A Review of Non-cultured Epidermal Cellular Grafting in Vitiligo

To study the efficacy of autologous non-cultured nontrypsinized epidermal cell grafting (Jodhpur technique) by using of suction blister membrane in stable vitiligo

Objectives

This study aimed to evaluate the efficacy of autologous non-cultured non-trypsinized melanocytekeratinocyte grafting (JT) with suction blister membrane as biological dressing in stable vitiligo patches.

Material and Methods

The study was conducted at Mathura Das Mathur Hospital (MDM), Jodhpur, on 43 patches of Stable vitiligo. It was a prospective single-arm interventional study. All patients were examined clinically and history and informed consent were taken before starting the procedure.

Results

About 95% of patches showed >50% repigmentation with 83.72% having good to excellent repigmentation. About 88% of patches showed good color matches with an excellent decline in Dermatology Life Quality Index (DLQI). No serious complication was observed in the present study. The most common complication observed both in the donor and recipient area was pain.

Conclusion

Our study indicates that combining JT with suction blister epidermal grafting is a comparatively effective technique in terms of good repigmentation (≥75% extent of repigmentation), color match, fewer side effects, good patient satisfaction, and DLQI reduction.

The Treatment of Refractory Vitiligo With Autologous Cultured Epithelium Grafting: A Real-World Retrospective Cohort Study

BACKGROUND

Surgical intervention is the main therapy for refractory vitiligo. We developed a modified autologous cultured epithelial grafting (ACEG) technique for vitiligo treatment. Between January 2015 and June 2019, a total of 726 patients with vitiligo underwent ACEG in China, with patient characteristics and clinical factors being meticulously documented. Using a generalized linear mixed model, we were able to assess the association between these characteristics and the repigmentation rate.

RESULTS

ACEG demonstrated a total efficacy rate of 82.81% (1754/2118) in treating 726 patients, with a higher repigmentation rate of 64.87% compared to conventional surgery at 52.69%. Notably, ACEG showed a better response in treating segmental vitiligo, lesions on lower limbs, age ≤ 18, and stable period > 3 years. A keratinocyte:melanocyte ratio below 25 was found to be advantageous too. Single-cell RNA sequencing analysis revealed an increase in melanocyte count and 2 subclusters of keratinocytes after ACEG, which remained higher in repigmented sites even after 1 year.

CONCLUSIONS

ACEG is a promising therapy for refractory vitiligo. Patient age, clinical type, lesion site, and stability before surgery influence repigmentation in ACEG. The mechanism of repigmentation after ACEG treatment is likely not confined to the restoration of melanocyte populations. It may also involve an increase in the number of keratinocytes that support melanocyte function within the affected area. These keratinocytes may aid the post-transplant survival and function of melanocytes by secreting cytokines and extracellular matrix components.

TRIAL REGISTRATION

registered with Chictr.org.cn (ChiCTR2100051405).

Evaluation of clinical efficacy and laboratory indicators of non-cultured epidermal cell suspension and hair follicle cell suspension in surgical management of stable vitiligo: A randomized comparative trial

BACKGROUND

Non-cultured epidermal cell suspension (ECS) and hair follicle cell suspension (HFCS) are well-established methods of surgical treatment of stable vitiligo.

AIMS

The aim of the present study was to compare the laboratory indicators and clinical efficacy of ECS and HFCS in the treatment of stable vitiligo.

METHODS

This was a single centre, open-labeled randomized trial. Vitiligo patches from 74 patients were randomized to receive either ECS or HFCS. Both cell suspensions were analyzed for total cell count, cell viability and melanocyte count. Percentage re-pigmentation was assessed at regular intervals for 36 weeks.

RESULTS

The percentage re-pigmentation with ECS was significantly higher than HFCS at week 4 (p = .01) and week 16 (p = .03) however, no difference was observed at weeks 24 (p = .38) and 36 (p = .05). Forty-seven patients completed the study follow-up duration and excellent re-pigmentation (>90%) was achieved in 61.7% and 53.2% and complete re-pigmentation (100%) was observed in 6.4% and 12.8% of participants using ECS and HFCS, respectively. Significantly higher cell yield (p < .01) and percentage of HMB45+ melanocytes (p = .01) were obtained using ECS. No difference was noted in the percentage of viable cells or S100 + melanocytes.

