The Therapeutic Effects of a Topical Tretinoin and Corticosteroid Combination for Vitiligo: A Placebo-Controlled, Paired-Comparison, Left-Right Study
April 2013 | Volume 12 | Issue 4 | Original Article | 63 | Copyright © April 2013
Hyok Bu Kwon MD,a Yunseok Choi MD,a Hwa Jung Kim MD,b and Ai-Young Lee MDa
aDepartment of Dermatology, Dongguk University Graduate School of Medicine, Goyang-si, South Korea
bDepartment of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, South Korea
BACKGROUND: Topical all-trans-retinoic acid (tretinoin) prevents skin atrophy induced by long-term use of topical corticosteroids, without abrogating their anti-inflammatory effects.
OBJECTIVE: The goal of this study was to determine the efficacy of tretinoin plus topical corticosteroids (tretinoin plus) for repigmentation in patients with vitiligo.
METHODS: A placebo-controlled, paired-comparison, left-right study was conducted for a period of 6 months on tretinoin plus and the vehicle plus the same topical corticosteroid (vehicle plus) treatment in 50 patients diagnosed with generalized vitiligo. Clinical responses were assessed using the computerized analysis, and the results were compared with the visual analysis.
RESULTS: The percentage agreement between the 2 analyses was 91.8%. Among 49 participants who successfully completed this study, 27 (55%) showed a better response to tretinoin plus than to vehicle plus. The improved response was noted at an early stage of treatment, during the first 3 months in 60% of patients.
CONCLUSION: Combined therapy with tretinoin plus topical corticosteroids is safe and effective and provides another option for treatment of patients with vitiligo. J Drugs Dermatol.
Topical corticosteroids are commonly used for the treatment of vitiligo. The slow repigmentation with treatment and the recurrent loss of pigmentation usually requires long-term use of topical steroids, which frequently causes skin atrophy, telangiectasia, and striae. In addition to the reduction of photoaging such as fine and coarse wrinkling,1-3 topical all-trans-retinoic acid (tretinoin) has been shown to prevent corticosteroid-induced skin atrophy.4-6 Furthermore, tretinoin has its own beneficial effects that can be maintained without abrogating the anti-inflammatory effects of topical corticosteroids.4,5 The anti-inflammatory effects associated with corticosteroid use are important for repigmentation in vitiliginous lesions.
An accurate determination of the efficacy of therapeutic modalities requires effective methods for the assessment of clinical responses. The visual analysis of lesions is limited by subjective assessment of pigmentation. To overcome this limitation, visual assessments of skin color and pigmentation have been conducted with grading systems, image analysis, spectrophotometry, a new digital image analysis system, and a method that incorporates evaluation of direct and polarized light photographs by 2 independent physicians. However, to date there is no consensus on the best evaluation method for the assessment of vitiligo. New assessment methods or combinations of existing methods may provide more accurate results.7
The goal of the present study was to determine the efficacy of tretinoin on repigmentation in patients with vitiligo. The effects of tretinoin plus were compared with the vehicle plus the same topical corticosteroid (vehicle plus). A placebo-controlled, paired-comparison, left-right study was conducted using computerized analysis of clinical responses. More than 50% of the patients had a better response to the tretinoin plus than to the vehicle plus.
PATIENTS AND METHODS
Fifty Korean patients diagnosed with generalized vitiligo participated in this study. Twenty-nine were male and 21 were female, with an age range of 7 to 70 years (mean, 40 years). Twelve patients were younger than 20 years, 7 were aged between 20 and 29 years, 3 were aged between 30 and 39 years, 13 were aged between 40 and 49 years, 9 were aged between 50 and 59 years, and 6 were older than 60 years.
Lesion locations varied and included the hands, forearms, lower extremities, abdomen, axillae, and neck and face. The lesions distal to the proximal interphalangeal joints of the fingers and toes were excluded from the study because of negligible responses. Twenty-five of 50 lesions being compared were on sun-exposed areas such as the hands, face, and neck. The duration of the disease ranged from 1 to 35 years, with an average duration of 10.7