Efficacy of Transplantation of Combinationof Noncultured Dermal and Epidermal Cell Suspensionvs Epidermal Cell Suspension Alone in VitiligoA Randomized Clinical TrialVishal Thakur, MD; Sheetanshu Kumar, MD; Muthu Sendhil Kumaran, MD, DNB, MNAMS; Hitaishi Kaushik, MSc;Niharika Srivastava, MSc; Davinder Parsad, MD

IMPORTANCE Surgical interventions, notably noncultured epidermal suspension (NCES), arethe next line of treatment in patients with vitiligo who fail to respond to medical therapy.Noncultured epidermal suspension is usually performed in patients with vitiligo with durationof clinical stability (DS) of 12 months or longer because DS is a vital parameter in determiningoutcome of NCES. In this pilot study, we planned to assess the efficacy of a novel combinationof noncultured epidermal cell suspension and noncultured dermal cell suspension (NCES andNDCS) in patients with vitiligo with shorter DS (3-6 months).

OBJECTIVE To compare the efficacy of transplantation of NCES and NDCS vs NCES alonein patients with vitiligo with DS of 3 to 6 months.

DESIGN, SETTING, AND PARTICIPANTS A single-center randomized clinical trial including 40patients with focal, segmental, or generalized vitiligo with DS of 3 to 6 months or more than12 months was carried out. Based on DS, 2 groups including 20 patients each were recruited(DS in group 1, 3 to 6 months; DS in group 2, more than 12 months). Each group was furtherrandomized into 2 subgroups, A and B.

INTERVENTION Patients in subgroups 1A and 2A underwent NCES alone, whereas patientsin subgroups 1B and 2B underwent NCES and NDCS.

MAIN OUTCOMES AND MEASURES Extent of repigmentation, color match, and patternof repigmentation at 24 weeks.

RESULTS Of the 40 study participants, mean (SD) age was 24.9 (4.0) years and 24 (60%)were women; in group 1 with DS for 3 to 6 months, more than 75% repigmentation at 24weeks was observed in all 10 patients in subgroup 1B (NCES and NDCS) compared with 3 of10 patients in subgroup 1A (NCES) (100% vs 30%, P = .003). In group 2 (DS > 12 months),the same was observed in 6 of 10 patients in subgroup 2A and 7 of 10 patients in subgroup 2B(NCES) (60% vs 70%, P > .99). The 2 groups and subgroups did not show any significantdifferences with respect to color matching and pattern of repigmentation.

CONCLUSIONS AND RELEVANCE Combination of NCES and NDCS resulted in excellentresponse in patients with vitiligo with shorter duration of clinical stability compared withNCES alone. This combination may be used early in the course of stable vitiligo withoutwaiting for a period of 12 months or more since last clinical activity.

TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03013049

JAMA Dermatol. 2019;155(2):204-210. doi:10.1001/jamadermatol.2018.4919Published online January 2, 2019.

Supplemental content

Author Affiliations: Department ofDermatology, Venereology, andLeprology, Postgraduate Institute ofMedical Education and Research,Chandigarh, India.

Corresponding Author: DavinderParsad, MD, Professor, Departmentof Dermatology, Venereology andLeprology, Postgraduate Institute ofMedical Education and Research,Sector 12, Chandigarh 160012, India(parsad@mac.com).

Research

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V itiligo is a complex pigmentary disorder, associated withselective and progressive melanocyte loss resultingin development of depigmented patches on the skin.

It is often associated with considerable psychosocial reper-cussions on patients. The prevalence of vitiligo worldwide isapproximately 1%. It is more common in India, with a preva-lence of approximately 4% (range, 0.46%-8.8%).1,2

Although medical therapy is the mainstay of treatment, itis not uniformly effective in all patients and residual lesionsoften require surgical intervention to achieve complete repig-mentation. Surgical methods, notably transplantation of non-cultured epidermal cell suspension (NCES) have proven to beeffective in stable vitiligo. A proper selection of cases for sur-gical therapy is of paramount importance and vitiligo stabilityis considered a vital parameter before considering any melano-cyte transplantation technique. Although consensus regard-ing the ideal period of stability is lacking, usually duration ofclinical stability (DS) longer than 1 year is considered optimal.3,4

VariousstudiessuggestthatperilesionalcytotoxicCD8+ Tcellsin vitiligo may adversely affect the outcome of melanocyte trans-plantation, particularly in patients with shorter DS, and strategiesagainst CD8+ T cells may be beneficial for patients undergoingtransplantation.5-7 Dermal mesenchymal stem cells (DMCs)are known to inhibit T-cell (both CD4+ and CD8+) proliferationand induce T-cell apoptosis,8-10 thus, the possible immuno-regulatory properties of DMCs from noncultured dermal cellsuspension (NDCS) might be used as an auxiliary agent toimprove the efficacy of NCES in vitiligo patients particularlywith DS of less than 12 months.10

We intended to carry out this prospective pilot study tocompare a novel method of autologous transplantation of NCESand NDCS vs NCES alone in vitiligo patients.

