Rapid initiation of repigmentation in vitiligo with Dead Sea climatotherapy in combination with pseudocatalase (PC-KUS)

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1 Oxford, IJD International Blackwell 41 UK Science, Journal Ltd 2002 of Dermatology Report Repigmentation Schallreuter et al. in vitiligo and hydrogen peroxide removal Rapid initiation of repigmentation in vitiligo with Dead Sea climatotherapy in combination with pseudocatalase (PC-KUS) Karen U. Schallreuter, MD, Jeremy Moore, PhD, Stephanie Behrens-Williams, MD, Angela Panske, BSc, and Marco Harari, MD From the Department of Biomedical Sciences, Clinical and Experimental Dermatology, University of Bradford, West Yorkshire, BD7 1DP, UK, the Institute for Pigmentary Disorders in association with the Ernst Moritz Arndt University of Greifswald, Greifswald, Germany, and DMZ-Mor Clinic, Ein Bokek, Israel Correspondence K U Schallreuter, MD Clinical and Experimental Dermatology Department of Biomedical Sciences University of Bradford West Yorkshire BD7 1DP UK K.Schallreuter@bradford.ac.uk Abstract Background Low catalase levels and cellular vacuolation in the epidermis of patients with vitiligo support major oxidative stress in this compartment. There is now in vivo evidence for increased epidermal hydrogen peroxide (H 2 O 2 ) accumulation in this patient group by utilizing noninvasive Fourier Transform Raman spectroscopy (FT Raman). Epidermal H 2 O 2 can be removed with a topical application of narrow band UVB activated pseudocatalase cream (PC-KUS). (Mn/EDTA-bicarbonate complex, patent No. EPO A), yielding initiation of repigmentation. Dead Sea climatotherapy is another successful treatment modality for vitiligo, but the mode of action has escaped definition so far. Methods Epidermal hydrogen peroxide (H 2 O 2 ) was assessed in vivo before and after 21 days treatment at the Dead Sea using noninvasive Fourier-Transform Raman spectroscopy. The effectiveness of repigmentation was followed in 59 patients with vitiligo by comparing Dead Sea climatotherapy alone with the combination of Dead Sea climatotherapy/pseudocatalase cream (PC-KUS) as well as Dead Sea climatotherapy/placebo cream. Clinical repigmentation was documented by standardized black/white photography using non-uv coated bulbs as flashlight and by color photography. Results This study on 59 patients who had vitiligo for an average time of 17 years (range 3 53 years) confirmed in vivo H 2 O 2 accumulation in mm concentrations in the epidermis of untreated patients. Furthermore, we demonstrated a pseudocatalase activity after 15 min of Dead Sea bathing, but the decrease of epidermal H 2 O 2 levels was significantly less compared to narrowband UVB activated pseudocatalase cream (PC-KUS). Initiation of repigmentation was already observed between day 10 and day 16 after a combination of Dead Sea climatotherapy/pseudocatalase cream compared to conventional pseudocatalase monotherapy (8 14 weeks) and Dead Sea climatotherapy alone (5 6 weeks). Conclusion The results of this study show a significantly faster initiation of repigmentation in vitiligo after a combination of short-term climatotherapy (21 days) at the Dead Sea in combination with a pseudocatalase cream (PC-KUS) compared to either conventional climatotherapy at the Dead Sea alone or with placebo cream in combination with climatotherapy. This combined therapy is significantly faster in repigmentation than narrowband UVB activated pseudocatalase cream (PC-KUS) treatment alone. The results of this study support the necessity of epidermal H 2 O 2 removal as well as the influence of solar UV-light in the successful treatment of vitiligo. 482 Introduction Vitiligo is an acquired depigmentation disorder affecting 0.5 4% of the world population. 1 Despite its early recognition, the etiology is still unclear. There are several hypotheses but none of them can satisfy the entire spectrum of this disfiguring disorder. 1,2 Almost all the publications describe decreased numbers of functioning melanocytes or the complete absence of these cells in the involved skin. 3 A recent paper by Tobin et al. showed that melanocytes are still present even in long standing disease. 4 In addition, altered functionality of Langerhans cells has been stressed. 5 Nowadays there is convincing evidence for the presence of oxidative stress in the skin of affected individuals Extremely high concentrations of International Journal of Dermatology 2002, 41, The International Society of Dermatology

