Clinical, dermoscopic, and histopathologic evaluation of vitamin C versus PRP, with microneedling in the treatment of mixed melasma: A split-face, comparative study.

Melasma is a common esthetic problem affecting the face with a lot of risk factors being incriminated. Although several treatment options are available, none of them is satisfactory. This split face prospective study aimed to compare the efficacy of microneedling with vitamin C versus with platelet-rich plasma (PRP) in the management of mixed melasma. Ten females with bilateral mixed facial melasma were treated with six sessions of microneedling. After the needling vitamin C was applied on the right side of the face and PRP was applied on the left side. Clinical, dermoscopic, and histological assessment of the used treatments was done 1 month after the last session. The clinical and dermoscopic clearance of melasma was proved significantly on both sides of the face but was more significant with vitamin C (P = 0.005). Reduction of epidermal melanin and dermal melanophages was more observed with vitamin C. Moreover, MART-1 stain revealed a more significant reduction in the epidermal, dermal, and the total MART-1 positive cells with vitamin C (P = 0.044, 0.039, and 0.035, respectively). Microneedling with vitamin C was more efficient in treating mixed melasma than with PRP.

Clinicopathological evaluation of the donor area following autologous suction blister epithelial grafting vs Thiersch grafting in vitiligo patients: A preliminary study.

Surgical vitiligo treatment is suggested for recalcitrant small stable lesions. One of the limitations of this approach is the presence of large lesions. The donor site should be designed to be hidden without previous or present lesions; this limits donor sites. Aim of the study was to clinically and histopathologically evaluate donor areas 3 months and 1 year after Thiersch grafting (TG) and suction blister epithelial grafting (SBEG). Forty patients with stable vitiligo were equally divided into two groups before TG and SBEG. In each patient, the donor site was clinically and histopathologically evaluated after 3 months and 1 year. After 3 months in Group I, hyperpigmentation, mixed pigmentation with atrophic scarring, hyperpigmentation with hypertrophic scarring, erythema, and tough skin were detected in 10%, 50%, 10%, 10%, and 20% of cases, respectively. The condition improved with time leaving, leaving tough skin in all cases after 1 year. In Group II, hyperpigmentation was observed in all patients after 3 months and disappeared completely after 1 year. Histologically, biopsies taken 3 months after TG, showed increased basal pigmentation with dermal changes mimicking scar tissue in 92.5% of cases. Collagen homogenization of and fragmented elastic tissue were reported in all cases. Biopsies showed the same features after 1 year. In the SBEG group, biopsies revealed only basal hyperpigmentation that disappeared after 1 year in all patients. We concluded that SBEG is a scarless operation and regrafting from the same area can be performed. This is in contrast to TG, which is considered a scarring operation, and wherein the donor site cannot be reused for grafting.

Noncultured epidermal suspensions obtained from partial-thickness epidermal cuts and suction blister roofs for vitiligo treatment: A prospective comparative study.

BACKGROUND: The treatment options for vitiligo are either nonsurgical, including medical treatments and phototherapy, or surgical, including autologous transplantation methods. Noncultured epidermal suspension transplantation is indicated for the treatment of stable vitiligo not responding to either medical treatment or phototherapy. Variable results have been reported for the various techniques used for the preparation of this suspension. AIM: To compare the outcome between suction blister roof grafts and partial-thickness epidermal cuts for the preparation of noncultured epidermal suspensions for the treatment of stable vitiligo. PATIENTS AND METHODS: Forty patients with localized stable vitiligo lesions resistant to conventional therapy were included in the study. They were randomly divided into two groups for treatment with noncultured epidermal suspension grafting. The suspensions in groups I and II were obtained from suction blister roofs and partial-thickness epidermal cuts, respectively. Repigmentation grade, color match with the surrounding skin, and any side effects were compared between the groups. RESULTS: In group I, complete repigmentation was achieved in 6 cases while repigmentation was considered excellent in 8 cases; very good, 4 cases; and no response, 2 cases. In group II, complete repigmentation was achieved in 4 cases, and repigmentation was considered excellent in 16 cases. The color of the repigmented area matched the normal surrounding skin in 70% of the cases in group I and 40% of the cases in group II. CONCLUSION: Both techniques yielded comparable repigmentation results with advantages and disadvantages of both techniques.

Factors affecting the outcome of the suction blisters using two different harvesting techniques in vitiligo patients.

