A Puneet Group Presentation

L IGHT ! D ID YOU SAY L IGHT ! T HE PATCH LOOKS LOVELY BRIGHT S OON THE WHITE PATCH G ROWS AND SPREADS T HE SUN MAKES IT A LITTLE RED, HOW CAN V ITILIGO H ARMLESS, NOT EVEN SKIN DEEP C AN CAUSE A TRAUMA SO DEEP ?

VITILIGO Chronic skin disease occurring worldwide in about 1% of the population, mostly between the age of White spots occur when the skin no longer forms melanin (pigment that determines the color of your skin, hair, and eyes) White patches of irregular shapes begin to appear on skin Total absence of melanocytes microscopically

CLINICAL FEATURES Totally amelanotic macule (patch) surrounded by normal skin Vitiligo macules characteristically have fairly discrete margins and they are round, oval or linear in shape Lesions enlarge centrifugally over time, but the rate may be slow or rapid Vitiligo macule patches ranges from millimeter to centimeter in size

DISTRIBUTION PATTERN OF VITILIGO Focal a few isolated lesions Segmental unilateral distribution Vulgaris fingers and around mouth Universal total depigmentation

S UB TYPES OF V ITILIGO Differ by anatomical location, and size of lesions Focal A few isolated lesions, most common in children Segmental Unilateral distribution Acrofacial Fingers and periorificial areas Universal Almost total depigmentation Mucosal Depigmentation of only the mucous membrane GENERALIZED Most common, symmetrical distribution, occurs symmetrically on both sides of the body

V ITILIGO CAUSE - MELANOCYTE DESTRUCTION 1.Stress to the skin in form of wound, burn, excessive sun exposure or contact with bleaching phenol 2.Differential gene expression among melanocytes 3.Inflammatory infiltrate of T cells & macrophages 4. Further induce melanocyte apoptosis

W HY IS THE TREATMENT IMPORTANT ??? Vitiligo - not harmful medically, but emotional and psychological effects can be devastating. Affects self-esteem. Women, are sometimes discriminated against in marriage. Developing vitiligo after marriage can be grounds for divorce. People suffering from vitiligo feel embarrassed, depressed, or worried about other people’s reaction.

T HE PRIMARY GOAL OF V ITILIGO THERAPY IS TO REPIGMENT THE AFFECTED SKIN. H OWEVER, IT IS NOT ALWAYS POSSIBLE. In such cases, depigmentation is the only available option

W HERE DE - PIGMENTATION THERAPY REQUIRED Patients with widespread and extensive vitiligo with Body Surface Area(BSA)>50%, who desire permanent matching of skin colour, and where the probability of achieving cosmetically significant repigmentation is low. Generally it can be considered if vitiligo involves more than 60% to 80% of BSA. Patients with less extensive disease (30-50% BSA) who have progressive disease or have shown resistance to standard therapies for repigmentation. Vitiligo extensively involving cosmetically sensitive areas of face and hands where covering cosmetics are ineffective, although it is unusual to treat only the exposed sites. Vitiligo involving areas known to be resistant to treatment, e.g. hands, malar areas.

L IST OF DEPIGMENTING AGENT S MONOBENZONE 88% phenol, Laser, cryotherapy First line agents Imatinib Imiquimod diphencyprone Second line agents Hydroquinone, 4-Ethoxyphenol,4-methylcatechol, Catechol, IFN-gamma, Busulfan, Vaccines using melanoma associated antigens etc Experimental agents

COMPOSITION:- MONOBENZONE USP…..20% W/W CREAM BASE…………..Q.S.

MONOBENZONE Monobenzyl ether of hydroquinone (MBEH) Chemical Name: P- (Benzyloxy) - Phenol Acts as a skin sensitizer Topical application decreases the excretion of melanin from melanocytes in animal Depigmentation spreads to distant sites unexposed to Monobenzone Progressive systemic reaction against melanocytes

M ECHANISM OF ACTION TYROSINEMELANOCHROMEMELANIN Tyrosinase

MONOBENZONE IS THE MOST WIDELY USED DEPIGMENTING AGENT

LIMITATIONS OF OTHER DEPIGMENTING AGENTS Requires longer time prior to the onset of visible depigmentation 4-Methoxy Phenol large areas applications proved to be toxic to Liver and Kidney. Cardiovascular shock, cardiac arrythmias, bradycardia as well as metabolic acidosis 88% Phenol Painful & expensive technique Available only at hospitals. Different type of lasers Hospital based treatment. It gives edema, pain and bulla formation as side effects. Not suitable for extensive vitiligo Cyro therapy Require further investigation Topical Imatinib, Imiquimod and Diphencyprone

E FFICACY OF MONOBENZONE THERAPY Residual patches of vitiligo affecting more than 70% of her skin surface Depigmentation after topical application of 20% Monobenzone daily after 8 months Pigment Cell Melanoma Res. 22; REVIEW ARTICLE Update on skin pigmentation therapies in vitiligo. Rafael Falabella and Maria I. Barona. Page No. 11

A DMINISTRATION : Apply a thin layer of to the normal coloured skin area which requires depigmentation usually two to three times daily or as directed by physician. There is no recommended dose for children under 12 years of age except under the advice and supervision of a physician. It may take up to 4 months before the full benefit of this drug takes effect. Once the desired skin colour is achieved, this medication is applied only as needed to maintain the new skin colour (usually 2 times a week).Use cream regularly to get the most benefit from it. Inform the doctor if your condition persists or worsens after 4 months.

S IDE E FFECTS OF M ONOBENZONE Mild burning, Irritation, Redness, Cracking, or Peeling of the treated skin may occur. If any of these effects persist or worsen, doctor needs to be informed.

PRECAUTIONS This medication is for use on the skin only. cream should be applied with a patch test for 48 h to detect hypersensitivity. Avoid application of to the eyelids and areas close to the eye. Avoid getting this product in your eyes or on the inside of your nose or mouth. If the cream is accidentally applied in these areas, flush with plenty of water. After using this medication, the skin will be permanently affected and sensitive to sunlight. Avoid prolonged exposure to sunlight. Always use a sunscreen of SPF 15 or greater, and wear protective clothing when outdoors.

A LBAQUIN TREATMENT EFFECTS As a depigmenting agent, Monobenzone lightens up the pigmented areas and matches them with the white patches arisen out of Vitiligo skin disorder and can provide following effects to the patients : Permanently depigmented skin Produce an even tone Match the skin around the vitiligo patches to a uniform light colour Create a feeling of normalcy for the patient

B RINGS ABOUT PERMANENT DE PIGMENTATION Only drug used worldwide as a depigmentation therapy for vitiligo Safe and well tolerated No toxicity to liver or kidney Permanently lightens skin IDEAL THERAPY FOR UNIFYING SKIN COLOUR

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