Journal of Dermatological Treatment

ISSN: 0954-6634 (Print) 1471-1753 (Online) Journal homepage: https://www.tandfonline.com/loi/ijdt20

Evaluation of the Effect of Combined Intralesional

Injection of Prostaglandin F2α with Narrow Band
UVB Phototherapy in Treatment of Resistant Cases
of Vitiligo

Zeinab A. Ibrahim, Shereen F. Gheida, Naglaa I. Sarhan, Nashwa N. Elfar &

Samah A. Eldelee

To cite this article: Zeinab A. Ibrahim, Shereen F. Gheida, Naglaa I. Sarhan, Nashwa N. Elfar
& Samah A. Eldelee (2019): Evaluation of the Effect of Combined Intralesional Injection of
Prostaglandin F2α with Narrow Band UVB Phototherapy in Treatment of Resistant Cases of Vitiligo,
Journal of Dermatological Treatment, DOI: 10.1080/09546634.2019.1658860

To link to this article: https://doi.org/10.1080/09546634.2019.1658860

Accepted author version posted online: 22

Aug 2019.

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Original article

Evaluation of the Effect of Combined Intralesional Injection of Prostaglandin

F2α with Narrow Band UVB Phototherapy in Treatment of Resistant Cases of

Vitiligo

Short title: Prostaglandin F2α in Vitiligo

Zeinab A. Ibrahim,1 Shereen F. Gheida, 1, Naglaa I. Sarhan2, Nashwa N. Elfar1,

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Samah A. Eldelee1 Department of Dermatology & Venereology1, Department of

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Histology2, Faculty of Medicine, Tanta University, Tanta, Egypt

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Zeinab Abdelsamd Ibrahim: MD, Professor of Dermatology and Venereology, Faculty of

Medicine, Tanta University.

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Shereen Farouk Gheida: MD, Professor of Dermatology and Venereology, Faculty of
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Medicine, Tanta University.

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Naglaa I. Sarhan: MD, Professor of Histology, Faculty of Medicine, Tanta University.

Nashwa Naeem Elfar: MD, Assistant professor of Dermatology and Venereology, Faculty of
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Medicine, Tanta University.

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Samah Ahmed Eldelee: M.B.B.CH, Dermatology and Venereology, Faculty of Medicine,

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Tanta University.

Place of the study: Faculty of Medicine, Tanta University, Tanta, Egypt.

Corresponding Author:

Name: Nashwa Naeem Elfar

Mailing Address: Department of Dermatology &Venereology, Faculty of Medicine, Tanta

University, Tanta, Egypt.

Tel: 0403418800

Mob: 01006023298

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E-mail: nashwaelfar3@gmail.com

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Text count: 3173 words

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Tables count: 3

Figures count: 9
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Abstract

Background: Vitiligo is a chronic cutaneous disease characterized with

hypopigmented patches that leave psychological impact on the patients. There

is increasing need for new treatment modalities to shorten the duration of

treatment of vitiligo with the least side effects.

Objective: to explore the effect of intralesional injection of prostaglandin F2α

on the outcome of narrow band ultraviolet rays B (NBUVB) for patients with

stable vitiligo.

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Patients and methods: The study included 27 stable vitiligo patients with

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overall symmetrical lesions. For each patient one patch was treated with

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NBUVB alone (control side) while another symmetrical patch was treated with

combined intralesional injection of prostaglandin F2α with NBUVB therapy,

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weekly for 3 months.
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Results: There was statistically significant improvement in the repigmentation

in the combination group compared with NBUVB group. Side effects were
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minimal.

Conclusion: Intralesional injection of prostaglandin F2α in combination with

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NBUVB therapy could be considered as safe and tolerable technique for

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treatment of vitiligo, it shortens the duration of NBUVB therapy. Longer

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follow up is needed.

