Comparison between autologous noncultured epidermal cell suspension and suction blister epidermal grafting in stable vitiligo: a randomized study

Regenerative medicine in the treatment of specific dermatologic disorders: a systematic review of randomized controlled clinical trials

AIMS AND OBJECTIVES

The aim of this study is to systematically review randomized controlled clinical trials (RCTs) studying various types of regenerative medicine methods (such as platelet-rich plasma, stromal vascular fraction, cell therapy, conditioned media, etc.) in treating specific dermatologic diseases. Rejuvenation, scarring, wound healing, and other secondary conditions of skin damage were not investigated in this study.

METHOD

Major databases, including PubMed, Scopus, and Web of Science, were meticulously searched for RCTs up to January 2024, focusing on regenerative medicine interventions for specific dermatologic disorders (such as androgenetic alopecia, vitiligo, alopecia areata, etc.). Key data extracted encompassed participant characteristics and sample sizes, types of regenerative therapy, treatment efficacy, and adverse events.

RESULTS

In this systematic review, 64 studies involving a total of 2888 patients were examined. Women constituted 44.8% of the study population, while men made up 55.2% of the participants, with an average age of 27.64 years. The most frequently studied skin diseases were androgenetic alopecia (AGA) (45.3%) and vitiligo (31.2%). The most common regenerative methods investigated for these diseases were PRP and the transplantation of autologous epidermal melanocyte/keratinocyte cells, respectively. Studies reported up to 68.4% improvement in AGA and up to 71% improvement in vitiligo. Other diseases included in the review were alopecia areata, melasma, lichen sclerosus et atrophicus (LSA), inflammatory acne vulgaris, chronic telogen effluvium, erosive oral lichen planus, and dystrophic epidermolysis bullosa. Regenerative medicine was found to be an effective treatment option in all of these studies, along with other methods. The regenerative medicine techniques investigated in this study comprised the transplantation of autologous epidermal melanocyte/keratinocyte cells, isolated melanocyte transplantation, cell transplantation from hair follicle origins, melanocyte-keratinocyte suspension in PRP, conditioned media injection, a combination of PRP and basic fibroblast growth factor, intravenous injection of mesenchymal stem cells, concentrated growth factor, stromal vascular fraction (SVF), a combination of PRP and SVF, and preserving hair grafts in PRP.

CONCLUSION

Regenerative medicine holds promise as a treatment for specific dermatologic disorders. To validate our findings, it is recommended to conduct numerous clinical trials focusing on various skin conditions. In our study, we did not explore secondary skin lesions like scars or ulcers. Therefore, assessing the effectiveness of this treatment method for addressing these conditions would necessitate a separate study.

The efficacy and safety of autologous epidermal cell suspensions for re-epithelialization of skin lesions: A systematic review and meta-analysis of randomized trials

BACKGROUND

Successful usage of autologous skin cell suspension (ASCS) has been demonstrated in some clinical trials. However, its efficacy and safety have not been verified. This latest systematic review and meta-analysis aim to examine the effects of autologous epidermal cell suspensions in re-epithelialization of skin lesions.

METHODS

Relevant articles were retrieved from PubMed, Embase, Cochrane Database, Web of Science, International Clinical Trials Registry Platform, China National Knowledge Infrastructureris, VIP Database for Chinese Technical Periodicals and Wanfang database. The primary output measure was the healing time, and the secondary outputs were effective rate, size of donor site for treatment, size of study treatment area, operation time, pain scores, repigmentation, complications, scar scale scores and satisfaction scores. Data were pooled and expressed as relative risk (RR), mean difference (MD) and standardized mean difference (SMD) with a 95% confidence interval (CI).

RESULTS

Thirty-one studies were included in this systematic review and meta-analysis, with 914 patients who received autologous epidermal cell suspensions (treatment group) and 883 patients who received standard care or placebo (control group). The pooled data from all included studies demonstrated that the treatment group has significantly reduced healing time (SMD = -0.86; 95% CI: -1.59-0.14; p = 0.02, I2 = 95%), size of donar site for treatment (MD = -115.41; 95% CI: -128.74-102.09; p<0.001, I2 = 89%), operation time (MD = 25.35; 95% CI: 23.42-27.29; p<0.001, I2 = 100%), pain scores (SMD = -1.88; 95% CI: -2.86-0.90; p = 0.0002, I2 = 89%) and complications (RR = 0.59; 95% CI: 0.36-0.96; p = 0.03, I2 = 66%), as well as significantly increased effective rate (RR = 1.20; 95% CI: 1.01-1.42; p = 0.04, I2 = 77%). There were no significant differences in the size of study treatment area, repigmentation, scar scale scores and satisfaction scores between the two groups.

CONCLUSION

Our meta-analysis showed that autologous epidermal cell suspensions is beneficial for re-epithelialization of skin lesions as they significantly reduce the healing time, size of donar site for treatment, operation time, pain scores and complications, as well as increased effective rate. However, this intervention has minimal impact on size of treatment area, repigmentation, scar scale scores and satisfaction scores.

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.

Lesional CD8+ T-Cell Number Predicts Surgical Outcomes of Melanocyte-Keratinocyte Transplantation Surgery for Vitiligo

The melanocyte-keratinocyte transplantation procedure (MKTP) treats stable and recalcitrant vitiligo. Despite careful selection of candidates based on clinical stability, the success of the procedure is unpredictable. The aim of our study was to define the immunological profile of stable vitiligo lesions undergoing MKTP and correlate them with clinical outcomes. We included 20 MKTP candidates with vitiligo and a patient with piebaldism as a control. Prior to MKTP, T-cell subsets and chemokines in the recipient skin were measured by flow cytometry and ELISA. During MKTP, melanocytes in the donor skin were quantified by flow cytometry. After MKTP, patients were followed for 12 months and repigmentation was assessed clinically and by ImageJ analysis of clinical photographs. Baseline immunologic biomarkers, duration of clinical stability, and transplanted melanocyte number were correlated to postsurgical repigmentation scores. CD8+ T cells were elevated in 43% of the clinically stable vitiligo lesions. CD8+ T-cell number negatively correlated with postsurgical repigmentation scores (r = -0.635, P = 0.002). Duration of clinical stability, skin chemokines, and transplanted melanocyte number did not influence postsurgical repigmentation. This study demonstrates that CD8+ T-cell number correlates negatively with success of postsurgical repigmentation and can be a biomarker to identify ideal surgical candidates.

