CLINICAL AND LABORATORY INVESTIGATIONS BJD British Journal of Dermatology Noncultured extracted hair follicle outer root sheath cell suspension for transplantation in vitiligo S. Mohanty, A. Kumar, J. Dhawan,* V. Sreenivas and S. Gupta* Stem Cell Facility, Departments of *Dermatology and Venereology and  Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India Correspondence Somesh Gupta. E-mail: someshgupta@hotmail.com Accepted for publication 18 January 2011 Funding sources None. Conflicts of interest None declared. DOI 10.1111/j.1365-2133.2011.10234.x Summary Background Current noncultured cell-based transplantation therapies for vitiligo largely involve shave skin biopsy for preparation of noncultured melanocyte sus- pension. As the overall proportion of melanocytes is low in the epidermis, these techniques require basal cell layer enrichment, which adds additional steps. We tried follicular unit extraction (FUE) to harvest hair follicles as a source of mela- nocytes. Objectives To evaluate the efficacy of a novel surgical method for vitiligo: non- cultured extracted hair follicular outer root sheath (ORS) cell suspension trans- plantation. Methods Fourteen patients with vitiligo, stable for at least 3 months, were included in this prospective study. Fifteen to 25 hair follicles were extracted from occipital scalp using the FUE method. Hair follicles were incubated with trypsin–ethylene- diamine tetraacetic acid solution at 37 °C for 90 min to separate ORS cells. The cell suspension was filtered through a 70-lm cell strainer, then centrifuged for 5 min at 1000 r.p.m. to obtain a cell pellet. The pellet was resuspended and applied to the dermabraded recipient area and dressed. Results The mean ± SD repigmentation was 65Æ7 ± 36Æ7%. Overall, nine of 14 patients achieved > 75% repigmentation. Mean percentage repigmentation was significantly higher in patients with ‡ 1 year stability than those with < 1 year stability (P =0Æ02). Conclusions Extracted hair follicular ORS cell suspension can be a useful simplified transplantation method for vitiligo. The transplantation procedure should be reserved for patients with vitiligo stable for at least 1 year. A larger study is needed for further evaluation. Vitiligo is a common skin pigmentary disorder resulting from the loss of melanin which causes depigmented skin. It has a huge negative psychological and social impact on the patient. Various therapeutic options for repigmentation of vitiligo are available including corticosteroids, calcineurin derivatives and phototherapy. Surgical treatment is indicated in stable disease not responding to medical treatment. There are various surgical modalities available for vitiligo, which are based on the idea of restoring melanocytes on the recipi- ent site. These can be tissue grafting such as suction blister epidermal grafting, thin and ultrathin split-thickness skin grafting, minigrafting (punch grafting) and follicular graft- ing, or cellular transplantation such as cultured pure melano- cyte transplantation, cocultured melanocyte–keratinocyte suspension cell transplantation, cultured epidermis, and non- cultured basal cell layer enriched epidermal cell suspension transplantation. 1 Each of these techniques has some advanta- ges and some disadvantages and attempts are ongoing to develop a better technique. Treatment of vitiligo on hairy skin by the tedious procedure of hair follicle grafting has been carried out by a few investigators. This is based on the fact that the outer root sheath (ORS) of the hair follicle is a rich source of melanocytes and melanocyte precursor cells. Traditionally, hair follicles for follicle grafting are obtained by elliptical scalp biopsy, and then single hair follicles are cut and transplanted to the recipient site. In a preliminary study, Vanscheidt and Hunziker 2 have used single cell sus- pensions of plucked hair follicles in the treatment of vitiligo, with good results. We describe for the first time the use of a single cell suspension of the ORS of hair follicles harvested by the follicular unit extraction (FUE) method. This tech- nique has been utilized in hair transplantation surgery and has the advantage of invisible or insignificant scarring. The cell suspension prepared from hair follicles obtained by FUE can also be a potential source of multipotent epidermal and mesenchymal stem cells. Ó 2011 The Authors BJD Ó 2011 British Association of Dermatologists 2011 164, pp1241–1246 1241