CONCLUSION

The median cell yield was eight times higher in ECS than in HFCS with a significantly higher percentage of HMB45+ melanocytes in the former group. The median percentage of re-pigmentation in both groups was 90% at the end of 36 weeks. ECS provides faster re-pigmentation; however, both ECS and HFCS have comparable safety and efficacy over a longer duration of follow-up.

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.

Treatment of recalcitrant vitiligo by autologous non-cultured and trypsinized melanocyte grafting in the west of Iran

Background

Vitiligo is a common disease with a high burden, and its recalcitrant type is unresponsive to current medical treatments. Autologous non-cultured and trypsinized melanocyte grafting, which is a simple and experience-based procedure, has been suggested for the treatment of vitiligo.

Objective

To assess autologous non-cultured and trypsinised melanocyte grafting in recalcitrant vitiligo.

Methods

This clinical trial was done on 28 patients (20 females and 8 males). After demarcation and preparation of both donor and recipient sites, both sites were shaved by a curette. The materials harvested from the donor site were trypsinized and centrifuged. The resulting suspension was mixed with hyaluronic acid gel and was spread over the shaved recipient area.

Results

Twenty-eight patients with a total of 108 lesions and a mean age of 25.93 ± 7.11 years were included in the present study. Generalized vitiligo (57.1%) was the most common clinical type and the face and neck regions (38%) were the most frequent treated sites. Good to excellent repigmentation was seen in the face and neck, trunk, upper extremity, and genitals in 31 (57.4%), 11 (20.4%), 9 (16.7%) and 3 (5.5%) patients, respectively. Face and neck showed significantly better results (p < 0.05).

Study limitations

Low sample size and single-center study.

Conclusion

Autologous non-cultured and trypsinized melanocyte grafting is a safe method with satisfactory outcomes in recalcitrant vitiligo. Appropriate training of physicians and proper use of specialists’ experiences can be effective in increasing the improvement rate.

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.

Validation of an implantable bioink using mechanical extraction of human skin cells: First steps to a 3D bioprinting treatment of deep second degree burn

Clinical grade cultured epithelial autograft (CEA) are routinely used to treat burns covering more than 60% of the total body surface area. However, although the epidermis may be efficiently repaired by CEA, the dermal layer, which is not spared in deep burns, requires additional treatment strategies. Our aim is to develop an innovative method of skin regeneration based on in situ 3D bioprinting of freshly isolated autologous skin cells. We describe herein bioink formulation and cell preparation steps together with experimental data validating a straightforward enzyme-free protocol of skin cell extraction. This procedure complies with both the specific needs of 3D bioprinting process and the stringent rules of good manufacturing practices. This mechanical extraction protocol, starting from human skin biopsies, allows harvesting a sufficient amount of both viable and growing keratinocytes and fibroblasts. We demonstrated that a dermis may be reconstituted in vitro starting from a medical grade bioink and mechanically extracted skin cells. In these experiments, proliferation of the extracted cells can be observed over the first 21 days period after 3D bioprinting and the analysis of type I collagen exhibited a de novo production of extracellular matrix proteins. Finally, in vivo experiments in a murine model of severe burn provided evidences that a topical application of our medical grade bioink was feasible and well-tolerated. Overall, these results represent a valuable groundwork for the design of future 3D bioprinting tissue engineering strategies aimed at treating, in a single intraoperative step, patients suffering from extended severe burns.

Autologous noncultured, nontrypsinized melanocyte-keratinocyte graft homogenized in plasma gel followed by narrow-band ultraviolet B therapy for stable vitiligo: A novel technique

There is a continuous need for modifications of epidermal cell grafting techniques treating stable vitiligo to make it easier, more economic, and with better outcome. To evaluate the efficacy and safety of noncultured, nontrypsinized epidermal cell graft homogenized with plasma gel, followed by narrow band-ultraviolet B (NB-UVB) in treatment of stable vitiligo, about 40 patients with stable vitiligo underwent harvesting of epidermal cells from the donor site by dermabrasion then the harvested cells were prepared, homogenized with autologous plasma gel, and applied to the abraded recipient, followed by 16 NB-UVB sessions after complete healing. Patches within the same anatomical site received only NB-UVB as controls. The percentage of improvement ranged from 23.33% to 100% with more than 75% uniform, homogenous repigmentation in 65% of patients. Donor site healed completely with normal skin. Noncultured, nontrypsinized epidermal cell grafting technique homogenized with plasma gel followed by NB-UVB sessions gave positive responses and was well tolerated in different body sites in stable resistant vitiligo.