Has the core outcome (domain) set for vitiligo been implemented? An updated systematic review on outcomes and outcome measures in vitiligo randomized clinical trials

BACKGROUND

In 2015, a major achievement in vitiligo research was the development of an internationally agreed upon core outcome domain set for randomized clinical trials (RCTs). Three outcomes were identified as being essential: repigmentation, side-effects/harms and maintenance of gained repigmentation. Four items were further recommended for inclusion. The following recommendations then followed: repigmentation should be assessed by measuring the percentage of repigmentation in quartiles (0-25%, 26-50%, 51-79%, 80-100%) and cosmetic acceptability of the results should be assessed using the Vitiligo Noticeability Scale.

OBJECTIVES

The primary objective of this study was to assess uptake of the core outcome domain set for RCTs in vitiligo. Secondary objectives were to update the systematic review on outcomes reported in vitiligo RCTs, and to assess whether repigmentation and cosmetic acceptability of the results were measured using the above-mentioned recommended scales.

METHODS

We searched PubMed, Cochrane Library (CENTRAL and Systematic Reviews) and ClinicalTrials.gov for vitiligo RCTs between November 2009 and March 2021. Screening and data extraction were independently performed on title and summary by two researchers. All outcomes and outcome measures reported in eligible RCTs were retrieved and collated.

RESULTS

In total, 174 RCTs were identified: 62 were published between 2009 and 2015, and 112 were published between 2016 and 2021.Thirty-eight different outcomes were reported. Repigmentation was the primary outcome in 89% of trials (150 of 169). Forty-nine different tools were used to measure repigmentation. Side-effects and harms were reported in 78% of trials (136 of 174). Maintenance of gained repigmentation was reported in only 11% of trials (20 of 174) and duration of follow-up varied greatly from 1 to 14 months. Cosmetic acceptability of the results and cessation of disease activity were assessed in only 2% of trials (four of 174). Quality of life of patients with vitiligo was assessed in 13% of trials (22 of 174). Finally, only 11 of 112 RCTs (10%) published between 2016 and 2021 reported all three essential core outcome domains (repigmentation, side-effects and maintenance of gained repigmentation) and none of the trials reported both essential and recommended core outcome domains.

CONCLUSIONS

Efforts are still needed to close the gap between set recommendations and RCT outcome reporting.

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.

Quality of life measurement in vitiligo. Position statement of the European Academy of Dermatology and Venereology Task Force on Quality of Life and Patient Oriented Outcomes with external experts

Members of the European Academy of Dermatology and Venereology (EADV) Task Force on Quality of Life (QoL) and Patient Oriented Outcomes reviewed the instruments available for health-related (HR) QoL assessment in vitiligo and together with external vitiligo experts (including representatives of the EADV Vitiligo Task Force) have made practical recommendations concerning the assessment of QoL in vitiligo patients. The Dermatology Life Quality Index (DLQI) was the most frequently used HRQoL instrument, making comparison of results between different countries possible. Several vitiligo-specific instruments were identified. The vitiligo Impact Scale (VIS) is an extensively validated vitiligo-specific HRQoL instrument with proposed minimal important change and clinical interpretation for VIS-22 scores. VIS-22 was developed for use in India, where there are some specific cultural beliefs concerning vitiligo. The EADV Task Force on QoL and Patient Oriented Outcomes recommends use of the DLQI and the Children's Dermatology Life Quality Index (CDLQI) as dermatology-specific instruments in vitiligo. There is a strong need for a valid (including cross-cultural validation) vitiligo-specific instrument that can be either a new instrument or the improvement of existing instruments. This validation must include the proof of responsiveness.

The humanistic burden of vitiligo: a systematic literature review of quality-of-life outcomes

Despite historical mischaracterization as a cosmetic condition, patients with the autoimmune disorder vitiligo experience substantial quality-of-life (QoL) burden. This systematic literature review of peer-reviewed observational and interventional studies describes comprehensive evidence for humanistic burden in patients with vitiligo. PubMed, EMBASE, Scopus and the Cochrane databases were searched through February 10, 2021, to qualitatively assess QoL in vitiligo. Two independent reviewers assessed articles for inclusion and extracted data for qualitative synthesis. A total of 130 included studies were published between 1996 and 2021. Geographical regions with the most studies were Europe (32.3%) and the Middle East (26.9%). Dermatology-specific instruments, including the Dermatology Life Quality Index (DLQI; 80 studies) and its variants for children (CDLQI; 10 studies) and families (FDLQI; 4 studies), as well as Skindex instruments (Skindex-29, 15 studies; Skindex-16, 4 studies), were most commonly used to measure humanistic burden. Vitiligo-specific instruments, including the Vitiligo-specific QoL (VitiQoL; 11 studies) instrument and 22-item Vitiligo Impact Scale (VIS-22; 4 studies), were administered in fewer studies. Among studies that reported total scores for the overall population, a majority revealed moderate or worse effects of vitiligo on patient QoL (DLQI, 35/54 studies; Skindex, 8/8 studies; VitiQoL, 6/6 studies; VIS-22, 3/3 studies). Vitiligo also had a significant impact on the QoL of families and caregivers; 4/4 studies reporting FDLQI scores indicated moderate or worse effects on QoL. In general, treatment significantly (P < 0.05) improved QoL, but there were no trends for types or duration of treatment. Among studies that reported factors significantly (P ≤ 0.05) associated with reduced QoL, female sex and visible lesions and/or lesions in sensitive areas were most common. In summary, vitiligo has clinically meaningful effects on the QoL of patients, highlighting that greater attention should be dedicated to QoL decrement awareness and improvement in patients with vitiligo.

S1 Guideline: Diagnosis and therapy of vitiligo

Vitiligo is a common skin disorder characterized by immune-mediated destruction of melanocytes. Non-segmental vitiligo, the most common clinical subtype, has usually a chronic course and often results in significant psychosocial consequences for the affected patient. Early recognition, awareness of comorbidity, precise assessment of disease extent and activity, evaluation of impairment of quality of life as well as rapid initiation of treatment based on currently available evidence-based therapies are crucial cornerstones in the management of vitiligo. This S1 guideline helps German dermatologists to better diagnose and treat vitiligo.

Tertiary Health Care-Based Randomized Controlled Study to Compare Autologous, Non-cultured, Non-trypsinized Epidermal Cell Transplant (Jodhpur Technique) with Split-Thickness Skin Grafting (STSG) in Stable Vitiligo

Background

Surgical treatment of vitiligo is reserved for stable recalcitrant vitiligo patches. Split-thickness skin grafting (STSG) is an important established modality for the surgical treatment of vitiligo, whereas autologous, non-cultured, non-trypsinized epidermal cell transplant, also known as Jodhpur technique (JT), is an unconventional innovative surgical modality for the treatment of stable vitiligo.

