Faculty Bibliography

Postinflammatory hypopigmentation is an acquired form of hypopigmentation that occurs secondary to an exogenous or endogenous insult to the skin. It can occur in all skin phototypes but is more visually apparent in skin of color. Due in part to greater attention given to its counterpart, postinflammatory hyperpigmentation, there is dearth of literature describing this entity and treatment options remain limited. This review provides a comprehensive update on the pathogenesis, diagnostic evaluation and treatment of postinflammatory hypopigmentation, with a focus on newly reported treatment modalities.

BACKGROUND:Vitiligo is associated with medical conditions, primarily autoimmune; however, only few studies in the United States have investigated these associations. OBJECTIVE:The purpose of the study is to investigate the diseases associated with vitiligo in the New York City population and to evaluate if these associations differ by race/ethnicity and gender. METHODS:This was a retrospective study that analyzed data collected from the medical records of 1487 vitiligo patients seen at New York University (NYU) over a ten-year period. RESULTS:Vitiligo patients had a statistically significant higher prevalence of hypothyroidism, multiple sclerosis, rheumatoid arthritis, idiopathic thrombocytopenic purpura (ITP), seronegative arthritis, pernicious anemia, myasthenia gravis, inflammatory bowel disease, lymphoma, and systemic lupus erythematosus. Rates of comorbid autoimmune diseases varied by race and gender. LIMITATIONS/CONCLUSIONS:Medical charts did not consistently report race/ethnicity, type of vitiligo and total body surface area affected. Information from non-dermatology medical visits was also included. CONCLUSION/CONCLUSIONS:This study found multiple new disease associations with vitiligo including multiple sclerosis, ITP, and lymphoma as well as previously reported associations with other autoimmune diseases, the most common being hypothyroidism followed by rheumatoid arthritis. Associations did vary by race/ethnicity and gender.

Photolichenoid dermatitis is an uncommon eruptive dermatitis that often occurs in association with a photosensitizing drug. Photodermatitis, in general, is an uncommon clinical manifestation of human immunodeficiency virus (HIV), most often affecting patients of African and Native American descent. Photolichenoid dermatitis has infrequently been reported in patients with HIV who have not been exposed to a photosensitizing drug. We report a case of an African patient with a photodistributed depigmenting eruption without exposure to a photosensitizing drug. Histologic examination revealed a patchy perivascular and bandlike lymphocytic infiltrate with melanophages, interface changes, and dyskeratotic keratinocytes, consistent with photolichenoid dermatitis. Laboratory examination was significant for a positive HIV-2 antibody. Photolichenoid dermatitis may be a presenting sign of HIV infection and may not necessarily be associated with exposure to a photosensitizing drug. Testing for HIV should be done in patients who present with photodistributed depigmenting eruptions, even in the absence of exposure to a photosensitizing drug, and particularly in patients of African and Native American descent.

BACKGROUND:There is no cure nor firm clinical recommendations for the treatment of vitiligo. One of the main issues is the heterogeneity of outcome measures used in randomised controlled trials (RCTs) for vitiligo. OBJECTIVE:This study was conducted with an aim to define successful repigmentation from patients' point of view and propose how and when repigmentation should be evaluated in clinical trials in vitiligo. METHODS:We conducted 3 workshops with vitiligo patients and their parents/care givers. Workshop 1: World Vitiligo Day (Detroit, MI); Workshop 2: the University of Texas Southwestern Medical Centre; Workshop 3: Vitiligo and Pigmentation Institute of Southern California, University of California. RESULTS:73 participants were recruited. Consensus on the following questions was achieved unanimously: Definition of "successful repigmentation" was 80-100% of repigmentation of a target lesion. Both an objective and a subjective scale to measure repigmentation should be used. LIMITATIONS/CONCLUSIONS:Workshops were conducted in the USA due to pre-existing organisational supports and availability of funding. CONCLUSION/CONCLUSIONS:This was the largest patients' outcomes workshop. We followed the HOME roadmap, guidance from the CSG-COUSIN and the Vitiligo Global Issues Consensus Group (VGICG). Our recommendation to use of percentage of repigmentation quartiles (0-25%, 26-50%, 51-79%, 80-100%) and the vitiligo noticeability scale are based on the best available current evidence.

Vitiligo, an acquired depigmentation disorder, results from autoimmune targeting of melanocytes. Vitiligo can be triggered following exposure to phenols such as monobenzone (MBEH) and 4-tertiary butyl phenol (4-TBP). Melanocytes from individuals with idiopathic vitiligo (trigger is not known) are more sensitive to MBEH and 4-TBP. We hypothesized that stress response pathways activated following exposure to vitiligo triggers may be dysregulated in individuals who develop the disorder. We delineated the response of melanocytes from normally pigmented individuals (NMs) to challenge with MBEH and 4-TBP and identified two key survival pathways activated following exposure: the NRF2-regulated antioxidant response and the unfolded protein stress response (UPR). NRF2 knockdown sensitized NMs to MBEH (p < 0.0001), while NRF2 activation by knockdown of its repressor KEAP significantly decreased sensitivity (p < 0.0001). Similarly, inhibition of the PERK-eIF2alpha arm of the UPR with the chemical inhibitor GSK2606414 increased sensitivity to MBEH (cleaved PARP observed at 250 muM MBEH with GSK2606414 and 400 muM without). Activation of NRF2-regulated antioxidant responses and PERK-mediated phosphorylation of eIF2alpha following MBEH exposure was impaired in melanocytes from individuals who developed vitiligo. We have thus identified two stress response pathways that may be dysfunctional in vitiligo and contribute to the onset of depigmentation

Frontal fibrosing alopecia (FFA) was first described as a progressive recession of the frontal hairline in postmenopausal women. Since its initial description, recognition and understanding of FFA has expanded. The condition is now defined as a patterned, symmetric, frontotemporal scarring alopecia that is considered to be histopathologically indistinguishable from lichen planopilaris. Numerous case reports and series have suggested clinical variants of and associations with FFA. In addition to reviewing the literature on FFA's associations, this article includes a case series of 5 women with skin of color (Hispanic and black) who presented with various cutaneous findings in association with FFA, including lichen planus pigmentosus (LPP), facial papules, and eyebrow loss. Recognition of the conditions that can occur in association with FFA in individuals with skin of color is important in further expanding our knowledge and understanding of FFA as a disease entity.