Vitiligo: surgical repigmentation of leukotrichia

Treatment of Vitiligo Associated Eyebrow and Eyelash Leukotrichia - A Systematic Review of Existing Information

Background

Vitiligo in hair bearing areas, especially segmental vitiligo, is frequently associated with leukotrichia. Leukotrichia, in general, is considered a predictor of unsatisfactory response to conventional treatment methods like phototherapy. This review aims to systematically review various available treatment options in patients with eyebrow and eyelash leukotrichia and assess the response to these therapeutic modalities.

Materials and Methods

Articles were searched using the keywords "eyelid", "eyelash", "leukotrichia", either singly or combined. The databases searched include Pubmed, Cochrane Library, Embase, and Science Direct. The strategy was to include studies in which any therapeutic modalities were undertaken for treatment of eyelash or eyebrow leukotrichia.

Results

After applying the inclusion and exclusion criteria, this review included 15 studies. There was a positive response to the surgical treatment options for eyebrow and eyelash leukotrichia. Topical tofacitinib has emerged as a promising new therapeutic option, but further studies are needed to establish its efficacy.

Conclusion

In conclusion, there are several treatment options for eyebrow and eyelash leukotrichia. However, further studies are needed to better understand their efficacy and optimal applications.

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.

Comparison of efficacy of noncultured hair follicle cell suspension and noncultured epidermal cell suspension in repigmentation of leukotrichia and skin patch in vitiligo: a randomized trial

BACKGROUND

Vitiligo manifests as hypo- to de-pigmented macules, which are sometimes associated with leukotrichia. For complete cosmetic improvement, the repigmentation of leukotrichia is an important component.

METHODS

This randomized controlled trial included patients with stable vitiligo with leukotrichia. Two vitiligo patches in each patient were randomized to receive either of the two procedures. The patients were followed up for 9 months posttransplantation. The efficacy of hair follicle cell suspension (HFCS) with epidermal cell suspension (ECS) in repigmentation of leukotrichia and skin in vitiligo was compared.

RESULTS

A total of 20 patients underwent the procedure, and 19 completed the follow-up. The area of the vitiligo patch and the number of leukotrichia in the patches were comparable between the two groups. There was a significant difference in the mean ± S.D. number of cells transplanted between the two groups (5.06 × 10⁵ in HFCS vs. 39.8 × 10⁵ in ECS, P < 0.0001). The percentage viability of cells and proportion of melanocytes were comparable between the two groups. A total of 10 patients in HFCS and eight patients in ECS had repigmentation of leukotrichia. The mean ± S.D. percentages of depigmented hair showing repigmentation at nine months were 7.42 ± 11.62% in HFCS and 11.42 ± 17.90% in ECS (P = 0.4195), whereas the mean ± S.D. percentage repigmentation of vitiligo patches was 61.58 ± 42.68% in HFCS and 78.68 ± 30.03% in ECS (P = 0.1618).

CONCLUSIONS

The mean number of cells transplanted in the HFCS group was about eight times less than those in ECS. ECS was better than HFCS in repigmentation of leukotrichia and vitiligo, although the difference was not statistically significant.

Follicular Transplantation, Microneedling, and Adjuvant Narrow-band Ultraviolet-B Irradiation as Cost-Effective Regimens for Palmar-Plantar Vitiligo: A Pilot Study

Treatment of refractory palmar-plantar vitiligo is particularly challenging because the skin in these regions has a limited supply of follicle-derived melanocytic stem cells. Autologous hair transplantation monotherapy is effective in some forms of vitiligo through the provision of melanocytic stem cells. CO₂ laser followed by exposure to light (i.e., sunlight or narrow-band ultraviolet-B [nbUVB]) has independently shown to be an effective treatment strategy. Recently, it was found that the combination of hair transplantation and CO₂ laser followed by nbUVB exposure had superior efficacy to either modality as monotherapy. Similar to CO₂ laser, microneedling produces skin cell proliferation and releases pro-pigmentary cytokines. Given the important role of the cytokines in vitiliginous skin, microneedling may also be an effective therapeutic modality for refractory vitiligo. Herein, we conducted a pilot study to evaluate the efficacy of hair transplantation and CO₂ laser or microneedling followed by nbUVB. Microneedling and fractional CO₂ laser in combination with hair transplantation and nbUVB both demonstrated utility in the induction of repigmentation in refractory palmar-plantar vitiligo; however, a larger trial would be needed to determine a difference in treatment efficacy. Nonetheless, microneedling is cost-effective and requires minimal training; therefore, microneedling can be easily incorporated into standard dermatological practice.

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.

Successful Treatment of Vitiligo on the Scalp of a 9-Year-Old Girl Using Autologous Cultured Pure Melanocyte Transplantation

Leukotrichia frequently accompanies vitiligo on hairy areas such as the scalp. Treatment with conventional medical therapy is usually unsuccessful because of deficiencies in the melanocyte reservoir. We describe transplantation of autologous cultured pure melanocytes for scalp vitiligo with leukotrichia in a 9-year-old girl, resulting in almost complete and stable repigmentation of skin and hair.

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.

