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According to this diagnosis&#44; he started treatment with topical testosterone 2&#37; gel once a day for six months&#44; which he applied at level of the chest and thighs&#46; He noticed the first depigmentation area on the hands&#44; during the fourth month of treatment&#46; For vitiligo areas&#44; pimecrolimus 1&#37; cream was prescribed&#46; After six months of follow-up&#44; the treated vitiligo areas are stable and no further depigmented areas arose&#46; The patient continues to perform the endocrinological consultations with good hormonal compensation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The etiology of vitiligo is still unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Several hypotheses have been proposed to explain the causes of melanocyte dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this regard&#44; Kotb et al&#46; also investigated the hormonal theory&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Specifically&#44; they found a significant decrease in testosterone levels in the serum of males in both active and stable vitiligo groups when compared to controls&#44; and in the active vitiligo group compared to the stable vitiligo group&#59; besides&#44; they did not find significant difference in testosterone levels between males and females in the active vitiligo group&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; testosterone can be also involved in the downregulation of the inflammation&#46; Indeed&#44; testosterone suppresses immunity&#44; affecting T-cell immunity by inhibiting T-helper 1 differentiation&#44; justifying the sex differences in the response to viruses and autoimmunity&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> All these findings confirm that hypogonadism may explain the predisposition for the onset of vitiligo in the present patient&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Drug-induced vitiligo is a rare side effect of several systemic and topical drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In these cases&#44; skin depigmentation is indistinguishable from vitiligo and appears to be due to activation of melanocyte-specific autoimmunity&#59; for these reasons&#44; this phenomenon should be known as drug-induced vitiligo&#44; rather than with the less accurate term &#8220;drug-induced depigmentation&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Goldstein et al&#46; reported that testosterone may interact with tyrosine hydroxylase activity&#59; besides&#44; it is known that agents that interact with tyrosinase activity can paradoxically disrupt melanin production&#44; by inducing the cellular stress response with inflammation and autoimmune destruction of melanocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; to date&#44; there is no evidence of testosterone-induced vitiligo&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As far as the authors know&#44; the present case represents the first clinical confirmation of the onset of vitiligo in a patient with hypogonadism&#44; supporting the thesis that hypogonadism can be associated with vitiligo&#46; At the same time&#44; there is insufficient evidence to support a role of testosterone replacement therapy in the development of vitiligo&#46; Indeed&#44; no areas of depigmentation were observed at the testosterone application sites &#40;chest and thighs&#41;&#46; Further studies are needed to investigate the role of testosterone in pigmentation&#44; also extending the research to possible new therapeutic implications&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Giovanni Paolino&#58; Drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Pietro Bearzi&#58; Drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Santo Raffaele Mercuri&#58; Approval of the final version of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Onset of vitiligo in a patient with acquired secondary hypogonadism under treatment with testosterone gel 2%: inside the pathogenesis
Giovanni Paolino, Pietro Bearzi
Corresponding author
pietro.bearzi@gmail.com

Corresponding author.
, Santo Raffaele Mercuri
Department of Dermatology, IRCCS Ospedale San Raffaele, Milan, Italy
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 61-year-old man presented with a three-month history of symmetric depigmented lesions on the hands and perilabial region &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; No other anatomical area was involved&#46; Under Wood&#8217;s light the lesions appeared bright white and sharply demarcated&#44; confirming the diagnosis of vitiligo&#46; His personal and family medical history was negative for autoimmune disorders&#46; The patient reported that eight months before&#44; a diagnosis of acquired secondary idiopathic hypogonadism due to aging was made &#40;low levels of testosterone&#59; normal LH and FSH levels&#59; negative MRI of the hypothalamic-pituitary region and normal body mass index&#41;&#46; Laboratory investigations and analysis of autoimmunity showed no alterations&#46; Thyroid function was normal and thyroid antibodies were absent&#46; According to this diagnosis&#44; he started treatment with topical testosterone 2&#37; gel once a day for six months&#44; which he applied at level of the chest and thighs&#46; He noticed the first depigmentation area on the hands&#44; during the fourth month of treatment&#46; For vitiligo areas&#44; pimecrolimus 1&#37; cream was prescribed&#46; After six months of follow-up&#44; the treated vitiligo areas are stable and no further depigmented areas arose&#46; The patient continues to perform the endocrinological consultations with good hormonal compensation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The etiology of vitiligo is still unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Several hypotheses have been proposed to explain the causes of melanocyte dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this regard&#44; Kotb et al&#46; also investigated the hormonal theory&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Specifically&#44; they found a significant decrease in testosterone levels in the serum of males in both active and stable vitiligo groups when compared to controls&#44; and in the active vitiligo group compared to the stable vitiligo group&#59; besides&#44; they did not find significant difference in testosterone levels between males and females in the active vitiligo group&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; testosterone can be also involved in the downregulation of the inflammation&#46; Indeed&#44; testosterone suppresses immunity&#44; affecting T-cell immunity by inhibiting T-helper 1 differentiation&#44; justifying the sex differences in the response to viruses and autoimmunity&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> All these findings confirm that hypogonadism may explain the predisposition for the onset of vitiligo in the present patient&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Drug-induced vitiligo is a rare side effect of several systemic and topical drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In these cases&#44; skin depigmentation is indistinguishable from vitiligo and appears to be due to activation of melanocyte-specific autoimmunity&#59; for these reasons&#44; this phenomenon should be known as drug-induced vitiligo&#44; rather than with the less accurate term &#8220;drug-induced depigmentation&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Goldstein et al&#46; reported that testosterone may interact with tyrosine hydroxylase activity&#59; besides&#44; it is known that agents that interact with tyrosinase activity can paradoxically disrupt melanin production&#44; by inducing the cellular stress response with inflammation and autoimmune destruction of melanocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; to date&#44; there is no evidence of testosterone-induced vitiligo&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">As far as the authors know&#44; the present case represents the first clinical confirmation of the onset of vitiligo in a patient with hypogonadism&#44; supporting the thesis that hypogonadism can be associated with vitiligo&#46; At the same time&#44; there is insufficient evidence to support a role of testosterone replacement therapy in the development of vitiligo&#46; Indeed&#44; no areas of depigmentation were observed at the testosterone application sites &#40;chest and thighs&#41;&#46; Further studies are needed to investigate the role of testosterone in pigmentation&#44; also extending the research to possible new therapeutic implications&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Giovanni Paolino&#58; Drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Pietro Bearzi&#58; Drafting and editing of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Santo Raffaele Mercuri&#58; Approval of the final version of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Paolino G&#44; Bearzi P&#44; Mercuri SR&#46; Onset of vitiligo in a patient with acquired secondary hypogonadism under treatment with testosterone gel 2&#37;&#58; inside the pathogenesis&#46; An Bras Dermatol&#46; 2020&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.abd.2020.02.010">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;abd&#46;2020&#46;02&#46;010</span></p>"
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ISSN: 03650596
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