Surgical Interventions for Patients With Vitiligo: A Systematic Review and Meta-analysis

Computer-aided assessment of repigmentation rates in vitiligo patients: Implications for treatment efficacy - a retrospective study

Precise evaluation of repigmentation in vitiligo patients is crucial for monitoring treatment efficacy and enhancing patient satisfaction. This study aimed to develop a computer-aided system for assessing repigmentation rates in vitiligo patients, providing valuable insights for clinical practice. A retrospective study was conducted at the Dermatology Department of Shenzhen People's Hospital between June 2019 and November 2022. Pre- and post-treatment images of vitiligo lesions under Wood's lamp were collected, involving 833 participants stratified by sex, age, and pigmentation patterns. Our results demonstrated that the 'marginal' pigmentation pattern exhibited a higher repigmentation rate of 72% compared to the 'central non-follicular' pattern at 45%. Males had a slightly higher average repigmentation rate of 0.37 in comparison to females at 0.33. Among age groups, individuals aged 0-20 years showed the highest average repigmentation rate at 0.41, while the oldest age group (61-80 years) displayed the lowest rate at 0.25. Analysis of multiple visits identified the 'marginal' pattern as the most prevalent (60%), with a mean repigmentation rate of 40%. This study introduced a computational system for evaluating vitiligo repigmentation rates, enhancing our comprehension of patient responses, ultimately contributing to enhanced clinical care.

The Treatment of Refractory Vitiligo With Autologous Cultured Epithelium Grafting: A Real-World Retrospective Cohort Study

BACKGROUND

Surgical intervention is the main therapy for refractory vitiligo. We developed a modified autologous cultured epithelial grafting (ACEG) technique for vitiligo treatment. Between January 2015 and June 2019, a total of 726 patients with vitiligo underwent ACEG in China, with patient characteristics and clinical factors being meticulously documented. Using a generalized linear mixed model, we were able to assess the association between these characteristics and the repigmentation rate.

RESULTS

ACEG demonstrated a total efficacy rate of 82.81% (1754/2118) in treating 726 patients, with a higher repigmentation rate of 64.87% compared to conventional surgery at 52.69%. Notably, ACEG showed a better response in treating segmental vitiligo, lesions on lower limbs, age ≤ 18, and stable period > 3 years. A keratinocyte:melanocyte ratio below 25 was found to be advantageous too. Single-cell RNA sequencing analysis revealed an increase in melanocyte count and 2 subclusters of keratinocytes after ACEG, which remained higher in repigmented sites even after 1 year.

CONCLUSIONS

ACEG is a promising therapy for refractory vitiligo. Patient age, clinical type, lesion site, and stability before surgery influence repigmentation in ACEG. The mechanism of repigmentation after ACEG treatment is likely not confined to the restoration of melanocyte populations. It may also involve an increase in the number of keratinocytes that support melanocyte function within the affected area. These keratinocytes may aid the post-transplant survival and function of melanocytes by secreting cytokines and extracellular matrix components.

TRIAL REGISTRATION

registered with Chictr.org.cn (ChiCTR2100051405).

Human Mesenchymal Stem Cell-Derived Exosomes Promote the Proliferation and Melanogenesis of Primary Melanocytes by Attenuating the H2O2-Related Cytotoxicity in vitro

Background

Mesenchymal stem cell-derived exosomes (MSC-Exo) have therapeutic potential. However, the impact of MSC-Exo on the survival and melanogenesis of human primary melanocytes following H2O2-induced damage has not been clarified. We therefore investigated the effects of MSC-Exo on the H2O2-affected survival of human primary melanocytes and their proliferation, apoptosis, senescence, and melanogenesis in vitro.

Methods

MSC-Exo were prepared from human MSCs by sequential centrifugations and characterized by Transmission Electron Microscopy, Western blot and Nanoparticle Tracking Analysis. Human primary melanocytes were isolated and treated with different concentrations of MSC-Exo, followed by exposing to H2O2. Furthermore, the impact of pretreatment with MSC-Exo on the proliferation, apoptosis, senescence and melanogenesis of melanocytes were tested by CCK-8, flow cytometry, Western blot, L-Dopa staining, tyrosinase activity and RT-qPCR.

