الفهرس 
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Abstract
Acrofacial vitiligo can affect face, head, hands, feet and more particularly involve the perioral region and the extremities of digits (Iannella et al., 2016). The most popular theory for resistance of AFV to treatment is the relatively less melanocytes and hair density in the acral areas (Mutalik, 2007). Resistance of the acral areas to treatment was attributed to the relatively lower density or absence of pilosebaceous follicles, the reservoirs from which the melanocytes migrate. Less melanocyte density and high chances of koebnerization over these friction and injury prone anatomical sites were other factors for reduced response in these areas (Esmat et al., 2012).
The LT induced repigmentation in patients with vitiligo has been attributed to the fact that it has a known periocular and iridal pigmentation side effects as PGF2α analogue is used in the treatment of glaucoma (Anbar et al., 2015). This repigmentation is proposed to activation of PGF2α (PF) receptors by their agonist results in modulating melanocyte dendricity, proliferation, tyrosinase expression melanocyte and melanosomal transfer (Park et al., 2009). All the PGF2α was reported to stimulate the formation of PGE2, so repigmentation may be induced, in part, via endogenous PGE2, which is a stimulator of melanogenesis (Sasaki et al., 2005).
The rational for Mn is to improve drug penetration through stratum corneum that may potentiate its activity (Donnelly et al., 2010). In addition, skin perforation during Mn causes processes like wound healing response which produces cytokines and growth factor beneficial for repigmentation (Li et al., 2015). Mechanical trauma stimulates the melanocytes migration from the pigmented areas to the vitiliginous lesions helping in an additional melanocytic autoinoculation. Furthermore, the micro trauma may increase the dermal melanophages and hyperpigmentation via basal cell layer damage. All of these can increase and promote melanogenesis (Ebrahim et al., 2020).
In this study, we evaluated therapeutic outcomes of topical LT 0.005% eye drops preceded by microneedling in AFV. Seventy-two patients with AFV were divided into two groups A & B. group A received topical LT 0.005% eye drops preceded by Mn in the form of sessions every two weeks (n = 36) and group B received topical LT 0.005% eye drops alone (n =36) for 12 weeks. VASI and repigmentation rates were determined at baseline and 2-weeks intervals.
In group A, 12-week’s VASI [0.45 (0.18 - 0.64)] was significantly lower than baseline VASI [0.5 (0.21- 0.67); p = 0.003]. In group B, 12-week’s VASI [0.43 (0.25- 1)] was not significantly different from baseline VASI [0.43 (0.25- 1)]. In group A, 12-week’s VASI score was significantly lower than baseline score especially on the face lesions (n=18; p = 0.002). Repigmentation was observed on the face in12/18 (66.67%), on the hands in 6/27 (22.22%) and on the feet in 4/12 (33.33%) of patients in group A versus 0/36 (0.0%) in group B. In group A, 2/36 (5.56%) patients had excellent repigmentation, 2/36 (5.56%) patients had very good repigmentation, 4/36 (11.11%) patients had good repigmentation, 10/36 (27.77%) patients had satisfactory repigmentation and 18/36 (50%) patients had poor repigmentation. The mode of repigmentation was both marginal in the majority of cases and perifollicular in few cases. The acquired repigmentation was stable up to 24 weeks in all patients in group A, who returned for follow-up.
The combination of LT with Mn offers a new therapeutic option for treatment of acrofacial vitiligo especially on the face. The repigmentation was observed in approximately 50% of patients after 12 weeks of treatment with Mn and topical LT 0.005% eye drops. The repigmentation started to appear in the vitiliginous lesions after 6 weeks as evidenced by significant reduction of VASI scores. The combination was safe as there were no major cutaneous adverse events. Adverse events included pain with Mn occurred in 41.67% of cases, erythema occurred in 13.89% of cases, burning sensation occurred in 13.89%, while in 8.33% of cases there was an increase in size of lesions (koebnerization). These adverse events disappeared spontaneously in the subsequent visits, and the patients did not need to stop the treatment.
Recommendations
Multicenter studies are recommended to test the efficacy of LT as a monotherapy and combined with other therapeutic modalities for longer duration (> 3 months). Long term follow up is warranted to test the safety of LT therapy in vitiligo.