Follicular unit extraction as a therapeutic option for vitiligo

Follicular unit extraction (FUE) is a surgical procedure, which can be used to transplant follicular units into vitiliginous areas. Such follicular unit transplant has been recently used to repigment stable vitiligo patches. FUE was done for a 12-year-old female with a stable vitiligo patch with leukotrichia on the eyebrow. Repigmentation was noted in 6 weeks and complete pigmentation seen at 12 weeks. Leukotrichia resolved over a period of 6 months. No recurrence was noted at the end of 6 months follow-up with excellent colour match. This case is presented to highlight the simplicity, safety and effectiveness of FUE in stable vitiligo patches with leukotrichia.

Vitiligo treatment options: An evolving scenario

Sequential displays of several treatment options for vitiligo have been scanned from the literature, and are presented here. A few of the medical modalities have been resigned to history, whereas others have become customary in clinical practice. There has also been a recent surge of interest in the surgical treatment of this disease. Accordingly, this has been appraised and summarized. Special attention has been given to prevalent medical modalities so that they may be effectively utilized by those currently in practice.

Vitiligo and the melanocyte reservoir

Repigmentation of vitiligo depends on available melanocytes from three possible sources: from the hair follicle unit which is the main provider of pigment cells, from the border of vitiligo lesions, and from unaffected melanocytes within depigmented areas; pigment cells at these locations originate a perifollicular, border spreading and a diffuse repigmentation pattern. In order for repigmentation to take place under stimulation with diverse therapies, melanocytes should be present in appropriate numbers. Melanocyte tissue stem cells located in the niche at the bulge region of the hair follicle are the most important sources for providing immature pigment cells that undergo terminal differentiation and originate repigmentation, but cytokines, UVR and other molecules acting in melanogenesis with adequate regulation mechanisms contribute to successful recovery in vitiligo. The presence of keratinocyte stem cells in the interfollicular epidermis raises the question on the possibility of melanocyte stem cells in a similar location and the development of future strategies for therapeutic purposes.

Isolation and characterization of outer root sheath melanocytes of human hair follicles

BACKGROUND

Outer root sheath melanocytes (ORSM) are not yet routinely cultured and their biology is not known in detail because of their relatively low numbers in the hair follicle and their limited proliferative capacity in in vitro culture in routine media.

OBJECTIVES

To develop a method for culturing ORSM more easily and to investigate the length of telomeres and antigenic characteristics of ORSM compared with epidermal melanocytes (EM).

METHODS

Hair follicles were obtained from three Korean individuals during hair transplantation surgery. Single-cell suspensions of the outer root sheath were made and cultured in melanocyte growth medium with stem cell factor. After 21 days, second-passage outer root sheath keratinocytes (ORSK) (2 x 10(4) mL(-1) MGM) were added into the culture plates. We studied the proliferation pattern, morphological and antigenic characteristics of ORSM for each passage of cultured cells, and observed ORSM telomere length.

RESULTS

We established an ORSM culture method using ORSK. Two morphologically different ORSM types were obtained in the primary cultures. At the end of primary culture, ORSM appeared as whitish-cream pellets. The proliferation pattern of ORSM showed a sigmoidal shape, the accumulated numbers of population doublings showed a plateau after approximately 5 months, and senescence occurred at approximately 33 +/- 5 accumulated population doublings. The length of ORSM telomeres continued to shorten as the cells proliferated. In contrast, EM showed a marked proliferation from the early proliferation period which formed a plateau pattern towards the later period, and the number of accumulated population doublings was estimated to be 18 +/- 5 after 2 months. ORSM in the primary culture reacted variably with l-dihydroxyphenylalanine (DOPA): some cells were DOPA negative, some DOPA positive. There were some different antigenic expressions of microphthalmia-associated transcription factor (MITF) showing cytoplasmic expression in ORSM and nuclear expression in EM. By nuclear extraction and Western blotting, we showed that MITF expression of ORSM was marked in the cytoplasm and minimal in the nucleus. Antigenic expression of MITF and Bcl-2 gradually decreased with increasing passage number, whereas tyrosinase-related protein-1 expression did not change.

CONCLUSIONS

Culture of ORSM requires ORSK or ORSK-related factors; ORSM have greater proliferation potential and show different MITF antigenic expression compared with EM; and the length of ORSM telomeres shortens with repeated proliferation.

Single hair grafting for the treatment of vitiligo

BACKGROUND

Vitiligo is a disease of unknown cause, and many medical and surgical therapeutic methods are used to treat it.

OBJECTIVE

Our purpose was to evaluate the effectiveness of single hair grafting in patients with vitiligo.

METHODS

Single hairs were grafted into vitiliginous areas of 21 patients. The diameter of the spreading pigmentation was evaluated periodically.

RESULTS

Perifollicular repigmentation around the grafted hair was observed in 15 patients (71%) within 2 to 8 weeks. The diameter of the spreading pigmentation ranged from 2 to 10 mm during a 12-month follow-up period. In cases of generalized vitiligo, perifollicular pigmentation was seen in one of four patients (25%), whereas it was observed in 14 of 17 patients (82%) with localized/segmental vitiligo. Transformation of depigmented hairs into pigmented ones occurred in five patients.

CONCLUSION

Single hair grafting appears to be an effective method for treating localized/segmental vitiligo, especially on hairy parts of the skin, including the eyelids and eyebrows, and for small areas of vitiligo.