ORIGINAL ARTICLE

Year : 2009 | Volume : 54 | Issue : 2 | Page : 124--127

Childhood vitiligo : Response to methylprednisolone oral
minipulse therapy and topical fluticasone combination

Imran Majid, Qazi Masood, Iffat Hassan, Dilshad Khan, Muzammil Chisti
Department of Dermatology, STD and Leprosy, Govt. Medical College, Srinagar, Kashmir, India
Correspondence Address:
Imran Majid
Department of Dermatology, STD and Leprosy, SMHS Hospital, Srinagar, Kashmir - 190010
India

Abstract

Background: Childhood vitiligo is always a challenge to treat, especially when the
disease is progressing rapidly in such a patient. Oral minipulse with betamethasone has
been tried in childhood vitiligo and also in some other immune mediated skin disorders
with good results. Aims: The aim of the present study was to see the overall efficacy of
methylprednisolone oral minipulse therapy in combination with topical fluticasone in
progressive childhood vitiligo. The combination was tried to achieve a significant amount
of repigmentation of vitiligo lesions already present at the initial visit.Materials and
Methods: Four hundred children with progressive vitiligo were enrolled for this study
and were prescribed oral methylprednisolone on two consecutive days every week in a
minipulse form for a period of six months. In addition, the patients were instructed to
apply fluticasone ointment topically once a day on their vitiligo lesions. The patients were
assessed for the remission achieved as well as the extent of repigmentation of their
already existent lesions. Results: More than 90% of patients went into complete
remission after the start of the therapy. Moreover, about 65% (two-thirds) of patients
achieved good to excellent repigmentation of lesions at the end of six months of therapy.
The therapy was also well tolerated and the side effects seen were almost
negligible. Conclusions: Oral minipulse treatment with methylprednisolone is an
effective treatment option for controlling the disease spread in childhood vitiligo and with
the addition of topical fluticasone the extent of repigmentation achieved is also quite
significant.

How to cite this article:
Majid I, Masood Q, Hassan I, Khan D, Chisti M. Childhood vitiligo : Response to
methylprednisolone oral minipulse therapy and topical fluticasone combination.Indian J Dermatol
2009;54:124-127

How to cite this URL:
Majid I, Masood Q, Hassan I, Khan D, Chisti M. Childhood vitiligo : Response to
methylprednisolone oral minipulse therapy and topical fluticasone combination. Indian J Dermatol
[serial online] 2009 [cited 2014 May 22 ];54:124-127
Available from: http://www.e-ijd.org/text.asp?2009/54/2/124/53185

Full Text
Introduction


Vitiligo is one of the commonest skin disorders, affecting about 1% of the world
population. [1] The disease presents more commonly in children than in adults.
Treatment options for progressive vitiligo are quite limited, especially in pediatric
patients. [2] This stems from the fact that systemic treatments commonly used for the
disease have the potential of causing serious adverse effects in this age group. [2] Both
oral as well as topical corticosteroids have been used as treatment options in vitiligo with
variable therapeutic results. Oral steroids, if given as a daily therapy in children, can
cause serious side effects, especially HPA axis suppression and growth retardation due to
premature epiphyseal closure. Different pulse therapies with systemic steroids have been
devised to minimize these side effects, of which the oral minipulse (OMP) therapy has
been used particularly in vitiligo, [3],[4],[5] and more recently, in alopecia areata and
lichen planus. [6],[7],[8]
Materials and Methods


Four hundred patients of progressive vitiligo from ethnic Kashmiri origin and belonging to
the pediatric age group (below 15 years of age) were enrolled for this study. Patients
with any of the morphological variants of vitiligo, but having a progressive disease were
included. The epidemiological data from all the patients were noted down and this
included weight and height of the patients, morphological type of vitiligo, age of onset,
duration of vitiligo, any familial involvement, percentage of body surface area involved,
predominant sites on the body involved, as well as the past treatments used for the
disease. A thorough clinical assessment was made to exclude other related cutaneous
and systemic disorders. Laboratory investigations for other related disorders were
however performed only if there was a clinical evidence of such a possibility. After this
thorough assessment, the patients were initiated on OMP therapy of methylprednisolone
for two consecutive days every week up to a minimum duration of six months. The dose
of methylprednisolone used was 0.8mg/kg body weight in each patient with the
maximum dose of 32 mg on each day. This was also combined with once daily topical
application of 0.01% fluticasone ointment to the lesional skin at bedtime. The patients
were monitored every two weeks for the first month and then once a month for the rest
of the study period. The efficacy of treatment was judged on two counts: An arrest of
the disease process as well as the extent of repigmentation of lesions already present.
The treatment was continued for a minimum duration of two months in every patient
and thereafter in only those patients who showed remission of the disease. Patients
showing a continuous progression of the disease, even after two months of treatment
from the time of initiation were administered alternative therapies. Any adverse
reactions to the therapy were also noted down, in the form of weight gain (comparison
of initial weight with that at the end of therapy), Cushingoid facies, growth retardation,
gastrointestinal upset, bone pains, and acne. The extent of repigmentation achieved was
graded as poor (90%). In those patients in whom the disease had gone into remission
and who had a partial repigmentation of lesions at the end of six months study period,
the OMP treatment was continued and either topical PUVASOL or any other topical
treatment was added to the treatment protocol. However, the final assessment of
treatment for the study was done only at the end of six months.
Results


The age of patients enrolled for the present study ranged from a minimum of 18 months
to a maximum of 15 years (chosen as the upper age limit). The age distribution of
patients is shown in [Table 1].

