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Letter To Editor
2008:74:2;169-169
doi: 10.4103/0378-6323.39717
PMID: 18388390

Vitiligo, psoriasis and imiquimod: Fitting all into the same pathway

Bell Raj Eapen
 Consultant dermatologist, Kaya Skin Clinic, Dubai, United Arab Emirates

Correspondence Address:
Bell Raj Eapen
Kaya Skin Clinic, Dubai
United Arab Emirates
How to cite this article:
Eapen BR. Vitiligo, psoriasis and imiquimod: Fitting all into the same pathway. Indian J Dermatol Venereol Leprol 2008;74:169
Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

I read with interest the letter describing imiquimod-induced vitiligo-like depigmentation. [1] There are other similar case reports [2],[3] and 68 reports of pigmentary changes related to imiquimod use listed by FDA. [4] The most widely accepted theory is that imiquimod activates the cell-mediated arm of the immune system via the stimulation of multiple pro-inflammatory cytokines which up-regulates a Type-1 cell response (Th1) that unmasks an innate predilection for the development of vitiligo. [5]

The mode of action of imiquimod involves activation of Toll-like receptors (TLR) 7 and 8, which initiates a signaling cascade leading to the production of pro-inflammatory cytokines like IFN-α and TNF-α. However, TLR 7 and 8 also initiates ubiquitin-mediated proteolysis and apoptosis through the myeloid differentiation factor 88-dependent pathway as evident from the pathway map [6] hsa04620 available from KEGG. [7] In a previous letter to IJDVL , I presented the genomic evidence for ubiquitin-mediated melanocyte-specific apoptotic process in vitiligo. [8] Hence, the ubiquitin-mediated proteolysis may be important in the pathogenesis of vitiligo-like lesions following treatment with imiquimod.

A Th1 type response with increased TNF-α is vital in the pathogenesis of psoriasis. [9] Hence, it is hardly surprising that there are several reports of imiquimod-induced psoriasis. [10],[11],[12],[13] Psoriasis is a proliferative disorder while vitiligo is an apoptotic disorder. It is interesting to note that these disparate conditions converge at a fundamental pathway level.

References
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Gilliet M, Conrad C, Geiges M, Cozzio A, Thurlimann W, Burg G, et al . Psoriasis triggered by toll-like receptor 7 agonist imiquimod in the presence of dermal plasmacytoid dendritic cell precursors. Arch Dermatol 2004;140:1490-1495.
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