2 Schallreuter et al. Repigmentation in vitiligo and hydrogen peroxide removal Report 483 Figure 1 Clinical result of narrowband UVB activated pseudocatalase cream (PC-KUS) therapy. Extensive repigmentation of facial vitiligo in a female black patient (photo skin type VI) before (a) and after (b) 14 months treatment with narrowband UVB activated pseudocatalase (PC-KUS) monotherapy twice daily N.B. This result can be achieved even after the duration of vitiligo for 47 years epidermal H 2 O 2 together with low catalase levels have been identified in vivo and in vitro using Fourier Transform Raman spectroscopy (FT Raman). 12,13 It has been shown that the missing catalase activities can be substituted with a narrowband activated pseudocatalase cream (PC-KUS) which is based on a bis manganese EDTA bicarbonate complex (Patent No. EPO A). This complex successfully removes the high H 2 O 2 levels from these patients leading to initiation of repigmentation and to recovery from vacuolation in the epidermal cells. 4,12 15 The time course for repigmentation can vary considerably in the patients, but repigmentation can be achieved in long-term vitiligo even after 47 years 12 (Fig. 1). Since the combination of solar radiation and sea water bathing at the Dead Sea is a successful treatment modality in various skin diseases, such as psoriasis and atopic eczema, as well as vitiligo, we wanted to investigate whether we could enhance the effect of the conventional pseudocatalase cream (PC-KUS) monotherapy in combination with the Balneoclimatotherapy at the Dead Sea. 16 Until now it is generally believed that the high salt concentration (346 g/l) contributes to the efficacy of the therapy by several mechanisms. A release of pro-inflammatory and chemotactic mediators has been proposed. 16,17 Only recently the effect of the high magnesium chloride (MgCl 2 ) concentration of this water has been further elucidated by Schempps et al. who were able to show that MgCl 2 dramatically influences the antigen presenting capacity of Langerhans cells. 18 Furthermore, it is generally believed that the unique solar UV spectrum in the Dead Sea basin contributes to the sea water bathing. In this context an increased photosensitivity after the salt bathing has been implicated. 19,20 Solar radiation at the Dead Sea is filtered by an additional 400 m below sea level atmosphere and it has been shown that the shortest part of UVB does not arrive at the Dead Sea These conditions 2002 The International Society of Dermatology International Journal of Dermatology 2002, 41,

3 484 Report Repigmentation in vitiligo and hydrogen peroxide removal Schallreuter et al. could foster activation of the inactive manganese-edta bicarbonate complex of the conventional pseudocatalase cream (PC-KUS) therapy. 12,13 model 1100 Atomic Absorption spectrometer. Samples of Dead Sea water were diluted 1 : 20 with de-ionized distilled water and made up to 1 L. Patients and methods Patient selection and study design The clinical observation was based on a randomised three-arm study, in order to compare the effect of climatotherapy alone (group 1/control arm) vs. placebo cream in combination with climatotherapy (group 2) and pseudocatalase cream (PC-KUS) in combination with climatotherapy (group 3) at the Dead Sea basin over 21 days. The patients were eligible for the study when they had vitiligo according to a full body clinical examination in association with Wood s light. Fifty-nine English and German patients with vitiligo (14 men and 45 women) with a mean age of 38.6 years (range years) from the Institute for Pigmentary Disorders in Greifswald, Germany were included in the study. The majority of the group (86%) had the most common clinical subtype vulgaris and 14% presented with acrofacial vitiligo. Only patients with photo skin type III (Fitzpatrick classification) were included in order to exclude any possible effect of other skin types. 