BACKGROUND: Suction blister grafting (SBG) technique has been used for long to treat various skin conditions. Different suction methods have been used such as syringes, Chinese cups, and suction device. There are some limitations of its use as time consumption, failure of induction or incomplete blister formation and pain. AIM: The aim of this work was to evaluate the outcome of using two different suction techniques, namely the syringes and the Chinese cups in induction of suction blisters. The effect of the device diameter and preheating of the donor area on the suction blister induction time (SBIT) was studied. The effect of saline injection in the blister formation and its completion was also evaluated. METHODS: The study was a left-right comparative study that included 50 patients with stable nonsegmental vitiligo. They were classified into four groups: Group 1 included 15 patients where different diameters of syringes (1.3, 1.7, and 2 cm) were compared against each other, group 2 included 15 patients where different diameters of cups (2, 3.5, and 5 cm) were compared against each other, group 3 included 20 patients subdivided into two groups; 10 patients each, where the effect of preheating the skin on blister induction was tested with use of cups (3a) and syringes (3b). Lastly, group 4 included randomly chosen 40 incomplete or multilocular blisters where the effect of saline injection on blister completion and coalescence of multilobulation was examined. SBIT was calculated in all patients. RESULTS: The use of the small diameter syringes or cups gave shorter SBIT; however, the difference, which was significant between all sizes of cups, was significant between the 1.3- and 2-cm-diameter syringes only. Preheating of the donor area shorten SBIT significantly. No complications were reported at the donor site except for transient postinflammatory hyperpigmentation in all patients. CONCLUSION: The small diameter syringes or cups and preheating of the donor area shorten the SBIT, while intra-blister saline injection increased the blister size and turns the multilocular blisters to unilocular ones.

Clinical evaluation of interrupted versus continuous narrowband ultraviolet B phototherapy in nonsegmental vitiligo treatment: A prospective randomized comparative study.

Phototherapy is the pillar of vitiligo treatment. One of its main obstacles is noncompliance. It was noticed that patients continue to repigment even after stopping sessions, so the idea of interrupted phototherapy emerged. To evaluate the effectiveness of interrupted versus continuous NB-UVB in nonsegmental vitiligo treatment. A prospective randomized comparative study of 23 patients with bilateral, nonsegmental vitiligo with no age or sex limits. All patients were treated with NB-UVB phototherapy for 1 month, after which one side of the body received continuous therapy (Side A) and the other received an interrupted course (Side B) for a total of 6 months. Two more groups of 10 patients were enrolled to exclude the systemic effect of NB-UVB. One group received continuous NB-UVB treatment, and the other received interrupted courses for 6 months. Evaluation of the results was performed clinically, by digital photography, planimetry and Vitiligo Area Scoring Index (VASI) prior to and 3 and 6 months after treatment. There was a significant clinical improvement in Group 1 compared to baseline (p < .05). However, there was no significant difference between the sides with regards to the clinical evaluation, point counting, and VASI scores (p > .05). When comparing the other two groups, there was a significant clinical improvement in each group after 6 months of treatment compared to baseline (p < .05), while there was no significant difference between them (p > .05). The current study suggests that interrupted NB-UVB phototherapy is a good alternative to continuous treatment with improved patient compliance, fewer side effects, and a lower cost of treatment.

Syringes versus Chinese cups in harvesting suction-induced blister graft: a randomized split-body study.

BACKGROUND: Suction blister grafting (SBG) is a technique where the pigmented epidermis is harvested from the donor site by induction of a blister using different suction methods as syringes, Chinese cups, suction device, etc. However, pain, time consumption, incomplete blister formation, and failure of blister development are the main limitations. OBJECTIVE: To compare between cups and syringes of similar diameter in inducing suction blisters. PATIENTS AND METHODS: In 30 patients with stable nonsegmental vitiligo, 2-cm-diameter (20 ml) syringe was applied on the anterolateral aspect of one thigh and a 2-cm-diameter cup on the corresponding site of the other thigh where right and left sides were chosen randomly. Patients were observed untill complete blister development or for a maximum of 3 hours. Suction blister induction time (SBIT) and the blister diameter were recorded for each patient. Pain during the process of induction was evaluated. RESULTS: Incomplete blister development was noted in 9 out of 30 (30%) with 2 cm syringes and 6 out of 30 (20%) with the similar diameter cups with no significant difference (P = 0.49). No significant difference was found between SBIT induced by the 2 cm syringes and the similar size cups (101.17 ± 68.14 minutes, 98 ± 56.84 minutes, respectively) (P = 0.85). Meanwhile, blister diameter induced by either syringe or cup was not significantly different (P = 0.37). Anesthesia was for short duration with xylocaine, and pain was intolerable in both sides in the first seven patients. A combination of xylocaine and bupivacaine was used with prolonged loss of pain in 17 of the remaining 23 patients and tolerable pain in six patients similarly in both sides. CONCLUSION: According to present results, the differences in SIBT, diameter of blisters, and number of complete blister formation induced by either syringes or cups of similar size were not significant. Therefore, whatever the available and feasible technique for the surgeon will be the ideal choice. A combination of xylocaine and bupivacaine is recommended to overcome the accompanying pain of the procedure.