Outcomes of autologous non-cultured melanocyte keratinocyte transplantation in vitiligo and nevus depigmentosus

BACKGROUND

Melanocyte-keratinocyte transplantation procedure (MKTP) is an effective surgical technique for restoring skin pigmentation in all types of vitiligo and leukoderma patients who are unresponsive to medical and/or phototherapy treatment. Data specific to the outcomes of MKTP among Thai vitiligo and nevus depigmentosus patients are currently scarce.

OBJECTIVES

To evaluate the efficacy and safety of MKTP in patients with vitiligo or nevus depigmentosus at the short-term (≤6 months) and long-term (≥12 months) follow-up.

MATERIALS AND METHODS

A retrospective review of the medical records of vitiligo or nevus depigmentosus patients who underwent MKTP at the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during 2016 to 2019 was conducted. Repigmentation outcomes were evaluated by Vitiligo Area Scoring Index (VASI).

RESULTS

Twenty-five patients had 27 MKTP surgeries on 32 anatomically-based lesions. The mean age was 32.4 years, the mean age at onset was 25.5 years, and 19 patients were male. Segmental vitiligo, non-segmental vitiligo, and nevus depigmentosus had significantly improved VASI scores at the short-term follow-up (-74.2% ± 23.2%, -100%, and -62.5% ± 17.6%, respectively) and the long-term follow-up (-81% ± 27.7%, -95.0% ± 7.0%, and -83.3% ± 14.4%, respectively).

CONCLUSION

MKTP is a safe and effective method for treating refractory vitiligo and nevus depigmentosus in Thai patients.

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.

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.

Non-cultured melanocyte transfer in the management of stable vitiligo

Background and Aims

Present study aimed to determine the clinical outcome for non-cultured melanocyte transfer in the management of stable vitiligo.

Methods

A hospital based prospective study was conducted including 50 stable unresponsive patients of vitiligo undergoing non-cultured melanocyte transplant. Re-pigmentation was analyzed on the basis of baseline photographs after 6 months post procedure. Degree of re-pigmentation was estimated to the nearest of one of the following percentages and the final outcome of re-pigmentation for statistical analysis was graded as: >70% re-pigmentation: Good; 30-69% re-pigmentation: Fair and; <30% re-pigmentation: Poor.

Results

The mean age of study group was 29.79 ± 13.8 with 52% males and 48% females. Out of total 50 patients, 31 (62%) patients showed good re-pigmentation, 10 (20%) showed fair re-pigmentation while 9 (18%) patients showed poor re-pigmentation. Patches over face, lips, trunk and legs showed good re-pigmentation, however patches over acral areas and bony prominences had poor re-pigmentation.

Conclusion

Autologous non-cultured melanocyte transfer have an edge over the other modalities, however, proper patient selection, proper technique and good laboratory set up is required. It has an advantage over conventional split skin thickness grafting as it requires very little donor site skin.

Clinical Application of Cultured Stratified Epithelial Sheets Grown Under Feeder or Feeder-Free Conditions for Stable Vitiligo

BACKGROUND

Autologous cultured therapy has emerged as an effective treatment for stable vitiligo. However, culture methods may include harmful agents and be unsuitable for therapeutic use in humans.

OBJECTIVE

To investigate the safety and efficacy of autologous cultured epithelial sheets propagated under serum-free and feeder-free conditions for the treatment of stable vitiligo.

METHODS

Twenty-eight patients with stable vitiligo were included in this study. Keratinocytes and melanocytes from 14 patients were cultured under serum-free, feeder-free conditions (Group A). Epithelial cells from the remaining 14 patients were cultured according to Rheinward and Green's technique (Group B). Patients were followed up at 1, 3, 6, and 12 months after transplantation.

