How To Cure A Skin Disease Vitiligo

How to Cure a Skin Disease
VITILIGO
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How to Cure a Skin Disease
VITILIGO
JS Pasricha MD PhD
Professor and Head (Retd)
All India Institute of Medical Sciences
New Delhi, India
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© 2014, JS Pasricha
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How to Cure a Skin Disease: Vitiligo
First Edition: 2014
ISBN: 978-93-5152-119-8
Printed at
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Dedication
A disease can be cured only if the patient follows the protocol strictly and
completes the treatment properly and diligently.
There are, however, several associates of the patient who (unintentionally)

try to misguide the patient because of their own misconcepts.
This book is dedicated to all the patients who displayed adequate wisdom
to avoid being misguided by the distractors and carried out the treatment
as per the protocol.
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Preface
Every patient desires that his/her disease should be cured for life. This
desire, however, is an unrealistic and illogical demand because there is
almost no disease which does not have recurrences.
We, on the other hand, have been able to cure some very serious
and even potentially fatal skin diseases like pemphigus, systemic lupus
erythematosus (SLE), systemic sclerosis, etc. with the dexamethasone-
cyclophosphamide pulse (DCP) regimen designed by us for these
diseases. The patients have remained free of the disease for 10-20 years
of follow-up after completing the treatment without any maintenance
therapy.
This encouraged us to believe that skin diseases can, in fact, be cured
for life if the patient receives proper medicines in an appropriate dose for
an adequate duration of treatment. In all such cases, it is essential that the
patient follows the protocol strictly.
The Modified Oral Mini-pulse (OMP) regimen designed for curing
vitiligo has shown us very promising results and it is hoped that vitiligo
can also now be added to the group of Curable Skin Diseases.
JS Pasricha
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Contents
1. Vitiligo is Curable 1
Clinical Features 1
2. General Principles for Curing Skin Diseases 7

Corticosteroids: The Most Wonderful Drugs,
but Misused and Abused 8
The Side Effects of Corticosteroids:
The Reality and the Guidelines 9
3. Treatment Protocol for Vitiligo 11

Treatment of Vitiligo 11
Favorite Prescription for Vitiligo 14
4. Case Histories 15
Patients Treated with Full-Dose Modified OMP Regimen 15
Patients Treated with the Half-Dose Modified OMP Regimen 40
Patients Treated with Levamisole 49
5. Mistakes Committed by Other Practitioners 62
Repigmentation of the Vitiligo Lesions during Treatment 63
Index 75
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CHAPTER
Vitiligo is Curable
1
Vitiligo is known to the medical profession since time immemorial. All
through this period, this disease has been treated with the administration
of topical or systemic photosensitizing agents followed by exposure
to the sun or the ultraviolet rays produced artificially.
The photosensitizers were initially obtained from the plants but
later on the active principles were synthesized in the laboratory so that
it has now become possible to use standardized dosages of the drugs
and fixed exposures to the ultraviolet rays.
The major limitations of this method has been that: (1) This
approach does not control the disease process and therefore, if the
disease is active, the patient can continue to develop new lesions,
(2) It does not eliminate the disease process and thus the disease can
reactivate at any time later in life.
The Modified Oral Mini-pulse Therapy (OMP) regimen as designed
by the author & co-workers (1) Controls the disease process as soon as
the treatment is started so that there are no new lesions, (2) It leads to
repigmentation of all the white patches wherever the melanocytes have
not been destroyed, and (3) It eliminates the disease process in the
body completely so that there is no chance of reactivation of the disease
in future.
However, this is possible only if the protocol is followed strictly
and completely.
CLINICAL FEATURES
Vitiligo is a disease which produces white patches on the skin. The
patches are of variable sizes and shapes, smaller patches tend to be
circular, while large patches can assume any shape.
The skin in these patches is completely normal (no redness, no
scaling, no papulation), except that it has lost its pigment.
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2 How to Cure a Skin Disease: Vitiligo
The loss of pigment may be complete or partial (hypo-

pigmentation) and both these types of patches may co-exist.
It can involve any part of skin and/or mucous membrane and the
extent of involvement may vary from a few small patches to almost
complete involvement of the entire skin.
The disease can start at any age, from early childhood to old age.
Both sexes are equally involved.
The progression of the disease is very variable and unpredictable.
Some patches may disappear even without treatment (if the body is
able to overcome the disease process), or it may continue to spread with
the appearance of new lesions at other body sites and also peripheral
extension of the existing patches.
In the most aggressive disease, called explosive vitiligo, several
small lesions, appear at the periphery of the existing lesions and even
at other places and the entire skin may tend to lose its pigment and
become white.
The hairs in the white patches may also lose their pigment and
become white, this is termed leucotrichia.
At any stage, the disease can also become quiescent without any
obvious reason and may even start repigmenting but it can reactivate
later.
Although the lesions can be located at any part of the body,
localization of the lesions on the elbows, knees, ankles and knuckles
suggests the effect of trauma (Fig. 1.1), location of the lesions on the
flanks suggests the effect of pressure of the petticoat or salwar string
(Fig. 1.2) and location of the lesions on the feet (slipper straps) (Fig. 1.3),
hands (gloves), center of the forehead (Bindi area) (Fig. 1.4), and upper
part of breast (purse) (Fig. 1.5), suggests the damaging effect of anti-
oxidants present in the plastic or rubber articles of daily use.
Bilateral and symmetrical location of the lesions generally suggests
autoimmunity as the cause of vitiligo (Figs 1.6A and B and 1.7).
In some patients, the lesions are strictly limited to one side of the
body (segmental vitiligo), as shown in Figures 1.8A and B.
Whether this variety of clinical patterns suggests a multitude of
diseases or these are various manifestations of the same disease is
debatable.
The response of various forms of this disease to the therapeutic
modalities is the same except that the obvious cause has to be removed
apart from the therapeutic procedure, wherever applicable.
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Vitiligo is Curable 3
Fig. 1.1: Multiple areas of depigmented skin on the knuckles and paronychial
areas, possibly caused by minor routine trauma
Fig. 1.2: Depigmentation on the waist corresponding to the area

of the petticoat string, possibly caused by tight pressure
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Fig. 1.3: Depigmentation corresponding to the straps of

the slippers caused by the chemicals in the rubber
Fig. 1.4: Depigmentation at the centre of the forehead possibly caused by

phenolic compounds present in the adhesive of plastic bindi
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Vitiligo is Curable 5
Fig. 1.5: Depigmentation above the left breast caused by

the plastic purse kept under the brassiere
A B
Figs 1.6A and B Fast spreading vitiligo with multiple small satellite lesions
almost symmetrical, possibly caused by autoimmunity
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Fig. 1.7: Fast spreading vitiligo with multiple small satellite lesions almost
symmetrical, possibly caused by autoimmunity
A B
Figs 1.8A and B: Segmental vitiligo
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CHAPTER
General Principles for

Curing Skin Diseases 2
It should be possible to cure every skin disease. For achieving this
however, two persons are very important:
• The doctor who should suggest the correct treatment, and
• The patient who must follow the protocol very strictly
Compromise at any level is expected not to achieve the optimum
result
Almost every skin disease is curable provided the patient receives
appropriate treatment.
Treating a disease is like fighting a war. If the war has to be won,
your forces and strategy has to be superior to that of the enemy.
The forces for treating a skin disease consist of correct drugs, adequate
dosages, and appropriate duration of treatment (without interruptions).
If this protocol is followed, almost every skin disease can be cured.
The major reason for lack of recovery from a disease consists of use
of milder drugs or smaller dosages (for the fear of side effects)
The major reason for recurrence of the disease is an attempt to stop
the treatment earlier (again for the fear of side effects).
Side effects are associated with almost every activity of life such
as going to school for studies, driving a car, travelling to other towns by a
train or a plane, even lighting a fire for cooking.
It is thus foolish to expect that the treatment of a disease will not
produce side effects.
Many a times there are no side effects. Most of the side effects are
temporary and reversible.
Most of the times they are minor and can be tolerated/ignored.
If a side effect cannot be ignored, the patient can take additional
treatment to control them.
If some side effect is permanent, it is essential to assess what is more
serious, the disease or the side effect of the drug.
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CORTICOSTEROIDS:
The most wonderful drugs, but misused and abused
Corticosteroids are hated by the physicians and feared by the patients.
These are however, the most wonderful drugs ever created in the
medical history.
• These can induce instantaneous recovery and provide immediate
relief
• These can induce remissions even in difficult cases
• Incurable and fatal skin diseases can also be cured with
corticosteroids.
However, it is necessary to use these powerful drugs in a proper
manner.
The physician should therefore learn how to use corticosteroids,
and the patients should follow the instructions strictly and carefully.
It is the misuse of powerful weapons which leads to disasters.
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General Principles for Curing Skin Diseases 9
THE SIDE EFFECTS OF CORTICOSTEROIDS:

The reality and the guidelines
There are five major side effects for which corticosteroids are
incriminated.
The realities are as follows:
• Increase in body weight: Persons taking corticosteroids tend to
put on weight because corticosteroids lead to increased appetite.
People who control their food intake do not put on weight, while
those who continue to eat more, come back with increased body
weight. Corticosteroids do not provide fat and thus, the cause of
increased body weight is inability to control the food intake and not
the corticosteroids.
• Corticosteroids induce diabetes: A patient who does not have a family
history of diabetes does not develop diabetes during the treatment
with corticosteroids. Diabetes is a genetic disease and if a person has
inherited the gene for diabetes from his parents, he is bound to
develop diabetes irrespective of whether he takes corticosteroids
or not. He may develop diabetes before the corticosteroid therapy,
during the treatment or after the treatment. Corticosteroids do
increase the blood sugar levels and in diabetics, the treatment
for diabetes will need to be reset for that period. Corticosteroids
cannot induce diabetes and therefore are not contraindicated in
diabetics.
• Corticosteroids induce hyperacidity and gastric upsets: Hyperacidity
occurs mostly in individuals whose worry is dispropotionate
to their problems. In case a person takes appropriate measures,
almost every problem can be solved, and if something cannot be
solved it must be accepted. Corticosteroids enhance this tendency,
but only in those individuals who worry disproportionately.
Although, hyperacidity can be treated with H2 blocking agents
and antacids, proper training of the mind and attitudes certainly
helps in such situations.
• Osteoporosis caused by corticosteroids: Most Orthopedicians
incriminate corticosteroids when a person develops osteoporosis
during corticosteroid therapy. But osteoporosis can develop when
the patient is lying down (due to sickness) even without taking
corticosteroids. Many people do not develop osteoporosis
when they maintain their physical activity in spite of taking
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corticosteroids. Thus, whether the corticosteroids lead to

