INTRODUCTION

Vitiligo is a common autoimmune and acquired depigmentation of skin earmarked by well-circumscribed ivory-white asymptomatic macules.[1] Histologically, it is characterized by the absence of melanocytes in the affected area and hair follicles. Vitiligo patches, which are not responding to medical therapy and are stable in nature, are reserved for surgical methods of treatment.[2] Surgical methods work on the principle of transfer of melanocytes from uninvolved skin to the stable vitiligo patch in the form of either tissue graft or cellular graft.

Our study was a randomized study, which was planned to compare the outcome of two surgical modalities. One was “hair follicle unit transplantation”[3] and another was “autologous non-cultured non-trypsinized, epidermal cell grafting (Jodhpur technique)”[4] in patients with stable vitiligo in terms of change in patient’s psychosocial quality of life, extent of repigmentation, color matching of repigmented area, and any adverse events. Follicular unit transplantation (FUT) is tissue graft type of surgical technique that provides a reservoir of undifferentiated stem cells to the depigmented lesional skin. Autologous, non-cultured, non-trypsinized, melanocyte plus keratinocyte grafting is a simple method of melanocyte transfer and does not require special setup.

MATERIALS AND METHODS

TECHNIQUE OF TRANSPLANTATION

RESULTS

Table 1 shows of the total 30 patients, 21 were males and 9 were females. Mean duration of disease was 9.26 ± 5.10 years with 4.08 ± 2.67 years of disease stability.

Table 2 shows anatomical distribution of vitiligo patches.

At 4 weeks, no patient showed >75% extent of repigmentation in both FUT and JT group; 0%–25% extent of repigmentation was shown by 26 (52%) patches in FUT and 13 (26%) patches in JT with a significant P value (0.013).

However at the end of study, that is, at 20 weeks of follow-up, 35 of 50 (70%) patches in FUT group [Figure 1] and 36 (72%) of 50 patches in JT group [Figure 2] showed >75% extent of repigmentation but the P value was insignificant.

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Figure 1

(A) Vitiligo patch before FUT. (B) Vitiligo patch after FUT at 20 weeks

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Figure 2

(A) Vitiligo patch before JT. (B) Vitiligo patch after JT at 20 weeks

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In 40 of 50 (80%) lesions in FUT group [Figures 1 and 3] and 34 of 50 (68%) lesions in JT group, the color of the repigmented area matched excellently with the normal surrounding skin. In 10 of 50 (20%) lesions in FUT group and 16 of 50 (32%) lesions in JT group, somewhat darker pigmentation at the end of study but with a tendency to match with normal skin color over passing time at 4 weeks was observed.

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Figure 3

(A) Leukotrichia before FUT. (B) Improvement in leukotrichia after FUT at 20 weeks

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The color of the repigmented area matched excellently with the normal surrounding skin at 20 weeks in 49 of 50 (98%) lesions in both groups, One of 50 (2%) lesions in FUT group and JT group [Figure 4] showed somewhat darker pigmentation at the end of study but with a tendency to match with normal skin color over passing time with nonsignificant P value of 1.505.

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Figure 4

(A) Vitiligo patch before JT at foot. (B) Vitiligo patch after JT at 20 weeks

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While considering time taken for repigmentation, we found that 25%–50% and 50%–75% repigmentation was observed in 27 of 50 (54%) and 8 of 50 (16%) lesions in JT group and in 22 of 50 (44%) and 2 of 50 (4%) lesions in FUT group at 4 weeks, which suggests an earlier onset of repigmentation in JT group.

Patients in both groups were highly satisfied with the treatment outcomes. Patients in which patches treated with JT were more satisfied than patches treated with FUT according to the patient satisfaction questionnaire 1, 2 and 3. Overall PSQ-4 score was 93/7 (in 93 patches, patients want to choose this treatment again as yes and in 7 patches they chosen as no) with 46/4 in FUT group and 47/3 in JT group (P = 1.000).

DISCUSSION

Several modalities are currently available for the treatment of vitiligo, but they generally do not result in complete cure of the disease. Surgical modalities appear to be the method of choice in those stable vitiligo lesions, which do not respond to medical therapies. Both JT and FUT are simpler and cheaper methods, requiring minimal infrastructure, but the surface areas that can be covered using JT, is larger than those, which can be treated with FUT. FUT has an advantage that they permit the treatment of difficult to treat areas.

