Prpco 2 Laservitiligo
Prpco 2 Laservitiligo
Prpco 2 Laservitiligo
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Original Article
Abstract
Background: The treatment of vitiligo is often challenging and requires a multi-modality approach. Fractional carbon dioxide (FCO2)
laser has been studied as an adjuvant therapy in cases of vitiligo. Autologous platelet-rich plasma (PRP) is rich in growth factors,
which may contribute to the growth of melanocytes, and thus help in the repigmentation of vitiligo patches. We aimed to study the
combination of these two modalities for the treatment of vitiligo. Aims and Objective: The aim of this study was to compare the
efficacy and safety of FCO2 laser with PRP and FCO2 laser alone as an adjuvant therapy in stable non-segmental vitiligo (NSV)
patients. Settings and Design: A prospective, randomized, comparative, open-label interventional study was carried out for a period of
18 months from December 2017 to June 2019, at a tertiary care hospital. Materials and Methods: Seventy patients with stable, NSV
were assessed for eligibility; 66 patients were randomized equally into two groups. Group A received treatment with FCO2 laser with
intralesional PRP, whereas Group B was treated with FCO2 laser alone. Patients in both the groups were treated with one therapy
session and were followed up monthly for a period of 3 months. All the patients received topical psoralen with ultraviolet A (UVA)
PUVA-sol treatment. Baseline and monthly assessments were done by VITILIGO AREA SEVERITY INDEX and standardized
photographs. Results: VASI score reduction was significantly more in the Group A with (mean ± standard deviation [SD]) 9.5 ±
0.22, 5.8 ± 1.12, and 3.6 ± 1.81 as compared to Group B 11.9 ± 2.83, 9.9 ± 3.11, and 8.9 ± 3.46 at each subsequent follow-up visits,
respectively. Side effects such as burning sensation, erythema, and crusting were seen less frequently and lasted for a short period
in Group A in comparison to those in Group B. Conclusion: Combination of FCO2 laser and autologous intralesional PRP has a
synergetic effect in treating patients with vitiligo as an adjuvant therapy with minimal adverse effects.
Keywords: Autologous platelet-rich plasma, fractional carbon dioxide laser, non-segmental vitiligo, VASI score
© 2021 Journal of Cutaneous and Aesthetic Surgery | Published by Wolters Kluwer - Medknow 49
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
FCO2 laser acts by the principle of fractional thermolysis, and on each subsequent visit, and was evaluated by a
and it has been postulated to improve vitiligo by shrinkage blinded observer.
of the vitiliginous area, migration of melanoblasts
from adjoining normal skin, and post-inflammatory
pigmentation.[2-4]
Safety evaluation
Assessment of adverse effects was done during and after
Platelet-rich plasma (PRP) is a biological cocktail of each session based on the complaints by the patients
multiple growth factors.[5] The possible mechanism of PRP and the observation of skin responses such as erythema,
in vitiligo could be due to these growth factors enhancing edema, crust formation, scarring, pigmentary changes,
the proliferation of keratinocytes and fibroblasts. PRP infection, or any allergic manifestations.
could also increase the interaction of melanocytes with
keratinocytes and stabilize the melanocytes.[6] FCO2 laser device
FCO2 laser and autologous PRP have been individually A 30 W ablative FCO2 laser device (model: FIRE XEL
studied in the treatment of vitiligo. We conducted this from Bison Medical approved by the Korean FDA) was
study to analyze the efficacy and safety of combining used. Topical anesthesia cream was applied 45 min before
FCO2 laser and PRP over FCO2 laser alone as an adjuvant the procedure. The depigmented area was lased with the
therapy in stable non-segmental vitiligo (NSV). following parameters: 1 mm density, 1500 µs pulse width,
3000 microsecond repeat delay, 9 times overlap, and 202.5
mJ energy.
Materials and Methods
This is a randomized, comparative, open-label, PRP preparation
interventional study. All patients with stable NSV who A total of 20 mL blood was drawn from the patient’s
presented to the department of dermatology at a tertiary medial cubital vein using a syringe under aseptic
care hospital between December 2017 and June 2019, conditions and was then transferred to a vial containing
were recruited for the study. anticoagulant citrate dextrose solution formula A (ACD-
Institutional ethics committee approval was obtained A). It was centrifuged at 1500 rpm for 10 min using a
before the study, and written informed consent was REMI R-8C centrifuge (REMI R-8C centrifuge (REMI
obtained from the patients. ELEKTROTECHNIK, Korea)). The supernatant was
transferred to another sterile conical bottom tube without
Sample size calculation any anticoagulant. The second tubes were centrifuged at
The sample size was estimated by Raosoft software to 3000 rpm for 10 min. The platelet pellets collected at the
be 67, for a population size of 80 with a 95% confidence bottom of the tubes were obtained. Homogenized platelet
interval for a period of 18 months. A total of 70 patients pellets were thoroughly mixed into 2 mL of plasma at
were enrolled considering possible dropouts. The inclusion the bottom of the tube. The homogenized mix was then
criteria for the study were patients with NSV of either injected via the intralesional route into the vitiliginous
gender between the ages of 18 and 50 years with stable sites after FCO2 laser. The treatment site was covered with
disease for at least a year, patients being off any topical or JELONET Paraffin gauze dressing, (Smith & Nephew,
systemic treatment for at least last 3 months, and vitiligo India).
patches with size between 25 and 50 cm2. Exclusion criteria
for the study were patients with any history of keloid, Statistical analysis
infections such as herpes, human immunodeficiency Paired t test was used to compare the VASI score in the
virus, and hepatitis B virus infection, diabetes mellitus, same group in both the treatment arms, and the unpaired
hypertension, cardiopulmonary insufficiency, collagen t test was implicated to compare two different treatment
vascular disease, bleeding tendency, or coagulation arms (Group A and Group B) at the baseline, and on each
disorders. Pregnant or lactating women, patients with subsequent follow-up visits (Day 30, 60, and 90).
unrealistic expectations, and vitiligo on mucosal areas, A P value <0.05 was considered to be significant.
scalp, palms, and soles were also excluded.