Results

Pretreatment with lower doses of MSC-Exo protected human primary melanocytes from the H2O2-triggered apoptosis, while pretreatment with higher doses of MSC-Exo enhanced the H2O2-induced melanocyte apoptosis. Compared with the untreated control, pretreatment with a lower dose (1 µg/mL) of MSC-Exo enhanced the proliferation of melanocytes, abrogated the H2O2-increased p53, p21, IL-1β, IL-6 and IL-8 expression and partially rescued the H2O2-decreased L-dopa staining reaction, tyrosinase activity, MITF and TRP1 expression in melanocytes.

Conclusion

Our findings indicate that treatment with a low dose of MSC-Exo promotes the proliferation and melanogenesis of human primary melanocytes by ameliorating the H2O2-induced apoptosis and senescence of melanocytes. MSC-Exo may be a promising therapeutic strategy of vitiligo.

Single-cell sequencing reveals increased LAMB3-positive basal keratinocytes and ZNF90-positive fibroblasts in autologous cultured epithelium

Autologous cultured epithelium grafting (ACEG) presents a promising treatment for refractory vitiligo, yet concerns regarding infections and immunological reactions hinder its surgical use due to serum and feeder dependencies. Addressing this, we culture autologous epithelium under serum- and feeder-free (SFF) conditions, comparing its safety and efficacy with serum- and feeder-dependent (SFD) conditions in stable vitiligo patients, and we discover no significant differences in repigmentation between the SFF and SFD grafts. Single-cell RNA transcriptomics on SFF- and SFD-cultured epithelium alongside healthy skin reveal increased populations of LAMB3+ basal keratinocytes and ZNF90+ fibroblasts in the SFF sheets. Functional analyses showcase active cellular metabolism in LAMB3+ basal keratinocytes, vital in extracellular matrix homeostasis, while ZNF90+ fibroblasts demonstrate increased differentiation, essential in collagen formation for cell adhesion. Importantly, these cell populations in SFF sheets exhibit enhanced interactions with melanocytes compared to SFD sheets. Further, knockdown experiments of LAMB3 in keratinocytes and ZNF90 in fibroblasts lead to a downregulation in melanocyte ligand-receptor-related genes. Overall, SFF sheets demonstrate comparable efficacy to SFD sheets, offering superior safety. LAMB3+ basal keratinocytes and ZNF90+ fibroblasts act as potential drivers behind repigmentation in ACEG under SFF conditions. This study provides translational insights into ACEG repigmentation and potential therapeutic targets for vitiligo.

Management of the refractory vitiligo patient: current therapeutic strategies and future options

Vitiligo is an autoimmune disease that leads to disfiguring depigmented lesions of skin and mucosa. Although effective treatments are available for vitiligo, there are still some patients with poor responses to conventional treatment. Refractory vitiligo lesions are mostly located on exposed sites such as acral sites and lips, leading to significant life stress. Understanding the causes of refractory vitiligo and developing targeted treatments are essential to enhance vitiligo outcomes. In this review, we summarized recent treatment approaches and some potential methods for refractory vitiligo. Janus kinase inhibitors have shown efficacy in refractory vitiligo. A variety of surgical interventions and fractional carbon dioxide laser have been widely applied to combination therapies. Furthermore, melanocyte regeneration and activation therapies are potentially effective strategies. Patients with refractory vitiligo should be referred to psychological monitoring and interventions to reduce the potential pathogenic effects of chronic stress. Finally, methods for depigmentation and camouflage may be beneficial in achieving uniform skin color and improved quality of life. Our ultimate focus is to provide alternative options for refractory vitiligo and to bring inspiration to future research.

