Treatment of Generalized Vitiligo With Anti-TNF-α Agents
April 2012 | Volume 11 | Issue 4 | Case Reports | 534 | Copyright © April 2012
AbstractBackground: Although the exact pathogenesis of vitiligo is not fully understood, it appears to be an autoimmune disease. It is hypothesized that tumor necrosis factor alpha (TNF-α) plays an important role in vitiligo. TNF-α can destroy melanocytes through the induction of various apoptotic pathways. In addition, TNF-α can inhibit melanocyte stem cell differentiation.
Objective: To evaluate the efficacy and safety of treating vitiligo patients with anti-TNF-α agents.
Methods: A total of 6 patients were recruited. All patients had widespread non-segmental vitiligo. Biologics, including infliximab, etanercept, and adalimumab, were given according to treatment regimens used for psoriasis. Photographs were taken at the initial visit, every two months during the therapy and then six months after therapy completion.
Results: All patients completed the treatment; two patients were treated with infliximab, two with etanercept, and two with adalimumab. All of the biologics were well tolerated throughout the treatment period, and none of the patients reported any significant adverse events. Digital images were compared before, during and after treatment. Repigmentation of the vitiliginous areas was not observed in any of the patients. Vitiligo worsened in one patient who was treated with infliximab and developed a psoriasiform rash. However, the remaining patients did not develop any new depigmented patches during treatment or at the six-month follow-up; vitiligo was considered stable in these five patients.
Conclusions: Although the anti-TNF-α agents were well tolerated in all six vitiligo patients, efficacy was not observed. Further evaluation with larger studies may be required.
J Drugs Dermatol. 2012;11(4):534-539.
The efficacy of biologics for psoriasis treatment has been shown in several randomized clinical trials.1 However, little is known regarding the use of these drugs for the treatment of vitiligo. Although the exact etiology of vitiligo remains unclear, autoimmunity is currently recognized as one of the most likely pathologic mechanisms.2 Both cellular and humoral immune responses have been implicated in the development of vitiligo, and their roles continue to be investigated. Peripheral blood and skin biopsies of patients with vitiligo show that T-cells, mononuclear cells, various pro-inflammatory cytokines, and auto-antibodies all damage melanocytes.3
The aim of this pilot study was to evaluate the efficacy and safety of using the anti Tumor necrosis factor-alpha (anti-TNF-α) agents infliximab, etanercept, and adalimumab for the treatment of widespread vitiligo.
Six patients with widespread vitiligo covering 5% or more of the body surface area were recruited from the dermatology clinic at King Khalid University Hospital, Riyadh, Saudi Arabia. Two patients were treated with etanercept, two with infliximab, and two with adalimumab. Patient data and the outcomes of vitiligo treatment are summarized in Table 1.
All patients had unstable vitiligo (with increasing lesions within last 6 months) and had received no treatment for vitiligo for at least the past three months. The re-pigmentation and decrease in lesion size were assessed at baseline, every 2 months during the therapy, and six months after therapy completion using digital photography.
Laboratory investigations for all six patients included chest X-rays (CXR), intradermal purified protein derivative tests (PPD),