1. Pharmacology-4 PHL 425 Second Lecture By Abdelkader Ashour, Ph.D. Phone: 4677212Email: aeashour@ksu.edu.sa

2. Management of vitiligo  The approaches to the management of vitiligo are as follows: I.Sunscreens: They should be used by all patients with vitiligo. Their objectives are: 1.Protection of involved skin from acute sunburn reaction or repeated solar damage to depigmented skin 2.Limitation of tanning of normally pigmented skin, especially in fairer-skinned patients  Active ingredients of sunscreens include chemical agents that absorb incident solar radiation in the UVB and/or UVA ranges (e.g., PABA, avobenzone & oxybenzone) and physical agents (e.g., titanium dioxide & zinc oxide) that contain particulate materials that can block or reflect incident energy and reduce its transmission to skin  The major measurement of sunscreen photoprotection is the sun protection factor (SPF): the ratio of the minimal dose of incident sunlight that will produce erythema or redness (sunburn) on skin with the sunscreen in place (protected) and the dose that evokes the same reaction on skin without the sunscreen (unprotected)  Except for total sun avoidance, sunscreens are the best single method of protection from UV-induced damage to the skin  Sunscreens with a SPF>30 are reasonable choices to prevent sunburn for most vitiligo patients and to limit the tanning reaction in fairer-skinned individuals. While all skin phototypes (SPTs) have a need for sun protection, sunscreens alone are often adequate management for those vitiligo patients with SPTs I, II and sometimes III  Vitiligo also can be managed by the use of a cosmetic cover-up solution

3. Management of vitiligo II.Repigmentation  The objective of repigmentation is the permanent return of normal melanin pigmentation. This may be achieved for local macules with topical glucocorticoids or topical psoralens and UVA and for widespread macules with oral psoralens and UVA (PUVA), as follows: 1.Topical glucocorticoids  Glucocorticoids are prescribed frequently for their immunosuppressive and anti- inflammatory properties. They are administered locally, through topical and intralesional routes. They are prescribed for patients with small patches of vitiligo  Mechanisms of action includes apoptosis of lymphocytes, inhibitory effects on the arachidonic acid “AA” cascade (via inhibition of phospholipase A2  inhibition of AA synthesis) & depression of production of many inflammatory cytokines  Initial treatment with intermittent (4 weeks on, 2 weeks off) topical class I glucocorticoid ointments is practical, simple, and safe for single or a few macules. If there is no response in 2 months, it is unlikely to be effective Potent topical corticosteroids can cause hypopigmentation or atrophy in normal surrounding skin Side effects occur in areas where the skin is thin, such as on the face and armpits In general, only nonfluorinated glucocorticoids should be used on armpits and on the face (perioral dermatitis can develop after the use of fluorinated compounds, e.g., diflorasone, on the face) Glucocorticoid creams are not as effective as psoralen photochemotherapy

4. Management of vitiligo, contd. 2.Topical photochemotherapy  Phototherapy and photochemotherapy are treatment methods in which UV or visible radiation is used to induce a therapeutic response either alone or in the presence of a photosensitizing drug  It employs topical 8-methoxypsoralen (8-MOP; a photoreactive chemical ) and UVA (320–400 nm). This procedure should be undertaken for small macules only by experienced physicians  Mechanism of action of PUVA: The UV radiation promotes overproduction of MSH which binds to the melanocortin receptor 1, and stimulates melanocyte proliferation and induces the activation of tyrosinase, the rate-limiting enzyme in the melanin pathway  skin pigmentation  Psoralens must be photoactivated by UVA to produce a beneficial effect. Psoralens intercalate with DNA and, with subsequent UVA irradiation, cyclobutane adducts are formed with pyrimidine bases. DNA adducts are formed, causing interstrand cross- links. These DNA photoproducts may inhibit DNA synthesis  decrease in DNA- dependent proliferation  suppression of infiltrating lymphocytes  PUVA also alters cytokine profiles and cause immunocyte apoptosis, thereby interrupting immunopathologic processes. In addition, PUVA augments transfer of melanosomes from melanocytes to keratinocytes because of the UVA

5. Management of vitiligo, contd. 2.Topical photochemotherapy, contd.  The patient is given “psoralen” (topically for small, scattered patches less than 20% or orally for extensive vitiligo more than 20%)  Patients treated with these modalities should be monitored for concomitant use of other potential photosensitizing medications, e.g. benzodiazepines, NSAIDs, thiazides, sulfonamides and sulfonylureas, before initiation of therapy  Side effects of PUVA Nausea, itching, blistering and painful erythema Hyperpigmentation of the treated patches or the normal skin surrounding the vitiligo patches Accelerated skin ageing and increased risk of skin cancer with long-term exposure to the drug

6. Management of vitiligo, contd. 3.Topical calcineurin inhibitors (Topical immuno-modulators)  The calcineurin inhibitor tacrolimus is a potent macrolide immunosuppressant traditionally used to prevent kidney, liver and heart allograft rejection  Tacrolimus ointment is effective in people with small areas of vitiligo, especially on the face and neck  It is effective in repigmenting vitiligo but only in sun-exposed areas. It is reported to be most effective when combined with UVB  Calcineurin is a phosphatase that normally dephosphorylates the cytoplasmic subunit of nuclear factor of activated T cells (NFAT), thus permitting NFAT to translocate to the nucleus and augment transcription of numerous cytokines  Tacrolimus works by inhibiting the phosphatase activity of calcineurin, thereby inhibiting early activation of T-lymphocytes and the production of pro-inflammatory cytokines, with subsequent suppression of humoral and cell-mediated immune responses  A major benefit of topical tacrolimus compared with topical glucocorticoids is that tacrolimus does not cause skin atrophy and therefore can be used safely in locations such as the face  It is well-tolerated when used for extended periods There is concern that this may be associated with an increased risk of skin cancer

7. Management of vitiligo, contd. 4.Systemic photochemotherapy  For more widespread vitiligo, oral PUVA is more practical. Oral PUVA may be done using sunlight (in summer or in areas with year-round sunlight) and 5-MOP or with artificial UVA and either 5-MOP or 8-MOP 5.Narrow-band UVB, 311 nm  This is just as effective as PUVA and does not require psoralens. It is the treatment of choice in children <6 years of age III.Minigrafting  Minigrafting (transplantation of cultured autologous melanocytes) may be a useful technique for refractory and stable segmental vitiligo macules  PUVA may be required after the procedure to unify the color between the graft sites IV.Depigmentation  The objective of depigmentation is "one" skin color in patients with extensive vitiligo or in those who have failed PUVA, who cannot use PUVA, or who reject the PUVA option  Bleaching of normally pigmented skin with monobenzylether of hydroquinone 20% (MEH) cream is a permanent, irreversible process (see details later, in melasma)  The success rate is >90%. The end-stage color of depigmentation with MEH is chalk- white, as in vitiligo macules  All those who have bleached are at risk for sunburn from acute solar irradiation