vitiligo - my experience of 25 years and 19156 patients by dr. a.salafia
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Vitiligo: my experience of 25 years and 19.156 patients
Dr. Antonio Salafia Dermatologist & Head Dept. Reconstructive Surgery.
Vimala Dermatological Centre, Mumbai
St.Petersburg, Russia.
July 7th 2011
Antonio Salafia
The experience of a clinician.
• In the early 1980’s I was disappointed with
PUVA, so I explored other avenues:
a) From the year 1980 Dapsone was used at Vimala
Dermatological Centre, with some success.
b) In 1983 I set a protocol:Dapsone, Vitamin
B6 -suggested by C. Frati from IDI,Rome.
• In 1985 I began experimenting with new lotions,
inspired by the work of Prota. (Protocol C).
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Protocol ‘C’
ORAL THERAPY: • Dapsone: 0.5 mgs K/wt.
• Vitamin B6 100-300 mg. a day, Iron, Folic Acid.
LOCAL APPLICATION:
• Face: Locoid (Hydrocortisone Butyrate) Tacrolimus.
• Neck: Lotion A (the mildest).
• Body / Arms and Legs: Lotion B (strong).
• Arms, Legs, Hands, Feet : Lotion 5 –F (strongest).
Antonio Salafia
Dapsone: possible mode of action.
a) Antioxidant: a. Potent scavenger of free radicals (T. Ryan)
b. Decreases H2O2 - as good as Catalase (Wozel). c. Weak inhibitor of prostaglandin synthesis. d. Scavenger of oxidative intermediates, and suppressor of PMN (which produce ROS).
B) Decreases the level of Glutathione: skin of vitiligo patients has a higher content of Glutathione. By suppressing Glutathione we favor the formation of Eumelanins instead of Pheomelanins (Ito).
C) Possible beneficial effects.
DDS is an immunomodulator + suppressor of PMN cells, hence effective in diseases wherein there is dense infiltrate of PMN: Dermatitis Herpetiformis, Subcorneal Pustular Dematosis, Scarring/ Bullous Pemphigoid and more than 20 other diseases.
Antonio Salafia
Vitamin B6: importance.
• Vitamin B6 is a potent antioxidant.
• Involved in the homeostasis of Glutathione and Cysteine (switching mechanism of Ito).
• In high doses, is capable of transforming Glutammic acid into Pyrrolecarboxylic acid and prevents the formation of Glutathione (Frati).
• In my experience, it helps to prevent new patches, so I advise my pts. to keep on taking for years.
• (It prevents homocysteine-induced atherosceloris in rats).
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First experiments with my protocol and my lotions.
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Face: Locoid Arms: Lotion B Cure in 6 months.
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Lotion 5-F
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Dapsone+B6 and Locoid
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Locoid… Lotion A
Protocol C + Lotion 5-F.
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Face: Locoid. Neck: Lotion A
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Lotion B
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Lotion 5-F. Stopped oral
medications and relapsed.
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Chemical Vitiligo: Lotion A
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Lt. Lotion B. Rt.Lotion 5-F
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Lotion 5-F
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Results in 8730 (out of 13.119)
• Protocol ‘A’: Vitamins, Iron, Copper; creams: Betnovate/Placenta extract.
• Protocol ‘B’ : Orally as above + Dapsone+ locally Locoid/ Betnovate.
• Protocol ‘C’: Dapsone 0.5 -1.0 mg/k/w + all the Vitamins, Local application Children : Locoid for face, Lotion A for body. Adults: Face & Neck: Locoid / Lotion A /Tacrolimus. Body: Lotion B. Limbs: Lotion 5-F.
• Protocol ‘D’ : all of these except Dapsone; in its place, oral steroids.
• Given the large number of patients treated, protocol A can be considered as ‘control group’ vs. protocol ‘B’ and ‘C’’.
• I cannot due ‘double-blind trials’ in patients who are desperate for a cure.
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• Worse/Nil = are self-explanatory.
• Poor = improvement less than 25%.
• Fair = improvement 25% to 50%.
• Good = > 50% but < 75%.
• Excellent = more than 75%.
• Almost cure = extensive lesions, ‘cured’ except
for one or two stubborn patches.
• Cure = total and permanent cure.
How to read the charts.
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Protocol A: Vitamins…
0
100
200
300
400
500
600
700
CURE AC E G F P N W
Protocol A – 1673 pts.
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Protocol B: Vitamins+DDS
0
100
200
300
400
500
C AC EX G F P N W
Protocol B - 1587 pts.
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Protocol C: DDS+Vitam+My Lotions
0
200
400
600
800
1000
1200
C AC EX G F P N W
Protocol C - 4661 pts.
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Protocol D: Steroids + Vitamins + Lotions
0
50
100
150
200
C AC EX G F P N W
Results with Protocol D – 809 pts.
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0
50
100
150
200
C AC EX G F P N W
Protocol D – 809
pts.
0
200
400
600
800
1000
1200
C AC EX G F P N W
Protocol C –
4661
0
100
200
300
400
500
C AC EX G F P N W
Protocol B - 1587
0
100
200
300
400
500
600
700
CURE AC E G F P N W
Protocol A – 1673
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Results could be better, and lately they are.