osteoporosis is a matter of personal perception. In any case,
additional treatment can be given whenever necessary
• Increased susceptibility to infections: Corticosteroids do suppress
the immune mechanism as long as the drugs are being given, but
(1) This effect is temporary and recovers when the treatment is
ultimately stopped, (2) It does not occur in every individual and (3)
It may not lead to clinical infections. Thus, if a person develops
an infection during the treatment with corticosteroids, it has to
be treated with appropriate anti-infective agents, irrespective
of whether the infection was due to corticosteroid therapy or
otherwise. The infection must be controlled adequately along with
corticosteroid therapy.
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CHAPTER
Treatment Protocol
for Vitiligo 3
TREATMENT OF VITILIGO
The treatment of vitiligo consists of 3 components:
• Complete control of the disease (so that there are no new lesions)
• Repair of the damage done so far (repigmentation of the lesions
present on the body)
• Elimination of the disease process from the body so that there is no
reactivation of the disease after the treatment has been completed.
Of the treatment options available for vitiligo, phototherapy
(UVB and narrow band), photochemotherapy (PUVA or PUVASOL),
Intense Pulsed Light (IPL) and lasers, are all aimed at stimulating the
melanocytes to produce the pigment, but in a particular lesion if there
are no melanocytes the area is not likely to get repigmented. Moreover,
if the disease is active, new lesions can continue to appear at other
sites even when the old ones are improving, because these therapeutic
modalities are by and large not able to control the disease process and
prevent new lesions.
Similarly, topical agents alone (placenta extracts or topical
corticosteroids) cannot prevent the development of new lesions at
other sites in the body.
The oral mini-pulse (OMP) regimen, originally designed and used
by the author and his co-workers in 1989 and subsequently modified by
the addition of azathioprine in a daily dose has completely changed the
outlook in this disease.
The modified OMP regimen which consists of using azathioprine
in a dose of 100 mg every day with breakfast, combined with 5 mg of
betamethasone orally with breakfast on two consecutive days per week
(preferably Saturdays and Sundays) along with topical application of
fluticasone cream on the vitiligo lesions once a day at night time, has
been observed to control the disease activity in every patient within
the first month itself.
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In addition, continuation of the same treatment leads to progressive

repigmentation of the existing lesions. The repigmentation generally
starts after 2 months.
Some lesions repigment faster, some repigment at a later stage, while
some lesions do not repigment at all in spite of adequate treatment.
The lesions which do not repigment at all are those which have lost
the melanocytes during the disease process.
In case the patient receives proper treatment at an early stage of
the disease, the proportion of the permanent damage is expected to
be less and the patient can obtain complete repigmentation of all the
lesions. But in case, the proper treatment is delayed the proportion of
the permanent damage is likely to be more and thus several areas are
likely to persist in spite of treatment.
The treatment for such residual patches lies in either accepting
them as the scars of the disease or the patient can opt for surgical
replacement of the skin from the normally pigmented skin areas.
It has been observed that if a patient takes this treatment
continuously for a period of 4 years (2 years of full dose and for the next
2 years, half the dose), there is as a rule no reactivation of the disease,
after the complete withdrawal of the treatment.
Thus, with the modified-OMP regimen as described here, almost
all patients can achieve the desired response and recover from vitiligo.
In case, however, the parameters of the protocol are not followed
strictly, the disease will have its natural course. In that case if the body
is able to overcome the disease process on its own the disease will stop
progressing and even the patches may repigment spontaneously. But
when the disease is active and more aggressive, new lesions will continue
to appear and the whole body can become totally depigmented (white).
If a patient is too afraid of the side effects of the drugs, he may
choose to let the disease have its natural course, vitiligo is not a life
threatening disease, though it has a profound psychological effect on self
respect. Moreover, loss of pigment does make a person more vulnerable
to the effects of sunlight on the skin.
The drugs used for vitiligo as a rule are well tolerated.
Azathioprine has been listed to have a variety of side effects but
practically when used in this dose, it has hardly ever produced any
side effect. There is only an occasional patient who cannot tolerate
azathioprine. Such a patient can be treated with cyclophosphamide
in the same dose. And there is no patient who cannot tolerate either of
these drugs.
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Treatment Protocol for Vitiligo 13
Betamethasone, being a corticosteroid, is also considered to be a

notorious drug capable of producing a large variety of side effects. But
most patients and some doctors do not realize that there is a tremendous
difference between using a corticosteroid on a daily basis or a pulse
form of dosage schedule.
All the side effects of corticosteroids are recorded for using the
drug on a daily basis. When used in pulse form, even a dose of 300 mg
betamethasone given once in 4 weeks does not produce the same side
effects as produced by 2 mg of betamethasone given every day. This is
because the pulse dose of betamethasone remains in the body for less
than 5 days and for the remaining 23 days there is no betamethasone in
the body. Thus, with the pulse form of therapy, the therapeutic effect
is enhanced, while the side effects are reduced. The concept of oral
mini-pulse (OMP) therapy, also was developed on the same basis. The
corticosteroid is present only for 3 days in the body and for the rest of
the week there is no corticosteroid.
The major problem with the betamethasone OMP is an increase in
body weight and if a patient realizes that the fat in the body comes from
food and not the drug, a proper reduction in the food intake coupled
with a regular check on body weight will reduce this side effect.
Betamethasone can be given to even diabetics and the treatment
for diabetes can be readjusted to keep the blood sugar levels under
control.
The other side effects, such as acneform eruptions, and hirsutism
occur only in young individuals and more often these are concomitant
diseases and not the side effects of OMP.
More serious side effects of corticosteroids such as osteoporosis,
avascular necrosis, immune suppression, increased infections etc.
have almost never been observed, unless there is an additional cause
responsible for the same.
If the person does not put on excessive weight, there is no chance of
developing stretch marks.
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FAVORITE PRESCRIPTION FOR VITILIGO

• Azoran (50 mg)
2 tablets daily with breakfast
(Do not use in children)
• Betnesol Forte (1.0 mg)
5 tablets with breakfast every Saturday and Sunday
(Reduce the dose proportionately in children)
• Flutivate cream
Massage on the white patches once a day (preferably at night)
• No restrictions for food
After 2 years of uninterrupted treatment
• Reduce Azoran (50 mg) to 1 tablet daily
• Reduce Betnesol Forte (1.0 mg) to 3 tablets every Saturday and
Sunday
• Continue Flutivate cream once a day.
After 2 more years of uninterrupted treatment
• Stop all oral drugs
• Continue Flutivate cream once a day on the residual lesions.
• Can opt for skin grafting over the residual lesions.
Check for complete control of the disease:
No new lesions, No extension of the old lesions, with photographic
records of all the lesions
If the treatment is interrupted at any stage for any reason, the whole
treatment will have to be started all over again.
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CHAPTER
Case Histories
4
This chapter contains a collection of a few case histories, selected from
among the patients treated with 3 different treatment schedules:
• Explosive vitiligo treated with the full dose modified OMP regimen
• Mildly active vitiligo treated with half dose modified OMP regimen
• Very mildly active or stable vitiligo treated with oral levamisole and
topical fluticasone cream.
Different patients have been selected to represent their behavior and
response of the different patients to the treatment schedules.
PATIENTS TREATED WITH FULL DOSE

MODIFIED OMP REGIMEN
Name: IM, 40 years, Female

(Vitiligo Activity ++)
Date of visit and
Observations Management/Treatment
investigations
27.8.2008 Duration: 10 years 1. Photographs of all the
Lesions on hands, finger tips, white patches
BSA – 5%
feet, flank 2. Start Azoran (50 mg)
Body weight – 64 Kg 2 tablets daily
15.9.2008 Spreading since 1 year 3. Start Betnesol Forte
Hb – 12.8 Taken Homeopathy but still (1.0 mg) 5 tablets with
TLC – 10230 increasing breakfast every Saturday
ESR – 30 and Sunday
Blood sugar – 103 Review after 1–2 months 4. Start Flutivate cream once
Blood urea – 19 a day on the white patches
SGOT – 29 5. No restrictions for food
SGPT – 32 No Homeopathy
No Ayurvedic medicine
6. Start Lancid-30
1 tablet daily
7. No interruptions
Units used: Hb – g/dL, TLC – per mm3, ESR – mm (first hour), Blood sugar – mg/dL,
Blood urea – mg/dL, SGOT and SGPT – IU/L
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Date of visit and

investigations
23.12.2008 Finger tip lesions: improving 1. Continue Azoran (50 mg)
Toe-tips: almost normal 2 tablets daily
Weight – 67 Kg
Flank lesion: fainter 2. Continue Betnesol Forte
13.12.2008 Heels: better (1.0 mg) 5 tablets every
Hb – 12.1 Saturday and Sunday
TLC – 6560 3. Continue Flutivate cream
Repeat visit after 3 months
ESR – 15 once a day
Blood sugar – 97 4. Photographs to be
Blood urea – 17.2 repeated
SGOT – 37
SGPT – 16
7.10.2009 Did not report 1. Do not use any color on
Says, she continued the feet
Weight – 67 Kg
treatment 2. Continue Azoran (50 mg)
5.10.2009 Had used red color (Alta) 2 tablets daily
Hb – 11.4 on feet 3. Continue Betnesol Forte
TLC – 4580 (1.0 mg) 5 tablets every
ESR – 11 Saturday and Sunday
Review after 3 months
Blood sugar – 88 4. Continue Flutivate cream
Blood urea – 8 once a day
SGOT – 17 No interruptions
SGPT – 18 5. Take other drugs as
required
6. Cifran OD (1000 mg)
1 tablet daily for loose
motions
21.5.2010 Did not report 1. Continue the same
Almost no lesion except on treatment
Weight – 66 Kg
heels
19.6.2010 95% recovery
Hb – 12.4
TLC – 8300 Review after 3 months
ESR – 45
Blood sugar – 73
Blood urea – 20
SGOT – 19
SGPT – 12
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Case Histories 17
Date of visit and