Keywords: Narrow-band UVB, prostaglandin F2α, vitiligo

Introduction:

Vitiligo is an acquired, idiopathic, depigmenting disorder of the skin

(1)
and mucous membranes . Vitiligo depigmentation is considered to be a

consequence of melanocyte disappearance (2) mediated by the immune system,

(3,4) (5)
toxic materials , oxidative stress . Other theories include non-

immunological pathogenetic mechanisms in vitiligo, functional impairment of

(4) (4,6)
epidermal cells , environmental factors and genotype . Various

therapeutic options are currently used in vitiligo treatment although often

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(1)
without complete satisfactory therapeutic outcome . The narrow band

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ultraviolet B (NB-UVB) phototherapy is considered to be a very important

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modality in vitiligo treatment since its first use in 1997. It was proved to be of
(7)
higher efficacy, better tolerated, and superior to the other lines of treatment .
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Nevertheless, it is an office-based treatment that may require more than 1 year
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for its completion. Although successful in many cases, some patients may find

this long duration of therapy inconvenient due to social and financial reasons
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(8)
.
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PGF2α commonly used in the treatment of ocular hypertension was tried

in vitiligo based on the presence of irreversible iris pigmentation and

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(9)
reversible peri-ocular hyperpigmentation observed in glaucoma patients .
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PGF2α however exerts its effect indirectly through induction of COX-2 and

PGE2 and has been reported to be a promising therapeutic option for vitiligo

in both animal and human studies with increased efficacy (10,11).

This study aimed to evaluate the safety & efficacy of intralesional injection of

prostaglandin F2α on the outcome of NB-UVB in treatment of resistant cases

vitiligo.
Patients and Methods:

A total of 27 Egyptian patients were enrolled in the study. They were

collected from the Outpatient Clinic of Dermatology and Venereology

Department, Tanta University Hospitals, Egypt, during the period from

December 2017 to September 2018 after obtaining the approval of the research

ethics committee of the Tanta University Hospitals. They had overall

symmetrical [site, size and duration] stable lesions [absence of new areas of

depigmentation or enlargement of the preexisting lesions for 6 months and

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absence of koebner phenomena during the same period]. Patients who were

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known to have a good or rapid response to conventional modalities

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[Phototherapy, medical or topical treatment] were excluded from the study.

Pregnant or lactating females were also excluded from this study. For each
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patient, one vitiligo patch was treated with NB-UVB alone to be considered as
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control, while another more or less symmetrical patch was treated with NB-

UVB therapy in addition to intradermal injection of prostaglandin F2α every

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week. Patients were photographed at the first visit, in the middle and at the end

of therapy. Each patient signed a written consent form to be included in the

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study and to be photographed.

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NB-UVB therapy
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All patients received NB-UVB sessions twice per week until complete

repigmentation was achieved or for a maximum of 3 months. The NB-UVB

source was eight NB fluorescent tubes (Philips TL 100, Hamburg, Germany)

with a spectrum of 310–315 nm and a maximum wave length of 311 nm

installed in a Waldmann UV-100 unit. The dose of UVB was 0.33 J/cm2 (we

started with 0.21 J/cm2 and increased gradually by 20% every session till the

minimal erythema dose was achieved) (12).

Prostaglandin F2α

A Prostaglandin F2α analogue, latanoprost 0.005%, was used for

intradermal injection in the next day of NB-UVB sessions.

For treated areas, after local anesthesia, the vitilignous lesions were

cleaned and sterilized with 70% alcohol. The injection was done using insulin

syringe (28G x ½) at a depth of 3-4 mm with 1 cm distance between each

point of injection. The procedure was repeated once weekly for each patient

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until improvement occurred or for maximum 3 months (12 sessions).

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Evaluation of the treatment

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The patients were examined in the first visit and were reviewed weekly

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for the progress of therapy and the presence of any side effects. Evaluation of
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pigmentation was done by three independent dermatologists. The

repigmentation response was expressed qualitatively as: No change (0%), poor

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(1 –25%), moderate (26–50%), good (51 –75%), excellent (76–99%),

complete regimentation (100%)(11).

