, EpiLight, MultiLight, Facial Light, and Photo Facial.

A popular IPL treatment is called Photoderm, which is most effective for people with light-colored skin. If you have darker skinned (even if you are normally fair-skinned but have a tan), you are poor candidates for this procedure because you will be at greater risk of your skin being burned.

ReLume Repigmentation is an IPL treatment that works to stimulate the production of melanin to restore lost pigment for stretch marks and post surgical scars and for vitiligo patients.

IPL Side Effects

Even though the IPL energy bursts do not break the skin, they can be painful. Anesthesia is not required, but you may want to request a numbing cream to minimize discomfort. Dermatologists often describe IPL treatment as feeling like a rubber band snapping against your skin. Some people who have undergone IPL treatment say it can be more uncomfortable, and can even inflict stinging pain.

Some common complications include - but may not be limited to - red, slightly puffy, or occasionally blistered skin, burns or other injuries from the heat, scarring, and skin discolorations. In some patients, reactivation of a previous herpes simplex cold sore may occur. A doctor is the best source of information for getting a complete understanding of the potential risks and complications from IPL.

IPL Hair Removal

If you have unwanted dark hair and you're sick of waxing, tweezing, and shaving, you may want to consider IPL (light colored hair does not respond to IPL treatments). IPL hair removal works by delivering energy to the dark hair follicle. The energy heats up the follicle and eventually destroys the hair-growing structure. That said, according to the UK Department of Health, IPL does not provide permanent hair removal. Laser hair removal may offer better results.

IPL Hair Removal vs. Laser Hair Removal

According to the American Academy of Dermatology, lasers can work broader areas of skin than IPL. As a result, IPL hair removal is often more time consuming and costly than laser hair removal. This may explain why you'll find dozens of laser hair removal centers in your area with constant advertised discounts and relatively few IPL hair removal providers

Beijing starlight science & technology development co., ltd

ST-B Pigmentation reduction and hair removal machine

[ST-B] [China] Posted Date: November 23, 2007 Free Member | Rate this company

Description

(1)Treatment principle The IPL skin-rejuvenating system emits varied wavelength, intense pulse, and broad spectrum light. It can permeate the cuticle to the derma and take effect on the abnormal pigment and vessel such target tissues to break the abnormal pigment cells, close the abnormal blood vessels, stimulate the proliferation of the collagen and improving the rearrangement of elastic fibers, finally achieving the purpose of pigment removal and skin rejuvenation. (2)Features of system 1. Broad-spectrum, non-invasive photodynamic therapy 2. Double handles, selectively absorption, aiming at different symptoms 3. Strong penetrating force: decomposing the deep pigment effectively 4. Effectively filtering the harmful light with triple light filter systems 5. Three cooling systems: Built-in Circle water-cooling system Air cooling system Semiconductor cooling device 6. Silver catoptric system: remarkable optical effect 7. Water-electricity separator inside: insuring the system safety 8. Double counter system: insuring the quality 9. LCD screen with low failure rate 10. Magnetic drive pump controlled water circulation: lower noise, longer lifetime 11. Smaller handle with the same spot size 12. Automobile paint appearance: showing the quality (3)Indications 1. Pathology of the pigment: chloasma, sun burn, speckles, age spot, coffee spot and pigmentation 2. Removing unexpected hair on lips, armpits, hairline, bikini, and limbs 3. Pathology of the blood vessel: red blood streak, bottlenose 4. Improve the rough skin, enhance skin elasticity, rejuvenating the skin 5. Repair various scars and acnes

Other Information

Location: China

Minimum Order: 1

Price for Minimum Order:

(This price is only for minimum order, for large quantities, please contact)

Sample Available: No

Pseudocatalase For Vitiligo

Pseudocatalase has recently become a drug of interest for patients suffering from vitiligo. Vitiligo affects 3 to 6 million people in the United States today, however, many are unaware of this rarely talked about skin condition.1 Also known as leukoderma, vitiligo is a pigmentation disorder of the skin resulting in the formation of irregular white spots or patches, despite the retention of the skin’s normal texture.1,2 It is a progressive condition that destroys the melanocytes (the cells that make pigment) in the skin, the mucous membranes (tissues that line the inside of the mouth, nose, genital and rectal areas) and the retina (inner layer of the eyeball).2 Although its cause is not greatly understood, vitiligo is non-contagious often affecting all races and both sexes equally. It may appear at any age and is believed to be hereditary.

The primary goal when treating vitiligo is to restore the skin’s function to as close to normal as possible and to improve the patient’s appearance and overall quality of life. Today, vitiligo is a treatable condition, though it can take years for patients to see results. The choice of therapy, however, ultimately depends on the degree of white patches and how widespread they are on a patient’s body.2 With the recent discovery of the role elevated hydrogen peroxide (H2O2) levels combined with low catalase activity play in the skin of patients afflicted by vitiligo, a new treatment involving a topical cream consisting of pseudocatalase and calcium was developed. Originally created by Dr. Karin U. Schallreuter and her colleagues, a professor of clinical and experimental dermatology at the University of Bradford in West Yorkshire, England, patients were told to apply the cream twice daily and to expose themselves to the sun or to a short-term narrow-band of ultraviolet B (UVB) phototherapy

Protopic

Protopic (Tacrolimus) is a newer medication that has is prescribed by some

dermatologists for vitiligo. Protopic, an ointment made by Fujisawa Pharmaceuticals in Japan, works to down-regulate (suppress) the immune response in an area of

vitiligo. Studies have shown repigmentation success in some (but not all) people who use it. Protopic ointment is currently indicated for the treatment of moderate to severe atopic dermatitis (eczema). Currently, the approved label has no specific mention of vitiligo, and the Food and Drug Administration (FDA) regulatory requirements do not support the clinical investigation or use of Protopic in vitiligo at this time. The product

is available in .03% strength and the stronger .1% strength . The risks and side effects of Protopic are not entirely known, and should be discussed with your doctor.

A black box warning was added to Protopic in early 2005, warning that there had been several reported cases of lymphoma or skin cancer following its use. Some doctors dispute these findings, suggesting the numbers of cancer and lymphoma

cases reported are no higher than would be seen in the general population. Many experts believe that vitiligo is the result of the immune system improperly generating antibodies to one's own pigment cells, which then attack and kill or

weaken such cells. Immunomodulators may inhibit immune cells (t-cells) from attacking the pigment cells.

Surgical treatment :

Patients who have small areas of vitiligo with stable activity are candidates for surgical transplants.

• Punch grafts

o Punch biopsy specimens from a pigmented donor site are transplanted into depigmented sites.

o Repigmentation and spread of color begin about 4-6 weeks after grafting.

o The major problem is a residual, pebbled, pigmentary pattern.

• Minigrafts

o Small donor grafts are inserted into the incision of recipient sites and held in place by a pressure dressing.

o The graft heals readily and begins to show repigmentation within 4-6 weeks.

o Some pebbling persists but is minimal, and the cosmetic result is excellent.

• Suction blister o Epidermal grafts can be obtained by vacuum suction usually with 150

mm Hg. o The recipient site can be prepared by suction, freezing, or

dermabrasion of the sites, 24 hours before grafting. o The depigmented blister roof is discarded, and the epidermal donor

graft is placed on the vitiliginous areas.

• Autologous cultures and autologous melanocytes grafts:

Abstract

BACKGROUND \ Surgical treatment of vitiligo is indicated when lesions are localized in poorly responding areas.

OBJECTIVES \ The objectives were:

(1) to establish the melanocyte culture obtained from the epidermis of vitiligo patients for future treatment;

(2) to estimate the influence of selected factors on the formation of suction blisters and the results of culture;

(3) to compare the results of treatment of vitiliginous macules localized in the dorsum of the hands and lower limbs by transplantation of cultured autologous melanocytes plus psoralen

and ultraviolet A (PUVA) therapy (CMP), suction blister transplantation plus PUVA therapy (SBP), cryotherapy plus PUVA-therapy (CP), and only PUVA therapy (OP).

METHODS \ Forty patients were qualified for the study. The roofs of the suction blisters were used as a melanocyte source for culture establishment or were directly transplanted.

RESULTS \ The CMP procedure was successfully performed on only 10 of 20 patients because of the difficulties in cell culture establishment. The SBP method was carried out on all 20 patients. A total lack of effectiveness was found in CP and OP methods.

CONCLUSIONS \ The effectiveness of culture depends on time of suction blister forming, phototype, and previous PUVA therapy. This study demonstrated the advantage of the SBP over the CMP method.

WO/2006/005977) NOVEL METHOD FOR CULTURING KERATINOCYTES, MELANOCYTES AND FIBROBLASTS FOR SKIN GRAFTING

In summary, it can thus be stated that skin cell transplantations in connection with the methods and compositions according to the present invention disclosed herein not only much simpler to carry out as compared to other methods, but in addition also significantly promote the success of the transplantation or the repigmentation in question. This aspect is in particular important for example in the context of vitiligo therapy. Finally, it was also found that autologous skin cell transplants comprising cultured autologous keratinocytes and/or melanocytes and/or fibroblasts in a carrier matrix exhibiting plasticity and a gel-like consistency also exhibit very good transport and application properties. Thus, the inventive keratinocyte, melanocyte and fibroblast suspensions are useful for the in situ production of (cell) transplants, e.g. autologous (cell) transplants. The invention particularly relates to the use of transplants for treating patients with chronic ulcers of different origins, with burn wounds, post-traumatic wound defects, and for covering defects of extensive, benign, naevoid skin changes and of scars after prior dermabrasion, vitiligo, piebaldism, etc. In chronic leg ulcers and extensive two and three degree burns autologous keratinocyte transplantation is a new line of treatment instead of conventional split thickness grafts. In such cases autologous keratinocytes are prepared and cultured from the patient's own skin. Donor site for such skin samples is usually the groin, the upper leg and arm. Since hair follicles contain a higher number of undifferentiated keratinocytes, keratinocyte cultures established from hairy scalp have a better mitotic potential, making them more suitable for keratinocyte transplantation. The invention allows to produce transplants, which contain keratinocytes or melanocytes or fibroblasts, production of the keratinocyte composition or melanocyte composition or fibroblast composition, and to produce collagen-free two-constituent compositions.

• Micropigmentation o Tattooing can be used to repigment depigmented skin in dark-skinned

individuals.

Therapeutic tattoos for leukoderma and vitiligo

Dr. Kalpana Sarangi fills up the patches caused by leukoderma and vitiligo with therapeutic tattoos, which are similar to the

colour of the skin of the person concerned. However the therapeutic tattoo can only be done if disease hasn’t been spreading for the last six months and is therefore stable.

So, first you should be under medication to arrest the disease and receive positive results. Also, anyone who is diabetic, has any infection on the depigmented area, has a pacemaker or is HIV-

positive cannot get a tattoo.

Tattooing is a quick process. One square inch of the skin just requires 30 minutes to tattoo. Only a local anesthetic cream is used. One shouldn’t wash the tattoo for seven days or wash it sparingly. Also one must take

care to avoid infections during the tattoo healing period. If there is infection there will be scab formation and the whole tattoo will come out.

Antibiotics and anti-inflammatory medication are prescribed for a week post-treatment.

Skin grafting is yet another way of treating leukoderma and vitiligo patches. The skin is taken from the buttocks or the thighs. Skin grafting is

a more effective way of treating these white patches and also more expensive than tattooing. So one can choose tattooing or grafting based on what she can afford.

