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• W2896841514 abstract "To the Editor: Vitiligo is a common acquired depigmenting skin disorder that is caused by the loss of melanocytes. Conventional therapies, including narrowband ultraviolet B light phototherapy, are not always successful,1Bae J.M. Jung H.M. Hong B.Y. et al.Phototherapy for vitiligo: a systematic review and meta-analysis.JAMA Dermatol. 2017; 153: 666-674Crossref PubMed Scopus (0) Google Scholar and patients express enormous interest in complementary and alternative medical approaches despite a lack of evidence for these approaches.2Grimes P.E. Nashawati R. The role of diet and supplements in vitiligo management.Dermatol Clin. 2017; 35: 235-243Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The use of antioxidants is often advocated for patients with vitiligo; however, their actual role remains unclear.3Harris J.E. Cellular stress and innate inflammation in organ-specific autoimmunity: lessons learned from vitiligo.Immunol Rev. 2016; 269: 11-25Crossref PubMed Scopus (60) Google Scholar We conducted a systematic review and metaanalysis to explore the efficacy of antioxidant supplements in combination with phototherapy compared with phototherapy alone for vitiligo (Table I).Table IInterventions and clinical outcomes described in all included studiesStudyCountryStudy designAntioxidant componentDosageFrequency of phototherapyTreatment duration (mo)Enrolled patientsCompleted patientsSuccessful patientsTCTCTCStudy 1SpainDB RCTPolypodium leucotomosNDPUVA, ND310910950Study 2ItalyDB RCTLipoic acid (50 mg), vitamin C (50 mg), vitamin E (20 mg), polyunsaturated fatty acids (12%), and cysteine monohydrate (50 mg)2 tablets/dayNBUVB, twice weekly621141711124Study 3EgyptRCTα-tocopherol400 IU/dayNBUVB, thrice weekly6121211985Study 4EcuadorDB RCTPolypodium leucotomosNDNBUVB, twice weekly6764442C, Control group; DB, double-blind; NBUVB, narrowband ultraviolet B light phototherapy; ND, not determined; PUVA, psoralen plus ultraviolet A light phototherapy; RCT, randomized controlled trial; T, treatment group. Open table in a new tab C, Control group; DB, double-blind; NBUVB, narrowband ultraviolet B light phototherapy; ND, not determined; PUVA, psoralen plus ultraviolet A light phototherapy; RCT, randomized controlled trial; T, treatment group. We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library on April 23, 2017, using the keywords “vitiligo,” “antioxidant,” “vitamin,” and the names of various antioxidants. Two investigators independently screened and selected all relevant randomized controlled trials, extracted data, and determined study quality. The outcome of interest was treatment success, defined as ≥50% repigmentation of all lesions in an individual patient. Intention-to-treat analysis was planned if possible. We estimated relative risk using a random-effects model, and sensitivity analysis was performed by performing repeated sequential metaanalyses excluding each study. Funnel plots were used to assess publication bias. Database searches identified 398 records, and 30 full-text articles remained after screening the titles and abstracts (Fig 1, A). Ultimately, 4 studies involving 91 patients met our inclusion criteria. Table I shows the interventions and clinical outcomes of all included studies. The addition of antioxidant supplements to phototherapy yielded significantly better efficacy than phototherapy alone (4 studies: relative risk 1.87 [95% confidence interval 1.10-3.17]; Fig 1, B). Sensitivity analysis revealed that the result was robust and not dependent on any individual study. The funnel plot did not indicate publication bias (data not shown). No sustained adverse event was noted, except that 1 study reported reversible nausea and dizziness. Increasing evidence suggests that oxidative stress plays a role in the pathogenesis of vitiligo.3Harris J.E. Cellular stress and innate inflammation in organ-specific autoimmunity: lessons learned from vitiligo.Immunol Rev. 2016; 269: 11-25Crossref PubMed Scopus (60) Google Scholar Melanocytes from patients with vitiligo were intrinsically defective in managing cellular oxidative stress and exhibited increased secretion of inducible heat-shock protein 70 during oxidative stress.4Denat L. Kadekaro A.L. Marrot L. Leachman S.A. Abdel-Malek Z.A. Melanocytes as instigators and victims of oxidative stress.J Invest Dermatol. 2014; 134: 1512-1518Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar, 5Mosenson J.A. Eby J.M. Hernandez C. Le Poole I.C. A central role for inducible heat-shock protein 70 in autoimmune vitiligo.Exp Dermatol. 2013; 22: 566-569Crossref PubMed Scopus (40) Google Scholar Therefore, the use of antioxidants counteracting oxidative stress is a reasonable approach in patients with vitiligo. Antioxidants may afford additional benefits: reducing ultraviolet light–induced photooxidative stress and the cumulative ultraviolet B light dosage and accelerating the initial repigmentation in patients who are receiving narrowband ultraviolet B light phototherapy. In conclusion, our results showed that antioxidant supplements in combination with phototherapy were more effective than phototherapy alone for vitiligo. When we consider the role of oxidative stress in the pathogenesis of vitiligo, it might be worth encouraging patients to take antioxidant supplements. However, the results are provisional because of limitations of our study, including the small number of enrolled patients and a high degree of heterogeneity among studies. In addition, elaborate studies analyzing individual body parts could not be included because we sought to investigate the overall beneficial effects of systemic antioxidants in individual patients. It would also be difficult to apply our findings to specific body parts, such as acral sites. More controlled trials with large sample sizes are needed. We thank Drs Roberta Colucci, Janeth Rojas de Soca, and Middelkamp-Hup for providing important data from their randomized controlled trial exploring antioxidant supplement therapy for vitiligo patients, and thank Dr Pearl E. Grimes for advising us on the effects of antioxidants on patients with vitiligo." @default.
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• W2896841514 title "Antioxidant supplements in combination with phototherapy for vitiligo: A systematic review and metaanalysis of randomized controlled trials" @default.
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