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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 6
| Issue : 2 | Page : 77-83 |
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Comparative study of noncultured epidermal cell suspension and postage stamp skin grafting in stable vitiligo
Ashwant Kaur, Suresh K Malhotra, Tejinder Kaur
Department of Dermatology, Venereology & Leprosy, Government Medical College and Guru Nanak Dev Hospital, Amritsar, Punjab, India
| Date of Web Publication | 19-Dec-2019 |
Correspondence Address:
Suresh K Malhotra
HIG 943, Sector 3, Housing Board colony, Ranjit avenue, C Block, Amritsar, 143001, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/Pigmentinternational.Pigmentinternational_
Background: Vitiligo is an acquired primary depigmentary disorder, with a worldwide prevalence of 1%. Up to 80% of patients respond to medical treatment but for the rest of the patients, surgical methods are the treatment options. There is a scarcity of comparative studies of different surgical techniques in vitiligo. Aims: This article compares the efficacy of noncultured epidermal cell suspension (NCES) and postage stamp skin grafting in stable vitiligo. Methods: It was an experimental analytical study conducted over a period of 2 years. Two lesions in each patient were selected and those two lesions in each individual were randomized between Group A (NCES) and Group B (postage stamp grafting technique). Forty lesions in the 20 patients were divided into two groups − Groups A and B comprising of 20 lesions in each were taken up for surgery with two different procedures, that is, NCES and postage stamp grafting, respectively. Digital photographs were taken at every sitting. An analysis was performed using the Wilcoxon signed-rank test and Mann–Whitney tests and grading was done for response in the form of repigmentation as excellent (>75%), good (50%–75%), fair (25%–50%), and poor (<25%). Results: The patients included in the study belonged to different strata of society. Postage stamp split skin grafting being a simple and cost-effective technique showed excellent repigmentation in 19/20 (95%) of lesions as compared to NCES in which it was only seen in 13/20 (65%) lesions at the end of study over the period of 12 weeks. Conclusion: Postage stamp skin grafting is easy to perform, relatively inexpensive, and shows early and better results with minimum complications than NCES.
Keywords: NCES, postage stamp skin grafting, vitiligo
How to cite this article:
Kaur A, Malhotra SK, Kaur T. Comparative study of noncultured epidermal cell suspension and postage stamp skin grafting in stable vitiligo. Pigment Int 2019;6:77-83 |
| Introduction | |  |
Vitiligo is a commonly acquired discoloration of the skin characterized by well-circumscribed ivory white macules with the worldwide overall prevalence of 1%. However, its incidence ranges from 0.1% to 8.8% and have remissions and exacerbations correlating with triggering events.[1] Up to 80% of patients respond to medical treatment and the remaining have patches in which response to medical treatment is unsatisfactory. In present days, various surgical modalities for vitiligo, such as autologous suction blister grafting,[2] minipunch grafting,[3] follicular unit grafting,[4] smash grafting, and cultured epidermal suspension,[5] are available with variable results. Both autologous melanocytic transplantation by noncultured epidermal grafting and postage stamp grafting (a modification of split skin grafting) are simple and easy to perform techniques.[6] The idea of postage stamp grafting was taken from mathematical model conceptualized by Meek that the multiple small pieces out of a large graft provide more active edges for regeneration.[7] This procedure has distinct advantages because it can be performed quickly and easily, with minimal scarring. As it does not require special equipment or a laboratory, it has the added advantage of low cost. There is a paucity of data worldwide on the usage of technique of postage stamp grafting in vitiligo.
| Methods | | |
It was open, randomized, and prospective study that was conducted in the outpatient department of a tertiary care center over a period of 2 years after taking ethical clearance from the institutional review board. Written consent was obtained from each patient before subjecting to either of the procedures. Twenty patients of stable vitiligo who attended the outpatient clinic of the Department of Dermatology were included in the study [Table 1]. It was an intraindividual comparatively study in which two lesions in each patient were selected and those two lesions in each individual were randomized between Group A (noncultured epidermal cell suspension, NCES) and Group B (postage stamp grafting technique). Forty lesions in these 20 patients were divided into two groups, that is, Group A (NCES) and B (postage stamp grafting technique).
