Epidermal grafting for vitiligo in adolescents

Comparative study of the efficacy and safety of two grafting procedures (an automated epidermal harvesting system and non-cultured epidermal cell suspension) in the treatment of stable vitiligo

Background

The non-cultured epidermal cell suspension method is a well-established but tedious grafting modality in the management of stable vitiligo. Recently a more user-friendly automated epidermal harvesting system has been introduced.

Aim

This was a pilot study to compare the efficacy and safety outcomes of the above two grafting procedures.

Study design

The study was a single-blinded split-body randomised controlled trial. After scientific and ethical clearance, the trial was registered with CTRI (CTRI/2018/05/014225). Thirty consenting patients of stable vitiligo with 60 near-symmetrical patches were recruited. Block randomisation was done using computer-generated randomisation software and each patch was allocated either of the two grafting modalities. Efficacy was assessed by the Physician Global Assessment Scale on serial images and pain by the Numerical Rating Pain Scale.

Results and conclusion

The non-cultured epidermal cell suspension was found to be an overall statistically superior technique to the automated epidermal harvesting system in terms of efficacy (re-pigmentation). Both donor and recipient site complications were significantly less with the automated epidermal harvesting system grafting and this method had the distinct advantage of being a painless and easy technique with minimal recovery time. A novel observation was that a good colour match and near-complete re-pigmentation occurred in patients with a darker skin colour with both techniques.

Limitations

The main limitation of our study was the small sample size. Also, the size of the treated patches was limited such that they could be covered by the 5 × 5 cm size of the automated epidermal harvesting system blade. However, a larger area can be covered with multiple sessions.

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

Importance

Surgical interventions are a key part of the therapeutic arsenal, especially in refractory and stable vitiligo. Comparison of treatment outcomes between the different surgical procedures and their respective adverse effects has not been adequately studied.

Objective

To investigate the reported treatment response following different surgical modalities in patients with vitiligo.

Data Sources

A comprehensive search of the MEDLINE, Embase, Web of Science, and Cochrane Library databases from the date of database inception to April 18, 2020, was conducted. The key search terms used were vitiligo, surgery, autologous, transplantation, punch, suction blister, and graft.

Study Selection

Of 1365 studies initially identified, the full texts of 358 articles were assessed for eligibility. A total of 117 studies were identified in which punch grafting (n = 19), thin skin grafting (n = 10), suction blister grafting (n = 29), noncultured epidermal cell suspension (n = 45), follicular cell suspension (n = 9), and cultured epidermal cell suspension (n = 17) were used.

Data Extraction and Synthesis

Three reviewers independently extracted data on study design, patients, intervention characteristics, and outcomes. Random effects meta-analyses using generic inverse-variance weighting were performed.

Main Outcomes and Measures

The primary outcomes were the rates of greater than 90%, 75%, and 50% repigmentation response. These rates were calculated by dividing the number of participants in an individual study who showed the corresponding repigmentation by the total number of participants who completed the study. The secondary outcomes were the factors associated with treatment response to the surgical intervention.

Results

Among the 117 unique studies and 8776 unique patients included in the analysis, rate of repigmentation of greater than 90% for surgical interventions was 52.69% (95% CI, 46.87%-58.50%) and 45.76% (95% CI, 30.67%-60.85%) for punch grafting, 72.08% (95% CI, 54.26%-89.89%) for thin skin grafting, 61.68% (95% CI, 47.44%-75.92%) for suction blister grafting, 47.51% (95% CI, 37.00%-58.03%) for noncultured epidermal cell suspension, 36.24% (95% CI, 18.92%-53.57%) for noncultured follicular cell suspension, and 56.82% (95% CI, 48.93%-64.71%) for cultured epidermal cell suspension. The rate of repigmentation of greater than 50% after any surgical intervention was 81.01% (95% CI, 78.18%-83.84%). In meta-regression analyses, the treatment response was associated with patient age (estimated slope, -1.1418), subtype of vitiligo (estimated slope, 0.3047), and anatomical sites (estimated slope, -0.4050).

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that surgical intervention can be an effective option for refractory stable vitiligo. An appropriate procedure should be recommended based on patient age, site and size of the lesion, and costs.

Factors affecting the outcome of the suction blisters using two different harvesting techniques in vitiligo patients

BACKGROUND

Suction blister grafting (SBG) technique has been used for long to treat various skin conditions. Different suction methods have been used such as syringes, Chinese cups, and suction device. There are some limitations of its use as time consumption, failure of induction or incomplete blister formation and pain.

AIM

The aim of this work was to evaluate the outcome of using two different suction techniques, namely the syringes and the Chinese cups in induction of suction blisters. The effect of the device diameter and preheating of the donor area on the suction blister induction time (SBIT) was studied. The effect of saline injection in the blister formation and its completion was also evaluated.