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Safety assessment
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The patients were informed to report any complications as; erythema,

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pain, ulceration, burning sensation, ecchymosis, infection, or any allergic

manifestations.
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Electron microscopic examination

2 millimeter punch biopsy specimens were taken from the lesional sites

before treatment, and another biopsy was taken from the same site after the

end of treatment sessions from each side of 6 patients. The biopsy specimens

were examined by electron microscopy, to study changes in the end of the

treatment sessions.
Follow-up assessment

The patients were followed-up monthly for 3 months after the end of

the treatment sessions to detect any recurrence, complications or worsening of

the lesions.

Statistical analysis

The data were collected, tabulated and statistically analyzed using SPSS

software statistical computer package version 12. For quantitative data, the

mean and standard deviation were calculated. The difference between two

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means was statistically analyzed using the Student’s t-test. P-value less than

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0.05 was considered statistically significant.

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Results

This study included 27 patients with localized stable non-segmental,

symmetrical vitiligo, regarding the gender of the patients, there were 11 males

(40.7%) and 16 females (59.3%), the age of the patients ranged from 11 to 55

years with a mean of 29.93 ± 15.32 and median 30. Six patients (22.2%) had

positive family history of vitiligo while 21 patients (77.8%) had negative

family history of the disease. Regarding the skin type of the patients, 8 patients

(29.6%) were skin type III and 19 patients (70.4%) were of skin type IV.

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While regarding the duration of vitiligo; it ranged from 1 to 9 years with a

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mean of (2.67 ± 1.66) with median 2 years.

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Clinical assessment

In patches which were treated with prostaglandin F2α / NBUVB, one

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patient (3.7%) showed no improvement , 9 patients (33.3%) showed poor
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improvement, 2 patients (7.4%) showed moderate improvement, 9 patients

(33.3%) showed good improvement, and 6 patients (22.2%) showed excellent

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improvement (Photos 1-4).

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While with NBUVB, 5 patients (18.5%) showed no improvement, 22

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patients (81.5%) showed poor improvement, and no patients showed moderate,

good, or excellent improvement (Photo 5). There was statistically significant

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difference between the two treatment sides regarding the degree of

repigmentation of vitilignous lesions (P= <0.001).

The percentage of improvement with prostaglandin F2α / NB-UVB

ranged from 0 – 96.67% with a mean of 47.22 ± 32.26 and a median of

63.33%. While with the NB-UVB treated patches, the percentage of

improvement ranged from 0 – 30% with a mean of 15.19 ± 10.42 and a

median of 15%. There was statistically significant difference between the two

treatment sides (P= <0.001), (Table 1).

Regarding the side effects, in the patches were treated with

prostaglandin F2α / NB-UVB, there were no complications in 17 patients

(63%), while in the remaining 10 patients, 2 patients (7.4%) had erythema, 5

patients (18.5%) experienced pain during injection, and 3 patients (11.1%)

showed recurrence after 3 months.

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Electron microscopic monomorphic findings and image analysis (Photos 6-

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9):

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Regarding the number of melanosomes per keratinocyte: before treatment with

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combined NB-UVB/PGF2α ranged from 4.2 - 15.0 with a mean of 9.08 ± 3.81
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and a median of 8.60, while after treatment the number of melanosomes per

keratinocyte ranged from 12.5 - 24.7 with a mean of 16.45 ± 5.12 and a
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median of 13.80, and there was statistically significant difference between

them (p = 0.028).
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Regarding the number of melanosomes per melanocyte before treatment with

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combined NBUVB/PGF2α ranged from 3.0 to 74.0 with a mean of 22.0 ±

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25.96 and a median of 14.0, while after treatment with combined NB-

UVB/PGF2α the number of melanosomes per keratinocyte ranged from 35.0

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to 189.0 with a mean of 76.50 ± 57.39 and a median of 59.50, and there was

statistically significant difference between them (p = 0.028), (Table 2).

