Role of the ACTH test and estimation of a safe dose for high potency steroids in vitiligo: A prospective randomized study

Abstract

Background:Topical corticosteroids are used as first line of therapy for vitiligo, although side effects such as adrenal insufficiency are possible.Objectives:To establish the role of ACTH test before, during, and after treatment with high potency topical steroids; to determine if adrenal insufficiency occurs secondary to the use of high potency topical steroids in patients with vitiligo and intact cutaneous barrier; and also to determine response to treatment and side effects.Materials and Methods:Forty-four adults with non-segmental vitiligo affecting 20% or less of the body surface area were included and randomized to receive topical clobetasol propionate 0.05% cream (group 1) or placebo (group 2) for 12 weeks, with a maximum dose of 50 g per week. The placebo group was crossed over after week 6 and started on clobetasol until completion of the study. Serum cortisol levels with the 1 μg ACTH test were determined at baseline and on weeks 6 and 12.Results:No adrenal insufficiency was detected nor statistical significance was achieved when comparing cortisol levels between and within the groups at baseline and weeks 6 and 12. Group 1 had a better response to therapy but with more side effects.Conclusions:Doses of 50 g or less per week of clobetasol during a period of 12 weeks are safe on adult vitiligo patients, although local side effects are possible. Repigmentation rates were incomplete with single steroid therapy, making combined therapy a better option.

Melanogenesis and Hypopigmentation

“…Topical corticosteroids have been observed as effective in recent and facial lesions; however, to reduce the risk of side effects the administration should be limited to small areas, avoiding prolonged use and introducing another topical therapy after some weeks of continuous administration. [ 47 48 ]…”

Consensus on the treatment of vitiligo – Brazilian Society of Dermatology

“…The authors demonstrated that weekly use of 50 g (or less) of 0.05% clobetasol propionate cream for 12 weeks is safe, with no evidence of adrenal insufficiency, although local effects may occur. 15 To minimize the risk of side effects, topical corticosteroids should be limited to small areas, avoiding prolonged use on the face and flexures.…”

Transplantation of melanocyte stem cells in vitiliginous skin

“…The basic mechanism has not yet been clearly identified, however, various mechanisms have been proposed, including genetic association, 1,2 autoimmunity and oxidative stress, [3][4][5] neurohormonal imbalance, 6 abnormalities in the microenvironment surrounding the melanocytes [7][8][9] and intrinsic defects of melanocytes and periphery T cell regulator which promote innate immune attack. 10,11 Various modalities have been developed to treat vitiliginous skins, among others : a) anti-oxidant agents such as: Polypodium leucotomos as adjunct therapy with PUVA, 12 or fish oil 13 ; b) immunosuppressive agents such as: topical corticosteroid, 14 tacrolismus, [15][16][17] or calcipotriol, 18,19 either used as single modality or in combination with NB-UVB or excimer laser; c) UVA light combined with photosensitizer agent such as: psoralen, 20,21 ; d) oral minocycline 22,23 which nevertheless less effective than NB-UVB. 24 Previous study showed that minocycline could protect melanocytes from H 2 O 2 -induced cell death.…”