Aims

To compare the two techniques, JT and STSG, with regards to the extent and pattern of repigmentation achieved, color matching of the repigmented area, patient satisfaction (Dermatology Life Quality Index [DLQI] questionnaire and patient global assessment), and adverse events (if any) in patients with stable vitiligo.

Materials and Methods

It was a randomized comparative study. We randomized 32 patients with 180 stable vitiligo lesions into two groups. Patients in group 1 were treated with JT, and those in group 2 with STSG. They were subjectively evaluated 20 weeks post-surgery for the extent of repigmentation, color match, change in DLQI score, and patient satisfaction. The categorical data were presented as number (percent) and were compared among groups using Chi-square test. Mean and standard deviation were calculated for demographic data, and they were also compared by using student t-test. Probability P value < 0.001 was considered statistically significant.

Results

The extent of repigmentation was excellent (90%-100% repigmentation) in 72.5% of lesions in the JT group and in 40% of lesions in the STSG group (P < 0.001). Seventy-five percent repigmentation (good repigmentation) was observed in 95% of lesions in the JT group and in 83.75% of lesions in the STSG group (P = 0.040). There was a highly significant decline in DLQI score. Post-procedure DLQI (0.79 ± 1.13) and pre-procedure DLQI (15.39 ± 4.76) in the JT group were compared with post-procedure DLQI (3.85 ± 2.89) and pre-procedure DLQI (16.19 ± 4.56) in the STSG group. The mean decline among groups differed significantly (P < 0.001). Adverse events were significantly higher in the STSG group at the recipient site.

Conclusions

JT is found to be significantly better than STSG with regard to the degree of repigmentation.

Fractional versus full ablative CO2 laser in recipient site of non-cultured melanocytes and keratinocyte transplantation in treatment of vitiligo

BACKGROUND

Melanocyte-keratinocyte transplant procedure (MKTP) or non-cultured epidermal cell suspension transplantation is a very popular surgical modality for treating stable vitiligo. The recipient-site preparation is one potential determinant in the repigmentation outcomes.

AIM

To assess the efficacy of fractional CO₂ (FCO₂ ) laser in recipient-site preparation before MKTP and comparing it to the frequently used full surface laser ablation.

METHODS

This randomized comparative trial included 19 patients with 40 stable vitiligo lesions. In each patient, the treated sites were randomly categorized into two groups according to the recipient-site ablation (either fractional or full ablative CO₂ laser). Assessment of repigmentation was performed six months after the procedure.

RESULTS

Both modalities achieved successful repigmentation of a median of 80% and 77.5% for fractional and full ablation groups, respectively, with a non-statistically significant difference between them. The median of VASI change percent was -73% and -71% with fractional and full surface ablation, respectively.

CONCLUSIONS

FCO₂ laser ablation is effective for recipient-site preparation before cell suspension transplantation as well as the full ablative CO₂ laser.

Cultured epidermal autografts for treatment of stable vitiligo: Quantitative analysis of color matching with surrounding normally pigmented skin

Cultured epidermal autografts (CEA) are surgical therapeutic alternatives for patients with stable vitiligo resistant to conventional medical treatments. In the present study, we assessed color matching before and at 12 months after CEA treatment. Eleven patients with 16 vitiligo lesions were included in this prospective study. The recipient sites were prepared by CO₂ laser superficial ablation and subjected to CEA application. We clinically evaluated and categorized the color matching of the repigmented skin as well as the percentage of repigmentation. We also obtained three color values (L*a*b*) for the vitiligo lesions and surrounding normally pigmented skin. We then calculated the color differences between the two regions and compared them before and at 12 months after treatment. The mean percentage of repigmentation was 63.3% at 12 months. Six of the 16 lesions were categorized as “same as” and had color difference values of ≤5 at 12 months after treatment. Clinical evaluation of the color matching coincided well with the calculated color difference values. CEA application after CO₂ laser superficial ablation was useful for treating vitiligo assessed by the percentage of repigmentation and color matching. Quantification of color differences may be a useful parameter for evaluating color matching in vitiligo.

Electrofulguration-assisted dermabrasion is comparable to manual dermabrasion in patients undergoing autologous non-cultured epidermal cell suspension for treatment of stable vitiligo: A randomized controlled trial

BACKGROUND

Recipient site preparation is a crucial step in non-cultured epidermal cell suspension (NCES) as it facilitates proper uptake of the grafted melanocytes.

OBJECTIVES

To compare the repigmentation rate of recipient sites prepared with manual dermabrasion (MD) versus electrofulguration-assisted dermabrasion (EF) in patients undergoing NCES for treatment of stable vitiligo.

METHODS

This was a prospective randomized study including 26 patients of stable vitiligo (VIDA 0 or -1), each having two patches of size greater than 3 × 3 cm located symmetrically or at the same site or a single patch of 6 × 6 cm or larger. After randomization of patches in the given patient, MD and EF were performed on recipient areas followed by NCES. The patients were followed up at 4 weekly intervals up to 24 weeks and assessed for extent of repigmentation and adverse effects if any.

RESULTS

Greater than 75% repigmentation was observed in 69.3% of the patches prepared by MD as compared to 73.1% patches prepared by EF at the end of 24 weeks (p = 0.791). The mean improvement in target VASI was 64.0% in the MD group as compared to 68.8% in the EF group (p = 0.21). Patches prepared by EF achieved successful repigmentation earlier as compared to patches prepared by MD (9.4 weeks vs 11.4 weeks, p = 0.12).

CONCLUSION

Both MD and EF have comparable outcomes with respect to all parameters.

Donor to recipient ratios in the surgical treatment of vitiligo and piebaldism: a systematic review

Stabilized vitiligo resistant to conventional therapy (e.g. segmental vitiligo) and piebaldism lesions can be treated with autologous cellular grafting techniques, such as non-cultured cell suspension transplantation (NCST) and cultured melanocyte transplantation (CMT). These methods are preferred when treating larger surface areas due to the small amount of donor skin needed. However, the donor to recipient expansion ratios and outcomes reported in studies with cellular grafting vary widely, and to date, no overview or guideline exists on the optimal ratio. The aim of our study was to obtain an overview of the various expansion ratios used in cellular grafting and to identify whether expansion ratios affect repigmentation and colour match. We performed a systematic literature search in MEDLINE and EMBASE to review clinical studies that reported the expansion ratio and repigmentation after cellular grafting. We included 31 eligible clinical studies with 1591 patients in total. Our study provides an overview of various expansion ratios used in cellular grafting for vitiligo and piebaldism, which varied from 1:1 up to 1:100. We found expansion ratios between 1:1 and 1:10 for studies investigating NCST and from 1:20 to 1:100 in studies evaluating CMT. Pooled analyses of studies with the same expansion ratio and repigmentation thresholds showed that when using the lowest (1:3) expansion ratio, the proportion of lesions achieving >50% or >75% repigmentation after NCST was significantly better than when using the highest (1:10) expansion ratio (χ² P = 0.000 and χ² P = 0.006, respectively). Less than half of our included studies stated the colour match between different expansion ratios, and results were variable. In conclusion, the results of our study indicate that higher expansion ratios lead to lower repigmentation percentages after NCST treatment. This should be taken into consideration while determining which expansion ratio to use for treating a patient.

