Clinical approach to a patient with hypopigmentation

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Discussion with Dr. JS Pasricha, Professor of Dermatology (Retd.), AIIMS

  • The commonest is condition is vitiligo. The hypopigmented patches can also be seen after pregnancy, burns and/or any injury.
  • Vitiligo is not contagious. It is curable if given proper treatment
  • When the disease is active, new patches appear or the existing patches increase in size. At this time, it is important to control the disease completely, repair the damage done and ┬áre-pigment the hypopigmented areas.
  • Once the disease is totally controlled, the leftover depigmented skin can be treated surgically by skin grafting.
  • The treatment is oral azathioprine 100 mg daily. If the patient cannot tolerate this, then cyclophosphamide 100 mg daily can be started. This is to be given along with betamethasone 5 mg in 2 consecutive doses in a week (Saturday, Sunday). Fluticasone ointment is also applied once in a day at the affected area.
  • The treatment has to continue for four years. Give full treatment for 2 years and then reduce the dose by half for 2 years, if there is no reactivation.
  • If the disease is mild and localized, half the dose can be administered for four years but if the disease is active and severe, then follow a 2+2 formula i.e. 2 years full dose and 2 years half dose. This is also called OMP, the Oral Mini Pulse therapy. The disease gets controlled in 1 month and repigmentation starts in 2 months.
  • Henna or Mehendi can be applied in hypopigmented areas; the color lasts for about 7 days.
  • KMNO4 also stains the skin and can be used temporarily for hiding the vitiligo patches.
  • Tattooing can be used to pigment the affected area. Tattooing is at the level of dermal skin and pigmentation is at the level of epidermal skin.

Concern about proton pump inhibitors

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  • PPIs and Clostridium difficile: This was a concern listed by the US FDA.
  • PPIs and clopidogrel: Concern continues about the interaction between clopidogrel and PPIs, and the FDA, narrowed this down to omeprazole and esomeprazole.
  • PPIs and methotrexate: An FDA alert was issued in December 2011, following case reports describing patients who received high-dose induction methotrexate intravenously and who had very high serum levels of methotrexate, which were potentially attributed to exposure to a PPI — in this case, omeprazole.
  • PIs and bone density: Studies continue to suggest an increased risk for fractures with long-term use of PPIs.
  • PPIs and antidepressants: Combination of PPIs and citalopram has raised some concern, particularly with the racemic mixture. This drug has (R) and (S) enantiomers, and the (S) enantiomer is the one involved in the antidepressant effect. The same is true for escitalopram, a drug is often prescribed and that can contribute to the toxicity of QRS prolongation in torsade de pointes.