investigations
7.10.2010 The lesions only on the sides 1. Reduce Azoran (50 mg) to
of feet (heels) 1 tablet daily
Weight – 66 Kg
2. Reduce Betnesol Forte
4.10.2010 (1.0 mg) to 3 tablets every
TLC – 6830 3. Flutivate cream once a day
ESR – 31 4. Photographs of the
Blood sugar – 149 residual lesions
Blood urea – 22 5. Treatment for anemia
SGOT – 26 (consult physician)
SGPT – 21
14.7.2011 Vitiligo lesions are present 1. The same treatment has to
only on the heels, which too be continued to extinguish
Weight – 71 Kg
are fading the disease process
12.7.2011 Cataract completely
Hb – 12.2 2. Can go in for cataract
TLC – 8050 operation if necessary
ESR – 25 3. Tenovate-M cream on the
Blood sugar – 70 paronychial fold 4–5 times
Blood urea – 26 a day
SGOT – 14
SGPT – 15
20.6.2012 Lesions on the left heel 1. Continue the same
fading treatment
Weight – 75 Kg
Not much change on right
18.6.2012 heel
Hb – 13.8 Noticed a few small spots
TLC – 8300
ESR – 45 Review after 6 months
Blood sugar – 102
Blood urea – 22
SGOT – 27
SGPT – 22
28.11.2012 Completed 4 years of 1. The treatment for vitiligo
treatment has been completed
Weight – 73 Kg
Vitiligo patches on the heels 2. Stop Azoran
17.11.2012 are quite faint now 3. Stop Betnesol
Hb – 13.1 4. Continue Flutivate cream
TLC – 6800 once a day on the heels
Review after 6 months or
ESR – 21 5. Repeat photographs of the
earlier if necessary
Blood sugar – 111 heels
Blood urea – 24
SGOT – 17
SGPT – 18
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Summary
IM, 40 years, Female
• She had vitiligo for 10 years and the disease had (++) activity at the
time of starting the treatment. The disease was spreading since the
last one year and involved 5% of the body surface area (BSA). Full
dose Modified OMP regimen for 2 years (27.8.2008 to 7.10.2010)
followed by half dose treatment for another 2 years (7.10.2010 to
28.11.2012) led to almost complete recovery with residual lesions on
the heels which too were fading
• Her body weight increased from 64 Kg to 73 Kg by the end of the
treatment. She had also developed loose motions for which
ciprofloxacin was given, cataract which was operated and candidial
infection of the finger nail.
Salient Features
Name, Age, Sex IM, 40/F
Duration of the disease 10 years
Activity of the disease (++)
Body surface area of involvement (5%)
Duration of treatment
Full dose 2 years 1 month
Half dose 2 years 1 month
Extent of repigmentation 99%
Changes in Body Weight

Full dose
64 67 67 66
27.8.2008 23.12.2008 7.10.2009 21.5.2010
Half dose
66 71 75 73
7.10.2010 14.7.2011 20.6.2012 28.11.2012
• While taking full dose, the increase in body weight was only 2 Kg
• On half the dose, the body weight increased from 66 to 73 Kg
• The body weight increases if the patient does not control the food
intake.
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Case Histories 19
Name: SS, 25 years, Female

(Vitiligo Activity +)
Date of visit and
investigations
20.12.2007 Duration since June 2006 1. Close up photographs of
Lesions on legs all the white patches
Weight – 42 Kg
2. Start Azoran (50 mg)
BSA – 5%
Review after 2–3 months 2 tablets daily
25.12.2007 3. Start Betnesol Forte
Hb – 9.8 (1.0 mg) 5 tablets every
TLC – 7600 Saturday and Sunday
ESR – 25 4. Start Flutivate cream
Blood sugar – 96 once a day at any time
Blood urea – 22 5. Expose to sun whenever
SGOT – 35 possible
SGPT – 27 No restrictions for food
No Homeopathy
No Ayurvedic medications
29.3.2008 No new lesions 1. Continue Azoran (50 mg)
Several lesions are 2 tablets daily
Weight – 45 Kg
repigmenting 2. Continue Betnesol Forte
25.3.2008 (1.0 mg) 5 tablets every
Blood sugar – 97
Blood urea – 20
SGOT – 49
SGPT – 85
2.7.2008 Approximately 30% 1. Continue Azoran (50 mg)
repigmentation 2 tablets daily
Weight – 45 Kg
2. Continue Betnesol Forte
Hb – 11 Saturday and Sunday
Blood sugar – 108 4. Blemish lotion on
Blood urea – 26 pigmented areas of cheeks
SGOT – 15 2–3 times a day
SGPT – 24
Ch-4.indd 19 09-01-2014 11:29:41

Date of visit and

investigations
15.10.2008 Further repigmentation 40% 1. Continue Azoran (50 mg)
2 tablets daily
Weight – 46 Kg
Review after 3 months 2. Continue Betnesol Forte
Blood sugar – 95 4. Clotrin lotion on back
Blood urea – 23 (Pityriasis versicolor) twice
SGOT – 18 a day
SGPT – 21
4.2.2009 Slow changes 1. Continue Azoran (50 mg)
2 tablets daily
Weight – 46 Kg
Review after 3–4 months 2. Continue Betnesol Forte
Blood sugar – 109 4. Fresh photographs
Blood urea – 16
SGOT – 34
SGPT – 24
16.6.2009 All lesions are reducing 1. Continue Azoran (50 mg)
Weight – 45 Kg Patient is keen for grafting 2 tablets daily
13.6.2009
Review after 4–6 months (1.0 mg) 5 tablets every
Hb – 10.7
Saturday and Sunday
TLC – 5300
3. Continue Flutivate cream
ESR – 50
once a day
Blood sugar – 97
4. Can use narrow band UVB
Blood urea – 23
for further repigmentation
SGOT – 20
SGPT – 22
21.10.2009 Most lesions are reducing 1. Continue Azoran (50 mg)
Weight – 45 Kg and are small 2 tablets daily
15.10.2009
Review after 6 months (1.0 mg) 5 tablets every
Hb – 10
Saturday and Sunday
TLC –5200
3. Flutivate cream once a day
ESR – 25
4. For Pityriasis versicolor
Blood sugar –117
Repeat Clotrin lotion twice
Blood urea – 16
a day (face)
SGOT – 21
5. For boils:
SGPT – 18
Cephadroxyl (500 mg)
1 tablet twice a day for
1–2 weeks
Ch-4.indd 20 09-01-2014 11:29:41

Case Histories 21
Date of visit and

investigations
8.6.2010 Further reduction 1. Reduce Azoran (50 mg) to
Narrow band (NB) exposures 1 tablet daily
Weight – 47 Kg
for 3 months in Patna were 2. Reduce Betnesol Forte
5.6.2010 of no additional benefit (1.0 mg) to 3 tablets every
ESR – 60
Blood sugar – 98
Blood urea – 32
SGOT – 16
SGPT – 27
Date Almost static 1. Continue Azoran (50 mg)
5.4.2011 1 tablet daily
Weight – 50 Kg
(1.0 mg) 3 tablets every
2.4.2011 Saturday and Sunday
Hb – 10.6 3. Flutivate cream once a day
TLC – 5700 4. Can opt for grafting for the
ESR – 34 residual lesions
Blood sugar – 106
Blood urea – 20
SGOT – 27
SGPT – 33
5.11.2011 Has not brought previous 1. Continue Azoran (50 mg)
records 1 tablet daily
Started treatment on 2. Continue Betnesol Forte
Reduced on 8.6.2010 Saturday and Sunday
The lesions are fading 3. Flutivate cream once a day
15.5.2012 Only a few spots on feet 1. Stop Azoran (50 mg)
(also fading) 2. Continue Betnesol Forte
Weight – 49 Kg
Review after 1 year Saturday and Sunday
After 6 months, reduce
Betnesol to 3 tablets only
on Sundays
Ch-4.indd 21 09-01-2014 11:29:42

Summary
SS, 25 years, Female
• She had a low (+) activity disease which had started 1.5 years ago
• Full dose Modified OMP between 20.12.2007 to 8.6.2010 (2.5 years)
followed by half dose Modified OMP between 8.6.2010 to 15.5.2012
(2 years) led to almost complete repigmentation except for a few
spots on the feet which were also fading
• Her body weight was 42 Kg at the start of treatment and 49 Kg at the
last visit. She also developed pityriasis versicolor during this period.
Salient Features
Name, Age, Sex SS, 25/F
Duration of the disease 1 year 6 months
Activity of the disease (+)
Full dose 2 years 6 months
Half dose 2 years

Full dose
42 45 45 46 46 45
20.12.2007 29.3.2008 2.7.2008 15.10.2008 4.2.2009 16.6.2009
45
21.10.2009
Half dose
47 50 Not recorded 49
8.6.2010 5.4.2011 5.11.2011 15.5.2012
Ch-4.indd 22 09-01-2014 11:29:42

Case Histories 23
Name: RB, 17 years, Male

Date of visit and
investigations
9.4.2008 Duration: 10 years 1. Close up photographs of
Various treatments taken; all the white patches
BSA – 7%
Homeopathy for 2 years 2. Start Azoran (50 mg)
Weight – 52 Kg
Ram dev 2 tablets daily
Lesions mostly on legs, feet,
ankles, right elbow and
TLC – 8500 Saturday and Sunday with
forehead
ESR – 11 breakfast
Blood sugar – 89 4. Start Flutivate cream once
Blood urea – 27 Review after 1 month
a day at any time
SGOT – 26 5. No restrictions for food
SGPT – 11 No interruptions
No Homeopathy
No Ayurvedic medicines
22 .9.2008 Started the treatment on 1. Continue Azoran (50 mg)
21.8.2008 2 tablets daily
Weight – 54 Kg
Several lesions look 2. Continue Betnesol Forte
20.9.2008 improved (1.0 mg) 5 tablets every
TLC – 6600 3. Massage Flutivate cream
Blood sugar – 73
Blood urea – 10
SGOT – 18
SGPT – 14
24.12.2008 10% repigmentation 1. Continue Azoran (50 mg)
Some lesions have 2 tablets daily
Weight – 62 Kg
disappeared 2. Continue Betnesol Forte
17.12.2008 Most others reduced (1.0 mg) 5 tablets every
Review once in 3 months
ESR – 5 4. Reduce body weight
Blood sugar – 100
Blood urea – 19
SGOT – 16
SGPT – 20
Ch-4.indd 23 09-01-2014 11:29:42

Date of visit and

investigations
2 tablets daily
Weight – 62 Kg
ESR – 8 4. For acne:
Blood sugar – 86 Cifran OD (1000 mg)
Blood urea – 21 1 tablet daily for 1 month
SGOT – 13 5. Dipgenta cream on
SGPT – 15 pimples twice a day
21.9.2009 Further repigmentation 1. Continue Azoran (50 mg)

2 tablets daily
19.9.2009
Hb – 13.90
TLC – 5900
Saturday and Sunday
ESR – 20
Blood sugar – 91
Blood urea – 17
SGOT – 21
SGPT – 19
29.3.2010 Almost 40% repigmentation 1. Reduce Azoran (50 mg) to