Effectiveness of dermabrasion plus 5-fluorouracil vs suction blister in treating vitiligo: A comparative study

Vitiligo is a prevalent destructive melanocyte skin disease that negatively affects the patients' life in terms of self-esteem. Suction blister and dermabrasion plus 5-fluorouracil are effective treatments for vitiligo. The present study was conducted to compare the outcomes of these two techniques. The present clinical trial was conducted on 36 patients with persistent refractory vitiligo which defined as the lack of any new or progressed lesion during the previous year as well as no responding to conventional therapies of vitiligo including topical treatments and phototherapy. Individuals with two vitiligo patches, with similar baseline Vitiligo Area Severity Index (VASI) scores were randomly allocated to dermabrasion plus 5-fluorouracil or suction blister treatments. VASI and repigmentation scores were measured and compared at the baseline, four, and 12 weeks after performing the procedures. Both of the approaches accompanied with significant improvement in both entities of VASI and repigmentation scores (P value < .05) at the end of the study, besides the trend of VASI and repigmentation scores between the two groups revealed insignificant difference (P > .05). The short-term follow-up of the patients was the limitation of this study. The present findings suggested that both surgical techniques of dermabrasion plus 5-fluorouracil and suction blister posed acceptable outcomes within 12-week follow-up.

A prospective, randomized clinical study to compare the efficacy of recipient site preparation using dermabrasion, cryoblister, and dermaroller in autologous noncultured epidermal cell suspension in stable vitiligo

Noncultured epidermal cell suspension (NCES) is a well-established surgical treatment modality for stable vitiligo. The outcome of this procedure significantly depends on the method of recipient site preparation, a critical step to achieve cosmetically acceptable repigmentation. To compare the efficacy of recipient site preparation using three methods namely, dermabrasion, cryoblister, and dermaroller followed by NCES in stable vitiligo. In this single-center, prospective, intra-patient, randomized clinical trial; 36 participants having at least three vitiligo patches in same anatomic region with minimum lesional stability of 1 year were randomized 1:1:1 for recipient site preparation using manual dermabrasion, cryoblister, and dermaroller followed by NCES. Patients were followed up at 4, 8, and 12 weeks and assessment of extent and pattern of repigmentation, color match and patient satisfaction were done. Among 36 patients, 22 (61.1%) were females; mean (SD) age was 28.33 (9.4) years. Dermabrasion and cryoblister techniques showed equal efficacy with respect to extent of repigmentation (>75% repigmentation; 55.6% vs 47.2%; P = .63) and patient satisfaction score (20.2 ± 9.6 vs 19.9 ± 7.9, P = .194). However, dermabrasion was superior to cryoblister in terms of rapidity (65% vs 32.5% at 4 weeks, P = .04) and color match (47.2% vs 19.4%, P = .004). Dermaroller had poor repigmentation outcomes compared to both dermabrasion and cryoblister. Cryoblister as a method of recipient site preparation is equally effective as manual dermabrasion in NCES for attaining good to excellent repigmentation, but with risk of hyperpigmentation. However, dermaroller is inferior to both dermabrasion and cryoblister.

Quantitative Outcome Assessment of Color Match and the Extent of Repigmentation after Pixel Array Epidermal Grafting for Head and Neck Stable Vitiligo: A Prospective Cohort Study

BACKGROUND

Epidermal grafting with an automatic harvesting system has been reported as a simple and efficacious procedure for stable vitiligo. However, no prospective cohort study has quantitatively evaluated the color matching and extent of repigmentation in the head and neck area by this method.

OBJECTIVE

To evaluate the color matching and extent of repigmentation after pixel array epidermal grafting by image analysis software and physicians' naked eye.

METHODS

Ten Asian patients with head and neck vitiligo lesions stable for at least 6 months were treated with pixel array epidermal grafting with an automatic harvesting system and post-grafting phototherapy. The patients were evaluated 1, 3, and 6 months post grafting for the percentage of repigmentation by blinded physicians' assessment and image analysis software. The color matching index of repigmentation was evaluated by measuring the melanin index in the grafted area and the juxta non-vitiliginous area.

RESULTS

The average blister harvest time was 46.3 ± 9.7 min. The area percentile of repigmentation by the image analysis software were 32.3 ± 26.8, 64.6 ± 29.4, and 76.5 ± 25.9 at 1, 3, and 6 months post grafting, respectively. There were no significant differences between the physicians' assessments and the results from the image analysis software. The change in the area percentile of repigmentation between 3 and 6 months post grafting was only statistically significant using image analysis software. The grafted area achieved a color match of 83.1 ± 13.4% that of the juxta non-vitiliginous area 6 months after grafting. Three patients had repigmentation of leukotrichia.

CONCLUSION

By quantitative measurement, uniform pixel array micrografts provide a very good extent of repigmentation and color match in the head and neck area. Image analysis software revealed a steady increase in repigmentation after POM3 until POM6, which was not detected by subjective assessment.

A Comparative Study between Follicular Unit Transplantation and Autologous Non-cultured Non-trypsinized Epidermal Cells Grafting (Jodhpur Technique) in Stable Vitiligo

Introduction

Several modalities are currently available for the treatment of vitiligo, but generally they do not result in complete cure of the disease. Despite the limitations and some side effects, surgical modalities appear to be the method of choice in recalcitrant stable vitiligo. Both Jodhpur technique (JT) and follicular unit transplantation (FUT) are simpler and cheaper methods, requiring minimal infrastructure.

Materials and Methods

Hundred patches in 30 patients were divided into Group A and Group B, that is, hair follicle transplantation and autologous non-cultured non-trypsinized epidermal cell suspension grafting (JT), respectively. Fifty patches were included in each group. Efficacy of both the techniques, extent of pigmentation, and color match assessment were the main objectives.