24 The duration of the disease process varied from 3 to 53 years with a mean age of 16.7 years. Family history was positive in 28/59 patients (47.5%). The patients were otherwise healthy. Written consent was obtained from the local ethics committee from each patient prior to this clinical study. The study took place at the DMZ-Mor Clinic in Ein Bokek, Israel during the months of June and July FT-Raman protocol to follow epidermal H 2 O 2 removal in vivo in the skin All patients (n = 59) were tested in vivo before treatment and at the end of the 21-day stay at the Dead Sea basin for epidermal H 2 O 2 concentrations using in vivo FT-Raman spectroscopy. The results were compared to 15 healthy photo skin-type matched controls. 12 FT-Raman spectra were obtained with a Bruker RFS 100/S spectrometer equipped with a liquid nitrogen cooled germanium detector. Sample excitation was accomplished using a Nd 3+ /YAG laser operating at 1064 nm with a laser power of 400 mw. Each spectrum was accumulated over 5 min with 300 scans and a resolution of 4 cm 1. Total H 2 O 2 was visualized as a well defined peak at 875 cm 1 based on the oxygen-oxygen (O-O) stretch vibration. 12 The study design was approved by the local Ethics Committees. Atomic Absorption Spectroscopy In order to elucidate the content of transition metals in the Dead Sea water we utilized Atomic Absorption Spectroscopy. Total transition metal analyzes were carried out using a Perkin-Elmer Treatment protocol All patients had to bathe for 15 min in the Dead Sea twice daily. The bath was followed by a shower to wash off the salt. Group 1 (n = 10) then underwent directly total body sun exposure, whereas group 2 (n = 10) and group 3 (n = 39) applied their creams to the entire body surface prior to sun exposure. The exposure times were slowly increased to a maximum of 1 h. The treatment took place in the morning between 7.30 am and am and in the afternoon between 2.30 pm and 5.30 pm. The patients had to record the exposure times. Clinical assessment by standardized photography For a valid clinical assessment of the repigmentation of the face and hands we utilized black and white photographs using a fixed frame assembly holding the camera (Pentax MZ-M with a 90-mm lens and an Ilford 828 glass filter) and a Kodak T-MAX 400 film. The flashlight with non-uv coated bulbs was also fixed (Bowens Esprit 500). This technique assures a good quality comparison of subsequent photographs and allows, even in very fair skin, the objective evaluation of affected areas. In addition, we used whole body color photographs with a standard camera and flash light (Minolta) to follow disease stability during this treatment period. Patients were photographed before treatment and at the end of the therapy at the Dead Sea after 21 days. Assessment of efficacy The efficacy of each treatment modality was assessed after 21 days based on the special photographic documentation of the face and hands. The grading was based on the repigmentation of affected areas by comparison of the photos before and after 21 days. Statistical analysis For statistical analysis we used the Wilcoxon signed rank test for paired samples. Values P < 0.05 were significant. Results The Dead Sea water has pseudocatalase activity The Dead Sea water analysis showed the presence of transition metals such as manganese (7140 p.p.m.), copper (582 p.p.m.), and iron (1398 p.p.m.), as well as high concentrations of sodium bicarbonate and calcium chloride. These results were obtained from analysis of the Dead Sea water using Atomic Absorption Spectroscopy. Since these transition metals can form the chemical base for pseudocatalases, we expected that the Dead Sea water bathing would act as a pseudocatalase In order to test this assumption, we International Journal of Dermatology 2002, 41, The International Society of Dermatology