RESULTS

The epithelial sheets cultured in Group A were thinner and more fragile than Group B, but there were no significant differences in repigmentation between the 2 groups. At 12-month follow-up, in Group A, repigmentation at graft sites was classified as excellent in 9 patients and good in 2 patients. In Group B, repigmentation was excellent in 8 patients and good in 4 patients. Scars at the donor sites were the most frequent adverse events associated with the procedure.

CONCLUSION

Autologous epithelial sheet cultured in serum-free, feeder-free conditions is a safe and efficacious approach to cure stable 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.

Cultured Epidermal Melanocyte Transplantation in Vitiligo: A Review Article

BACKGROUND

The color of the skin is highly heritable but can be influenced by the environments and endocrine factors. Many other factors, sometimes destructive, are also involved in the formation of skin color, which sometimes affects pigmentation patterns. Vitiligo is an autoimmune hypopigmentation painless disorder with appearance of white patches and psychological effects on patients. It is a disease in which melanocytes of the skin are destroyed in certain areas; therefore depigmentation appears.

METHODS

We studied more than 60 articles. Several therapeutic methods have been used to return the color of skin in vitiligo. These methods include non-invasive treatment and surgical techniques. Among all these therapies, cell transplantation is an advanced procedure in regenerative medicine. Extraction of melanocytes from normal skin and then their cultivation in the laboratory provides a large number of these cells, the transplanting of which to depigmentation areas stimulates the site to irreversibly produce melanin.

RESULTS

The transplantation methods of these cells have been evolved over many years and the methods of producing blister have been changed to the injection of these cells to the target sites.

CONCLUSION

In this review, autologous cultured melanocyte transplantation has been considered to be the most viable, safe, and effective method in the history of vitiligo treatments.

Noncultured Extracted Hair Follicle Outer Root Sheath Cell Suspension versus Noncultured Epidermal Cell Suspension in the Treatment of Stable Vitiligo

Background:

Various treatment modalities exist for vitiligo, yet none of them are curative. Vitiligo is still considered a challenging disease to manage. Surgical treatment offers an excellent option for patients with stable vitiligo, especially those who fail to respond to medical treatment. Cell suspension techniques carry the advantage of covering large surface areas.

Objective:

To compare noncultured extracted hair follicle outer root sheath cell suspension (NCORSHFS) and noncultured epidermal cell suspension (NCES) in producing repigmentation.

Subjects and Methods:

Twenty patients were randomly allocated into two groups. They were objectively evaluated for the extent of repigmentation (after 1, 2, and 3 months), complications, cosmetic outcome, and satisfaction.

Results:

In NCORSHFS group, 10% showed excellent pigmentation, 20% showed good pigmentation, 50% fair, and 20% poor pigmentation. In NCES group, 10% showed excellent pigmentation, 10% good pigmentation, 40% fair, and 40% poor pigmentation. This difference was not statistically significant. Excellent color match was observed in 80% of NCORSHFS and in 70% of NCES. Donor area complications were absent in NCORSHFS group, whereas in NCES, mild scarring in 20% and hyperpigmentation in 40% of patients was observed. The difference in patients’ satisfaction between the two groups was not statistically significant.

Conclusion:

Both NCORSHFS and NCES are effective in producing good repigmentation with perfect color match and patients’ satisfaction. NCORSHFS has no donor area complications because it is a scarless procedure.

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.

Mapping architectural and transcriptional alterations in non-lesional and lesional epidermis in vitiligo

In vitiligo, chronic loss of melanocytes and consequent absence of melanin from the epidermis presents a challenge for long-term tissue maintenance. The stable vitiligo patches are known to attain an irreversible depigmented state. However, the molecular and cellular processes resulting in this remodeled tissue homeostasis is unclear. To investigate the complex interplay of inductive signals and cell intrinsic factors that support the new acquired state, we compared the matched lesional and non-lesional epidermis obtained from stable non-segmental vitiligo subjects. Hierarchical clustering of genome-wide expression of transcripts surprisingly segregated lesional and non-lesional samples in two distinct clades, despite the apparent heterogeneity in the lesions of different vitiligo subjects. Pathway enrichment showed the expected downregulation of melanogenic pathway and a significant downregulation of cornification and keratinocyte differentiation processes. These perturbations could indeed be recapitulated in the lesional epidermal tissue, including blunting of rete-ridges, thickening of stratum corneum and increase in the size of corneocytes. In addition, we identify marked increase in the putrescine levels due to the elevated expression of spermine/spermidine acetyl transferase. Our study provides insights into the intrinsic self-renewing ability of damaged lesional tissue to restore epidermal functionality in vitiligo.

