Low-Dose Oral Mini-Pulse Dexamethasone Therapy in Progressive Unstable Vitiligo

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1 BASIC/CLINICAL SCIENCE Low-Dose Oral Mini-Pulse Dexamethasone Therapy in Progressive Unstable Vitiligo Amrinder J. Kanwar, Rahul Mahajan, and Davinder Parsad Background: The course of vitiligo is unpredictable. If the disease is spreading rapidly, the progression can be controlled with the use of systemic steroids daily or in pulsed form. The present study was planned to assess the efficacy of low-dose dexamethasone oral mini-pulse therapy in progressive unstable vitiligo. Materials and Methods: In this retrospective study, the case records of patients with vitiligo during the period from January 2006 to December 2010 were studied. Patients who had progressive unstable disease were included. These patients were administered oral dexamethasone 2.5 mg per day on 2 consecutive days after breakfast in a week. The patients were asked to come for regular follow-up to assess the arrest of disease activity, relapse of disease activity, and adverse effects. Results: A total of 444 patients were analyzed. In 408 (91.8%) patients, arrest of disease activity was achieved at a mean duration of weeks. In addition, some repigmentation of the lesions was seen in all patients after a mean of weeks. During the follow-up, 50 of 408 (12.25%) patients experienced one or two episodes of relapse in disease activity, which were treated with reinstitution of low-dose dexamethasone oral mini-pulse therapy. The mean disease-free survival (DFS) until the first relapse was weeks, and the mean DFS until the second relapse was weeks. Adverse reactions such as weight gain, lethargy, and acneiform eruptions were observed in 41 (9.2%) patients. Conclusion: Low-dose oral mini-pulse dexamethasone therapy is a good option for arresting progressive unstable vitiligo with minimal adverse effects. Contexte: L évolution du vitiligo est imprévisible. Si la maladie s étend rapidement, on peut en ralentir l évolution par l administration quotidienne ou pulsée de corticostéroïdes par voie générale. L étude visait à évaluer l efficacité de la dexaméthasone administrée à faible dose, par voie orale, sous forme mini-pulsée, dans le traitement du vitiligo instable, évolutif. Matériel et méthode: Il s agit d une étude rétrospective dans laquelle ont été examinés les dossiers des patients atteints de vitiligo et traités durant la période s étendant de janvier 2006 à décembre Les cas de vitiligo instable, évolutif ont été retenus. Les patients visés ont reçu de la dexaméthasone, par voie orale, à raison de 2.5 mg par jour, pendant 2 jours consécutifs par semaine, après le déjeuner. Les sujets devaient faire l objet d un suivi régulier au centre de recherche pour une vérification du degré d activité morbide: arrêt ou rechute de la maladie et de la présence d effets indésirables. Résultats: Au total, 444 patients ont été examinés. Chez 408 (91.8%) d entre eux, il y a eu arrêt de la maladie, après une durée moyenne de traitement de semaines. De plus, une certaine pigmentation des lésions est réapparue chez tous les patients après une période moyenne de semaines. Au cours du suivi, 50 patients sur 408 (12.25%) ont fait une ou deux rechutes, épisodes qui ont été traités par la répétition du traitement à la dexaméthasone administrée à faible dose, par voie orale, sous forme mini-pulsée. Le temps moyen exempt de maladie, écoulé avant la première rechute s élevait à semaines, et celui avant la deuxième rechute, à semaines. Des effets indésirables tels qu une prise de poids, la léthargie et des éruptions acnéiformes ont été observés chez 41 (9.2%) patients. Conclusions: Le traitement par la dexaméthasone administrée à faible dose, par voie orale, sous fome mini-pulsée se révèle une bonne formule thérapeutique pour arrêter l évolution du vitiligo instable, tout en produisant très peu d effets indésirables. From the Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Address reprint requests to: Amrinder J. Kanwar, MD, FAMS, Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh , India; ajkanwar1948@gmail.com. DOI / # 2013 Canadian Dermatology Association Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

