Evaluation of the efficacy of intralesional methotrexate versus intralesional triamcinolone acetonide in treatment of localized vitiligo: comparative intra individual study

INTRODUCTION

Vitiligo is a disorder that is multifactorial and has a complicated pathogenesis. It has a significant detrimental psychosocial impact, especially among people of color. The melanocytes in the damaged skin epidermis physically disappear or stop functioning due to genetic predisposition, immune-mediated harm, or various unknown toxins, whereas those in the hair follicles are normally spared; nevertheless, the specific mechanism remains unknown. Vitiligo is frequently linked to other autoimmune disorders. ⁽¹⁾  

Any repigmenting plan for vitiligo therapy should have two main objectives: stabilization and repigmentation. ⁽²⁾

The global incidence of vitiligo was 0.5% ⁽³⁾, with Egypt having an incidence of up to 1.22%. ⁽⁴⁾

The most frequent therapy for localized vitiligo was monotherapy using topical steroids. The negative effects of systemic absorption, such as epidermal atrophy, striae distensae, telangiectasia, and steroid folliculitis, make it difficult to use topical steroids for a long time. ⁽⁵⁾

Intralesional steroids are currently being debated as a therapy for localized vitiligo. ^(6)(7)(8)(9)T-lymphocyte proliferation is significantly inhibited by methotrexate (MTX), a folic acid antagonist and cell proliferation inhibitor ⁽¹⁰⁾. It downregulates B cells as well as suppressing T cell activation and expression of intracellular adhesion molecules. ⁽¹¹⁾

Because it suppresses T cells that produce TNF alfa, MTX was employed to treat vitiligo . ⁽¹²⁾  

As a result, it has the potential to halt the progression of disease. ⁽¹³⁾

The present work aimed to evaluate the efficacy of intralesional methotrexate against intralesional         triamcinolone acetonide in treating localized non-segmental vitiligo.

PATIENTS AND METHODS

This research was carried out on thirty patients with localized vitiligo from August 2021 to January 2022. The patients were diagnosed by typical clinical findings. The patients were able to read and give consents. Patients with localized vitiligo, age ≥ 18 years of both sexes were included.

Patients under any other treatment modalities, with extensive or segmental vitiligo, age less than 18 years, pregnant, breast feeding, with chronic hepatic, or haematological disorders and immunocompromised patient were excluded.

Patients were selected from the out-patient clinics of the Al-Azhar University Hospitals' Dermatology, Venereology, and Andrology Departments.

All patients underwent a complete general history, skin examination, and documented digital photography. Thirty subjects with two comparable patches were split into two groups: 

Group A (MTX group):

30 patients with stable vitiligo received an intralesional injection of methotrexate (12.5 mg/mL). A methotrexate vial containing 50 mg/2 ml was employed at a concentration of 12.5 mg/ml. MTX has been administered intradermally at 1 cm intervals using a volume of 0.02 ml/site, all under strict aseptic precautions. A 0.5-inch long, 30-gauge needle connected to an insulin syringe was used to inject a maximum of 0.1–0.2 ml (2.5–5 mg) each session.

Group B (TrA group):

The same 30 patients presenting with localized vitiligo will be treated with an intralesional injection of triamcinolone acetonide (40 mg/ml). The intralesional steroids' original strength (epirelefan ® 40 mg/ml) was 40 mg/ml. Intradermally, one-fourth diluted triamcinolone acetonide (2.5 mg/ml TrA) has been administered at 1 cm intervals using an injecting volume of 0.05–0.1 ml/site. With a 0.5-inch long, 30-gauge needle connected to an insulin syringe, a maximum of 2 ml can be injected.Treatment was used as once per 2 weeks, for maximum 6 sessions.

Response to treatment:

(i) excellent response: 75% repigmentation or more, (ii) good responce:  50% repigmentation or more, (iii) fair response: 25% repigmentation or more, and (iv) poor response: less than 25% repigmentation.

Statistical analysis:

The IBM SPSS software package version 20.0 was used to analyze the results of the present study statistically (Armonk, NY: IBM Corp). The Shapiro-Wilk test has been done to ensure that the distribution is normal. The mean, standard deviation, median, and interquartile range (IQR) have been employed to describe quantitative data. The obtained findings have been determined to be significant at the 5% level. The Mann-Whitney U test has been employed to compare numerical data, while the Chi-square test has been employed to compare categorical data. The significance was determined by a P value of less than 0.05.

RESULTS

There was a statistical highly significant difference between studied Triamcinolone patches Before And After treatment as regard improvement grades and score with p value

There was a statistical highly significant difference between studied Methotrexate patches Before And After  treatment as regard improvement grades and score with p value

There was a statistical no significant difference between studied patches as regard improvement grades and score (table 3).

Table 1: Comparison between before and after treatmentaccording to triamcinolone..

Table 2: Comparison between before and after treatment according to Methotrexate.

Table 3: Comparison between studied patches as regard improvement grades and score.

Fig 1: Comparison between studied patches as regard improvement grades.

Fig 2: Comparison between studied patches as regard improvement score.