Cellular grafts in management of leucoderma

The story of melanocyte: a long way from bench to bedside

Skin is composed of major layers, namely a superficial epidermis and a deeper dermis. The color of skin is influenced by a number of pigments, including melanin, which is produced by cells called melanocytes. Most skin disorders are relatively benign, but a few, including melanomas, can be fatal. A number of more noticeable disorders, namely albinism and vitiligo, affect the appearance of the skin and its accessory organs. Vitiligo is associated with significant psycho-social morbidity and a major effect on quality of life. Topical steroids, calcineurin inhibitors, phototherapy and surgery are the most common treatments for melanoma. However, there are many patients who do not respond to any of these modalities. The transplantation of cultured or non-cultured melanocyte is the most important treatment for hypopigmentory disorders. This study aims at reviewing the history of melanocyte cultivation, and evaluating the effectiveness of transplantation of cultured cells. For this purpose, the authors examined the initial process of isolation, characterization, and transplantation of epidermal cells. This review, thus, summarizes the current understanding of the cutaneous pigmentary system from the start of synthesis in the pigment cells, along with the response of repigmentation. During the production of melanin, melanosomes are transferred to neighboring keratinocyte in order to form perinuclear melanin caps. The objective of this review is to analyze the melanocytes transplantation in the last century to date, and explore the methods epidermal cells can increase pigmentation in hypo-pigmented areas in skin disorders. Moreover, the focus is on the story of the melanocyte back to 1950s. In addition, prior systemic therapy was associated with a significant increase, based on combined additional therapy, achieving desired results and improved outcomes. Despite the short study of a long way of melanocyte assessment and following up patient treatment, results of the all reports confirmed the efficacy of the method used in the treatment of stable vitiligo patients, who did not respond to the common algorithms of non-invasive treatments.

Melanocyte-Keratinocyte Transplantation in Post-Burn Leukoderma Scars: Preliminary Experience Using a Modified Technique

Post-burn leukoderma, commonly affecting the African and Asian communities, results from deep dermal burns. The associated stigma exacerbates the condition and significantly affects the rehabilitation and reintegration of post-burn survivors into society. Melanocyte-keratinocyte transplantation (MKTP) is a promising single-stage treatment for repigmentation in vitiligo. However, its use in post-burn leukoderma is undetermined. This study aims to evaluate the MKTP treatment in post-burn leukoderma patches. Six patients (five males and one female, mean age = 29±5.51 years) with ten patches of post-burn leukoderma underwent single-stage MKTP without adjuvant pigmentation therapy. The postoperative follow-up period ranged from twelve to twenty-four months for all the patients. The average size of leukoderma treated was 16.25±9 cm2. Repigmentation was observed in 92.16±11.05% of the total treated area by the end of one year after MKTP application. All six patients were satisfied with the treatment outcome. MKTP without adjuvant therapy is an effective surgical treatment to treat post-burn leukoderma patches. Future studies should cover a larger sample over a longer follow-up period.

A comparative study of efficacy of split-thickness skin grafting versus autologous melanocyte transfer in the management of stable vitiligo

Background

Vitiligo is a depigmenting skin disorder resulting from the loss of melanocytes in the epidermis. Surgical treatment is indicated in resistant stable vitiligo that does not show adequate response to medical therapy. This study aims at comparing the efficacy of repigmentation by split-thickness skin grafting (STSG) versus autologous non-cultured melanocyte transfer (AMT) in the management of stable vitiligo.

Methods

A total of 22 patients were recruited, which included 100 stable vitiligo patches. Fifty patches were subjected to STSG, and the remaining 50 were subjected to AMT. The patients were followed up at monthly intervals for six months to assess the degree of repigmentation.

Results

The results at the end of six months were as follows: 40% patches in group A and 42.5% in group B exhibited >75% repigmentation. The outcome was better over the limbs, acral parts and joints. The average donor-to-recipient area ratio for group A was 1:1, whereas that for group B was 1:3.2.

Conclusion

Both STSG and AMT are effective surgical modalities in the management of stable vitiligo. However, AMT has cosmetically better good outcomes, requires a smaller size of the donor area and has minimal complications over both recipient and donor areas.

