Our Treatment Strategies
Individualized Treatment
At MelanoSite, we take an individualized approach to the management of vitiligo, considering various factors such as the type of vitiligo, the stage of vitiligo, the extent of vitiligo, and the individual characteristics of the patient. We understand that each patient is unique and their treatment option should be individualized to their specific aspects.
In addition to considering the disease aspects of vitiligo, we also take into account the patient’s age, lifestyle, stress levels, psychosocial aspects, familial and personal responsibilities, and commitments. We believe that addressing these factors is crucial in providing comprehensive care and achieving successful outcomes.
By considering all these parameters, we can develop an individualized treatment approach that is specifically planned for each patient. Our goal is to provide the best possible care and support to our patients, helping them to manage their vitiligo and improve their quality of life
Patient Evaluation
This is the initial step in diagnosing and treating vitiligo. A thorough medical history is taken to know various patient and vitiligo parameters which help in individualizing the treatment. Photographs under normal light and special blue light taken to analyse and diagnose. A panel of tests known as the Vitiligo Panel of Tests is conducted to identify specific parameters in the blood that play a role in the development and progression of vitiligo. These tests help us understand the underlying causes of the condition. Based on these we can focus on corrective treatments. This targeted approach aims to address the root causes of vitiligo and promote effective and individualised treatment.
Aim Of Treatment
At our Centre we help patients to transform a phenotype (appearance of white patches due to genetic defects +inducing factors) to a genotype (no white patch due to the targeted management of inducing factors but you will be having the genetic defect which will be dormant).
Since there is no specific way for eliminating genotype especially in vitiligo, one needs to focus on maintaining it as genotype with out manifesting in to phenotype.
Efforts to treat or manage the condition that causes the loss of skin pigment (melanocytes) can involve various approaches. These include:
1. Reducing or eliminating immune cells that attack melanocytes.
2. Safeguarding against autoimmunity or preventing an overactive immune system from producing these harmful immune cells.
3. Lowering the production of harmful free radicals.
4. Enhancing the body’s ability to neutralize free radicals.
5. Stimulating the cells in a gentle and effective manner to promote the growth and movement of melanocytes to the areas without pigment. However, this requires a reservoir of cells, such as those found at the edges of the affected area or the roots of black hair, as well as stem cells that can differentiate into melanocytes when necessary.
6. If the reservoir of cells is depleted, replenishment can be achieved through cellular transplantation.
7. Maintaining positive outcomes through lifestyle changes, dietary adjustments, and general skincare practices, among other measures.
4 Phases of Treatment
1. Stabilization or Arresting Phase
Stabilizing the spreading vitiligo is main step in the treatment. During this phase of treatment, the main focus is on stabilizing the spreading of vitiligo. The goal is not to bring back color to the affected areas at this point. It is important to understand that immune cells target and attack melanocytes, the cells responsible for producing pigment in the skin. If we try to increase the number of melanocytes while immune cells are still present, they will continue to be targeted and killed.
The first step in this phase is to remove the immune cells that are killing the melanocytes. Additionally, any deficiencies or imbalances in the patient’s blood will be addressed and treated. This helps to create a more favorable environment in the affected patches, eliminating the hostile conditions.
The next goal is to create a suitable condition for the melanocytes to proliferate and migrate, resulting in repigmentation of the white patches once stability is achieved . This phase typically lasts for a duration of 6 weeks to 3 months.
The main measures during this phase of treatment include:
1. Immunomodulation and Immunosuppression: This involves methods that focus on reducing /stopping immune-mediated cell death, aiming to regulate the immune response and reduce the attack on melanocytes.
2. Increased Cell Survival or Decreased Cell Death: By correcting any deficiencies and removing toxins, the hostility in the affected areas is reduced. This creates a more favorable environment for the survival and proliferation of melanocytes, ultimately leading to repigmentation.
2. Pigmentation Phase
During this phase , medications of the first stage will continue to be administered but some will be gradually phased out over time. The goal will be to stimulate melanocyte reservoirs in order to promote repigmentation. Harsh medications like psoralens that induce blistering, burning or deplete cellular reservoirs will be avoided. Most patients are offered either clinic based NBUVB phototherapy(whole body and or targeted phototherapy) or narrowband UVB light treatment at home or mild sun exposure . The clinic based phototherapy (whole body and or targeted phototherapy) has been shown to be more effective. The home based phototherapy is considered better than sun exposure but proven inferior to clinic based light therapy. This phase of treatment typically spans from three to nine months.