2 Kanwar et al T HE TREATMENT OF VITILIGO is difficult and usually requires prolonged therapy. The choice of treatment depends on the morphologic subtype and the extent of vitiligo. Whereas patients with stable segmental and nonsegmental vitiligo may respond satisfactorily to surgical and medical therapy, those with unstable nonsegmental vitiligo or with widespread cutaneous involvement may show an unpredictable course and a less than satisfactory response to treatment. Moreover, such patients always live in fear of further progression of disease. To stop the progression of disease, systemic steroids and phototherapy are considered the treatment of choice. 1 However, the usefulness of systemic steroids has thus far been evaluated only in open-label studies, and high-dose steroids are also associated with significant adverse effects. In 1993, Pasricha and Khaitan for the first time reported the successful use of 5 mg of oral betamethasone on 2 consecutive days in a week to control fast-spreading vitiligo. 2 Later, this oral mini-pulse (OMP) therapy and its variations were employed by several other authors, with comparable results. The present study was aimed at assessing the effectiveness of low-dose dexamethasone OMP therapy in arresting the progression of vitiligo. Materials and Methods This was a retrospective study. The case records of patients who had attended the pigmentary clinic at our institute were screened for recruitment into the study during the time period from January 2006 to December The inclusion criterion was progressive unstable vitiligo. The exclusion criteria were stable vitiligo and progressive unstable vitiligo with contraindications for the use of systemic corticosteroids, such as active infection, poorly controlled hypertension or diabetes mellitus, osteoporosis, cataract, and pregnancy. Definitions Progressive unstable disease was defined arbitrarily as the appearance of multiple lesions (at least three or more) in the preceding 3 months. Arrest of disease activity was defined as stoppage in the appearance of new lesions and enlargement of existing lesions for at least 12 weeks. Relapse of disease activity was defined as reappearanceofthreeormorelesionsinthepreceding3 months after the patient had initially achieved an arrest in disease activity. Data Collection and Treatment Protocol Patients with a clinical diagnosis of progressive unstable vitiligo were classified into one of the morphologic subtypes. A detailed history and clinical examination were conducted, and the extent of body surface area (BSA) involvement and the presence of mucosal and hair involvement were noted. Based on the BSA involved, the disease was defined as mild when the involvement was 5% or less at baseline. Moderate to severe disease signified involvement of. 5% BSA at the outset. Low-dose OMP therapy consisted of administration of 2.5 mg dexamethasone on 2 consecutive days after breakfast in a week (on Saturdays and Sundays) in progressive unstable vitiligo. The drug was given on weekends to increase adherence, and patients were asked to follow up at regular intervals (usually after every 4 weeks). The oral therapy was continued until the arrest of disease activity or for a maximum of 6 months, whichever was earlier. No other topical, systemic, or phototherapy except cosmetic camouflage was advised while the patients were receiving lowdose OMP therapy. Outcome Assessment The primary objective of the present study was to calculate the percentage of patients in whom the disease stabilized after initiating low-dose OMP therapy and the duration required to achieve stability. The extent of repigmentation and any adverse effects seen were also noted. The extent of repigmentation was graded as follows: excellent improvement,. 75% repigmentation; moderate improvement, 50 to 75% repigmentation; good improvement, 25 to 50% repigmentation; and minimal improvement,, 25% repigmentation. For the purpose of statistical analysis, SPSS 17.0 (SPSS Inc, Chicago, IL) was used. The chi-square test was used to assess the homogeneity of data and to compare the effectiveness of treatment in mild and moderately severe disease. Time-to-event analyses were performed for clearing and relapse of lesions using the Kaplan-Meier method to account for truncated observations. We analyzed differences between event curves by means of the log-rank test. A p value,.05 was taken as significant. Results The case records of 444 patients on OMP therapy were analyzed. Table 1 summarizes the baseline characteristics 260 Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

