Autologous Cultured Melanocytes in Vitiligo Treatment
Czajkowski R, Placek W, Drewa T, Kowaliszyn B, Sir J, Weiss W
Dermatol Surg. 2007;33:1027-1036
Vitiligo is an autoimmune skin disorder characterized by discrete patches of hypopigmentation. It can vary in severity from localized to generalized disease. Management to date primarily consists of attempts to reduce inflammation (eg, topical corticosteroids and/or calcineurin inhibitors) while stimulating repigmentation (eg, narrowband UV-B phototherapy and psoralen and UV-A [PUVA] photochemotherapy). Areas that are classically refractory to these methods, such as acral skin, respond best to surgical techniques, including minigrafting, suction blister transplantation, and autologous cultured melanocyte transplantation.
In a small multiarm study, Czajkowski and colleagues enrolled 40 patients (25 women and 15 men; median age, 30.2 years; skin phototypes II-III) with clinically stable vitiligo (unchanged for at least 6 months). Treatment sites were all localized to the dorsal hands and lower extremities, and each patch of vitiligo underwent 1 of 4 therapies:
Autologous cultured melanocyte transplantation plus PUVA photochemotherapy;
Suction blister transplantation plus PUVA photochemotherapy;
Cryotherapy plus PUVA photochemotherapy; or
PUVA photochemotherapy alone.
Suction blisters were harvested from arm or forearm donor sites with an electric vacuum suction machine. The roof of each blister was either directly transferred onto prepared patches of vitiligo or placed in Petri dishes to produce autologous melanocyte cultures. Recipient patches of vitiligo were sprayed with neomycin sulfate, treated with either suction blister or autologous melanocyte grafts, and then covered with a dressing for 7 days. Some sites were treated with nitrous oxide cryotherapy application followed by PUVA therapy, whereas other sites were treated only with PUVA therapy (3x per week, initial UV-A dose of 0.5 J/cm2, 1.2 mg of 5-methoxypsoralen per kg of body weight). The investigators measured the level of repigmentation observed 6 months after treatment.
Only 10 of 20 potential autologous melanocyte recipient sites underwent transplantation due to difficulties in melanocyte cell-culture establishment. Despite these technical limitations, the combination of autologous cultured melanocyte transplantation and PUVA therapy yielded repigmentation in 100% of the recipient sites. In contrast, all 20 patient sites designated to receive suction blister transplantation underwent successful engraftment, and 98.7% of these grafts produced repigmentation following PUVA therapy. Repigmentation in these sites persisted for at least 6 months after treatment. Vitiligo patches treated with PUVA alone or PUVA combined with cryotherapy showed no repigmentation.
Current vitiligo therapies[2,3] can be divided into 3 main strategies:
Inflammation reduction (eg, topical corticosteroid or calcineurin inhibitor application, systemic immunosuppressive agents);
Melanocyte stimulation (narrowband UV-B phototherapy PUVA photochemotherapy); and
Surgical correction via transfer of autologous melanocytes (minigrafting, split-thickness skin grafting, suction blister transplantation and autologous cultured melanocyte transplantation).
Noting that vitiligo in areas such as acral skin is extremely hard to repigment, Czajkowski and colleagues studied a combination approach using PUVA combined with either suction blister transplantation or autologous cultured melanocyte transplantation They designed their study to include internal controls, with one group of volunteers (n = 20) receiving CMP and PUVA monotherapy (administered to contralateral, matched treatment sites) and another group (n = 20) receiving SBP and PUVA plus cryotherapy (administered to contralateral, matched treatment sites). This format confirmed that PUVA alone or combined with cryotherapy does not yield repigmentation, whereas grafting (suction blister transplantation or cultured melanocyte transplantation) plus PUVA yields excellent, durable repigmentation even in hard-to-treat acral patches of vitiligo. Of note, the suction blister technique for harvesting melanocytes proved to be both relatively simple and safe, with some donor sites developing only transient hyperpigmentation.
In summary, for those few dermatologists with the expertise and facilities to produce autologous cultured melanocytes, this technique offers the prospect of multiple grafting sessions to treat even the most refractory patches of vitiligo. Most clinicians, however, will lack the ability to create and sustain such cell lines, rendering this technique less feasible than suction blister transplantation. Alternative techniques, such as split-thickness or pinch skin grafting, may cause unwanted cosmetic complications at the donor sites (eg, scarring, new patches of vitiligo); in contrast, the suction blister technique used above only induced transient hyperpigmentation. Optimal engraftment and repigmentation appear to require PUVA therapy, although the investigators did not study alternative phototherapy options, such as narrowband UV-B.
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Cite this: Vitiligo Treatment With Autologous Cultured Melanocytes - Medscape - Feb 15, 2008.