The number of melanocytes, there was statistically significant increase in the

number of melanocytes among vitiligo patients after combined intralesional

injection of PG F2α/NB-UVB (p=0.039). As a result of estimation of

melanocyte number in five non overlapping fields in each slide among each
vitiligo patient, the number of melanocytes in each patient ranged from 0 to 1

before treatment with combined intralesional injection of PG F2α/NB-UVB

with a mean of 0.67 ± 0.52, while after treatment with combined intralesional

injection of PG F2α/NB-UVB the number of melanocytes in each patient

ranged from 1 - 3 with a mean of 2 ± 0.89 and a median of 2 and there was

statistically significant difference between them

(p=0.039),(Table3).

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Discussion

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In this study after 3 months of the treatment sessions repigmentation was
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observed in 96.2% of patients treated with combination PG F2α/NBUVB with

excellent response in 22.2%, good in 33.3%, moderate in 7.4%, poor in 33.3%

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and no improvement in 3.7% patients. These results were significant compared

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to NB-UVB alone.
(13)
These findings were similar to that of Parsad et al. 2002 and Kapoor et
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al. 2009 (14) , but they used PGE2 gel for 6 months.
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(13,14)
The previous studies were performed on PGE2 to induce repigmentation

in vitiligo, while PGF2α is a newer agent that is introduced and it was reported
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to stimulate the formation of PGE2.

(15)
Moreover, Korobko et al. 2016 , proved that PGF2α is superior to

tarolimus in the treatment of vitiligo. He used and dermaroller with PGF2α

followed by NBUVB. Repigmentation was seen in 58.3% of patients with PG

F2α.
 (16)
However our results were superior to Stanimirovic et al. 2016 ,who used

combination of narrowband UVB and topical PGF2α with and without

dermaroller 0.5 mm needle length-assisted microneedling on 25 patients with

bilateral symmetrical vitiligo vulgaris and acrofacial vitiligo. Repigmentation

was observed in 36% and 32% of lesions with and without microneedling,

respectively. He concluded that combination of topical PGF2α and NB-UVB

can result in some repigmentation of resistant lesions. However, the addition

of microneedling did not improve the efficiency, as the depth of penetration

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was 0.5mm which remains epidermal, while in our study, repigmentation was

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observed in 96.2% of cases probably because the intradermal injection of

PGF2α facilitates its direct action on the melanocytes.

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Lotti, et al. 2018(17), achieved superior results to ours by using a Fraxel
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Erbium laser, the successive topical application of PG F2α, and by the

irradiation with UVA - 1 laser on 30 patients. The difference with present

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study results is probably because of the combined use of multiple techniques

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(Fraxel Erbium and UVA -1 laser) and the longer duration of treatment as the

treatment has been repeated every 21 days, for nine month, while in ours it
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was 3 months only.

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One of the remarkable finding in our study was that, the reported side

effects of intradermal injection of PGF2α in vitiligo patients were few and

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minor if not at all, and all patients tolerated the procedure well. Pain during

injection occurred in 74.1% of cases, erythema occurred in 37% of cases,

while in 22.2% of cases recurrence occurred after 3 months.

(14) (11)
Consistent with these findings Kapoor et al 2009 , Anbar et al 2015 ,
(15) (17)
Korobko et al 2016 and Lotti et al. 2018 . They recorded no or minimal

side‐ effects for the treatment with PG F2α, either topical or after dermaroller.
The commonest side effects were transient burning sensation, transient

inflammation (erythema and oedema) and itchy sensation.

Regarding the efficacy of treatment on different body sites, PG F2α/NB-

UVB showed excellent to good response in the trunk and face, while

extremities and acral parts showed moderate response, but there were no

statistical significance relations between different parts of body.

Parallel to our observation, Anbar et al. (18), Yones et al., (19) and Kanwar et

al (20) who found that vitiligo of the face achieved the best results.

