A comparative study between suction blistering graft, mini punch graft, and hair follicle transplant in treatment of patients with stable vitiligo

Transversely Sectioned Mini-Punch Grafting: A Novel Technique for Effective Treatment of Hairline Vitiligo

Objective

Hairline vitiligo is a special area. Hairy areas within the hairline often require repigmentation and regrowing hair shafts. The face and forehead outside the hairline do not require regrowing hair shafts, only repigmentation. To tackle this issue, we modified the conventional mini-punch grafting with a combined application of mini-punch grafting and follicular hair transplant.

Methods

Five patients with localized hairline stable vitiligo aged 26-32 years old had a history of nonsurgical treatments for at least 3 months and without progress. The grafts were transversely sectioned. The intact half follicles were preserved below the cross-section. Sectioned grafts were placed into the chambers for transplanting with forceps.

Results

The treatment using transversely sectioned mini-punch grafting with the patient was performed for all five patients, and the results were satisfactory. In the area of the forehead outside the hairline with the sectioned mini-punch grafting above the cross-section, hair loss and repigmentation were observed. In the area of the hairy areas within the hairline, growing hair shafts and repigmentation were observed, without hair loss.

Conclusion

Our report can help to manage hairline vitiligo or hairy areas vitiligo. This method can be considered a potential method for the treatment of hairline vitiligo, thus providing a simple solution to complex problems.

Management of Stable Vitiligo-A Review of the Surgical Approach

At present, vitiligo is the most common depigmenting skin disorder, characterized by clearly demarcated discolored patches of various shapes and sizes. Depigmentation results from the initial dysfunction and subsequent destruction of melanin-producing cells, called melanocytes, which are located in the basal layer of the epidermis and in hair follicles. This review concludes that the extent of repigmentation, regardless of the treatment method, is greatest in stable localized vitiligo patients. The aim of this review is to provide an overview of the clinical evidence for which the vitiligo treatment method (cellular or tissue) is more effective. The treatment relies on multiple factors, ranging from patient skin predisposition for repigmentation to the experience of the facility performing the procedure. Vitiligo is a significant problem in modern society. Although it is a typically asymptomatic and not life-threatening disease, it may have significant psychological and emotional impacts. Standard treatment relies on pharmacotherapy and phototherapy; however, the treatment of patients with stable vitiligo varies. The stability of vitiligo more than often implies the exhaustion of the potential for skin self-repigmentation. Thus, the surgical methods that distribute normal melanocytes into the skin are crucial elements of these patients' therapy. The most commonly used methods are described in the literature, with an indication of their recent progress and changes. In addition, information on the efficiency of the individual methods at specific locations is compiled in this study, and the prognostic factors indicating repigmentation are presented. Cellular methods are the best therapeutic option for large-sized lesions; although they are more exorbitant than tissue methods, they benefit from more rapid healing times and presenting fewer side effects. Dermoscopy is a valuable tool used to assess the further course of repigmentation, where it is of great value to evaluate the patient prior to and following an operation.

Has the core outcome (domain) set for vitiligo been implemented? An updated systematic review on outcomes and outcome measures in vitiligo randomized clinical trials

BACKGROUND

In 2015, a major achievement in vitiligo research was the development of an internationally agreed upon core outcome domain set for randomized clinical trials (RCTs). Three outcomes were identified as being essential: repigmentation, side-effects/harms and maintenance of gained repigmentation. Four items were further recommended for inclusion. The following recommendations then followed: repigmentation should be assessed by measuring the percentage of repigmentation in quartiles (0-25%, 26-50%, 51-79%, 80-100%) and cosmetic acceptability of the results should be assessed using the Vitiligo Noticeability Scale.

OBJECTIVES

The primary objective of this study was to assess uptake of the core outcome domain set for RCTs in vitiligo. Secondary objectives were to update the systematic review on outcomes reported in vitiligo RCTs, and to assess whether repigmentation and cosmetic acceptability of the results were measured using the above-mentioned recommended scales.

