Combination of Follicular and Epidermal Cell Suspension as a Novel Surgical Approach in Difficult-to-Treat Vitiligo

Abstract

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.

Four compartment method as an efficacious and simplified technique for autologous non‐cultured epidermal cell suspension preparation in vitiligo surgery: A randomized, active‐controlled study

“…The overall reported efficacy of NB‐UVB phototherapy in attaining >75% repigmentation ranged from 12.5% to 75%, that too after a period of 1 year . The similar outcome can be achieved within 4 months by NCES as per the published clinical trials . Hence, NCES is an efficacious alternative to phototherapy in stable vitiligo.…”

“…have demonstrated improvement of repigmentation outcome by suspending the melanocytes in the patients’ own serum. Razmi et al . have shown that the addition of non‐cultured hair follicular cell suspension into the NCES improves its repigmentation outcome, even in difficult‐to‐treat vitiligo.…”

Development and validation of the Vitiligo Extent Score for a Target Area (VESTA) to assess the treatment response of a target lesion

“…A transparent sheet affords reliable measurement of lesion size (Aydin et al., ); however, it is difficult to assess the extent of perifollicular repigmentation after treatment. Digital image analysis systems accurately measure lesion size (van Geel, Vander Haeghen, Ongenae, & Naeyaert, ; Lommerts et al., ; Razmi et al., ), but require a set of pre‐ and post‐treatment photographs of the same size and angle of incidence, which is not always available. A quartile method based on a rough estimate has often been used to evaluate the treatment response (Bae, Yoo, Kim, Lee, & Kim, ; Passeron et al., ; Silpa‐Archa et al., ), but this approach has never been validated and is somewhat arbitrary.…”

Vitiligo surgery: A journey from tissues via cells to the stems!

“…Further comparative studies on FCS have reinforced the impression of inferior results obtaining with FCS, questioning the added advantage of melanocyte precursors in FCS. Recent evidence from our study suggests that deficient keratinocyte‐derived growth factors as a possible cause of less than expected repigmentation outcome in FCS. Even though better OCT4 + stem cells and stem cell factor were documented in FCS solution, it was deficient in basic fibroblast growth factor, compared to combined NCES and FCS solution.…”

“…In a pilot study, we have documented superior repigmentation of combined NCES and FCS over either NCES or FCS alone in acral vitiligo. Our group (2018) have also demonstrated superior and quicker repigmentation outcome in combined NCES and FCS compared to NCES alone based on a randomized study involving patients with difficult‐to‐treat vitiligo. Apart from better melanocyte growth factors, better OCT4 + stem cells were noted in combined NCES and FCS compared to NCES.…”