Melanocyte transplantation to skin prepared by controlled PUVA-induced sunburn-like blistering for vitiligo treatment - A pilot clinical trial

Vitiligo is a common acquired disease of pigment loss. In lesions recalcitrant to non-invasive treatment, transplantation of cultured autologous melanocytes is an emerging choice. Conventionally, the recipient site is often prepared by laser-mediated or mechanical dermabrasion. Such preparation procedures have disadvantages including prolonged transplantation duration, long period for reepithelialization and potential scarring. We propose a method of preparing recipient sites by psoralen and controlled ultraviolet A (PUVA)-induced blistering followed by transplanting suspended melanocytes. We introduced this method in 10 patients with segmental vitiligo on their recipient site 3 to 5 days before transplantation and blistering developed in 2 to 3 days afterwards. On the day of transplantation, the blister roof could be peeled off easily without bleeding and the recipient site preparation could be completed in 20 min. The recipient site became reepithelialized within 1 week. Progressive repigmentation was observed for up to 6 months, with an average of 65.06% repigmentation in the recipient site without scarring at the end of follow-up. Hence, preparation of the recipient site by controlled PUVA-induced sunburn-like blistering can potentially facilitate melanocyte transplantation and prevent scarring.

Vitiligo: Current Therapies and Future Treatments

The current management of vitiligo remains challenging; however, different strategies can be proposed to patients with a good efficacy in many cases. First, it is important to identify patients in the active phase of the disease because treatment should start as soon as possible to halt its progression. For patients with a stable disease, the treatment strategy is now well-stratified and is based on a combination of phototherapy (natural or in a cabin) and topical immunomodulatory agents. Surgical treatments are useful for localized and stable vitiligo, as well as for segmental vitiligo. Depigmentation remains indicated in very extensive forms. The recent approval of topical ruxolitinib cream in both the US and Europe brings new approaches for the management of vitiligo and paves the way for the development of new topical or oral targeted drugs.

Disease Awareness and Treatment Preferences in Vitiligo: A Cross-sectional Study in China

In China, there is a lack of data regarding the awareness and treatment preferences among patients with vitiligo and their families. To address this gap, a cross-sectional questionnaire-based study was conducted to investigate disease awareness and treatment preferences in Chinese patients with vitiligo. The study also evaluated willingness to pay, using 2 standardized items, and assessed quality of life, using the Dermatology Life Quality Index (DLQI) score. Data from 307 patients with vitiligo (59.3% women, mean age 28.98 years, range 2-73 years) were analysed. Of these patients, 44.7% had insufficient knowledge of vitiligo, particularly those from rural areas or with low levels of education. Mean DLQI total score was 4.86 (5.24 for women and 4.30 for men). Among the most accepted treatments were topical drugs, phototherapy, and systemic therapy. Patients were relatively conservative about the duration and cost of treatment, with only 27.7% willing to pay more than 10,000 Chinese yuan renminbi (CNY) for complete disease remission. High level of education, high income, skin lesions in specific areas, and skin transplantation therapy predicted higher willingness to pay. Insufficient knowledge was associated with a higher burden of disease. In order to reduce the disease burden and improve treatment adherence it is crucial to enhance disease awareness and take into account patient preferences.

Understanding of Pathomechanisms and Clinical Practice for Vitiligo

Vitiligo is a disease caused by the acquired depletion of melanocytes and/or melanocyte precursor cells in response to genetic and environmental factors, resulting in depigmentation of the entire body. It is roughly divided into segmental and non-segmental vitiligo, and it has been found that abnormalities of melanocytes themselves and dysregulation of autoimmune responses to melanocytes are greatly involved in the pathology of non-segmental vitiligo. Segmental vitiligo pathology is largely unknown; however, it has been suggested that it may be caused by skin or melanocyte mosaicism. Treatments for vitiligo include topical therapy, ultraviolet therapy, and surgical transplantation, and it is extremely important to correctly understand the pathology to perform optimal treatment. In recent years, the development of vitiligo treatments using Janus kinase (JAK) inhibitors has progressed rapidly. We herein outline the latest pathology of vitiligo, from general vitiligo treatment to the progress of clinical trials using JAK inhibitors, along with what clinicians should consider in archiving precision medicine, including my own ideas thereon.