LASER TATTOO REMOVAL UNITS (ALL COLORS)

BIRTHMARKS - AGE SPOTS - FRECKLE - SOLAR - NEVUS

MD-TT12

BENEFITS

Start your new business or upgrade your equipment. Why spend between $100.00 and $200.00 per session when you can own your own unit for you, your family and friends. Get a new unit at the wholesale price. Upgrading your machine? We also have the solution for you. Over the past ten years, Q-Switch YAG lasers have been shown to be very effective at

removing tattoos. Q-Switch YAG lasers deliver very high power but very short pulses of laser light, which pass through the skin and break up the particles of tattoo pigment, which are then destroyed by the body, by white blood cells and the lymphatic system. This is also the reason why tattoos usually fade over time. Q-Switch YAG laser treatments make the pigment particles small enough to be destroyed much faster. Multiple treatments, given about one month apart are necessary for best results. What is Q-Switch YAG Laser treatment? This is a laser procedure in which a beam of light at a specific wavelength is applied to the skin and is absorbed by colored pigments in the skin, including melanin and tattoo pigments. How many treatments will I need? Light pigmentation like freckles, age spots and sun marks may disappear after a single treatment. Most pigment will disappear after two treatments. Tattoo removal will require 2 to 5 treatments depending on the size of the tattoo and the different colors used. It has been observed in about 20% of cases that a dark spot appears once the scab has fallen off after treatment. Normal pigmentation of the skin should be achieved within 2 to 3 months. Get an extra discount! Don’t overspend your money, we have the solution for you. Get the service you deserve! If we cannot fix your unit on time, we will simply replace it by another one. Many other distributors or suppliers are offering Q Switch Yag systems. The technology may look the same but is really not. The price seems attractive but: Does that machine have different cooling system? Does it have a dedicated water tank to cool down the Handpiece? Of course not! Same for your laser. You need to work without having to stop you machine and a fan is not enough. Some suppliers answer to that question by telling you that yes, they have a cooling system but they are only talking about fans. You absolutely need to have a dedicated water tank to cool down the handpiece or you will need to stop your unit during a treatment because your handpiece will get too hot and your unit will overheat. Are you looking at a North American unit or is it a Chinese unit? Are you on the professional market to get a reliable machine and the service you deserve? How much output power does the machine have? What is the frequency, how fast can you shoot? These are real questions you should ask and answers you should get before making your decision. A lot of supplier pretend to be in the professional market by offering units with a maximum output at 500mj and a maximum frequency at 3. The MD-TT10 goes up to 1000mj, and has a frequency from 1 to 6. The unit works at 532 namometers and 1064 nanometers. Both crystals are delivered with the unit as well as 1 pair of goggles, 1 pair of protective eyewear and a foot pedal. The TT12SC Shots and Vaccums the pigment for faster results. This is a real professional machine. The fastest you treat the better it is. Get trained like never bebore! A visit to our office for a free 2 day training, Telephone assistance, detailed user manual are just a few advantages of dealing with Medicamerica. Deal with a manufacturer and buy from Medicamerica. Get the wholesale price.

Laser Wavelength : 1064nm / 532nm

Maximum Laser output

energy : 1000mJ / 400mJ Up to 1000 volts

Laser Pulsed Width : <=10ns

Indication Light : 5mW semiconductor Laser

Yag Laser : Shots and Vaccums the pigment for faster results.

Vaccum : Pressure Gauge Control

Vaccum : Switch control. ON or OFF. Unit can be operated with or without the vaccum option.

Output : Laser Gun activated by Foot Pedal

Environmental

temperature : 10 - 30 Degrees Celcius

Power supply : AC 110V-240V 50-60Hz

Frequency : 1-6 Hz

Weight : 28Kgs 60Lbs

Dimension : 102cm HX45 WX28cm D or 40 X 18 X 18 inches

o Color matching is difficult, and the color tends to fade. Skin can be dyed with dihydroxyacetone preparations, though the color match is often poor.

Dihydroxyacetone

Fake tanners, sunless tanners or preparations used to imitate a tan are becoming much more popular as people are becoming more aware of the dangers of long term sun exposure and sunburn. There are now several ways of achieving a tan without having to expose your skin to the sun, these include:

• Stainers (dihydroxyacetone) • Bronzers (dyes) • Tan accelerators (tyrosine and psoralens) • Solaria (sunbeds and sunlamps)

The sunless tanner dihydroxyacetone (DHA) is currently the most popular way of gaining a tan-like appearance without sun exposure as it carries less health risks than any of the other available methods. To date, it is the only active ingredient approved by the US Food & Drug Administration (FDA) for sunless tanning.

How does DHA work?

All effective sunless tanners contain DHA. It is a colourless 3-carbon sugar that when applied to the skin causes a chemical reaction with amino acids in the surface cells of the skin producing a darkening effect DHA does not damage skin as it only affects the outermost cells of the epidermis (stratum corneum).

What formulations of DHA are available?

There are many self-tanning preparations containing DHA on the market and many will claim to be best formulation available. Consider the following points when deciding upon the preparation most suitable for you.

• Concentrations of DHA can range from 2.5 to 10% or more (mostly 3-5%). This may coincide with product ranges that list shades as light, medium, or dark. A lower concentration (lighter shade) product may be better for new users as it is more forgiving of uneven application or rough surfaces.

• Some formulations will also contain moisturisers. Users with dry skin will benefit from this.

• Alcohol based preparations will be more suitable for oily-skinned users. • DHA provides some protection against UV rays. To increase UV protection some

products also include a sunscreen. • Alpha hydroxy acids promote the sloughing off of excess dead skin cells so should

improve the evenness of colouration. • Other ingredients may be added to facilitate application or to make the colour last

longer. Consult your pharmacist for advice.

Who should use DHA-containing preparations?

Anyone wanting a tanned appearance without having to expose himself or herself to UV light can use these preparations. However, the final look will depend on the formulation used, individual's application technique, and the user's complexion type.

Clinical uses may be for vitiligo, camouflage of some skin irregularities such as leg spider veins, or possibly as protection for individuals with certain photosensitivity disorders.

How do you use DHA-containing preparations?

The final result obtained from DHA self-tanning preparations is highly dependent upon the individual's application technique. Care, skill and experience are necessary when using these products. The following are some self-application tips to achieving a smooth and even look.

• Prepare skin by cleansing then by exfoliation using a loofah; this will avoid uneven application of colour.

• Wipe skin down with hydroalcoholic, acidic toner, as this will remove any alkaline residues from soaps or detergents that may interfere with the reaction between DHA and amino acids.

• Moisturise the area first, being careful to include the bony parts of the ankles, heels and knees.

• Apply to skin in thin layers wherever you want colour, less to thicker skin, as colour is maintained longer in these areas.

• To avoid uneven darkening on areas such as the elbows, ankles and knees, remove excess cream over bony prominences with a wet cotton pad or damp flannel.

• Wash hands immediately after application to avoid tanned palms. Alternatively, wear gloves to apply.

• To avoid staining of clothes, wait 30 minutes for the product to dry before putting on clothes.

• Don't shave, bathe, or swim for at least an hour after applying the product. • Reapply regularly to maintain colour.

Tanning salons, spas and gyms may offer professional application of sunless tanning products.

• Lotion can be applied by an experienced technician. • Solution can be airbrushed onto the body. • Step into a sunless tanning booth for a uniform full-body application.

Be careful to cover eyes, lips and mucous membranes to prevent swallowing or inhaling the DHA-containing mist.

Is the tan instantaneous and how long does it last?

A colour change is usually apparent within an hour of application. Maximal darkening may take 8-24 hours to develop. If a darker colour is desired, several successive applications every few hours may be done to achieve this.

An artificial tan produced by DHA will last until the dead skin cells rub off, usually 5-7 days with a single application. Depending on the area, the same colour can be maintained with repeat applications every 1 to 4 days.

Effects of tanning cream

Undesirable staining

Darkened scaly lesions

Peeling

What precautions are there when using DHA self-tanning preparations?

The most important thing to remember when using DHA self-tanners is that they do not protect your skin against the sun. Although DHA does provide some UV protection and many products contain additional sunscreen, the UV protection provided is much more short-lived than the skin colour change. The stated SPF for the product is only applicable for a few hours after application of the self-tanner.

Despite darkening of the skin, an individual is just as susceptible to harmful UV rays, therefore it must be stressed that an overall sun protection program is still very necessary.

Are there any side effects from using DHA self-tanning preparations?

DHA reacts quickly in the stratum corneum minimizing systemic absorption. Contact dermatitis caused by DHA has rarely been reported. Most causes of sensitivity are due to other ingredients such as preservatives in the preparation

Adjunctive Therapies

• Sunscreens • Cosmetics • Counseling and support

Sunburn

What is sunburn?

Sunburn is simply a burn or erythema (reddening) and oedema (swelling) on your skin from excessive exposure to the sun’s rays, more specifically the ultraviolet (UV) radiation that is emitted from the sun. Sunburn may also occur from exposure to other UV light sources such as solaria or tanning salons.

At a cellular level, sunburn is associated with microscopic changes in the skin. There is the formation of UV induced sunburn cells and a reduction in Langerhan cells and mast cells, which play an essential part of the body's immune defence system.

What causes sunburn?

To better understand the causes of sunburn we need to take a look at some basic principles of the electromagnetic (light) spectrum. This spectrum is divided according to wavelength into ultraviolet (<400nm), visible (400-760nm), and infrared (>760nm). The ultraviolet (UV) spectrum is further divided into 3 broad areas:

• Ultraviolet A (UV-A) = 320-400nm • Ultraviolet B (UV-B) = 290-320nm • Ultraviolet C (UV-C) = <290nm

UV-C radiation is filtered out or absorbed in the outer atmosphere so does not pose a problem to humans. It is UV-A and UV-B radiation that are the primary causes of sunburn. Although both wavelengths are implicated in sunburn, the skin reacts differently to each one.

Reactions to UV-A and UV-B radiation

UV-A UV-B

Less potent than UV-B but is the wavelength that reaches the surface of the earth most (about 90% at midday) Also penetrates into the middle skin layer (dermis) and subcutaneous fat causing damage to the site where new skin cells are created Long-term exposure causes injury to the dermis resulting in ageing skin

Much more potent at causing erythema About 90% is absorbed by the surface skin layer (epidermis) Epidermis responds by releasing chemicals that cause the reddening and swelling characteristic of the early signs of sunburn Repeated exposure causes injury to the epidermis resulting in ageing skin

Who is at risk of sunburn?

Skin phototyping categorises people into one of six groups based on baseline skin colour and the tendency to tan and/or burn when exposed to UV radiation.

Skin

Phototype Typical Features Tanning ability

MED

(mJ/cm2)

I Pale white skin, blue/hazel eyes, blond/red hair

Always burns, does not tan

15-30

II Fair skin, blue eyes Burns easily, tans poorly 25-40

III Darker white skin Tans after initial burn 30-50

IV Light brown skin Burns minimally, tans easily

40-60

V Brown skin Rarely burns, tans darkly easily

60-90

VI Dark brown or black skin Never burns, always tans darkly

90-150

People with type I skin phototyping are at much greater risk of sunburn than their type VI counterparts. The amount of UV radiation, measured in energy per unit area, to produce erythema at an exposed site is called the minimal erythema dose (MED) and this is significantly lower in people with a low skin phototype grading.

Other factors that increase the incidence of sunburn include:

• Regions situated closer to the equator • Areas at high altitude – UV radiation increases 4% for every 300m increase in

elevation • Skin exposure between 10am and 2pm – 65% of UV radiation reaches the earth

between these times • Clear skies: clouds and environmental pollution reduce UV radiation • Environmental reflection – UV radiation is 80% reflected by snow and ice

What are the signs and symptoms of sunburn?

The signs and symptoms of sunburn differ for each individual according to their skin phototype and length of exposure to UV radiation. Fifteen minutes of midday sun exposure may cause sunburn in a white skin person, while a darker skinned person may tolerate the exposure for hours.

Signs and symptoms usually occur after 2-6 hours of exposure and peak at 12-24 hours, they may include:

• Erythema (redness) • Oedema (swelling) • Tenderness and/or irritation • Skin feels hot to touch • Pain • Blistering (severe cases) • Chills and fever (severe cases)

Around 4-7 days after exposure skin may start to peel and flake off.

