Surgical Treatment of Vitiligo

Autologous skin cell suspension plus phototherapy in stable vitiligo: findings from a US economic model

INTRODUCTION

A cell harvesting device for preparing non-cultured autologous skin cell suspension (ASCS) at the point-of-care is FDA-approved for repigmentation of stable depigmented vitiligo lesions in patients 18 years and older. The pivotal RSVP trial showed ≥80% repigmentation at Week-24 in 36% of lesions treated with laser ablation, ASCS, and narrowband ultraviolet B phototherapy compared to 0% with phototherapy alone (p = 0.012). The objective of this analysis was to evaluate the potential economic impact of laser ablation plus ASCS with phototherapy versus phototherapy alone for repigmentation of stable vitiligo lesions from a US payer perspective.

METHODS

A 5-year decision-tree model was developed reflecting clinical pathways of adults with stable vitiligo lesions who had an inadequate response to prior topicals and phototherapy. Patients entering the model were treated with ASCS plus phototherapy or phototherapy alone and assessed for treatment response at Weeks-24 and 52 based on the RSVP trial's effectiveness endpoints. Durable response for Year-2 onwards was proxied by melanocyte-keratinocyte transplantation data. Model outcomes included per-patient total and incremental healthcare costs, treatment costs and total costs, cost per-patient per-month (PPPM), and cost per-patient per-year (PPPY). One-way sensitivity analyses assessed model result robustness.

RESULTS

The cumulative total per-patient cost for ASCS plus phototherapy increased from $28,177 to $92,779 between Year-1 and Year-5. Phototherapy alone increased from $21,146 to $101,518 over the same period. Compared to phototherapy alone, ASCS plus phototherapy incurred $7,030 more total per-patient cumulative costs in Year-1 and $8,738 less by Year-5 (-$146 PMPM; -$1,748 PPPY). Breakeven occurred between Years 2-3. Results were most sensitive to changes in ASCS response at Weeks-24 and 52 and healthcare costs.

CONCLUSION

Among adults with stable vitiligo with prior inadequate response to topicals or phototherapy, ASCS treatment may lead to lower all-cause direct medical costs over 5 years compared to phototherapy alone.

[Vitiligo-update on pathogenesis, diagnostics and therapy]

Vitiligo is a common skin disease leading to depigmentation that is associated with progressive destruction of melanocytes. The main subtype, nonsegmental vitiligo (NSV), is considered a chronic autoimmune disease leading to activation of melanocyte-specific CD8+ lymphocytes and development of a cutaneous immune memory. Vitiligo can result in significant impairment of quality of life and is associated with a number of comorbidities. Despite the existence of national guidelines and international treatment recommendations, there is a strong need for improved health care for patients with vitiligo. The options in the treatment algorithm for vitiligo are similar and consisted until recently of only topical and systemic corticosteroids, topical calcineurin inhibitors, phototherapy, and surgical interventions. New insights into the pathobiological role of the interferon signature in vitiligo have most recently contributed to the approval of the first vitiligo-specific therapy with the topical Janus kinase 1/2 inhibitor ruxolitinib for patients with NSV.

Vitiligo: A Review of Pathogenesis and Treatments, Including New Therapies on the Horizon

Vitiligo is an acquired depigmentation skin disease caused by the immune-mediated death of melanocytes. It is the most common cause of depigmentation with an estimated worldwide prevalence of 1% but has shown insufficient response to current therapies. The latest research in vitiligo pathogenesis has translated into finding new molecular targets [type I interferon and Janus kinase signal transducers and transcription activators (JAK STAT) pathways], with new therapies generating promising results, such as JAK inhibitors. Other therapeutic strategies include phototherapy, surgical treatment, and complementary options such as micropigmentation, microneedling, and lasers. This review aimed to discuss the mechanisms involved in the development of the disease and the new therapeutic options that have become available, as well as the evidence on complementary therapies. For this purpose, a review of the evidence was conducted using the PubMed database. Based on this review, it was concluded that the progress in understanding the pathophysiology of vitiligo has allowed for the consideration of new molecular targets, with JAK inhibitors showing particular promise in both systemic and topical applications. Nonetheless, further investigation is required to assess the safety of JAK inhibitors and to determine the optimal regimen and dosage for administering these drugs. Complementary treatments should be considered on a case-by-case basis.