4 Schallreuter et al. Repigmentation in vitiligo and hydrogen peroxide removal Report 485 Table 1 Photographic assessment of repigmentation in the face after 21 days Repigmentation* Group 1 (n = 10) Group 2 (n = 10) Group 3 (n = 39) Figure 2 Efficacy of a 15-min Dead Sea water bath on the removal of epidermal H 2 O 2, in patients (n = 16) with vitiligo using in vivo FT-Raman spectroscopy. Measurements were taken before and after the bath, showing a significant reduction of H 2 O 2 (p = 0.001) Figure 3 A comparison of the in vivo efficacy of Dead Sea water and combination of Dead Sea water and pseudocatalase cream (PC-KUS) on epidermal H 2 O 2 removal in vitiligo using FT- Raman spectroscopy. The results are presented in percentage of H 2 O 2 levels standardized to 100% before treatment. A significantly stronger effect of pseudocatalase cream (PC-KUS)/ Dead Sea bath is shown. The pseudocatalase activity of the Dead Sea water alone is much weaker. The placebo cream has no effect on H 2 O 2 removal. Healthy controls have no detectable H 2 O 2 level in their skin (the data are presented ± SEM) followed in vivo the reduction of H 2 O 2 levels in 16 of 59 patients using FT Raman spectroscopy. The results showed a significant decrease of epidermal H 2 O 2 after a 15-min bathing session (p = 0.001). The data of this analysis are presented in Fig. 2. This in vivo observation identified the Dead Sea water as a pseudocatalase. A comparison of the efficacy of the Dead Sea bathing alone (group 1), and pseudocatalase cream (PC-KUS) plus Dead Sea bathing (group 3) showed a significantly more potent catalase activity for pseudocatalase cream (PC-KUS)/Dead Sea bathing after 21 days (p = ). The results are presented in Fig. 3. In order to rule out a possible contribution of the cream base, we treated *Grading was based on a scale ranging from 0, 1 +, 2 + and (0 = no signs of repigmentation; 1 + = minimal follicular repigmentation; 2 + = follicular repigmentation < 50% of the involved areas; 3 + > 50% follicular/confluent repigmentation of involved areas). 10 patients with this placebo cream plus Dead Sea bathing for 21 days (group 2). There was no significant difference between the H 2 O 2 reduction after Dead Sea bathing alone (group 1) and the combination of placebo cream/ Dead Sea bathing (group 2) (P > 0.05) (Fig. 3). Evaluation of repigmentation after 21 days The clinical result was assessed after 21 days by Wood s light and by photodocumentation. None of the patients was fully repigmented at day 21 nor did any patient develop new white patches during this time. The examination with Wood s light identified more repigmentation which could not be appreciated by eye alone. Since the hands and face were photodocumented under the special UV-conditions as outlined in the methods section, we therefore only evaluated the face and the hands. The results on facial regimentation are presented in Table 1. The repigmentation of the hands was not further evaluated because the changes were too small after 21 days treatment. The outcome showed that patients treated with placebo cream/ Dead Sea climatotherapy (n = 10) (group 2) and patients treated with climatotherapy only (n = 10) (group 1) had significantly less follicular repigmentation in the face compared to the patient group treated with pseudocatalase cream (PC-KUS) in combination with climatotherapy (group 3). One example of extensive follicular repigmentation in the face is shown in Fig. 4. There was no significant difference between Dead Sea climatotherapy (group 1) and placebo cream in combination with climatotherapy (group 2). Discussion The positive healing effect of climatotherapy at the Dead Sea basin has been well established in the treatment of psoriasis and atopic eczema. 28 The treatment protocol for these diseases usually lasts for consecutive days and the response rates are described as high as 80%. 29 Studies on UV-intensities at the Dead Sea area showed that 9.4% of UVB 2002 The International Society of Dermatology International Journal of Dermatology 2002, 41,

