(FCS). Hair follicles have a better melanocyte-keratinocyte ratio
and have the advantage of various stem cells with melanogenic
properties. However, the repigmentation outcome of FCS is only
comparable or slightly inferior to that of ECS. Recently, a newer
approach using a combination of ECS and FCS showed better
repigmentation outcome compared to ECS even in difﬁcult-to-
treat vitiligo (Table 1).
It is noteworthy that various modiﬁcations have simpliﬁed the
procedure of ECS. Kumar et al.
proposed the “four compart-
ment method”, and Gho et al.
described the “6-well plate” tech-
nique to address the same. Similarly, ReCell
London, U.K.) is an automated cell harvesting device that obvi-
ates the need for a research laboratory for preparation of cell
In summary, contrary to the conclusion drawn by the authors
of the review, the evidence for the efﬁcacy and safety of MKTP is
robust. It is one of the treatments of choice for stable vitiligo
patches that fail to repigment with different medical modalities.
The use of various terminologies for the cellular transplantation
methods in vitiligo surgery by different authors might have led to
the inadvertent omission of the above-mentioned clinical trials in
the review. Hence, it is important to enlist these synonyms as key
words for PubMed indexing or as search terms for literature
search in future clinical studies or literature reviews, respectively.
Muhammed Razmi T
Department of Dermatology, Venereology and Leprology,
Postgraduate Institute of Medical Education and Research,
Conﬂicts of interest: None.
1 Vakharia PP, Lee DE, Khachemoune A. Efﬁcacy and safety of
noncultured melanocyte-keratinocyte transplant procedure for
vitiligo and other leukodermas: a critical analysis of the evidence.
Int J Dermatol 2018. https://doi.org/10.1111/ijd.13895
2 Barrett C, Whitton M. Interventions for vitiligo (protocol).
Cochrane Database Syst Rev 2001; Issue 2: Art. No.:
3 Kumar R, Parsad D, Singh C, et al. Four compartment method: a
simpliﬁed and cost-effective method of noncultured epidermal cell
suspension for the treatment of vitiligo. Br J Dermatol 2014; 170:
4 Goh BK, Chua XM, Chong KL, et al. Simpliﬁed cellular grafting
for treatment of vitiligo and piebaldism: the “6-well plate”
technique. Dermatol Surg 2010; 36: 203–207.
5 van Geel N, Ongenae K, De Mil M, et al. Double-blind placebo-
controlled study of autologous transplanted epidermal cell
suspensions for repigmenting vitiligo. Arch Dermatol 2004; 140:
6 Sahni K, Parsad D, Kanwar AJ, et al. Autologous noncultured
melanocyte transplantation for stable vitiligo: can suspending
autologous melanocytes in the patients’ own serum improve
repigmentation and patient satisfaction? Dermatol Surg 2011; 37:
7 Budania A, Parsad D, Kanwar AJ, et al. Comparison between
autologous noncultured epidermal cell suspension and suction
blister epidermal grafting in stable vitiligo: a randomized study. Br
J Dermatol 2012; 167: 1295–1301.
8 Singh C, Parsad D, Kanwar AJ, et al. Comparison between
autologous noncultured extracted hair follicle outer root sheath
cell suspension and autologous noncultured epidermal cell
suspension in the treatment of stable vitiligo: a randomized study.
Br J Dermatol 2013; 169: 287–293.
9 Razmi TM, Kumar R, Rani S, et al. Combination of follicular and
epidermal cell suspension as a novel surgical approach in
difﬁcult-to-treat vitiligo: a randomized clinical trial. JAMA Dermatol
2018; 154: 301–308. https://doi.org/10.1001/jamadermatol.2017.
Frontal ﬁbrosing alopecia: is the melanocyte of the upper
hair follicle the antigenic target?
Frontal ﬁbrosing alopecia (FFA) is a lymphocytic primary scar-
ring alopecia, most commonly affecting postmenopausal
Many authorities consider it as a variant of lichen
Nevertheless, the etiopathogenesis, and
even the true nature of FFA, are still debated. Autoimmune
mechanisms have been implicated, involving a Th1-biased cyto-
toxic T-cell activation that targets the infundibulum and the
bulge area of the follicle.
An androgen-dependent etiology has
been proposed based on the typical localization on the frontal
scalp, the predominance of postmenopausal women, and the
clinical improvement seen with anti-androgens.
tion is commonly seen in the FFA-affected area, and this may
result from the scarring process or by previously sun protected
areas becoming exposed by frontal recession.
Recently, Lin et al. found signiﬁcantly lower melanocyte counts
in lesional biopsy specimens from ﬁve patients with FFA, com-
pared with four patients with LPP (P = 0.012 for Melan-A, and
P = 0.043 for tyrosinase staining) and 10 healthy controls
(P = 0.006 for Melan-A staining).
In addition, epidermal thick-
ness was signiﬁcantly higher in patients with LPP (P = 0.018), fol-
lowed by controls (P = 0.085) and patients with FFA. The authors
concluded that FFA is associated with hypopigmentation, clini-
cally evident under Wood’s lamp examination, and atrophy, in
contrast to LPP.
In a retrospective study of 20 cases diagnosed
with FFA at our Academic Department during a 14-month period,
there were two patients, a 72-year-old female and a 48-year-old
male, who developed FFA on preexisting vitiligo of the forehead.
Anatomical colocalization supports the hypothesis that a causal
link may exist, in terms of interrelated immunologic events and
pathologic processes that may underlie both these skin condi-
Furthermore, we studied prospectively 27 females (mean
age 67 years) with FFA and found that eight (29.6%) had autoim-
mune thyroiditis with positive anti-thyroid autoantibodies, and ﬁve
ª 2018 The International Society of Dermatology International Journal of Dermatology 2018, 57, e30–e43