MethodsThis randomized clinical trial was carried out in the depart-ment of Dermatology, Venereology, and Leprology, Postgrad-uate Institute of Medical Education and Research (PGIMER),Chandigarh, India. Institutional ethical clearance was obtainedandthetrialwasregisteredonClinicalTrials.gov(NCT03013049).The trial protocol is available in Supplement 1.

Patients18yearsoroldervisitingoutpatientdepartmentfromJanuary 2016 to November 2016 with focal, segmental, or gen-eralized vitiligo with DS of either 3 to 6 months or more than 12months, with lesions nonresponsive or partially responsive tomedical therapy were included in the study after obtaining writ-ten informed consent. Pregnant women, and patients with his-tory of koebnerization, keloidal tendencies, or bleeding disor-ders were excluded. Baseline clinical and demographic data ofrecruited patients was recorded. Size of vitiligo patch selectedfor surgical interventions in the study was less than 100 cm2.

Based on DS, 2 groups comprising 20 patients with vitiligoeach were recruited (Figure 1). Patient DS was defined as the timeelapsed since last noticed activity in vitiligo lesions in the formof appearance of new lesions or the increase in the size of ex-isting lesions. Group 1 comprised patients with DS of 3 to 6months whereas group 2 comprised patients with DS longer than

12 months. Patients in both the groups were further random-ized (simple randomization) into 2 subgroups of 10 patients eachusing a computer-generated random number table. Patients inthe first subgroups of both the groups (subgroups 1A and 2A)underwent NCES alone, whereas those in the second sub-group of both the groups (subgroups 1B and 2B) underwent com-bination of NCES and NDCS. Centralized allocation conceal-ment was performed. Random number table was generatedby one of the authors (S.K.), participant enrollment was doneby another one of us (M.S.K.), surgery was performed by2 authors (V.T. and S.K.), and the outcomes were assessed byanother author (D.P.). Cell suspension was prepared by 2authors (H.K. and N.S.). The physician assessing the outcomeswas blinded to the information regarding the patient’s group andsubgroup. The design of the study is depicted in Figure 1.

Operative TechniqueNoncultured Epidermal Cell Suspension (NCES)A donor site with an area of about one-tenth the area of the recipi-ent site was selected and a split-thickness skin graft (STSG) washarvested. The STSG was transferred to a trypsin-EDTA solution(0.25%trypsinand0.02%EDTA)maintainingasepticprecautions.The specimen was incubated overnight at 4°C. A cell suspensionwas prepared after washing 3 times in phosphate buffer solution(PBS).Thesuspensionwascentrifugedat1000rpmfor5minutes.The pellet-containing cells from stratum basale (rich in melano-cytes) were taken. Using trypan blue staining, viable epidermalcells(keratinocytesandmelanocytes)werecountedinNeubauer'schamber under light microscopy and the blue stained nonviablecellswereexcludedfromthecount.Phosphatebuffersolutionwasadded to the pellet to prepare a suspension of noncultured epi-dermal cells, which was used for autologous transplantation.

Noncultured Dermal Cell Suspension (NDCS)A 4-mm skin punch biopsy specimen from the donor site was col-lected under aseptic precautions in PBS with added antibiotics.The epidermis was carefully separated from the dermis and thedermiswasincubatedovernightincollagenase(1mg/mL)atroomtemperature. After incubation, the contents were diluted inPBSandcentrifugedat1000rpmfor5minutes.Pelletwaswashed3 times with PBS to remove any remnant collagenase. Withtrypan blue staining, viable cells were counted in Neubauer'schamber as described above. Phosphate buffer solution was

Key PointsQuestion Is surgical management of vitiligo with duration ofclinical stability (DS) of 3 to 6 months feasible using a novelcombination of noncultured dermal and epidermal cell suspension(NCES and NDCS)?

