INTRODUCTION:

Vitiligo is a pigmentation disorder that cause through the destruction of the melanocyte cells, these cells are responsible for the production of skin pigment (Melanin).^[1] The loss of melanocyte functions is responsible for vitiligo but the real cause of vitiligo is unknown, some conditions including autoimmune disorder, genetic, neural, viral infections and oxidative stress perform an important role in vitiligo.^[2] In this disease, the white patches/spots are formed on skin due to the destruction of melanocyte. About 1% population are affected from this disease in all our world.^[3] The maximum case of this disease is record in India, Egypt and Japan; it ranges from 1.25% to 6% of the population. Vitiligo is usually more in childhood or in young adults (20–30 years of age) and in about 30 % there is a positive family history. These are mainly 3 types-Segmental Vitiligo (SV), Non-segmental Vitiligo (NSV), and Mixed Vitiligo (MV).^[4,5] Due to this disorder, the white patches are form on the hands and wrists, feet, arms, face, lips, axillae and perioral, periorbital and anogenital skin.

Due to this disorder, the white patches are form on the hands and wrists, feet, arms, face, lips, axillae and perioral, periorbital and anogenital skin. It can also affect the mucous membrane of the body.^[6]In most people, it tends to change slowly, with periods of stability often lasting several years. The pigment may return in some patients after some time, but is not sure, and scant returns completely.^[7] These white patches are spread to other areas of the body but in some patients, the white patches do not spread, while some people patches spread slowly and in some people quickly. Those patients are suffered from higher physical or chemical and emotional stress, white patches are spread more rapidly.^[8] The main cause of vitiligo include Autoimmunity, Neurohumoral factors toxic to melanocyte, self-destruction of melanocyte.^[9]

Sign and Symptoms:

The common symptoms of vitiligo are Depigmentation, White Spot, and patches on the skin. Initially, the white spots are very small but after some time they enlarged and formed patches.^[15] These white spots are firstly observed on hand, wrists, neck and face. The spreading process of this disease is usually slow and progressive. In some cases, most of the skin are covered with white patches.^[16]

Some pictures of Vitiligo patients:

Figure 1.1:

Classification:

According to the Vitiligo Global Issues Consensus Conference (VGICC) between 2011 - 2012, vitiligo can be classified into mainly two types:

1. Segmental Vitiligo

2. Non-segmental vitiligo

1. Segmental Vitiligo:

This type of Vitiligo is affecting only one or two segments. One segmental Vitiligo are formed a white macules on the body, like as Shoulder and body Hair, Face.^[10] Segmental vitiligo lesions are characterised by their unilateral and segmental or band-shaped distribution. It is further classiﬁed as:

a. Focal Vitiligo: In this type of vitiligo, the one or more parts are affected and discoloured of a single body.

b. Mucosal Vitiligo: In this type of vitiligo, firstly the mucous membranes are affected.^[11]

2. Non Segmental vitiligo:

Its lesions are typically bilaterally distributed in an acrofacial pattern, or scattered symmetrically on the complete body.^[12,13] It is subdivided into 6 types:

a. Acrofacial: Mostly it affects the face, head, feet, and hands, and preferably involves the perioral region.

b. Mucosal: It affects the oral and genital mucosa, Furthermore areas of mucosa may also be affected in patients with acrofacial.

c. Generalized or common: It can affect any part of the tegument, mainly hands, fingers, face and trauma-exposed areas.

d. Universal: It affects about 80-90% part of the whole body and it is the most common form in adulthood.

e. Mixed: It shows the both segmental and non-segmental vitiligo. Most often, the segmental form precedes NSV.

f. Rare forms: It consists of punctata, minor and follicular. These types were also considered unclassifiable.^[14,19,20]

Diagnosis:

Diagnosis of vitiligo is very complicated in patients having light complexion of the skin colour, but we are easily identify in patients having normal and dark skin colour. A blood test to check thyroid function should be considered in view of the high prevalence of autoimmune thyroid disease in patients with vitiligo. Some instruments/Techniques are used for the determination of vitiligo like as- Wood’s Light Lamp, Speech Audiometer, Immittance meter, Cochlear Emission Analyzer Madsen, Evoked Response Audiometer Nickolet Compact four.^[17,18]

Pathophysiology of Vitiligo:

The single main cause of vitiligo is unknown, but some evidence based hypothetic pathogen have been proposed to explain the loss of melanocyte in skin.^[21] Some important cause of vitiligo are