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Kapoor et al. 2009(14), also confirmed that head and neck lesions showed the

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best response, when he assessed using topical PG E2 , while in the contrary

Lotti et al. 2018,(17) observed no difference in repigmentation for lesions with

different localization.
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(21)
Halder and Chappell in 2009 proposed that facial skin has greater

permeability, a larger number of residual melanocytes in the uninvolved skin,

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greater follicular reservoirs, so melanocyte damage is more easily reversed.

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The exact mechanism of action of PG on the melanocytes is unknown, but

different mechanisms of the induction of hyperpigmentation by prostaglandins

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have been suggested, including: (i) influencing the responsiveness of

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melanocytes to neuronal stimuli; (ii) causing melanocyte proliferation; and

(iii) a direct or second messenger mediated interaction with melanocytes via

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the stimulation of tyrosinase activity (22).

Activation of FP receptors by their ligands or agonists results in modulating

(23)
melanocyte dendricity, proliferation, and tyrosinase expression .

Melanocyte proliferation and melanosomal transfer are also proposed

mechanisms for PGF2α -induced repigmentation. All the PGF2α was reported

to stimulate the formation of PGE2; therefore, it is likely that repigmentation

may be induced, in part, via endogenous PGE2, which is a stimulator of

melanogenesis (24).

The PGE2 also has other biologic activities. It increases the formation of

tonofilaments and keratohyalin in keratinocytes. It blocks the

processing/presenting function of Langerhans cells in skin (13).

The significant improvement in lesions treated with the combination of

PGF2α/NB-UVB, in comparison with those treated with NB-UVB alone,

could be explained by many possibilities. First, NB-UVB stimulates the

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release of PGs in situ allowing the applied exogenous PGF2α to exert an
(24)

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additive effect on pigmentation . The second possibility is the synergistic

effect of other mediators released on exposure to NB-UVB, e.g., endothelin-1,

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alpha-melanocyte-stimulating hormone, adrenocorticotropic hormone, stem
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(25)
cell factor, and nerve growth factor28 with topically applied PGF2α .

Thirdly, exposure to NB-UVB not only stimulates the synthesis of PGF2α in

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melanocytes but also upregulates FP receptors expression, allowing the

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exogenous PGF2α to exert more effect (25).

Although the use of prostaglandin analogues is not a recent approach for

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treatment of vitiligo, to our knowledge this is the first study to date to use
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intradermal injection of PGF2α to improve the outcome of narrow band UVB

in treatment of vitiligo.
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In the current work, electron microscopic examination from the vitiliginous

skin biopsy before treatment with PGF2α/NB-UVB showed: Very few

melanocytes could be demonstrated in lesional skin before treatment, which is

(26)
concomitant with the finding of Tobin et al. .However absence of

melanocytes in vitiliginous skin was reported in previous research performed

by both Prignano et al.in 2009 (27) and in 2011 (28).

 Melanocyte detachment and retracted dendrites was a remarkable

observation in our study was detected by Ding et al.(29) and and Fawzy et al.(30)

previously. They suggested that melanocyte detachment is supposed to take

place in perilesional skin followed by their trans-epidermal elimination and

(31)
loss in lesional sites . This had led to the arousal of a theory of

‘‘melanocytorrhagy’’.

However, Benzekri et al.(32) found a reduced expression of E-cadherin

adhesion molecule at the cell membrane in the perilesional skin of vitiligo,

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indicating an impairment in the adhesion of melanocytes also involved in the

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retraction of dendrites.

Before treatment with PGF2α/NB-UVB, the cytoplasm of melanocytes

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exhibited few small electron-dense melanosomes and some electron-lucent
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vacuoles also it showed dilated rough endoplasmic reticulum (RER) which is

parallel to findings of Boissy et al. (33)

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Fawzy et al.(30) added the finding that two types of degenerative changes
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could be detected in vitiliginous skin, defined as electron-lucent and electron-

dense (dark) degeneration and were both reduced after treatment. Regarding
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keratinocytes, cells were separated by wide intercellular spaces in the current