Findings In this randomized clinical trial of 40 patients, more than 75%repigmentation at 24 weeks was observed in all 10 participants withvitiligo (100%) with DS of 3 to 6 months treated with NCES and NDCScompared with 3 of 10 (30%) patients with DS treated with NCES alone.

Meaning Combined NCES and NDCS is a novel technique that canbe used successfully in patients with vitiligo with shorter durationof disease stability (3-6 months).

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added to make a suspension of noncultured dermal cells foruse in autologous transplantation. For patients undergoingtransplantation with NCES and NDCS, a suspension containingboth components in a 1:1 ratio was used.

Characterization of DMCs in NDCSDermal mesenchymal stem cells in NDCS were identified by flowcytometric analysis using CD90 (559869, BD Pharmingen). Thiswasdoneintheinitial3samplestoconfirmthepresenceofDMCs.The proportion of CD90+ cells was found to be 22.2%, 24.7%, and20.6% in these 3 samples. A representative plot of one of thepatients is depicted in the eFigure in Supplement 2.

Transplantation ProcedureThe recipient site was prepared and dermabrasion was done un-til appearance of tiny pinpoint bleeding spots. The denuded areawas washed with PBS. The suspension of interest (NCES alone orNCES/NCDS) was carefully transferred to a tuberculin syringe.Using an 18-gauge needle, the suspension was placed over the de-nudedsurfaceandevenlyspread.Thiswascoveredwithameshedcollagen sheet (Kollagen M, Eucare Pharmaceuticals). After this,Bactigrasdressing(Smith&NephewPty,Ltd)wasplacedfollowedby an additional layer of small gauze piece moistened with PBS.Tegaderm(3MMedical)wasthenplacedandfinallyanelasticplas-ter (Dynaplast, Johnson & Johnson) was applied. The patientswere kept under observation for 1 hour and were subsequentlydischarged. The patients were followed up on day 8 and weeks4, 8, 16, and 24 after the transplantation procedure. No additionaltreatment was given during the follow-up period.

Outcome ParametersThe outcome parameters were extent of repigmentation, colormatching of repigmentation, and pattern of repigmentation. Theextent of repigmentation was assessed subjectively usingserial photographs taken in the same settings and objectivelyby serial paper markings and was categorized using the follow-ing criteria4: 25% or less repigmentation (minimal repigmen-

tation), 25% to 50% repigmentation (mild repigmentation), 51%to 75% repigmentation (moderate repigmentation), 76% to 90%repigmentation (marked repigmentation), and more than 90%repigmentation (excellent repigmentation). The color match-ing of repigmented skin to surrounding skin was done and cat-egorized as lighter color, same color, or darker color comparedwith the surrounding skin. Repigmentation pattern wasassessed and classified as diffuse, perifollicular, or marginal.11

Statistical AnalysisStatistical analysis was carried out using Statistical Package forSocial Sciences (SPSS; version, 22.0 for Windows; IBM Corp).Normalcy of continuous data was checked using Kolmogorov-Simrnov Test. Mean and standard deviation were calculated forall normally distributed continuous variables (eg, age, durationof disease, size of graft, and percentage body surface area [BSA]treated). Unpaired t test was used to compare means betweenstudy groups. χ2 or Fisher exact tests were used to comparecategorical variables.

ResultsBaseline Patient CharacteristicsBaseline clinical characteristics, operative sites, and mean sur-faceareaoperatedasdescribedinTable1werecomparableamongthe groups and subgroups. There were no statistically significantdifferences in the demographic characteristics (age, sex, durationof disease, and duration of clinical stability) between the 2 sub-groups of each group.

OutcomesAll patients completed 24 weeks of follow up. Comparisons ofextent of repigmentation, color matching, and repigmentationpatterns among the subgroups are summarized in Table 2. Withincreasing follow-up interval, a gradual increase in the extent ofrepigmentation was noted in both the groups. In group 1, the

Figure 1. Flowchart Depicting Study Protocol With Inclusion and Exclusion of Patients and Allocation of PatientsInto Groups and Subgroups

20 Randomized to group 1

20 Randomized to group 2

236 Patients with vitiligo screened for eligibility

24 Disease stability of 3-6 months 23 Disease stability >12 months

189 Excluded164 Did not fulfill inclusion

criteria25 Declined to participate

Exclusion criteriaPregnancy, koebnerization, hypertrophic scar

or keloidal tendencies, bleeding tendencies

3 Excluded2 Koebnerization1 Keloidal tendency

4 Excluded3 Koebnerization1 Keloidal tendency

10 Included in subgroup1A NCES

10 Included in subgroup1B NCES + NDCS

10 Included in subgroup2A NCES

10 Included in subgroup2B NCES + NDCS

Inclusion criteriaAge >18 years, disease stability of

3-6 months or more than 12 months,nonresponsive or partially

responsive to medical therapy

NCES indicates nonculturedepidermal suspension;NDCS, noncultured dermalcell suspension.