The effect of latanoprost on vitiligo: a preliminary comparative study.

Latanoprost (LT), a prostaglandin F 2alpha (PGF2a ) analogue used in the treatment of glaucoma, was found to induce skin pigmentation in guinea pigs in addition to its known periocular and iridal pigmentation side effects. This study aims to evaluate the efficacy of topical LT in the induction of skin repigmentation in patients with vitiligo and to compare its potency with narrow band ultraviolet (UV) B (NB-UVB). The result of their combination was also assessed. This study involved 22 patients with bilateral and symmetrical vitiligo lesions, stable for the last three months, divided into three groups: group I, to evaluate LT vs. placebo; group II, to evaluate LT vs. NB-UVB; and group III, to evaluate the effect of their combination. The response to treatment was evaluated by taking photographic records of the treated lesions with follow-up photography every two weeks. After three months, assessment of the degree and extent of repigmentation was performed. Follow-up assessment was done six months after termination of the trial for the persistence of pigmentation, recurrence, or development of any side effects. LT was found to be better than placebo and comparable with the NB-UVB in inducing skin repigmentation. This effect was enhanced by the addition of NB-UVB. LT could be a promising treatment for vitiligo, especially the periocular variant. Its effect on skin repigmentation could be enhanced by NB-UVB exposure.

Clinical study of nail changes in vitiligo.

Both vitiligo and alopecia areata (AA) are associated together, associated with other autoimmune diseases, and autoimmunity is one of the important theories in their etiology. Nail changes are a known association with AA, thus we hypothesized that nail changes can be found in vitiligo patients. On revising the literature, only two types of nail changes were described in association with vitiligo. Our aim was to study the frequency and types of nail changes among vitiligo patients in comparison with normal healthy volunteers. This multi-centric study was carried on 91 patients with vitiligo, as well as 91 normal healthy control subjects who were age- and sex-matched. Nails were examined for changes in nail plates as regards striations, texture, curvature, dystrophy, and pigmentation. The presence or absence of the thumb lunula was also reported. Nail changes were observed in 62 patients (68.1%) and 46 (50.5%) control subjects with a statistically significant difference (P = 0.016). Longitudinal ridging and absent lunula were significantly higher in patients than in the controls (P = 0.001 and 0.037, respectively). Other reported nail abnormalities in the current study included punctate leukonychia, pitting, flag sign, and Terry's nails. Awareness of this association will widen the clinician's perspective to carefully examine the nail changes in vitiligo patients and conversely examine patients with nail changes for vitiligo.

Effect of PUVA therapy on melanocytes and keratinocytes in non-segmental vitiligo: histopathological, immuno-histochemical and ultrastructural study.

BACKGROUND AND AIMS: Psoralen ultraviolet A (PUVA) is an important modality in treating vitiligo. Its effect on melanocytes and keratinocytes is not sufficiently studied. In this work, we investigated 30 cases of non-segmental vitiligo regarding the changes of melanocytes and keratinocytes in both vitiliginous and nearby areas before and after PUVA therapy. METHODS: Three skin biopsies were obtained from each patient from the vitiliginous, marginal and perilesional areas before and after 12 months of PUVA. Biopsies were examined histologically using haematoxylin and eosin, Masson-Fontana stains and 3,4-dihydroxyphenylalanine (DOPA) reaction and histochemically using human melanoma black-45 (HMB-45) antibody while ultrastructural examination was performed on six patients. Control biopsies were taken from five healthy volunteers. RESULTS: In 10% of pretreated biopsies from the centre of vitiligo lesions, scanty melanocytes were detected histologically and ultrastructurally, while they did not stain with DOPA or HMB-45 antibody suggesting that these melanocytes were inactive. Moreover, degenerative changes were detected by electron microscopy in both melanocytes and keratinocytes in all areas. After PUVA therapy, obvious improvement of the histopathological changes occurred with significant increase in active melanocytes. The degeneration of melanocytes and keratinocytes was also reduced at the ultrastructural level. CONCLUSION: Vitiligo affects both melanocytes and keratinocytes causing degenerative changes. These changes were present in both the leucodermic and the apparently normal perilesional skin. PUVA increases the number of active epidermal melanocytes in the three tested areas and recovers the melanocyte and keratinocyte degeneration.

A new morphometric technique for assessment of melanization in skin of guinea pigs.