3 Low-Dose Oral Mini-Pulse Dexamethasone Therapy Table 1. Baseline Characteristics of Study Population Age (yr) Age at Onset (yr) M:F Ratio Body Surface Area Involved Family History of Vitiligo Leukotrichia, n (%) NSV vs SV Mean 6 SD :151 (1.3:1) % 79 (17.8%) 97 (21.8%) 398 vs 46 Range NSV 5 nonsegmental vitiligo; SV 5 segmental vitiligo. of the study cohort. The mean age of the study cohort was years, and the mean age at onset was years. There were 251 males and 193 females (M:F 5 1.3:1). The most common site of involvement was the face in 30.1% of patients, followed by the legs in 19.8% of patients. In nearly one-third of the patients (30%), a precipitating factor for disease exacerbation (eg, trauma, photosensitivity, stress, or drug intake) was present. A positive family history of vitiligo in a first- or second-degree relative was present in 79 (17.8%) patients. Of 444 patients, 398 (88.6%) had nonsegmental vitiligo and 46 (11.4%) had segmental vitiligo. Leukotrichia was present in 97 (21.8%) patients. A total of 333 (75%) patients had mild disease, and the remaining 25% (111) patients had moderate to severe disease involving 6 to 80% BSA at the outset. Figure 1 shows the flowchart of the study results. In 408 (91.8%) patients, arrest of disease activity was achieved with low-dose OMP therapy. The time taken to achieve arrest of disease progression varied from 12 to 24 weeks, with a mean of weeks. In all of these patients, new lesions stopped appearing. In 36 (9.2%) Figure 1. Flow chart of study results showing the number of patients achieving arrest of disease activity and experiencing relapse. OMP 5 oral mini-pulse therapy. Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

4 Kanwar et al patients, arrest of disease activity was not achieved despite 6 months of treatment, although all of them reported a decrease in the number of new lesions. We analyzed the effectiveness of low-dose OMP therapy in patients with mild vitiligo (n 5 333) and moderate to severe vitiligo (n 5 111). The mean number of weeks required to achieve arrest of disease activity was weeks in patients with mild vitiligo compared to weeks in moderate to severe vitiligo (p ). Twenty-two patients with mild vitiligo and 14 patients with moderate to severe vitiligo did not achieve arrest of disease activity (p 5.82). In addition, the patients were further categorized on the basis of the presence of leukotrichia and on the basis of their diagnosis (nonsegmental vitiligo vs segmental vitiligo). Patients with leukotrichia did not differ significantly from the patients who did not manifest leukotrichia in terms of the number of weeks required to achieve disease arrest (p 5.08). Similarly, both nonsegmental vitiligo and segmental vitiligo showed a good response to treatment (p 5.68). Table 2 shows the comparison between the various subgroups. Among 36 patients who did not show arrest of disease activity, low-dose OMP therapy was continued in 15 patients for another 3 months, whereas it was discontinued in 21 patients due to adverse effects (12 patients complained of weight gain, 7 developed acneiform eruptions over the face and back, and 5 patients complained of generalized weakness and lethargy). Arrest of disease activity was reported in 13 of 15 patients, whereas the remaining 2 patients continued to manifest a few new patches. Of 444 patients, 121 (27.25%) followed up for a period of 6 months, 107 (24.1%) for 12 months, 132 (29.7%) for 18 months, and 84 (18.9%) for 24 months. Relapse of disease activity was seen in 50 of 408 (12.25%) patients. Of 121 patients who were lost to follow-up soon after achieving initial arrest of disease activity, only 8 (6.61%) reported with a relapse, whereas in the remaining 323 patients, relapse was observed in 42 (13%) patients. The mean duration from achieving disease arrest and the first relapse of disease activity varied between 12 and 96 weeks, with a mean of weeks. Twenty-seven (6.1%) patients experienced a single relapse, whereas 23 (5.1%) patients experienced two episodes of disease relapse. The mean time interval between the initial arrest of disease activity and second relapse was weeks. For each episode of relapse, low-dose OMP therapy was reinstituted for 3 to 6 months, which again led to arrest of disease