1 tablet daily
Weight – 47 Kg
Review after 6 months 2. Reduce Betnesol Forte
ESR – 43 Repeat foot photographs
Blood sugar – 81
Blood urea – 16
SGOT – 22
SGPT – 19
21.9.2010 Slow recovery 1. Continue Azoran (50 mg)
Also Pityriasis versicolor 1 tablet daily
Weight – 60 Kg
Blood sugar – 114 Saturday and Sunday
Blood urea – 24 3. Continue Flutivate cream
SGOT – 26 once a day
SGOT – 18 4. For pityriasis versicolor:
Continue Clotrin lotion
twice a day for 1–2 months
Ch-4.indd 24 09-01-2014 11:29:42

Case Histories 25
Date of visit and

investigations
28.5.2011 Slow improvement 1. Continue the same
treatment
Weight – 70 Kg
Review after 6 months 2. No interruptions
25.5.2011
Hb – 14.50
TLC – 8500
ESR – 7
Blood sugar – 83
Blood urea – 19
SGOT – 20
SGPT – 19
26.12.2011 Slow repigmentation 1. Continue the same
treatment
Weight – 75 Kg
Review after 6 months 2. Etaze-AF cream in the
22.12.2011 private parts
Hb – 14.6 2–3 times a day for fungal
TLC – 7800 infection or Tenovate-M
ESR – 30 cream in the groins twice a
Blood sugar – 90 day for 2 months
Blood urea – 16
SGOT – 26
SGPT – 26
26.9.2012 4 years of treatment 1. Stop Azoran
completed 2. Reduce Betnesol Forte
Weight – 72 Kg
(1.0 mg) to 3 tablets only
21.9.2012 on Sundays for 6 months
Review after 1 year
Hb – 13.20 then stop
TLC – 4500 3. Flutivate cream
ESR – 09 4. Photographs
Blood sugar – 86/114 5. Calcium Pantothenate
Blood urea – 23 (200 mg) 1 tablet daily
SGOT – 21 (Vighan-CP) for grey hairs
SGPT – 19
Ch-4.indd 25 09-01-2014 11:29:42

Summary
RB, 17 years, Male
This patient started having vitiligo 10 years ago and had been treated
with Homeopathy and Ayurvedic medicines before coming to us.
Full dose Modified OMP for 1.5 years (21.8.2008 to 29.3.2010)
followed by half dose for 2.5 years (29.3.2010 to 26.9.2012) produced the
desired result.
Side effects included increase in body weight (52 Kg to 72 Kg in
4 years) and pityriasis versicolor and tinea cruris.
Salient Features
Name, Age, Sex RB, 17/M
Full dose 1 year 7 months
Half dose 2 years 6 months

Full dose
52 54 62 62 Not recorded
9.4.2008 22.9.2008 24.12.2008 22.5.2009 21.9.2009
Half dose
47 60 70 75 72
29.3.2010 21.9.2010 28.5.2011 26.12.2011 26.9.2012
Body weight increased whenever he did not control his food intake.
Ch-4.indd 26 09-01-2014 11:29:42

Case Histories 27
Name: NT, 15 years, Female

Date of visit and
investigations
14.3.2008 Duration: 3 years 1. Photographs of all the
Treated by Dinesh Govil white patches
BSA – 25%
2. Start Azoran (50 mg)
Weight – 50 Kg Lesions on eyelids, neck,
2 tablets daily
cubital fossae, flanks, legs
3. Start Betnesol Forte
Increasing rapidly since
1 month
Saturday and Sunday with
breakfast
Review after 1–2 months
4. Start Flutivate cream,
massage on the white
patches once a day at any
time
5. No restrictions
No interruptions
No Homeopathy
5.6.2008 Adequate response 1. Continue Azoran (50 mg)
15% repigmentation on 2 tablets daily
Weight – 50 Kg
almost all areas 2. Continue Betnesol Forte
3.6.2008 No new lesions (1.0 mg) 5 tablets every
Blood sugar – 94
Blood urea – 25
SGOT – 27
SGPT – 30
4.9.2008 Photographs left at home 1. Not to miss any dose
Missed 2–3 doses of Azoran 2. Continue Azoran (50 mg)
Weight – 50 Kg
2 tablets daily
30.8.2008 3. Continue Betnesol Forte
TLC – 6900 Saturday and Sunday with
ESR – 30 breakfast
Blood sugar – 96 4. Continue Flutivate cream
Blood urea – 22 once a day
SGOT – 40 5. To bring photographs
SGPT – 36 every time
Ch-4.indd 27 09-01-2014 11:29:42

Date of visit and

investigations
2 tablets daily
Weight – 53 Kg
Blood sugar – 70
Blood urea – 39
SGOT – 50
SGPT – 24
1.5.2009 70% repigmentation 1. Fresh photographs
2. Continue Azoran (50 mg)
Weight – 50 Kg
Review after 3–4 months 2 tablets daily
19.5.2009 3. Continue Betnesol Forte
Hb – 10 (1.0 mg) 5 tablets every
TLC – 6900 Saturday and Sunday
ESR – 58 4. Continue Flutivate cream
Blood sugar – 100 once a day
Blood urea – 24
SGOT – 19
SGPT – 23
31.10.2009 Further repigmentation 1. Continue Azoran (50 mg)
Weight – 51 Kg 2 tablets daily
Review after 6 months (1.0 mg) 5 tablets every
Saturday and Sunday
12.4.2010 Further repigmentation 1. Reduce Azoran (50 mg) to

1 tablet daily
Weight – 56 Kg
Review after 6 months 2. Reduce Betnesol Forte
ESR – 47
SGOT – 26
SGPT – 29
Ch-4.indd 28 09-01-2014 11:29:42

Case Histories 29
Date of visit and

investigations
27.11.2010 Most of the lesions have 1. Continue the same
faded except those on the treatment
Weight – 54 Kg
ankle and legs 2. Fresh photographs to be
taken
Review after 6 months 3. No interruption
27.7.2011 Slow improvements in the 1. Continue the same
remaining lesions treatment
Weight – 54 Kg

9.6.2012 Lesions only on ankles 1. Stop Azoran
Others have faded 2. Reduce Betnesol Forte
Weight – 50 Kg
(1.0 mg) 3 tablets only on
8.6.2012 Sundays
Hb – 10.6 3. Continue Flutivate cream
TLC – 7000 once a day
ESR – 25 4. Fresh Photographs of the
SGOT – 40 residual lesions
SGPT – 27
7.3.2013 The remaining lesions are 1. Stop Betnesol

static 2. Continue Flutivate
Weight – 51 Kg
cream once a day on the
6.3.2013 remaining areas
Hb – 10 3. To report if there is
or 1 year
TLC – 8400 reactivation of the disease
ESR – 20
SGOT – 60
SGPT – 50
Ch-4.indd 29 09-01-2014 11:29:42

Summary
NT, 15 years, Female
This patient had a relatively recent disease, and followed the protocol
of treatment fairly satisfactorily (full dose for 2 years and half dose for
2 years) and showed a very good response (90% repigmentation).
The increase in body weight was well controlled (50 to 51 Kg) during
full dose treatment and once again during half dose treatment although
it had increased in between whenever the food intake was not controlled
adequately.
Salient Features
Name, Age, Sex NT, 15/F
Full dose 2 years 1 month

Full dose
50 50 50 53 50 51
14.3.2008 5.6.2008 4.9.2008 22.1.2009 1.5.2009 31.10.2009
Half dose
56 54 54 50
12.4.2010 27.11.2010 27.7.2011 9.6.2012
Follow up
51
7.3.2013
Ch-4.indd 30 09-01-2014 11:29:42

Case Histories 31
Name: AT, 14 years, Male

Vitiligo Reactivating with OMP—less dose (Activity ++)
Date of visit and
investigations
1.7.2008 Vitiligo started in Feb 2007 1. Photographs of all the
Treated with Levamisole white patches for accurate
Weight – 44 Kg
with partial control assessment
BSA – 0.5%
Started Betnesol Forte 2. Start Azoran (50 mg)
7.7.2008 2 OMP on October 2007 2 tablets daily with
Hb – 13.9 Reactivating breakfast
TLC – 10900 3. Start Betnesol Forte
ESR – 4 (1.0 mg) 5 tablets every
Review after 1 month
Blood sugar – 115 Saturday and Sunday with
Blood urea – 8 breakfast
SGOT – 29 4. Start Flutivate cream,
SGPT – 20 massage on the white
patches once a day at any
convenient time
5. No restrictions
No interruptions
No Homeopathy
13.8.2008 No new lesion 1. Continue Azoran (50 mg)
Noticed a lesion on the left 2 tablets daily
Weight – 44 Kg
big toe 2. Continue Betnesol Forte
Blood sugar – 75
Blood urea – 5
SGOT – 18
SGPT – 23
7.11.2008 Several lesions have 1. Continue Azoran (50 mg)
disappeared 2 tablets daily
Weight – 45 Kg
40% repigmentation 2. Continue Betnesol Forte
31.10.2008 Acne on forehead (1.0 mg) 5 tablets every
Hb – 13.8 Pityriasis versicolor Saturday and Sunday
Blood sugar – 101 4. Clotrin lotion on scaly
Blood urea – 24 patches twice a day
SGOT – 22
SGPT – 20
Ch-4.indd 31 09-01-2014 11:29:42

Date of visit and

investigations
7.3.2009 At present lesions only on 1. Continue Azoran (50 mg)
feet 2 tablets daily
Weight – 45 Kg
All others have repigmented 2. Continue Betnesol Forte
Review in 3–4 months
Blood sugar – 88 4. Clotrin lotion twice a day
Blood urea – 18
SGOT – 19
SGPT – 7
15.5.2010 Did not report but 1. Continue the same
continued the treatment treatment for 2 months
10.5.2010
A lesion only on left foot more
Hb – 12.7
outer side 2. After that reduce Azoran
TLC – 14500
All others repigmented (50 mg) to 1 tablet daily
ESR – 10
Blood sugar – 90
Review after 3–6 months (1.0 mg) to 3 tablets every
Blood urea – 15
Saturday and Sunday
SGOT – 22
4. Flutivate cream on the
SGPT – 32
remaining lesion
5. Photograph the remaining
lesion
27.6.2011 Did not report 1. Continue the same
Reduced the dose in July treatment
Weight – 61 Kg
2010
23.6.2011 The lesions are fading
Hb – 14.6 No new lesions
TLC – 7800
Platelets – 178 Review once in 6 months
ESR – 8
Blood sugar – 85
Blood urea – 9
SGOT – 20
SGPT – 10
Ch-4.indd 32 09-01-2014 11:29:42

Case Histories 33
Date of visit and

investigations
1.2.2012 A single lesion on the left 1. Continue the same
outer malleolus treatment
Weight – 65 Kg
27.1.2012 Review after 6 months