In severe cases of sunburn, severe skin burning may result in second-degree burns, dehydration, electrolyte imbalances, secondary infection, shock or even death.

Sunburn

What is the treatment?

The treatment of sunburn is to provide relief of the discomfort it can cause. This can be achieved with the use of analgesics (pain-killers), cool baths, aloe vera lotions and moisturisers.

However, sunburn is better prevented than treated. Sun protection is your best defence against sunburn and other damaging effects of UV radiation.

• Avoid sun exposure, especially between 10am to 2pm • Wear protective clothing, including wide-brimmed hats • Regularly apply sunscreen with a Sun Protection Factor (SPF) of 30+

An oral food supplement containing Polypodium leucotomas may provide additional oral photoprotection and reduce sunburn.

If you are inadvertently exposed and expect to be sunburned:, you may lessen the severity of the burn with the following measures:

• Take two aspirin immediately and then two every four hours • Apply a topical steroid to exposed areas twice daily for two or three days

What are the long-term consequences?

It is now clearly apparent that the long-term consequences of overexposure to the sun or other sources of UV radiation are significant (click on links below for further information). One blistering sunburn is said to double the likelihood of developing skin cancer.

• Premature ageing skin and wrinkling • Brown spots and freckles (lentigos) • Development of premalignant lesions (solar keratoses) • Development of skin cancer (e.g. melanoma, basal cell carcinoma, squamous cell

carcino

Sun protection

Why should one protect one's skin from the sun?

It is vital to protect skin and eyes from the damaging effect of the sun because exposure to ultraviolet radiation contributes to ageing skin and is the main cause of skin cancer. Some people may need to take particular care because of photosensitivity.

So:

No matter what the weather, or what you are doing, cover up! Take particular care in summer – between September and May in New Zealand – especially between eleven a.m. and four p.m. Make sure your children are protected as well as yourself.

You should also be careful to protect your skin if you are at high altitude in any season, particularly when in the snow because it reflects extra ultraviolet radiation onto your skin.

Ultraviolet measurements

The maps below demonstrate the variation in ultraviolet radiation according to the time of day and cloudiness in mid-summer, and the variation according to the time of year. The 15-minute and 30-minute burn times are also shown.

Data collected at Waikato Hospital 1989

UV levels in December

Average UV Levels on a clear day

In recent years, publication of the Global Solar Ultraviolet Index has become the standard way to determine the risk of sunburn. Sun protective clothing

The damaging effects of the sun are well established. Exposure to ultraviolet radiation contributes to ageing skin and is the main cause of skin cancer. Sun protection methods are extremely important in preventing these damaging effects. One method is to wear sun protective clothing.

What is sun protective clothing and UPF?

Sun protective clothing is clothing that is manufactured from ultraviolet (UV) protective fabric. The definition of a sun protective fabric is a fabric that must achieve a minimum UV Protection Factor (UPF) rating of at least UPF15 after the equivalent of 2 years of normal wear and tear. UPF is similar to SPF (sun protection factor) used to rate sunscreens but UPF

is the rating used to measure the amount of UV rays that pass through fabrics when exposed to UV radiation. UPF ratings are shown in the table below.

UPF Protection category

15 or 20 Good protection

25, 30 or 35 Very good protection

40,50 or 50+ Excellent protection

In New Zealand genuine sun protective clothing must be made from fabric that complies with the standard AS/NZS4399:1996. Clothing that has met this standard will carry a label stating one of the UPF rating as shown in the table above.

Much research is going into producing sun protective fabrics. A team at the University of New South Wales in Australia has developed a material that looks like pure close-knit cotton with a UPF of 100. Research has shown that a simple white cotton T-shirt only provides the same protection as applying a sunscreen with SPF 5. The amount of protection fabric provides depends on the type of fabric and the weave or knit of the fabric. In general, the tighter the weave or knit, the higher the UPF.

UPF category of common fabrics

Provide better protection Provide worse protection

• Specially manufactured fabrics for sun protection

• Blue or black denim jeans • 100% polyester • Shiny polyester blends • Satin-finish silk of any weight • Tightly woven fabrics • Unbleached cotton

• Polyester crepe • Bleached cotton • Viscose • Knits, especially loosely

woven • Undyed, white denim jeans • Threadbare, worn fabric

It is not necessary to go out and buy clothing made from specially manufactured sun protective fabric, as a wide variety of everyday apparel will provide some protection. To assess protection simply hold the material up to a window or lamp and see how much light gets through. Less light filtering through means greater protection. In addition, darker colours provide more protection than fabrics of the same material in light colours.

Any fabric, including special sun protective clothing will have their protection reduced by one third to a half when they get wet.

Where can I get sun protective clothing?

Sun protective clothing made from UV protective fabric is available from many stores; just look at the labelling to make sure it complies with the standard and has a UPF rating. There are numerous Internet sites that market sun protective clothing.

By following the simple tips below you can protect yourself from the sun with the clothes you already own.

• Choose clothing made from fabrics that provide better protection, e.g. 100% polyester (high UPF as it contains a benzene ring that absorbs UV light)

• Wear dark clothing instead of white. Dark colours provide 5 times more protection than white because the dye absorbs UV rays.

• Choose clothing that is made from tightly woven fabrics • Wear long sleeves, long pants, long skirts and shirts with collars and high necklines • Wear loose fitting clothing – the folds in loose clothing double the fabric’s sun

protection • Cover up with dry clothes after swimming or getting wet • Wash clothes with detergents that contain optical fluorescent brighteners to make

clothes appear whiter or brighter. These act like dyes and improve the UV absorption of fabric so making them more sun protective.

Topical sunscreen agents

Based on their mechanism of action, topical sunscreens can be broadly classified into two groups, chemical absorbers and physical blockers. Chemical absorbers work by absorbing ultraviolet (UV) radiation and can be further differentiated by the type of radiation they absorb, UVA or UVB, or both UVA and UVB. Physical blockers work by reflecting or scattering the UV radiation.

Chemical absorbers

The table below is a list of some of the common chemical absorbers available and the protection they provide against the UV range.

Chemical UVB

(290-320nm)

UVA II

(320-340nm)

UVA I

(340-400nm)

Aminobenzoic acid derivatives

PABA Partial None None

Glyceryl PABA Partial None None

Padimate O Partial None None

Roxadimate Complete Partial None

Benzophenones

Dioxybenzone Complete Complete Partial

Oxybenzone Complete Complete Partial

Sulisonbenzone Complete Complete Partial

Cinnamates

Octocrylene Complete Complete Partial

Octyl methoxycinnamate Complete None None

Salicylates

Homosalate Partial None None

Ethylhexyl salicylate Complete None None

Trolamine salicylate Complete None None

Chemical absorbing sunscreens often contain a combination of ingredients to get coverage against both UVB and UVA radiation. Some are also combined with physical blockers.

Some organic formulations may degrade when exposed to sunlight; they may therefore not perform as well as expected.

Physical blockers

Physical blockers are effective at protecting against both UVA and UVB radiation. The two most common physical blockers are titanium dioxide and zinc oxide. These agents are the near ideal sunscreen as they are chemically inert, safe, and protect against the full UV spectrum. Their only drawback is their poor cosmetic appearance when applied to the skin. By decreasing the particle size, microsized or ultrafine grades have been developed, thereby reducing the whitening appearance. In some products, bright fluorescent colours have been added.

What is SPF?

SPF stands for Sun Protection Factor and is the system used worldwide to determine how much protection a sunscreen provides, applied to the skin at a thickness of 2 mg/cm2. The test works out how much UV radiation (mostly UVB) it takes to cause a barely detectable sunburn on a given person with and without sunscreen applied. For example, if it takes 10 minutes to burn without a sunscreen and 100 minutes to burn with a sunscreen, then the SPF of that sunscreen is 10 (100/10).

A sunscreen with a SPF of 15 provides >93% protection against UVB. Protection against UVB is increased to 97% with SPF of 30+. The difference between a SPF 15 and a SPF 30 sunscreen may not have a noticeable difference in actual use as the effectiveness of a sunscreen has more to do with how much of it is applied, how often it is applied, whether the person is sweating heavily or being exposed to water. Hence a sunscreen with SPF 15+ should provide adequate protection as long as it is being used correctly. However, most people apply their sunscreen at about one third the thickness used for testing; they fail to apply it to all exposed areas of skin; and they forget to reapply it every couple of hours. Therefore, the actual protection may be a lot less than the tests indicate.

Currently there is no internationally agreed test for measuring UVA protection in human skin. An estimate is made by a laboratory test in which the proportion of radiation passing through a measured amount of sunscreen is determined. To ensure some protection against UVA, products with physical blocking agents making up some of the active ingredients are recommended.

How to use sunscreens

To get the best protection from your sunscreen you should consider the following points:

• Use a good broad-spectrum sunscreen of at least SPF 15 and made up of a benzophenone chemical absorber plus a physical blocker (titanium dioxide or zinc oxide).

• Choose a product that complies with the current Australian and New Zealand Standard for Sunscreens (AS/NZS2604:1998), or equivalent in other countries.

• Apply sunscreen liberally to all sun-exposed areas so that it forms a film when initially applied. Most people use sunscreens improperly by not applying enough.

• It takes 20-30 minutes for sunscreen to be absorbed by the skin and it can be rubbed off very easily, so apply it at least half an hour before going out in the sun. Reapply after half an hour so that the ‘mountains’ as well as the ‘valleys’ are protected (imagine you are painting a wall – two coats of paint provide a more even cover than one).

• Re-apply sunscreen every 2 hours if staying out in the sun for more than an hour during the day.

• Re-apply immediately after swimming, excessive sweating, or if rubbed off by clothing or toweling. This should be the case even if the product claims to be “water resistant”.

• Insect repellents reduce the sunscreen’s SPF so when using together, use a sunscreen with a higher SPF and re-apply more often.

Alcohol-based lotions, sprays or gels are better for oily or hairy skin. Creams are suitable for dry skin, and milky lotions are the easiest to apply. Special sticks are suitable for noses, lips and around the eyes.

Rashes from sunscreens

Unfortunately, some people find that sunscreens irritate, and others develop dermatitis where they have applied them.

Sometimes this is because of generally sensitive skin (irritant contact dermatitis), at other times because of an allergic reaction to one of its components: this may be a fragrance, a preservative or a sunscreen chemical.

The cause can be difficult to work out, so if simply changing the brand doesn't solve the problem, ask your dermatologist for advice. He or she may organise patch tests. Be careful to test a new product on a small area for a day or two before applying it widely.

Photoallergic contact dermatitis to sunscreen

Antioxidant photoprotective agents

In recent years, there has been much interest in the use of oral and topical antioxidants as photoprotective agents. These antioxidants work against the harmful effects of UV radiation via a number of ways that may include:

• Scavenging free radicals and reactive oxygen species (ROS) that are harmful to the body

• Decreasing the number of UV-induced sunburn cells forming • Preserving Langerhans cells

Antioxidant photoprotective agents that are available in oral and/or topical preparations include:

• Vitamin C • Vitamin E • Carotenoids, such as beta-carotene • Green tea • Extract from fern plant Polypodium leucotomos

Oral preparations are commonly available as nutritional/dietary supplements from health food suppliers.

Vitamins that may be helpful

Supplementation with the amino acid L-phenylalanine (LPA) may have value when combined with ultraviolet (UVA) light therapy. Several

clinical trials, including one double-blind trial, indicated that LPA (50 mg per 2.2 pounds of body weight per day—3,500 mg per day for a 154-pound person—or less) increased the extent of repigmentation induced by

UVA therapy. LPA alone also produced a more modest repigmentation in some people.2 A study of vitiligo in children reported that LPA plus UVA

was an effective treatment in a majority of the children.3

A group of Spanish doctors reported on their experience using LPA over a six-year period. Some of the 171 people with vitiligo received LPA (50 or 100 mg per 2.2 pounds body weight per day) for up to three years.