activity in all patients. Patients with mild disease required significantly fewer weeks to achieve Table 2. Response to Treatment in Various Subgroups Percentage of Repigmentation No. of Weeks of Repigmentation DFS untill Second Relapse Time to Second Relapse DFS until First Relapse Time to First Relapse No. of Weeks of Stability Body Surface Area Involved Age at Onset Mild vs moderate to severe disease Mild disease (n 5 333) % % Moderate severe disease (n 5 111) % % p *.006*.0001* *.0001*.33.02* On the basis of presence of leukotrichia Leukotrichia positive (n 5 97) No leukotrichia (n 5 347) % p * NSV vs SV NSV (n 5 398) % SV (n 5 46) % p.008*.003* *.09 DFS 5 disease-free survival; NSV 5 nonsegmental vitiligo; SV 5 segmental vitiligo. *p value, Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

5 Low-Dose Oral Mini-Pulse Dexamethasone Therapy disease stability and had a significantly longer interval between arrest of disease activity and relapse (both first and second; see Table 2). Figure 2 and Figure 3 illustrate the time to relapse and disease-free survival of the study population using Kaplan-Meier graphs to account for the cases who were lost to follow-up. Patients with mild disease experienced disease relapse after significantly more weeks (log rank,.05), although the disease-free survival until first relapse did not reach significant levels (log rank,.2). The presence of leukotrichia had little bearing on disease relapse as 12 of 97 patients with leukotrichia and 38 of 347 patients without leukotrichia experienced relapse of disease activity (p 5.89). However, relapse of disease activity was observed only in the nonsegmental vitiligo group (50 of 398 patients), whereas none was reported in the segmental vitiligo subgroup. All patients noticed some repigmentation of the lesions after a mean lag period of weeks. Repigmentation could be observed as early as 8 weeks after starting treatment, but in 5% of patients, it was delayed until 36 weeks or later. The extent of repigmentation also varied. At the end of 6 months, 6 (1.2%) patients had achieved excellent improvement. Moderate improvement was seen in another 56 (12.6%) patients, and good improvement was observed in 303 (68.3%) patients. The remaining 79 (17.9%) patients reported minimal improvement in their repigmentation. There was a statistically significant difference between the two groups when the time to initial repigmentation was compared ( weeks in mild vitiligo vs weeks in moderate to severe vitiligo; p ). The percentage of repigmentation was significantly higher in the former group ( % vs %; p ). Using Kaplan-Meier graphs, the time to initial repigmentation was achieved in significantly fewer weeks in mild vitiligo (log rank,.0001; Figure 4). Adverse reactions were observed in 41 (9.2%) patients. These included an increase in body weight in 31 (7%) patients, bloated appearance and gastric upset in 15 (3.5%) patients each, lethargy in 5 (1%) patients, and acneiform eruptions and joint pains in 7 (1.5%) patients each. These adverse effects were more common in patients who received dexamethasone therapy for more than 16 weeks. However, all of these effects were reversible after stoppage of therapy. Discussion Vitiligo, referred to as shwetakustha in the ancient Indian literature, is characterized by localized or generalized depigmentation of the skin or mucous membrane. In India, its prevalence has been variably reported between 0.46 and 1.13%. 3 The disease affects all ages and both sexes. It has been broadly classified into segmental and Figure 2. Kaplan-Meier graph showing the number of weeks until the first relapse in mild versus moderate to severe vitiligo. BSA 5 body surface area. Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

6 Kanwar et al Figure 3. Kaplan-Meier graph showing the number of weeks of diseasefree survival (DFS) until the first relapse in mild versus moderate to severe vitiligo. BSA 5 body surface area. nonsegmental vitiligo. The course of nonsegmental vitiligo is unpredictable. Classically, the disease starts as focal patches of leukoderma over the hands and feet. Thereafter, it may either stabilize, leading to a localized disease, or spread explosively or more gradually into generalized vitiligo. Liu and colleagues estimated that in 75% of patients, the disease starts as focal vitiligo, and nearly half of these develop generalized vitiligo. 4 Hence, it may be postulated that stabilizing the disease earlier with aggressive therapy may limit the total cutaneous Figure 4. Kaplan-Meier graph showing the time interval required for initiation of repigmentation in mild versus moderate to severe vitiligo. BSA 5 body surface area. 264 Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

