Dr. Antonio Salafia. Presentation from the World Vitiligo Symposium 2011. Sponsored by the VR Foundation.

1. Vitiligo: my experience of 25 years and
19.156 patients
Dr. Antonio Salafia
Dermatologist & Head Dept. Reconstructive Surgery.
Vimala Dermatological Centre, Mumbai
St.Petersburg, Russia.
July 7th 2011

2. The experience of a clinician.
• In the early 1980’s I was disappointed with
PUVA, so I explored other avenues:
a) From the year 1980 Dapsone was used at Vimala
Dermatological Centre, with some success.
b) In 1983 I set a protocol:Dapsone, Vitamin
B6 -suggested by C. Frati from IDI,Rome.
• In 1985 I began experimenting with new lotions,
inspired by the work of Prota. (Protocol C).
Antonio Salafia

3. Protocol ‘C’
ORAL THERAPY:
• Dapsone: 0.5 mgs K/wt.
• Vitamin B6 100-300 mg. a day, Iron, Folic Acid.
LOCAL APPLICATION:
• Face: Locoid (Hydrocortisone Butyrate) Tacrolimus.
• Neck: Lotion A (the mildest).
• Body / Arms and Legs: Lotion B (strong).
• Arms, Legs, Hands, Feet : Lotion 5 –F (strongest).
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4. Dapsone: possible mode of action.
a) Antioxidant: a. Potent scavenger of free radicals (T. Ryan)
b. Decreases H2O2 - as good as Catalase (Wozel).
c. Weak inhibitor of prostaglandin synthesis.
d. Scavenger of oxidative intermediates, and
suppressor of PMN (which produce ROS).
B) Decreases the level of Glutathione: skin of vitiligo patients has a
higher content of Glutathione. By suppressing Glutathione we
favor the formation of Eumelanins instead of Pheomelanins (Ito).
C) Possible beneficial effects.
DDS is an immunomodulator + suppressor of PMN cells, hence
effective in diseases wherein there is dense infiltrate of PMN:
Dermatitis Herpetiformis, Subcorneal Pustular Dematosis, Scarring/
Bullous Pemphigoid and more than 20 other diseases.
Antonio Salafia

