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

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.

Old Wine in New Bottle: Lentigo Transplant for Beauty Spot Creation

Melanocytic nevi especially on the face, neck, and chest are considered a sign of beauty since historic times. Since historic times and in various cultures, these nevi are associated with beauty and attractiveness, thus called beauty spots. Artificial beauty marks have been fashionable since the medieval era. it requires repetitive use easily making it a cumbersome process. Tattooed beauty marks by medical professionals or tattoo artists are commonly done but require frequent touch-ups with a risk of complications. So we came up with a very innovative technique of tissue grafting of an existing lentigines/melanocyte nevus to the desired site which gave a natural and permanent solution.

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

Background

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

Aim

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

Study design

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

Results and conclusion

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

Limitations

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

Current Debates on Etiopathogenesis and Treatment Strategies for Vitiligo

Vitiligo is an acquired, chronic, and progressive depigmentation or hypopigmentation characterized by the destruction of melanocytes and the occurrence of white patches or macules in the skin, mucosal surface of eyes, and ears. Melanocytes are the melanin pigment-producing cells of the skin which are destroyed in pathological conditions called vitiligo. Approximately 0.5 - 2.0% of the population is suffering from vitiligo, and a higher prevalence rate of up to 8.8% has been reported in India. It is caused by various pathogenic factors like genetic predisposition, hyperimmune activation, increased oxidative stress, and alteration in neuropeptides level. Genetic research has revealed a multi- genetic inheritance that exhibits an overlap with other autoimmune disorders. However, melanocytes specific genes are also affected (such as DDR1, XBP1, NLRP1, PTPN22, COMT, FOXP3, ACE, APE, GSTP1, TLR, SOD, and CTLA-4). A number of therapeutic options are employed for the treatment of vitiligo. The topical corticosteroids and immunomodulators are currently in practice for the management of vitiligo. Phototherapies alone and in combinations with other approaches are used in those patients who do not respond to the topical treatment. The main focus of this review is on the etiopathological factors, pharmacological management (phototherapy, topical, systemic, and surgical therapy), and herbal drugs used to 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.

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

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

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.

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.

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.