Non-invasive Imaging Techniques for Monitoring Cellular Response to Treatment in Stable Vitiligo

Punch grafting procedures, where small pieces of normal skin are transplanted into stable vitiligo patches, results in repigmentation in only half of patients treated, yet the factors that determine whether a patient responds to treatment or not are still unknown. Reflectance confocal microscopy (RCM) is adept at visualizing melanocyte migration and epidermal changes over large areas while multiphoton microscopy (MPM) can capture metabolic changes in keratinocytes. With the overall goal of identifying optical biomarkers for early treatment response, we followed 12 vitiligo lesions undergoing punch grafting. Dendritic melanocytes adjacent to the graft site were observed before clinical evidence of repigmentation in treatment responsive patients but not in treatment non-responsive patients, suggesting that the early visualization of melanocytes is indicative of a therapeutic response. Keratinocyte metabolic changes in vitiligo skin adjacent to the graft site also correlated with treatment response, indicating that a keratinocyte microenvironment that more closely resembles normal skin is more hospitable for migrating melanocytes. Taken together, these studies suggest that successful melanocyte transplantation requires both the introduction of new melanocytes and modulation of the local tissue microenvironment.

Ultrathin Skin Grafting Versus Suction Blister Epidermal Grafting in the Treatment of Resistant Stable Vitiligo: A Self-Controlled Comparative Study

BACKGROUND

Surgical therapies are effective methods to treat resistant stable vitiligo, with each method having advantages and disadvantages.

OBJECTIVE

This study aimed to compare the efficacy and safety of ultrathin skin grafting (UTSG) and suction blister epidermal grafting (SBEG) to treat stable vitiligo.

METHODS

A total of 15 patients with 45 vitiligo patches were recruited. Each vitiligo patch was divided in half; 1 half was treated by UTSG, whereas the other half was treated by SBEG. The patients were followed up monthly for 3 months to assess the repigmentation rate, relative melanin index (RMI), and relative erythema index (REI) at different timepoints.

RESULTS

Excellent repigmentation was observed in 97.8% of patches that underwent UTSG and 93.3% that underwent SBEG. The RMI and REI at 1, 2, and 3 months after the grafting procedure did not significantly differ between the 2 methods. At the recipient site, incomplete fall-off of the graft occurred in 4.4% of patches that underwent UTSG, whereas a "cobblestone appearance" was observed in 66.7% of patches that underwent SEBG. UTSG caused fewer complications at the donor site than SBEG.

CONCLUSION

Compared with SBEG, UTSG is faster and achieves better cosmetic outcomes at the recipient and donor sites.

Generating Functional and Highly Proliferative Melanocytes Derived from Human Pluripotent Stem Cells: A Promising Tool for Biotherapeutic Approaches to Treat Skin Pigmentation Disorders

Melanocytes are essential for skin homeostasis and protection, and their loss or misfunction leads to a wide spectrum of diseases. Cell therapy utilizing autologous melanocytes has been used for years as an adjunct treatment for hypopigmentary disorders such as vitiligo. However, these approaches are hindered by the poor proliferative capacity of melanocytes obtained from skin biopsies. Recent advances in the field of human pluripotent stem cells have fueled the prospect of generating melanocytes. Here, we have developed a well-characterized method to produce a pure and homogenous population of functional and proliferative melanocytes. The genetic stability and potential transformation of melanocytes from pluripotent stem cells have been evaluated over time during the in vitro culture process. Thanks to transcriptomic analysis, the molecular signatures all along the differentiation protocol have been characterized, providing a solid basis for standardizing the protocol. Altogether, our results promise meaningful, broadly applicable, and longer-lasting advances for pigmentation disorders and open perspectives for innovative biotherapies for pigment disorders.

