January 7, 2018

On going

table

Wrinkle and scar acne

The rejuvenation and regeneration of the skin that has been damaged by aging or acne scars has always been a challenge for beauty practitioners. Oscar acne is s common skin condition that occurs in 95% of patients. Despite new treatments, 30% of acne patients undergo significant scar which sustained patient in both of physiological and social complications.

Regarding to importance of skin regeneration to dermatologists and community, there are some methods to overcome this issue which including chemical fillers, autologous adipose, bovine collagen, autologous human collagen and hyaluronic acid. All of these different methods have been used in last decades. Topical injection of botulinum toxin into the facial lines is another way of treating wrinkles and acne. Limitation of common treatments such as high cost, short term effects and long term side effects such as edema and necrosis lead to think of researcher about new treatment method. In recent years, replacing damaged fibroblasts with autologous or allogenic of it has been considered. Therefore, the Royan institute has been studied on the injection of fibroblasts from the skin of the patients in acne and scars as a safe and effective method.

Therapeutic steps:

The fibroblasts are derived from a small pieces of the skin behind the patient’s ear and proliferated in a specific culture medium. The time period of cell proliferation is about 6 weeks. The duplicated cells are injected into the lesion sites such as wrinkles, wounded or acne regions in three times.

The fibroblasts begin to produce collagen in the injection site and fill the curve of the lesion sites in the patients. The ability to express collagen in fibroblast cells in proven by microscopic examination.

Cell therapy by fibroblast cells:

Skin stem cells are unipotent cells, which include fibroblast, melanocyte and keratinocyte cells. Fibroblast cells are consisting lined tissue scaffold which derived from extracellular matrix and collagen in animal tissues. This type of cells are the most common type of cell in connective tissues that have an effective role in removing wrinkles due to secretion of collagen and cytokine in lesion sites for repair damaged skin areas

Study 1

In this study, the safety and efficacy of fibroblast cell transplantation of ear skin was studied in patients with wrinkles and acne scars.

Patient selection:

In this study, 76 scar acne patients who have been admitted to the skin clinic of Royan institute and 57 patients were selected for inclusion to study an informed consent was obtained from them.

 

Inclusion criteria:

1-Ranging age is 15-65 years

2- Wrinkle lesion with severity 3-7

3- Scar acne lesion with severity 3-7

4- Do not had use lifting or filler procedures

5- Negative results of viral disease such as hepatitis or ADIS.

 

Exclusion criteria:

1- Use of retinoid family medications at least in the last 6 months

2- Pregnancy and breastfeeding

3- Use of laser therapy at least in the last 6 months

4- Permanent filler injection

5- Temporary filler injection in the last 6 months

6- With a history of any cancer or chronic disorders

7- Any history of chemo therapy

8- A history of mesotherapy or plastic surgery

9- Active infection in injection site

10- History of transplantation or cell therapy

11- Patients with viral diseases

 

Study description

In this study, for 57 patients (37 wrinkle patients, 20 scar acne patients) and 168 lesion sites (132 wrinkles and 36 scar acne) were transplanted autologous fibroblast.

The active substance is the cultured fibroblasts isolated from the skin behind the patient’s ear. The sample is 8-10 mm length and 2-3 mm width which provided by a full thickness of the needle. Subsequently, the fibroblasts are isolated from the skin sample using a standard enzyme digestion method and proliferated using a standard medium.

A cell suspension of 20 million cells in 2 ml of normal saline is injected intradermal in nasolabial droplets or in the links around the eyes or forehead. 10 million fibroblast cells in 1 ml of normal saline is injected in the eyebrows lines or glabella area.

Cell injection was performed at 3 times within 2 months. After the last injection, patients were followed for 2,6,12 and 24 months after the third injection for the efficacy of the treatment. The assessment of improvement in each injection area is done by the physician based on the 7th criteria and in the patients view based on the 10th criteria.

 

Results

The response rate of patients after injection based on physician and patient satisfaction after 6 months of latest injection were evaluated by the scoring criteria of 0-7 and 0-10 respectively.

