In this episode of Topical Conversations, Naiem Issa, MD, PhD, explores the use of microneedling as a promising approach to facilitate repigmentation in patients with vitiligo. 

Looking beyond topical anti-inflammatory agents in challenging cases 

After months or years of treatment, vitiligo may reach a stable phase or burn out, rendering topical anti-inflammatory agents, such as ruxolitinib, tacrolimus, and pimecrolimus, and topical and oral corticosteroids, ineffective in promoting repigmentation. Dr Issa emphasizes the need to shift focus towards melanocyte or melasome regeneration in these cases. 

Identifying melanocyte reservoirs: three key locations 

In these challenging cases, Dr Issa emphasizes the need to allow for melanocyte or melanosome regeneration and repigmentation. 

Melanocyte stem cell niches and reservoirs are pivotal for repigmentation, utilizing chemotaxis to enter vitiliginous lesions to begin proliferating and dropping pigment through melanosome generation. 

Dr Issa highlights 3 primary locations where stem cell niches are found: 

• The hair follicle bulge: in the bulge, stem cells can awaken through a number of inflammatory cytokines, called the cytokine milieu, to grow, divide, and mature into melanocytes and migrate into vitiliginous lesions 
• The outer edges of vitiliginous patches: with an active lesion, some melanocytes may persist at the rim 
• The dermal papillae: some melanocytes and melanocyte precursors may be present below the epidermis; this is typically found on acral sites such as the hands and feet, which are often more difficult to repigment 

The role of microneedling: repigmentation stimulation 

Microneedling, utilizing controlled wounds typically ranging from 1.5 to 2.5 millimeters in depth, serves 2 crucial purposes in vitiligo therapy: 

• Enhanced medication delivery: By creating microchannels, microneedling facilitates the effective delivery of medications, including topical anti-inflammatories and agents promoting regeneration like bimatoprost 
• Proinflammatory milieu activation: The process triggers an increase proinflammatory milieu, involving cytokines such as platelet-derived growth factors and TNF beta. These signals jump-start the melanocyte and melanosome reservoirs, fostering an environment conducive to repigmentation 

Clinical insights: microneedling techniques 

Dr Issa shares his experience with microneedling using the skin pen, detailing a technique that uses it on the lesion itself and also extends use 1 cm beyond the vitiliginous lesion to maximize melanocyte recruitment and increase the chances of successful repigmentation. 

As a cost-effective alternative, Dr Issa highlights cases where manual microneedling, using an 18 or 20 gauge needle, has yielded impactful results at low cost. 

Microneedling as a viable step in vitiligo repigmentation 

Microneedling has emerged as a promising step in the therapeutic ladder for patients with vitiligo who have exhausted traditional treatments. By harnessing controlled wounds and activating a proinflammatory milieu, microneedling opens new avenues for repigmentation.