Study to evaluate effect of oral mini pulse corticosteroid therapy for unstable vitiligo on hypothalamic pituitary adrenal axis suppression

Background: The treatment of vitiligo is difficult and usually requires prolonged therapy. All exogenous glucocorticoid therapies can lead to the hypothalamic-pituitary-adrenal axis (HPA) suppression. Steroid therapy in the form of an intermittent pulse therapy is a much safer option than daily administration. Very few studies have been carried out to evaluate the effect of oral minipulse prednisolone (OMP) on HPA axis, and there are no concrete guidelines regarding the tapering of steroids after OMP, if needed at all. This study is a pilot study to evaluate the effect of use of OMP on HPA axis suppression in unstable vitiligo.

Methods: It is an observational prospective study approved by the Institutional Ethics Committee (IEC) of institution carried out on 30 patients with unstable vitiligo being initiated on OMP between the ages of 20-50 yrs carried out at a tertiary care hospital of Western Maharashtra for a period of one year. Inclusion criteria was all new cases of unstable vitiligo attending dermatology OPD with patients in the age group 20-50 years. Patients treated with systemic corticosteroids in the last six months, on prolonged topical steroid therapy, patients on any other immunosuppressive therapy, patients having contraindications for exhibiting systemic steroids were excluded from the study.

Results: Thirty steroid-naive patients (11 women, 19 men) with a median duration of vitiligo of 10.67 months duration were evaluated. A total of 19 (63.3%) were males and 11 (36.6%) were females with mean age 29.13 years. Serum cortisol levels at baseline, one week, and the end of therapy were 291.1 nmol/L, 288.7 nmol/L, and 304 nmol/L, respectively. Acton Prolongatum (ACTH) stimulated serum cortisol levels at baseline, one week, and the end of therapy were 658.3 nmol/L, 626.1 nmol/L, and 630.1 nmol/L, respectively. Time taken to achieve stability was a mean of 4.41 months post-initiation of OMP in 22/25(73.3%) patients. In 4/30 (13.3%) patients, no stability was achieved at six months of follow-up.

Conclusions: This pilot study has shown that there is no suppression of serum cortisol levels by OMP prednisolone if taken in a weekly dose. OMP steroid therapy is not very effective to achieve a decent level of repigmentation alone; hence, they should be used in combination with other modalities like topical steroids or phototherapy to achieve better repigmentation. The patients did not develop any systemic or cutaneous side effects due to the drug; hence, prednisolone can be considered a safe drug for pulse therapy.