METHODS

The study was a left-right comparative study that included 50 patients with stable nonsegmental vitiligo. They were classified into four groups: Group 1 included 15 patients where different diameters of syringes (1.3, 1.7, and 2 cm) were compared against each other, group 2 included 15 patients where different diameters of cups (2, 3.5, and 5 cm) were compared against each other, group 3 included 20 patients subdivided into two groups; 10 patients each, where the effect of preheating the skin on blister induction was tested with use of cups (3a) and syringes (3b). Lastly, group 4 included randomly chosen 40 incomplete or multilocular blisters where the effect of saline injection on blister completion and coalescence of multilobulation was examined. SBIT was calculated in all patients.

RESULTS

The use of the small diameter syringes or cups gave shorter SBIT; however, the difference, which was significant between all sizes of cups, was significant between the 1.3- and 2-cm-diameter syringes only. Preheating of the donor area shorten SBIT significantly. No complications were reported at the donor site except for transient postinflammatory hyperpigmentation in all patients.

CONCLUSION

The small diameter syringes or cups and preheating of the donor area shorten the SBIT, while intra-blister saline injection increased the blister size and turns the multilocular blisters to unilocular ones.

Flavonoids as adjuvant in psoralen based photochemotherapy in the management of vitiligo/leucoderma

Vitiligo is a disorder characterized by the decrease in melanin pigment of skin. This depigmenting disorder has prevalence among worldwide, irrespective of age and sex. There is an existence of different treatment modalities for the management of vitiligo. But irrespective of treatment methods, the main drawback in the management of vitiligo is the occurrence of side effects during the implication of treatment. Among the treatment modalities, photochemotherapy seems to be the better choice of treatment for vitiligo. Photochemotherapy involves the usage of UV rays for photoactivation of the drug to cause photosensitization of skin which in turn leads to repigmentation. The main aim of the study is to develop novel combination strategy of lipid based nanoemulsion gel for the treatment of leucoderma using trimethylpsoralen and flavonoid. We assume that if this hypothesis of combination therapy proves successful it can be used as an additional novel treatment strategy in the management of vitiligo.

Vitiligo in Children: A Review of Conventional Treatments

Vitiligo is an important skin disease of childhood, which may lead to deep psychological trauma, resulting in a poor quality of life and low self-esteem. The Authors discuss a short review of the more conventional therapies available for the treatment of vitiligo in children.

Treatment of vitiligo in children and adolescents by autologous cultured pure melanocytes transplantation with comparison of efficacy to results in adults

BACKGROUND

Transplantation of autologous cultured pure melanocytes is a well-established procedure for the treatment of refractory and stabilized vitiligo. However, there was no report specifically comparing the efficacy with the regard to defined age groups (children-adolescence-adult).

OBJECTIVE

  We analysed the efficacy of this procedure in the treatment of vitiligo in children and adolescents and compare it with the results in adults treated during the same period and using identical procedures.

METHODS

Melanocytes were isolated from the roof of suction blister, cultured and expanded with Hu16 medium in vitro, and transplanted to laser-denuded receipt area. A total of 12 children (8-12 years), 20 adolescents (13-17 years) and 70 adults with vitiligo were treated using this procedure.

RESULTS

The patients obtained satisfactory results (repigmentation of 50% or more) results in children, adolescents and adults were 83.3%, 95.0% and 84.0% respectively. The mean extent of repigmentation in children, adolescents and adults was 80.7%, 78.9% and 76.6% respectively. There was no statistical difference in repigmentation among these three groups. After adjusting for all factors (gender, type of vitiligo, period of stability, location of the lesion or transplanted cell density) individually or totally using multiple regression analysis, age still did not correlate to the extent of repigmentation.

CONCLUSIONS

The satisfactory results obtained in the treatment of vitiligo in children and adolescents by transplantation of cultured autologous pure melanocytes are comparable with the results in adults. Therefore, this procedure can be considered in refractory and stable vitiligo in children and adolescents, especially in patients with large vitiliginous lesions.

Vitiligo treatment in childhood: a state of the art review

Vitiligo is a common depigmenting disorder affecting about 1-2% of the world population. Approximately half of the affected individuals develop the disease before adulthood. Etiologic hypotheses for vitiligo include biochemical, neural and autoimmune mechanisms. The most compelling of these suggests a combination of genetic and immunologic factors that result in an autoimmune melanocyte destruction. We reviewed studies carried out on various treatment modalities used in childhood vitiligo. Topical corticosteroids were found to have excellent repigmentation rates, whereas calcineurin inhibitors have comparable efficacy and a better safety profile compared with topical corticosteroids. These two groups of topical medications are good first-line treatment modalities for localized vitiligo. For the treatment of generalized vitiligo, phototherapy has excellent efficacy. Narrow-band ultraviolet B (UVB) has better overall repigmentation rates and safety profile than either topical or oral psoralens and ultraviolet A (PUVA). Other treatment modalities may be considered depending on a patient's specific condition, such as surgical options and depigmentation. With adequate sun protection, the option of no treatment with or without corrective camouflage, is an innocuous alternative to any of these treatment modalities.