METHODS

We searched PubMed, Cochrane Library (CENTRAL and Systematic Reviews) and ClinicalTrials.gov for vitiligo RCTs between November 2009 and March 2021. Screening and data extraction were independently performed on title and summary by two researchers. All outcomes and outcome measures reported in eligible RCTs were retrieved and collated.

RESULTS

In total, 174 RCTs were identified: 62 were published between 2009 and 2015, and 112 were published between 2016 and 2021.Thirty-eight different outcomes were reported. Repigmentation was the primary outcome in 89% of trials (150 of 169). Forty-nine different tools were used to measure repigmentation. Side-effects and harms were reported in 78% of trials (136 of 174). Maintenance of gained repigmentation was reported in only 11% of trials (20 of 174) and duration of follow-up varied greatly from 1 to 14 months. Cosmetic acceptability of the results and cessation of disease activity were assessed in only 2% of trials (four of 174). Quality of life of patients with vitiligo was assessed in 13% of trials (22 of 174). Finally, only 11 of 112 RCTs (10%) published between 2016 and 2021 reported all three essential core outcome domains (repigmentation, side-effects and maintenance of gained repigmentation) and none of the trials reported both essential and recommended core outcome domains.

CONCLUSIONS

Efforts are still needed to close the gap between set recommendations and RCT outcome reporting.

The application of electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation for the treatment of vitiligo-associated leukotrichia

BACKGROUND

Leukotrichia is one of the difficulties of vitiligo treatment. Hair follicle transplantation is an efficient method to treat vitiligo-associated leukotrichia. A trichiasis electrolyzer, commonly used for treating trichiasis, can be used to damage and remove the depigmented hair follicles.

OBJECTIVE

To evaluate the efficacy of the electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation for the treatment of vitiligo-associated leukotrichia.

METHODS

A total of 15 patients with stable vitiligo-associated eyebrow and eyelash leukotrichia were enrolled from Department of Dermatology, Hangzhou Third People's Hospital between January 2020 and January 2021. All patients were treated using a trichiasis electrolyzer combined with single hair follicle transplantation. The patients were followed up at the first week, the first month, the third month, and the sixth month after surgery. The texture and growth state of the transplanted hair were observed, and the number of surviving transplanted follicles and regenerating depigmented follicles were recorded.

RESULTS

The transplanted hair grew as expected with natural shape. No local infection or obvious scar were observed. Most of the depigmented hair in the lesion area re-pigmented and only a few depigmented hairs regenerated. The average survival rate of the transplanted hair follicles was 71.6%, and the average regeneration rate of the depigmented hair was 11.6%.

CONCLUSION

The electrolysis of depigmented hair using a trichiasis electrolyzer combined with single hair follicle transplantation was an effective and safe method to treat vitiligo-associated leukotrichia.

Surgical procedures and innovative approaches for vitiligo regenerative treatment and melanocytorrhagy

Surgical treatments for vitiligo are a safe and effective treatment modality for select patients with vitiligo. Many techniques of vitiligo surgery exist, each with unique advantages and disadvantages. We reviewed the various surgical therapies and innovative approaches for vitiligo regenerative treatment reported in the literature. Surgical therapies can be subdivided into tissue grafting methods and cellular grafting methods. Tissue grafting methods mainly include mini punch grafts, suction blister roof grafts, and hair follicle grafts. Cellular grafting methods include cultured and non-cultured treatments. The efficacy needs to be improved largely due to the poor proliferation and quality of the autologous melanocytes. Rho-associated protein kinase inhibitor enhances primary melanocyte culture proliferation from vitiligo patients to prevent apoptosis. Innovative approaches using stem cell methods could prove invaluable in developing a novel cell therapy for patients suffering from vitiligo. We succeeded in inducing melanin pigmentation in mice skin in vivo using our human induced pluripotent stem cell-derived melanocytes. In addition, we reviewed melanocytorrhagy, detachment and transepidermal loss of melanocytes, and melanocyte-related adhesion molecules. These adhesion molecules include epithelial cadherin, discoidin domain receptor tyrosine kinase 1, glycoprotein non-metastatic melanoma protein B, macrophage migration inhibiting factor, 17β-hydroxysteroid dehydrogenase 1, and E26 transformation-specific 1.

