Vitiligo is a common skin condition characterized by depigmentation affecting 0.5-4% of the global population, often beginning between ages 2 and 40. Treatment options include a mix of cosmetic camouflage, repigmentation therapies, and various combination therapies involving topical and phototherapy, with evidence suggesting that combination approaches yield superior results over monotherapies. Further studies are needed to optimize treatment efficacy and assess long-term safety, especially concerning the risks associated with immunomodulators and phototherapy.

1. Combination Therapy Torello Lotti Florence, Italy professor @ torellolotti.it www.torellolotti.it The International School of Vitiligo & Pigmentary Disorders Barcelona, Spain 2-5 November 2011

2. Vitiligo: Definition Primitive acquired pigmentation disorder with focal depigmentation of the skin; Characterized by well circumscribed milky white cutaneous/mucous macules; Patches arise as a consequence of destruction and/or functional inactivation of melanocytes underlying a complex syndrome; Acquired (only in few cases congenital), often familial (23% of the cases).

3. Vitiligo Vitiligo affects 0.5-4% of the World population. The disease generally begins between the ages of 2 and 40. In a Dutch study, 50% of patients reported the occurrence before the age of 20.

4. Adults and children of both sex are equally affected; No difference in races or skin type; The greater number of reports among females is probably due to greater social consequence to woman and girls affected by this condition; 50% of patients  before the age of 20; 25% of patients  before the age of 8. Vitiligo in 2011

5. Is vitiligo an unmanageable disease? Only 16% of dermatologists in The Netherlands are in favour of active treatment of vitiligo Njoo MD et Al, Int J Dermatol 1999;38:866-872 84% of dermatologists in The Netherlands are reluctant to start any active treatment in vitiligo; 82% in the Mediterranean area either prescribe placebos or treatments of cosmetic relevance only Lotti T. La vitiligine: nuovi concetti e nuove terapie. UTET – Torino, 2000

6. How to treat vitiligo? Cosmetic camouflage (dihydroxyacetone) Depigmentation ( Monobenzyl ether of hydroquinone, Q-switched ruby laser) Repigmentation (corticosteroids, psoralen photochemotherapy, UVB phototherapy) The efficacy of UVB in vitiligo therapy is probably due to: Its immunesuppressive effect Stimulation of melanocytes

7. VITILIGO TREATMENT: AN OVERVIEW Lotti T, Gori A, Zanieri F, Colucci R, Moretti S. Vitiligo: new and emerging treatments. Dermatol Ther 2008; 21:110-117.

8. VITILIGO TREATMENT: AN OVERVIEW Lotti T, Gori A, Zanieri F, Colucci R, Moretti S. Vitiligo: new and emerging treatments. Dermatol Ther 2008; 21:110-117.

9. General considerations: how to treat vitiligo Dermatologists are prescribing less PUVA in favour of UVB; Growing introduction of combined treatments targeted UVB + “active” topicals; Repigmentation rates show the therapeutic success of phocused microphototherapy which is more remarkable when used in combination.

10. Vitiligo: what’s new in treatment Excimer laser / Monochromatic excimer light (MEL) Focused microphototherapy Calcineurine inhibitors with NB-UVB

11. COMBINATION THERAPIES in VITILIGO Improve efficacy and decrease toxicity of each individual agent. Most of the studies that assessed combination interventions employed light therapies (UVA, PUVA, or UVB). In general combination interventions were superior to monotherapies.

12. Whitton ME, Pinart M, Batchelor J, Lushey C, Leonardi-Bee J, González U. Cochrane Database Syst Rev. 2010 Jan 20;(1): Intervention for Vitiligo

13. TOPICAL STEROIDS + PHOTOTHERAPY Sassi F et al. Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligo of the face and neck. Br J Dermatol. 2008;159(5):1186-91. Topical hydrocortisone 17-butyrate plus excimer laser versus excimer laser alone. There was a statistically significant difference in favour of the combination treatment ; these participants weremore than twice as likely to achieve 75% repigmentation than those receiving laser treatment alone (RR 2.57; 95% CI 1.20 to 5.50 ). Hyperpigmentation can occur in some participants receiving combination treatment but this was also seen in participants receiving only laser treatment.

