Indian Journal of Dermatology
SURGICAL PEARL
Year
: 2006  |  Volume : 51  |  Issue : 2  |  Page : 142--144

Study of transplantation of melanocyte keratinocyte suspension in treatment of vitiligo


Swati Rastogi, Puneet Goyal, Kanu Mangla, Neel Bhavsar, Himanshu Patel, RC Rawal 
 Department Dermatology, Smt. N. H. L Medical College, V. S. Hospital, Ahmedabad, Gujarat - 380006, India

Correspondence Address:
R C Rawal
2, Friends Avenue, Pakwan Cross Road, 100 Feet Bopal Road, S. G. Highway, Bodekdev, Ahmedabad - 380059
India

Abstract

Background: Vitiligo is a common skin disease; however it still remains a difficult disease to treat. Not all patients respond to current forms of treatment. Surgical techniques offer a potential solution for patients with vitiligo who fail to respond to medical treatments. Aims: Aims of the study were to evaluate response of transplantation of melanocyte keratinocyte cell suspension in patients of stable vitiligo. Materials and Methods: Total 10 patients of stable localized vitiligo were included in the study and were treated with transplantation of autologous melanocyte keratinocyte suspension after motor/manual dermabrasion. Results: Out of total 10 patients, 40% [4 patients] had excellent [95 to 100%] response, 30% [3 patients] had good [65 to 94%] response, 20% [2 patients] had fair [20 to 64%] response and 10% [1 patient] had poor response [0 to 19%]. Age and sex of the patients and size and location of lesions, did not show significant influence on results of transplantation. Conclusion: Autologus melanocyte keratinocyte suspension combined with motor/manual dermabrasion is an effective affordable treatment for patients with stable vitiligo who fail to respond to medical treatments.



How to cite this article:
Rastogi S, Goyal P, Mangla K, Bhavsar N, Patel H, Rawal R C. Study of transplantation of melanocyte keratinocyte suspension in treatment of vitiligo.Indian J Dermatol 2006;51:142-144


How to cite this URL:
Rastogi S, Goyal P, Mangla K, Bhavsar N, Patel H, Rawal R C. Study of transplantation of melanocyte keratinocyte suspension in treatment of vitiligo. Indian J Dermatol [serial online] 2006 [cited 2021 Sep 20 ];51:142-144
Available from: https://www.e-ijd.org/text.asp?2006/51/2/142/26941


Full Text

 Introduction



Vitiligo is a disorder in which owing to disappearance of melanocytes in skin, sharply delimited symmetrically arranged white patches develop. The condition occurs in 1 to 2% of the population mostly between the ages of 10 and 30 years, and as often in males as in females. The cause of vitiligo is unknown. Hereditary factors, autoimmunization, neurological disorders and autodestruction have been hypothesized. Currently, several medical treatments for vitiligo are available including topical corticosteroids, photochemotherapy using psoralen - UVA and narrow band UVB. However in many cases the results of medical therapies are less than satisfactory. For a patient in whom vitiligo has been non-responsive to medical treatment and who has been stable, surgical treatment is a viable alternative. Currently available surgical treatments are, Full thickness punch graft, Split thickness graft, Suction blister graft,[1] melanocyte suspension.[2],[3],[4],[5] The technique of making cell suspension and culture has advantage of treating large depigmented areas by expanding cell numbers from a small piece of normal pigmented skin.

 Materials and Methods



Ten patients of stable localized vitiligo [i.e., have no new lesion or no increase in size of old lesion since last two years] were selected for the procedure.

Inclusion criteria:

a) Stable vitiligo for 12 months.

b) Should not be on any immunosuppressive therapy.

c) Should not have keloidal and bleeding tendency.

d) Should not have koebner phenomenon.

Exclusion criteria:

a) More than 30% body surface involvement

b) Acrofacial vitiligo

c) Age less than 12 years

d) Presence of any other autoimmune disorder

e) Family history of malignancy

Equipment

Skin grafting knife [Silve's knife], Dermabraders - manual/electrical, incubator, centrifuge, laminar flow bench, Petri dishes, iris secissors, jeweller's forceps, ring forceps, spatula, test tubes, marking pen, K Y jelly.

Donor site

In selected patient donor area of one tenth [10%] of recipient ara is marked on lateral aspect of gluteal region with skin marking pen. Then this area and surrounding skin is cleaned with povidone iodine and 70% ethanol is draped. The area is then anaesthesized with 2% xylocaine injection with adrenaline. The skin is stretched uniformly and graft is taken with a silver's skin grafting knife [uptil where tiny bleeding points start appearing clinically]. The wound so created is covered with Vaseline gauze.