Between April and October of each year, participants also applied a 10% LPA gel, prior to exposing their skin to the sun for 30 minutes. Some

improvement was seen in 83% of participants, and the results were rated as good in 57% (75% improvement or better).4

A clinical report describes the use of vitamin supplements in the treatment

of vitiligo.5 Folic acid and/or vitamin B12 and vitamin C levels were abnormally low in most of the 15 people studied. Supplementation with large amounts of folic acid (1–10 mg per day), along with vitamin C (1

gram per day) and intramuscular vitamin B12 injections (1,000 mcg every two weeks), produced marked repigmentation in eight people. These

improvements became apparent after three months, but complete repigmentation required one to two years of continuous supplementation. In another study of people with vitiligo, oral supplementation with folic

acid (10 mg per day) and vitamin B12 (2,000 mcg per day), combined

with sun exposure, resulted in some repigmentation after three to six months in about half of the participants.6 This combined regimen was

more effective than either vitamin supplementation or sun exposure alone.

When used topically in combination with sun exposure, a pharmaceutical

form of vitamin D, called calcipotriol, may be effective in stimulating repigmentation in children with vitiligo. In a preliminary study, children

applied a cream containing calcipotriol daily and exposed themselves to sunlight for 10–15 minutes the following morning.7 After 11 months, marked to complete repigmentation occurred in 55% of the children,

moderate repigmentation occurred in 22%, and little or no improvement was seen in 22%. None of the children developed new areas of vitiligo.

The first evidence of repigmentation occurred within 6 to 12 weeks in the majority of the children. All participants tolerated the cream well, with approximately 17% complaining of mild, transient skin irritation.

Calcipotriol is a prescription medication to be used only under the supervision of a doctor. It is not known whether vitamin D as a dietary

supplement has any effect on vitiligo.

In one early report, lack of stomach acid (achlorhydria) was associated with vitiligo. Supplementation with dilute hydrochloric acid after meals resulted in gradual repigmentation of the skin (after one year or more).8

Hydrochloric acid, or its more modern counterpart betaine HCl, should be taken only under the supervision of a doctor.

Another early report described the use of PABA (para-aminobenzoic

acid)—a compound commonly found in B-complex vitamins—for vitiligo. Consistent use of 100 mg of PABA three or four times per day, along with

an injectable form of PABA and a variety of hormones tailored to individual needs, resulted, in many cases, in repigmentation of areas affected by vitiligo.9

Herbs that may be helpful

In a double-blind study of 52 people with slowly spreading vitiligo,

supplementation with Ginkgo biloba extract (standardized to contain 24% ginkgoflavonglycosides), in the amount of 40 mg three times per day for

up to six months, resulted in marked to complete repigmentation in 40% of cases, compared with only 9% among those receiving a placebo.10

An extract from khella (Ammi visnaga) may be useful in repigmenting the

skin of people with vitiligo. Khellin, the active constituent, appears to work like psoralen drugs—it stimulates repigmentation of the skin by increasing sensitivity of remaining melanocytes to sunlight. Studies have used 120–

160 mg of khellin per day.11

In preliminary trial, Picrorhiza, in combination with the drug methoxsalen and sun exposure, was reported to hasten recovery in people

with vitiligo compared with use of methoxsalen and sun exposure alone.12

Between 400 and 1,500 mg of powdered, encapsulated picrorhiza per day has been used in a variety of studies.

Cosmetics

Some patients with vitiligo cover depigmented patches with stains, makeup, or selftanning lotions.

These cosmetic products can be particularly effective for people whose vitiligo is limited to exposed areas of the body. Dermablend, Lydia

O’Leary, Clinique, Fashion Flair, Vitadye, and Chromelin offer makeup or dyes that patients may find helpful for covering up depigmented patches

SOME QUESTIONS.

• Are there cosmetics available to cover vitiligo spots? Yes, there are many products out there to provide excellent camouflage of vitiligo spots. Some people prefer traditional waterproof makeup, designed to match every skin tone, and which can be applied to the spots only. Though they are waterproof, they are not always friction proof, and some men will not wear them. These types of covers are available in every skin tone, from very fair to dark black. Other people prefer stains (or sunless tanners as they are often called) which are both waterproof and friction proof and which last for several days. Sunless tanner products should be applied ONLY to the white areas, as they will darken all skin relatively. Thus applying them all over a body part, may result in the spots still being visible. There is some controversy about the safety of sunless tanners, in particular those that contain the chemical Dihydroxy Acetone (DHA) which blocks UV rays from reaching the skin, and which may not be healthy for the skin environment. Nevertheless, many people use sunless tanners (at least on occasion), and find them a source of great relief.

Is it true that I can make my own safe skin-colored stain to cover the

spots? Yes! Some members of Vitiligo Support have created their own safe homemade skin stain, made entirely out of rubbing alcohol (isopropyl) and ordinary Food Coloring. By mixing the ingredients together, a brownish color results, and the tone can easily be adjusted to match your skin.

Is it safe for someone with vitiligo to use hair dyes or bleaches? Experts recommend that if you have vitiligo, you should avoid hair colorings and bleaches. Chemicals in these products called Phenols may cause the onset or further spreading of vitiligo. Temporary hair colourings however, such as henna, which do not contain phenols or phenol derivatives, are generally accepted as safe. When in doubt, you should consult with your physician.

• Counseling and support

nutrition

The following is a list of recognized foods with powerful natural chemicals that boost the capacity of the skin to recover and stay healthy. No supplement can substitute a rich diet. A "vitiligo diet" may include:

Whole-grain food (great source of fibers, vitamins, minerals and "oligoelements").

Spinach (loaded with iron, and folic acid, helps reduce blood levels of homocysteine, a

substance that may damage blood vessels. It contains phytochemicals that help prevent degeneration (ex. macular degeneration in the eye) and protect your skin.

Broccoli, brussels sprouts, cabbage, etc. - Contains abundant phytochemicals (good, protective substances found in vegetables and fruits) that may prevent skin cancer and balance the immune response, vitamin C, beta-carotene (it should not be overcooked).

Vegetables of different colours - Each one contains different types of phytochemicals plus vitamins, minerals and other nutrients.

Different sources of protein (if possible include fish and soy products).

Nuts (if not allergic) - Rich in vitamin E, contain protective phytochemicals and "good fats", all beneficial for your skin.

Oats - Help lower cholesterol and high blood pressure but it also contain vitamin E like compounds (tocotrienols), which protect the skin.

Garlic - Protects the heart and skin, has antibacterial, antifungal properties plus other properties.

Blueberries - Probably contain more anti-oxidants than any other fruit or vegetables. Contain powerful phytochemicals: anthocyanins that not only protect the skin but boost brainpower including memory.

Green tea - Source of vitamin C and phytochemicals known as polyphenols (100 times more oxidant power than Vit C) plus antibacterial properties, and prevention of cancer and heart disease.

Tomatoes - Contains lycopene, the most powerful antioxidant among the carotenoids. Carotenoids gives fruits and vegetables an orange colour. Also a great source of Vit C.

Olive oil - "Good, protective fat", helps absorb beneficial substances in vegetables.

Fruits - Contain different combinations of nutrients, vitamins, minerals, phytonutrients, and antioxidants of great benefit for your body in general and very importantly, for your skin.

Enough fluids - Several glasses of water per day. Consider supplementing your treatment with 7 to 10 servings of fruits or vegetables a day. One serving of a vegetable or fruit is: - 1 medium sized vegetable or fruit - ½ cup (125 ml) juice - ½ cup raw, cooked, fresh, or canned, vegetables or fruits - 1 cup (250 ml) raw, leafy vegetables - ¼ cup dried fruit

Dietary instruction in Vitiligo:

There are a few instructions for patients regarding their diet in vitiligo especially with mention of what they shavoid during the treatment of vitiligo. Following are some of our observations based on our clinical experience of treating a large number of patients (clinical observations):

:: Foods that are excessively sour should be avoided. Vitamin C (ascorbic) is known to inhibit the production of the melanin, the color pigment. Patients with vitiligo are suggested to refrain from citrus fruits, sour yogurt, sour pickles, etc.

:: Non vegetarian foods are also to be avoided as they act as a foreign body to pigment cells.

:: Artificial colors used in various food preparations should also be avoided.

There may not be enough scientific evidence to prove how these foods worsen vitiligo but our clinical experience has shown that many patients report worsening of their vitiligo from these items and hence they are better avoided.

The author of this write up is of the opinion is that the since the process of melanin formation calls for physiological pH, in the process where tyrosinase converts tyrosine to dihydroxyphenylalanine (DOPA) and then to dopaquinone, intake ofmay work adversely, hence hampering the process of melanogenesis

EMOTIONAL, SOCIAL AND RELATIONSHIP ISSUES

How we deal with the emotional issues of vitiligo? The change in appearance caused by vitiligo can affect a person's emotional and psychological well-being and may create difficulty in professional and social situations. People with vitiligo can experience emotional stress, particularly if vitiligo develops on visible areas of the body, such as the face, hands, arms, feet, or on the genitals. Adolescents, who are often particularly concerned about their appearance, can be devastated by widespread vitiligo. Some people who have vitiligo feel embarrassed, ashamed, depressed, or worried about how others will react. Several strategies can help a person cope with vitiligo. First, it is important to find a doctor who is knowledgeable about vitiligo and takes the disorder seriously. The doctor should also be a good listener and be able to provide emotional support. Patients need to let their doctor know if they are feeling depressed because doctors and other mental health professionals can help people deal with depression. Patients should also learn as much as possible about the disorder and treatment choices so that they can participate in making important decisions about medical care. Talking with other people who have vitiligo can help a person cope. VitiligoSupport.org provides message boards and chat rooms for this very purpose, and most members here have found them an invaluable source of support. Physicians, family and friends are another important source of support. As discussed above, many people with vitiligo have found that cosmetics that cover the white patches improve their appearance and help them feel better about themselves. A person may need to experiment with several brands of concealing cosmetics before finding the product that works best. Finally, counseling with a licensed therapist can help you examine your fears, improve your self esteem, and find ways to deal with the emotional and social issues that everyone with vitiligo faces. This type of counseling is covered by many health insurance plans.

explain vitiligo to people

We suggest that you be honest and open, and explain to people that vitiligo is a genetic condition, in which the body's immune system sees pigment cells as foreign bodies, and attacks them. Explain that it is a rather common condition, that it does not hurt or itch, and that it is not contagious. Finally, explain to them that treatment technology for the condition is improving, and that genetic advances may one day solve the condition. No matter who they are, everyone can identify with genetic ailments, such as cancer, leukemia, multiple sclerosis, Parkinson’s, and other conditions. When they realize that this is a condition just like every other miserable condition humans inherit, they are less likely to be afraid of it. IF you have a child with vitiligo. What should I do? Children usually cope best with vitiligo when their parent(s) is/are prepared to talk about the condition as openly and truthfully as possible. To pretend you haven't noticed something so obvious may make it difficult for your child to talk to you about it. Because this is often so difficult for parents to cope with, especially as relates to other children, it is important to talk with teachers, and counselors, and to be

conscious if your child is being teased or bullied. Support your child, and encourage them to get involve with activities and hobbies. Teach them that it is OK to be different, and that it doesn't make them any less important. A wonderful book for children to read, is Lori Mitchell's "Different Just Like Me" which teaches children that there are many different people in the world, and that they really are very much alike, despite their obvious differences. good counselor or psychotherapist to help patient with the emotional issues Physicians and friends and family are all good sources for referral to a therapist. As with all professionals, personal referrals are often the most valuable. Second to that, you should try to find a therapist who has experience in counseling people with medical conditions or conditions which affect their appearance. These types of therapists may be able to explore with you ways to deal with vitiligo, both inwardly and socially, and can work with you to maintain your self-esteem and pride.