14. Tacalcitol plus 308nm monochromatic excimer light (MEL) vs placebo plus MEL. A statistically significantly greater proportion of participants in the tacalcitol plus MEL group achieved greater than 75% repigmentation (RR 4.50; 95% CI 1.05 to 19.35). TOPICAL CALCIPOTRIOL + PHOTOTHERAPY . Lu-yan T etal. Topical tacalcitol and 308-nm monochromatic excimer light: a synergistic combination for the treatment of vitiligo. Photodermatol Photoimmunol Photomed. 2006;22(6):310-4 Possible adverse effects: mild to moderate erythema xerosis and itching after combination treatment with tacalcitol and MEL.

15. Ermis O et al. Is the efficacy of psoralen plus ultraviolet A therapy for vitiligo enhanced by concurrent topical calcipotriol? A placebo-controlled double-blind study. Br J Dermatol. 2001;145(3):472-5. TOPICAL CALCIPOTRIOL + PUVA Possible adverse effects: mild to moderate erythema xerosis and itching. Calcipotriol plus PUVA vs placebo plus PUVA. The side of participants treated with the calcipotriol plus PUVA had a significant 4 fold increase in the likelihood of achieving greater than 75% repigmentation sooner than the side treated with placebo plus PUVA (paired OR OR 4.25 (95% CI 1.43, 12.64).

16. Two studies compared topical 0.1% tacrolimus plus 308 nm xenon chloride excimer laser with placebo plus laser, both studies used a within-participant design. A meta-analysis of these two studies demonstrated that patches treated with the combination of topical tacrolimus plus laser were more likely to achieve 75% repigmentation than those treated with laser alone (RR 3.15; 95% CI 1.46 to 6.76); Passeron T et al. Topical tacrolimus and the 308-nm excimer laser: a synergistic combination for the treatment of vitiligo. Arch Dermatol. 2004;140(9):1065-9. Kawalek AZ et al. Combined excimer laser and topical tacrolimus for the treatment of vitiligo: a pilot study. Dermatol Surg. 2004 Feb;30(2 Pt 1):130-5. TOPICAL TACROLIMUS + PHOTOTHERAPY

17. Mild to moderate erythema was reported in all vitiligo patches treatedwith tacrolimus plus laser,with blistering occurring at one site. 80% participants treated with this combination experienced a tingling and burning sensation and erythema at the treatment site, compared to 30% treated with placebo plus laser. Moderate to severe erythema at least one time was observed in all participants from both groups; localised bullous eruptions were observed in two lesions in both groups. However, stinging was only observed in five participants treated with laser and topical tacrolimus. ADVERSE FFECTS Kawalek AZ et al. Combined excimer laser and topical tacrolimus for the treatment of vitiligo: a pilot study. Dermatol Surg. 2004 Feb;30(2 Pt 1):130-5. Passeron T et al. Topical tacrolimus and the 308-nm excimer laser: a synergistic combination for the treatment of vitiligo. Arch Dermatol. 2004;140(9):1065-9.

18. Topical non-steroidal immunomodulators such as tacrolimus as alternatives to corticosteroids are a form of care that appear promising, particularly in combination with light therapies such as laser. Caution should be observed when combining topical immunomodulators with light therapies due to the theoretical long term risk of skin cancer. TOPICAL TACROLIMUS + PHOTOTHERAPY

19. ORAL THERAPIES+ PHOTOTHERAPY Oral minipulses of betamethasone (OMP: 0.1 mg/kg body weight twice weekly for 3 months followed by tapering of the dose by 1 mg every month over the following 3 months) with 3 different combination interventions, namely: OMP plus PUVA; OMP plus NB-UVB, and OMP plus BB-UVB was compared. There was a statistically significant difference in favour of OMP plus NB-UVB compared to OMP alone (RR 7.41; 95% CI 1.03 to 53.26,), but not for OMP plus PUVA versus OMP alone (RR 3.70; 95% CI 0.47 to 29.28) or for OMP plus BB-UVB versus OMP alone (RR 1.67; 95% CI 0.11 to 24.26 ). Rath N et al. An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo. Indian J Dermatol Venereol Leprol 2008;74:357-60

20. Nausea and weight gain in eleven participants receiving OMP plus PUVA and excessive erythema and blistering of the skin in five. Weight gain was reported in ten participants plusNB-UVB. Excessive erythema occurred in six participants receivingMOP plus BB-UVB and weight gain in five. Ten participants receiving OMP alone experienced weight gain. Rath N et al. An open labeled, comparative clinical study on efficacy and tolerability of oral minipulse of steroid (OMP) alone, OMP with PUVA and broad / narrow band UVB phototherapy in progressive vitiligo. Indian J Dermatol Venereol Leprol 2008;74:357-60 ADVERSE FFECTS

21. Oral azathioprine ( 0.6-0.75 mg/kg) plus 8-MOP plus UVA versus 8-MOP plus UVA. Those in the group receiving azathioprine were statistically significantly more likely to achieve greater than 75% repigmentation 4 months after treatment (RR 17.77; 95% CI 1.08 to 291.82 ). ORAL THERAPIES+ PHOTOTHERAPY Possible adverse effects : gastrointestinal upset on participants receiving azathioprine plus PUVA Radmanesh M, Saedi K. The efficacy of combined PUVA and low-dose azathioprine for early and enhanced repigmentation in vitiligo patients. J Dermatolog Treat. 2006;17(3):151-3.