Patients were evaluated by a physician as a following criteria: improvement of lesions at least one from 4 site of injection site in wrinkle, and 2 degree in scar acne lesion.

Table 1- Response rate to treatment 6 months after third injection

Assessment type Wrinkle Group (n=37)
Glabella Periorbital Nasolabial Forehead  Total
 (n=35) (n=35) (n=28)  (n=34) (n=132)
The response rate to the treatment 2(1/4-2/4) 2(1/6-2/5) 2(1/4-2/4) 1/7(1/4-2/1) 2(1/5-2/3)
Number of cases with two degree recovery 17(48/6) 21(60) 18(64/3) 18(52/9) 74(56/1)
Number of cases with at least one degree of recovery   32(91/4)  32(91/4) 25(89/3) 31(91/2) 120(90/1)
Self-assessment +1 and +2  27(77/1) 25(71/4) 20(71/4) 21(61/8) 93(70/5)

Table 2- Response rate to treatment 6 months after third injection

Assessment type Wrinkle Group (n=37)
Forehead Temporal Cheek Total
 (n=9) (n=7) (n=20) (n=36)

 

The response rate to the treatment 1/4(0/6-2/3) 2(0/7-3/3) 2/2(1/6-2/9) 2(1/2-2/8)
Number of cases with two degree recovery 4(44/4) 4(57/1) 15(75) 23(63/9)
Number of cases with at least one degree of recovery  7(77/8) 6(85/7) 18(90) 31(86/1)
 Self-assessment +1 and +2  9(100) 6(85/7) 15(75) 30(83/3)

 

Image 1) a- 36-month follow-up of treatment sites in wrinkle patients b- 36-month follow-up in wrinkle patients by site separation c- 24-month follow-up of all sites treated for acne scar. d- 24-month follow-up of treatment site for acne scar patients by site separation.

 

fibroblast-cell therapy

 

 

Image 2) The images demonstrated that acne scar and facial wrinkles before and after fibroblasts transplantation.

 

Cell therapy in vitiligo disorder

Epidermal skin, like many other epithelium, replaces damaged or dead cells due to the presence of adult stem cells. This process repeated throughout animal life. Accordingly, after scarring or any limited damages, the skin is able to regenerate and repair damaged area. Whenever the damage is too extensive, such as acute burns, genetic disorders, vitiligo disease, psoriasis, scleroderma chronic wounds and diabetic wounds, the repair of skin is impossible without any medical intervention.

Vitiligo disease (rash or pussy-licking) appears with dysfunction of the skin pigment (eliminating pigments). In this disorder skin cells lost the ability to produce melanin and creates white spots which is due to the sharp discrepancy in the exposed parts for patients cause severe stress with depression, reducing self-esteem and even social problems.

There are several different treatments of vitiligo like topical and systematic corticosteroids, calcineurin inhibitors, phototherapy, lysing treatments and transplantation of hair and skin follicular which none of them do not have definitive results.

The resistance of some patients to common treatments and the side effects of these therapies makes it necessary to find more effective and safe methods. Cell therapy as a new treatment for vitiligo was introduced in 1987 with the transplantation of cultured melanocytes on vitiligo lesions. For the first time, they were used epidermal cell cultured suspension to re-pigmentation of vitiligo lesions. Many studies have been shown safety and efficacy of uncultured epidermal cell suspension in the treatment of vitiligo patients. In these studies, various methods have been used to prepare damaged regions for cell transplantation including CO2 laser or creating a blister on the skin of the receptor region suing negative pressure and injected cell suspension into the blisters. Several side effects have been seen in this study such as pain, hypopigmentation, scaring and allergic reaction. Since the Botox and Filler have a short term effect on patients and need re-injection. Using these kinds of cosmetic methods will need more time and money for patients. As a result, cell therapy will be a more favorable treatment. In cell-based therapies, fibroblast cell transplantation leads to secretion of collagen and cytokines in the lesion site which will have a better and long time effects to repair of damaged areas.