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study, indicating that the degenerative changes in vitiligo include keratinocytes

as well as melanocytes.
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The ultra-structural study in this work showed regression of the

degenerative changes in both keratinocytes and melanocytes after treatment

with the combination of PGF2α/NB-UVB. In addition, significant increase in

the number of melanocytes, melanocytes could be clearly detected between

basal keratinocytes, increased number of the melanosomes within melanocytes

(34)
and keratinocytes, and these findings were similar to that of Anbar et al.
(30)
and Fawzy et al. . Improvement in the structure of rough ER, and narrow
intercellular spaces were also present, which could be also reported by Fawzy
(30) (30,34)
at al. . The previous two studies reached these findings after one year

of treatment with phototherapy, while in the present study, it needed only 3

months of treatment with combined of PGF2α/NB-UVB to reach the same

result, and this prove that PGF2α increased the efficacy of NB-UVB and

shortened the duration of repigmentation.

In conclusion, this study demonstrated that intradermal injection of PG F2α

enhanced the outcome of NB-UVB as regard rate and degree of

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repigmentation of lesions in stable vitiligo. This combination seems to be safe

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and effective in different body sites, cheap, shortens the duration of NB-UVB

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therapy and does not require costly devices and well equipped rooms. Further

studies are required with larger number of cases, longer treatment periods, and
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follow up to determine the long term efficacy and safety of intradermal
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injection of Latanoprost in combination with narrow band UVB.

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28.Prignano F, Ricceri F, Bianchi B, et al. Dendritic cells: ultrastructural and

immunophenotypical changes upon nb-UVB in vitiligo skin. Arch Dermatol

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Res. 2011; 303: 231–8.
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29.Ding GZ, Zhao WE, Li X, , et al. A comparative study of mitochondrial

ultrastructure in melanocytes from perilesional vitiligo skin and perilesional

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halo nevi skin. Arch Dermatol Res. 2015; 307: 281–9.

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30.Fawzy MM, El Maadawi ZM, Hegazy RA, et al. Vitiligo - The story from
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within: A transmission electron microscopic study before and after narrow-

band ultraviolet B. Ultrastruct Pathol. 2016; 40: 265–75.

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31.Gauthier Y, Cario Andre M, Taieb A. A critical appraisal of vitiligo

etiologic theories. Is melanocyte loss a melanocytorrhagy? Pigment cell Res.

2003; 16: 322–32.

32.Benzekri L, Hmamouchi I, Gauthier Y. Possible patterns of epidermal

melanocyte disappearance in nonsegmental vitiligo: a clinicopathological

study. Br J Dermatol. 2015; 172: 331–6.

33.Boissy RE, Liu YY, Medrano EE, et al. Structural aberration of the rough

endoplasmic reticulum and melanosome compartmentalization in long-term

cultures of melanocytes from vitiligo patients. J Invest Dermatol 1991; 97:

395–404.

34.Anbar TS, El-Sawy AE, Attia SK, et al. Effect of PUVA therapy on

melanocytes and keratinocytes in non-segmental vitiligo: histopathological,

immuno-histochemical and ultrastructural study. Photodermatol

Photoimmunol Photomed 2012; 28: 17–25.

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Legends of figures:

Photo 1: A-Male patient before treatment with prostaglandin F2α / NB-UVB sessions. B- At

the end of treatment showing excellent improvement.

Photo 2: A- Female patient before treatment with prostaglandin F2α / NB-UVB sessions. B-

At the end of treatment showing excellent improvement.

Photo 3: A-Male patient before treatment with prostaglandin F2α / NB-UVB sessions. B- At

the end of treatment showing good improvement.

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Photo 4: A- Female patient before treatment with prostaglandin F2α / NB-UVB sessions. B-

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At the end of treatment showing poor improvement.

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Photo 5: A- Male patient before treatment with prostaglandin NB-UVB sessions. B- At the
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end of treatment showing poor improvement.
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Photo 6: A-Electron micrograph of ultrathin section of skin biopsy from vitiligo patient before

treatment with PGF2α/NB-UVB showed melanocyte (M) that contains few melanosomes
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(arrow) with multiple large cytoplasmic vacuoles (V) and dilated rough ER (RER). B- After
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treatment showed melanocyte with relatively many melanosomes, dilated RER and

cytoplasmic vacuoles (x11700).