Hb – 15.6
TLC – 7500
ESR – 03
Blood sugar – 71
Blood urea – 23
SGOT – 23
SGPT – 10
17.7.2012 The only lesion on the left 1. Stop Azoran
lateral malleolus is persisting 2. Continue Betnesol Forte
Weight- 66 Kg
No increase (1.0 mg) 3 tablets every
13.7.2012 Saturday and Sunday
Hb – 13.1 3. Flutivate cream once a day
TLC – 7.60 After 6 months reduce
or 1 year
ESR – 02 Betnesol Forte (1.0 mg) to
Blood sugar – 81 3 tablets only on Sundays
Blood urea – 8
SGOT – 24
SGPT – 30
9.2.2013 Only minor lesions on left 1. Reduce Betnesol Forte
foot (1.0 mg) to 3 tablets only
Weight – 65 Kg
on Sundays for 6 months
Review after 6 months 2. Flutivate cream once a day
Ch-4.indd 33 09-01-2014 11:29:42

Summary
AT, 14 years, Male
This patient was given approximately 2 years of full dose Modified OMP
and the next 2 years half dose with almost complete recovery.
In between, he did not report (which is a bad practice) but continued
the treatment.
The only side effects/concomitant diseases were increase in body
weight (From 44 kg to 65 kg in 4 years), acne and pityriasis versicolor.
Salient Features
Name, Age, Sex AT, 14/M
Duration of the disease 1 year 5 months
Body surface area of involvement (0.5%)
Full dose 2 years
Half dose 2 years

Full dose
44 44 45 45
1.7.2008 13.8.2008 7.11.2008 7.3.2009
Half dose
Not recorded 61 65 66 65
15.5.2010 27.6.2011 1.2.2012 17.7.2012 9.2.2013
The body weight was under control in spite of full dose as long as the
food intake was controlled.
It however, increased when the food intake was not controlled.
Ch-4.indd 34 09-01-2014 11:29:43

Case Histories 35
Name: AKJ, 49 years, Male

(Vitiligo Activity +++) with diabetes
Date of visit and
investigations
9.7.2008 Started in 2005 1. Photographs of all the
Treated by VP Kaushik white patches
Weight – 73 Kg
OMP-3 2. Start Azoran (50 mg)
BSA – 20%
Trimop 2 tablets daily
10.7.2008 Repigmented in 3. Start Betnesol Forte
Hb – 12.5 3–5 months (1.0 mg) 5 tablets every
TLC – 8600 Recurrence Saturday and Sunday with
ESR – 6 Homeopathy breakfast
Blood sugar – 181 Increased 4. Start Flutivate cream,
Blood urea – 22 No treatment since massage on the white
SGOT – 35 1 month patches once a day at any
SGPT – 34 Lesions on: time
25.7.2008 Hands, finger tips, 5. No restrictions for food
Hb – 12.8 forearms, elbow, lips, or medicines for other
Blood sugar – 164 feet, ankles, toe tips, diseases
knee, legs, upper back, 6. Control diabetes
neck (Physician)
7. No Homeopathy
Review after 1 month No Ayurvedic products
No interruptions
13.8.2008 No extension of lesions 1. Continue Azoran (50 mg)
No new lesions 2 tablets daily
Weight – 73 Kg
Some lesions are already 2. Continue Betnesol Forte
11.8.2008 repigmenting (1.0 mg) 5 tablets every
Blood sugar – 190 4. No restrictions
Blood urea – 24
SGOT – 10
SGPT – 12
Ch-4.indd 35 09-01-2014 11:29:43

Date of visit and

investigations
24.10.2008 Several lesions have 1. Continue Azoran (50 mg)
Weight – 67 Kg disappeared/reduced 2 tablets daily
20.10.2008 Review after 3 months (1.0 mg) 5 tablets every
ESR – Not done once a day
Blood sugar – 122/104
Blood urea – 24
SGOT – 21
SGPT – 17
Weight – 74 Kg 2 tablets daily
Review in 3 months 2. Continue Betnesol Forte
Blood sugar – Not
done
Blood urea – 22
SGOT – 19
SGPT – 21
10.5.2010 Taking Betnesol Forte 1. Fresh photographs
Weight – 77 Kg 2 tablets since 2 weeks 2. Continue Full dose
Only a few lesions, Azoran (50 mg) 2 tablets
1.5.2010 mostly on hands and daily
Hb – 14.5 feet Betnesol Forte (1.0 mg)
TLC – 6600 5 tablets every Saturday
ESR – 5 and Sunday till 9.7.2010
Blood sugar – 98 Review after 6 months 4. Then reduce Azoran
Blood urea – 20 (50 mg) to 1 tablet daily
SGOT – 21 and Betnesol Forte
SGPT – 18 (1.0 mg) to 3 tablets
every Saturday and
Sunday
Ch-4.indd 36 09-01-2014 11:29:43

Case Histories 37
Date of visit and

investigations
1.3.2011 He continued to take 1. Change to proper half
Azoran 2 tablets daily dose
Weight – 79 Kg
Reduced Betnesol Forte 2. Reduce Azoran (50 mg) to
17.2.2011 to 2 tablets Saturdays and 1 tablet daily
Hb – 14.8 Sundays on 9.7.2010 3. Increase Betnesol Forte
TLC – 5700 (1.0 mg) to 3 tablets every
ESR – 05 Saturday and Sunday
Blood sugar – 94 4. Flutivate cream once a day
Blood urea – 19
SGOT – 23
SGPT – 20
1.5.2013 Did not report 1. Stop Azoran
Continued the treatment 2. Stop Betnesol
Weight – 77 Kg
Completed (2+2) years of 3. Continue Flutivate cream
5.7.2012 treatment once a day
Hb – 11 The residual patches are 4. Fresh photographs of the
TLC – 6200 fading residual lesions
ESR – 10
Blood sugar – 103 Review once in 6 months
Blood urea – 24
5.4.2013
Hb – 12
TLC – 6400
ESR – 05
Blood sugar – 88
Blood urea – 18
SGOT – 19
SGPT – 13
Ch-4.indd 37 09-01-2014 11:29:43

Summary
AKJ, 49 years, Male
This patient had highly active vitiligo, but was easily controlled with the
full dose Modified OMP therapy. He also showed a remarkable recovery
but since he had changed the treatment in between on his own, he is
vulnerable for a relapse in future. The patient is expected not to interfere
with the treatment protocol if he wants to recover from the disease
completely.
Salient Features
Name, Age, Sex AKJ, 49/M
Activity of the disease (+++)
Full dose 2 years

Full dose
73 73 67 74 77
9.7.2008 13.8.2008 24.10.2008 5.2.2009 10.5.2010
Half dose
79 77
1.3.2011 1.5.2013
Ch-4.indd 38 09-01-2014 11:29:43

Ch-4.indd 39
Table 4.1 Comparison of the response in 6 patients treated with the Full dose Modified OMP regimen
No. Name Age & Sex Duration Activity BSA Treatment Full dose Half dose %
(years) (%) (years) (years) Repigmentation
1. IM 40/F 10 ++ 5% 2.1 2.1 99%
2. SS 25/F 1.6 + 5% 2.6 2 90%
3. RB 17/M 10 ++ 7% 1.7 2.6 40%
4. NT 15/F 3 ++ 25% 2.1 2.2 90%
5. AT 14/M 1.5 ++ 0.5% 2 2 99%
6. AKJ 49/M 3 +++ 20% 2 2.10 95%
Case Histories
39
09-01-2014 11:29:43
PATIENTS TREATED WITH

THE HALF DOSE MODIFIED OMP REGIMEN
Patients in whom the activity of the disease is low can be treated with
half the dose of the Modified oral mini-pulse therapy (OMP) regimen
(1 tablet of Azoran 50 mg daily, and 3 tablets of Betnesol Forte 1.0 mg
every Saturday and Sunday).
The treatment in these cases however, will have to be continued for 4
years without interruptions.
Flutivate cream in any case will have to be applied once a day till the
patches disappear completely.
Name: RCP, 60 years, Male

(Vitiligo Activity +)
Date of visit and
investigations
12.7.2003 Duration: 2 years 1. Explained the approach for
Started on the lips treating the disease
25.7.2003
Treatment taken: 2. The disease can be
Hb – 11.50
Patna controlled adequately
TLC – 9900
(Amar Kant) – 6 to 7 if proper treatment is
ESR – 30
months instituted
Blood sugar – 110
Rama Prasad – 3 months 3. All other treatments will
Blood urea – 24
Homeopathy – 3 to 4 have to be stopped
SGOT – 11
months, kept increasing 4. Close up photographs
SGPT – 18
GG Dhir Melaginina of the white patches for
Taking Decaris monitoring the progress
(Amar Kant) 5. Start Azoran (50 mg)
Taken several treatments 1 tablet daily
irregularly 6. Start Betnesol Forte
At present: (1.0 mg) 3 tablets with
Unani – till date breakfast every Saturday
? PUVA topical and Sunday
Lesions on 7. Start Flutivate cream
Lips massage on the white
Dorsum of hands patches once a day
Forehead 8. No restrictions for food
Scalp or medicines for other
Glans diseases
No history of Diabetes or
Hypertension
Ch-4.indd 40 09-01-2014 11:29:43

Case Histories 41
Date of visit and

investigations
14.8.2003 No new lesion 1. Continue Azoran (50 mg)
No extension 1 tablet daily
2.12.2003
No repigmentation 2. Continue Betnesol Forte
Hb- 13.0
TLC – 7800
Review after 2–3 months Saturday and Sunday
ESR – 10
Blood sugar – 100
Blood urea – 27
SGOT – 10
SGPT – 14
10.1.2004 All the lesions are 1. Continue Azoran (50 mg)
repigmenting 1 tablet daily
Weight – 73 Kg
Hb- 13.5 Saturday and Sunday
Blood sugar – 106 4. Take fresh photographs
Blood urea – 27
SGOT – 10
SGPT – 20
22.5.2004 Upper lip lesion (skin): 1. Continue Azoran (50 mg)
60% repigmented 1 tablet daily
Weight – 76 Kg
Lip lesions(mucosal): 2. Continue Betnesol Forte
14.5.2004 slightly improved (1.0 mg) 3 tablets every
Hb – 12.50 Forehead lesion: 40% Saturday and Sunday
TLC – 6600 repigmented 3. Continue Flutivate cream
ESR – 43 Hand lesion: 10% once a day
Blood sugar – 86 repigmented
Blood urea – 19
SGOT – 19 Review after 3-4 months
SGPT – 20
27.8.2004 Photographs have not been 1. Continue Azoran (50 mg)
brought 1 tablet daily
Weight – 72 Kg
Lesion on: 2. Continue Betnesol Forte
Forehead—very small (1.0 mg) 3 tablets every
Upper and lower lip: Saturday and Sunday
still present 3. Continue Flutivate cream
Hand lesion: static once a day
Ch-4.indd 41 09-01-2014 11:29:43