RESULTS from treatment

EVALUATION OF THE TREATMENT POLICY BEFORE DEVELOPMENT

OF THE GUIDELINES

The NIPD is a specialized national outpatient clinic for patients with pigmentary skin diseases. In 1997, 1951 new patients were seen at this

institute. Of these, 8.3% (162/1951) were patients from the city of Amsterdam and its surrounding areas, and 91.7% (1789/1951) came from

outside this region. Seven hundred forty-one patients with vitiligo were diagnosed in 1997 (38% of all diagnoses). In 1997, 5751 new patients visited the outpatient clinic of the Department of Dermatology of the

Academic Medical Center of the University of Amsterdam. Patients came from the city of Amsterdam and its surrounding areas (65% [3738/5751])

as well as from outside this region (35% [2013/5751]). In 1997, 43 patients (0.7% of all diagnoses) were diagnosed as having vitiligo, of which 90% were referred to the NIPD. At the beginning of the study in

September 1997, the NIPD consisted of 1 dermatologist and 2 residents. The Department of Dermatology comprised 9 dermatologists and 12

residents.

To detect variations in current treatment policy and disagreements in estimates of treatment outcome and adverse effects, an evaluation was

made of the existing strategies for the treatment of vitiligo. The evaluation consisted of a questionnaire and a structured interview. An inventory was made of the therapy choices and regimens for the treatment of vitiligo

using a questionnaire. All physicians were asked for their definition of a successful event in vitiligo therapy. Subsequently, all participants were

interviewed by one of the investigators (M.D.N.) and asked to comment on their own therapy selection. For each therapeutic option, their opinion was solicited regarding the expected percentage of patients achieving a

successful event and on the expected rates of adverse effects.

Of the 23 questionnaires sent, 14 were filled in and returned. Nine physicians (all from the Department of Dermatology) reported that they

had too little experience with the treatment of vitiligo, since they had treated no more than 5 patients with vitiligo over the past year. These physicians did not complete the questionnaire.

The first-choice therapies of the remaining 14 respondents are listed in Table 1. The results show that the respondents were not unanimous in their selection of a first-choice therapy. For children younger than 12

years, topical corticosteroid therapy was chosen by 79% (11/14) of the respondents for localized vitiligo, 79% (11/14) for generalized vitiligo, and

86% (12/14) for stable vitiligo. In children with generalized vitiligo, phototherapeutic modalities, such as narrowband UV-B and oral psoralen–UV-A (PUVA), were prescribed by 14% (2/14) and 7% (1/14) of the

respondents, respectively. Children with lip-tip vitiligo or universal vitiligo

were not given any therapy by 79% (11/14) and 93% (13/14) of the

physicians, respectively. Autologous transplantation methods were not chosen as first-choice therapy for children by any of the respondents.

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Table 1. Evaluation of First-Choice Therapies

For adults, topical corticosteroid therapy was prescribed by 64% (9/14) of

the physicians for localized vitiligo, 71% (10/14) for generalized vitiligo, and 79% (11/14) for lip-tip vitiligo. In patients with generalized vitiligo, other treatment choices were narrowband UV-B therapy (14% [2/14]) and

oral PUVA (7% [1/14]). In patients with stable vitiligo, most respondents

(71% [10/14]) recommended autologous transplantation as the first-

choice therapy. There was also no consensus regarding the therapy for patients with universal vitiligo; 64% (9/14) would offer depigmentation therapy, whereas 36% (5/14) would prescribe repigmentation therapy

with oral PUVA.

During the interviews, it appeared that most respondents (12 of 14) regarded "more than 75% repigmentation" as a cosmetically acceptable

level of repigmentation. Therefore, this was defined as a successful event of vitiligo therapy. Table 2 shows that physicians working at the NIPD are

generally more optimistic toward treatment outcome than those working at the Department of Dermatology. The expected rates of adverse effects were more or less consistent among the respondents (results not shown).

Many respondents questioned whether therapy-induced repigmentations

were permanent. They did not agree on the maximum recommended

dosage for phototherapies in view of the long-term carcinogenic risks.

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Table 2. Mean Estimated Percentages of Patients

With Vitiligo Who Achieved Repigmentation (>75%) Induced by First-Choice Therapies*

SYSTEMATIC REVIEW OF THE LITERATURE

We have performed a meta-analysis and a systematic review of the available literature (last update, December 1997) on the most applied

forms of nonsurgical repigmentation therapy and autologous transplantation methods, respectively, with regard to both effectiveness

and safety. The methods and results of these studies have been reported elsewhere.14-15 In addition, a systematic review was performed on the effectiveness and safety of depigmentation therapies for vitiligo (M.D.N.,

W.W., J.D.B., and P.M.M.B., unpublished study, 1987). Data sources consisted of computerized searches of bibliographic databases (using

MEDLINE [National Library of Medicine, Bethesda, Md] and EMBASE [Elsevier Science BV, Amsterdam, the Netherlands), a complementary manual literature search, and contacts with researchers and

pharmaceutical firms. Predefined selection criteria were applied to both randomized controlled trials (RCTs) and nonrandomized controlled trials.

Two investigators (M.D.N. and W.W.) independently assessed the articles for inclusion. When there was a disagreement, a third investigator (P.M.M.B.) was consulted. A preliminary search revealed that only a minor

number of RCTs had been performed on vitiligo therapies. Therefore, analysis was also performed on the available patient series. Because

comparative or placebo-controlled trials can contain a description of at least 2 patient series, the total number of patient series could exceed the

total number of studies included.

META-ANALYSIS OF NONSURGICAL REPIGMENTATION THERAPIES

Sixty-three studies were found on therapies for localized vitiligo. Of these, 10 of 11 RCTs and 29 of 110 patient series were included. One hundred seventeen studies on therapies for generalized vitiligo were found. Of

these 10 of 22 RCTs and 46 of 231 patient series were included. Most studies were excluded because they described combination therapies or an

obsolete drug or dosage scheme and because there were inadequate or insufficient data on effectiveness.

Among RCTs on localized vitiligo, the pooled odds ratio vs placebo for

topical class 3 corticosteroid therapy was 14.32 (95% confidence interval [CI], 2.45-83.72). In the patient series, topical class 3 and class 4 corticosteroid therapies had the highest mean success rates (56%; 95%

CI, 50%-62%; and 55%; 95% CI, 49%-61%, respectively). Topical methoxsalen (8-MOP; ICN, Costa Mesa, Calif) therapy had the highest

proportion of patients developing phototoxic reactions (58%; 95% CI, 51%-65%), followed by trioxsalen therapy (39%; 95% CI, 23%-56%) and unsubstituted psoralen therapy (25%; 95% CI, 12%-38%). Atrophy was

the most common adverse effect for local corticosteroid therapy, occurring most commonly in patients receiving treatment with intralesional

corticosteroids (33%; 95% CI, 22%-43%), followed by patients treated with class 4 corticosteroids (14%; 95% CI, 10%-18%) and class 3 corticosteroids (2%; 95% CI, 1%-5%).

In the RCTs on generalized vitiligo, the odds ratio vs placebo for treatment with oral 8-methoxsalen and sunlight was 23.37 (95% CI, 1.33-409.93), and for treatment with oral unsubstituted psoralen and sunlight it was

19.87 (95% CI, 2.37-166.32); for treatment with oral trioxsalen and

sunlight the pooled odds ratio was 3.75 (95% CI, 1.24-11.29). In the series, the best mean success rates were reported for narrowband UV-B

(63%; 95% CI, 50%-76%), broadband UV-B (57%; 95% CI, 29%-82%), and oral methoxsalen and UV-A (51%; 95% CI, 46%-56%) therapies.

Treatment with oral methoxsalen and UV-A was associated with the highest rates of adverse effects, including nausea and vomiting in 29%

(95% CI, 24%-35%) and phototoxic reactions in 25% (95% CI, 20%-

30%) of the cases. No adverse effects were reported with narrowband or broadband UV-B therapy.

The results of this study allowed us to conclude that class 3 corticosteroids

and UV-B were the most effective and safest therapies for localized and for generalized vitiligo, respectively.

SYSTEMATIC REVIEW OF AUTOLOGOUS TRANSPLANTATION

METHODS

Sixty-three studies were found, of which 16 reported on minigrafting, 13 on split-thickness skin grafting, 15 on grafting of epidermal blisters, 17 on grafting of cultured melanocytes, and 2 on grafting of noncultured

epidermal suspension. Of these, 39 patient series were included in our analysis. Autologous transplantation methods were performed in cases of

stable and segmental vitiligo. Patients with lesions on sites that did not respond to nonsurgical therapies, such as lips, hands, feet, fingers (so-

called lip-tip vitiligo), and genital areas, were also treated with these methods.

The highest mean success rates were achieved with split-thickness skin (87%; 95% CI, 82%-91%) and epidermal blister (87%; 95% CI, 83%-

90%) grafting. The average success rate for 5 culturing techniques varied from 13% to 53%. However, for 4 of the 5 culturing methods, fewer than

20 patients were reported. Minigrafting had the highest rate of adverse effects. Scar formation of the donor site occurred in 40% of the cases (95% CI, 34%-47%), and cobblestoning appearance of the grafts at the

acceptor site was seen in 27% of the cases (95% CI, 21%-33%). Nevertheless, minigrafting was shown to be the easiest, fastest, and least

expensive method.

Because no comparative controlled trials were included, the treatment recommendations for transplantation should be viewed with caution. Split-

thickness skin or epidermal blister grafting can be recommended as the most effective and safest techniques. No definite conclusions can be drawn with regard to the effectiveness of culturing techniques, since only a small

number of patients have been studied. The choice of transplantation method also depends on disease characteristics as well as on the

availability of specialized personnel and equipment.

SYSTEMATIC REVIEW OF DEPIGMENTATION THERAPIES FOR VITILIGO UNIVERSALIS

Two studies were found on therapy with monobenzone. One was a case report and had to be excluded. The second was an open retrospective

study of 18 patients.16 One patient dropped out of this study. Eight (47%; 95% CI, 23%-72%) of the remaining 17 patients who were treated with

monobenzone achieved 100% depigmentation.

Only 1 study was found on depigmentation therapy using the Q-switched

ruby laser.17 In 3 (38%; 95% CI, 9%-76%) of 8 patients who received

treatment with the Q-switched ruby laser, 100% depigmentation was observed.

Burning, erythema, contact dermatitis, and pruritus occurred most commonly in patients who were treated with depigmenting cream.

Patients who were treated with laser therapy experienced pain in 50% of the cases and erythema in all cases. These adverse effects disappeared

after 2 or 3 days.

Treatment recommendations regarding the most effective and safest

depigmenting therapy for vitiligo universalis can only be made with caution, since only 1 study has been found for the 2 different modalities.

For now, no large differences in the levels of effectiveness can be inferred from the 2 trials included in the analysis. One may prefer the use of a

cream over laser therapy, since cream is less expensive and easier to apply. A major disadvantage, however, is that bleaching with cream may

take months or years to result in evident signs of depigmentation. In contrast, laser therapy is faster, and it is possible to treat larger areas of residual pigment at once, but one must keep in mind that patients with a

negative Koebner phenomenon will not respond to laser therapy.

THE DEVELOPMENT OF PRELIMINARY GUIDELINES

Nine dermatologists and 12 residents from the Department of

Dermatology, 1 dermatologist and 1 resident from the NIPD, and an

independent clinical epidemiologist participated in the first internal meeting. During this meeting, the results of the questionnaires,

interviews, and literature studies were presented and discussed.

Based on the results of the questionnaire, the literature studies, and the first internal meeting, preliminary guidelines for the treatment of vitiligo were synthesized. These guidelines were distributed by internal mail to all

potential users (staff dermatologists and residents of both target institutions).