Management of Stable Vitiligo-A Review of the Surgical Approach

At present, vitiligo is the most common depigmenting skin disorder, characterized by clearly demarcated discolored patches of various shapes and sizes. Depigmentation results from the initial dysfunction and subsequent destruction of melanin-producing cells, called melanocytes, which are located in the basal layer of the epidermis and in hair follicles. This review concludes that the extent of repigmentation, regardless of the treatment method, is greatest in stable localized vitiligo patients. The aim of this review is to provide an overview of the clinical evidence for which the vitiligo treatment method (cellular or tissue) is more effective. The treatment relies on multiple factors, ranging from patient skin predisposition for repigmentation to the experience of the facility performing the procedure. Vitiligo is a significant problem in modern society. Although it is a typically asymptomatic and not life-threatening disease, it may have significant psychological and emotional impacts. Standard treatment relies on pharmacotherapy and phototherapy; however, the treatment of patients with stable vitiligo varies. The stability of vitiligo more than often implies the exhaustion of the potential for skin self-repigmentation. Thus, the surgical methods that distribute normal melanocytes into the skin are crucial elements of these patients' therapy. The most commonly used methods are described in the literature, with an indication of their recent progress and changes. In addition, information on the efficiency of the individual methods at specific locations is compiled in this study, and the prognostic factors indicating repigmentation are presented. Cellular methods are the best therapeutic option for large-sized lesions; although they are more exorbitant than tissue methods, they benefit from more rapid healing times and presenting fewer side effects. Dermoscopy is a valuable tool used to assess the further course of repigmentation, where it is of great value to evaluate the patient prior to and following an operation.

Vitiligo Treatments: Review of Current Therapeutic Modalities and JAK Inhibitors

Vitiligo is a chronic autoimmune disease characterized by loss of pigment of the skin, affecting 0.5-2% of the population worldwide. It can have a significant impact on patients' quality of life. In recent years, there has been significant progress in our understanding of the pathogenesis of vitiligo. It is believed that vitiligo develops due to a complex combination of genetics, oxidative stress, inflammation, and environmental triggers. Conventional treatments include camouflage, topical corticosteroids, topical calcineurin inhibitors, oral corticosteroids, phototherapy, and surgical procedures, with the treatment regimen dependent on the patient's preferences and characteristics. With increased understanding of the importance of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) pathway in the pathogenesis of vitiligo, treatment has expanded to include the first US FDA-approved cream to repigment patients with vitiligo. This review summarizes our understanding of the major mechanisms involved in the pathogenesis of vitiligo and its most common available treatments.

Current Status of Cell-Based Therapies for Vitiligo

Vitiligo is a chronic pigmentary disease with complex etiology, the signs of which are caused by the destruction of melanocytes in the epidermis, leading to the lack of melanin pigment responsible for skin coloration. The treatment of vitiligo, which aims at repigmentation, depends both on the clinical characteristics of the disease as well as on molecular markers that may predict the response to treatment. The aim of this review is to provide an overview of the clinical evidence for vitiligo cell-based therapies taking into account the required procedures and equipment necessary to carry them out as well as their effectiveness in repigmentation, assessed using the percentage of repigmentation of the treated area. This review was conducted by assessing 55 primary clinical studies published in PubMed and ClinicalTrails.gov between 2000 and 2022. This review concludes that the extent of repigmentation, regardless of the treatment method, is highest in stable localized vitiligo patients. Moreover, therapies that combine more than one cell type, such as melanocytes and keratinocytes, or more than one method of treatment, such as the addition of NV-UVB to another treatment, increase the chances of >90% repigmentation. Lastly, this review concludes that various body parts respond differently to all treatments.

Whole structural reconstruction and quantification of epidermal innervation through the suction blister method and skin-clearing technique

Three-dimensional (3-D) analysis of intraepidermal nerve fibers (IENFs) is conducted to advance assessment methods for peripheral neuropathies and pruritic skin disorders. The skin-clearing technique was proven to be a reliable method for 3-D imaging of IENFs. Nonetheless, it still requires further improvement in the imaging process. The aim of this study was to standardize the 3-D evaluation method of IENFs and to suggest promising 3-D biomarkers for clinical application. A total of nine healthy individuals were prospectively enrolled. The newly adopted suction blister method was combined with the tissue-clearing technique. The detailed structure of the IENFs was reconstructed and quantified using the neuron tracing software. The suction blister method showed improved linear integrity of IENFs compared with those obtained from the previously used salt-split skin test. The 3-D parameters most significantly related to natural aging were the convex hull two-dimensional perimeter and the total length (both p = 0.020). The meaningful correlations were followed by total volume (p = 0.025), ends (p = 0.026), convex hull 3-D surface, and complexity (both p = 0.030). Thus, the 3-D parameters could be utilized as possible biomarkers to identify ambiguous pathologies of peripheral neuropathies and pruritic skin disorders.