Results

Excellent repigmentation (>75%), at the end of 20 weeks post surgery, was observed in 70% lesions in FUT group and 72% of lesions in JT group. Good response (extent of repigmentation of 50%-75%) was seen in 18% of lesions in FUT group as compared to 26% in JT group. JT and FUT technique were almost equal in producing excellent repigmentation. Color match was same for both the groups, that is, 49 of 50 patches showed same color as surrounding in both groups at the end of 20 weeks. Repigmentation of the depigmented hairs occurred in 11 of 46 patients with associated leukotrichia.

Conclusion

Our study indicates that both JT and FUT are safe and effective techniques in terms of repigmentation but JT is somewhat superior to FUT in producing excellent and good repigmentation, side effects, patient satisfaction, and dermatology life quality index reduction, while the color match was almost same with both techniques.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.

Noncultured epidermal suspensions obtained from partial-thickness epidermal cuts and suction blister roofs for vitiligo treatment: A prospective comparative study

BACKGROUND

The treatment options for vitiligo are either nonsurgical, including medical treatments and phototherapy, or surgical, including autologous transplantation methods. Noncultured epidermal suspension transplantation is indicated for the treatment of stable vitiligo not responding to either medical treatment or phototherapy. Variable results have been reported for the various techniques used for the preparation of this suspension.

AIM

To compare the outcome between suction blister roof grafts and partial-thickness epidermal cuts for the preparation of noncultured epidermal suspensions for the treatment of stable vitiligo.

PATIENTS AND METHODS

Forty patients with localized stable vitiligo lesions resistant to conventional therapy were included in the study. They were randomly divided into two groups for treatment with noncultured epidermal suspension grafting. The suspensions in groups I and II were obtained from suction blister roofs and partial-thickness epidermal cuts, respectively. Repigmentation grade, color match with the surrounding skin, and any side effects were compared between the groups.

RESULTS

In group I, complete repigmentation was achieved in 6 cases while repigmentation was considered excellent in 8 cases; very good, 4 cases; and no response, 2 cases. In group II, complete repigmentation was achieved in 4 cases, and repigmentation was considered excellent in 16 cases. The color of the repigmented area matched the normal surrounding skin in 70% of the cases in group I and 40% of the cases in group II.

CONCLUSION

Both techniques yielded comparable repigmentation results with advantages and disadvantages of both techniques.

Efficacy of Transplantation of Combination of Noncultured Dermal and Epidermal Cell Suspension vs Epidermal Cell Suspension Alone in Vitiligo: A Randomized Clinical Trial

Importance

Surgical interventions, notably noncultured epidermal suspension (NCES), are the next line of treatment in patients with vitiligo who fail to respond to medical therapy. Noncultured epidermal suspension is usually performed in patients with vitiligo with duration of clinical stability (DS) of 12 months or longer because DS is a vital parameter in determining outcome of NCES. In this pilot study, we planned to assess the efficacy of a novel combination of noncultured epidermal cell suspension and noncultured dermal cell suspension (NCES and NDCS) in patients with vitiligo with shorter DS (3-6 months).

Objective

To compare the efficacy of transplantation of NCES and NDCS vs NCES alone in patients with vitiligo with DS of 3 to 6 months.

Design, Setting, and Participants

A single-center randomized clinical trial including 40 patients with focal, segmental, or generalized vitiligo with DS of 3 to 6 months or more than 12 months was carried out. Based on DS, 2 groups including 20 patients each were recruited (DS in group 1, 3 to 6 months; DS in group 2, more than 12 months). Each group was further randomized into 2 subgroups, A and B.

Intervention

Patients in subgroups 1A and 2A underwent NCES alone, whereas patients in subgroups 1B and 2B underwent NCES and NDCS.

Main Outcomes and Measures

Extent of repigmentation, color match, and pattern of repigmentation at 24 weeks.

Results

Of the 40 study participants, mean (SD) age was 24.9 (4.0) years and 24 (60%) were women; in group 1 with DS for 3 to 6 months, more than 75% repigmentation at 24 weeks was observed in all 10 patients in subgroup 1B (NCES and NDCS) compared with 3 of 10 patients in subgroup 1A (NCES) (100% vs 30%, P = .003). In group 2 (DS > 12 months), the same was observed in 6 of 10 patients in subgroup 2A and 7 of 10 patients in subgroup 2B (NCES) (60% vs 70%, P > .99). The 2 groups and subgroups did not show any significant differences with respect to color matching and pattern of repigmentation.

Conclusions and Relevance

Combination of NCES and NDCS resulted in excellent response in patients with vitiligo with shorter duration of clinical stability compared with NCES alone. This combination may be used early in the course of stable vitiligo without waiting for a period of 12 months or more since last clinical activity.

Trial Registration

ClinicalTrials.gov identifier: NCT03013049.

The use of noncultured regenerative epithelial suspension for improving skin color and scars: A report of 8 cases and review of the literature

BACKGROUND

Regenerative Epithelial Suspension can lead to the restoration of wound and repigmentation, which can be gained by ReCell medical device to treat scar and depigmentation diseases.

OBJECTIVES

To report the effectivity of ReCell combined with microdermabrasion in scar and depigmentation diseases and review the literature of this new technology.

METHODS

We gave a differential donor⁄recipient ratio of about 1:20-30 with vitiligo, 1:40 with postburn construction, 1:80 with acne scar, and 1:120 with adult congenital melanocytic nevus, 1:80 with pediatrics, respectively. Photographs of patients before treatment and 3 months following the last treatment session were used to evaluate the effectivity.

RESULTS

A total of 8 patients including vitiligo vulgaris, postburn reconstruction, acne scars, and congenital melanocytic nevi treated by ReCell technology combined with microdermabrasion showed significant improvement in skin texture and color. And 17 studies of the research on ReCell technology were totally included in the systematic review.

CONCLUSION

Our investigation showed that Regenerative Epithelial Suspension gained by ReCell technology combined with microdermabrasion may improve scar and depigmentation diseases.

