الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
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Abstract
There are several surgical modalities for treatment of stable vitiligo such as tissue grafting in the form of suction blister grafts, split-thickness grafts, autologous punch grafts, follicular unit grafts and cellular grafting as melanocyte keratinocyte transplantations. Follicular unit extraction (FUE) grafting is a surgical procedure which provides the vitiliginous patches with undifferentiated stem cells of the hair follicles. There are many advantages of this procedure in terms of treatment response and the high safety profile. The present study was carried out at the Department of Dermatology, Venereology and Andrology, Assiut University Hospitals, Assiut, Egypt during the period from February 2017 till March 2019. The study included 53 patients with 94 lesions with stable non segmental vitiligo. The age of the patients ranged from 10-55 years. 42 (79.2%) patients were females. 19 (35.8 %) patients were skin phototype III and 34 (64.2%) patients were skin phototype IV. Disease duration ranged from 1.0-22.0 years. Size of treated lesions ranged from 0.3-25.0 cm2. The most common treated sites were the legs (26.6%), feet (16.0%) followed by forearms (10.7%), elbows and knees (9.5% for each). All patients were treated with follicular unit extraction (FUE) grafting technique. Patients were divided into three groups: group 1 (16 patients with 30 lesions were treated by FUE grafting alone), group 2 (18 patients with 32 lesions who were treated by FUE grafting and topical betamethasone- calcipotriol ointment twice daily for 4 months) and group 3(19 patients with 32 lesions were treated by FUE grafting and NB-UVB phototherapy twice weekly for 4 months). Postoperative assessment of the treatment responses was done by evaluating the onset of repigmentation in weeks, grades of repigmentation, color match, percentage of size reduction and dermoscopic evaluation of perifollicullar pigment spread as well as patterns of repigmentation during the follow up periods of 2 and 4 months. Skin biopsies were taken from perilesional areas from 25 patients (7 patients in group 1, 11 patients in group 2 and 7 patients in group 3) by using punch biopsy (2.5 mm). Two biopsies were taken, the first one (baseline) on the day of transplantation and the second one 4 months after treatment for histopathological assessment and immunohistochemical evaluation of CD8+t lymphocytes. Among group 1, initial repigmentation was observed at 3 weeks in 6.2% of lesions and at 4 weeks in 62.5 % of lesions. Merge of repigmentation was noted in 33.34% of lesions. After 4 months, excellent repigmentation was reported in 33.3% of lesions, good repigmentation in 23.3% of lesions and fair repigmentation in 13.3% of lesions. Regarding color match, after 4 months, excellent color match was detected in 23.3% of lesions and good color match in 63.3% of lesions. The mean percent of size reduction among all the treated lesions of group 1 was 52.43% after 4 months and a 75-100% size reduction was noticed in 33.3% of lesions. Better treatment response was achieved after 4 months of treatment than after 2 months by using all methods of assessment except color match among lesions of group 1. While in group 2, initial repigmentation was observed at 2 weeks in 16.7% of the lesions and at 3 weeks in 33.3% of the lesions. Merge of repigmentation was noted in 56.25% of lesions. After 4 months, excellent repigmentation was reported in 43.8% of lesions, good and fair repigmentation in 25.0% of lesions each. Regarding color match, after 4 months, excellent color match was in 75% of lesions and good color match in 18.8% of lesions. The mean percent of size reduction among all the treated lesions of group 2 was 64.56% and a 75-100% size reduction was noticed in 46.9% of lesions. Also, better treatment response was achieved after 4 months of treatment than after 2 months by using all methods of assessment except color match among lesions of group 2. In group 3, initial repigmentation was observed at 2 weeks in 10.5% of lesions and at 3 and 4 weeks in 26.3% and 31.6% of lesions respectively. Merge of repigmentation was noted in 43.75 of lesions. After 4 months, excellent repigmentation was reported in 34.4% of lesions and good repigmentation in 31.3% of lesions. Regarding color match, after 4 months, excellent color match was noted in 53.1% lesions and good color match in 28.1% of lesions. The mean percent of size reduction among all the treated lesions of group 3 was 47.95% and a 75-100% size reduction was in 15.6% of lesions. Also, better treatment response was achieved after 4 months of treatment than after 2 months by using all methods of assessment except color match among lesions of group 3. Comparing the 3 groups, the fastest onset of repigmentation was observed in both groups 2 and 3 in the second week (16.7%, 10.5%, respectively) and in the third week in 6.2% of lesions group 1. Grades of repigmentation are not sensitive; we could not detect any significant difference in grades of repigmentation between the 3 studied groups at the end of 4 months. Regarding color match, a statistically significant difference in color match was found between groups 2 and 3 versus group 1 (p= 0.000 and p = 0.018, respectively). A statistically significant difference in the mean percent of size reduction of treated areas between group 2 and 3 after 4 months of treatment (p= 0.041). By using all methods of assessment, group 2 had the best treatment response of the 3 studied groups. Our results indicate that site and stability duration have no significant effect on treatment outcome when FUE grafting is used as the main therapeutic intervention. Dermoscopic evaluation of the pattern of repigmentation among the all treated lesions revealed perifollicular diffuse pigmentation as the commonest pattern of repigmentation in 63.8% of treated lesions, perifollicular minimal repigmentation in 22.3% of lesions, perifollicular reticular repigmentation in 8.5% of lesions and perifollicular diffuse repigmentation with patchy hyperpigmentation in 5.3% of lesions. group 2 has achieved the highest percent of perifollicular diffuse pigmentation as well as perifollicular diffuse pigmentation with patchy hyperpigmentation in 75.0 %, 9.4%, respectively. Perifollicular pigment spread was also evaluated by the aid of dermoscopy. The mean perifollicullar pigment spread among all treated lesions was 2.48 mm after 4 months and group 2 achieved the highest value of perifollicullar pigment spread followed by group 3 and lastly group 1. Regarding immunohistochemical evaluation of perilesional skin biopsies, there was a statistically significant decrease in perilesional CD8+T lymphocytes expression among the all treated lesions after 4 months of treatment ( p= 0.000) as well as in each of the 3 groups. Also, we found a statistically significant negative correlation between the number of CD8 +T cells after treatment and the percent of size reduction in treated areas among the all 25 treated patients as well as among patients of groups 1 and 2. Our reported complications at the recipient site were folliculitis in 3 (3.2%) lesions, inclusion cyst in 2 (2.1%) lesions, cobblestone appearance in 2 (2.1%) lesions and koebnerization in 3 (4.2%) lesions after 4 months. No donor site complications were reported among the all studied patients.