Inclusion criteria
Patients with stable lesions (at least for 12 months), emotionally stable, and aged more than 12 years without any active infections were included in the study.
Exclusion criteria
Patients of younger age (age less than 12 years) with active disease and infection at the site of transplantation or on any other part of body, keloidal and bleeding diathesis, positive Kobners phenomenon, pregnancy, and lesions over mucosa, palms, and soles were excluded from the study.
Preoperative protocol
A preinformed written consent, history, clinical examination, and relevant investigations like hemogram, urine complete examination, bleeding and clotting time, fasting blood sugar, liver and kidney function tests, viral markers, and skin biopsy for histopathological confirmation of the disease were carried out and recorded in prestructured proforma.
Procedure
Preoperatively, both the donor and the recipient site was anesthetized with the application of the eutectic mixture of local anesthetics for 60 minutes. Recipient vitiligenous sites were dermabraded manually till tiny bleeding points were visible and the perimeter of the lesions was then feathered gently into the surrounding 1 cm of the normal skin. Normally pigmented skin of anterolateral aspect of thigh was selected for donor grafts. After surgical preparation, the split skin graft from donor site was harvested with the cutting edge of razor blade advanced tangentially through the upper papillary dermis. After achieving hemostasis, pressure dressing was applied to the donor areas. The harvested thin split skin graft was divided into two parts for the two study groups, that is, Groups A and B.
Group A
One part of the graft specimen was transferred under aseptic conditions to the test tube containing 0.25% trypsin-ethylene diamine tetra acetic acid (EDTA) solution and incubated at 37°C for 50 minutes followed by pipetting out of the trypsin-EDTA solution. It was followed by washing in phosphate buffer saline to neutralize the trypsin. The dermis was separated from the epidermis and the dermal side of the epidermal layer was scraped using a blunt forceps to release cells from the basal layer of the epidermis into the saline. The solid waste of the tissue was removed and the suspension thus obtained was centrifuged at 1000 rpm for 5 minutes. The supernatant was then discarded and the pellet containing melanocytes was placed over the dermabraded recipient area followed by collagen and betadine gauze dressing in two layers. Patients were advised for strict immobilization for 10 days and dressing was removed after 10 days [Figure 1] and [Figure 2]. | Figure 2 Steps in the transfer of grafts to the recipient site in both the groups.
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Group B
The second part of the harvested graft was kept in phosphate buffer saline at room temperature and was cut into multiple small 1 × 1 cm2 grafts. These grafts were placed over a paraffin gauze piece with epidermal side facing the gauze. This gauze with multiple grafts was placed over the dermabraded recipient area in such a way so that the dermal part of grafts was in close apposition with the recipient area. It was followed by betadine gauze dressing. Dressing was changed after 48 hours, and finally removed after 10 days of surgery [Figure 1] and [Figure 2].
Postoperatively, oral antibiotics, analgesics, and antiinflammatory drugs were given for 10 days to the patients of both the groups and follow-up was done at 2nd, 4th, 8th, and 12th weeks. No adjuvant treatment was given except for sunlight exposure after 2 weeks of surgery.
Repigmentation of all the recipient areas was assessed as:
% of repigmentation = Y/X × 100
where X = area of vitiligo and Y = area of repigmentation (shaded area).
At the end of study, depending on the percentage of repigmentation, final outcome was recorded as follows:- Grade I (Poor): <25% of pigmentation.
- Grade II (Fair): 26%–50% of pigmentation.
- Grade III (Good): 51%–75% of pigmentation.
- Grade IV (Excellent): >75% of pigmentation.