Date of visit and

investigations
24.12.2004 The lesions are almost static 1. Continue Azoran (50 mg)
Weight – 77 Kg No significant change 1 tablet daily
22.12.2004 (1.0 mg) to 2 tablets on
Hb – 13.8 Saturdays and 3 tablets on
TLC – 5800 Sundays
ESR – 27 3. Continue Flutivate cream
Blood sugar – 82 once a day
Blood urea – 12
SGOT – 18
SGPT – 19
1.7.2005 Upper lip lesion is reduced 1. Continue Azoran (50 mg)
Lower lip: insignificant 1 tablet daily
change 2. Reduce Betnesol Forte
Forehead lesion: smaller (1.0 mg) to 2 tablets on
Finger lesion: static Saturdays and Sundays
After 3 months reduce
Review after 6 months further to 2 tablets only on
Sundays
3. Continue Flutivate cream
once a day
4. Suggested grafting over
the finger lesion
1.5.2006 All the papers have not been 1. Stop Betnesol
brought. 2. Continue Azoran (50 mg)
Weight – 73 Kg
The lesions are almost static 1 tablet daily to be taken
for 6 months more and
Review after the grafting then stop
or if there is reactivation 3. Suggested grafting
over the remaining areas
at convenience
17.2.2007 No significant change 1. Stop Azoran
2. Can continue to use
Weight – 70 Kg
Review once a year or if Flutivate cream
there is recurrence 3. No restrictions
4. Grafting at convenience
5. Fresh photographs to be
taken
24.11.2007 Noticed a small new area on 1. Continue Flutivate cream
the chin 3–4 months ago once a day
Weight – 71 Kg
2. Photograph the area
Ch-4.indd 42 09-01-2014 11:29:43

Case Histories 43
Date of visit and

investigations
30.1.2012 Did not report 1. Repeat photographs
Some lesions static 2. Continue Flutivate cream
No new lesion once a day

to 1 year
Ch-4.indd 43 09-01-2014 11:29:43

Summary
RCP, 60 years, Male
This patient was having a restricted disease which was not being
controlled by other methods of treatment, as used by a variety of other
doctors and systems.
Since his disease was not very active, it was decided to treat him with
half the dose rather than the full dose OMP.
Follow up revealed that the Half dose OMP was sufficient for him.
After 1.5 years (instead of the standard 2 years), the dosages of the
drugs were progressively reduced. Betnesol was completely stopped
after nearly 3 years, and Azoran after another 9 months. (Total duration
of treatment is from 12.7.2003 to 17.2.2007).
A follow up of nearly 5 years after complete withdrawal of treatment
revealed that there was no reactivation of the disease though the residual
lesions persisted.
The patient was not interested in grafting
Salient Features
Name, Age, Sex RCP, 60/M
Full dose Nil

Full dose: Not used
Half dose
Not recorded Not recorded 73 76 72
12.7.2003 14.8.2003 10.1.2004 22.5.2004 27.8.2004
77 Not recorded 73 70 71
24.12.2004 1.7.2005 1.5.2006 17.2.2007 24.11.2007
Ch-4.indd 44 09-01-2014 11:29:43

Case Histories 45
Name: AS, 9 years, Female

Vitiligo reactivated after incomplete OMP
Date of visit Observations Management/Treatment
27.8.2007 Duration: 4 years 1. Close up photographs of
Body weight – 26 Kg Treated with OMP for 1.5 all the white patches
years (Saraswat) controlled 2. Start Azoran (50 mg)
Stopped the treatment on 1 tablet daily
Reactivation on stopping (1.0 mg) 3 tablets every
The lesions at present on Saturday and Sunday with
finger tips, chest, feet, breakfast
ankles, knees, lips 4. Start Momate cream once
a day at any convenient
Review after 1–2 months time
5. No restrictions
15.10.2007 No new lesions 1. Continue Azoran (50 mg)
No extension 1 tablet daily
Weight – 28 Kg
Lesions on feet, knees are 2. Continue Betnesol Forte
repigmenting (1.0 mg) 3 tablets every
Saturday and Sunday
Review after 3 months 3. Continue Momate cream
once a day
4. For pain abdomen use
Lancid (30 mg)
1 tablet daily
14.1.2008 Knee lesions: significant 1. Continue Azoran (50 mg)
improvement 1 tablet daily
Weight – 30 Kg
Other areas: less change 2. Continue Betnesol Forte
Review after 3 months Saturday and Sunday
3. Can start Lancid (30 mg)
1 tablet daily
4. Momate cream once a day
19.3.2008 Developed jaundice 1. Restart Azoran (50 mg)
Treatment was stopped on 1 tablet daily
Weight – 30 Kg
21.2.2008 for 15 days 2. Restart Betnesol Forte
Jaundice has recovered (1.0 mg) 3 tablets every
and the lab tests are normal Saturday and Sunday
again 3. Restart Momate cream
Photographs do not reveal once a day
any increase 4. The tests should be
A single lesion on the right repeated after 7 days and
elbow 1 month

earlier if required
Ch-4.indd 45 09-01-2014 11:29:43


30.6.2008 Improvement in most areas 1. Continue Azoran (50 mg)
including paronychial areas 1 tablet daily
Weight – 32 Kg
No new lesions 2. Continue Betnesol Forte
Review once in 3 months Saturday and Sunday
2.1.2009 40% repigmentation 1. After 1 month stop Azoran
Weight – 38 Kg including the paronychial 2. Reduce Betnesol Forte
areas (1.0 mg) to 2 tablets every
Saturday and Sunday
Review after 4-6 months 3. Momate cream once a day
14.9.2009 No new lesions 1. Fresh photographs of all
Old photographs show the remaining lesions
Weight – 38 Kg
improvement 2. Continue Betnesol Forte
Review after 6 months Saturday and Sunday
29.3.2010 Almost static 1. Reduce Betnesol Forte
(1.0 mg) to 2 tablets only
Weight – 44 Kg
Review after 6 months on Sundays
13.6.2011 Mild changes 1. Stop Betnesol
Weight – 44 Kg
Review after 6 months to continue
or 1 year
1.8.2011 The patient feels the lesions 1. Fresh close up
Weight – 45 Kg on fingers have increased photographs of the lesions
The changes are not 2. Continue Momate cream
convincing 3. No need yet to start the
oral medicines
earlier if required
1.10.2012 All the white patches are 1. Continue Momate cream
faded on the white patches once
Weight – 45 Kg
Reaction at Tattoo site (done a day.
in Goa) Apply 2–3 times a day on
the tattoo
Review after 1 year 2. No need for oral medicines
3. Photographs of the
remaining lesions
Ch-4.indd 46 09-01-2014 11:29:44

Case Histories 47
Summary
AS, 9 years, Female
This girl had vitiligo for the last 4 years. She was treated with OMP
therapy for 1.5 years during which the lesions were static, but the disease
reactivated on stopping the treatment.
Her treatment was restarted on 27.8.2007 with 50 mg azathioprine
daily and 3 mg betamethasone on 2 consecutive days per week.
The disease was completely under control but the treatment had to
be stopped for 15 days because of jaundice. Restarting the treatment
on 19.3.2008 led to repigmentation to the extent of 40%. In Feb 2009,
Azoran was stopped while betamethasone was reduced to 2 mg on 2
consecutive days per week. Betamethasone was stopped after another
2 years (13.6.2011).
On 1.10.2012, the residual lesions were faint and hardly visible.
Salient Features
Name, Age, Sex AS, 9/F
Full dose Nil
Half dose 3 years, 10 months

Full dose: Not used
Half dose
26 28 30 30 32
27.8.2007 15.10.2007 14.1.2008 19.3.2008 30.6.2008
38 38 44 44 45 45
2.1.2009 14.9.2009 29.3.2010 13.6.2011 1.8.2011 1.10.2012
Ch-4.indd 47 09-01-2014 11:29:44

Ch-4.indd 48
48
Table 4.2 Response of 2 patients treated with the Half dose Modified OMP regimen
No. Name Age & Sex Duration Activity BSA Treatment Half dose %
How to Cure a Skin Disease: Vitiligo
years( (%) Full dose (years) (years) Repigmentation

1. RCP 60/M 2 + 2% Nil 3.7 30%
2. AS 9/F 4 + 3% Nil 3.10 95%
09-01-2014 11:29:44
Case Histories 49
PATIENTS TREATED WITH LEVAMISOLE

Patients with very low activity of the disease, can be treated with
Levamisole using 150 mg every Saturday and Sunday with meals, along
with local applications of Flutivate cream once a day.
For children less than 5 years of age, the dose of Levamisole should
be reduced to 50 mg every Saturday and Sunday, and for those between
5–10 years, the dose should be 100 mg every Saturday and Sunday.
The duration of treatment in these cases will have to be 2 years at
least.
If Levamisole cannot be tolerated or if this regimen is unable to
control the disease activity completely (new lesions), the treatment
should be changed to the Modified OMP regimen.
Name: SS, 7 years, Male

Vitiligo limited slow spreading disease (Activity +)
1.4.2002 Started 1 year ago 1. Close up photographs of
Following trauma on the all the white patches for
left knee monitoring the progress
Right hand knuckle: 2. Start Levamisole (50 mg)
5 months 2 tablets every Saturday
Right leg: 6–7 months and Sunday with meals
Had 2 patches at the angles preferably at night.
of mouth To be continued
Treatment taken: 3. Start Flutivate cream once
Treated by Dr. Bose with a day on the white patches
Topical PUVA at any convenient time
Homeopathy for 1 year 4. No restrictions
No other treatment
Next visit after 1–2 months

11.5.2002 Started the treatment only 1. Continue/Start
yesterday (10.5.2002) Levamisole (50 mg)
No new lesion 2 tablets every Saturday
and Sunday
Next visit after 2 months 2. Start Flutivate cream once
a day
3. No restrictions
Ch-4.indd 49 09-01-2014 11:29:44


25.7.2002 Two patches (left knee 1. Continue Levamisole
and right leg) are showing (50 mg) 2 tablets every
repigmentation Saturday and Sunday
Hand lesion is very slightly 2. Continue Flutivate cream
smaller Massage once a day
3. Repeat photographs
13.11.2002 The lesions are showing 1. Continue Levamisole
repigmentation (50 mg) 2 tablets every
Saturday and Sunday
Next visit after 3 months 2. Continue Flutivate cream
once a day
3. For the scaly patches
start Lobate-M cream
2–3 times a day
6.3.2003 RIght leg: 80% repigmented 1. Continue Levamisole
Left knee: lower part (50 mg) 2 tablets every
repigmented and in upper Saturday and Sunday
part some pigmented spots 2. Continue Flutivate cream
seen once a day
Hand lesion: less change