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extent of repigmentation at each follow-up was significantlyhigher in patients of subgroup 1B compared with those in sub-group 1A (Figure 2). At the end of 24 weeks, more than 75%repigmentation was observed in all the 10 patients of subgroup1B compared with 3 patients in subgroup 1A (100% vs 30%,P = .003). In group 2, the extent of repigmentation was compa-rable in both the subgroups at all the follow-up visits (Figure 3).

No significant difference in color matching was notedamong any of the subgroups. Most of the patients demon-strated a diffuse pattern of repigmentation. None of the pa-tients showed marginal pattern of repigmentation. Overall,there was no statistical significant difference in the pigmen-tation pattern among the subgroups.

ComplicationsOverall, the intervention was well tolerated in all the pa-tients. Superficial donor site infection was seen in 1 patient(subgroup 2A), which was treated successfully with topicalantibiotics. Mild hyperpigmentation or hypopigmentationat donor site was seen in 2 patients (1 each in subgroup 1A and2B). There were no complications at the recipient site. Post-surgery perilesional halo developed in a total of 8 patients.

DiscussionSince its introduction, the technique of NCES in treatingvitiligo has underwent multiple modific ations andsimplifications.12,13 The outcome of NCES in terms of repig-mentation rate has varied considerably in different studiesprobably owing to differences in duration of follow-up, dis-ease characteristics, method of assessment of repigmenta-tion, technique of preparation of the cell suspension, and post-operative treatment.12 A recent study14 that evaluated the novelcombination of follicular and epidermal cell suspension invitiligo found it to be superior compared with epidermal cell

suspension alone. In this study, we compared another novelcombination of NCES and NDCS with NCES alone in patientswith vitiligo. In patients with vitiligo with shorter DS (3-6months), the outcome of NCES and NDCS was excellent interms of repigmentation rate and was also significantly supe-rior to NCES. Whereas in vitiligo patients with longer DS (>12months), the outcome of NCES and NDCS and NCES alone werecomparable in terms of repigmentation rate. The findings ofour study are encouraging and suggest that surgical interven-tions using the novel combination of NCES and NDCS can beused in vitiligo patients with shorter DS (3-6 months) withoutwaiting for 12 months or more since last clinical activity.

No significant difference in terms of color matching and pat-terns of repigmentation was observed with both the techniquesin either of the groups. Most patients showed a diffuse patternof repigmentation, few showed a perifollicular pattern, and noneshowed a marginal pattern of repigmentation. It is noteworthythat perifollicular or marginal pattern of repigmentation isobserved when the repigmentation is owing to stimulation ofmelanocyte reserves in hair follicles, which occurs after derm-abrasion and phototherapy.4 Predominantly diffuse pattern ofrepigmentation observed in our study suggests that the cause ofrepigmentationwastransplantationofmelanocytesbyNCESandnot the induction of the melanocyte reserve by dermabrasion.In previous studies on vitiligo surgery as well, diffuse pattern wasthe most commonly observed pattern.4

Table 1. Clinico-Epidemiological Characteristics of Patients

CharacteristicGroup 1 Group 21A (n = 10) 1B (n = 10) 2A (n = 10) 2B (n = 10)

Age, mean (SD), y 25.6 (4.24) 25.3 (3.86) 25.5 (3.89) 23.2 (4.23)Sex, No. (%)

Males 5 (50) 4 (40) 6 (60) 1 (10)Females 5 (50) 6 (60) 4 (40) 9 (90)

Duration, mean (SD)Disease, y 6.45 (6.98) 5.5 (4.03) 8.6 (3.74) 12.3 (5.73)Stability, mo 4.6 (0.51) 4.5 (0.70) 45.6 (32.8) 58.8 (52.2)

Vitiligo subtypeVulgaris 1 1 3 2Acrofacial 3 6 5 3Segmental 6 3 2 5

Hands and feet 4 2 3 5Arms and legs 2 2 2 0Trunk 2 2 2 4Face 2 4 3 1Surface areatreated,mean (SD), cm2

43.7 (13.8) 47.4 (20.7) 42.0 (16.9) 48.2 (16.7)

Abbreviation: SD, standard deviation.