22. Larger studies are needed in order to provide stronger evidence for the many combination interventions that have shown promise in treating vitiligo. Because vitiligo is a disease affecting pigment cells, the use of some form of phototherapy may be necessary in order for these cells to proliferate and develop, thus giving faster repigmentation. Combination therapy may therefore be more desirable from both the clinician and participant point of view. FUTURE PERSPECTIVES Whitton ME, Pinart M, Batchelor J, Lushey C, Leonardi-Bee J, González U. Cochrane Database Syst Rev. 2010, 20;(1)

23. Combination therapy in 2011

24. Combination therapy in 2011 Open study Tacrolimus 0.1% ointment, Pimecrolimus 1% cream, Betamethasone dipropionate 0.05% cream, Calcipotriol ointment 50mcg/g, 10% L-phenylalanine cream  alone or in combination with 311nm nb-UVB microphototherapy 470 patients affected by vitiligo (<10% skin surface) Lotti T et al. Dermatol Ther 2008;21 Suppl 1:s20-6

25. Group 1 BIOSKIN ® alone Group 2 0.1%Tacrolimus+ BIOSKIN ® Group 3 1% Pimecrolimus+BIOSKIN ® Group 4 Betamethasone dipropionate 0.05%+BIOSKIN ® Group 5 Calcipotriol ointment 50mcg/g+BIOSKIN ® Group 6 10% L-phenylalanine+BIOSKIN ® Group 7 0.1% Tacrolimus alone Group 8 1% Pimecrolimus alone Group 9 Betamethasone dipropionate 0.05% Group 10 Calcipotriol ointment 50mcg/g alone Group 11 10% L-Phenylalanine alone

26. Percentage of repigmentation in patients treated with BIOSKIN ® alone or in combination, or with active topicals alone. Treatment (n° of patients) Excellent (>75%) Marked (50-75%) Moderate (25-50%) Minimal (<25%) Group 1: BIOSKIN ® alone (100) 72% 19.8% 4.6% 3.6% Group 2: 0.1% Tacrolimus + BIOSKIN ® (59) 76.5% 18.2% 3.3% 2% Group 3: 1% Pimecrolimus + BIOSKIN ® (63) 76.1% 20.1% 2.7% 1.1% Group 4: Betamethasone dipropionate 0.05% + BIOSKIN ® (28) 90.2% 6.7% 2.2% 0.9% Group 5: Calcipotriol ointment 50 mcg/g + BIOSKIN ® (60) 75.6% 14.1% 7.4% 2.9% Group 6: 10% L-Phenylalanine + BIOSKIN ® (60) 74.8% 11.3% 10.1% 3.8% Group 7: 0.1% Tacrolimus alone (22) 61% 16.1% 18.4% 4.5% Group 8: 1% Pimecrolimus alone (19) 54.6% 18.4% 21.7% 5.3% Group 9: Betamethasone dipropionate 0.05% alone (23) 71.2% 25% 2.1% 1.7% Group 10: Calcipotriol ointment 50 mcg/g (18) 59.1% 10.6% 27.1% 3.2% Group 11: 10% L-Phenylalanine alone (18) 29.3% 8.1% 55% 7.6%

27. Repigmentation rates: beginning of repigmentation (weeks) as assessed by clinical evaluation

28. Repigmentation rates and final repigmentation results: visual comparison of different treatment groups as assessed by clinical evaluation

29. WHAT ABOUT SURGERY?

30. Surgical therapies are only suitable for stable or segmental vitiligo. Split-thickness grafting appears to be better than control, suction blister or combined split thickness/suction grafts. Photherapy may enhance its efficacy. More studies are needed. Surgical Interventions

31. Lahiri K, Malakar S, Sarma N, Banerjee U. Int J Dermatol. 2006;45(6):649-55.

32. Lahiri K, Malakar S, Sarma N, Banerjee U. Int J Dermatol. 2006;45(6):649-55. Punch Grafting was performed with 1.5-mm punches Postsurgically, the recipient areas were exposed to NB-UV-B (311 nm) 2 times/week