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.

Efficacy and safety of noncultured melanocyte-keratinocyte transplant procedure for vitiligo and other leukodermas: a critical analysis of the evidence

Vitiligo is an acquired pigmentary skin of depigmentation occurring secondary to melanocyte destruction. Vitiligo and other leukodermas have a profound impact on quality of life. Current therapies include medical options, such as phototherapy, topical and systemic corticosteroids, topical calcineurin inhibitors, immunomodulators, and antioxidiants, and surgical options. Surgical options provide melanocytic cells to previously depigmented areas and use either tissue grafting or cellular grafting methods. Topical treatments are often insufficient, and many of the current surgical procedures have shown variable response rates. In this review, we discuss the process of the cellular grafting melanocyte-keratinocyte transplantation procedure (MKTP) and critically analyze its efficacy and safety in the treatment of vitiligo and other leukodermas. PubMed was searched for studies (2001-2017) describing the use of MKTP in patients with vitiligo or other leukodermas. Articles or trials discussing the use of MKTP for these patients were selected for in-depth review. Clinically relevant results regarding efficacy and safety of MKTP in vitiligo and leukoderma patients were analyzed. Numerous trials and case series/reports have demonstrated tolerability and efficacy of MKTP with repigmentation for patients with refractory, stable vitiligo. However, the response rates have been variable, likely influenced by vitiligo type and affected areas. Future research and clinical reporting will provide more insight on which phenotypes may benefit from MKTP.

A Study of the Outcome of Primary Excision and Closure Technique in the Management of Lip Leukoderma in 30 Patients

Context:

Lips being one of the graceful cosmetic units of the face, any disfigurement, including depigmentation, can be embarrassing, psychologically distressing, and socially stigmatizing. Even with the evolution of various surgical modalities, none of the techniques ensure 100% pigmentation with a good cosmetic appearance. With this background, this study was undertaken to study the efficacy of the technique—primary excision and closure in treatment of lip leukoderma (LL).

Aims:

To study the efficacy, cosmetic outcome, and recurrence following primary excision and closure technique in the management of LL.

Settings and Design:

A prospective single-center open-label uncontrolled study.

Materials and Methods:

Thirty patients with LL involving inner margin of the lower lip and those who fulfilled inclusion and exclusion criteria were included in the study. After obtaining consent and physician fitness, patients were posted for primary excision and closure of the vitiliginous area of the lip. Patients were followed up at the immediate postoperative period and 6 months later. Patient satisfaction scale was done by asking the patient to grade the response between one and ten.

Statistical Analysis Used:

Mean and percentiles.

Results:

Out of 30 patients, 29 patients achieved complete clearance that was cosmetically acceptable. Only one patient showed recurrence at the end of 6 months. Average patient satisfaction scale showed an average of 9.66.

Conclusions:

Primary excision and closure technique is one of the safe, inexpensive modality in the management of LL involving the inner margin of the lip with immediate result.

Grafting in vitiligo: how to get better results and how to avoid complications

Grafting procedures in vitiligo have become quite popular over the last one or two decades especially in India. Starting with the simplest punch grafting we have now a multitude of different grafting techniques available in vitiligo. All of these grafting procedures are associated with certain complications. In addition there are certain factors and surgical pearls that can go a long way in improving the cosmetic results achieved with any of these grafting techniques. This paper will try to address these specific factors and complications associated with these grafting techniques and the ways and means to avoid them.

Potential of regenerative medicine for treatment of vitiligo patients

The article presents a review of publishes sources on the efficacy of methods such as tissue engineering and cellular transplantation of autologous melanocytes for treatment of vitiligo patients. The article describes general principles of treatment and particular features of current melanocyte transplantation methods.

Fat and epidermal cell suspension grafting: a new advanced one-step skin regeneration surgical technique

BACKGROUND

Dystrophic skin scarring commonly occurs following skin cancer resections. In particular, the cosmetic outcome of skin graft reconstructions, following epidermoidal carcinoma removal, is generally poor due to wide marginal tumour excision, loss of subcutaneous tissues, and subsequent pigmented atrophic scarring of the graft coverage. Skin grafting sequelae need a three dimensional correction to restore either the epidermal layer or the dermal/subdermal volume and vascularization.