7 Low-Dose Oral Mini-Pulse Dexamethasone Therapy involvement. The definition of stability has been used primarily to select patients fit for surgical therapy and has been defined as a lack of appearance of new lesions or enlargement of existing lesions or absence of Koebner phenomenon in the first year, with different authors proposing the period of inactive disease to be between 3 months and 2 years. 5 7 Given that the most accepted hypothesis explaining the pathogenesis of vitiligo involves autoimmune damage to the melanocytes, 8 it is plausible that administration of systemic steroids may lead to decreasing the formation of these autoantibodies and suppress the disease process. To support this hypothesis, studies have shown that oral corticosteroids lead to a decrease in complement-mediated cytotoxicity to melanocytes and a reduction in antibody titer to surface antigens of melanocytes in patients with actively spreading vitiligo. 9,10 In 1967, Farah and colleagues, for the first time, reported the use of a combination of oral triamcinolone and oral psoralen plus ultraviolet A (PUVA) to be better than oral PUVA alone in the treatment of vitiligo. 11 Later, an intradermal injection of triamcinolone acetonide was used by Kandil and colleagues with good effect. 12 Gokhale and Gokhale treated 27 patients with vitiligo with twiceweekly injections of long-acting adrenocorticotropic hormone (25 40 IU twice weekly for 5 6 weeks) and noted encouraging results. 13 Similar observations were made by Inamura and Tagami. 14 However, both of these studies concentrated on the extent of repigmentation, with no reference to the stability of the disease. Kim and colleagues reported the use of low-dose prednisolone (0.3 mg/kg/d for 2 months followed by gradual tapering over the next 2 months) in 81 patients with vitiligo. 15 They observed arrest of disease activity in 87.7% and repigmentation in 70.4% of their patients without serious adverse effects. Pulse therapy refers to the administration of suprapharmacologic doses of drugs in an intermittent manner to enhance the therapeutic effect and reduce the side effects of a particular drug. To minimize the side effects with daily steroid intake, OMP therapy with betamethasone has been tried in vitiligo patients with extensive or fast-spreading disease. Pasricha and colleagues were the first to employ OMP therapy in vitiligo. 16 In their first reported study, betamethasone was given as a single oral dose of 5 mg on 2 consecutive days per week. This dose of steroids was decided on arbitrarily. The disease progression was arrested in 91% of the patients. Subsequently, few trials on the use of OMP therapy in vitiligo have been published by other researchers with similar results (Table 3) The present study showed good efficacy of low-dose dexamethasone OMP in controlling disease activity, with more than 90% of patients achieving an arrest of disease activity. When the duration of therapy was increased to 9 months in patients not showing an adequate response, the success rate approached 95%. However, 5% of the patients did not achieve arrest of disease activity despite 6 to 9 months of OMP therapy. As expected, the time required to achieve stability was significantly lower in patients with mild vitiligo compared to those with moderate to severe disease. Relapse of disease activity was observed in 12.25% of patients, all of whom responded to a repeated course of low-dose OMP. Two relapses were seen in 5.1% of patients, which again points toward the remitting and relapsing course of this autoimmune disorder. The secondary benefit achieved was repigmentation. As with disease stability, the percentage of repigmentation achieved was significantly higher in patients with mild vitiligo, although there was no statistically significant difference in the number of weeks at which repigmentation started between the two groups. The presence of leukotrichia did not significantly affect the response to treatment or relapse in disease