Detection of melanocyte lineage-specific genes in vitiligo lesions

Vitiligo is an acquired pigmentary disorder characterized by the loss of skin color and functional melanocytes. The pathogenesis of vitiligo remains unclear, which means that effective clinical treatment is difficult. However, if melanocyte linkage-specific genes are identified in vitiligo lesions, the appropriate treament for melanocytes may be implemented. The current study aimed to detect the expression of melanocyte lineage-specific genes in vitiligo lesion needle biopsies and to predict the occurrence of perifollicular repigmentation in depigmented macules. A total of 6 patients with stable vitiligo and 4 healthy volunteers were recruited from the Department of Dermatology, Wuhan Third Hospital. Total RNA was extracted from skin tissue needle biopsies from the periphery and center of depigmented macules, and adjacent normal skin. The expression of dopachrome tautomerase (Dct), tyrosinase (Tyr) and β-actin (ACTB) genes were detected using a reverse transcription (RT)-semi quantitative polymerase chain reaction (PCR) assay. RNA extracted from 7 mg of skin samples was sufficient to amplify all three genes. The expression profile of each patient was then observed in the center of vitiligous lesions and were deemed to be Dct+Tyr-ACTB+, Dct-Tyr-ACTB+ or Dct+Tyr+ACTB+. At 5 months, patient follow-up indicated that perifollicular repigmentation was efficaciously induced by 308 nm eximer light radiation in a patient who had a Dct+Tyr-ACTB+ gene expression. The results demonstrated that needle skin biopsy and RT-semi quantitative PCR may be used as a less traumatic and reliable method to detect the expression profiles of melanocyte lineage-specific genes in needle biopsies, which may have the potential to predict the occurrence of perifollicular repigmentation in vitiligo.

Combination of Follicular and Epidermal Cell Suspension as a Novel Surgical Approach in Difficult-to-Treat Vitiligo: A Randomized Clinical Trial

Importance

Epidermal cell suspension (ECS) and follicular cell suspension (FCS) are successful surgical modalities for the treatment of stable vitiligo. However, repigmentation in generalized and acrofacial vitiligo and over acral or bony sites (eg, elbows, knees, iliac crests, and malleoli), which are difficult to treat, is challenging.

Objective

To study the efficacy of transplanting a combination of autologous, noncultured ECS and FCS (ECS + FCS) compared with ECS alone in stable vitiligo.

Design, Setting, and Participants

A prospective, observer-blinded, active-controlled, randomized clinical trial was conducted at a tertiary care hospital, with treatment administered as an outpatient procedure. Thirty participants who had stable vitiligo with symmetrical lesions were recruited between October 18, 2013, and October 28, 2016. All of the lesions were resistant to medical modalities with minimum lesional stability of 1 year. Intent-to-treat analysis was used.

Interventions

ECS + FCS was prepared by mixing equal amounts (in cell number) of FCS with ECS. After manual dermabrasion, ECS was applied to 1 lesion and ECS + FCS was applied to the anatomically based paired lesion of the same patient. No adjuvant treatment was given.

Main Outcomes and Measures

Patients were followed up at 4, 8, and 16 weeks by a blinded observer and extent of repigmentation, color match, pattern of repigmentation, patient satisfaction and complications were noted. Both the visual and the computerized image analysis methods were used for outcome assessment. Cell suspensions were assessed post hoc for OCT4+ stem cell counts using flow cytometry; expression of stem cell factor and basic fibroblast growth factor was evaluated using quantitative relative messenger RNA expression.

Results

Of the 30 patients included in the study, 18 (60%) were women; mean (SD) age was 23.4 (6.4) years. Seventy-four percent of the lesions (62 of 84) were difficult-to-treat vitiligo. ECS + FCS showed superior repigmentation outcomes compared with ECS: extent (76% vs 57%, P < .001), rapidity (48% vs 31%, P = .001), color match (73% vs 61%, P < .001), and patient satisfaction (mean [SD] patient global assessment score, 23.30 [6.89] vs 20.81 [6.61], P = .047). Melanocyte stem cell counts (2% in ECS + FCS vs 0.5% in ECS) as well as expression of basic fibroblast growth factor (11.8-fold) and stem cell factor (6.0-fold) were higher in ECS + FCS suspension (P<.05 for both).

Conclusions and Relevance

The findings from this study establish ECS + FCS as a novel approach in vitiligo surgery for attaining good to excellent repigmentation in a short period with good color match, even in difficult-to-treat vitiligo.

Trial Registration

ctri.nic.in Identifier: CTRI/2017/05/008692.

Subacute cutaneous lupus erythematosus leukoderma treated with melanocyte-keratinocyte transplantation procedure

Depigmented lesions may occur as postinflammatory sequelae of subacute cutaneous lupus erythematosus (SCLE), leading to great psychosocial impact. A 53-year-old male patient presented with post-SCLE depigmented facial lesions after five years of disease stability. We proposed surgical treatment with melanocyte-keratinocyte transplantation procedure (MKTP), and after five months the patient achieved 90% repigmentation, without Koebner phenomenon (KP). In theory, KP is a possible complication of MKTP procedure since the preparation of the receptor area involves the use of dermabrasion. In an attempt to avoid it, we suggest to maintain the treatment of the underlying disease and wait for a minimum period of disease stability before the procedure.

Quality of life of adult vitiligo patients using camouflage: A survey in a Chinese vitiligo community

Background

Vitiligo is an acquired depigmented skin disease resulting in white macules, which may significantly impair the quality of life (QoL) of the patients.

Objective

To estimate the QoL in Chinese vitiligo patients using camouflage with a more detailed description, and to identify the possible risk factors related to poor QoL.

Methods

An online survey was conducted in vitiligo patients using camouflage from a vitiligo community. Survey questions included demographic, clinical information, dermatology- and vitiligo-specific QoL questionnaires. Multivariate logistic analysis was performed to identify risk factors that related to poor QoL.

Results

In total, 884 respondents were included in the analyses, of which 413 (46.7%) were male. The score of DLQI was 5.83±5.75 (mean± SD). Age, gender, marriage status, occupational status, anogenital involvement, patient-perceived severity (presented by VAS score), symptoms as itching, pain, sunburn and koebner phenomenon, total cost of treatment and degree of satisfaction in camouflage therapy were independently associated with DLQI score (p<0.05).

Conclusion

Vitiligo has considerable impact on QoL of affected patients in Chinese population even when they were using camouflage. Camouflage might be helpful to improve QoL of the patients.

Autologous non-cultured melanocyte-keratinocyte transplantation in the treatment of vitiligo: patient selection and perspectives

Autologous non-cultured melanocyte–keratinocyte transplantation procedure (MKTP) is one of the simplest cellular grafting techniques. Various modifications were done over the years to make the technique easier and more economical which led to its great popularity among dermatologists. Proper patient selection and good technical skills are essential for achieving success with this technique. In this review, different patient-related and procedure-related factors that affect the outcome are discussed. This review may guide dermatologists to select suitable candidates, and explains what to expect in each case and indicates different techniques which can be used. The expected complications and stability of acquired pigmentation, which are an essential part of the pretreatment patient counseling, are also discussed.

