Stabilizing the spreading vitiligo is the primary step in the treatment. We don’t try to bring back color in this case. One has to know that melanocytes are the primary aim for the immune cells. So if there are immune cells nearby a white patch, if we expand the number of melanocytes, they will eventually be killed by immune cells. First, we have to kill those killing cells and treat patients to Patients deficiencies and derangements in the blood. It will excrete a hostile atmosphere in the patch and produces a suitable condition for cells to migrate and proliferate and so that the white patches re pigment in the next stage. Duration will be six weeks to 3 months.
In this phase, the main aim will be to stop the progression of the vitiligo through the following measures
- Immunomodulation and Immunosuppression
- Methods will focus on immune-mediated cell death.
- Increased Cell Survival or Decreased Cell Death
- Decreased hostility with established favourable conditions will achieve this by improving the and scavenging and deficiencies of the toxins
In the first stage, therapy for vitiligo will remain, but some of the medicines are phased out constantly. We will try to excite melanocyte reserves to get re-pigmentation. We don’t prefer harsh drugs which induce blistering, burn, and exhaust the cell repository. We usually offer either mild sun exposure or home-based NBUVB exposure (which is more effective and powerful). This stage will cross from 3 months to 9 months.
Besides medications and phototherapy, we do micro-needling improved either with cells or growth factors in gradual responding patches.
Pigmentation is achieved by following methods
- Improved Cell Survival.
- Compatible but safer stimulation of store ( hair root cells, and neighboring cells in the edges of the patch)
- Improved division and migration of pigment cells.
- Release of good substances by making blocks (keratinocytes), which will provide new pigment cells
- Endured immunomodulation and reduced cell death.
One could go for cellular transplantation for those who don’t pigment with medicines, and their patches are stable. The choice for transplantation will be held at six months to 18 months of the initiation of arresting phase. In those who don’t have a reservoir or depleted reservoir, we have to treat them in the refractory stage. Cellular transplantation replenishes lost cells but has a very minimal role in tackling underlying causes.
Ideal cell transplantation should achieve the following things to achieve better results.
Replacement of fixed Keratinocytes. Vitiligo is no longer a disease of Melanocytes. Over time it results in modifications of keratinocytes (building blocks of skin) which no longer need Melanocytes. Melanocytes produce color, melanin transferred to several keratinocytes, and this melanin protects keratinocytes from UV damage (sun damage). Once keratinocytes need to live without melanin and melanocytes, they adapt to live without color and defend themselves from UV damage. So, they don’t deliver any distress substances, which require the presence of melanocytes and nurture the color-producing cell near keratinocytes. To improve this situation, one needs to replace the existing clone of adapted keratinocytes with a new clone of cells from elsewhere that need melanocytes to survive.
One needs to replenish lost melanocytes. We can get a fresh clone of melanocytes from the donor site and place them in the exact level of the skin where melanocytes remain.
Cell migration and Proliferation:
Whether it is melanocyte or keratinocyte, one can place only a limited number of cells. For the first time, they don’t scatter evenly over all over the patch post-transplantation. One must have an inception number of melanocytes to deliver good pigmentation. Migration and proliferation (Increase in numbers) of transplanted cells are required to deliver better results. The cell transplantation procedure should concentrate on producing better cell migration and proliferation.
Collagen remodelling is significant. Suitable Fibroblasts in quality and quantity needed to achieve proper colour and texture match post-transplantation. The biggest challenge is modified vitiligo, where repeated ineffective treatments try to stimulate over store damage to the middle layer of skin (where fibroblasts remain). When transplantation is done on these patches, color and texture mismatch occurs. The same result happens in corrective transplantation procedures done over previously blotched-up wrong surgeries. Melanocyte detachment due to reasons like the presence of MIA (Melanoma Inhibitory Antigen) could be a factor to lose the pigment cells after the procedure. Our transplantation procedure, to an excellent extent, addresses both the concerns.
Patients will have minimum medicines but have to follow lifestyle alterations, dietary limitations, and overall skincare measures. It is for patients who deliver maximum pigmentation because of the entire repository of cells or parents of cells. The patient is also asked to undergo follow-up examinations once every 3-6 months to make sure that they don’t have any derangements (contributing to disease onset) and deficiencies.
But, the duration of the phases or skipping of certain stages is done according to the patient’s need.