Dear Editor, Autologous cell suspension is a well‐demonstrated effective approach for treating segmental or stable and localized forms of vitiligo.1 Full surface dermabrasion is considered to be the gold standard technique for preparing the skin before grafting. Fractional ablative laser or microneedling have been shown to enhance the penetration of topical agents into the skin.2 Using an ex vivo skin model, we demonstrated that microneedling allows for the successful grafting of a melanocyte suspension into the skin and that this procedure was as effective as fractional ablative lasers in this setting.3 In the same study, we showed that a microneedle depth of 200 μm was optimal for delivering the melanocytes in the epidermis. The interest in using microneedling before a graft of epidermal suspension was further suggested by a pilot open study reporting excellent repigmentation in three patients and mild repigmentation in two of the five treated patients.4 These interesting results required confirmation as the treated lesions were located on the face and the study took place in a sunny country; spontaneous repigmentation cannot be ruled out as the study was not controlled. We thus conducted a randomized controlled prospective study to compare the efficacy of microneedling with full surface erbium:yttrium aluminium garnet (YAG)‐assisted dermabrasion (IRB Sud‐Méditerranée V15·075; NCT02660320). Patients with nonsegmental vitiligo that had been stable for more than 3 months were included. The lesions had to be resistant to at least one medical procedure, including topical tacrolimus, topical steroids or ultraviolet (UV)B for 6 months. In each patient, three separate test areas ranging from 2 cm² to 50 cm² were selected in the same part of the body. For each patient a scheme with the three areas, designated A, B and C (clockwise), was sent to the Department of Research and Innovation of our hospital. This department then used a random number table for each patient and relayed to us which type of procedure should be carried out for each location. One area was pretreated with dermaroller and received hyaluronic acid suspension and the two other areas received epidermal cell suspension in hyaluronic acid after pretreatment either with dermaroller or laser‐assisted dermabrasion, with each patient acting as his/her own control. The dermaroller had 540 microneedles of 200‐μm depth. A total of 12 passages were performed on the treated area to achieve 60% coverage. Laser‐assisted dermabrasion was performed using a 2940‐nm erbium:YAG laser (spot size 5 mm; 13 J cm−2, 5 Hz, repeated passages until pinpoint bleeding was noticed) (Burane, Alma Lasers, Liege, Belgium). The epidermal suspension was prepared by using the VITICELL® kit (Genevrier, Sophia‐Antipolis, France) with a ratio of 1 : 5. Targeted phototherapy with a 308‐nm excimer lamp (Exciplex, Clarteis, Sophia‐Antipolis, France) was applied on all treated areas 2 weeks after cell grafting and performed twice a week for 3 months. The primary efficacy end point was the rate of repigmentation lesions at 3 months. Using standardized direct and UV pictures (Fig. 1), the rate of repigmentation was graded as 0%, 1–25%, 26–50%, 51–75% or 76–100% by two physicians (H.M., T.P.) who were blinded to the treatment received. An intention‐to‐treat analysis was performed. (a) Vitiligo lesions before treatment. (b) Vitiligo patch 3 months after laser‐assisted dermabrasion and autologous epidermal cell suspension. (c) Ultraviolet (UV) picture of vitiligo patch 3 months after laser‐assisted dermabrasion and autologous epidermal cell suspension. (d) Vitiligo patches 3 months after dermaroller followed by autologous epidermal cell suspension (upper lesion) or by hyaluronic acid only (lower lesions). (e) UV pictures of vitiligo patches 3 months after dermaroller followed by autologous epidermal cell suspension (upper lesion) or by hyaluronic acid only (lower lesions). A total of six patients were included (four women and two men) with Fitzpatrick skin type I–V. No patients were lost during follow‐up. The mean age was 44·5 years (range 29–63). Treated lesions were localized on the lower limbs in three cases, on the arms for two patients and on the axillae for one patient. None of the six patients treated with microneedling, either followed by the suspension graft or not, had any repigmentation. Two patients had 90% repigmentation of the area treated with erbium:YAG dermabrasion followed by epidermal suspension. One patient achieved 75% repigmentation with the same procedure and the three remaining patients did not have any repigmentation. A Cochran's Q test was used to assess the rate of repigmentation ≥ 75% for erbium:YAG dermabrasion followed by epidermal suspension compared with microneedling alone or followed by epidermal suspension. In both cases the dermabrasion performed statistically better (P = 0·018 for the two comparisons). Pain was graded 1·2 (range 0–2) with microneedling and 4·7 (range 2–7) with the erbium:YAG dermabrasion. No infection or scars were noted for all groups. The microneedling is appealing owing to minimal levels of pain, ease of procedure and limited cost, but our results suggest that such a procedure is ineffective for preparing the grafting bed. The main limitation of our study is the small sample size. Moreover, we cannot exclude that other protocols using different depth or density of microneedles, or adding cells before performing the microneedling as Benzekri et al. did,4 might provide better results. Interestingly, fractional CO2 laser was also initially reported to be effective in the same indication.5 However, a prospective randomized controlled trial performed in segmental vitiligo and piebaldism showed that the full surface dermabrasion is superior to the fractional CO2 laser.6 In accordance with our results, these authors did not observe any repigmentation when using the fractional CO2 laser. We can hypothesize that the ineffectiveness of fractional CO2 or microneedling could be explained by the fact that the melanocytes account for only a minor proportion of the cells grafted when using epidermal suspension and that the limited number of cells allowed to penetrate the epidermis using fractional procedures is not enough to induce repigmentation. Funding sources: this research was funded by Genevrier, Sophia‐Antipolis, France. Conflicts of interest: S.L., J.‐P.L. and T.P. have received travels fees and honoraria from Genevrier.
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Lagrange et al. (2018) studied this question.
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