26.5.2003 Hand lesion is almost static 1. Continue Levamisole
(50 mg) 2 tablets every
Next review after Saturday and Sunday
3–4 months 2. Continue Flutivate cream
once a day
3. Take fresh photographs
for assessing further
improvement
4. For nausea/vomiting
correlate with the intake
of Levamisole and consult
a pediatrician for any
concomitant disease
Ch-4.indd 50 09-01-2014 11:29:44

Case Histories 51

7.11.2003 No significant further 1. Continue Levamisole
change in the left knee, (50 mg) 2 tablets every
and right leg lesion Saturday and Sunday
(photographs dated To be continued for
26.5.2003) 6 months more and
Hand lesion: a small then stop
pigmented area at the 2. Continue Flutivate cream
centre once a day
No nausea now 3. Grafting over the residual
area can be undertaken at
Review after 6 months a convenient time
9.6.2004 The knee lesion had 1. Stop Levamisole
improved 2. Continue Flutivate cream
3 months ago, had an injury 3. Repeat photographs of the
with recurrence (left) knee lesion
4. Grafting at a convenient
Review after 6 months time
to 1 year or earlier if
necessary
2.8.2004 Developed scaly 1. Maintain thorough
hypopigmented patches on cleaning with soap
the back of neck 2–3 days 2. Start Clotrin lotion:
ago Massage twice a day till the
Pityriasis versicolor skin colour is normal
Review if necessary
6.8.2005 The knee lesion is much 1. Fresh photographs
smaller 2. Continue Flutivate cream
Hand lesion is also showing once a day
pigmented spots
Right leg lesion: almost
repigmented

or 1 year
13.10.2006 All the lesions are slowly 1. Continue Flutivate cream
reducing once a day
Review after 1 year or

earlier if the lesions
increase
Ch-4.indd 51 09-01-2014 11:29:44


12.5.2008 No reactivation 1. Use Flutivate cream on the
Knee lesion has right hand patch
repigmented 2. Take fresh photographs
A single lesion at present on 3. Can also opt for
the dorsum of right hand NBUVB exposures or
almost static grafting in the area at
convenience
Review after 1 year or
earlier if necessary
24.5.2010 Continuing repigmentation 1. Continue Flutivate cream
Developing acne once a day
2. Fresh photographs to be
Review after 1 month taken
3. For pimples:
Pure soap for bathing
Wash the face thoroughly
twice a day
4. Pure shampoo for hair,
daily and thoroughly
5. No oil, No cream on skin or
hair
6. Face lotion:
Massage all over the face
and other areas twice a day
and continue
7. Lupiderm-G cream on
pimples/scars twice a day
1 tablet daily for
1–2 months
9. No restrictions for food
30.6.2010 Few acne lesions are active 1. Thorough cleaning of the
skin and hair
Body weight – 94 Kg
Review after 1–2 months 2. Continue Face lotion all
over the face twice a day
pimples and scars twice a
day
1 tablet daily for 1 month
more
Ch-4.indd 52 09-01-2014 11:29:44

Case Histories 53

9.8.2010 Only a few inflammatory 1. Maintain thorough
lesions and scars cleaning
Body weight – 93 Kg
Several milia like lesions Pure soap and Pure
shampoo
Review after 2 months 2. Continue Face lotion all
over the face twice a day
day
1 tablet daily for 1 month
29.10.2010 A few inflammatory and 1. Thorough cleaning of the
milia are present skin and hair
Scars are fading 2. No cream, No oil on skin or
hair
Review after 1 month or 3. Continue Face lotion all
2 months over the face twice a day
day
5. Stop Cifran
6. Electrocoagulation of the
milia
27.3.2012 The 3 residual vitiligo lesions 1. Thorough cleaning with
are almost imperceptible Pure soap and Pure
Weight – 87 Kg
Acne is in remission shampoo
2. No oil, no cream
3. Face lotion all over as a
moisturizer after washing
twice a day
4. Betagel-G cream as
required
Ch-4.indd 53 09-01-2014 11:29:44

Summary
SS, 7 years, Male
This boy had only a few lesions which started 1 year ago following
trauma, but new lesions were appearing though at a very slow rate in
spite of PUVA and Homeopathy.
Levamisole 100 mg on two consecutive days per week stopped
the appearance of new lesions and Flutivate cream led to slow
repigmentation of the lesions.
Levamisole given for 2 years continuously (between 10.5.2002 to
9.6.2004) was sufficient in this case.
But any injury or an inflammatory lesion can leave behind a
depigmented area which will respond to Flutivate cream used whenever
required.
The patient returned in 2010 for acne.
And on 27.3.2012 the residual vitiligo lesions were almost
imperceptible.
Levamisole as an immuno-modulator given for 2 years is generally
sufficient for a slow-spreading limited disease.
Ch-4.indd 54 09-01-2014 11:29:44

Case Histories 55
Name: R, 4 years, Male

Vitiligo (limited early disease with halo nevus)
21.3.2002 Single vitiligo patch on the 1. Photographs of the white
right upper eyelid noticed patches
3–4 months ago 2. Start Levamisole (50 mg)
Halo nevus on the right 1 tablet (or syrup) every
chest 2–3 weeks ago Saturday and Sunday
Treatment taken: 3. Restart Flutivate cream
Initially treated with Evion Massage on the white
1 month patches once a day at any
Later with homeopathy time (prefer at night)
4. No restrictions for food,
Review after 1–2 months or medicines for other
diseases
No Homeopathic drugs
No Ayurvedic products
5. No interruptions
25.5.2002 No new patch 1. Continue Levamisole
Mild improvement at eyelid (50 mg) 1 tablet (or syrup)
Weight – 22 Kg
lesion every Saturday and Sunday
Halo nevus almost same 2. Continue Flutivate cream
No problem with levamisole once a day
3.12.2002 Eyelid lesion smaller 1. Continue Levamisole
Halo around the halo nevus (50 mg) 1 tablet (or syrup)
Weight – 22 Kg
almost disappeared every Saturday and Sunday
Noticed two paronychial 2. Continue Flutivate cream
areas of depigmented skin once a day
on right middle and left 3. Repeat photographs of all
index fingers 15 days ago the areas
15.3.2003 Eyelid lesion further 1. Continue Levamisole
improved (50 mg) 1 tablet (or syrup)
Weight – 22 Kg
Halo around nevus fully every Saturday and Sunday
repigmented 2. Continue Flutivate cream
Right middle finger area once a day
smaller 3. Repeat photographs
Left index lesion almost not
visible
Developed a lesion on
left cheek which has
disappeared
Review after 3-4 months
Ch-4.indd 55 09-01-2014 11:29:44


20.6.2003 Photographs taken on 1. Continue Levamisole
11.6.2003, so assessment not (50 mg) 1 tablet (or syrup)
possible every Saturday and Sunday
Noticed an area of alopecia 2. No treatment for the patch
areata 15–20 days ago: No of alopecia
increase 3. No treatment for Pityriasis
Pityriasis alba on face alba

3.10.2003 Slight improvement in 1. Stop Levamisole
upper eyelid lesion 2. Continue Flutivate cream
Right middle finger lesion once a day
smaller 3. No treatment for alopecia
Alopecia areata on the left areata
forearm, left leg, left thigh
are the same

13.3.2004 No reactivation of the 1. Continue Flutivate
lesions cream once a day on the
The eyelid lesion smaller and remaining lesions
fainter 2. No restrictions
Middle finger lesion almost 3. Repeat photographs
faint
Halo nevus smaller

28.8.2004 No further change in the 1. Continue Flutivate cream
patch and Halo nevus 2. Observe for any new
No reactivation lesions
3. No restrictions
Review after 6 months 4. Grafting can be
undertaken at a
convenient time if desired
12.2.2005 Suspected some 1. Continue Flutivate cream
increase in the eyelid 2. No need for oral treatment
lesion photographed on
27.12.2004
Restarted using Flutivate
cream
No increase
Ch-4.indd 56 09-01-2014 11:29:44

Case Histories 57

3.9.2005 Eyelid lesion reduced 1. Take fresh photographs for
further assessment
Review after 6 months 2. Continue Flutivate cream
3. No oral treatment
necessary
5.12.2011 Eyelid lesion almost 1. Fresh photograph of the
disappeared eyelid
Noticed a single white 2. Continue Flutivate cream
eyebrow hair 3. Can start:
Calcium pantothenate
Review after 6 months (200 mg) daily
(Curlzvit or Vighan CP)
(To be continued)
Ch-4.indd 57 09-01-2014 11:29:44

Summary
R, 4 years, Male
This boy had a small depigmented area on the right eyelid with a Halo
nevus on the chest. Treatment with Evion and Homeopathy produced
no result.
He was treated with 50 mg Levamisole on 2 consecutive days per
week and Flutivate cream on the white patches.
As the previous lesions were improving, two new lesions were
noticed in the paronychial areas of the fingers.
The same treatment however led to improvement in all the areas.
Levamisole was stopped after 1.5 years (21.3.2002 to 3.10.2003).
On 5.12.2011, the lesions had almost faded but there was a single
white eyebrow hair for which calcium pantothenate was prescribed.
Ch-4.indd 58 09-01-2014 11:29:44

Ch-4.indd 59
Table 4.3 Response of 2 patients treated with oral levamisole and topical fluticasone
No. Name Age & Sex Duration Activity BSA Treatment %