Surgical Treatment of Vitiligo

Vitiligo is described as a dermatological condition characterized by pigmentation disorders in both the skin and mucous membranes. Clinically, this disease is characterized by the presence of well-defined white areas of various shapes and sizes, which are a manifestation of a reduced number of melanocytes. Due to the fact that vitiligo can be a significant cosmetic problem for patients, a number of methods are currently available to help fight for a better skin appearance. If all the available non-invasive procedures turn out to be ineffective, surgery can help, which is a very good alternative in the case of difficult-to-treat but stable changes. Both the development of new techniques and modifications to the already available treatment of cell and tissue transplantation give hope to numerous patients around the world. The effectiveness of a particular method is determined by its appropriate selection depending on the lesions undergoing therapy. Each form of surgical intervention has its advantages and disadvantages, which, along with the location or size of the treated hypopigmentation area, should be analyzed by a doctor and discussed with their patient. This article is an overview of the currently available methods of surgical treatment of vitiligo and a comparison of their pros and cons.

Surgical procedures and innovative approaches for vitiligo regenerative treatment and melanocytorrhagy

Surgical treatments for vitiligo are a safe and effective treatment modality for select patients with vitiligo. Many techniques of vitiligo surgery exist, each with unique advantages and disadvantages. We reviewed the various surgical therapies and innovative approaches for vitiligo regenerative treatment reported in the literature. Surgical therapies can be subdivided into tissue grafting methods and cellular grafting methods. Tissue grafting methods mainly include mini punch grafts, suction blister roof grafts, and hair follicle grafts. Cellular grafting methods include cultured and non-cultured treatments. The efficacy needs to be improved largely due to the poor proliferation and quality of the autologous melanocytes. Rho-associated protein kinase inhibitor enhances primary melanocyte culture proliferation from vitiligo patients to prevent apoptosis. Innovative approaches using stem cell methods could prove invaluable in developing a novel cell therapy for patients suffering from vitiligo. We succeeded in inducing melanin pigmentation in mice skin in vivo using our human induced pluripotent stem cell-derived melanocytes. In addition, we reviewed melanocytorrhagy, detachment and transepidermal loss of melanocytes, and melanocyte-related adhesion molecules. These adhesion molecules include epithelial cadherin, discoidin domain receptor tyrosine kinase 1, glycoprotein non-metastatic melanoma protein B, macrophage migration inhibiting factor, 17β-hydroxysteroid dehydrogenase 1, and E26 transformation-specific 1.

A comparative study of suction blister epidermal grafting and automated blister epidermal micrograft in stable vitiligo

The automated blister epidermal micrograft (ABEM) is a newly introduced surgical transplantation for refractory vitiligo. Comparative analysis of other surgical methods is lacking. We conducted a retrospective study to compare the efficacy, safety, and experience of ABEM with conventional suction blister epidermal graft (SBEG). A total of 118 anatomically based vitiligo lesions from 75 patients were included. The primary outcome was the degree of repigmentation; the patient and operator experience were evaluated. SBEG had a significantly greater incidence of repigmentation (p < 0.001), as measured by the Physician Global Assessment, as well as improvements in the Vitiligo Area Scoring Index, particularly on the face/neck area (p < 0.001). ABEM, on the contrary, had reduced donor harvest time, a better patient operative experience, and more significant Dermatology Life Quality Index improvements. In a subgroup of 38 lesions from ten patients who received both SBEG and ABEM concomitantly, there was no difference in the degree of repigmentation in the same recipient area. Overall, the degree of repigmentation for SBEG is higher than ABEM, especially in the mobilized region, and the cost is less expensive. On the contrary, ABEM requires less procedure learning curve and can supply a greater transplanting zone with shorter donor site recovery. Understanding the benefits and drawbacks of two blister grafting procedures is essential for optimal surgical outcomes for vitiligo grafting.

