SJ O’Shea, S RogersIreland

History58-year-old manPMHx: psoriasisClinical findingsAreas of hypopigmentation

DiagnosisClinical diagnosisPhototherapySkin type

Psoriasis and vitiligoCoexistence known since 1950s1

1989 Menter et al.2

Vitiligo after phototherapy3,4

Similar immune pathwayKoebner phenomenon

1. Selenyi A. Vitiligo and psoriasis on the same side with syringomyelia. Borgyogy Vener Szemle 1955; 9: 94-6.2. Menter A, Boyd AS. Silverman AK. Guttate psoriasis and vitiligo: Anatomic cohabitation. JAAD 1989; 20: 698-9.3. Halcin C, Hann S-K, Kauh YC. Vitiligo following the resolution of psoriatic plaques during PUVA therapy. Int J Dermatol 1997; 36:

534–6.4. Goodwin RG, Finlay AY, Anstey AV. Vitiligo following narrow-band TL-01 phototherapy for psoriasis. Br J Dermatol. 2001; 144:

1264-66.

HypothesesGenetic factorsAutoimmunityNeurogenicSelf-destruct theory of Lerner

TreatmentsCamouflageSPFPhototherapyExcimer laserTopical steroidsTacrolimusBleachingGrafts

Missing link?

What do we know?Absent melanocytes

What do we know?Absent melanocytesMelanin productionLangerhans’ cellsT cellsPerifollicular repigmentation

Why is the hair follicle special?Pigment changes can occurTendency to spare folliclesSite of immune privilege

What have we tried?Stimulating melanocytesReplacing melanocytesIrritantsDestroying residual pigmentMinimizing UV exposure

Where do we go now?• Thermal-induced changes• Medications• 2010 Parsad et al5

5. Parsad D, Kanwar A. Oral minocycline in the treatment of vitiligo – a preliminary study. Dermatol Ther. 2010; 23(3): 305-7

Where do we go now?• Vitamin D• Basal layer disruption• Immunosuppression• Molecular genetics

Where do we go now?• Induction of mediators

Potential difficultiesDurationUnpredictableImmunosuppression vs. disease

How do we target the mediators?TNF-alpha and IL-1-alpha increased in

vitiligo6,7

Improvement with infliximab8

Progression with infliximab9

New onset with adalimumab10

6. Birol A, Kisa U, Kurtipek GS, Kara F, Kocak M, Erkek E, Caglayan O. Increased tumour necrosis factor alpha (TNF-alpha) and interleukin 1 alpha (IL-1 alpha) levels in the lesional skin of patients with nonsegmental vitiligo. Int J Dermatol. 2006; 45: 992-3.

7. Moretti S, Spallanzani A, Amato L, Hautmann G, Gallerani I, Fabbri P. New insights into the pathogenesis of vitiligo: imbalance of epidermal cytokines at sites of lesions. Pigment Cell Res 2002; 15: 87–92.

8. Lv Y, Li Q, Wang L, Gao T. Use of anti-tumour necrosis factor agents: a possible therapy for vitiligo. Med Hypotheses 2009; 72: 546–547.

9. Alghamdi KM, Khurram H, Rikabi A. Worsening of vitiligo and onset of new psoriasiform dermatitis following treatment with infliximab. J Cutan Med Surg. 2011; 15(5): 280-4.

10. Posada C, Florez A, Batalla A, Alcazar JJ, Carpio D. Vitiligo during treatment of Crohn’s disease with adalimumab: adverse effect or co-occurrence? Case Rep Dermatol. 2011; 3(1): 28-31.

AnakinraRecombinant IL-1 receptor antagonist

ConclusionLimited treatments? Role of immunomodulatorsMore research