Some patients could not follow the therapy because:
- Sunlight not possible: working hours, ladies with lesions
on chest, thighs; artificial lamps are costly.
- Some patients live far away, even outside India…
- Others changed residence, job, got married…
- Some poor patients could not afford the treatment.
- Others expected miracles.
- Certain areas of the body are ‘difficult’ : fingers, toes, bony prominences…..
- Few of them came to rule out ‘Leprosy”.
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Private Patients from Jan. 2005 to Dec. 2008. 2940 pts.
• Protocol C + Inj. Triamcinolone 40 or 20
mgs. I.M. once a month x 3 - 5.
• Fast results (due to Kenacort) and
• Consistent results (due to Dapsone and B6).
• Patients treated 2940: report on
‘regulars’ only: i.e. 2012 cases.
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Private Patients: Results.
0
100
200
300
400
500
600
Cure A-cure Exc Good Fair Nil Worse
1 – 19
20 - >
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Cure Acure Excellent Good Fair Nil Worse Total
_________________________________________________________
• Face 427 301 375 175 56 37 0 1371
-----------------------------------------------------------------------------------
• Limbs 523 319 362 187 110 94 17 1822
-----------------------------------------------------------------------------------
• Hand/
Feet 71 52 95 104 159 287 31 819
------------------------------------------------------------------------------------
• Body 467 262 326 24 43 37 16 1175
-----------------------------------------------------------------------------------
• Vagina 58 21 33 17 14 21 0 164
------------------------------------------------------------------------------------
• Penis 15 11 16 30 42 31 5 150
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Results, as per area of the body.
0
100
200
300
400
500
600
700
800
Cure Excellent Fair Worse
Face
Limbs
(each)
Hands/ Feet
(each)
Body
Vagina
(mucosa)
Penis
(glans)
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Results as per body area: Face: 1371 Body: 1175 Limbs: 1822 0
100
200
300
400
500
Cure Good Worse
Face
0
100
200
300
400
500
600
Limbs
0
100
200
300
400
500
Body
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Results: Hands/ Feet: 819 Vagina: 164 Glans Penis: 150
0
50
100
150
200
250
300
Hand/
Feet
0
10
20
30
40
50
60
Vagi
na
0
10
20
30
40
50
Penis
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Applied Aloe Vera, got Vitiligo.
Protocol C + Tacrolimus 0.1%.
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Difficult cases Lotion A x 1 year.
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First Locoid, then Lotion A.
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Segmental: lotion A; 6 mth- 1year.
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Arms: lotion 5-F. Face not responding to anything.
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Good response in majority of patients:
Face: lotion A. Legs: lotion 5-F.
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Protocol C + Lotion A.: 3 months. (very irregular patients) 19 months.
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Lotion A: 6 months.
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Neck: Lotion A. Arms: Lotion B.
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Father & Mother affected too.
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Protocol C + Tacroz 0.1%: 20.08.2009 11.12.2009
4.04.2011
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Lotion A: - 22.08.2008 - 19.09.2008 - 5 months. Duration of Disease 8 years.
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Lotion 5-F: 4 months.
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Lotion 5-F: 4 months.(very irregular).
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Face: Tacroz … Lotion A Hands: Lotion 5-F.
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Neck: A. Arms: 5-F, 4-6 months.
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Face:Tacroz. Arms and Legs: Lotio 5-F.
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Locoid: 6 months.
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Lotion A.
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Neck: Lotion A. Arms: Lotion 5-F.
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Locoid: 5-6 months. 17 years later.
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Neck: Lotion A. Legs: Lotion 5-F.
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Tacroz 0.1. Arms: lotion 5-F.
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Lotion A, Lotion 5-F.
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Girl: Tacrolimus. CHILD: Vitix: worse, 9.8.2008. Locoid: 27.9.208 cure in 2 months.
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Lotion A : 2 months.(treatment is going on)
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Face: Locoid. Neck: Lotion A. After 2 months. (Photoes: 20.9.08 18.10.08 15.11.08)
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Treated elsewhere with only locoid. My protocol + Locoid for face. Legs: A
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Face Lotion A, Abdomen Lotion B
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Patient lives in England: 4 months.
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Lotion B: 2 months. 5 months.
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Face:Locoid Arms: Lotio 5-F:
6 months. Disease Ext. Duration 8 yrs
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Face:Locoid, Neck:Lotion A Arms:Lot. B: 6 months
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Tacroz 0.03%, later on Homeopathy x 2 years…Worse. Protocol C + Tacroz 0.1%. Photo 12.3.11 16.4.11
Latest photos: 18 June of 2011.
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ANA and anti-DNA –ve. Anti-Thyroglobulin +ve. Photos: 10.9.2010, 13.12.2010, 2.7.2011. Dapsone, Tacroz 0.1%, latest: Lotion A.
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Surgery. Good and bad surgery.
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Surgery done elsewhere by a well-known dermatosurgeon.
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Punch graft by same dermato(surgeon).
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Operated twice with punch graft.
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Conclusion: Most patients can be cured; but, there are difficult cases and difficult areas. We are still working on it, because our aim is set high..
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Thanks to you all and
a big thanks to the organizers.
Antonio Salafia
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