Statistical analysis
Mann–Whitney U tests were used to compare percentage, onset, and completion of repigmentation. The chi-square test was used to compare complications of the two procedures. The paired t test was used to assess maximum pigment spread. P < 0.05 was taken as significant.
| Results | | |
All the patients completed the study of 12 weeks and were included in the final analysis. Baseline characteristics of the patients were recorded. All 20 cases in our study had a history of prior treatments: corticosteroids (oral or topical), PUVASOL (oral or topical), placentrex gel, topical irritants, levamisole, and indigenous and homeopathic medicine. All patients had not attempted any treatment for 3 months prior to enrolment in the current study. The sociodemographic profile of patients is given in [Table 1].
At the end of 12 weeks, the status of repigmentation of the two groups was analyzed. Excellent (>75%) repigmentation was noticed in 13 (65%) lesions of Group A (NCES group) and 19 (95%) lesions of Group B (postage stamp grafting group) that was statistically highly significant (P = 0.021). It indicated that the procedure in group B gave better repigmentation than group A after 12 weeks of study. Good (50%–75%) repigmentation was observed in six (30%) lesions in Group A and in remaining one (5%) lesion in Group B, whereas one (5%) lesion of Group A did not repigment at all.
Secondary infection in one case, color mismatch in three cases and atrophy in two cases of Group A whereas milia formation in three cases of Group B was noticed. No other complications were seen in patients of either group.
Sixteen cases in our study had nonsegmental and four cases had segmental vitiligo. All the cases of segmental vitiligo in both the groups had excellent (>75%) repigmentation whereas nine (45%) lesions of Group A and 15 (75%) lesions of Group B of nonsegmental vitiligo had excellent repigmentation. The lesions over bony prominences did not show excellent results in Group A. In our study, all the lesions in group B had excellent repigmentation except one lesion that showed very good repigmentation over left leg whereas in Group A, one (5%) lesion located over left ankle did not show any repigmentation, six (30%) lesions over the left leg and right leg had very good (50%–75%) repigmentation, and the remaining 13 (65%) lesions distributed over face, chin, chest, trunk, and neck had excellent repigmentation.
| Discussion | | |
During past 3 decades, several surgical procedures have been developed, modified, and standardized to treat stable recalcitrant vitiligo, which have given variable results. In the present study, two different techniques, that is, autologous melanocytic transplantation by noncultured epidermal grafting and postage stamp grafting (a modification of split skin grafting), were compared.
All the cases showed resistance to treatment with various medical therapies in the past. However, there was no effect of duration of disease on the response to treatment.
Vitiligo lesions can repigment by three ways, that is, perifollicular when predominant repigmentation is follicular, marginal when predominant repigmentation is from the borders of the patches, and diffuse when generalized darkening occurs across the patches of vitiligo.[8]
In our study, two lesions in each patient were selected and those two lesions in each individual were randomized between Group A (NCES) and Group B (postage stamp grafting technique). In Group A, most of the lesions showed repigmentation that began from the margins and spread centripetally; however, in some patches, initially the repigmentation was perifollicular that later on coalesced. In Group B, all the patients showed the perimarginal type of repigmentation, that is, pigment spread was seen circumferentially around the grafts placed which later on turned diffuse on merging with the pigmentation from the adjacent grafts. This signifies that the repigmentation was due to transplanted melanocytes by noncultured epidermal grafting and postage stamp grafting. Perifollicular or marginal repigmentation is mainly induced by melanocyte reserve in the hair follicle that is stimulated by dermabrasion or phototherapy.[9]
At the end of 12 weeks of follow-up, it was observed that maximum lesions, that is, 19 (95%) lesions of Group B and 13 (65%) lesions of Group A, achieved excellent repigmentation (P = 0.021) [Figure 3]. Thus, postage stamp grafting gave better degree of repigmentation than NCES. | Figure 3 Preoperative and postoperative repigmentation in both the groups.