Comparative study between combined follicular and epidermal cell suspension versus epidermal cell suspension in treatment of stable vitiligo

Recent developments in the treatment of vitiligo focus on minimizing adverse effects while also reducing the overall treatment duration. This work aimed to compare the advantages and limitations of epidermal cell transplantation versus combined epidermal and follicular cell transplantation in the treatment of stable vitiligo. This study was conducted on 20 vitiligo patients, aged between 15 and 50 years, all of whom presented with symmetrical lesions. The first lesion was treated with epidermal cell suspension (ECS), while the second lesion received a combined treatment of ECS and follicular cell suspension (FCS). The third lesion served as the control. A notable improvement in pigmentation was observed in the combined treatment group compared to the epidermal treatment group. Control patches exhibited resistance to NB-UVB therapy, showing minimal improvement and a slight reduction in depigmentation, in contrast to the treated patches. A significant correlation was found between the site of vitiligo, the tensity stages of the vitiligo extent tensity index (VETI) score after treatment, and the percentage of improvement (P < 0.05). Additionally, a significant relationship was observed between the vitiligo area severity index score and the tensity stages of the VETI score after treatment, as well as the percentage of improvement (P < 0.05). The combination of ECS and FCS as an innovative approach in vitiligo surgery, achieving good to excellent repigmentation within a short period. This method also ensures a favorable color match, even in cases of vitiligo that are typically resistant to treatment.

The Efficacy of 308-nm Excimer Laser With TopicalBimatoprost 0.03% for Facial Vitiligo

BACKGROUND

Vitiligo is a commonly acquired autoimmune pigmentary disorder. Some patients resist conventional treatments, leading to the search for combination therapies.

AIMS

This study aimed to compare the efficacy of 308-nm excimer laser monotherapy versus combined treatment with topical bimatoprost 0.03% in patients with facial vitiligo.

PATIENTS AND METHODS

A single-blind randomized clinical trial was conducted at Razi Hospital, Tehran, on 38 patients with facial vitiligo who had at least one facial vitiligo patch and had not undergone treatment in the past 3 months. The patients were randomly allocated to either the intervention group (n = 18) or the control group (n = 20). Both groups received 308-nm EL therapy twice weekly for 15 weeks, while the intervention group additionally applied 0.03% bimatoprost solution daily. The patients were visited at the end of every 5 weeks and after the 15th week. Efficacy was evaluated using the scale for improvement assessment (SAI), visual analog scale satisfaction (VASS), and visual analog scale improvement (VASI). Data analysis was performed using the Mann-Whitney and t-tests, with a significance level set at p < 0.05.

RESULTS

Of the total patients, 27 (71.05%) were female and 11 (28.95%) were male. The male-to-female ratio was 50% in the intervention group and 33.33% in the control group. The mean VASI score, as the primary outcome, showed a significant increase over time in the intervention group (p ≤ 0.001), increasing from 4.53 to 7.20 (an increase of 2.67 units). Additionally, the intervention had a significant effect on the VASI outcome compared to the control (p ≤ 0.001; mean difference: 2.55 [1.63 to 3.47]). As the secondary outcomes, the mean VASS and SAI scores significantly decreased over time in the intervention group (p ≤ 0.05). The intervention also significantly affected the VASS and SAI outcomes compared to the control (p ≤ 0.001). The side effects of the intervention group were hypertrichosis in three patients and erythema burning in one patient.

CONCLUSIONS

Adding bimatoprost 0.03% to the treatment regimen may improve the outcomes of patients with facial vitiligo who are resistant to conventional treatments.

A Canvas of Contemporary Insights into Clinical Vitiligo

Vitiligo is a chronic skin condition characterized by the loss of melanocytes, resulting in white patches on the skin. While its exact cause is unknown, it's believed to be an autoimmune disorder involving genetic, environmental, and immunologic factors. Various treatments, including topical drugs, phototherapy, and surgery, exist, but further research is needed for more targeted therapies. Standardization of treatment goals and outcome measures is crucial. Future directions involve personalized treatments based on genetic and immunologic profiles, along with advancements in melanocyte biology for more effective therapies. Collaborative research is the key to improving outcomes and quality of life for vitiligo patients.

Efficacy of non-cultured non-trypsinized dermabraded epidermal cell graft followed by narrowband ultraviolet B phototherapy in stable vitiligo

Objectives

The objective of this study was to evaluate the efficacy and adverse effects of non-cultured, nontrypsinized dermabraded epidermal cell graft followed by narrowband ultraviolet B (NB-UVB) therapy for stable vitiligo.

