Early Systemic Immunomodulation Recommended for Treatment of Vitiligo

Sarah Ibrahim Ismail, MD

A new investigation from Egypt cited early systemic immunomodulation for recent localized vitiligo as a “successful approach” for achieving early control of disease activity.

Investigators led Sarah Ibrahim Ismail, MD, Faculty of Medicine, Cairo University, also noted that systemic immunomodulation also aided in minimizing the incidence of recurrence.

Though the development of multiple therapeutic regimens in recent years has been promising, disease relapse for patients with vitiligo is prevalent. As such, most guidelines consider systemic treatments for rapidly progressive disease with wider surface areas.

In the present study, Ismail and colleagues assessed the ability of early systemic therapy of localized (<2% BSA), recent onset (<6 months) vitiligo to control disease activity and minimize the possibility of recurrence.

The Methods

A prospective analytical study was conducted from January 2015 to December 2020 in the outpatient clinical of the Dermatology Department in Cairo University.

A total of 25 patients were included in the study.

Inclusion criteria for eligible patients included being 6 years or older, having early inset vitiligo (<6 month duration), and body surface area (BSA) affected ≤2%.

The personal and family history, as well as the history of associated diseases and previous diseases of all patients was recorded in the study.

From there, clinical examinations were conducted. All vitiligo lesions were evaluated, as was the largest diameter of the lesion and the presence of absence of the clinical signs of vitiligo activity.

Each patient was treated with systemic corticosteroids for a total of 6 months (dexamethasone 6 mg per week divided on two successive days for adults and children ≥ 45 kg or 3 mg for children < 45 kg divided on 2 consecutive days).

Further treatment included systemic antioxidants (gingko biloba), phototherapy, NB-UVB (total body NB-UVB) 2-3 times/week (or according to patient’s convenience, topical calcineurin inhibitors, and topical corticosteroid.

Investigators continued this treatment until the complete closure of lesions followed by maintenance therapy using the topical medications applied twice weekly. This was continued for 6 months after complete closure.

Patients were assessed monthly until successful re-pigmentation of 80 - 100% was achieved and maintained for at least 6 months. A biannual assessment was done for 4 years after the study to detect early recurrence.

The Findings

During the 4-year follow-up period, 17 patients (68%) had stayed pigmented with no evidence of recurrence of the disease.

Recurrence was reported in 8 patients (32%) with 5 out of 8 patients (20%) recurring after the first year.

Despite fluctuating activity, the recurrence that was documented was confined to the originally affected sites, and their total BSA did not exceed 2% all through the 4-year follow-up period.

Additionally, there was a significantly higher incidence of recurrence in cases with bilateral distribution of lesions, and patients with longer disease duration showed a higher incidence of recurrence yet did not reach statistical significance (P= <0.001, 0.057 respectively).

In their concluding statement, Ismail and colleagues suggested that systemic immunomodulatory treatment should be started early to minimize and possibly prevent recurrence, citing a “race against time”.

“This could be the only way out to prevent development of otherwise incurable acral vitiligo which has been resistant even to surgical treatment,” the team wrote.

The study, “Early localized vitiligo,medical emergency: long term follow up study,” was published online in Dermatologic Therapy.