 Preparation of autologous melanocyte keratinocyte cell suspension from tissue



The thin skin sample is transferred to a petridish containing about 4 ml of 0.2% w/v trypsin solution. The sample is shaken to ensure that it comes in complete contact with the solution. Finally, the sample is kept with epidermis upwards. Incubation of the petridish containing sample is done for 50 minutes at 37 degree Celsius. To neutralize action of trypsin, about 2 ml of trypsin inhibitor is added to petridish. The dermis is separated from the epidermis and is transferred to a test tube containing 3 ml of melanocyte medium and mixed for 15 seconds. The dermal pieces are then discarded. The epidermis in petridish is broken down into multiple small pieces, washed with M 2 medium and then transferred to test tube containing the same medium. The test tube containing epidermal pieces is then centrifuged for 6 minutes. The cell pellet thus settles to the bottom and epidermal pieces are discarded and the cell pellet is suspended in 1ml syringe with detachable needle, the quantity of suspension prepared is approximately 0.5 ml. The suspension thus contains half of stratum spinosum but nothing above that layer.

 Recipient site



Recipient is marked out with marker, cleaned with povidone iodine and 70% ethanol and anaesthetized with 1% xylocaine and shaved.

 Transplantation



The recipient area is abraded down to dermo-epidermal junction with a high speed [2000 RPM] dermabrader fitted with a diamond fraise wheel. The ideal level is achieved when pin point bleeding spots start to appear. The denuded area is covered with sterile gauze pieces moistened with normal saline. Gauze pieces are then removed after 10 min and cell suspension applied evenly with help of syringe with needle. Denuded are is first covered with collagen and then tigaderm transparent dressing. Patient is asked to remain in same position for 30 minutes and then allowed to go home. The patient is cautioned against any vigorous activity for two weeks which could displace dressing. Antibiotics are prescribed for 7 days. Dressing is removed after 1 week. Patients are followed up every month, PUVA has been given to all patients after transplantation.

 Results



The treated area appears bright pink immediately after removal of dressing. The earliest pigmentation is noticed 3 weeks post surgery.

Results were evaluated on basis of:

a) VAS score [visual analogue system score]

Grade 0 75% repigmentation-excellent response

b) Wood lamp examination

Positive +, ++, +++

Negative -

c) Type of pigmentation - Folicular/diffuse

Results were evaluated as follows:

a) Poor response:

Grade 0, Wood lamp examination [-ve],

No follicular or diffuse pigmentation.

b) Fair response

Grade 1, Wood lamp examination [+],

Follicular repigmentation and no or diffuse repigmentation.

c) Good response

Grade 2, Wood lamp examination [++], Follicular and diffuse repigmentation.

d) Excellent response

Grade 3, Wood lamp examination [+++],

Diffuse repigmentation.

Response has been evaluated after 6 months of transplantation and has been shown in [Table 1].

 Conclusion



This method replenishes the missing melanocytes. Repigmentation obtained lasts long, as more than 95% patients have stayed pigmented. Considering the aesthetic outcome and ability to treat larger area with very small skin, this technique may replace the present methods of treatment of stable vitiligo but more trials specially at multiple centers involving statistically significant population should be done.

 Discussion



This method is very simple and can be carried out as out patient treatment. The time required to complete the entire transplantation procedure is about 2 to 3 hours, depending upon the number of patches, anatomical location and total area under treatment. Absolute immobilization is not required. Rest at home for 7 days is sufficient. In case, transplantation fails to produce repigmentation, the procedure can be repeated at same place without scarring. Any anatomical site can be treated, large areas even upto 300 sq. cm can be transplanted in single session. Cosmetic acceptability is very superior as there is no cobble-stoning or scarring. The greatest advantage is the ten-fold increase of recipient areas over donor area.[6]

The use of a culture medium while preparing cell suspension, leaving them under occlusive dressing together with release of growth promoting factors during healing are responsible for multiplication of melanocytes after being applied to recipient area.

This method does not cure the disease but serves to replenish the missing melanocytes. In the long run, this method should prove to be a cosmetically most acceptable and cost effective therapy.

References

1Lerner AB, Halaben R, Klaus SN, Moellmann GE. Transplantation of human melanocytes. J Invst Dermatol 1987;89:219-24.
2Olsson MJ, Juhlin L. Repigmentation of vitiligo by transplantation of cultured autologous melanocytes. Acta Dermatol Venereol [Stockh] 1993;73:49-51.
3Olsson MJ, Juhlin L. Transplantation of melanocytes in vitiligo Br J Dermatol 1995;132:587-91.
4Lontz W, Olsson MJ, Moellmann G, Lerner AB. Pigment cell transplantation for treatment of vitiligo. A Progress Report. J Am Acad Dermatol 1994;30:591-7.
5Yu-Fu chen, Pei-Yu Yang, Dan-Ning Hu, Feng-Sheng Kuo, Cheng-Sheng Hung, Chih-Minhg Hung. Treatment of vitiligo by transplantation of cultured pure melanocyte suspension. Analysis of 120 cases. J Am Acad Dermatol 2004;51:68-74.
6Olsson MJ, Juhlin L. Leucoderma treated by transplantation of a basal cell layer enriched suspension. Br J Dermatol 1998;138:644-8.