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Photo 7: A- Electron micrograph of ultrathin section of skin biopsy from vitiligo patient
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before treatment with PGF2α/NB-UVB showing many keratinocytes (K) with few or without

melanosomes. The nearby white bounded melanocyte (M) is swollen, distorted and devoid of

melanin with cytoplasmic rarefaction. The melanocytic nucleus shows dark chromatin

granules. B- After treatment showing keratinocytes displaying relatively many melanosomes

(x5850).
Photo 8: Electron micrograph of ultrathin section of skin biopsy from vitiligo patient before

treatment with PGF2α/NB-UVB showing keratinocytes (K) with central nucleus and

prominent nucleolus and few cytoplasmic melanosomes and complexes. The white bounded

melanocyte shows few melanin, cytoplasmic vacuoles and retracted dendrites. B- After

treatment showing keratinocytes with relatively many electron dense melanosomes (x5850).

Photo 9: Electron micrograph of ultrathin section of skin biopsy from vitiligo patient before

treatment with PGF2Α/NB-UVB showing, keratinocytes (K) containing few melanosomes.

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The white bounded melanocyte displays depletion from melanosomes (M), indented nucleus

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and retracted dendrites. B- After treatment showing keratinocytes with few melanosomes and

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indented nucleus (x5850).

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Tables:

Table (1): Comparison between prostaglandin F2α/NB-UVB site and NB-UVB site according

to degree to improvement and percentage of improvement

Prostaglandin NB-UVB side

F2α / NBUVB side Test of
p
sig.
No. % No. %
Degree to
improvement
No 1 3.7 5 18.5

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Poor 9 33.3 22 81.5
Moderate 2 7.4 0 0.0 MH <0.001*

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Good 9 33.3 0 0.0
Excellent 6 22.2 0 0.0
Percentage of
improvement us
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Min. – Max. 0.0 – 96.67 0.0 – 30.0
Z=
Mean ± SD. 47.22 ± 32.26 15.19 ± 10.42 <0.001*
3.701*
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Median 63.33 15.0

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MH: Marginal Homogeneity Test Z: Wilcoxon signed ranks test

p: p value for comparing between treatment site and Control site
*: Statistically significant at p ≤ 0.05
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Table (2): Average number of melanosomes per keratinocyte and per melanocyte before and

after treatment with combined prostaglandin F2α/ NB-UVB (n= 6).

Before
Average number of After prostaglandin
prostaglandin F2α/ Z p
melanosomes F2α/ NB-UVB
NB-UVB
Per keratinocyte
Min. – Max. 4.20 – 15.0 12.50 – 24.70

2.201* 0.028*
Mean ± SD. 9.08 ± 3.81 16.45 ± 5.12
Median 8.60 13.80

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Per melanocyte
Min. – Max. 3.0 – 74.0 35.0 – 189.0

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Mean ± SD. 22.0 ± 25.96 76.50 ± 57.39 2.201* 0.028*
Median

MH: Marginal Homogeneity Test

14.0

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59.50

Z: Wilcoxon signed ranks test

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p: p value for comparing between treatment site and Control site
*: Statistically significant at p ≤ 0.05
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Table (3): Average number of melanocyte before and after combined prostaglandin F2α/ NB-

UVB (n= 6).

Before After
Number of
prostaglandin prostaglandin Z p
melanocyte
F2α/ NB-UVB F2α/ NB-UVB
Min. –Max. 0.0 – 1.0 1.0 – 3.0
Mean ± SD. 0.67 ± 0.52 2.0 ± 0.89 2.060* 0.039*
Median 1.0 2.0

MH: Marginal Homogeneity Test Z: Wilcoxon signed ranks test

p: p value for comparing between treatment site and Control site

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*: Statistically significant at p ≤ 0.05

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