In the second internal meeting, which was attended by the same

personnel as the first, participants gave their comments on the preliminary guidelines. At the same time, a draft of the preliminary guidelines was mailed to the external expert for critical review.

THE FINAL VERSION OF THE GUIDELINES

Comments from the staff members and the residents of both institutions

and comments from the external expert were incorporated in a new draft

of the guidelines. The final version was then synthesized in the form of a treatment scheme (Table 3). Recommendations regarding first and

alternatives choices were given according to the age of the patient, clinical type, severity of disease, and disease activity. Recommendations on the minimum and maximum treatment duration were made during a

consensus meeting with a smaller group of experts, consisting of members of the guideline development group, an expert on phototherapeutic

therapies, and a photobiologist. When sufficient scientific evidence was

lacking, recommendations on the selection of therapy and dosage

schemes were made during this same consensus meeting.

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Table 3. Treatment Scheme for Vitiligo

For children younger than 12 years, treatment with class 3 topical

corticosteroids (eg, fluticasone propionate or betamethasone valereate) was recommended as the first-choice therapy. This choice was made regardless of the clinical type. When no repigmentation was observed after

6 months, localized UV-B therapy or topical PUVA therapy could be prescribed and the "skin-saving principle" applied (ie, parts of the body

where no lesions were present [especially the face] should be shielded during treatments). Additionally, parts of the body that had repigmented

satisfactorily during the course of the therapy should, if possible, be shielded during subsequent treatments (eg, trousers should be worn). In children, genital areas should always be protected during UV exposures.

Treatment with topical corticosteroid may be combined with UV-A radiation. In a recent left-right comparative study, it was shown that the

combined treatment with fluticasone and UV-A led to a higher repigmentation grade than treatment with either fluticasone or UV-A alone.18 A facial tanner or a sun bed may be used as the UV-A source.

In adult patients, treatment choice was guided by clinical type. Patients

with only localized vitiligo could be treated with class 3 corticosteroids combined with UV-A therapy. If there is no response after 6 months,

localized UV-B or topical PUVA therapy could be given as an alternative. Narrowband UV-B therapy was recommended as the most effective and safest therapy for generalized vitiligo. A minimum treatment duration of 6

months was recommended for narrowband UV-B therapy. Responsive patients could be given this treatment for a maximum of 24 months. After

the first course of 1 year, a resting period of 3 months was recommended to minimize the annual cumulative dose of UV-B.

The therapy selected as the first choice for segmental, stable, or lip-tip

vitiligo was autologous transplantation. In the NIPD, split-thickness skin grafting and minigrafting are performed on a routine basis for these

conditions. For patients who do not desire a surgical intervention, alternatives may be considered.

In patients with extensive areas of depigmentation (>80%) and/or

disfiguring lesions on the face who do not respond to repigmentation therapies, depigmentation of the residual melanin should be considered. During and upon completion of the therapy, patients are permanently at

risk for acquiring sunburn from acute solar irradiation. Patients should therefore be advised to minimize sun exposure and to apply broad-

spectrum sunscreens. The use of a potent bleaching cream and/or laser therapy (eg, the Q-switched ruby laser) is considered to be the cornerstone of depigmentation therapy for these patients.

In all cases, advice regarding the use of camouflage and sunblocking

agents should always be given. If necessary, psychological counseling may be recommended.

These guidelines were distributed together with detailed treatment

protocols (not included in this article).

DISSEMINATION AND IMPLEMENTATION OF THE FINAL VERSION OF THE GUIDELINES

The guidelines were mailed to all potential users. A copy of the guidelines

was placed on the desk of every treatment room as a reminder. The guidelines were incorporated into the specific dermatological treatment

protocol index to which every dermatologist and resident has access. Furthermore, the guidelines were presented and commented on during an internal meeting and again during a local symposium on pigmentary

disorders. The implementation of the guidelines was discussed once a week during regular staff meetings and their use was encouraged.

EVALUATION

After 6 months, use of the guidelines was evaluated by means of a

questionnaire. Since during this period almost all patients with vitiligo had been referred to the NIPD for treatment, evaluation of the use of the

guidelines took place primarily at the NIPD. The second questionnaire was also sent to physicians working at the Department of Dermatology; physicians were asked to evaluate whether dissemination and

implementation of the guidelines had also succeeded there.

Information was obtained from NIPD patient record forms regarding the therapy given to patients with vitiligo between June 1998 and January

1999. In addition, in individual cases the reasons for not adhering to the guidelines were noted.

In the questionnaire, all physicians were asked to indicate whether they

were familiar with the guidelines and how many new patients with vitiligo they saw during the past 6 months. They were also asked to indicate what

sources of information they used to make a first choice of therapy. All physicians were also asked to give their opinion regarding the context and

content of the guidelines and their usefulness in daily practice.

Twenty-three questionnaires were sent to the physicians working at both institutions. In the introduction period, 2 new part-time staff members and 1 new resident were employed at the Department of Dermatology and at

the NIPD, respectively.

Eighteen staff members and residents of the Department of Dermatology

had seen fewer than 5 patients with vitiligo during the introduction period.

These physicians did not report responses regarding the context and content of the guidelines. However, all 18 physicians reported that they were familiar with the guidelines.

The questionnaire was completed by 2 respondents from the Department

of Dermatology and by 3 respondents from the NIPD. All 5 reported that they used the guidelines during therapeutical decision making. They also

agreed that the guidelines gave clear directions for which patient group and clinical types the treatments were recommended. Treatment

recommendations as presented in the guidelines were found to be reader-friendly and comprehensive. Furthermore, the responding physicians believed that the objectives were clearly defined and that dosage schemes

were adequately adapted for clinical use. Finally, they found that circumstances in which exceptions might be made and patients'

preferences were clearly defined in the treatment protocols that were attached to the guidelines.

In the introduction period, 302 vitiligo patients had visited the NIPD). Among them were 44 children younger than 12 years with vitiligo. The

clinical type of their vitiligo is shown in In 23 cases (52%), therapy with class 3 corticosteroids and UV-A was the first choice, which is in accord

with the guidelines. In 18 children, localized narrowband UV-B therapy was prescribed. The reasons for not adhering to the guidelines in these

cases were "fast stabilization required" (n = 14) and "on specific request of the parents" (n = 4). Three patients (1 was aged 9 years and 2 were aged 11 years) received autologous transplantation by minigrafting

technique because they had localized and stable vitiligo patches.

There were 258 adults patients with vitiligo. Of the 21 patients with localized vitiligo, the guidelines were followed in the treatment of 15

patients (71%); 3 were given localized narrowband UV-B therapy (all on specific request of the patient), and 3 did not desire therapy. Two hundred

seven patients had generalized vitiligo, of whom 82% (170/207) received treatment with narrowband UV-B, according the guidelines. In 33 patients, class 3 corticosteroids plus UV-A therapy was prescribed because patients

specifically requested this therapy (n = 11) or because they found the distance to the hospital too great (n = 13), lacked time (n = 2), or wanted

only to treat facial lesions (n = 7). The remaining 4 patients with generalized vitiligo did not wish to be treated. There were 21 patients with segmental and stable vitiligo, all of whom received autologous

transplantation, a choice that was in accord with the guidelines. There was 1 patient with lip-tip vitiligo who did not want any treatment. Five adult

patients were diagnosed as having vitiligo universalis, 4 of whom (80%)

had started with depigmentation therapy and 1 of whom did not desire depigmentation therapy.

COMMENT

The successful introduction of clinical guidelines depends on the strategies for developing, disseminating, and implementing these guidelines in daily practice.19 The introduction of guidelines for the treatment of vitiligo, as

described in this study, has taken in account all 3 crucial stages. Guidelines are more likely to achieve the desired health effects if they are

consistent with the available scientific evidence or, in the absence of such evidence, with the best clinical judgments.20 Compliance with guidelines has been shown to be enhanced if these guidelines are developed and

adopted by those who will use them.21 Therefore, we linked scientific evidence from 3 literature studies with the results of 2 questionnaires and

interviews among the potential users of the guidelines, 3 internal expert meetings, and 1 local expert meeting, during which the guidelines were presented and commented on. After the guidelines were accepted and

introduced in daily practice, the final version was evaluated.

The results of the first questionnaire showed that there was no uniformity in treatment choices and in estimates of treatment outcome. In view of

the potential long-term carcinogenic risks of UV-B and oral PUVA, many physicians asked the guideline development group to come up with recommendations on the maximum treatment duration for these

phototherapeutic modalities. The literature review therefore focused on clinical trials in which the percentage of repigmentation, adverse effect

profiles, and treatment duration were all adequately reported and analyzed. The best available evidence is delivered by RCTs and

summarized in systematic reviews and meta-analyses.11 However, our own systematic reviews of the available literature showed that only a small number of properly designed RCTs have been performed for both

nonsurgical repigmentation therapies and autologous transplantation

methods in vitiligo. The systematic review of depigmentation therapies in vitiligo showed that no RCT has yet been performed. In such analyses,

calculated weighted estimates on treatment outcome and safety from uncontrolled studies cannot be considered as measures of effectiveness,

since these studies are prone to selection bias. Such summary estimates should therefore be interpreted with caution. Furthermore, only a few studies were found on the treatment of vitiligo in children. In most trials,

both children and adults were included in the study and treatment

outcomes were not analyzed separately. Recommendations for children

could therefore not be entirely evidence-based. The additional input from experts that was generated during the internal and expert meetings was needed to develop explicit guidelines.

Six months after their introduction, the dissemination of the guidelines had succeeded both in the Department of Dermatology and at the NIPD. All 23 participating physicians were familiar with the guidelines. However,

implementation was only partly successful, since only 5 of these physicians had treated a substantial number of patients with vitiligo during

this period (>5 patients). These 5 physicians considered the guidelines to be an easy, practical, and useful tool for making a specific treatment choice.

Analysis of first treatment choices made for 302 new patients with vitiligo

revealed that the guidelines were followed for most adults (n = 258). In children with vitiligo, the physicians adhered to the guidelines for 52% of

the cases. This relatively low compliance rate compared with adults may be explained by the way that the treatment scheme was formulated for children (ie, no further distinction was made in the several clinical types or

the disease activity). The effectiveness and safety of narrowband UV-B therapy for children with generalized vitiligo is currently being

investigated. In the future, the data from this trial could lead to an evidence-based adjustment of the treatment scheme for children.

The finding that the guidelines were not followed in all cases confirms the

general belief that guidelines should not be regarded as rigid criteria, but that they are intended to be flexible. Guidelines should guide action in most cases. Depending on the patient, the setting, the circumstances, or

other factors, any part of the guidelines can and should be adjusted to fit individual needs.22 Quantitative measures of patient preferences also need

to be further investigated for patients with vitiligo, in a manner similar to that previously described by Zug et al23 for patients with psoriasis.

The results of this study show that clinical guidelines for the treatment of vitiligo can be successfully developed and disseminated for daily clinical

practice. Implementation of these guidelines was only partly successful, however, since the number of physicians using the guidelines was low.

Therefore, the results of the implementation of these guidelines should be confirmed in other centers involving more physicians who see more

patients with vitiligo. Guidelines are not static and should regularly be updated to take into account changes in medical knowledge and practice and particularly the results of randomized trials and meta-analyses. Future

studies in vitiligo treatment should also focus on the permanency of

therapy-induced repigmentations and on the long-term risk-benefit ratios of the different modalities.