In addition to medications and phototherapy, slow-responding areas may be treated with microneedling enhanced with growth factors or cellular suspensions, in order to further encourage repigmentation.
Pigmentation can be achieved through the following methods:
1. Increased cell survival through nutrition and antioxidant means.
2. Consistent but safe stimulation of the reservoir cells (such as stem cells, hair root cells, and neighboring cells located at the borders of the affected area)
3. Better migration and division of pigment cells within the white patch.
4. Release of beneficial chemicals from structural cells (keratinocytes) that sustain newly developed pigment cells.
5. Continued regulation of the hyperactive immune response and decreased rates of cell death to allow pigment cells to persist long-term.
3. Refractory phase
For patients who do not achieve repigmentation from medical treatments and have stable vitiligo patches, cellular transplantation may be considered. The decision to pursue transplantation would typically be made between 6 to 18 months after initiating stabilization. Those without an active reservoir or having a depleted reservoir would be considered as refractory cases. Cellular transplantation can replenish lost melanocytes but plays a minimal role in addressing underlying causes. Close monitoring is recommended post-transplantation to determine effectiveness and watch for any signs of recurrence. Overall success depends on intervention at right time, stability period, the extent of lesions, and individual’s response to procedure. A combination with medical managements along with surgery generally provides the best outcome.
Ideal cell transplantation should achieve the following objectives to achieve better results:
1. Cell Replenishment: Substituting altered keratinocytes. Vitiligo is no longer solely a disorder of melanocytes. Over time, it results in modifications of keratinocytes (the building blocks of skin) which no longer require melanocytes. Melanocytes produce color known as melanin, which is transferred to multiple keratinocytes, protecting them from UV damage (sun damage). Once keratinocytes forced to live without melanin and melanocytes, they adapt to live without color and protect themselves from UV damage by other alternate means. As a result, they do not release any distress signals requesting the presence of melanocytes or nurture nearby color-producing cells. To change this situation, one needs to replace the existing clone of adapted keratinocytes with a new clone of cells from elsewhere still requiring melanocytes for their survival.
2. Cell Replacement: One must also replenish lost melanocytes. We can acquire a fresh clone of melanocytes from a donor site and place them at the precise skin level where melanocytes reside.
3. Cell Proliferation and Migration: Regardless of whether the cells are keratinocytes or melanocytes, one can only transplant a limited number initially. In the early stages, they do not spread uniformly across the entire grafted area. Achieving satisfactory pigmentation requires a threshold number of melanocytes, relying on their proliferation (increased numbers) and migration. The cell transplantation technique should focus on achieving better cell proliferation and migration.
4. Stem Cell Advantage: Stem cells present in the cell suspension should provide advantages of regeneration and immunomodulation. Regeneration assists with replacement and replenishment via respective precursor cells. Immunomodulation prevents attack from immune cells, which can destroy the vulnerable transplanted cells and also hinder their proliferation and migration. These advantages are crucial to achieve faster results and long-lasting good outcomes. This also achieves satellite repigmentation of untreated patches in some cases.
5. Other Factors: Collagen remodeling is also very important. Good fibroblasts in quality and quantity are needed to accomplish proper color and texture matching post-transplantation. The biggest challenge is treatment modified vitiligo, where repeated ineffective past treatments overstimulating reservoirs, damage the middle skin layer (where fibroblasts reside). When conducting transplants on these patches, mismatches in color and texture occur. Similar results happen with corrective transplants done over previously messed up and improper surgeries. Melanocyte detachment due to factors like the presence of MIA (Melanoma Inhibitory Antigen) could also cause pigment cell loss following the procedure. Our transplantation procedure largely addresses both concerns.
4. Maintenance Phase
Once recovered patients require minimal medications to maintain disease free status but lifestyle changes, dietary restrictions, and general skincare measures should be continued. Those who have achieved maximal pigmentation due to an intact reservoir of pigment-producing cells or cell precursors or transplantation of cells from elsewhere, we have maintenance phase. Patients will also undergo follow up testing once every 3-6 months to ensure there are no deficiencies or derangements that could contribute to disease recurrence.
The duration and sequencing of treatment phases will be Individualized to each patient’s individual needs and response to therapy. Not all phases may be required for every patient. The decision based on the clinical acumen of the treating vitiligo specialist.