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CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 70-72

Colocalization of psoriasis and vitiligo treated with apremilast and narrowband ultraviolet B combination in an adolescent girl


1 Department of DVL, IMS and Sum Hospital, Siksha O Anusandhan University, Bhubaneswar, Odisha, India
2 Department of DVL, Hi-Tech Medical College and Hospital, Utkal University, Bhubaneswar, Odisha, India
3 Department of DVL, JP Hospital, Rourkela, Odisha, India

Date of Submission09-Aug-2019
Date of Acceptance21-Sep-2019
Date of Web Publication24-Dec-2019

Correspondence Address:
Dr Trashita Hassanandani
Department of DVL, IMS and Sum Hospital, Siksha O Anusandhan University, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_82_19

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  Abstract 


Coexistence of psoriasis and vitiligo in the same patient is a therapeutic challenge; several modalities have been tried with varying results. Apremilast is a PDE4 inhibitor used in psoriasis, while recent reports are highlighting its additional role in repigmentation of vitiligo. However, data are scarce, regarding its usage in the pediatric population. Narrowband ultraviolet B therapy (NB-UVB) is an effective treatment modality in both psoriasis and vitiligo and can be safely combined with apremilast. Here, we present an adolescent girl with anatomical colocalization of psoriasis and vitiligo effectively treated with combination of apremilast and NB-UVB therapy.

Keywords: Apremilast, narrowband ultraviolet B, psoriasis, vitiligo


How to cite this article:
Hassanandani T, Panda M, Patro N, Kar D. Colocalization of psoriasis and vitiligo treated with apremilast and narrowband ultraviolet B combination in an adolescent girl. Indian J Paediatr Dermatol 2020;21:70-2

How to cite this URL:
Hassanandani T, Panda M, Patro N, Kar D. Colocalization of psoriasis and vitiligo treated with apremilast and narrowband ultraviolet B combination in an adolescent girl. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Nov 28];21:70-2. Available from: https://www.ijpd.in/text.asp?2020/21/1/70/273842




  Introduction Top


Vitiligo and psoriasis are common skin disorders, and their coexistence is frequently seen. However, anatomical colocalization of vitiligo and psoriasis is a rarity.[1] This colocalization can be a mere coincidence or the result of a common etiopathogenetic pathway. Several genetic and environmental factors such as the Koebner phenomenon are involved in the development of these diseases.[2],[3] Simultaneous treatment of both the conditions is a therapeutic challenge. Several therapeutic modalities have been tried such as topical steroids, tacrolimus, ultraviolet B (UVB) phototherapy, and etanercept with varying results. Apremilast is a PDE4 inhibitor, recently approved by the US Food and Drug Administration for the treatment of psoriasis. A study also demonstrated repigmentation of tenacious vitiligo with apremilast.[4] It can also be safely combined with narrowband (NB) UVB therapy to increase the therapeutic efficacy.[5] Although clinical trials are absent in the pediatric population, an isolated case report has documented the efficacy and safety of apremilast in an adolescent boy with psoriasis at the adult dosage (30 mg twice daily).[6] Here, we report a case of anatomical colocalization of vitiligo and psoriasis successfully treated with apremilast and NB-UVB therapy in a pediatric patient.


  Case Report Top


A 13-year-old girl presented with gradually progressive depigmented patches over the face, scalp, trunk, and bilateral limbs for the past 6 months. Four months later, she developed scaly, hyperkeratotic plaques exactly over the depigmented patches [Figure 1]. Clinical examination was suggestive of psoriasis plaques over vitiligo patches. Routine biochemistry including thyroid status and autoimmune screening was within the normal limits. Family history and drug history were unremarkable. The patient was administered NB-UVB (300 mJ/cm2) with a 20% increment twice weekly and oral apremilast 30 g twice daily for 12 weeks. Psoriasis Area Severity Index (PASI) 75 was achieved at week 12 with a significant improvement in the Dermatology Life Quality Index. More than 50% repigmentation of the vitiligo patches was observed [Figure 2]. The drug was well tolerated without any adverse effects. After week 12, NB-UVB therapy was discontinued, and apremilast is being continued with appreciable results.
Figure 1: Colocalization of psoriasis and vitiligo over the face, lower limbs, and abdomen at the baseline

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Figure 2: PASI 75 achieved at week 12 with repigmentation of vitiligo patches

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  Discussion Top


Vitiligo is a common disorder characterized by acquired development of depigmented macules on the skin due to the loss of functioning melanocytes in the skin, the hair, or both. Although the pathogenesis is not known, it is presumed to be a cumulative effect of various mechanisms, including autoimmune, neurohormonal, genetic, oxidative stress, and cytotoxic damage. Psoriasis is linked to a dysregulated immune system caused by a pro-inflammatory cytokine network.

