Restoration of Pigmentation by Follicular Unit Extraction Transplant in Three Cases of Focal Vitiligo Recalcitrant to Therapy including with Previous Nonculture Melanocyte-keratinocyte Transplant

Abstract

Vitiligo is an acquired, idiopathic depigmentary disease resisting satisfactory repigmentation despite multimodal therapy. Based on the concept of activation of the existing undifferentiated stem cells in the outer root sheet of the hair follicles, follicular unit extraction (FUE) transplant is an interesting advancement in the field of minimally invasive surgery for vitiligo. We herein present three cases of vitiligo whose residual recalcitrant foci as well as poliosis – refractory to therapy including with previous nonculture melanocyte-keratinocyte transplant – repigmented satisfactorily after FUE transplant.

INTRODUCTION

Vitiligo is an acquired idiopathic depigmentary melanocytopenic dermatosis which is difficult to treat despite multimodal therapy comprising topical/systemic immunosuppressives, phototherapy, excimer laser, surgery, etc.[1] Despite causing mere cosmetic impairment, vitiligo leads to disproportionate psychosocial distress, particularly in the Indian population.[2] Surgical grafting comprising either the melanocyte-rich tissue (split thickness skin, suction blisters, and hair follicle/mini punch) or the melanocytes per se can be used to treat cases of “stable” vitiligo, i.e., those lacking Koebner phenomenon, eruption of new lesions, and progression of lesions over the last 1 year.[3,4]

We herein present [Table 1] three adult males whose residual foci of vitiligo, recalcitrant not only to preceding medical/physical therapy but also to autologous nonculture melanocyte-keratinocyte transplant (nonculture epidermal cell suspension; NCES), repigmented satisfactorily after follicular unit extraction (FUE) transplant [Figure 1]. To the best of our knowledge, no previous report probably exists in English literature regarding restoration of pigmentation by FUE in vitiligo recalcitrant to therapy including NCES.

Table 1.

Clinical summary of cases with duration of therapy and follow-up after follicular unit extraction

Figure 1.

Clinical photographs (a-c) before, and (d-f) after, follicular unit extraction transplant of cases 1, 2, and 3, respectively

PROCEDURE

Patients’ written informed consent was obtained after counseling. Their complete hemogram and bleeding/clotting times were normal. None had lignocaine hypersensitivity.

After tumescent anesthesia, donor follicles were extracted from the occipital area using 0.9-mm sharp punch and kept in a Petri dish containing normal saline. Transplantation was done using 18 g needle and angled Jeweler forceps in the directions of existing hairs with 5 mm interfollicular gap using stick and place method. Tacrolimus/mometasone cream, as in previous use by the patients, was restarted now after stoppage of a week.

DISCUSSION

Staricco demonstrated active and inactive forms of melanocytes in the outer root sheet (ORS) of the hair follicles, whereas only active (DOPA-positive) melanocytes exist in the epidermis of normal skin. In vitiligo, the active melanocytes are destroyed and the preserved inactive ones within the ORS serve as the source for repigmentation.[5] Ortonne et al. described that the DOPA negative, nondendritic pigment cells migrate from the ORS toward the basal cell layer to become functionally active in patients treated with psoralen and ultraviolet A therapy for vitiligo.[6]

Follicular unit transplant, introduced in 1998, involves removal of a strip of patients’ occipital scalp followed by dissection into individual follicular units before implantation. This stripping likely leaves a noticeable linear scar.[7,8]

Extraction of individual follicular units from occipital area, chest, back, beard, etc., not only avoids scarring but also can be usefully employed even in the surgically challenging sites such as non-glabrous, eyelash, or angle of the mouth.[8] This technique is also devoid of complications such as cobblestoning, hypertrophic scar, and postoperative hyperpigmentation.[7] However, a long learning curve is required for attaining proficiency in the delicate, tedious, and time-consuming process of individual hair extraction. Moreover, with this technique, it is difficult to treat medium to large lesions, glabrous areas, and unstable vitiligo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.