Follicular unit grafting is based on the transfer of the reservoir of melanocytes, which serve as a source of pigmentation for the depigmented vitiligo lesions. However, it is suitable only for small stable lesions affecting hairy part of body. After grafting, the vitiliginous skin heals slowly with this method because the grafted melanocytes require a long time to spread. Autologous, non-cultured non-trypsinized melanocytes plus keratinocyte grafting (JT) is a simple and new method of melanocytes transfer, which has not been standardized yet and is still in early phase of development.

JT and FUT technique were almost equal in producing excellent repigmentation. However, good extent of repigmentation was obtained more in JT group. This may be because in JT pigmentation, the treated areas gradually increased in size due to melanocyte proliferation and migration under the influence of cytokines secreted by surrounding keratinocytes. We used a very simplified method in vitiligo surgery in JT, as described by Kachhawa and Kallal,[4] who used the epidermal material entangled in ointment obtained by dermabrasion for non-cultured cellular suspension instead of melanocyte media or phosphate buffered saline (PBS). The results of this technique were comparable to the other surgical techniques, including non-cultured melanocyte and keratinocyte transfer. Pandya et al.[5] reported that an excellent response was observed in 52.17% cases with non-cultured epidermal suspension technique and in 50% with the melanocyte culture technique. Gupta et al.[6] developed a scoring system with an original approach, considering the extent of pigmentation, color match, and the complications of both the donor and the recipient area.

Gauthier and Surleve-Bazeille[7] had observed 70% repigmentation in 63.6% of the patients with vitiligo treated by non-cultured melanocyte transplantation. They had included only patients of focal and segmental vitiligo.

While considering time taken for repigmentation, we found that 25%–50% and 50%–75% repigmentation was seen in 27 of 50 and 8 of 50 lesions in JT group and in 22 of 50 and 2 of 50 in FUT group, which suggests an earlier onset of repigmentation in JT group. This is against the hypothesis suggested by Budania et al.,[8] according to which tissue grafts have an early onset of repigmentation as compared to cellular graft. Delayed proliferation of melanocytes and their upward migration from infundibulum to epidermis might explain the delayed onset of pigmentation in FUT technique.

Color match was same for both the groups, that is, 49 of 50 patches showed same color as surrounding in both groups at the end of 20 weeks. The cause of acceptable color match in FUT could be related to the stem cell migration from the graft and then location-specific transient amplifying cell proliferation, and in JT, due to melanocyte proliferation and migration under the effect of cytokines released by keratinocytes.

Perifollicular repigmentation was the most common pattern of repigmentation observed in 49 of overall lesions with 47 (78%) of lesions in FUT group. Diffuse was the most common repigmentation pattern observed in JT group in 34 patches. This signifies that pigmentation in FUT is due to melanocytes from hair follicle itself, and that in JT is due to transplanted melanocytes.

We also carried out patient’s global assessment with the help of a patient satisfaction questionnaire, including three questions—“Grade the change in pigmentation in the transplanted area,” “Are you satisfied with the treatment?,” and “ do you find the treatment worthwhile?” Patients were asked to answer in terms of scoring from 0–10. The scores obtained by this patient satisfaction questionnaire were significantly higher in JT group than those in FUT group. The reasons why patients with JT group were more satisfied that FUT group were because of the exact color match and its ability to treat large areas with minimal complications.

We compared two simplified techniques of vitiligo surgery. Cellular transplantation techniques have been found to be sophisticated, costly, require laboratory and somewhat difficult to be performed at clinic. But we used a very cheaper technique of JT without any melanocyte culture media, trypsin inhibitor, hyaluronic acid, and PBS. We did not use any sophisticated or costly apparatus. We just used simple epidermal material entangled in ointment obtained by dermabrasion.

Our study indicates that both JT and FUT are safe and effective techniques in terms of repigmentation, but JT is somewhat superior to FUT in excellent and good repigmentation, side effects, and patient satisfaction, whereas the color match was almost same with both techniques.

CONCLUSION

This is the first study of this kind to compare a new cellular transplantation technique with an established tissue transplantation technique.

We found that JT was significantly better than FUT in terms of extent of repigmentation. Another benefit of JT described previously in literature is that it can cover larger body surface area with smaller grafts. JT is superior to FUT in difficult to treat areas such as finger, ankle foot, elbow. FUT is time-consuming as compared to JT. It is almost similar to JT in terms of color match. FUT is superior to JT when the lesions present with leukotrichia. Both FUT and JT have the advantage of not leaving any visible scar over the donor area.

Therefore, FUT can be preferred if small, hairy, and cosmetically important area has to be treated, whereas in case of treating large and difficult to treat sites, then JT is preferred.