Unilateral/Segmental Vitiligo in a 9-year-old boy receiving Melagenina as treatment

HPI: The patient is a 9-year-old boy who developed loss of pigmentation on the right side of his face over a 3-month-period. The depigmentation of the skin progressed rapidly with no antecedent eruption, redness or trauma. There was no history of exposure to a chemical or irritant prior to depigmentation of the skin.

No medical history of hypothyroidism or other medical conditions.  No family history of vitiligo or autoimmune diseases. He often spends 2 to 6 hours in the sun playing outside only beginning to wear sunscreen recently. 

Diagnosis:  He appears to have a segmental or unilateral vitiligo.

He lives in Cozumel, Quintana Roo, Mexico and has been evaluated by a dermatologist locally who confirmed the diagnosis clinically.  No biopsy was obtained.

Labs: TSH, complete blood count and chemistry panel were normal.

Prior/Current Treatment:  Melagenina solution

Since the patient is a citizen of Mexico, he and his family were able to travel freely to Cuba and obtained an appointment in the Vitiligo clinic evaluation and treatment after a 6-month wait. Their first visit to Cuba was in August, and they are expected follow-up in 6 months. He was given Melagenina solution to be applied twice a day to the depigmented areas of skin. Melagenina solution can only be obtained in Cuba at this time.  It is derived from placental extract that is mixed with an alcohol solution. He will return to Cuba in February 2016 for a follow-up visit and to obtain more Melagenina.

Images:

 

His mother has noticed some repigmentation of the treated areas.  The pictures shown are after using the treatment for 4 months.

Second Opinion in USA and Plan:

We recommended adding tacrolimus (Protopic 0.1%) ointment and a low-dose steroid such as mometasone furoate cream to his Melagenina treatment regimen to be applied twice a day. The patient was counseled on the importance of using a titanium and zinc oxide waterproof sunscreen on the face to prevent further darkening of the surrounding area and to protect the areas of depigmentation.

Discussion:

Vitiligo is a common skin disorder affecting about 1 to 2% of the world population. It commonly affects children and can be seen in different patterns.  This patient appears to have a unilateral or segmental pattern but not necessarily dermatomal. 

It has been shown that segmental vitiligo in children is relativley common and less frequently associated with systemic autoimmune diseases or endocrine disorders.

Treatment in the USA and Mexico includes using narrow band UVB phototherapy or psoralen with UVA phototherapy as well as topical low-dose steroids and tacrolimus combinations. Narrow band UVB phototherapy is considered one of the most efficacious treatments and can be used alone and in combination with topical steroids and tacrolimus. Some patients are also treated with the excimer lasers and have undergone melanocyte transplants. Melagenina or placental extracts are not used currently.

In the General de Mexico hospital, up to 50 cases of vitiligo are seen per day.  Many efforts are being made to increase awareness about vitiligo. One controversial issue in Mexico has been the exploration of naturalist physician care and unresearched treatments options. As we are aware, this is a consideration in the U.S. as well. Although the medical community wants to be open to new ideas involving topical and oral nutritional and botanical substances, in Mexico the concern is that patients will use their limited financial resources on unsubstantiated treatments. Phototherapy clinics treat vitiligo patients in the larger cities of Mexico, but unfortunately many patients, including this patient, could not travel regularly to these established clinics due to financial and transportation limitations.

1)   How safe, well regulated and efficacious is the Melangenina solution in the treatment of vitiligo? Should this be something explored more for patients in the USA?

2)   Should the patient inform the physicians in Cuba that they will be adding other topical medications to the regimen?

Out of respect to the Cuban dermatologists, we encouraged them to inform the clinic that a second opinion was sought out and new medications were started.  The patient and his family were unsure if the treatment with Melagenina was part of a clinical trial.

3)   Should we consider oral minipulse therapy with methylprednisolone? 

Although there are relapses and other considerations with oral steroid use in children, a few case reports and clinical trials have shown some benefits.

 

Lo, Yuan-Hsin, Gwo-Shing Cheng, Chieh-Chen Huang, Wen-Yu Chang, and Chieh-Shan Wu. "Efficacy and Safety of Topical Tacrolimus for the Treatment of Face and Neck Vitiligo." The Journal of Dermatology 37.2 (2010): 125-29. Web.

 http://onlinelibrary.wiley.com/doi/10.1111/j.1346-8138.2009.00774.x/full

Majid, Imran et al. “Childhood vitiligo: response to methylprednisolone oral minipulse therapy and topical fluticasone combination.” Indian Journal of Dermatology 54.2 (2009): 124–127. PMC.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807150/ 
 

 Shrestha, S., AK Ha, and DP Thapa. "An Open Label Study to Compare the Efficacy of Topical Mometasone Furoate with Topical Placental Extract versus Topical Mometasone Furoate with Topical Tacrolimus in Patients with Vitiligo Involving Less than 10% Body Surface Area." Nepal Medical College Journal 16.1 (2014): 1-4. Web.

Xu, Aie, Dekuang Zhao, and Yongwei Li. "Melagenine Modulates Proliferation and Differentiation of Melanoblasts." International Journal of Molecular Medicine Int J Mol Med (2008): n. pag. Web.

 http://www.spandidos-publications.com/ijmm/22/2/193