Medical and physical treatments
Systemic and local PUVA-therapy

This is a kind of photochemotherapy combining the photosensitizing action of psoralens, substances of a vegetal origin, with exposure to ultraviolet type-A rays, both from the sun and artificially produced. Hence the acronym PUVA, Psoralens + UVA.

UVA rays are known to penetrate down to the dermis, thus causing the so-called photoaging, or early skin aging; on the other hand, the Ratok®therapy, based on the use of UVB rays does not pass through the skin. Unlike UVA irradiation, the Ratok®therapy is focused and punctiform, i.e. UVB rays fall within the edges of vitiligo patches. While the Ratok®therapy promotes the reactivation or onset of new melanocytes, the cells devoted to melanin production, UVA rays just increase the existing melanin without affecting melanocytes, so that their action in the PUVA-therapy basically consists in psoralen activation.

8-methylpsoralen (8-MOP) and trimetylpsoralen (TMP), combined with UVA rays, are the most frequently used oral psoralens; treatment may go on for several months or years.

8-MOP is administered 2 to 2.5 hours before exposure to UVA rays; it is extremely powerful and may cause significant skin reactions. This is why treatment should be carefully monitored by the dermatologist in charge, who should determine each time the dose and number of UVA-ray applications. TMP has a lower toxicity, may be combined with sun exposure, and is administered 2 hours before sun or UVA-ray exposure.

The introduction of psoralens for treatment purposes aroused much hope at the time, in the light of the good rate of positive results they could provide especially in recent vitiligo forms. Such hope was disappointed by the significant number of contraindications (including heart disease and arterial imbalance, gastroduodenal ulcer, kidney disorders, liver disorders, cataract, skin precancerosis, photopathies, photodermatosis, pregnancy and breast-feeding, children) and by the severity of the possible side reactions (including nausea, gastrointestinal disorders, photochemical eye reactions) of psoralens. Data are somewhat in disagreement with respect to the possible onset of skin cancer.

Before treatment, patients should undergo an eye examination and haematochemical checks of liver and kidney functions, to be repeated at six-month intervals during treatment. Upon drug intake, and throughout the day, patients should wear sun-glasses and avoid exposure to sun rays.

The local PUVA-therapy, generally recommended in children, in limited vitiligo forms with small and isolated patches, or in patients who should avoid psoralen intake, provides for the application of a 0.1% 8-MOP isopropanol solution or water or oil emulsion to the vitiligo patches, half an hour to 2 hours before exposure to UVA rays. The solution should be thoroughly removed after photoexposure. Due to the high toxicity of psoralens, the local PUVA-therapy is not devoid of risks, including blisters and erythemas, often severe; the number of applications should therefore be as limited as possible.

The bath-PUVA-therapy is a variation of the local PUVA-therapy: psoralens are added to the bath water where the patient should sit for 15 minutes; exposure to UVA rays then occurs when the skin is still wet.

Systemic and local KUVA therapy

This is a form of photochemotherapy combining kellin (K, a furanchromon of a vegetal origin) with UVA rays, hence the acronym KUVA.

At equal results, the KUVA-therapy is likely to show a lower toxicity than the PUVA-therapy. Both oral doses and the 2% local solution should be used 2.5 hours before exposure to UVA rays. Authors disagree with respect to the positive effects of the KUVA-therapy in vitiligo; according to some researchers, similar results could be achieved with sun exposure alone.

PHE + UVA

Some authors suggest that vitiligo is due to the presence of antibodies against melanocytes; phenylalanine (PHE) acts by inhibiting the onset of such antibodies, while UVA rays promote melanocyte migration from normally pigmented regions to close-by vitiligo patches, and activate the so-called "rudimental" melanocytes that are found in the same patches. Based on these assumptions, phenylalanine was combined with UVA rays to achieve encouraging results, both upon oral intake and local use; no side reactions were observed with the latter. Other authors stressed the risks and contraindications of this treatment, including self-immune disorders, skin cancer, impaired liver and kidney functions, phenylketonuria, pregnancy, and breast-feeding.

Minoxidil + PUVA

Based on the idea that minoxidil acts by stopping hair at the anagen stage and that melanocytes are active at this stage of the hair cycle, some authors have decided to supplement a systemic PUVA treatment with a trial application of a 2% minoxidil solution to the vitiligo patches. Since no other tests have been carried out, no opinion may be expressed on the value of this therapy.

Cystine + sun therapy

The low plasma concentrations of cystine and cystinuria observed in vitiligo patients have encouraged to test an oral cystine + sun therapy combination in these patients. However, for the time being, the results thus obtained do not seem superior to those achieved with sun exposure alone.

Melagenin + IR

Melagenin is a 50% purified hydroalcoholic agent obtained from the human placenta, produced in Cuba according to a secret process. It is therefore unknown whether screening of the placenta extract is performed, as it should be, in order to exclude the presence of viral agents, including HIV, HBV, HCV as well as fungi, bacteria, etc. According to Miyares Cao, the gynaecologist and pharmacologist in charge of the Cuba study on the action of melagenin on melanocyte proliferation, this therapy provides for application of the compound 3 times daily to vitiligo patches, followed by exposure of the treated areas to infrared rays for an undefined time. Treatment should start in Cuba and continue for at least 6 months at the patient’s home. The International Scientific Centre (I.S.C.), operating some time ago in San Marino, has now been closed. Since reliability of the claims of the Cuban Dermatological Centre in terms of results, case record, toxicity, and contraindications may not be ascertained, no judgement can be expressed on the scientific value, on the actual effectiveness, and on the possible risks involved by this treatment. The use of melagenin has been prohibited in the US, in Canada, and in Italy.