Simplified Non-cultured Non-trypsinised Epidermal Cell Graft Technique Followed by Psoralen and Ultraviolet A Light Therapy for Stable Vitiligo

Background and Aims:

Stable vitiligo can be treated by various surgical procedures. Non-cultured melanocyte grafting techniques were developed to overcome the time-consuming process of culture while at the same time providing acceptable results. All the techniques using non-cultured melanocyte transfer involve trypsinisation as an integral step. Jodhpur technique used by the author is autologous, non-cultured, non-trypsinised, epidermal cell grafting.

Settings and Design:

The study was conducted on patients visiting the dermatology outpatient department of a tertiary health centre in Western Rajasthan.

Materials and Methods:

At the donor site, mupirocin ointment was applied and dermabrasion was done with the help of micromotor dermabrader till pinpoint bleeding was seen. The paste-like material obtained by this procedure containing melanocytes and keratinocytes admixed with the ointment base was harvested with spatula and was subsequently spread over the recipient area. Recipient site was prepared in the same manner by dermabrasion. After 10 days, dressing at both sites was removed taking utmost care at the recipient site as there was a theoretical risk of dislodging epidermal cells.

Results:

In a study of 437 vitiligo patches, more than 75% re-pigmentation (excellent improvement) was seen in 41% of the patches. Lesions on thigh (100%), face (75%) and trunk (50%) showed maximal excellent improvement, whereas patches on joints and acral areas did not show much improvement.

Conclusions:

This technique is a simplified, cost effective, less time-consuming alternative to other techniques which involve tryspsinisation of melanocytes and at the same time provides satisfactory uniform pigmentation.

Trends in Regenerative Medicine: Repigmentation in Vitiligo Through Melanocyte Stem Cell Mobilization

Vitiligo is the most frequent human pigmentary disorder, characterized by progressive autoimmune destruction of mature epidermal melanocytes. Of the current treatments offering partial and temporary relief, ultraviolet (UV) light is the most effective, coordinating an intricate network of keratinocyte and melanocyte factors that control numerous cellular and molecular signaling pathways. This UV-activated process is a classic example of regenerative medicine, inducing functional melanocyte stem cell populations in the hair follicle to divide, migrate, and differentiate into mature melanocytes that regenerate the epidermis through a complex process involving melanocytes and other cell lineages in the skin. Using an in-depth correlative analysis of multiple experimental and clinical data sets, we generated a modern molecular research platform that can be used as a working model for further research of vitiligo repigmentation. Our analysis emphasizes the active participation of defined molecular pathways that regulate the balance between stemness and differentiation states of melanocytes and keratinocytes: p53 and its downstream effectors controlling melanogenesis; Wnt/β-catenin with proliferative, migratory, and differentiation roles in different pigmentation systems; integrins, cadherins, tetraspanins, and metalloproteinases, with promigratory effects on melanocytes; TGF-β and its effector PAX3, which control differentiation. Our long-term goal is to design pharmacological compounds that can specifically activate melanocyte precursors in the hair follicle in order to obtain faster, better, and durable repigmentation.

Melanocytes from the outer root sheath of human hair and epidermal melanocytes display improved melanotic features in the niche provided by cGEL, oligomer-cross-linked gelatin-based hydrogel

