History of Vitiligo treatment

Vitiligo is a multi-causal disease, starting with the formation of a neoantigen, which triggers a cell mediated immune response leading to the destruction of melanocytes. The depigmented lesions of skin and hair can be localized or generalized. It belongs to the group of the auto-immune disorders, e.g. Diabetes type I and thyroid disease, with which it is often associated.

The prevalence is estimated at 0.5 to 1% worldwide, although in India a figure as high as 8% is reported. Skin diseases causing an altered or impaired appearance may profoundly affect those afflicted. Aside from causing physical discomfort and inconvenience, it has been demonstrated that they influence the patient’s personal and social life, daily functioning and psychologic status. Skin disease may provoke negative emotions such as shame or embarrassment, anxiety, lack of confidence and even psychiatric diseases like depression. The patients’ self-image may be profoundly depressed and his self-esteem threatened. In the western world the quality of life (QOL) index scores in vitiligo patients are slightly lower than those of psoriasis patients. In the tropical region, where vitiligo was often confused with leprosy, patients with this disease are highly stigmatized. In India the QOL index scores of vitiligo patients supersede those of psoriasis patients. Higher scores mean a lower quality of life.

Unlike psoriasis, the possibilities for treating vitiligo are limited to phototherapy, except for a small number of patients with stable vitiligo, who can be treated with skin autologous pigment grafts. The first report of the use of “phototherapy” in the treatment of skin disorders dates from about 1400 BC among Hindus, as already mentioned. They used “photochemotherapy”-administration of plant extracts, followed by sun exposure-for vitiligo.The same treatment was also used in ancient Egypt. The active ingredients in these plant extracts were isolated in 1947 by Fahmy et al.(16, 17, 18) as 8-methoxypsoralen (8-MOP) and 5-methoxypsoralen (5-MOP). In the same year, these authors and also El Mofty started to treat patients with vitiligo with 8-MOP and sun exposure.

Kromayer, a German dermatologist, designed in 1904 a water cooled mercury vapor UV lamp. He was the first to treat vitiligo with artificial UVB. In 1969 Fulton et al. used “black light” UVA tubes for the first time in combination with topical 8-MOP in the treatment of vitiligo. Parrish and Fitzpatrick introduced modern photochemotherapy with 8-MOP, having a peak sensitivity at 330 nm and UVA fluorescent tubes. They used fluorescent tubes emitting in the 320 - 380 nm waveband in the PUVA treatment of vitiligo. Although late effects, e.g. skin carcinogenesis, have rarely been reported in vitiligo, the frequently observed phototoxic responses were considered a severe practical problem.

Narrowband (NB)-UVB, or 311 nm UVB (Philips TL 01) has been used in the treatment of vitiligo now for 10 years and was first reported by Westerhof and Nieuweboer Krobotova. It is now considered as the treatment of choice, because of its advantages over PUVA treatment being: UVB 311 nm is more effective than PUVA and safer, as there are no psoralen-induced side effects and can be used in children and pregnant woman. The NB-UVB can also be achieved with the eximer laser (308 nm).A draw back is that only small areas can be treated at one time and the eximer laser is excluded from home treatment. Narrowband UVB is also recommended in combination with pigmentcel grafting of vitiligo lesions.