· Genetically

· Autoimmune Disorders

· Oxidative Stress

Genetically:

The vitiligo is spread through the genetic disorders, and it seen in familial members.^[22] Vitiligo is a polygenic disease, many gene contents that are associated in the regulation of immunity like as- angiotensin-converting enzyme (ACE), catalase (CAT), cytotoxic T lymphocyte antigen-4 (CTLA-4), catechol-O-methyltransferase (COMT), estrogen receptor (ESR), mannan-binding lectin (MBL2), protein tyrosine phosphatase, non-receptor type 22 (PTPN22), human leukocyte antigen (HLA), NACHT leucine-rich repeat protein 1 (NALP1), X-box binding protein 1 (XBP1), forkhead box P1 (FOXP1) and interleukin-2 receptor A (IL-2RA) etc.^[23,24] Some other vitiligo-associated autoimmune / auto-inflammatory syndromes are- HLA haplotypes, especially HLA-A2, −DR4, −DR7 and −DQB1 are play an important role in loses of melanocyte.^[25,26] The multiple autoimmune susceptibility(ASI) loci are associated with genes that control innate immunity.^[27] The AIS1 was located on chromosome1, AIS2 on chromosome 7 andAIS3 on chromosome 8.^[28] In recent study, the researchers are explored the role of microRNAs (miRNAs) and toll-like receptors (TLRs) in the pathogenesis of vitiligo.^[29] When checked the level of miRNA of a patient with vitiligo, the miR-99b, miR-125b, miR-155 and miR199a-3p levels were found to be increased while the miR145 level was found to be decreased in the skin. When increase the level of miRNA in skin, they inhibit the synthesis of melanocyte associated genes.^[30]

Autoimmune Disorders:

The Autoimmunity are performing the main role in pathogenesis of vitiligo.^[31] This hypothesis proposes, the destructions of melanocyte are observed in the immune system disorders. Some autoimmune disorders are associated with vitiligo like as - thyroid diseases rheumatoid arthritis, psoriasis, adult-onset diabetes mellitus, Addison’s disease, pernicious anaemia, alopecia areata, systemic lupus erythematosus etc.^[32,33] The thyroid disorders are main cause of destruction of melanocyte in skin. According to epidemiological survey of UK and North America, the 19·4% of patients with vitiligo aged 20 years or older are reported clinical history of autoimmune thyroid disease compared with 2·39% of the overall white population of the same age, mostly vitiligo patients are suffered with thyroid disorders.^[34,35] Some important auto antigens are related to IgG family as- HLA class , tyrosinase, tyrosinase-related protein (TRP)-1 and (TRP)-2 are responsible for vitiligo.^[36] According to adaptive immunity, the cytotoxic CD8 + T cells are responsible for the destruction of melanocyte and leads to decreased capacity and inhibit the active inflammatory process and cause autoimmune disorders.^[37] The T cells migration are depend on the chemokines proteins, like as IFN-gamma and IFN-gamma-induced chemokines. These proteins are present in normal blood and less in vitiligo patients because this is not main factor for this disease.^[38] the IFN-gamma /CXCL10 are may be an effective therapeutic agents and they will be used in the treatment of some autoimmune disorders including- psoriasis, Rheumatoid arthritis and Crohn's disease.^[39,40]

Oxidative Stress:

The oxiadative stress theory is define, the reactive oxigen are the main cause of pathogenesis of vitiligo because in this condition, the reactive oxigen are accumulate in the intra-epidermally in the form of H₂O₂and create the cellular stress. Due to this, the melanocyte are non-active /Death.^[41,42] Result in, decrease the level of catalase enzyme when increase the concentration of H₂O₂ in epidermal were observed in the skin of vitiligo patients.^[43]

Treatments:

The treatment of vitiligo is very difficult in this time because their main causing agent is unkown, but some herbal/medicinal treatment is available and used for the regeneration of melanocyte in the skin. Some important herbal drugs are:

1. Ginkgo Biloba: Ginkgo biloba is a common plant that is used in various diseases such as- allergies, varicose vein, premenstrual syndrome, headache, vertigo and others. The leaves and seeds of these plants had been used in medicine for a very long time. It is mostly showing the anti-inflammatory, repigmentary, immunomodulatory and antioxidant properties.^[44,45] The repigmentation of melanocyte are not uniform but maximum area of white patches are cure from this treatment. The drug is safe and well-tolerated at therapeutic dosages (normal value: 120mg/day). The daily dosage > 240mg may result in restlessness and gastrointestinal disorders, and this treatment is contraindicated for haemorrhagic patients because these drugs are interfuse the blood.^[46]