Efficacy and safety of automated epidermal micrograft in patients with stable segmental and nonsegmental vitiligo

Vitiligo is a common, psychologically devastating pigmentary disorder. Surgical graftings are used to treat stable vitiligo when medical treatment fails. An automated epidermal micrograft harvesting (AEMH) system was first designated to treat wounds, and very few studies investigated the application of AEMH in vitiligo. In this study, we investigated the efficacy and safety of the AEMH system in patients with stable segmental and nonsegmental vitiligo. The rate of repigmentation and adverse events was recorded bimonthly for at least 12 months. We analyzed the efficacy based on patient characteristics, vitiligo subtypes, and different anatomical locations. A total of 56 depigmented lesions from 34 patients were included. 95.50% of the automated epidermal micrografts were successfully grafted at the recipient sites. There was a significant improvement in Vitiligo Area Scoring Index (VASI) and Dermatologic Life Quality Index (DLQI) in patients treated with AEMH (p < 0.001). The rate of repigmentation by VASI score improves from 96.25 ± 8.59 to 48.30 ± 28.16 after the treatment (p < 0.001). Treatment outcomes were comparable between the patients of segmental and stable nonsegmental vitiligo. The face and neck region achieved a better outcome, followed by the trunk (chest, abdomen, back, and axilla), limbs, and the worse outcome was found in the acral region (p < 0.014). Conclusively, AEMH is an effective treatment procedure with limited adverse events in patients with stable vitiligo. This harvesting method may be a feasible option for vitiligo surgical treatment.

Clinical Features, Immunopathogenesis, and Therapeutic Strategies in Vitiligo

Vitiligo is an autoimmune disease of the skin characterized by epidermal melanocyte loss resulting in white patches, with an approximate prevalence of 0.5-2% worldwide. Several precipitating factors by chemical exposure and skin injury present commonly in patients with vitiligo. Although the diagnosis appears to be straightforward for the distinct clinical phenotype and specific histological features, vitiligo provides many challenges including chronicity, treatment resistance, frequent relapse, associated profound psychosocial effect, and negative impact on quality of life. Multiple mechanisms are involved in melanocyte disappearance, including genetics, environmental factors, and immune-mediated inflammation. Compelling evidence supports the melanocyte intrinsic abnormalities with poor adaptation to stressors leading to instability and release of danger signals, which will activate dendritic cells, natural killer cells, and innate lymphoid cells to initiate innate immunity, ultimately resulting in T-cell mediated adaptive immune response and melanocyte destruction. Importantly, the cross- talk between keratinocytes, melanocytes, and immune cells, such as interferon (IFN)-γ signaling pathway, builds inflammatory loops that give rise to the disease deterioration. Improved understanding of the immune pathogenesis of vitiligo has led to the development of new therapeutic options including Janus kinase (JAK) inhibitors targeting IFN-γ signaling pathways, which can effectively reverse depigmentation. Furthermore, definition of treatment goals and integration of comorbid diseases into vitiligo management have revolutionized the way vitiligo is treated. In this review, we highlight recent developments in vitiligo clinical aspects and immune pathogenesis. Our key objective is to raise awareness of the complexity of this disease, the potential of prospective therapy strategies, and the need for early and comprehensive management.

Vitiligo: Translational research and effective therapeutic strategies

This is an exciting phase of vitiligo research with the current understanding of vitiligo pathogenesis and its translation to successful treatment. The pathogenetic origin of vitiligo revolves around autoimmunity with supporting role from many other factors like oxidative stress, inherent melanocyte defects, or defective keratinocytes and fibroblasts. Vitiligo can be classified into segmental or non-segmental depending upon the clinical presentation, or it can be classified as progressing or stable based on the activity of the disease. Vitiligo treatments need to be stratified depending upon which type of vitiligo we are treating and at which phase the vitiligo patient presents to us. There are two different aims of treatment of vitiligo. The first involves rescuing the melanocytes from the damage to arrest the depigmentation. The second strategy focuses on replenishing the melanocytes so that successful repigmentation is achieved. It is also important to maintain the disease in a stable phase or prevent relapse. As stability in non-segmental vitiligo is a dynamic process, maintenance of the stability of repigmentation is also an important consideration in the management of vitiligo. In this review, we shall briefly discuss the current options and future insight into the management of vitiligo.