SummaryBackground Vitiligo is an acquired disorder of pigmentation caused by loss of epidermal melanocytes. Autologous noncultured epidermal cell suspension (NCES) and autologous noncultured extracted hair follicle outer root sheath cell suspension (NCORSHFS) are important surgical modalities for the treatment of stable vitiligo. Objectives To compare NCES and NCORSHFS for producing repigmentation in stable vitiligo. Methods We randomized 30 patients with 47 stable vitiligo lesions into two groups. Patients in group 1 were treated with NCES, and those in group 2 with NCORSHFS. They were evaluated 16 weeks postsurgery for the extent of repigmentation, colour match, change in Dermatology Life Quality Index (DLQI) score and patient satisfaction. Results The extent of repigmentation was excellent (90-100% repigmentation) in 83% of lesions in the NCES group and 65% of lesions in the NCORSHFS group (P = 0Á154). Repigmentation ! 75% (good repigmentation) was observed in 92% of lesions in the NCES group and 78% of lesions in the NCORSHFS group (P = 0Á425). There was a significant improvement in DLQI score in both the groups, but the mean decrease among groups did not differ significantly (P = 0Á244). However, patients in the NCES group were significantly more satisfied than the patients in the NCORSHFS group. No significant difference was seen in colour match and pattern of repigmentation. Adverse effects were minimal. Conclusions Both NCES and NCORSHFS are safe and effective techniques with comparable efficacy. To the best of our knowledge, this is the first study directly comparing two different cellular techniques.

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The absence of a basal level of expression of Ets-1 significantly decreases the expression and activity of MMP-2 and MMP-9. Significant decreases in MMP-2 and MMP-9 activity could possibly reduce the migration of melanocyte precursors (melanoblasts) from the outer root sheath of hair follicles or migration of melanocytes from the border of vitiligo lesions into clinically depigmented epidermis which is crucial to the repigmentation of vitiliginous skin.

The number of melanocytes and HFSC transplanted and absence of dermal inflammation were important determents of optimal repigmentation in patients undergoing NCORSHFS for treatment of stable vitiligo. Hence, refining the technique of NCORSHFS on the basis of these factors would help in achieving better surgical outcomes.

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.