METHODS

The surgeons combined CO2 laser ablation, subdermal lipofilling according to the Coleman's technique and epidermal cell suspension autografting to correct wide depressed and dyschromic facial scar. The Authors applied this new technique on three nasal skin cancer resected patients: two of them actually need a longer follow-up, the third patient, a 48 yr old caucasian male, presented a skin grafting scar due to sclerodermiform basal cell carcinoma removal. This case is reported discussing pre-intra and post-operative records up to a complete twelve months follow-up.

RESULTS

Records at six and twelve months follow-up after surgery demonstrate a fully integrated skin graft and a good restoration of the treated area, presenting the same texture and pigmentation of the adjacent untreated skin. Optimal, stable three-dimensional skin cosmetic restoration was obtained in a single stage surgical procedure.

CONCLUSION

Autologous non-cultured epidermal cell suspension transplantation on an epidermal laser ablated skin area, in combination with lipofilling subdermal reconstruction, appears to be an effective, simple and time-saving method to correct skin graft sequelae, in skin cancer patients. This new technique allows to restore a three-dimensional morphological structure of the treated area and to recover a natural appearance of the skin at the same time. The Authors believe that this technique can be safely used to treat any kind of dystrophic scarring.

Comparison of intradermal injection of autologous epidermal cell suspension vs. spraying of these cells on dermabraded surface of skin of patients with post-burn hypopigmentation

Introduction:

One of the most important complications after burning is hypo/depigmentation. This study was designed to compare two methods of cell spray and intradermal injection of epidermal cell suspension for treatment of burn induced hypopigmentation.

Material and Methods:

In this study, 28 patients with post burn hypo/depigmentation were selected and divided in 2 groups. A small skin biopsy was taken from normal skin of patients in operation room and epidermal cell suspension was prepared using NaBr 4N and trypsin. In the first group, the epidermal cell suspension was sprayed on the wound surface and then the area was dressed with amniotic membrane and gauze. In the second group, the cell suspension was injected in intradermal manner in the hypopigmented area. The patients were followed up and to evaluate the effect of the cells, photos were taken from the area before operation and also at follow-up. Clinical evaluation was done by the surgeon and a clinical score between “0” to “4” was used to demonstrate the clinical status from poor to excellent pigmentation. Skin biopsies were taken from depigmented area before and after interventions. Melanocytes were stained using anti S100 antibody and were counted in ×400 magnification fields.

Results:

Eighteen patients were in cell spray and 10 were in cell injection groups. Mean change of pigmentation in two group showed that there was no statistical significant differences in pigmentation between two groups, (P value = 0.52) although a limited improvement in pigmentation status was observed in both groups. Regarding melanocyte numbers per field, there was not a significant difference between two groups and also before and after interventions, but melanocyte number increased after treatment in both groups.

Conclusion:

We did not find noticeable differences between cell spray and intradermal injection methods. Although both methods showed a limited effect on pigmentation of depigmented skin, the clinical results were not satisfactorily for both patients and clinicians.

Current remedies for vitiligo

Vitiligo is a disorder with complex causes and is a type of autoimmune disease in which the immune system targets the body's own pigment cells and tissues. Our aim is to present an overall view of the current remedies widely adopted for the treatment of vitiligo. Medical treatments target the immune system, and try to reverse the destruction. The goal is to restore the skin's color by restoring healthy melanocytes to the affected area. Apart from melanocytes, vitiligo autoantigens appear also on other cells. Even though antibodies to pigment cells are not an agent of vitiligo, the most valuable contribution is that anti-melanocyte antibody reactivity can help in identifying relevant antigens. T cells from vitiligo skin are highly reactive towards melanoma cells and serve as an effective source to treat melanoma and stays as a solution for vitiligo. There have been many treatments to cure vitiligo such as use of steroid creams, PUVA (psoralen and ultraviolet A light), narrow band UVB (ultraviolet B), various surgical techniques, vitamin D analogues and pseudocatalase. These treatments are subjected for undesired side effects whereas some herbal and natural treatments act against the immune system with no side effects.