Latest Research on Vitiligo J Eur Acad Dermatol Venereol. 2007 Nov;21(10):1369-74. Critical evaluation of the variants influencing the clinical response of vitiligo: study of 60 cases treated with ultraviolet B narrow-band phototherapy. Brazzelli V, Antoninetti M, Palazzini S, Barbagallo T, De Silvestri A, Borroni G. Department of Human and Hereditary Pathology, Institute of Dermatology, University of Pavia, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy. Background The treatment of vitiligo is still a challenge, but ultraviolet B narrow-band (UVB-NB) therapy has been recently reported to be an effective and safe therapeutic option in patients with vitiligo. Objective The purpose of this study is a critical evaluation of the variants (body sites, age, duration of the disease, and duration of the therapy) influencing the clinical response to UVB-NB therapy. Methods Sixty patients (23 male and 37 female), aged 6 to 70 years, with vitiligo, were treated with UVB-NB therapy over a maximum period of 2 years. The evaluation of the percentage of repigmentation was done through photographs. Results The lesions located on the face obtained a complete repigmentation in 68% of the patients, on the neck in 57.89%, and on the trunk in 50% within the first year of the therapy. In young patients vs. adults patients, the lesions located on the neck obtained a complete repigmentation in 83.33% vs. 46.15%, on the upper limbs in 28.57% vs. 9.52%, and on the lower limbs in 25% vs. 16.67%. In patients with vitiligo of recent onset, the lesions located on the neck obtained a complete repigmentation in 83.33%, on the upper limbs in 33.33%, and on the lower limbs in 28.57%. Hands did not give a positive response in either groups. Conclusion This study shows that certain body sites respond better than others to the UVB-NB therapy; patients, aged less than 20 years, with recent vitiligo, achieve more repigmentation; the duration of the therapy can influence the response of the lesions over hands and lower limbs, showing only mild repigmentation. ----- Clin Exp Dermatol. 2007 Nov;32(6):631-6. Antioxidants and narrow band-UVB in the treatment of vitiligo: a double-blind placebo controlled trial. Dell'anna ML, Mastrofrancesco A, Sala R, Venturini M, Ottaviani M, Vidolin AP, Leone G, Calzavara PG, Westerhof W, Picardo M. Spedali Civili, Brescia, Italy. Background. Vitiligo is an acquired depigmenting disease with uncertain aetiopathogenesis, possibly associated with oxidative stress. Narrowband ultraviolet B phototherapy (NB-UVB) is the most widely used and effective treatment. Aim. To evaluate the clinical effectiveness of NB-UVB and the repairing of oxidative stress-induced damage, using oral supplementation with an antioxidant pool (AP). Methods. Patients (n = 35) with nonsegmental vitiligo were enrolled in a randomized, double-blind, placebo-controlled multicentre trial. The treatment group received, for 2 months before and for 6 months during the NB-UVB treatment, a balanced AP containing alpha-lipoic acid, vitamins C and E, and polyunsaturated fatty acids. The area and number of lesions, as well as some parameters of the oxidation-reduction (redox) status of the peripheral blood mononuclear cells (PBMCs) were estimated at the beginning, after 2 months, and at the end of the trial. Results. In total, 28 patients completed the study. After 2 months of AP supplementation, the catalase activity and the production of reactive oxygen species (ROS) were 121% and 57% of the basal values (P < 0.05 and P <

0.02 vs. placebo, respectively). The AP increased the therapeutic success of NB-UVB, with 47% of the patients obtaining > 75% repigmentation vs. 18% in the placebo group (P < 0.05). An increase in catalase activity to 114% (P < 0.05 vs. placebo) and decrease in ROS level of up to 60% (P < 0.02 vs. placebo) of the basal value was observed in PBMCs. Finally, the AP intake maintained the membrane lipid ratio (saturated : unsaturated fatty acids 1.8 : 3.1; P < 0.05), counteracting phototherapy-induced saturation. Conclusions. Oral supplementation with AP containing alpha-lipoic acid before and during NB-UVB significantly improves the clinical effectiveness of NB-UVB, reducing vitiligo-associated oxidative stress. ----- J Eur Acad Dermatol Venereol. 2007 Aug;21(7):956-63. Comparison between 308-nm monochromatic excimer light and narrowband UVB phototherapy (311-313 nm) in the treatment of vitiligo--a multicentre controlled study. Casacci M, Thomas P, Pacifico A, Bonnevalle A, Paro Vidolin A, Leone G. Dermatology Clinic, Huriez Hospital, University of Lille 2, France. BACKGROUND: Vitiligo is an acquired pigmentary disorder characterized by areas of depigmented skin resulting from loss of epidermal melanocytes. Recently, it has been shown that narrowband ultraviolet B (NB-UVB) phototherapy may be more effective than psoralen and ultraviolet A (PUVA) photochemotherapy in treating vitiligo, and that 308-nm monochromatic excimer light (MEL) may present some advantages as compared to NB-UVB for the treatment of vitiligo. AIM The aim of this study was to compare the effectiveness of NB-UVB phototherapy and 308-nm MEL in vitiligo patients. METHODS: The study was done in a randomized, investigator-blinded and half-side comparison design. Twenty-one subjects with symmetrical vitiligo lesions were enrolled in this study. Vitiligo lesions on one body side were treated twice weekly for 6 months with 308-nm MEL, while NB-UVB phototherapy was used to treat lesions on the opposite side. RESULTS: At the end of the study six lesions (37.5%) treated with 308-nm MEL and only one lesion (6%) treated with NB-UVB achieved an excellent repigmentation (score 4) while four lesions (25%) treated with 308-nm MEL and five lesions (31%) treated with NB-UVB showed a good repigmentation (score 3). CONCLUSIONS: It appears that 308-nm MEL is more effective than NB-UVB in treating vitiligo lesions and it induces repigmentation more rapidly. ----- J Eur Acad Dermatol Venereol. 2007 Aug;21(7):942-50. Treatment of vitiligo vulgaris with narrow-band UVB and oral Polypodium leucotomos extract: a randomized double-blind placebo-controlled study. Middelkamp-Hup MA, Bos JD, Rius-Diaz F, Gonzalez S, Westerhof W. Netherlands Institute for Pigment Disorders, Department of Dermatology, Academic Medical Center, 1100 DD Amsterdam, The Netherlands. m.a.middelkamphup@amc.uva.nl BACKGROUND: The first choice treatment for vitiligo vulgaris is narrow-band UVB (NB-UVB), but no satisfactory treatment exists. OBJECTIVES: To investigate if Polypodium leucotomos, an antioxidative and immunomodulatory plant extract, improves NB-UVB-induced repigmentation. METHODS: Fifty patients with vitiligo vulgaris randomly received 250 mg oral P. leucotomos or placebo three times daily, combined with NB-UVB twice weekly for 25-26 weeks. RESULTS: Repigmentation was higher in the P. leucotomos group vs. placebo in the head and neck area (44% vs. 27%, P = 0.06). Small repigmentation increases (P = n.s.) were observed for the trunk (6% increased repigmentation), extremities (4%), and hands and feet (5%) in the P. leucotomos group vs. placebo. Patients attending more than 80% of required NB-UVB sessions showed increased repigmentation in the head and neck area in the P. leucotomos group vs. placebo (50% vs. 19%, P < 0.002); no significant differences were seen in the other body areas. Patients with skin types 2 and 3

showed more repigmentation in the head and neck area in the P. leucotomos group vs. placebo (47% vs. 21%, P = 0.01), and no significant differences were seen in the other body areas. No conclusions could be drawn on skin types 4 and 5 due to low patient numbers. CONCLUSION: There is a clear trend towards an increase in repigmentation of vitiligo vulgaris affecting the head and neck area when NB-UVB phototherapy is combined with oral P. leucotomos. This effect may be more pronounced in light skin types. ----- J Eur Acad Dermatol Venereol. 2007 Aug;21(7):916-20. Narrow-band UVB phototherapy combined with tacrolimus ointment in vitiligo: a review of 110 patients. Fai D, Cassano N, Vena GA. Phototherapy Unit, Dermatology Service, AUSL LE2, Gagliano del Capo-Maglie, Via Umberto I 16, 73052 Parabita (LE), Salento, Italy. hello@dariofai.it BACKGROUND: Narrow-band ultraviolet B (NB-UVB) phototherapy and topical tacrolimus are included among the most innovative approaches to vitiligo. OBJECTIVE: To evaluate the efficacy and tolerability of combined treatment with NB-UVB and topical tacrolimus in vitiligo. METHODS: After informed consent, adult patients with chronic (> 1-year duration) stable vitiligo refractory to conventional treatments were enrolled in an open-labelled prospective study. Treatment regimen consists of once-daily application, in the evening, of tacrolimus 0.03% ointment to the lesions of the face, or tacrolimus 0.1% ointment to the vitiligous patches located on other areas. Concomitant NB-UVB phototherapy was performed twice weekly for 16 weeks. RESULTS: Study population included 110 patients (mean age, 42) with a total of 403 lesions. Within the treatment period, variable repigmentation was evident on more than 70% of lesions. Clinical response (repigmentation more than 50%) was observed in 42% of lesions. Response was strictly dependent on the site, being more frequent for face lesions (73%), followed by limbs (68%) and trunk (53.5%). The therapeutic effect on the extremities and genital areas was quite disappointing. Treatment was well tolerated. CONCLUSIONS: Our preliminary data suggest that the combination of topical tacrolimus with NB-UVB phototherapy can represent an alternative highly effective approach to refractory vitiligo located on the face, trunk and limbs. Long-term safety data and randomized controlled trials on a large number of patients are required. ----- J Eur Acad Dermatol Venereol. 2007 Aug;21(7):891-6. Narrowband UVB therapy for vitiligo: does the repigmentation last? Sitek JC, Loeb M, Ronnevig JR. Department of Dermatology, Ulleval University Hospital, Oslo, Norway. jcsitek@online.no BACKGROUND: Since 1997, a number of trials have shown promising results in treating generalized vitiligo with narrowband ultraviolet B (UVB) both in adults and children. However, there is little knowledge concerning the duration and permanency of the treatment-induced repigmentation. OBJECTIVE: Our main objective was to perform a follow-up trial of successfully treated patients receiving narrowband UVB for generalized vitiligo. METHODS: We have investigated to what degree the treatment-induced repigmentation remains stable for up to 2 years post-treatment. We performed an initial open trial including 31 patients with generalized vitiligo. They received narrowband UVB thrice weekly for up to 12 months. Patients experiencing > 75% repigmentation were defined responders and were included in the follow-up trial. Responders were followed every 6 months for up to 2 years after cessation of treatment. We observed the pigmentation status and registered any changes indicating loss of

pigmentation and relapse. RESULTS: Eleven of the 31 treated patients were included in the follow-up trial. Six patients had relapse and five patients had stable response 24 months after cessation of treatment. Four out of six relapses were within 6 months post-treatment. CONCLUSION: In our study population of 31 patients with generalized vitiligo, five patients (16%) experienced > 75% stable repigmentation 2 years after cessation of a treatment programme of up to 1 years narrowband UVB therapy.