Both these diseases have common pathogenesis, i.e., tumor necrosis factor-alpha (TNF-α) pathway. Kovacs demonstrated enhanced levels of neurotensin-induced TNF-α production from the melanocytes in vitiligo lesions.[7] Jain et al. found an elevated level of TNF-α in the perilesional skin of patients with vitiligo.[8] Furthermore, TNF-α is known to be one of the key cytokines in the pathogenesis of psoriasis, and the level of TNF-α is elevated in psoriatic lesions.

There has been a single case report of colocalization of vitiligo and psoriasis in a pediatric patient by Dhar et al. in the Indian literature who concluded that there could be structural similarities between anti-stratum corneum antibodies and anti-melanocyte antibodies and also a common neuropeptide might be responsible for cohabitation of vitiligo and psoriasis.[9]

Bakar-Dertlioǧlu et al.reported three such cases in the Turkish population.[10]

Apremilast induces an activation of the cyclic AMP (cAMP) pathway, leading to anti-inflammatory effect by decreasing the response of T-helper 1 (Th1) and Th17 lymphocytes. It causes the regulation of inflammatory mediators through the cAMP second messenger effect, for example, decreased expression of TNF-α, interleukin (IL)-17 and IL-23, interferon-gamma, as well as increased IL-10. The cAMP pathway is also well demonstrated to be the main pathway for promoting melanogenesis and for inducing the differentiation and the proliferation of melanocytes.[4],[5]

A study by Bagel et al. showed that 73% of patients with chronic plaque psoriasis achieved PASI 75 in 12 weeks with apremilast and NB-UVB combination.[5] There is an ongoing placebo-controlled trial to assess the safety and efficacy of apremilast and NB-UVB in vitiligo.

Common side effects of apremilast are diarrhea, headache, nausea, vomiting, weight loss, and depression; these adverse events typically present early and are self-limiting. The advantages of using apremilast in the pediatric age group include ease of oral administration, minimal drug interaction potential, least monitoring, and safety.

A case report suggested that oral apremilast at adult dose of 30 mg twice daily was found to be effective, well-tolerated treatment option for adolescent patients with psoriasis; hence, we gave full dose of apremilast. Although our patient did not have any adverse events, clinical trial data are necessary to fully understand the safety and efficacy of apremilast in these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Menter A, Boyd AS, Silverman AK. Guttate psoriasis and vitiligo: Anatomic cohabitation. J Am Acad Dermatol 1989;20:698-700.  Back to cited text no. 1
    
2.
Papadavid E, Yu RC, Munn S, Chu AC. Strict anatomical coexistence of vitiligo and psoriasis vulgaris a koebner phenomenon? Clin Exp Dermatol 1996;21:138-40.  Back to cited text no. 2
    
3.
Park JM, Kim HJ, Bae BG, Park YK. A case of concurrent vitiligo and psoriasis. Ann Dermatol 2009;21:330-3.  Back to cited text no. 3
    
4.
Huff SB, Gottwald LD. Repigmentation of tenacious vitiligo on apremilast. Case Rep Dermatol Med 2017;2017:2386234.  Back to cited text no. 4
    
5.
Bagel J, Nelson E, Keegan BR. Apremilast and narrowband ultraviolet-B combination therapy for treating moderate-to-severe plaque psoriasis. J Drugs Dermatol 2017;16:957-62.  Back to cited text no. 5
    
6.
Smith RL. Pediatric psoriasis treated with apremilast. JAAD Case Rep 2016;2:89-91.  Back to cited text no. 6
    
7.
Kovacs SO. Vitiligo. J Am Acad Dermatol 1998;38:647-66.  Back to cited text no. 7
    
8.
Jain R, Dogra S, Sandhu K, Handa S, Kumar B. Coexistence of vitiligo and pemphigus vulgaris in an Indian patient. Pediatr Dermatol 2003;20:369-70.  Back to cited text no. 8
    
9.
Dhar S, Malakar S, Dhar S. Colocalization of vitiligo and psoriasis in a 9-year-old boy. Pediatr Dermatol 1998;15:242-3.  Back to cited text no. 9
    
10.
Bakar-Dertlioǧlu S, Uçak H, Ciçek D, Bitiren M. Coexistence of vitiligo and psoriasis: Three case reports. Turk J Pediatr 2012;54:77-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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