activity. Similarly, the response to treatment was seen in both nonsegmental vitiligo and segmental vitiligo, although relapses were confined to patients in the nonsegmental vitiligo subgroup. This may point toward the autoimmune nature of nonsegmental vitiligo with a waxing and waning course. From this, we can infer that low-dose dexamethasone OMP therapy is uniformly effective in controlling disease activity in vitiligo. The results of the present study are comparable to those of other studies. Minor adverse effects were seen in 9.4% of our patients, which were reversible on stopping the treatment. The percentage of patients reporting these side effects was less compared to those with standard OMP, as reported by Pasricha and Khaitan 2 and Radakovic-Fijan and colleagues. 17 In an earlier prospective trial from our center, Kanwar and colleagues assessed the efficacy of OMP therapy in vitiligo. 18 Dexamethasone was given in a dose of 5 mg/d on 2 consecutive days per week, and the dose was halved in children 16 years of age or younger. Of the 32 patients evaluated, 43.8% had an arrest in disease activity, with mild to moderate repigmentation. The pigmentation appeared in the majority of patients within 15 weeks of starting treatment. There are few limitations in the present study as it was a retrospective study. Given that management of vitiligo involves prolonged treatment with topical agents and/or phototherapy, regular compliance with treatment and followup of the patient becomes an issue. In this study also, nearly 50% of patients were lost after 1 year of treatment and followup. Hence, it was difficult to accurately predict the relapse Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

8 Kanwar et al Table 3. Various Studies Where Systemic Steroids Have Been Used to Control Disease Activity in Vitiligo Study Study Design No. of Patients Dose of Steroids Arrest of Disease Activity Time Required to Achieve Stability Repigmentation Adverse Effects Gokhale and Prospective Gokhale 13 open-label trial Inamura and Prospective Tagami 14 open-label trial Kim et al 15 Prospective open-label trial Pasricha et al 16 Prospective open-label trial Kanwar et al 18 Prospective open-label trial Seiter et al 19 Prospective open-label trial Radakovic-Fijan Prospective et al 17 open-label trial Namita et al 20 Prospective open-label comparative trial 27 ACTH IU twice weekly for 5 6 wk, treatment free for 2 3 wk; 4 6 pulses Not mentioned Not mentioned Marked repigmentation in 59% Moderate repigmentation in 22% Good or less in 15% 22 Variable Not mentioned Not mentioned Marked repigmentation mg/kg/d for 2 mo followed by tapering 40 Betamethasone 5 mg/d for 2 d in a week 32 Dexamethasone 5 mg/d for 2 d in a week; halved in children, 16 yr 14 Intravenous 29; 25 with progressive disease 86 patients: 27 in group A, OMP + PUVA; 27 in group B, OMP + NBUVB; 12 in group C, OMP + BBUVB; 20 in group D, OMP methylprednisolone (8 mg/kg body weight) for 3 d Dexamethasone 10 mg/d for 2 d in a week Dexamethasone 5 mg/d for 2 d in a week in at least 1 patch in 35% Moderate repigmentation in 16.7% Reversible side effects such as moon facies, gastric distress seen 87.7% Not mentioned 70.4% 56.7%, mild 89% 1 3 mo Marked repigmentation in 2 25% Mild to moderate repigmentation in % Nearly 15 wk 43.8% None 85% Not mentioned 71% Hypertension in 1 patient 88% 18.2 wk Marked repigmentation in 6.9% Moderate repigmentation in 10.3% Helps in the arrest of disease progression No repigmentation in rest Not mentioned Marked repigmentation in 5% Moderate repigmentation in 10% 69% 50 60% 266 Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

9 Low-Dose Oral Mini-Pulse Dexamethasone Therapy Table 3. Continued Time Required to Achieve Stability Repigmentation Adverse Effects Arrest of Disease Activity Dose of Steroids No. of Patients Study Study Design Weight gain in 16.6% Gastric irritation in 5.2% Infections in 4.6% Acne in 3.2% 90.4% Not mentioned Marked repigmentation in 13.2% Moderate repigmentation in 66%, 25% repigmentation in rest 400 children Methyl prednisolone 0.8 mg/kg body weight for 2 d in a week plus topical fluticasone Majid et al 21 Prospective open-label trial ACTH 5 adrenocorticotropic hormone; BBUVB 5 broadband ultraviolet B; NBUVB 5 narrowband ultraviolet B; OMP 5 oral mini-pulse therapy; PUVA 5 psoralen plus ultraviolet A. rates after