Click here to view |
Our results in Group A were found to be better than reported by Van Geel et al. (2001) in their study wherein repigmentation was achieved in 3 to 12 months in their cases.[10],[11] Olsson and Juhlin[12] reported 85% success rate after application of basal cell layer epidermal cell suspension rich in melanocytes. Mulekar[11] in their study reported that more than 50% of their patients treated for difficult sites achieved more than 65% repigmentation when treated with noncultured epidermal suspension.
The idea of postage stamp grafting was taken from mathematical model conceptualized by Meek that the multiple pieces of a large graft provide more active edges for regeneration. Small-sized grafts if placed closely lead to traversing of lesser distance for epithelial migration. It is known that keratinocytes migrate from the graft edges to reepithelialize the wound. Thus, smaller grafts have greater potential for regeneration at a lesser duration of time.[7] The same concept was used in our study for melanocyte migration from the edges to achieve early and better repigmentation. This procedure has distinct advantages because it can be performed quickly and easily, with minimal scarring. Moreover, it has proved to be a simple and cost-effective technique (considering the cost of reagents, centrifuge machine, and an incubator), which even a dermatologist working in the field conditions, without fully equipped laboratory support, can perform and thus help his patients in mitigating their suffering.
However, in noncultured epidermal grafting, repigmentation although is slow but the spread, which is uniform around the grafts, is gratifying; thus, chances of variegate pigmentation are almost negligible and the tissue required for grafting is also very less with donor:recipient area ratio of 1:10 as compared to postage stamp split skin grafting in which it is in the ratio of approximately 1:3.
Except for secondary infection in one lesion (5%), color mismatch in three lesions (15%) and atrophy in two lesions (10%) of Group A and three lesions (15%) with milia formation in Group B, none of our cases who underwent transplantation by either of the techniques showed complications like perigraft halo, hypertrophic scar formation, bleeding, variegated appearance, and hypopigmentation, thus making both the procedures easy and simple to perform.
But for the cost of incubator and centrifuge machine used in NCES (Group A), both the techniques can be termed as inexpensive. Complications like cobblestoning or hyperpigmentation are absent and desirable repigmentation can be achieved. The limitation of the study was smaller sample of the study groups and shorter follow-up period. It can be recommended to study these techniques in larger number of patients over a longer period of time.
| Conclusion | | |
Postage stamp grafting was equally effective as NCES for treating stable vitiligo but it gives early and better results, and the cost of this procedure was lower than with NCES.
Presentation at a meeting
This article was presented at the Cuticon 2018 (North).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 4. | Malakar S, Dhar S. Repigmentation of vitiligo patches by transplantation of hair follicles. Int J Dermatol 1999;38:237-8. |
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| 8. | Kanwar AJ, Parsad D. Understanding the mechanism of repigmentation in vitiligo. In: Gupta S, Olosson JM, Kanwar AJ, Ortonne JP, editors. Surgical Management of Vitiligo. 1st ed. Chennai: Blackwell Publishing Ltd; 2007. pp. 14-9. |
| 9. | Singh C, Parsad D, Kanwar AJ, Dogra S, Kumar R. Comparison between autologous noncultured extracted hair follicle outer root sheath cell suspension and autologous non cultured epidermal cell suspension in the treatment of stable vitiligo: a randomized study. Br J Dermtol 2013;169:287-93. |
| 10. | Van Geel N, Ongenae K, Naeyaert JM. Surgical technique for vitiligo: a review. Indian J Dermatol Venereol Leprol 2001;202:162-6. |
| 11. | Mulekar SV. Long-term follow-up study of segmental and focal vitiligo treated by autologous, non cultured melanocyte-keratinocyte transplantation. Arch Dermatol 2004;140:1211-5. |
| 12. | Olsson MJ, Juhlin L. Repigmentation of vitiligo by transplantation of autologous cultured melanocytes. Acad Dermatol 1993;72:49-51. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1]
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