Non-invasively based cell treatments of depigmented skin disorders are largely limited by means of cell sampling as much as by their routes of application. Human melanocytes cultivated from the outer root sheath of hair follicle (HUMORS) are among the cell types that fit the non-invasive concept by being cultivated out of a minimal sample: hair root. Eventual implementation of HUMORS as a graft essentially depends on a choice of suitable biocompatible, biodegradable carrier that would mechanically and biologically support the cells as transient niche and facilitate their engraftment. Hence, the melanotic features of follicle-derived HUMORS and normal human epidermal melanocytes (NHEM) in engineered scaffolds based on collagen, the usual leading candidate for graft material for a variety of skin transplantation procedures were tested. Hydrogel named cGEL, an enzymatically degraded bovine gelatin chemically cross-linked with an oligomeric copolymer synthesized from pentaerythritol diacrylate monostearate (PEDAS), maleic anhydride (MA), and N-isopropylacrylamide (NiPAAm) or diacetone acrylamide (DAAm), was used. The cGEL provided a friendly three-dimensional (3D) cultivation environment for human melanocytes with increased melanin content of the 3D cultures in comparison to Collagen Cell Carrier^® (CCC), a commercially available bovine decellularized collagen membrane, and electrospun polycaprolactone (PCL) matrices. One of the cGEL variants fostered not only a dramatic increase in melanin production but also a significant enhancement of melanotic gene PAX3, PMEL, TYR, and MITF expression in comparison to that of both CCC full-length collagen and PCL scaffolds, providing a clearly superior melanocyte niche that may be a suitable candidate for grafting carriers. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 3115-3126, 2016.

Tumorigenicity Testing in Athymic Mice of Cultured Human Melanocytes for Transplantation in Engineered Skin Substitutes

Autologous engineered skin substitutes (ESS) have been shown to close excised, full-thickness burns, but are consistently hypopigmented due to depletion of human melanocytes (hM) during culture of keratinocytes. Hypothetically, addition of hM to ESS may restore uniform pigmentation, but may also promote neoplasia and tumor formation. To evaluate this risk, 16 strains of hM were isolated and propagated in selective culture medium, then injected subcutaneously into athymic mice (1 χ 107 hM/animal; n = 6/strain) and followed for 24 weeks. Human melanoma cells (SK-Mel-2, SK-Mel-5) served as positive controls. No detectable tumors formed from hM strains derived from normal skin. In contrast, SK-Mel-2 formed tumors in 50% of mice, and SK-Mel-5 formed tumors in 83% of mice. Histopathology confirmed the tumorigenic anatomy of the controls and the presence of hM that were not tumorigenic in the test groups. These results support the safety of cultured hM for transplantation to restore uniform skin pigmentation in wounds closed with ESS.

Vitiligo

Vitiligo, an acquired pigmentary disorder of unknown origin, is the most frequent cause of depigmentation worldwide, with an estimated prevalence of 1%. The disorder can be psychologically devastating and stigmatising, especially in dark skinned individuals. Vitiligo is clinically characterised by the development of white macules due to the loss of functioning melanocytes in the skin or hair, or both. Two forms of the disease are well recognised: segmental and non-segmental vitiligo (the commonest form). To distinguish between these two forms is of prime importance because therapeutic options and prognosis are quite different. The importance of early treatment and understanding of the profound psychosocial effect of vitiligo will be emphasised throughout this Seminar.

Vitiligo: an evidence-based update. Report of the 13th Evidence Based Update Meeting, 23 May 2013, Loughborough, U.K

The Evidence Based Update (EBU) meetings are annual one-day meetings held by the Centre of Evidence Based Dermatology at the University of Nottingham. The aim of the meeting is to discuss high-quality evidence, mainly in the form of systematic reviews and randomized controlled trials, on a different topic each year. The meetings are designed to be interactive with a panel discussion between international experts and delegates forming a key part of the meeting. The 13th EBU meeting was on vitiligo and took place on 23 May 2013 in Loughborough, U.K. The most recent research including new and unpublished studies was presented on the classification of vitiligo, the evidence behind different treatment options and current guidelines for vitiligo.

Extracted hair follicle outer root sheath cell suspension for pigment cell restoration in vitiligo

Vitiligo surgery has come up a long way from punch skin grafts to epidermal cell suspension and latest to the extracted hair follicle outer root sheath cell suspension (EHF-ORS-CS) transplantation. The progressive development from one technique to the other is always in a quest for the best. In the latest development- EHF-ORS-CS, which is an enriched source of follicular inactive melanocyte (melanocyte stem cells), seems to be a good addition to the prevailing cell-based therapies for vitiligo; however, need to be explored further in larger, and preferably randomized blinded studies. This review discusses the principle, technical details, and stem cell composition of hair follicular outer root sheath cell suspension.