Table 2. Number of Patients in Each Subgroup According to Extentof Repigmentation, Degree of Color Matching, and Patternof Repigmentation in Each Subgroup at Follow-up Visits

Categoriesof Extent ofRepigmentationat EachFollow-up Visit

Patients According to Extent of Repigmentation, No.

Subgroup1A(NCES)(n = 10)

Subgroup1B(NCES/NDCS)(n = 10)

PValue

Subgroup2A(NCES)(n = 10)

Subgroup2B(NCES/NDCS)(n = 10)

PValue

4 wk, %

<25 8 1

.005

6 7

>.99

26-50 2 8 3 3

51-75 0 1 1 0

76-90 0 0 0 0

>90 0 0 0 0

24 wk, %

<25 0 0

.002

0 0

.29

26-50 1 0 2 0

51-75 6 0 2 3

76-90 2 2 2 5

>90 1 8 4 2

Degree of color matching

24 wk

Lighter 0 0

.47

0 1

.63Same 8 10 8 6

Darker 2 0 2 3

Pattern ofrepigmentation

Diffuse 9 7

.58

8 9

>.99Perifollicular 1 3 2 1

Marginal 0 0 0 0

Abbreviations: NCES, noncultured epidermal cell suspension;NDCS, noncultured dermal cell suspension.

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The results of our study can probably be explained by thefindings of Rao et al5 and Zhou et al.10 Rao et al5 found a signifi-cantly higher lesional CD8+ T-cell count in patients with vitiligowith shorter DS (3-12 months) compared with those with longerDS (>12 months). They also observed higher number of lesionalCD8+ T cells in patients having poor repigmentation after mel-anocyte transplantation compared with those with favorablerepigmentation, concluding that activity of cytotoxic CD8 cellsin vitiligo lesions may be responsible for inferior posttransplantoutcome. Zhou et al10 studied the factors influencing efficiencyof autologous melanocyte transplantation in patients with vit-iligowhilefocusingonperilesionalskinCD8+ Tlymphocytes,andinvestigated the potential effects of dermal mesenchymal cells(DMCs) on CD8+ T-cell activity in vitro. Their patients with a highnumber of perilesional CD8+ T cells showed poor rate of repig-mentation. When cocultured, DMCs induced apoptosis andinhibited proliferation of CD8+ T cells, which, they concluded,may enhance the efficacy of melanocyte transplantation.

In terms of extent of repigmentation (primary outcome),the response in subgroup 1B was significantly better than sub-group 1A at every follow-up visit. At 24 weeks’ follow-up, 100%patients (10/10) achieved more than 75% repigmentation insubgroup 1B, which was significantly higher compared with sub-group 1A (3/10, 30%). However, in group 2 (duration of disease

stability more than 1 year), degree of repigmentation at 24 weekswas comparable in subgroups 2A and 2B. These findings sug-gest that there is significant benefit of addition of dermal cellsto the epidermal cell suspension in vitiligo patients with 3 to 6months DS but not in patients with DS more than 1 year.

Higher number of lesional CD8+ T-cells population inpatients of group 1 (shorter duration of clinical stability), mayhave resulted in the difference in extent of repigmentation inpatients who underwent NCES and NDCS compared with thosewho underwent NCES alone. Dermal mesenchymal cells or otherdermal components from NDCS probably have inhibited theactivity of cytotoxic T cells in subgroup 1B leading to better ac-ceptance of transplantation while unabated activity of CD8+ Tcells in subgroup 1A may have destroyed melanocytes in trans-planted NCES thus resulting in poorer repigmentation. In group2 (patients with longer DS), lower number of CD8+ T cells couldhave resulted in relatively better repigmentation result in boththe subgroups with no significant difference.

Singh et al4 in their study reported that 92% of their patientsexhibited more than 75% repigmentation after NCES; however,mean area treated in their study was much less than in our study.In another study by Bao et al,15 81% of the patients showed morethan 50% repigmentation following NCES method. Thus, thedegree of repigmentation achieved in our subgroup 2A (NCES in

Figure 2. Comparative Photographs of Study Participants at Presentation and at 24 Weeks’ Follow-upFollowing the Procedures in Subgroups 1A and 1B

Postoperative clinical image NCES/NDCSDPreoperative clinical image NCES/NDCSC

Postoperative clinical image NCESBPreoperative clinical image NCESA

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patients with duration of stability >1 year) is comparable toother previous reports.