Vitiligo in Children and Adolescents: a Lliterature Review / Vitiligo kod dece i omladine - pregled literature

Vitiligo is an acquired, often hereditary skin depigmentation disorder, characterized by discrete, well-circumscribed, chalk-white macules or patches. It affects all age groups, but in more than half of the patients it occurs before the age of twenty, when self-image is being formed and social acceptance is of great importance. Although similar to the disease in adults, vitiligo in children and adolescents does have differences in epidemiology, association with other endocrine and/or autoimmune disorders, and treatment. This is a review of vitiligo in the pediatric population, emphasizing key differences with vitiligo in adults. According to the literature reports, we suggest that children and adolescents with vitiligo, especially non-segmental type, should perform annual screening for thyroid dysfunction, particularly for parameters of autoimmune thyroiditis.

Cellular grafts in management of leucoderma

Cellular grafting methods constitute important advances in the surgical management of leucoderma. Different methods such as noncultured epidermal suspensions, melanocyte cultures, and melanocyte-keratinocyte cultures have all been shown to be effective. This article reviews these methods.

Punch grafting versus suction blister epidermal grafting in the treatment of stable lip vitiligo

BACKGROUND

Among surgical methods, punch skin grafting (PSG) and suction blister epidermal grafting (SBEG) are simple, inexpensive, and effective treatment methods for resistant lip vitiligo cases, but there is a lack of comparison between these procedures for lip vitiligo.

OBJECTIVE

The objective was to compare the outcome following PSG and SBEG in stable lip vitiligo.

METHODS

Eighteen patients with stable lip vitiligo were randomly selected. Eight patients were included in PSG group and 10 patients in SBEG. All patients were kept on PUVA-SOL (psoralen+ultraviolet A therapy of solar origin) treatment after grafting. The results were evaluated after a follow-up period of 6 months.

RESULTS

At the end of 6 months of grafting in PSG group, two patients had a repigmentation of 50% to 75%, one had 75% to 90%, and three had 90% to 100% in the recipient site in lip. In SBEG group, one patient had repigmentation of 50% to 75%, three had 75% to 90%, and two had 90% to 100%. The color match was statistically significant in PSG when compared to SBEG. In the recipient site, cobblestone appearance was the predominant complication in PSG whereas hyperpigmentation and thickening of grafts were common in SBEG. In the donor site, superficial scarring and hypopigmentation were the common findings in PSG group whereas hyperpigmentation was the main problem in SBEG group.

CONCLUSIONS

Although both the procedures are effective in lip vitiligo, PSG gives a better color match than SBEG.

Autologous cultured melanocytes in vitiligo treatment

BACKGROUND

Surgical treatment of vitiligo is indicated when lesions are localized in poorly responding areas.

OBJECTIVES

The objectives were: (1) to establish the melanocyte culture obtained from the epidermis of vitiligo patients for future treatment; (2) to estimate the influence of selected factors on the formation of suction blisters and the results of culture; and (3) to compare the results of treatment of vitiliginous macules localized in the dorsum of the hands and lower limbs by transplantation of cultured autologous melanocytes plus psoralen and ultraviolet A (PUVA) therapy (CMP), suction blister transplantation plus PUVA therapy (SBP), cryotherapy plus PUVA-therapy (CP), and only PUVA therapy (OP).

METHODS

Forty patients were qualified for the study. The roofs of the suction blisters were used as a melanocyte source for culture establishment or were directly transplanted.

RESULTS

The CMP procedure was successfully performed on only 10 of 20 patients because of the difficulties in cell culture establishment. The SBP method was carried out on all 20 patients. A total lack of effectiveness was found in CP and OP methods.

CONCLUSIONS

The effectiveness of culture depends on time of suction blister forming, phototype, and previous PUVA therapy. This study demonstrated the advantage of the SBP over the CMP method.

Dermatosurgical techniques for repigmentation of vitiligo

There are a number of dermatosurgery techniques available to achieve repigmentation of vitiligo, such as suction blister grafting, split-thickness skin grafting, punch grafting, follicular grafting, cultured-melanocytes transplantation, and noncultured-melanocytes transplantation. Each method has advantages and disadvantages. As there are no specific data available from the prospective studies in this field it is uneasy to recommend which surgical approach to vitiligo offers the best result. According to a systematic review by Njoo et al.,(17) suction blister and split-thickness skin grafting have the highest rates of success (87%), while the average success rates for other methods varied from 13% to 53%. Punch grafting has the highest rate of adverse effects, including cobblestoning appearance (27%) and scar formation (40%) in the donor site. Accordingly, it is also mandatory to appropriately select vitiligo patients in order to achieve a complete and permanent repigmentation.