5 IJD_1463.fm Page 486 Wednesday, August 14, :37 AM 486 Report Repigmentation in vitiligo and hydrogen peroxide removal Schallreuter et al. Figure 4 Follicular repigmentation after 21 days. Initiation of extensive follicular repigmentation in the face of a female patient (photo skin type III) after only 21 days combination therapy (climatotherapy/pseudocatalase cream (PC-KUS)) twice per day following the protocol as described in methods. (a) before treatment, (b) after 21 days. (For details of photographic documentation see methods) and 3.5% of UVA are filtered out yielding a unique environment in this region.29 The safety aspects of the solar phototherapy have been investigated and discussed extensively.30 It has been suggested that the UVB range at the Dead Sea could be a natural narrow-band therapy.29 In addition, the high mineral content of the Dead Sea has been considered a major factor in this successful treatment modality. The study presented here identified the Dead Sea water as a pseudocatalase. We were able to follow in vivo the reduction of epidermal H2O2 directly in the skin of patients with vitiligo. This reducing effect was much weaker than a narrowband UVB activated pseudocatalase cream (PC-KUS) in combination with Dead Sea water bathing. However, whether this H2O2 reduction was indeed beyond the mm range cannot yet be concluded due to the limitation in sensitivity of in vivo FT Raman spectroscopy.12 A significantly faster initiation of repigmentation compared to conventional pseudocatalase cream (PC-KUS) monotherapy or climatotherapy alone was observed using the combined protocol Dead Sea/pseudocatalase cream (PCKUS)/solar phototherapy twice daily in the early morning and late afternoon It should be noted that the treatment protocol in the study presented here used much less sun exposure than the conventional treatment recommendation at the Dead Sea for vitiligo. (2 h compared to 7 8 h per day). In conclusion, from the results of this placebo controlled study, it appears that the combination of climatotherapy and conventional pseudocatalase cream (PC-KUS) initiates a faster repigmentation in all patients studied. A comparison of our own results using narrow-band UVB activated pseudocatalase International Journal of Dermatology 2002, 41, cream (PC-KUS) and the combination therapy revealed that the combination therapy is much more effective in the onset of repigmentation This fast repigmentation continues for at least up to 3 months (unpublished results). This study did not investigate the contribution of the unique solar spectrum to the initiation of repigmentation in vitiligo. Since all patients (groups 1, 2, and 3) underwent their treatment at the same time of the year and during the same sun hours of the day, we believe that the data of this clinical observation are valid and support once more the importance of epidermal H2O2 removal and also underline the significant contribution of UV-light to initiating a successful repigmentation in this disease Acknowledgments We are grateful for the dedication of all patients. This work was supported by Deutscher Vitiligo Verein e.v. Hamburg, Germany, Bruker Karlsruhe, Germany and Stiefel International. Susan Shergill typed the manuscript. References 1 Ortonne JP, Bose SK. Vitiligo. Where do we stand? Pigment Cell Res 1993; 8: LePoole IC, Das PK, van den Wijngaard RM, et al. Review of the etiopathomechanism of vitiligo: a convergence theory. Exp Dermatol 1992; 2: LePoole IC, van den Wijngaard RM, Westerhof W, et al. Presence or absence of melanocytes in vitiligo lesions: an 2002 The International Society of Dermatology