It may be logical to compare the results of our study, particu-larly subgroups 1B and 2B, with previous studies that have evalu-ated the technique of minipunch grafting in vitiligo patients

becausepunchgraftscontainboththedermalandepidermalcom-ponent from the nonlesional area. Malakar et al16 reported morethan 70% repigmentation in 83% of patients with vitiligo with DSlonger than 6 months after minipunch grafting, which is compa-rable to more than 75% repigmentation in 70% of the subgroup2B patients and 100% of the patients in subgroup 1B. Almostevery patient in the study by Malakar et al16 was subjected toadditional PUVASOL therapy after surgery, which may haveimproved the outcome. Boersma et al,17 who performed mini-punch grafting in vitiligo patients with DS longer than 6 monthsreported more than 80% repigmentation in only 39% of lesions.

LimitationsBecause our trial was a pilot study with a follow up of 24 weeks,a small sample size and relatively short follow up were the ma-jor limitations. Prior sample size estimation was not performedbecause this was the first study evaluating NCES and NDCS. Theprocess of postsurgery repigmentation may proceed well beyond24 weeks, implying that longer follow up in participants may leadto different results. However, most of the previous studies on vit-iligo surgery had similar sample sizes and follow-up period.4,14,18

ConclusionsOur study suggests that NCES and NDCS is an effectiveapproach and superior to NCES alone in patients with vitiligowith DS ranging from 3 to 6 months. This novel approach (NCESand NDCS), may be used in patients with vitiligo early in thecourse of stable disease without waiting for 12 months or moreto elapse since last clinical activity. Future studies with lon-ger follow up and larger sample size are warranted to monitorthe long-term stability of achieved repigmentation, to estab-lish the efficacy of this novel approach and further investi-gate the implication of DMCs in patients with active vitiligo.

ARTICLE INFORMATION

Accepted for Publication: November 5, 2018.

Published Online: January 2, 2019.doi:10.1001/jamadermatol.2018.4919

Author Contributions: Drs Thakur and Parsad hadfull access to all of the data in the study and takeresponsibility for the integrity of the data and theaccuracy of the data analysis.Study concept and design: Thakur, Kumar, SendhilKumaran, Srivastava, Parsad.Acquisition, analysis, or interpretation of data:Thakur, Kumar, Kaushik, Srivastava, Parsad.Drafting of the manuscript: Thakur, Kumar,Kaushik, Srivastava, Parsad.Critical revision of the manuscript for importantintellectual content: Thakur, Kumar, SendhilKumaran, Srivastava, Parsad.Statistical analysis: Thakur, Kumar, Parsad.Administrative, technical, or material support:Thakur, Srivastava, Parsad.Study supervision: Thakur, Sendhil Kumaran,Parsad.

Conflict of Interest Disclosures: None reported.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank the patientsfor granting permission to publish this information.

REFERENCES

1. Das SK, Majumder PP, Chakraborty R, MajumdarTK, Haldar B. Studies on vitiligo. I. Epidemiologicalprofile in Calcutta, India. Genet Epidemiol. 1985;2(1):71-78. doi:10.1002/gepi.1370020107

2. Behl PN, Bhatia RK. 400 cases of vitiligo.A clinico-therapeutic analysis. Indian J Dermatol.1972;17(2):51-56.

3. Budania A, Parsad D, Kanwar AJ, Dogra S.Comparison between autologous nonculturedepidermal cell suspension and suction blisterepidermal grafting in stable vitiligo: a randomizedstudy. Br J Dermatol. 2012;167(6):1295-1301. doi:10.1111/bjd.12007

4. Singh C, Parsad D, Kanwar AJ, Dogra S, Kumar R.Comparison between autologous nonculturedextracted hair follicle outer root sheath cellsuspension and autologous noncultured epidermalcell suspension in the treatment of stable vitiligo:a randomized study. Br J Dermatol. 2013;169(2):287-293. doi:10.1111/bjd.12325

