A, A woman in her 30s with vitiligo on the neck and trunk. B, The Wood light examination clearly reveals sites of vitiligo. C, Three areas were randomized to receive: amniotic membrane–cultured epidermal cell grafting (area A), cultured epidermal cell suspension (area B), or placebo (area C). The randomization process was designed and executed by a distance centralized randomization service formed by staff with no clinical involvement in the trial. A computer-generated, permuted, block-randomization scheme was used to allocate interventions. Patients, data analysts, and physicians involved in the recruitment, as well as those delivering the intervention or measuring outcomes, were blinded to allocation. D, The achromic epidermis was removed using carbon dioxide laser, with a similar clinical appearance 96 hours later. E, Results 6 months after transplantation. F, Wood’s light examination following intervention.
Redondo P, Gímenez de Azcarate A, Núñez-Córdoba JM, Andreu EJ, García-Guzman M, Aguado L, Prosper F. Efficacy of Autologous Melanocyte Transplantation on Amniotic Membrane in Patients With Stable LeukodermaA Randomized Clinical Trial. JAMA Dermatol. 2015;151(8):897-899. doi:10.1001/jamadermatol.2015.0299
Vitiligo is a disfiguring disease with no definitive treatment options that significantly affects patients’ quality of life. We aimed to compare, for what we believe to be the first time, the repigmentation efficacy of cultured epidermal cell suspension (CES) and amniotic membrane (AM)–cultured epidermal cell grafting (CEG) in the treatment of stable vitiligo.
A 2½-year (December 15, 2010, to June 5, 2013), randomized, double-blind, intraindividually placebo-controlled clinical trial with a 6-month posttreatment follow-up period (last follow-up, November 26, 2012) was carried out in the dermatology department of the University Clinic of Navarra, Spain. The study was approved by the local institutional review board (Comité Ético de Investigación Clínica de Navarra, Health Department, Government of Navarra, Spain). Written informed consent was received from all patients. The participants did not receive financial compensation.
Of 30 eligible patients with stable leukoderma, 24 individuals (15 women; age range, 18-57 years) were included in the final analyses. Dermatologic examination was performed on each patient to select one large vitiligo lesion (≥90 cm2) or several smaller vitiligo lesions (up to 5 lesions, ≥90 cm2 in total) per patient.
Amniotic membranes were obtained during elective cesarean delivery as described.1 Melanocyte growth medium M2 (M2; PromoCell) was used for the culture. A superficial shave biopsy (0.5 cm2) was taken from pigmented buttock skin under local anesthesia. Epidermal cells were obtained (Dispase II neutral protease, grade II; Roche; and TrypLE Select enzyme; Gibco-Life Technologies) as described.1 Cells were subcultured in two 75-cm2 culture flasks. When 70% to 80% confluence was reached, cells from one of the flasks were harvested with TrypLE Select enzyme and the cell suspension was replated onto the basement membrane side of AM prepared, as described above, at a density of 5 to 25 × 103 cells/cm2. Cells were stained with monoclonal mouse antihuman melanosome antibody (clone HMB45; Dako), according to the manufacturer’s instructions. After laser carbon dioxide ablation (5.5-7 W with 0.2-second pulse; Sharplan 1030) of the areas of vitiligo, 3 different skin areas (≥30 cm2 per treated area) in each patient were randomly assigned to receive CES, AM-CEG, or no epidermal cell transplantation. A nonblinded investigator (P.R.) applied the different treatments. In summer, natural sun exposure was recommended during the following 2 months. In winter, UV-A irradiation (3-6 J/cm2) twice per week for approximately 2 months was indicated.
The primary outcome was the percentage of skin repigmentation in each of the 3 intraindividual randomized areas at the 3- and 6-month evaluations. The secondary outcome was the patients’ perception of pigmentation improvement. Statistical analysis was conducted using the Friedman test and the Wilcoxon matched-pairs signed-rank test.
The study results are summarized in the Table and Figure. The highest percentage points of repigmentation were observed in the skin area receiving CES. Both CES and AM-CEG treatments at the 3- and 6-month evaluations appeared to have a greater repigmentation effect compared with the control intervention. The CES and AM-CEG areas presented similar mean values of the score that evaluated the patients’ perception of pigmentation improvement at the 3- and 6-month visits. According to the patients’ perception, the pigmentation improvement for the CES and AM-CEG areas was greater than in the control areas at both visits, although these differences did not reach statistical significance.
All adverse events were classified as mild and occurred in 3 patients. These events included inflammation in a verruca vulgaris lesion in the first patient, minimal scarring in the second patient, and mild hypertrophy and delayed wound healing in the third individual.
This study showed differences in the repigmentation efficacy of CES and AM-CEG in the treatment of stable leukoderma, although they were not statistically significant. Two previous studies1,2 demonstrated the efficacy of AM as a scaffold for the implantation of autologous melanocytes in patients with stable vitiligo.
Factors that may explain the variable response to cellular implants include the anatomic site of the treated area and the history of the vitiligo regardless of the minimal period that vitiligo was stable and the type of vitiligo (segmental or nonsegmental).3- 5 These factors were fairly well controlled in the present study. The main limitations of the study were the small number of patients and the fact that follow-up could not be completed in all patients. The percentage of repigmentation achieved in the placebo area may be the result of epidermal trauma stimulated by UV-A irradiation, which could be a melanocyte-stimulating trigger to a reservoir of melanocytes.6 In conclusion, this study suggests greater efficacy of the transplantation techniques compared with placebo, being slightly more evident with CES compared with AM-CEG.
Accepted for Publication: February 5, 2015.
Corresponding Author: Pedro Redondo, MD, PhD, Department of Dermatology, University Clinic of Navarra, PO Box 4209, 31008 Pamplona, Spain (firstname.lastname@example.org).
Published Online: April 22, 2015. doi:10.1001/jamadermatol.2015.0299.
Author Contributions: Drs Redondo and Nuñez-Cordoba had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Redondo, de Azcarate, Prosper.
Acquisition, analysis, or interpretation of data: Redondo, de Azcarate, Núñez-Córdoba, Andreu, García-Guzman, Aguado.
Drafting of the manuscript: Redondo, de Azcarate, Núñez-Córdoba, Andreu, Aguado.
Critical revision of the manuscript for important intellectual content: Andreu, García-Guzman, Aguado, Prosper.
Statistical analysis: Redondo, Núñez-Córdoba.
Obtained funding: Redondo, Prosper.
Administrative, technical, or material support: Redondo, de Azcarate, Andreu, García-Guzman, Aguado, Prosper.
Study supervision: Redondo, de Azcarate, Andreu, García-Guzman, Aguado, Prosper.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by Investigación Clínica Independiente grant TRA-110 from the Ministerio de Sanidad, Spain.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Trial Registration: clinicaltrials.gov Identifier: NCT01701648.