 

In the Royan Institute, epidermal cell suspension is transplanted by an intra-epidermal injection, whose benefits are including lower cost, less side effects in the recipient regions, more tolerable curved surfaces of the body, such as joints and facial components.

 

Therapeutic steps:

In this method, the first step is checked by a specialist, if the symptoms of vitiligo are confirmed, subsequent examinations are done on the patient. The active substances of this product are melanocyte, producing melanin, and keratinocyte, transferring uniformly the pigments cells to the surface of the skin than are obtained from the epidermis layer of the patient’s skin in buttocks and applied for vitiligo patches through an intradermal injection.

 

Cell therapy by Melanocyte, Keratinocyte cells:

Skin stem cells are unipotent cells, which include fibroblast, melanocyte and keratinocyte. The active substances are autologous keratinocytes and melanocytes with abilities of proliferation, melanin production and transfer of the pigment cells to the surface of the skin.

 

Clinical trial of melanocyte cell transplantation in Vitiligo patients:

In this study, safety and efficacy of transplantation of melanocyte-keratinocyte cells isolated from the skin were studied in vitiligo patients.

 

Patient selection:

In this study, the vitiligo patients to vitiligo lesion on these skin who have been admitted to the skin clinic of Royan institute. 300 patients (189 woman and 111 men) from 2009_2014, were selected for inclusion to study and informed consent was obtained from them.

 

Inclusion criteria:

1-Ranging in age upper 12 years

2- Having active vitiligo for less than a year

3- Do not has use cytotoxic or immunosuppressant drugs within 6 months

4- Do not use of laser therapy or UV phototherapy during the last 6 months

5- Do not presence of cellulitis or infection in vitiligo patch

6- Do not use for pregnancy and breastfeed

 

Exclusion criteria:

1- Infection or inflammation

2- Pregnancy and breastfeeding

3- With a history of use cytotoxic or immunosuppressant drugs within 6 months

4- Use of laser therapy or UV phototherapy during the last 6 months

5-Patients with viral diseases such as hepatitis or AIDS.

6- The patient does not consent to participate in the study.

 

Study description

To prepare a skin sample with a relative thickness, the active substances of this product are melanocyte, producing melanin, and keratinocytes, transferring uniformly the pigment cells to surface of the skin, that are obtained from the epidermal layer of the patient’s skin in gluteal region (buttocks) using a standard enzyme digestion method. The active substances were injected into the intradermal regions.

Oral prednisolone (up to 8 weeks) and topical lotion containing low-dose steroids (up to 2 weeks) are used after cell injection.

Patients were followed for 6 to 30 months. Follow up visits were at 3,6,9,12,18 and 24 months after cell transplantation. In each visit, the rejection rate was assessed by a dermatologist and also by based on scoring system of patients. In this system, the score of 0, I، II، III, IV were respectively 0%- 1-25%, 25-49%, 50-74% and 75-100%.

 

Response rate Pigmentation rate
No response  Re pigmentation less than 25%
Mild recovery  Re pigmentation 26-50%
Moderate recovery  Re pigmentation 51-75%
Marked recovery  Re pigmentation more than 75%

 

Results:

In this study, 300 patients with stable vitiligo (189 women, 111 men) were under stem cell treatment. Approximately 1066 treated spots were located in the face and neck skin areas of patients. The side effects have not yet been reported. An upward trend is observed in the average of rejection rate at the end of the 30th month after the cell injection, this upward trend has been significant for 9 months. The highest average of re-pigmentation rate reported by physician and patient was 2.6 and 2.46 respectively, both of them were obtained 30 months after transplantation. In follow-up of patients, 83% of treated patients have been reported more than 25% of re-pigmentation at least in one of the treated spot. More than 50% of patients were satisfied with the above method. The mild recovery rate was 36%, moderate recovery rate was 18% and marked recovery response observed in 27% of patients. One of the best cell therapy response has been demonstrated in face skin patches (Nearly 47.5%).

 

Image 1) The above images show the vitiligo treated patches before the cell transplant (left image) and after the cell transplant (right side), they are respectively facial, abdomen, elbows and knees.