Surgical Interventions for Patients With Vitiligo: A Systematic Review and Meta-analysis

Importance

Surgical interventions are a key part of the therapeutic arsenal, especially in refractory and stable vitiligo. Comparison of treatment outcomes between the different surgical procedures and their respective adverse effects has not been adequately studied.

Objective

To investigate the reported treatment response following different surgical modalities in patients with vitiligo.

Data Sources

A comprehensive search of the MEDLINE, Embase, Web of Science, and Cochrane Library databases from the date of database inception to April 18, 2020, was conducted. The key search terms used were vitiligo, surgery, autologous, transplantation, punch, suction blister, and graft.

Study Selection

Of 1365 studies initially identified, the full texts of 358 articles were assessed for eligibility. A total of 117 studies were identified in which punch grafting (n = 19), thin skin grafting (n = 10), suction blister grafting (n = 29), noncultured epidermal cell suspension (n = 45), follicular cell suspension (n = 9), and cultured epidermal cell suspension (n = 17) were used.

Data Extraction and Synthesis

Three reviewers independently extracted data on study design, patients, intervention characteristics, and outcomes. Random effects meta-analyses using generic inverse-variance weighting were performed.

Main Outcomes and Measures

The primary outcomes were the rates of greater than 90%, 75%, and 50% repigmentation response. These rates were calculated by dividing the number of participants in an individual study who showed the corresponding repigmentation by the total number of participants who completed the study. The secondary outcomes were the factors associated with treatment response to the surgical intervention.

Results

Among the 117 unique studies and 8776 unique patients included in the analysis, rate of repigmentation of greater than 90% for surgical interventions was 52.69% (95% CI, 46.87%-58.50%) and 45.76% (95% CI, 30.67%-60.85%) for punch grafting, 72.08% (95% CI, 54.26%-89.89%) for thin skin grafting, 61.68% (95% CI, 47.44%-75.92%) for suction blister grafting, 47.51% (95% CI, 37.00%-58.03%) for noncultured epidermal cell suspension, 36.24% (95% CI, 18.92%-53.57%) for noncultured follicular cell suspension, and 56.82% (95% CI, 48.93%-64.71%) for cultured epidermal cell suspension. The rate of repigmentation of greater than 50% after any surgical intervention was 81.01% (95% CI, 78.18%-83.84%). In meta-regression analyses, the treatment response was associated with patient age (estimated slope, -1.1418), subtype of vitiligo (estimated slope, 0.3047), and anatomical sites (estimated slope, -0.4050).

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that surgical intervention can be an effective option for refractory stable vitiligo. An appropriate procedure should be recommended based on patient age, site and size of the lesion, and costs.

Comparative study between follicular unit transplantation with intact and non-intact hair bulb in treatment for stable vitiligo

OBJECTIVE

To compare the cosmetic efficacy of the transplantation of follicles with intact and non-intact hair bulbs in the treatment for vitiligo.

METHODS

The single-hair follicle units with intact hair bulbs and un-intact hair bulbs were transplanted into the skin of vitiligo. The diameters of regrowing hair shafts and repigmentation of implanted follicles were detected analyzed by dermatoscopy (Beining BN-PFMF Skin and Hair Visualizer).

RESULTS

The survival rates of follicles with intact and non-intact hair bulbs were 60.00% and 50.62%, respectively. The average diameters of hair shafts and repigmentation of the two groups were 92.83 ± 7.26 µm vs 55.86 ± 2.64 µm (p < .05), 2.62 ± 0.13 mm vs 2.63 ± 0.17 mm (p > .05), respectively.

CONCLUSION

Single follicle transplantation was an alternative effective choice for the treatment of vitiligo. The skin implanted with follicle with non-intact hair bulb was less hairy.

Home phototherapy for patients with vitiligo: challenges and solutions

Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is well-demarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo.