V E T F
Vitiligo European Task Force
VETF visit at the Vitiligo clinic of the National Skin Center (Singapore)
July 2007
A visit of VETF members (Alain Taïeb, Mauro Picardo and Jean-Paul Ortonne) with the common evaluation of patients was planned before the 2nd ASPCR by Prasad Kumarasinghe, the president of the ASPCR and head of the Vitiligo clinic of this impressive 3-floor dermatology facility which mixes public and private sectors (especially a superb laser clinic with the latest equipment).
The host vitiligo clinic team included Dr S Thng (who trained under W Westerhof in Amsterdam), Dr J Anjali, and Dr JY Pan allowed to examine 7 patients of chinese, malaisian or indian origin with segmental and non segmental forms of vitiligo, including a case of vitiligo universalis. Dr Prasad Kumarasinghe and Dr Goh Boon Kee, the other dermatologists who are manning the 'Pigment Clinic' , were unable to attend the workshop due to their commitments at another Pre-Congress workshop of the ASPCR 2007 Conference.
The patients were on a regimen which was not very different from that used in Europe. Basically, narrow band UVB local of total body phototherapy was used first and after a 6 month trial, non responders were considered, when stabilized, for grafting. Due to the more severe impact of the disease on Asian skin, grafting using minigrafting or cell suspensions is used more widely than in Europe for non segmental vitiligo with a secondary recurrence rate of around 30% (A minigraft test is proposed to all patients before the procedure).
The VETF scoring system was discussed before and during patient examination and the Singapour vitiligo clinic thinks of using it on a prospective basis. They may also try in parallel to the trial in European centers the comparison of a continuous versus discontinuous application of UVB phototherapy. Some technical points were raised :
- spreading may also include the appearance of new patches on a given area, if detected at serial examination (in addition to Wood’s lamp examination and patient’s opinion)
- Rule of nines with the patient’s palm size was found helpful for routine assessment and phototherapy follow-up, but photography is needed for grafting assessment.
Some remarks were generated by the examination of patients :
- “late onset” cases are apparently common in Singapore (or for some reason more commonly seen than in Europe), and usually repigment poorly after UVB treatment. The role of aging melanocytes in the reservoir was discussed.
- the near-constant refractory peripheral rim of white skin forming a limit between grafted skin and vitiligo patch limit was discussed, and should probably lead to newer therapeutic considerations
- Tacrolimus ointment is widely used but as in Europe without consensus about its efficacy and best/safe combination with UV light. Cooperative randomized trials are much needed to clarify the situation.
- The use of Vit B12/folic acid as well as antioxidant supplements was discussed and it was concluded that baseline blood determinations should be done in prospective trials to correlate data with repigmentation, especially when using UV treatment.
- Vililigo universalis : the adolescent patient of indian origin examined had developped a complete skin depigmentation in a few weeks following hepatitis (type unknown), but hairs were mostly spared. This case suggested that this rare subgroup of nonsegmental vitiligo should be in the future better identified and characterized by an international cooperation.
From left to right: JY Pan, J Anjali, M Picardo, JP Ortonne, S Thng, A Taïeb