5. Vitamin B6: importance.
• Vitamin B6 is a potent antioxidant.
• Involved in the homeostasis of Glutathione and
Cysteine (switching mechanism of Ito).
• In high doses, is capable of transforming
Glutammic acid into Pyrrolecarboxylic acid and
prevents the formation of Glutathione (Frati).
• In my experience, it helps to prevent new
patches, so I advise my pts. to keep on taking
for years.
• (It prevents homocysteine-induced atherosceloris in rats).
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6. First experiments with my protocol
and my lotions.
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7. Face: Locoid
Arms: Lotion B
Cure in 6 months.
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8. Lotion 5-F
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9. Dapsone+B6
and Locoid
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10. Locoid… Lotion A
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11. Protocol C + Lotion 5-F.
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12. Face: Locoid. Neck: Lotion A
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13. Lotion B
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14. Lotion 5-F. Stopped oral
medications and relapsed.
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15. Chemical Vitiligo: Lotion A
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16. Lt. Lotion B. Rt.Lotion 5-F
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17. Lotion 5-F
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18. Results in 8730 (out of 13.119)
• Protocol ‘A’: Vitamins, Iron, Copper; creams: Betnovate/Placenta extract.
• Protocol ‘B’ : Orally as above + Dapsone+ locally Locoid/ Betnovate.
• Protocol ‘C’: Dapsone 0.5 -1.0 mg/k/w + all the Vitamins,
Local application
Children : Locoid for face, Lotion A for body.
Adults: Face & Neck: Locoid / Lotion A /Tacrolimus.
Body: Lotion B.
Limbs: Lotion 5-F.
• Protocol ‘D’ : all of these except Dapsone; in its place, oral steroids.
• Given the large number of patients treated, protocol A can be considered as
‘control group’ vs. protocol ‘B’ and ‘C’’.
• I cannot due ‘double-blind trials’ in patients who are
desperate for a cure.
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19. How to read the charts.
• Worse/Nil = are self-explanatory.
• Poor = improvement less than 25%.
• Fair = improvement 25% to 50%.
• Good = > 50% but < 75%.
• Excellent = more than 75%.
• Almost cure = extensive lesions, ‘cured’ except
for one or two stubborn patches.
• Cure = total and permanent cure.
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20. Protocol A: Vitamins…
Protocol A – 1673 pts.
700
600
500
400
300
200
100
0
CURE AC E G F P N W
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21. Protocol B: Vitamins+DDS
Protocol B - 1587 pts.
500
400
300
200
100
0
C AC EX G F P N W
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22. Protocol C: DDS+Vitam+My Lotions
Protocol C - 4661 pts.
1200
1000
800
600
400
200
0
C AC EX G F P N W
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23. Protocol D:
Steroids + Vitamins + Lotions
Results with Protocol D – 809 pts.
200
150
100
50
0
C AC EX G F P N W
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24. Protocol A – 1673
700
Protocol C –
600 1200 4661
500 1000
400 800
300 600
200 400
100 200
0
CURE AC E G F P N W 0
C AC EX G F P N W
Protocol B - 1587
Protocol D – 809
500
200 pts.
400
150
300
200 100
100 50
0 0
C AC EX G F P N W C AC EX G F P N W
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25. Results could be better, and lately they are.
Some patients could not follow the therapy because:
- Sunlight not possible: working hours, ladies with lesions
on chest, thighs; artificial lamps are costly.
- Some patients live far away, even outside India…
- Others changed residence, job, got married…
- Some poor patients could not afford the treatment.
- Others expected miracles.
- Certain areas of the body are ‘difficult’ : fingers, toes,
bony prominences…..
- Few of them came to rule out ‘Leprosy”.
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26. Private Patients from Jan. 2005 to
Dec. 2008. 2940 pts.
• Protocol C + Inj. Triamcinolone 40 or 20
mgs. I.M. once a month x 3 - 5.
• Fast results (due to Kenacort) and
• Consistent results (due to Dapsone and B6).
• Patients treated 2940: report on
‘regulars’ only: i.e. 2012 cases.
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27. Private Patients: Results.
600
500
400
300 1 – 19
200 20 - >
100
0
Cure A-cure Exc Good Fair Nil Worse
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28. Cure Acure Excellent Good Fair Nil Worse Total
_________________________________________________________
• Face 427 301 375 175 56 37 0 1371
-----------------------------------------------------------------------------------
• Limbs 523 319 362 187 110 94 17 1822
-----------------------------------------------------------------------------------
• Hand/
Feet 71 52 95 104 159 287 31 819
------------------------------------------------------------------------------------
• Body 467 262 326 24 43 37 16 1175
-----------------------------------------------------------------------------------
• Vagina 58 21 33 17 14 21 0 164
------------------------------------------------------------------------------------
• Penis 15 11 16 30 42 31 5 150
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29. Results, as per area of the body.
800
Face
700
600 Limbs
(each)
500
Hands/ Feet
400 (each)
300 Body
200 Vagina
100 (mucosa)
Penis
0
(glans)
Cure Excellent Fair Worse
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30. 500
400
Results as per
300 body area:
200 Face Face: 1371
100 Body: 1175
0
Cure Good Worse
Limbs: 1822
500
600
500 400
400 300
300 Limbs Body
200
200
100
100
0 0
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31. Results:
300
250
200
Hand/
Feet
Hands/ Feet: 819
150
Vagina: 164
Glans Penis: 150
100
50
0
60 50
50 40
40 Vagi 30
na
30 Penis
20
20
10
10
0 0
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32. Applied Aloe Vera, got Vitiligo.
Protocol C + Tacrolimus 0.1%.
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33. Difficult cases
Lotion A x 1 year.
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34. First Locoid, then Lotion A.
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35. Segmental: lotion A; 6 mth- 1year.
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36. Arms: lotion 5-F. Face not responding to anything.
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37. Good response in majority of patients:
Face: lotion A. Legs: lotion 5-F.
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38. Protocol C + Lotion A.: 3 months.
(very irregular patients) 19 months.
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39. Lotion A: 6 months.
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40. Neck: Lotion A. Arms: Lotion B.
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41. Father & Mother affected too.
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42. Protocol C +
Tacroz 0.1%:
20.08.2009
11.12.2009
4.04.2011
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43. Lotion A:
- 22.08.2008 -
19.09.2008
- 5 months.
Duration of Disease
8 years.
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44. Lotion 5-F: 4 months.
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45. Lotion 5-F: 4 months.(very irregular).
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46. Face: Tacroz … Lotion A
Hands: Lotion 5-F.
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47. Neck: A. Arms: 5-F, 4-6 months.
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48. Face:Tacroz.
Arms and Legs:
Lotio 5-F.
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49. Locoid: 6 months.
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50. Lotion A.
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51. Neck: Lotion A. Arms: Lotion 5-F.
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52. Locoid: 5-6 months.
17 years later.
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53. Neck: Lotion A.
Legs: Lotion 5-F.
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54. Tacroz 0.1. Arms: lotion 5-F.
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55. Lotion A,
Lotion 5-F.
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56. Girl: Tacrolimus. CHILD: Vitix: worse, 9.8.2008.
Locoid: 27.9.208 cure in 2 months.
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57. Lotion A : 2 months.(treatment is going on)
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58. Face: Locoid. Neck: Lotion A. After 2 months.
(Photoes: 20.9.08 18.10.08 15.11.08)
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59. Treated elsewhere with only locoid. My
protocol + Locoid for face. Legs: A
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60. Face Lotion A, Abdomen Lotion B
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61. Patient lives in England: 4 months.
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62. Lotion B:
2 months.
5 months.
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63. Face:Locoid
Arms: Lotio
5-F:
6 months.
Disease Ext.
Duration 8 yrs
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64. Face:Locoid,
Neck:Lotion A
Arms:Lot. B:
6 months
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65. Tacroz 0.03%, later on Homeopathy x 2 years…Worse.
Protocol C + Tacroz 0.1%. Photo 12.3.11 16.4.11
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66. Latest photos: 18 June of 2011.
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67. ANA and anti-DNA –ve. Anti-Thyroglobulin +ve.
Photos: 10.9.2010, 13.12.2010, 2.7.2011.
Dapsone, Tacroz 0.1%, latest: Lotion A.
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68. Surgery. Good and bad surgery.
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69. Surgery done elsewhere by a well-known
dermatosurgeon.
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70. Punch graft by same dermato(surgeon).
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71. Operated twice with
punch graft.
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72. Conclusion:
Most patients can be cured; but, there are
difficult cases and difficult areas.
We are still working on it, because our aim is set high..
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73. Antonio Salafia

74. Thanks to you all
and
a big thanks to the organizers.
Antonio Salafia