Treatment – Done in 4 phases

A. Stabilization or Arresting Phase

Stabilizing the spreading vitiligo is main step in the treatment. We don’t try to bring back colour at this point. One has to understand that melanocytes are the main targets for the immune cells. So when there are immune cells around a white patch, if we increase the number of melanocytes, they will be killed by immune cells, eventually. First, we have to remove those killing cells and treat patient's deficiencies and derangements in the blood along with that. This will eliminate a hostile environment in the patch and creates a suitable condition for cells to proliferate and migrate so that the white patches re pigment in the next phase. Duration will be 6 weeks to 3 months.

In this phase main aim will be stopping the progression of the vitiligo through following measures

1. Immunomodulation and Immunosuppression

   Methods will focus on immune mediated cell death.

2. Increased Cell Survival or Decreased Cell Death

   Decreased hostility with established favourable environment    will achieve this by correcting the deficiencies and scavenging the toxins

B. Pigmentation Phase

In the first stage treatment for vitiligo will continue but some of the medications are phased out gradually. We will try to stimulate melanocyte reservoirs to get re pigmentation. We don’t prefer harsh medications which induce blistering, burning and deplete the cell reservoir. We usually offer either mild sun exposure or home based NBUVB exposure (which is more effective). This phase will span from 3 months to 9 months

Other than medications and phototherapy we do micro needling enhanced either with growth factors or cells in slow responding patches.

Pigmentation is achieved by following methods

1. Increased Cell Survival.
2. Consistent but safer stimulation of reservoir (stem cells, hair root cells and neighbouring cells in the borders of the patch)
3. Increased migration and division of pigment cells.
4. Release of good chemicals by building blocks (keratinocytes), which will sustain new pigment cells
5. Continued immunomodulation and decreased cell death.

C. Refractory phase

Those who don’t repigment with medicines and their patches are stable, one could go for cellular transplantation. The decision for transplantation will be taken at 6 months to 18 months of the initiation of arresting phase. In those who don't have reservoir or depleted reservoir, we have to treat them in refractory phase. Cellular transplantation replenishes lost cells but have a very minimal role in tackling underlying causes.

Cell Transplantation:

Ideal cell transplantation should achieve following things to achieve better results

Cell Replenishment: Replacement of of altered Keratinocytes. Vitiligo is no longer a disorder of Melanocytes. Over the time it results in modifications of keratinocytes (building blocks of skin) which no longer need Melanocytes. Melanocytes produce colour, melanin which is transferred to several keratinocytes and this melanin protects keratinocytes from UV damage (sun damage). Once keratinocytes need to live with out melanin and melanocytes, they adapt themselves to live with out colour and protect themselves from UV damage. So, they don’t release any distress chemicals which demand for the presence of melanocytes as well nurture the colour producing cell near keratinocytes. To change this situation one needs to replace existing clone of adapted keratinocytes by new clone of cells from elsewhere which need melanocytes for their survival.

Cell Replacement: Obviously one need to replenish lost melanocytes. We can get fresh clone of melanocytes from donor site and place them in exact level of skin, where melanocytes reside.

Cell Proliferation and migration: Whether it is keratinocyte or melanocyte, one can put only limited number of cells. In the initial time, they don’t spread uniformly over all over the patch post transplantation. One must have a threshold number of melanocytes to achieve satisfactory pigmentation. Proliferation (Increase in numbers) and migration of transplanted cells are essential to achieve better results. The cell transplantation technique should focus on achieving better cell proliferation and migration.

Stem Cell advantage: Stem cells present in the cell suspension should have advantages of regeneration and immunomodulation. Regeneration helps in replacement and replenishment of cells by respective precursor cells. Immunomodulation prevents the attack from immune cells which can destruct the new and prone transplanted cells and also pose roadblock for their proliferation and migration. These advantages are important to achieve faster results and longevity of good results.

Other Factors: Collagen remodelling is very important. Good Fibroblasts in quality and quantity needed to achieve proper colour and texture match post transplantation. Biggest challenge is modified vitiligo, where repeated ineffective treatments which try to over stimulate reservoir damage the middle layer of skin (where fibroblasts reside). When transplantation done on these patches, colour and texture mismatch occurs. Same result happens in corrective transplantation procedure done over previously blotched up wrong surgeries. Melanocyte detachment due to reasons like presence of MIA (Melanoma Inhibitory Antigen) could be a factor to loose the pigment cells after the procedure. Our transplantation procedure to great extent address both the concerns.

D. Maintenance Phase-
Where patient will be having minimal medications but have to follow lifestyle changes, dietary restrictions and general skin care measures. It is for patients who achieve maximum pigmentation because of the intact reservoir of cells or precursors of cells. The patient is also asked to undergo follow up tests once in every 3-6 months make sure that they don't have any deficiencies and derangements (contributing for disease onset)
However, the duration of the phases or skipping of certain phases is done according to the need of the patient

Authored By : Dr. Anantha Prasad Holla P