Repigmentation in vitiligo: position paper of the Vitiligo Global Issues Consensus Conference

The Vitiligo Global Issues Consensus Conference (VGICC), through an international e-Delphi consensus, concluded that 'repigmentation' and 'maintenance of gained repigmentation' are essential core outcome measures in future vitiligo trials. This VGICC position paper addresses these core topics in two sections and includes an atlas depicting vitiligo repigmentation patterns and color match. The first section delineates mechanisms and characteristics of vitiligo repigmentation, and the second section summarizes the outcomes of international meeting discussions and two e-surveys on vitiligo repigmentation, which had been carried out over 3 yr. Treatment is defined as successful if repigmentation exceeds 80% and at least 80% of the gained repigmentation is maintained for over 6 months. No agreement was found on the best outcome measure for assessing target or global repigmentation, therefore highlighting the limitations of e-surveys in addressing clinical measurements. Until there is a clear consensus, existing tools should be selected according to the specific needs of each study. A workshop will be conducted to address the remaining issues so as to achieve a consensus.

Fractional CO2 Laser Pretreatment to Autologous Hair Transplantation and Phototherapy Improves Perifollicular Repigmentation in Refractory Vitiligo: A Randomized, Prospective, Half-Lesion, Comparative Study

BACKGROUND

Fractional CO2 laser and autologous hair transplantation are independently effective in the treatment of refractory and stable vitiligo.

OBJECTIVE

The authors' purpose was to evaluate the therapeutic efficacy of fractional CO2 laser pretreatment compared with autologous hair transplantation and phototherapy alone for refractory and stable vitiligo.

METHODS

A total of 20 patients with refractory and stable vitiligo were enrolled from our clinic. Resistant lesions randomly divided into 2 regions as follows: (1) Part A: fractional CO2 laser pretreatment followed by autologous transplantation and phototherapy, and (2) Part B: autologous transplantation and phototherapy alone. Five days after fractional CO2 laser application to Part A, both treatment regions received a transplant of scalp grafts. On Day 11, the entire lesion was exposed to narrow-band UVB phototherapy, twice a week for 12 weeks. The diameter of perifollicular repigmentation was measured monthly with a caliper.

RESULTS

Perifollicular repigmentation was detectable surrounding 74% of grafted hair follicles by Month 3. Furthermore, Part A demonstrated a significantly greater diameter of repigmentation with 6.6 ± 5.8 mm in Part A compared with 4.3 ± 1.8 mm in Part B (p = <.001).

CONCLUSION

In this study, our results demonstrate improved efficacy of autologous hair transplantation and narrow-band UVB with fractional CO2 laser pretreatment in refractory and stable vitiligo.

An Automated and Minimally Invasive Tool for Generating Autologous Viable Epidermal Micrografts

OBJECTIVE:

A new epidermal harvesting tool (CelluTome; Kinetic Concepts, Inc, San Antonio, Texas) created epidermal micrografts with minimal donor site damage, increased expansion ratios, and did not require the use of an operating room. The tool, which applies both heat and suction concurrently to normal skin, was used to produce epidermal micrografts that were assessed for uniform viability, donor-site healing, and discomfort during and after the epidermal harvesting procedure.

DESIGN:

This study was a prospective, noncomparative institutional review board–approved healthy human study to assess epidermal graft viability, donor-site morbidity, and patient experience.

SETTING:

These studies were conducted at the multispecialty research facility, Clinical Trials of Texas, Inc, San Antonio.

PATIENTS:

The participants were 15 healthy human volunteers.

RESULTS:

The average viability of epidermal micrografts was 99.5%. Skin assessment determined that 76% to 100% of the area of all donor sites was the same in appearance as the surrounding skin within 14 days after epidermal harvest. A mean pain of 1.3 (on a scale of 1 to 5) was reported throughout the harvesting process.

CONCLUSIONS:

Use of this automated, minimally invasive harvesting system provided a simple, low-cost method of producing uniformly viable autologous epidermal micrografts with minimal patient discomfort and superficial donor-site wound healing within 2 weeks.

Use of a novel epidermal harvesting system in resource-poor countries

The 2010 earthquake in Port-au-Prince, Haiti, highlighted the need for wound care in resource-poor countries. Subsequently, the University of Miami in Florida established one of the first interprofessional wound care centers located at Bernard Mevs Hospital in the central portion of Port-au-Prince, caring for patients with acute and chronic wounds. In 2012, the authors used a novel epidermal harvesting system (CelluTome Epidermal Harvesting System; Kinetic Concepts Inc, San Antonio, Texas) to harvest epithelium to be grafted on 7 patients at the Mevs Hospital with longstanding wounds. Epidermal microblisters were obtained from each patient's thigh using the CelluTome Epidermal Harvesting System. After 35 minutes, microblisters were raised using the device harvester, and an adhesive dressing was inserted into the harvester for transfer to the wound site. In patients with lower-extremity wounds, a 2-layer compression dressing was placed over epidermal grafts. Six of the 7 wounds improved or achieved complete closure in 4 weeks. One of the patients with a 2-year-old thigh wound failed to demonstrate improvement; this may have been secondary to an inability to adequately secure the graft. All donor sites healed without any visible scarring. The authors were able to conclude that epidermal grafting may represent a viable reconstructive option for patients in resource-poor countries.

A Case Series of Complex Recalcitrant Wounds Treated with Epidermal Grafts Harvested from an Automated Device

Introduction: Epidermal grafting has several advantages over full-thickness or split-thickness grafts in the treatment of complex non-healing wounds. These include the low risk of donor site complications, minimal patient discomfort, and abstention from the operating room. Traditionally, the lack of reliable epidermal harvesting techniques has limited its clinical utilization. The development of an automated suction blister epidermal graft (SBEG) harvesting device may facilitate clinical utilization of this technique. The authors present a case series of multimorbid patients who were poor surgical candidates and were treated with this technique.

Methods: A retrospective review of all patients treated with CelluTome™​ Epidermal Harvesting System (KCI, an Acelity company, San Antonio, TX) prior to May 2016 at our institution was conducted.

Results: A total of 12 patients underwent 14 epidermal grafting procedures. Multiple comorbidities were identified, including smoking (33%), immunosuppression by immunotherapy or steroids (25%), chronic venous insufficiency (25%), diabetes mellitus (25%), malignancy (25%), polysubstance abuse (17%), HIV/AIDS (17%), and peripheral artery disease (8%). Among the two acute wounds (≤ 3 months) and 10 chronic wounds, the average wound size was 49.1 cm² (± 77.6 cm²) and the median wound duration was 5.7 months (interquartile range: 4.1 - 15.8 months) before SBEG was attempted. These complex wounds had failed prior therapies, such as local wound care (100%), incision and drainage (58%), vacuum-assisted closure (33%), split-thickness skin graft (16%), and hyperbaric oxygen (8%). Following the procedure, all donor sites healed within one week. Three patients were lost to follow-up. Of the remaining nine patients, four patients had complete resolution of their wounds at a median follow-up of 13.1 weeks (interquartile range: 6.8-17.3 weeks). Among those with partial resolutions, the average wound size was 4.2 cm² (± 2.1 cm²) with an average wound reduction of 79% (± 23%). No donor or recipient site complications were observed.