Females outnumbered males in every age group and the overall male:female ratio was
about 1:2 [Table 1].

The duration of vitiligo ranged from a minimum of about one week to a maximum of
four-and-a-half years with a mean of 4.3 months.

The different morphological types of vitiligo recorded were vitiligo vulgaris including focal
vitiligo (272 patients), segmental vitiligo (83 patients), acrofacial vitiligo (34 patients),
and mucosal vitiligo (11 patients).

Family history of vitiligo was recorded in 87 patients accounting for 21.75% of the whole
study group.

Alopecia areata was the commonest coexistent skin disorder seen in 22 patients (5.5%),
followed by psoriasis in 17 patients (4.25%). No significant association was found with
any systemic disorder, except hypothyroidism that was recorded in five patients
(1.25%). Other disorders seen in the study group are enumerated in [Table 2].

Response to therapy

Overall, 57 patients out of the study population of 400 did not come for regular follow up
and were dropped from the assessment protocol. Out of the remaining 343 patients who
completed the study, there were significantly only 33 (9.6%) patients who continued to
have fresh lesions of vitiligo even at the end of two months of the minipulse treatment.
The other group of 310 patients, which constituted 90.4% of the follow-up population,
went into complete remission as far as the progression of vitiligo was concerned.
Another significant observation was that almost all these patients, at least, remained in
remission for the whole study period of six months. Patients who continued to have a
progressive disease even after two months from therapy initiation were dropped from
any further assessment and were given alternative treatment options.

The extent of repigmentation of lesions was noted down at every follow-up visit and the
total repigmentation achieved at the end of treatment was also recorded. In about one-
third of patients (107) the extent of pigmentation was poor ( [9] and even conventional
doses of oral steroids cannot be employed in children with vitiligo because of the side
effect profile of these drugs. Steroids have always been a treatment option in vitiligo,
both in topical as well as oral forms. However, oral steroids have proved to be double-
edged weapons in vitiligo, and when given to a child, they can lead to irreversible and
serious side effects like premature closure of epiphysis leading to stunted growth,
Cushing's syndrome, etc. A modified method of prescribing oral steroids, which is
claimed to minimize their side effects to a large extent is the OMP therapy. [4],[5],[6]
Here a relatively large dose of an oral steroid is given on two consecutive days per week
with a rest period of five days in between the doses. In the original studies that have
commented upon the use of OMP in vitiligo, the steroid used has been either
betamethasone or dexamethasone. [3],[4],[5],[6],[7],[8] The drug has been given in a
dose of 5mg or approximately 0.1mg/kg body weight in these studies. The dosage has
however not been too fixed in these studies with frequent increases made in the dose in
unresponsive patients. We have modified this approach as we have used a relatively
safer steroid, methylprednisolone, instead of betamethasone, in a fixed dose of
0.8mg/kg body weight. This does is comparable in potency with the dose of
betamethasone used in the previous studies.

An additional modification in the present study was the addition of topical fluticasone
ointment 0.01% once daily to the treatment regimen. This was done with the aim of
increasing the chances of repigmentation of lesions already present as the original
studies of OMP therapy in vitiligo have failed to demonstrate any significant
repigmentation in their enrolled patients. [4],[5] Moreover, the patient or his/her
attendant is always keen to apply something on the white patches as it gives them a
sense of participation in the patient's treatment. This modification, in fact, went a long
way in improving the follow up in our patients.

The response to the treatment schedule described in the present study can be termed as
quite encouraging on an overall basis. We had a response rate of >90% if the halting of
progression of vitiligo is taken as the criterion for judging the response to therapy. This
no doubt is a remarkable figure in itself, as the first thing a patient or his/her parent and
even the treating physician want to see is a halt in spread of the disease in case of
progressive vitiligo. As far as the pigmentation of already present lesions is concerned
the response was good to excellent in about two-thirds (65.5%) of patients [Table 4],
while about one-third of patients showed a poor response ( [10] especially clobetasol
propionate, [11] betamethasone valerate, and even with new molecules like fluticasone
[12] and mometasone. However, the repigmentation got with these molecules has been
modest in most of the studies. We thus conclude that combination of OMP with
methylprednisolone and topical fluticasone ointment is a safe and effective treatment
option in the management of progressive childhood vitiligo.
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