A UT Southwestern Medical Center dermatologist has improved a technique to transplant pigment cells that can repair the affected area of skin discoloration from vitiligo.
Dr. Amit Pandya, Professor of Dermatology at UT Southwestern, refined and enhanced this technique, which uses a less painful process rather than cutting into the skin to obtain the cells needed for the transplant. The cells are harvested from a painless blister raised on the skin, then transferred to the area of involvement to replace the missing pigment cells and restore the individual's natural skin color. UT Southwestern is the only center in the United States to use this technique and one of only two to perform this type of cell transplant surgery, called non-cultured epidermal suspension (NCES) grafting, cellular grafting or melanocyte keratinocyte transplant procedure (MKTP).
"This provides new hope for patients with vitiligo," said Dr. Pandya, who holds the Dr. J.B. Shelmire Professorship in Dermatology. "The unique aspect of our procedure, which no one else in the world is doing, is the formation of blisters as the source of donor cells combined with laser surgery to prepare the grafted areas. The older method of cutting the skin leaves a scar."
Dr. Pandya, the only full-time pigmentary disorders specialist in Texas, has spent more than a decade treating vitiligo patients in the Pigmentation Disorders Clinic at UT Southwestern.
Vitiligo affects about 2 million people in the United States. Vitiligo occurs when the body is triggered to look at melanocytes, cells which give color to the skin, as foreign or abnormal. With vitiligo, the body's own immune system starts attacking those cells, which is why it's considered an autoimmune disease. Traditional treatments include phototherapy, requiring different types of machines to shine ultraviolet light on the whole body, localized areas, or the hands and feet. UT Southwestern also uses an excimer laser to treat smaller lesions.
For the transplant procedure, Dr. Pandya uses a syringe and a heat lamp to create a small blister graft on the thigh. Thousands of cells are removed from the blister roof and those cells are then applied to the affected area.
"It doesn't even hurt. It feels like something is sucking on your skin. Then using heat lamps we're able to form blisters about the size of a dime," explained Dr. Pandya, who traveled to China, India, and Detroit to be trained in non-cultured epidermal suspension grafting. Many patients seeking these treatments previously had traveled across continents to Europe and Asia, where the treatments were initially developed.
Blistering leaves pigmentation, which slowly fades over time. Dr. Pandya can use a blister only 0.7 centimeters to cover an area 10 times as large. After the cells are extracted from the blister roof they are put into a solution in a syringe that is dripped on the affected area. Thousands of melanocytes are transplanted into the areas of vitiligo with each procedure. How many procedures are required depends on the size of the area affected.
Good candidates for the NCES procedure have stable vitiligo, in which not more than 10 percent worsening has been seen in the last year and patients with segmental vitiligo, a type that appears on only one side of the face or body.
"The best candidates have improved with previous treatments but have reached a standstill in which they are neither improving nor worsening," said Dr. Pandya.
The donor blisters can come from the abdomen, thighs, or buttocks. Areas that respond well include the cheeks, forehead, neck, back, chest, abdomen, arms, and legs. The nose, skin around the mouth, lips, elbows, wrists, fingers, knees, ankles, and toes have a lower response. While most patients see at least 50 percent of their normal color returning to the treated area, success is not guaranteed and sometimes no pigmentation is seen after the procedure. The color of the new pigmentation may be lighter, darker, or blotchier than the normal surrounding skin, he said. Repigmentation can be sped up by using phototherapy once bandages have been removed in one week.
Dr. Pandya served as co-editor of the recently-published Dermatology Atlas for Skin of Color, which includes 50 chapters, more than 400 images, and concise discussions to address the presentation of common skin disorders in pigmented patients. Dr. Pandya also serves as medical director for the DFW Vitiligo Support Group, whose mission is to educate those with vitiligo about the diagnosis and treatment of vitiligo, to provide support for those affected by vitiligo, and to increase awareness of this disorder in the general public.
In addition to ongoing research to find an eventual cure for vitiligo, Dr. Pandya is compiling one of only five vitiligo registries in the world that collects data on patients and the disease. The Dallas Vitiligo Registry (DVR) is a national registry for vitiligo patients. Its goal is to enroll a large number (hundreds) of patients in order to better understand the causes of vitiligo, how it evolves over time, and how to treat vitiligo optimally. Among the goals is to follow patients receiving various therapies to determine which work best and for which types of vitiligo. Patients also are evaluated for disease associations such as thyroid disease, which occur in greater frequency in patients with vitiligo. The creation of a unified database that measures and tracks these factors over a long period of time will provide greater insight into the disease process and advance the boundaries of current research in the field. Additionally, measuring response or progression of disease with different treatments over longer periods of time will help physicians to improve their treatment protocols for affected patients.
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