5. Rao A, Gupta S, Dinda AK, et al. Study of clinical,biochemical and immunological factorsdetermining stability of disease in patients withgeneralized vitiligo undergoing melanocytetransplantation. Br J Dermatol. 2012;166(6):1230-1236. doi:10.1111/j.1365-2133.2012.10886.x

6. van den Boorn JG, Konijnenberg D, Dellemijn TA,et al. Autoimmune destruction of skin melanocytesby perilesional T cells from vitiligo patients. J InvestDermatol. 2009;129(9):2220-2232. doi:10.1038/jid.2009.32

7. Wańkowicz-Kalińska A, van den Wijngaard RM,Tigges BJ, et al. Immunopolarization of CD4+ andCD8+ T cells to Type-1-like is associated withmelanocyte loss in human vitiligo. Lab Invest. 2003;83(5):683-695. doi:10.1097/01.LAB.0000069521.42488.1B

8. Nauta AJ, Fibbe WE. Immunomodulatoryproperties of mesenchymal stromal cells. Blood.2007;110(10):3499-3506. doi:10.1182/blood-2007-02-069716

9. Plumas J, Chaperot L, Richard MJ, Molens JP,Bensa JC, Favrot MC. Mesenchymal stem cellsinduce apoptosis of activated T cells. Leukemia.2005;19(9):1597-1604. doi:10.1038/sj.leu.2403871

Figure 3. Comparative Photographs of Study Participantsat Presentation and at 24 Weeks’ Follow-up Following the Proceduresin Subgroups 2A and 2B

Preoperative clinical imageNCES

A Postoperative clinical image NCESB

Preoperative clinical imageNCES/NDCS

C Postoperative clinical image NCES/NDCSD

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© 2019 American Medical Association. All rights reserved.

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10. Zhou MN, Zhang ZQ, Wu JL, et al. Dermalmesenchymal stem cells (DMSCs) inhibitskin-homing CD8+ T cell activity, a determiningfactor of vitiligo patients’ autologous melanocytestransplantation efficiency. PLoS One. 2013;8(4):e60254. doi:10.1371/journal.pone.0060254

11. Mohammad TF, Hamzavi IH. Surgical Therapiesfor Vitiligo. Dermatol Clin. 2017;35(2):193-203.doi:10.1016/j.det.2016.11.009

12. van Geel N, Goh BK, Wallaeys E, De Keyser S,Lambert J. A review of non-cultured epidermalcellular grafting in vitiligo. J Cutan Aesthet Surg.2011;4(1):17-22. doi:10.4103/0974-2077.79181

13. Gauthier Y, Surleve-Bazeille JE. Autologousgrafting with noncultured melanocytes: a simplifiedmethod for treatment of depigmented lesions.

J Am Acad Dermatol. 1992;26(2 Pt 1):191-194. doi:10.1016/0190-9622(92)70024-A

14. Razmi T M, Kumar R, Rani S, Kumaran SM,Tanwar S, Parsad D. Combination of follicular andepidermal cell suspension as a novel surgicalapproach in difficult-to-treat vitiligo: a randomizedclinical trial. JAMA Dermatol. 2018;154(3):301-308.doi:10.1001/jamadermatol.2017.5795

15. Bao H, Hong W, Fu L, Wei X, Qian G, Xu A.Blister roof grafting, cultured melanocytestransplantation and non-cultured epidermal cellsuspension transplantation in treating stablevitiligo: A mutual self-control study. J DermatologTreat. 2015;26(6):571-574. doi:10.3109/09546634.2015.1034068

16. Malakar S, Dhar S. Treatment of stable andrecalcitrant vitiligo by autologous miniature punchgrafting: a prospective study of 1,000 patients.Dermatology. 1999;198(2):133-139. doi:10.1159/000018089

17. Boersma BR, Westerhof W, Bos JD.Repigmentation in vitiligo vulgaris by autologousminigrafting: results in nineteen patients. J AmAcad Dermatol. 1995;33(6):990-995. doi:10.1016/0190-9622(95)90292-9

18. Mohanty S, Kumar A, Dhawan J, Sreenivas V,Gupta S. Noncultured extracted hair follicle outerroot sheath cell suspension for transplantation invitiligo. Br J Dermatol. 2011;164(6):1241-1246. doi:10.1111/j.1365-2133.2011.10234.x

Research Original Investigation Transplantation of Combination of NCES and NDCS vs Epidermal Cell Suspension Alone in Vitiligo

210 JAMA Dermatology February 2019 Volume 155, Number 2 (Reprinted) jamadermatology.com

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