stopping low-dose OMP therapy. However, as mentioned earlier, vitiligo is an autoimmune disease that may show a sudden increase in disease activity (especially in the presence of precipitating factors such as trauma and stress), so such patients with progressive unstable vitiligo should be given repeated courses of low-dose OMP therapy. Conclusion Low-dose OMP therapy with dexamethasone is a good therapeutic option to arrest the activity of progressive unstable vitiligo. Its effectiveness in controlling disease activity is comparable to that of other schedules in which systemic steroids are administered at a much higher dose, albeit with less adverse effects. Irrespective of the disease severity at baseline, the majority of patients will respond to this low-dose OMP therapy, although those with moderately severe disease may take a longer time. However, it is not suitable alone for repigmentation of vitiligo lesions. Acknowledgment Financial disclosure of authors and reviewers: None reported. References 1. Taïeb A, Picardo M. Therapy of vitiligo: management overview. In: Picardo M, Taïeb A, editors. Vitiligo. 1st ed. New York: Springer; p Pasricha JS, Khaitan BK. Oral mini-pulse therapy with betamethasone in vitiligo patients having extensive or fast-spreading disease. Int J Dermatol 1993;32:753 7, doi: /j tb02754.x. 3. Alikhan A, Felsten LM, Daly M, Petronic-Rosic V. Vitiligo: a comprehensive overview part I. Introduction, epidemiology, quality of life, diagnosis, differential diagnosis, associations, histopathology, etiology, and work-up. J Am Acad Dermatol 2011;65:473 91, doi: /j.jaad Liu JB, Li M, Yang S, et al. Clinical profiles of vitiligo in China: an analysis of 3742 patients. Clin Exp Dermatol 2005;30:327 31, doi: /j x. 5. Moellmann G, Klein-Angerer S, Scollay DA, et al. Extracellular granular material and degeneration of keratinocytes in the normally pigmented epidermis of patients with vitiligo. J Invest Dermatol 1982;79:321 30, doi: / ep Cui J, Arita Y, Bystryn JC. Cytolytic antibodies to melanocytes in vitiligo. J Invest Dermatol 1993;100:812 5, doi: / ep Falabella R, Arrunategui A, Barona MI, Alzate A. The minigrafting test for vitiligo: detection of stable lesions for melanocyte transplantation. J Am Acad Dermatol 1995;32:228 32, doi: / (95) Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp

10 Kanwar et al 8. Picardo M, Taieb A. Pathophysiology overview. In: Picardo M, Taieb A, editors. Vitiligo. 1st ed. New York: Springer; p Hann SK, Kim HI, Im S, et al. The change of melanocyte cytotoxicity after systemic steroid treatment in vitiligo patients. J Dermatol Sci 1993;6:201 5, doi: / (93)90039-r. 10. Hann SK, Chen D, Bystryn JC. Systemic steroids suppress antimelanocyte antibodies in vitiligo. J Cutan Med Surg 1997;1: Farah FS, Kurban AK, Chaglassian HT. The treatment of vitiligo with oral psoralens and triamcinolone by mouth. Br J Dermatol 1967;79:89 91, doi: /j tb11461.x. 12. Kandil E. Treatment of localized vitiligo with intradermal injections of triamcinolone acetonide. Dermatologica 1970;140: , doi: / Gokhale BB, Gokhale TB. Corticotrophin and vitiligo (preliminary observation). Br J Dermatol 1976;98: Imamura S, Tagami H. Treatment of vitiligo with oral corticosteroids. Dermatologica 1976;153:179 85, doi: / Kim SM, Lee HS, Hann SK. The efficacy of low-dose oral corticosteroids in the treatment of vitiligo patients. Int J Dermatol 1999;38:546 50, doi: /j x. 16. Pasricha JS, Seetharam KA, Dashore A. Evaluation of five different regimes for the treatment of vitiligo. Indian J Dermatol Venereol Leprol 1989;55: Radakovic-Fijan S, Fürnsinn-Friedl AM, Hönigsmann H, Tanew A. Oral dexamethasone pulse for vitiligo. J Am Acad Dermatol 2001; 44:814 7, doi: /mjd Kanwar AJ, Dhar S, Dawn G. Oral minipulse therapy in vitiligo. Dermatology 1995;190:251 2, doi: / Seiter S, Ugurel S, Tilgen W, Reinhold U. Use of intravenous methyl prednisolone pulse therapy in progressive vitiligo. Int J Dermatol 2000;39:624 7, doi: /j x. 20. Namita R, Kar HK, Sunil S. 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, doi: / Majid I, Masood Q, Hassan I, et al. Childhood vitiligo: response to methylprednisolone oral minipulse therapy and topical fluticasone combination. Indian J Dermatol 2009;54:124 7, doi: / Canadian Dermatology Association Journal of Cutaneous Medicine and Surgery, Vol 17, No 4 (July/August), 2013: pp