(years) (%) Repigmentation
1. SS 7/M 1 + 2% 2 years 90%
(Levamisole)
2. R 4/M 0.4 + 0.1% 1.5 years 90%
(Levamisole)
Case Histories
59
09-01-2014 11:29:44
SUMMARY
A combination of azathioprine and betamethasone in the dosages used
in these patients was effective in controlling the disease in every patient.
As a general principle, more active disease should require
higher dosages of the drugs but 100 mg azathioprine daily and 5 mg
betamethasone on two consecutive days is as a rule sufficient even in
the severest of cases.
If the disease is static or has low (+) activity, half of the doses (50 mg
azathioprine per day and 3 mg betamethasone on 2 consecutive days
per week) were found to be sufficient. Also, levamisole (150 mg) on
2 consecutive days per week was found to be sufficient to control the
disease activity in low activity cases. In any case, if the new lesions
continue to appear or the existing lesions keep extending, the full dose
regimen must be started without delay.
Continued treatment leads to repigmentation of the existing
lesions, but some lesions (especially those located on the exposed
areas) repigment faster than others. Use of mid-potency corticosteroids
topically helps in repigmentation although it can occur even otherwise.
Exposure to sun further helps.
Continued treatment with Full dose Modified OMP regimen for 2
years followed by Half dose treatment for the next 2 years has as a rule
been found to eliminate the disease process (no reactivation on stopping
the treatment). Although in some cases, duration of 1.5 years full dose
and 1.5 years half dose has also been found to be sufficient but a shorter
duration of treatment has a greater risk of reactivation of the disease.
Author believes, a longer duration of treatment is a better option
than a shorter duration, because if the disease reactivates, the entire
treatment will have to be repeated all over again. Thus, some patients
took the full dose treatment for 2.5 years rather than 2 years.
Some patients are likely to be left with a few lesions which do not
repigment at all in spite of proper treatment. Such lesions (called
residual lesions) are actually those areas which have lost their pigment
cells (melanocytes) during the disease process. Patients who take proper
treatment at an early stage are likely to have a better (more complete)
repigmentation than those who waste their time in inappropriate
treatment modalities. That is why some patients obtain nearly 100%
repigmentation, while some others are left with significant residual
lesions.
Ch-4.indd 60 09-01-2014 11:29:44

Case Histories 61
For the residual lesions, some patients opt for skin grafting and other
methods of melanocyte replacement, while others decide to leave these
lesions alone and accept them as the scars left by the disease. Continued
use of topical flutivate on these areas has been observed to lead to
progressive fading of these areas and even though this process is slow, it
ultimately makes these residual lesions imperceptible.
Azathioprine has been well tolerated. Occasionally, if a patient
cannot tolerate azathioprine, the disease can be treated with
cyclophosphamide in the same dose.
Azathioprine and cyclophosphamide are better avoided in children
because these drugs can interfere with the growth of the child.
Betamethasone also does not produce much side effects in the
dosages used here because generally pulse doses produce less side
effects compared to daily doses.
The increase in body weight is actually caused by over-eating and
those patients who control their food intake do not put on weight and
come back with reduced body weight. Even otherwise the increase in
body weight is temporary and comes back to the original state when
betamethasone is ultimately withdrawn.
Acne has been seen in young persons only, so how much of acne
during this period is attributable to betamethasone is debatable.
Similarly, if a person develops hirsutism, it is essential to look for the
underlying PCOD rather than incriminate betamethasone.
Hyperacidity is seen only in the first few months in those patients
who are afraid of the side effects, and disappears as the treatment is
continued.
Fungal infections (dermatophytosis and pityriasis versicolor) need
appropriate antifungal treatment whenever they occur. Proper cleaning
of the skin would prevent such infections.
Ch-4.indd 61 09-01-2014 11:29:45

CHAPTER
Mistakes Committed by
Other Practitioners 5
• Modified OMP is the only regimen available at present which can
control the disease completely, so that once the treatment is started,
there should be no new lesion and the existing lesions should stop
expanding. With the other methods, new lesions often continue to
appear at other places even when the old lesions are repigmenting.
• Some people use milder drugs or smaller dosages in an attempt
to reduce/prevent the side effects of the treatment. It is however,
essential to use adequately strong medicines and appropriate
dosages to produce the desired therapeutic effect. The drug regimen
employed must be able to overcome the disease process completely.
We prefer betamethasone over prednisolone, because betametha
sone/dexamethasone are longer acting drugs and produce a better
effect.
Using less than 5 mg per dose may also fail to control the disease
completely. In addition, betamethasone alone (as used in initial
studies) may not be able to control the disease in all cases. OMP
reinforced with azathioprine or cyclophosphamide is able to control
the disease in all cases even when the disease is explosive.
• Some people try to stop the drugs prematurely to prevent/reduce
the side effects of the drugs. The drugs can be stopped only after
the disease process has been extinguished completely. Premature
interruption of the treatment is expected to lead to reactivation of the
disease. In case the disease reactivates the entire regimen will have
to be repeated all over again. It is a wiser policy to treat the patient
for a longer period rather than withdraw the treatment prematurely.
Azathioprine or cyclophosphamide should however, be avoided
in children because they can interfere with the growth of the child.
In contrast, in adults there is no such contraindication.
Ch-5.indd 62 09-01-2014 11:29:23

Repigmentation of the Vitiligo
Lesions During Treatment
Before treatment
15.11.2008
Following treatment
29.5.2009 19.6.2010
Ch-6_Cases.indd 63 09-01-2014 11:28:34

Before treatment Following treatment
19.4.2012 1.12.2012
25.10.2005 22.10.2007
Ch-6_Cases.indd 64 09-01-2014 11:28:34

Repigmentation of the Vitiligo Lesions During Treatment 65
23.3.2007 5.2.2008
Ch-6_Cases.indd 65 09-01-2014 11:28:34

23.9.2011 8.11.2011
28.11.2011 23.5.2013
9.4.2012 1.12.2012
Ch-6_Cases.indd 66 09-01-2014 11:28:35

13.11.2006 7.6.2007
2.6.2009 23.8.2011
Ch-6_Cases.indd 67 09-01-2014 11:28:35

9.4.2007 3.10.2007
2.6.2009 23.8.2011
Ch-6_Cases.indd 68 09-01-2014 11:28:36

19.5.2008 10.4.2009 19.5.2010
2.6.2009 23.8.2011
Ch-6_Cases.indd 69 09-01-2014 11:28:36

24.4.2006 23.6.2007
13.11.2006 7.6.2007
Ch-6_Cases.indd 70 09-01-2014 11:28:37

9.7.2012 10.6.2013
23.3.2007 5.2.2008
Ch-6_Cases.indd 71 09-01-2014 11:28:38

2.6.2009 23.8.2011
16.12.2005 26.12.2006
Ch-6_Cases.indd 72 09-01-2014 11:28:38

13.11.2006 7.6.2007
13.112006 7.6.2007
6.10.2007 23.10.2008
Ch-6_Cases.indd 73 09-01-2014 11:28:40

24.3.2008 7.5.2009
18.8.2006 4.2.2009
Ch-6_Cases.indd 74 09-01-2014 11:28:41

Index
Page numbers followed by f refer to figure and t refer to table
A L
Azathioprine 11, 12, 62 Levamisole 49
Loss of pigment 2
B
Betamethasone 11, 13 M
Betnesol forte 14 Modified oral mini-pulse therapy
regimen 1, 11, 12, 39t, 48t
C Mucous membrane 2
Concomitant diseases 13 Multiple small satellite lesions 6f
Corticosteroids 8, 9
Cyclophosphamide 12, 62 O
Oral
E levamisole 15, 59t
Elimination of disease process 11 mini-pulse
Explosive vitiligo 2 regimen 11
therapy 13
F Osteoporosis 9
Fast spreading vitiligo 5f, 6f

Flutivate cream 14 P
Photochemotherapy 11
G Progression of disease 2
Progressive repigmentation of existing
General principles for curing skin
lesions 12
diseases 7
I R
Incurable and fatal skin diseases 8 Repigmentation of vitiligo lesions
Intense pulsed light 11 during treatment 63
Index.indd 75 09-01-2014 11:28:15

S Treatment
of vitiligo 11
Segmental vitiligo 6 protocol for vitiligo 11
Side effects of corticosteroids 9
Skin disease 7
V
T Vitiligo 1, 14, 15, 19, 23, 27, 31, 35, 40,
45, 49, 55
Topical
application of fluticasone cream 11
fluticasone 59t W
cream 15 White patches 1
Index.indd 76 09-01-2014 11:28:16

How To Cure A Skin Disease Vitiligo

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How To Cure A Skin Disease Vitiligo

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How to Cure a Skin Disease

Prelims.indd 1 09-01-2014 11:27:48

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Prelims.indd 3 09-01-2014 11:27:48

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

How to Cure a Skin Disease: Vitiligo

First Edition: 2014

Prelims.indd 4 09-01-2014 11:27:48

There are, however, several associates of the patient who (unintentionally)

Prelims.indd 5 09-01-2014 11:27:48

Prelims.indd 7 09-01-2014 11:27:48

2. General Principles for Curing Skin Diseases 7

3. Treatment Protocol for Vitiligo 11

5. Mistakes Committed by Other Practitioners 62

Repigmentation of the Vitiligo Lesions during Treatment 63

Prelims.indd 9 09-01-2014 11:27:48

Ch-1.indd 1 09-01-2014 11:26:16

The loss of pigment may be complete or partial (hypo-

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Fig. 1.2: Depigmentation on the waist corresponding to the area

Ch-1.indd 3 09-01-2014 11:26:17

Fig. 1.3: Depigmentation corresponding to the straps of

Fig. 1.4: Depigmentation at the centre of the forehead possibly caused by

Ch-1.indd 4 09-01-2014 11:26:17

Fig. 1.5: Depigmentation above the left breast caused by

Ch-1.indd 5 09-01-2014 11:26:18

Figs 1.8A and B: Segmental vitiligo

Ch-1.indd 6 09-01-2014 11:26:18

General Principles for

Ch-2.indd 7 09-01-2014 11:30:14

Ch-2.indd 8 09-01-2014 11:30:14

THE SIDE EFFECTS OF CORTICOSTEROIDS:

Ch-2.indd 9 09-01-2014 11:30:14

corticosteroids. Thus, whether the corticosteroids lead to

Ch-2.indd 10 09-01-2014 11:30:14

Ch-3.indd 11 09-01-2014 11:29:58

In addition, continuation of the same treatment leads to progressive

Ch-3.indd 12 09-01-2014 11:29:58

Betamethasone, being a corticosteroid, is also considered to be a

Ch-3.indd 13 09-01-2014 11:29:58

FAVORITE PRESCRIPTION FOR VITILIGO

Ch-3.indd 14 09-01-2014 11:29:58

PATIENTS TREATED WITH FULL DOSE

Name: IM, 40 years, Female

Ch-4.indd 15 09-01-2014 11:29:41

Date of visit and

Ch-4.indd 16 09-01-2014 11:29:41

Date of visit and

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Changes in Body Weight

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Name: SS, 25 years, Female

Ch-4.indd 19 09-01-2014 11:29:41

Date of visit and

Ch-4.indd 20 09-01-2014 11:29:41

Date of visit and

Ch-4.indd 21 09-01-2014 11:29:42

Changes in Body Weight

Ch-4.indd 22 09-01-2014 11:29:42

Name: RB, 17 years, Male

Ch-4.indd 23 09-01-2014 11:29:42

Date of visit and

21.9.2009 Further repigmentation 1. Continue Azoran (50 mg)