Material and Methods

A hospital-based and prospective interventional study was carried out on 45 patients (18-65 years) of both genders after approval from the Ethics Committee. The donor site was dermabraded after applying mupirocin ointment, and the material obtained was spread over the dermabraded recipient site. NBUVB phototherapy was initiated 3 weeks after the procedure and given for 3 months. Photographs were taken before the procedure and at the end of 3rd month of phototherapy and assessed for extent, pattern, and color matching of repigmented area according to physician global assessment (PGA) score and patient satisfaction score (PSS). Dermoscopic improvement was also noted.

Results

Forty-five patients were enrolled in the study, out of which 43 patients completed the study. According to the intention to treat analysis, results were calculated in all 45 patients. Good to excellent response (50-100% improvement) was seen in 46.7% of patients according to the PGA score and in 57.8% of patients according to PSS. Most patients achieved the same color match with their normal skin at the end of the follow-up (73.3%). The most common repigmentation pattern was diffuse (46.7%), both clinically and dermoscopically. Among the clinical types, vitiligo vulgaris showed the maximum good to excellent repigmentation (61.3% and 77.4% of patients with PGA scores and PSS, respectively). Adverse effects were erythema, infection, and post-inflammatory hyper-pigmentation at the donor and recipient sites, whereas scarring was seen at the recipient site.

Conclusion

It is a safe, simplified, cost-effective, and less time-consuming technique than earlier techniques and provides good to excellent repigmentation in a considerable proportion of participants.

Potential execution of vitiligo surgery by the most conceivable technique - which, where, and why?

While various treatment options exist for vitiligo, surgical interventions have gained significant attention due to their potential for long-lasting repigmentation. Several surgical procedures have been developed, including miniature punch grafting, thin Theirsch's split-thickness skin grafting (STSG), suction blister technique, and ultrathin STSG. The decision-making process should also consider the potential risks and benefits associated with each technique. Factors such as graft survival, color match, post-operative complications, and long-term stability of repigmentation should be evaluated. In addition, patient factors such as comorbidities, skin type, and psychological impact should be carefully considered to ensure optimal surgical outcomes. We, hereby, aim to explore the potential execution of vitiligo surgery using the most conceivable technique, considering factors such as efficacy, safety, and patient-specific characteristics.

Ultrathin Skin Grafting Versus Suction Blister Epidermal Grafting in the Treatment of Resistant Stable Vitiligo: A Self-Controlled Comparative Study

BACKGROUND

Surgical therapies are effective methods to treat resistant stable vitiligo, with each method having advantages and disadvantages.

OBJECTIVE

This study aimed to compare the efficacy and safety of ultrathin skin grafting (UTSG) and suction blister epidermal grafting (SBEG) to treat stable vitiligo.

METHODS

A total of 15 patients with 45 vitiligo patches were recruited. Each vitiligo patch was divided in half; 1 half was treated by UTSG, whereas the other half was treated by SBEG. The patients were followed up monthly for 3 months to assess the repigmentation rate, relative melanin index (RMI), and relative erythema index (REI) at different timepoints.

RESULTS

Excellent repigmentation was observed in 97.8% of patches that underwent UTSG and 93.3% that underwent SBEG. The RMI and REI at 1, 2, and 3 months after the grafting procedure did not significantly differ between the 2 methods. At the recipient site, incomplete fall-off of the graft occurred in 4.4% of patches that underwent UTSG, whereas a "cobblestone appearance" was observed in 66.7% of patches that underwent SEBG. UTSG caused fewer complications at the donor site than SBEG.

CONCLUSION

Compared with SBEG, UTSG is faster and achieves better cosmetic outcomes at the recipient and donor sites.

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.

Regenerative Medicine-Based Treatment for Vitiligo: An Overview

Vitiligo is a complex disorder with an important effect on the self-esteem and social life of patients. It is the commonest acquired depigmentation disorder characterized by the development of white macules resulting from the selective loss of epidermal melanocytes. The pathophysiology is complex and involves genetic predisposition, environmental factors, oxidative stress, intrinsic metabolic dysfunctions, and abnormal inflammatory/immune responses. Although several therapeutic options have been proposed to stabilize the disease by stopping the depigmentation process and inducing durable repigmentation, no specific cure has yet been defined, and the long-term persistence of repigmentation is unpredictable. Recently, due to the progressive loss of functional melanocytes associated with failure to spontaneously recover pigmentation, several different cell-based and cell-free regenerative approaches have been suggested to treat vitiligo. This review gives an overview of clinical and preclinical evidence for innovative regenerative approaches for vitiligo patients.