Conclusions: The automated SBEG harvesting device is an effective and safe option for treating complex non-healing wounds in multimorbid patients who may be poor surgical candidates. This procedure demonstrates minimal contraindications to its use and donor or recipient site complications.

Epidermal skin grafting

Autologous skin grafts, such as full- and split-thickness, have long been part of the reconstructive ladder as an option to close skin defects. Although they are effective in providing coverage, they require the need for a trained surgeon, use of anaesthesia and operating room and creation of a wound at the donor site. These drawbacks can be overcome with the use of epidermal skin grafts (ESGs), which can be harvested without the use of anaesthesia in an office setting and with minimal to no scarring at the donor site. ESGs consist only of the epidermal layer and have emerged as an appealing alternative to other autologous grafts for the treatment of acute and chronic wounds. In this article, we provide an overview of epidermal grafting and its role in wound management.

Epidermal skin grafting in vitiligo: a pilot study

Vitiligo is a multifactorial acquired dermatosis characterised by achromic or hypochromic macules and by the absence of functioning melanocytes. Treatment depends on the extent of the affected areas and on disease activity. Surgical techniques have proven to be effective in stable cases but can be time-consuming and, in some cases, aesthetically unsatisfying or painful for the patients. The aim of the study was to assess the clinical safety and effectiveness of a new automatic epidermal skin harvesting device in patients with stable localised vitiligo over a minimum 12-month period. This new system (CELLUTOME™ Epidermal Harvesting System, KCI, an ACELITY Company, San Antonio, TX) is a commercially available epidermal skin harvesting system that can be used without local anaesthesia or other pre-treatments and has been shown to have low rates of donor site morbidity. Epidermal skin grafts can used in patients with acute and hard to heal chronic wounds, burns and stable vitiligo. The use of advanced therapies may improve the quality of life, have cost benefits and accelerate re-pigmentation of patients with vitiligo. In our preliminary study, this system was seen to be a safe and efficacious means of harvesting epidermal micrografts containing melanocytes for use in patients with stable vitiligo unresponsive to standard therapies.

Evaluation of the correlation between serum levels of vitamin D and vitamin D receptor gene polymorphisms in an Egyptian population

BACKGROUND

Vitiligo is an autoimmune depigmentation disorder. Polymorphisms in the vitamin D receptor (VDR) have been found to be associated with vitiligo.

OBJECTIVES

To evaluate the potential association between VDR gene polymorphisms (ApaI, TaqI, and FokI) and vitiligo susceptibility, and to detect if there is correlation between serum 25-hydroxyvitamin D [25(OH)D] levels and vitiligo and between VDR gene polymorphisms and 25(OH)D levels in vitiligo.

MATERIALS AND METHODS

Seventy-five patients with vitiligo and 75 age and sex-matched controls were subjected to detailed history taking and dermatological examination to determine the extent and clinical type of vitiligo. A blood sample (5 ml) was retrieved to investigate VDR gene polymorphisms and serum 25(OH)D level.

RESULTS

Our results showed that the serum level of vitamin D is statistically significantly lower in patients than controls. The frequency of the ApaI variant a allele, the variant genotype (aa), and the variant genotype (tt) were significantly higher among the vitiligo cases than among controls. Our study also showed that the serum 25(OH)D levels were not significantly different among the different ApaI, TaqI, and FokI genotypes.

CONCLUSION

The present study showed that serum level of 25(OH)D is statistically significantly lower in patients than controls, so screening for vitamin D deficiency seems of value in patients with vitiligo for the possibility of vitamin D supplementation. We also report that VDR gene polymorphisms may be a risk for the development of vitiligo in an Egyptian population.

Evidence-based management of vitiligo: summary of a Cochrane systematic review

Vitiligo affects around 1% of the world's population. Despite it being relatively common, there is still no effective treatment. The objective of this study was to update the Cochrane systematic review of randomized clinical trials (RCTs) to evaluate the efficacy of treatments for vitiligo. We carried out searches of a range of databases to October 2013 for RCTs of interventions for vitiligo regardless of language or publication status. At least two reviewers independently assessed study eligibility and methodological quality and extracted data using data extraction forms approved by the Cochrane Skin Group. Our primary outcomes of interest were quality of life, > 75% repigmentation and adverse effects. We retrieved 96 studies, of which 39 were new studies, with an overall total of 4512 participants. Repigmentation was assessed in all studies, although only five reported on all three of our primary outcomes. Regarding our two secondary outcomes, six studies measured cessation of spread but none assessed long-term permanence of repigmentation at 2 years' follow-up. Most of the studies evaluated combination treatments, which generally showed better repigmentation than monotherapies. Of the new studies, seven were surgical interventions. The majority of the studies had fewer than 50 participants. The quality of the studies was poor to moderate at best. Very few studies specifically included children or participants with segmental vitiligo. Five years after the last update of this review, there are still important variations in study design and outcome measures in clinical trials for vitiligo, limiting the evidence for the efficacy of different therapeutic options. The best evidence from individual trials showed short-term benefit from topical corticosteroids and various forms of ultraviolet radiation combined with topical preparations. Long-term follow-up and patient-rated outcomes should be incorporated into study design, and more studies should assess psychological interventions.

Immunological Parameters Associated With Vitiligo Treatments: A Literature Review Based on Clinical Studies

Vitiligo, a depigmentary disorder, caused by the loss of melanocytes, affects approximately 1% of the world population, irrespective of skin type, with a serious psychological impact on the patient quality of life. So far, the origin of vitiligo has not been traced and the pathogenesis is complex, involving the interplay of a multitude of variables. Although there is no treatment that ensures the complete cure of the disorder, there are some pharmacological, phototherapy, and surgical therapies available. A series of variables can affect treatment outcome, such as individual characteristics, emotional issues, type of vitiligo, stability of the lesions, and immunological status. The present literature review identified the main immunological parameters associated with treatments for vitiligo. Cytotoxic CD8+ T lymphocytes are the main cell type involved in treatment success, as fewer cells in skin lesions are associated with better results. Other parameters such as cytokines and regulatory T cells may also be involved. Further clinical scientific studies are needed to elucidate the complex mechanisms underlying vitiligo and its treatments, in order to expand the range of therapeutic approaches for each individual case.