6 Schallreuter et al. Repigmentation in vitiligo and hydrogen peroxide removal Report 487 immunohistochemical investigation. J Invest Dermatol 1993; 100: Tobin DJ, Swanson NN, Pittelkow MR, et al. Melanocytes are not absent in lesional skin of long duration vitiligo. J Pathol 2000; 191: Nordlund JJ, Ortonne JP. Vitiligo and depigmentation. Current Problems Dermatol 1992; 4: Moellman G, Klein-Angerer S Scollay DA, et al. Extracellular granular material and degeneration of keratinocytes in normally pigmented epidermis of patients with vitiligo. J Invest Dermatol 1982; 79: Bhawan J, Bhutani LK. Keratinocyte damage in vitiligo. J Cutaneous Path 1983; 10: Yohn JJ Norris DA, Yrastorza G, et al. Disparate antioxidant enzyme activities in cultured human cutaneous fibroblasts, keratinocytes and melanocytes. J Invest Dermatol 1991; 97: Schallreuter KU, Wood JM, Berger J. Low catalase levels in the epidermis of patients with vitiligo. J Invest Dermatol 1991; 97: Maresca V, Roccella M, Roccella F, et al. Increased sensitivity to peroxidative agents as a possible pathogenic factor of melanocyte damage in vitiligo. J Invest Dermatol 1997; 109: Boissy R, Liu YY, Medrano EE, Nordlund JJ. Structural aberration of the rough endoplasmic reticulum and melanosome compartmentalisation in long-term cultures of melanocytes from vitiligo patients. J Invest Dermatol 1991; 97: Schallreuter KU, Moore J, Wood JM, et al. In vivo and in vitro evidence for hydrogen peroxide accumulation in the epidermis of patients with vitiligo and its successful removal by a UVB-activated pseudocatalase. J Invest Dermatol Symp Proc 1999; 4: Schallreuter KU. Successful treatment of oxidative stress in vitiligo. Skin Pharmacol Appl Skin Physiol 1999; 12: Schallreuter KU, Moore J, Wood JM, et al. Epidermal H 2 O 2 accumulation alters Tetrahydrobiopterin (6BH4) Recycling in Vitiligo: Identification of a general Mechanism in Regulation of all 6BH4-Dependent Processes? J Invest Dermatol 2001; 116: Schallreuter KU, Wood JM, Lemke KR, et al. Treatment of vitiligo with a topical application of pseudocatalase and calcium in combination with short-term UVB exposure: a case study on 33 patients. Dermatol 1995; 190: Even-Paz Z, Shani J. The Dead Sea and psoriasis historical and geographical background. Int J Dermatol 1989; 28: Abels DJ, Rose T, Bearman JE. Treatment of psoriasis at a Dead Sea Dermatology Clinic. Int J Dermatol 1995; 34: Schempps CM, Diltmar HC, Hunnler D, et al. Magnesium ions inhibit the antigen presenting function of human epidermal Langerhans cells in vivo and in vitro. Involvement of ATPase, HLA-DRB7 molecules and cytokines. J Invest Dermatol 2000; 115: Wiedow O, Wiese F, Streit V, et al. Lesional elastase activity in psoriasis, contact dermatitis and atopic dermatitis. J Invest Dermatol 1992; 99: Boer J, Schotthorst AA, Boom B, et al. Influence of water and salt solutions on UVB irradiation of normal skin and psoriasis. Arch Dermatol Res 1982; 273: Even Paz Z. Dermatology at the Dead Sea. Spas Isr J Med Sci 1996; 32: Kushelewsky AP, Slifkin MA. Ultraviolet measurements at the Dead Sea and Beer Sheva. Isr J Med Sci 1975; 11: Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo with UV-B radiation vs topical psoralen plus UV-A. Arch Dermatol 1997; 133: Fitzpatrick TB. The validity and practicality of sun reactive skin types I through to VI. Arch Dermatol 1988; 124: Ya Sychev A, Isak VG, Van Lap D. Catalytic properties of carbonate complexes of manganese (II) in the decomposition of hydrogen peroxide. Zhornal Ficichewskoi Khimii 1977; 51: Stadtman ER, Berlett BS, Chock PB. Manganese-dependent disproportionation of hydrogen peroxide in bicarbonate buffer. Proc Natl Acad Sci USA 1990; 87: Hage R, Iburg JE, Kerschner J, et al. Efficient manganese catalysts for low temperature bleaching. Nature 1994; 369: Shani J, Seidl V, Hristakieva E, et al. Indications, Contraindications and possible side-effects of climatotherapy at the Dead Sea. Int J Dermatol 1997; 36: Harari M, Shani J. Demographic evaluation of successful anti-psoriatic climatotherapy at the Dead Sea (Israel) DMZ Clinic. Int J Dermatol 1997; 36: Kushelevsky AP, Harari M, Kudish AI, et al. Safety of solar phototherapy at the Dead Sea. J Am Dermatol 1998; 38: The International Society of Dermatology International Journal of Dermatology 2002, 41,