Teen With Progressive Depigmented Patches

by Dmitri La Cruz | December 29, 2010 7:17 PM EST

So HOW do you treat with pimecrolimus--b.i.d. for how long? Do you get MediCaid to cover the cost?

by Linda Geisler | January 03, 2011 5:00 PM EST

Comment from Dr Alexander K. C. Leung:

Treatment of vitiligo with topical calcineurin inhibitors
Topical calcineurin inhibitors such as tacrolimus and pimecrolimus are effective in repigmentation of vitiligo.(1,2)  Topical tacrolimus and pimecrolimus block the action of calcineurin, thereby downgrading the transcription of genes encoding pro-inflammatory cytokines.(2)   Topical calcineurin inhibitors have a better safety profile than corticosteroids and are generally preferred for lesions on the face, neck, genitalia, and intertriginous areas.(3,4)  Topical tacrolimus or pimecrolimus can be applied to the lesion twice a day.  The medication should be continued until the repigmentation is complete or until no further improvement is noted on continuous application of the medication.  Compared with topical corticosteroids, topical calcineurin inhibitors are a lot more costly.  In Canada, topical calcineurin inhibitors are covered by the majority of insurance plans. I am not familiar with MediCaid in the US system.

Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), FRCPCH, FAAP
Clinical Professor of Pediatrics
 The University of Calgary
Pediatric Consultant
 The Alberta Children's Hospital
Calgary, Alberta, Canada

REFERENCES
1. Isenstein AL, Morrell DS, Burkhart CN.  Vitiligo: treatment approach in children.  Pediatr Ann.  2009;38:339-344.
2. Lo YH, Cheng GS, Huang CC, et al.  Efficacy and safety of topical tacrolimus for the treatment of face and neck vitiligo.  J Dermatol.  2010;37:125-129.
3. Taïeb A, Picardo M.  Vitiligo.  N Engl J Med.  2009;360:160-169.
4. Leung AK.  Vitiligo.  In: Leung AK. (ed).  Common Problems in Ambulatory Pediatrics.  New York: Nova Science Publishers, Inc., 2011, pp.1249-1254.

by Chagai Dubrawsky | January 06, 2011 11:41 PM EST

Vitiligo in adolescent,whose mother had had Hashimoto's thyroiditis,indicates the need to check in this adolescent's thyroid status.Checking his T3 is mandatory.Checking his Lipid profile,especialy the H.D.L. is essential.This may be a presentation of the Metabolic Syndrome.Treatment:1)T3 supplementation 2)Niacin IR

(Immediate Release) B.I.D. P.C.

References;To be followed.

C.Dubrawsky M.D.

Family Practice(Ret.)

The Community Clinic

101 Pine Manor

Northridge. Texas

by Chagai Dubrawsky | January 07, 2011 12:06 AM EST

Addendum:

References

1) MD Ziaul M. et al. Thyroid function in Bagldeshi patients with Vitiligo(Sheti).J.Bio-Sci 16;101-105,2008

P.S. See the table showing that males did not have decrease of Thyroid function, In female, a dramatic drop in thyroid function is noted.

C.Dubrawsky M.D.The community ClinicNorthrige Tx

by Linda Geisler | January 11, 2011 1:56 PM EST

Comment from Dr. Alexander K. C. Leung, MD

I appreciate the comments by Dr. Dubrawsky. As per my case report, vitiligo is often associated with Hashimoto thyroiditis and Graves disease.(1) This is especially so when there is a family history of Hashimoto thyroiditis. As such, thyroid function tests, such as serum thyroid stimulating hormone (TSH), antithyroglobulin antibody, and antithyroid peroxidase antibody, would be appropriate. The importance to screen for an associated thyroid disorder has been emphasized in the section of Laboratory Studies.(1) In this regard, serum thyroid stimulating hormone (TSH) is a more sensitive test than T3 in screening for Hashimoto thyroiditis.
Dr. Dubrawsky has gone too far to suggest screening for and treatment of metabolic syndrome in an adolescent with vitiligo.  Three of the following five criteria are required for making the diagnosis of metabolic syndrome, namely, increased waist circumference, blood pressure of at least 130/85 mm Hg, elevated serum triglycerides, low serum high-density lipoprotein, and fasting blood glucose of at least 100 mg/dL (5.6 mmol/L).(2)  First of all, vitiligo is not listed as a diagnostic criterion of metabolic syndrome and it is not associated with the syndrome. Secondly, it would be inappropriate to order those laboratory tests without first performing a careful physical examination. The physical examination should include waist circumference and blood pressure, among other measurements. The patient described had none of the clinical features of metabolic syndrome.

Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), FRCPCH, FAAP
Clinical Professor of Pediatrics
University of Calgary
Pediatric Consultant
Alberta Children's Hospital

REFERENCES
1.  Leung AK, Wong AS.  Vitiligo.  Consultant For Pediatricians.  2010;9:433-435.
2. Tota-Maharaj R, Defilipps AP, Blumenthal RS, et al.  A practical approach to the metabolic syndrome: review of current concepts and management.  Curr Opin Cardio.  2010;25:502-512.