33. Lahiri K, Malakar S, Sarma N, Banerjee U. Int J Dermatol. 2006;45(6):649-55.

34. What’s new in surgery Punch micrografting seems to be very effective for the treatment of stable forms of vitiligo. Before Immediately after the surgery Our Experience

35. Before Immediately after surgery Before After 2 months

36. General considerations: how to treat vitiligo Both BIOSKIN ® and Potent topical corticosterod preparations alone are the first line treatment in vitiligo vulgaris affecting less than 10% of the skin surface . Association of these 2 treatments gives better results, with very high repigmentation rate in more than 90% of patients. High repigmentation rates are observed also for other combination treatments, while Tacrolimus and Pimecrolimus but not phenylalanine are relatively active when applied without UVB irradiation .

37. How to manage vitiligo Correct diagnosis Comorbidities Patient expectations Communication issue in 2011 and further

38. OUR CONTRIBUTIONS

39. Berti S, Bellandi S, Bertelli A, Colucci R, Lotti T, Moretti S. Vitiligo in an Italian outpatient center: a clinical and serologic study of 204 patients in Tuscany . Am J Clin Dermatol. 2011;12(1):43-9. Prignano F, Ricceri F, Bianchi B, Guasti D, Bonciolini V, Lotti T, Pimpinelli N. Dendritic cells: ultrastructural and immunophenotypical changes upon nb-UVB in vitiligo skin. Arch Dermatol Res. 2010 Arunachalam M, Sanzo M, Lotti T, Colucci R, Berti S, Moretti S. Common variable immunodeficiency in vitiligo. G Ital Dermatol Venereol. 2010;145(6):783-8. Becatti M, Prignano F, Fiorillo C, Pescitelli L, Nassi P, Lotti T, Taddei N. The involvement of Smac/DIABLO, p53, NF-kB, and MAPK pathways in apoptosis of keratinocytes from perilesional vitiligo skin: Protective effects of curcumin and capsaicin . Antioxid Redox Signal. 2010, 1;13(9):1309-1321.

40. Prignano F, Pescitelli L, Becatti M, Di Gennaro P, Fiorillo C, Taddei N, Lotti T. Ultrastructural and functional alterations of mitochondria in perilesional vitiligo skin . J Derm Sci 2009;54:157–167; Moretti S, Fabbri P, Baroni G, Berti S, Bani D, Berti E, Nassini R, Lotti T and Massi D. Keratinocyte dysfunction in vitiligo epidermis: cytokine microenvironment and correlation to keratinocyte apoptosis . Histol Histopathol 2009;24:849-857; Moretti S, Nassini R, Prignano F, Pacini A, Materazzi S, Naldini A, Simoni A, Baroni G, Pellerito S, Filippi I, Lotti T, Geppetti P and Massi D. Protease-activated receptor-2 downregulation is associated to vitiligo lesions . Pigment Cell Melanoma Res. 2009;22:335–338. Lotti T, Berti S, Moretti S. Vitiligo therapy. Expert Opin Pharmacother. 2009;10(17):2779-85.

41. Berti S, Buggiani G, Lotti T. Use of tacrolimus ointment in vitiligo alone or in combination therapy. Skin Therapy Lett. 2009;14(4):5-7; Lotti T, Buggiani G, Troiano M, Assad GB, Delescluse J, De Giorgi V, Hercogova J. Targeted and combination treatments for vitiligo. Comparative evaluation of different current modalities in 458 subjects . Dermatol Ther 2008;21 Suppl 1:s20-6; Prignano F, Pescitelli L, Ricceri F, Lotti T. The importance of genetical link in immuno-mediated dermatoses: psoriasis and vitiligo. Int J Dermatol 2008;47:1060–1062; Prignano F, Betts CM, Lotti T. Vogt-Koyanagi-Harada disease and vitiligo: where does the illness begin? J Electron Microsc (Tokyo). 2008 Lotti T, Prignano F, Buggiani G. New and experimental treatments of vitiligo and other hypomelanoses. Dermatol Clin. 2007;24(3):393-400 Hercogova J, Buggiani G, Prignano F, Lotti T. A rational approach to the treatment of vitiligo and other hypomelanoses . Dermatol Clin. 2007;24(3):383-392

42. Thank you for your attention Professor Torello Lotti Vice Chancellor, UniMarconi.it , Roma