BACKGROUND: The degree of melanization is an important finding in many skin disorders. An objective measurement of melanin density is needed to achieve an accurate evaluation. OBJECTIVES: The present work aims at translating the subjective increase of melanin particles after narrow band ultraviolet-B (NB-UVB) irradiation into objective numerical values ready for statistical analysis. MATERIALS AND METHODS: This study had involved 18 guinea pigs that were exposed to biweekly sessions of NB-UVB radiation for 4 weeks to induce skin pigmentation. Two skin biopsies were obtained from each animal; the first before treatment and the second at the end of the study, using 5 mm punch and stained with hematoxylin and eosin and Masson-Fontana (MF) stains. Surface area of both the epidermis (ESA) and the melanin particles (MPSA) were measured in µm(2) using a software supplied with Olympus light microscope. The MPSA/ESA percentage was calculated for each biopsy. The results before and after NB-UVB exposure were compared and statistically analyzed. RESULTS: In the MF-stained sections, the mean ± SD of the MPSA/ESA percentage were 0.24 µm(2) ± 0.09 and 6.21 µm(2) ± 2.45 at the start of the study and at its end, respectively, with a highly significant difference (P < 0.001). CONCLUSION: This technique offers a new methodology for an accurate numerical evaluation of epidermal melanization.

The effect of H1 and H2 receptor antagonists on melanogenesis.

BACKGROUND: Histamine was found to stimulate melanogenesis in cultured human melanocytes specifically mediated by histamine H 2 receptors via protein kinase A activation. Based on this finding, the effect of topically applied H 2 antagonist on UVB-irradiated Guinea pigs' skin was examined and found to be suppressive on the post-irradiation melanogenesis. AIMS: In this study, we tried to explore the role of topically applied H 1 and H 2 receptor antagonists, in inhibition of UVB-induced melanization. METHODS: The effect of topically applied H 1 and H 2 receptor antagonists in inhibition of melanization was done clinically and histochemically using Fontana Masson and DOPA reactions compared with placebo. RESULTS: The post-irradiation pigmentation was found to be brownish/black instead of the original light brown color. This color change occurred below the shaved orange-red fur suggesting a switch of melanogenesis from pheomelanin to eumelanin. The induced pigmentation was suppressed by topically applied H 2 antagonist while both H 1 antagonist and vehicle had no effect. The microscopic examination showed that the keratinocytes in the H 2 antagonist-treated areas contained few melanosomes while the nearby dendrites are full of them. CONCLUSION: H 2 antagonists' inhibition of UVB-induced pigmentation is not only due to suppression of melanization but also due to a specific action on melanosomes' transfer.

Effect of one session of ER:YAG laser ablation plus topical 5Fluorouracil on the outcome of short-term NB-UVB phototherapy in the treatment of non-segmental vitiligo: a left-right comparative study.

BACKGROUND: NB-UVB phototherapy is a very important modality in treating vitiligo but the treatment course usually exceeds 1 year. Skin ablation with mechanical dermabrasion with 5Fluorouracil (5FU) was introduced to treat vitiligo in 1983. This was modified replacing the mechanical dermabrasion by erbium-YAG (ER:YAG) laser ablation and resulted in better prognosis in periungual vitiligo. PURPOSE: In the present study, we are exploring the effect of the use of ER:YAG laser skin ablation and application of 5FU on the outcome of short-term NB-UVB therapy for patients with non-segmental vitiligo (NSV). METHODS: This study included 50 adult patients with a total of 65-paired symmetrical NSV lesions in different body parts. One side was treated with ER:YAG laser ablation, followed by 5FU application before simultaneous NB-UVB therapy of both sides for a maximum period of 4 months. The outcome was then evaluated both qualitatively and quantitatively. RESULTS: The overall response to therapy was better using the combination therapy. Fifty patients (78.1%) experienced a moderate-marked repigmentation response in the combination group compared with 23.4% in the mono-therapy group. The response was significantly higher when using the combination therapy in different body parts (P value is <0.05), except for feet lesions, which were better but not statistically significant (P value=0.15). Tolerable pain during ablation or at sites of 5FU application was reported in all cases. Transient hyperpigmentation occurred in 30% of cases and 3.1% of lesions healed by a transient slate blue color. Half of the treated periungual lesions showed a temporary tiny brownish spot on nail plates and Köebnerization was not detected in any patient. CONCLUSION: We concluded that prior use of ER:YAG laser skin ablation, followed by 5FU application before NB-UVB phototherapy for vitiligo is a safe and tolerable technique that improves the outcome of short-term NB-UVB therapy and is expected to increase patient compliance.