2. Muskmelon: Muskmelon is a fruit that belonging to the Cucurbitaceae family. It is mainly climbing plants, producing stems around 1.5 meters long that sprawl along with ground, and it’s mostly found in desert and river banks areas.^[44,47] In curcumas melo extract, the high superoxide dismutase are present that act as an antioxidant. This antioxidant is essential for the prevention of the destruction of melanocyte in oxidative stress.^[48] It is applied on the skin lesion combination with narrow band UVB and extract of curcumas melo and this combination are useful for the treatment of vitiligo.^[49]

3. Picrorhiza kurroa: Picrorhiza kurroa is also known as ‘kutki’. The Antioxidant and immuno-modulating properties are present in kutki extract and it is mostly used as a hepatoprotective agent. In recent study, the picrorhiza are shows the common effect in repigmentation due to this effect, this medicine is used in the treatment of vitiligo.^[50]

4. Psoralea corylifolia: The seeds of Psoralea corylifolia is also used in the treatment of leucoderma because the psoralen is present in this. The seeds are taken in the early morning in empty stomach.^[51] The extract of these seeds are used within the combination of ultraviolet A light (UVA), treatment involves taking a drug that increase the sensitivity of UV light. This therapy is required is BD (twiss a day) for 6-10 month or more. Narrowband ultraviolet B (UVB) phototherapy is now used more commonly than PUVA as it is show less harmful effect on the skin.^[52]

5. Ginger and Red Clay: The red clay and the ginger juice are mixed with each other and applied on depigmented areas so these are useful in the treatment of vitiligo.^[53] Copper are present in the clay, due to this,the skin pigmentation back and ginger facilitates increased blood flow to the white spot which helps into the repigmentation of the spots. The red clay is collected from the river bank and the hill slope.^[54]

6. Khellin: The Khellin is obtaining from the natural source; it is derived from the plant of Amni visnaga. This plant has been used as a herbal medicine for different type of diseases. It stimulates the melanocytes proliferation and melanogenesis. This medicine is not suitable for oral route because they show the hepatotoxicities. It show the best results in combination with UVA Phototherapy.^[55]

7. Polypodium leucotomos: Polypodium leucotomos is a tropical fern and is also called as “Calaguala”, and Polypodium aureum. It is belonging to the family of Polypodiaceae. It contains the antioxidant and photoprotective agents in maximum quantities, due to this effect this fern is mostly used in the treatment of various skin diseases such as- psoriasis, atopic dermatitis, vitiligo etc.^[56,57] It shows the better effect combination with PUVA therapy plus oral Polypodium leucotomos led to a higher repigmentation than the photochemotherapy alone.^[58]

8. Capsicum: The capsicum is one of the most important compounds of spices and in this, the Capsaicin is present and it’s an active compound of chilli peppers. It has the antinflammatory and antioxidant properties. From the last few decades, the capsaicin is used in the treatment of vitiligo because it stopped the cellular damage by ROS.^[59]

9. Corticosteroids: The corticosteroid therapy is considered as a first-line treatment of vitiligo, the corticosteroids are topically applied instead of systematically and prevent the risk of hepatic side effect. The use of high-potency topical corticosteroids is more suitable to treat small affected areas, being more effective on the face, elbows and knees.^[60,61] The class 3 topic corticosteroids has higher efficacy in the treatment of localized vitiligo, compared to class 4 and intralesional corticoids. The class 3 drugs have more re pigmentation power than the class 4 drugs, and the less side effects compare to others class of corticosteroids.^[62]

CONCLUSION:

Vitiligo is a skin disorder in which destruction of melanocyte by different means occurs. The main cause of vitiligo still remains unknown, although, it is clear that several different pathophysiological processes may be involved. The above discussed some treatments that treat this disorder. Some Ayurvedic drugs are used in this treatment, and Sun light is additive effect to promote the melanocyte formation. A treatment to completely cure vitiligo does not exist but some are prevent the formation of white patches and enhance the regeneration of melanocyte.

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Received on 05.05.2020 Revised on 30.05.2020

Asian J. Pharm. Res. 2020; 10(4):263-267.

DOI: 10.5958/2231-5691.2020.00046.5