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J Dtsch Dermatol Ges. 2007 Jun;5(6):467-75. Current state of vitiligo therapy--evidence-based analysis of the literature. [Article in English, German] Forschner T, Buchholtz S, Stockfleth E. Department of Dermatology, Venereology and Allergy, Charité Universitätsmedizin Berlin, Germany. tobias.forschner@charite.de Vitiligo is a skin disease with a worldwide prevalence ranging from 0.5% to 4%. Conservative therapies include photochemotherapy, phototherapy with UVB radiation (broadband UVB 290-320 nm, narrow band UVB 311 nm), systemic steroids and pseudocatalase. Modern therapeutic options include treatment with topical immunomodulators (tacrolimus, pimecrolimus), analogues of vitamin D3, excimer laser and surgery/transplantation. Our analysis compares these therapies for vitiligo and the evidence levels supporting their effectiveness. CONCLUSIONS: The face and neck respond best to all therapeutic approaches, while the acral areas are least responsive. For generalized vitiligo, phototherapy with UVB radiation is most effective with the fewest side effects; PUVA is the second best choice.Topical corticosteroids are the preferred drugs for localized vitiligo. They may be replaced by topical immunomodulators which display comparable effectiveness and fewer side effects.The effectiveness of vitamin D analogues is controversial with limited data. Surgical therapy can be very successful, but requires an experienced surgeon and is very demanding of time and facilities, thus limiting its widespread use. L-phenylalanine therapy appears effective on the face but enjoys neither widespread use nor extensive data support. No single therapy for vitiligo can be regarded as the most effective as the success of each treatment modality depends on the type and location of vitiligo. ----- Arch Dermatol. 2007 May;143(5):578-584. Randomized Double-blind Trial of Treatment of Vitiligo: Efficacy of Psoralen-UV-A Therapy vs Narrowband-UV-B Therapy. Yones SS, Palmer RA, Garibaldinos TM, Hawk JL. Dip Der, FCD, Photobiology Unit, Second Floor, St John's Institute of Dermatology, Division of Genetics and Molecular Medicine, Guy’s, King's and St Thomas' School of Medicine, King's College, London SE1 7EH, England. yones5@yahoo.com. OBJECTIVE: To compare the efficacy of oral psoralen-UV-A (PUVA) with that of narrowband-UV-B (NB-UVB) phototherapy in patients with nonsegmental vitiligo. DESIGN: Double-blind randomized study. SETTING: Phototherapy unit in a university hospital. Patients Fifty-six patients with nonsegmental vitiligo. Interventions Twice-weekly therapy with PUVA or NB-UVB. MAIN OUTCOME MEASURES: The change in body surface area affected by vitiligo and the color match of repigmented skin compared with unaffected skin were assessed after 48 sessions of therapy, at the end of the therapy course, and 12 months after the end of therapy. RESULTS: The results in the 25 patients each in the PUVA and NB-UVB groups who began therapy were analyzed. The median number of treatments was 47 in the PUVA-treated group and 97 in the NB-UVB-treated group (P = .03); we suspect this

difference was because of the differences in efficacy and adverse effects between the 2 modalities, such that patients in the NB-UVB group wanted a longer course of treatment. At the end of therapy, 16 (64%) of 25 patients in the NB-UVB group showed greater than 50% improvement in body surface area affected compared with 9 (36%) of 25 patients in the PUVA group. The color match of the repigmented skin was excellent in all patients in the NB-UVB group but in only 11 (44%) of those in the PUVA group (P<.001). In patients who completed 48 sessions, the improvement in body surface area affected by vitiligo was greater with NB-UVB therapy than with PUVA therapy (P = .007). Twelve months after the cessation of therapy, the superiority of NB-UVB tended to be maintained. Conclusion In the treatment of nonsegmental vitiligo, NB-UVB therapy is superior to oral PUVA therapy. ----- J Eur Acad Dermatol Venereol. 2007 May;21(5):638-42. Comparison of systemic PUVA and NB-UVB in the treatment of vitiligo: an open prospective study. Bhatnagar A, Kanwar AJ, Parsad D, De D. Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. 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. AIMS: To investigate the position of NB-UVB vis-à-vis PUVA in terms of efficacy, time to repigment and adverse effects and to help decide if one therapy has an advantage over another in the treatment of vitiligo. SUBJECTS AND METHODS: It was a randomized, open, prospective study of 50 patients divided equally in TMP PUVA and NB-UVB groups. The study period was from January 2004 to June 2005. RESULTS: The mean degree of repigmentation attained in the NB-UVB group was 52.24% over a mean treatment period of 6.3 months, whereas in the PUVA group it was 44.7% in a mean period of 5.6 months (P=0.144). After excluding the results of therapy-resistant sites, that is, hands and feet, the mean degree of repigmentation in the NB-UVB group was 67.57%, whereas in the PUVA group it was 54.2% (P=0.007). CONCLUSIONS: NB-UVB performed better in comparison to TMP PUVA in terms of mean total repigmentation when traditionally considered therapy-resistant sites were excluded. ----- Am J Clin Dermatol. 2007;8(3):157-73. The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis. Wollina U. Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany. The topical calcineurin inhibitors (TCIs) pimecrolimus and tacrolimus are approved for atopic dermatitis but have additional potential in other inflammatory skin diseases. This article reviews their clinical use in non-atopic dermatitis diseases. In seborrheic dermatitis, asteatotic eczema, and contact dermatitis, TCIs are of great benefit and can compete with topical corticosteroids. In psoriasis, TCIs have shown clinical efficacy and safety in facial and intertriginous lesions. Further investigations into possible combinations of TCIs with other established treatments such as UVB irradiation in this disorder are necessary. Initial studies in cutaneous lupus erythematosus have been promising, whereas the response in rosacea and rosacea-like eruptions has been mixed. TCIs have been associated with good clinical

responses in oral lichen planus and anogenital lichen sclerosus et atrophicus. In vitiligo, TCIs are associated with some degree of repigmentation, with better results being seen in children and in facial and neck areas. TCIs have a synergistic effect with UVB irradiation in vitiligo. There is a long list of small series and case reports documenting use of TCIs in various other skin conditions that warrant further validation. Although the established mode of action of TCIs is T-cell control, other effects also need to be considered. Specifically, TCIs reduce pruritus and erythema, which cannot be explained by T-cell interactions, and further investigations are needed in these fields. ----- J Eur Acad Dermatol Venereol. 2007 Apr;21(4):504-8. Combination of 308-nm xenon chloride excimer laser and topical calcipotriol in vitiligo. Goldinger SM, Dummer R, Schmid P, Burg G, Seifert B, Läuchli S. Department of Dermatology, University of Zurich, Zurich, Switzerland. BACKGROUND: A large variety of therapeutic agents are being used for the treatment of vitiligo, but treatment remains a challenge. Recently, monochromatic phototherapies such as 311-nm narrowband ultraviolet B therapy and 308-nm xenon chloride excimer laser have been reported to be an effective and safe therapeutic option in children and adult patients with vitiligo. Single reports stipulate that the addition of topically applied calcipotriol to phototherapy increases its effectiveness. OBJECTIVE: The purpose of the present pilot study was to determine if the addition of topical calcipotriol increases the efficacy of the 308-nm xenon chloride excimer in the treatment of vitiligo. METHODS: Ten patients with vitiligo with essentially bilateral symmetrical lesions were enrolled in this prospective right/left comparative, single-blinded trial conducted over a 15-month period. All patients received 308-nm XeCl excimer laser therapy three times weekly. Calcipotriol ointment (Daivonex) was applied to lesions on one side of the body twice daily. RESULTS: After 24 treatments (8 weeks), nine patients were evaluated. Eight patients showed evidence of repigmentation on both body sides, with no significant difference between the body side treated with calcipotriol and excimer laser and the side treated with excimer laser alone. The mean repigmentation rate was 22.4% (1-37%). CONCLUSION: The addition of calcipotriol ointment to 308-nm xenon chloride excimer laser phototherapy does not significantly enhance its efficacy. Small additive effects must be investigated in a larger trial.

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J Am Acad Dermatol. 2007 Feb;56(2):274-8. Efficacy, predictors of response, and long-term follow-up in patients with vitiligo treated with narrowband UVB phototherapy. Nicolaidou E, Antoniou C, Stratigos AJ, Stefanaki C, Katsambas AD. First Department of Dermatology, University of Athens School of Medicine, Andreas Sygros Hospital, Greece. BACKGROUND: Narrowband UVB (NB-UVB) phototherapy is considered an accepted therapy for vitiligo. OBJECTIVE: We sought to estimate the effectiveness of NB-UVB in patients with vitiligo, identify predictive factors of response, and assess the stability of NB-UVB-induced repigmentation. METHODS: In all, 70 patients with vitiligo were treated twice weekly with NB-UVB. RESULTS: Cosmetically acceptable (>75%) repigmentation was achieved in 34.4% of patients with lesions on the face and in 7.4% of patients with lesions on the body. Patients with phototypes III to V had a greater chance to achieve greater than 75% repigmentation on the face. Patients who responded in the first month of treatment were more likely to achieve better repigmentation rates. Repigmentation was stable in 14.3% of patients 4 years after cessation of treatment. LIMITATIONS: The study was uncontrolled. Treatment

frequency was twice weekly. These results may not be representative of different treatment regimens. CONCLUSION: Patients with vitiligo who have lesions on the face, darker phototypes, and early response to treatment have a greater chance to achieve satisfactory repigmentation after NB-UVB phototherapy. ----- J Am Acad Dermatol. 2007 Feb;56(2):236-41. Epub 2006 Oct 20. High-potency steroid use in children with vitiligo: a retrospective study. Kwinter J, Pelletier J, Khambalia A, Pope E. Faculty of Medicine, University of Ottawa, Canada. BACKGROUND: Data on efficacy and safety of treatments in children with vitiligo are limited. OBJECTIVE: We sought to describe the clinical outcomes and safety of children with vitiligo treated with high-potency topical corticosteroids. METHODS: Clinical improvement and laboratory data were retrospectively analyzed in 101 children (0-18 years) with vitiligo treated with moderate- to high-potency topical corticosteroids. RESULTS: Of patients, 64% (45 of 70) had repigmentation of the lesions, 24% (17 of 70) showed no change, and 11% (8 of 70) were worse than at the initial presentation. Local steroid side effects were noted in 26% of patients at 81.7 +/- 44 days of follow-up. Cortisol levels were abnormal in 29% of patients (21 of 73). Two children with low cortisol levels were given the diagnosis of steroid-induced adrenal suppression. Children with normal and abnormal cortisol levels were not significantly different by sex, age of onset, potency of the corticosteroid use, or family history. However, children with head and/or neck affected areas were 8.36 times more likely to have an abnormal cortisol level compared with children affected in other body areas (RR 95% confidence interval: 1.19, 58.60, P = .003, n = 72). Of patients, 8% (6 of 74) had an abnormal thyrotropin test result. LIMITATIONS: The retrospective design of this study presents inherent limitations. CONCLUSION: Moderate- to high-potency topical corticosteroids are efficacious in children with vitiligo, but may be associated with systemic absorption. ----- J Dtsch Dermatol Ges. 2006 Nov;4(11):942-6. Efficacy and safety of pimecrolimus cream 1% in adult patients with vitiligo: results of a randomized, double-blind, vehicle-controlled study. [Article in English, German] Dawid M, Veensalu M, Grassberger M, Wolff K. Division of General Dermatology, Department of Dermatology, University of Vienna, Vienna General Hospital, Vienna, Austria. BACKGROUND: Vitiligo is an acquired, pigmentary skin disorder which is disfiguring and difficult to treat. In an earlier open label study in adult patients with vitiligo, pimecrolimus cream 1% was reported to have similar efficacy as clobetasol propionate 0.05%. We performed a double-blind, intrapatient comparison of pimecrolimus cream 1% with placebo cream. PATIENTS AND METHODS: Twenty adult Caucasians with symmetrical vitiligo (predominantly on extremities, none in the face) were treated b.i.d. for 6 months left/right with pimecrolimus/vehicle (N = 10) or vehicle/pimecrolimus (N = 10), respectively. Primary efficacy endpoint was the size of the target lesion at month 6 and secondary efficacy endpoint was re-pigmentation. RESULTS: Treatment with pimecrolimus cream 1% or vehicle resulted in no significant change in mean target lesion size. Modest repigmentation (1-25%) was noted with pimecrolimus at month 2 in 12 of 17 patients (vehicle: 9 of 17 patients). Afterwards, the number of patients who experienced an improvement of pigmentation steadily decreased (3 of 14 patients with pimecrolimus and 2 of 14 with placebo at month 6).Treatment was well tolerated.There were no treatment-related adverse events, no induction of skin atrophy nor

any other application site side effects. CONCLUSION: In this group of adult patients with symmetrical vitiligo, treatment of body lesions (except face) with pimecrolimus cream 1% could not be shown to be effective.

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