All the calculations for the study were done using
Allocation, flow, and final analysis of patients are given Microsoft Excel (version: Microsoft Office Professional
in Figure 1. Plus 2016 for Windows).
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
Figure 1: Flow chart depicting passage of participants through four different stages of the study
respectively. The gender, age, duration of lesion stability, significantly lesser in Group A versus Group B at each of
and the distribution of the lesions were comparable the subsequent visits at the first, second, and third month,
between the groups at the baseline as shown in which is shown in Table 2.
Table 1.
A comparison of mean VASI score reduction was done
The mean VASI score in both the groups was comparable between the baseline with subsequent three follow-up
at the baseline (P = 0.066). The VASI score was visits in both the groups. The difference between the mean
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
VASI scores at each of the visits when compared with the Group B: The study did not reveal any significant
baseline VASI score was found to be highly significant difference between the VASI scores at the baseline
[Table 3]. versus third follow-up visit based on gender. Patients
of the age-group of 18–30 years showed significantly
Results of subgroup evaluation: All the patients were divided
more decrease in the mean VASI score than the
into two groups, each according to the four variables
age-group of 30–50 years at the third follow-up
taken into consideration in the study, namely gender, age,
(P = 0.015). No significant difference was observed
duration of lesion stability, and location of lesions, to
in the change in VASI score between the patients of
evaluate and compare the difference between the baseline
different durations of lesional stability, that is, more
and third follow-up mean VASI score, to assess response
and less than 2 years. Lesions on the trunk again
of the intervention in both the treatment arms.
showed a significant decrease in the VASI score than
Group A: No significant difference was observed in the the lesions on the limb in this group similar to Group
VASI scores between the third visit and the baseline with A [Table 5].
respect to the gender of the study population. Patients
Pain and burning sensation subsided within a day, and
of the age group of 18–30 years showed more decrease
erythema and crusting subsided within a week after laser
in the mean VASI score at the third visit than the age-
treatment without affecting the course of treatment.
group 30–50 years (P = 0.003). We found no significant
Infection, scarring, Koebner phenomenon, or further
difference in the change in VASI score between the
aggravation of vitiligo was not seen in any patient
patients of different durations of lesion stability, that is,
[Table 6].
more and less than 2 years in both the groups. The lesions
on the trunk had a significantly higher decrease in VASI Standardized photographs of the patients at the baseline
score between the baseline and final follow-up than the and after 90-day follow-up visit are shown in Figure 2A
lesions on the limbs (P = 0.011) [Table 4]. and B for Group A and Figure 3A and B for Group B.
Table 2: Comparison of mean VASI score at each visit in both the groups
VASI baseline VASI 1st follow-up VASI 2nd follow-up VASI 3rd follow-up
(mean ± SD) (mean ± SD) (mean ± SD) (mean ± SD)
Group A (FCO2 laser + PRP) 12.1 ± 0.85 9.5 ± 0.22 5.8 ± 1.12 3.6 ± 1.81
Group B (FCO2 laser alone) 12.7 ± 2.88 11.9 ± 2.83 9.9 ± 3.11 8.9 ± 3.46
P value 0.066 0.001 0.0001 0.0001
Table 3: Comparison of mean VASI score reduction between the baseline with each subsequent follow-up visits between both
the groups
Comparison between baseline Comparison between baseline Comparison between baseline and 3rd
and 1st follow-up visit and 2nd follow-up visit follow-up visit
Group A (FCO2 laser + PRP) Mean ± SD: 2.57 ± 0.82 Mean ± SD: 6.31 ± 1.55 Mean ± SD: 8.52 ± 1.85
P value: 0.0001 P value: 0.0001 P value: 0.0001
Group B (FCO2 laser alone) Mean ± SD: 0.79 ± 0.38 Mean ± SD: 2.70 ± 0.70 Mean ± SD: 3.75 ± 1.14
P value: 0.004 P value: 0.0001 P value: 0.0001
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
P value
P value
Table 6: Comparison of adverse effects between Group A and
0.011
0.013
0.20
0.15
Group B
Adverse effects reported Group A (FCO2 Group B (FCO2
10.81 ± 0.38
5.89 ± 1.54
9.9 ± 1.34
4.3 ± 2.01
(n = 30) (%) (n = 28) (%)
Pain (mild to moderate) 30 (100) 28 (100)
Burning sensation 23 (76.6) 28 (100)
Erythema 20 (66) 25 (89.2)
Crusting 11 (36.6) 19 (67.8)
11.01 ± 0.31
7.33 ± 1.23
10.4 ± 1.57
Discussion
0.104
0.30
0.39
0.10
Lesional stability
11.9 ± 2.51
8.35 ± 2.41
2.53 ± 1.37
>2 years
(n = 10)
>2 years
10.6 ± 2.6
<2 years
(n = 21)
(n = 18)
12.7 ± 3.7
Table 5: Comparison of variables of the patients at the baseline and at third follow-up visit in Group B
P value
0.003
0.07
30–50 years
(n = 15)
Age
18–30 years
3.01 ± 0.12
13.5 ± 2.91
8.62 ± 2.57
(n = 13)
11.7 ± 2.9
P value
0.93
0.60
F (n = 19)
11.4 ± 3.5
3.1 ± 2.4
12.6 ± 2.9
9.13 ± 3.0
12.7 ± 2.3
8.54 ± 2.6
Group B (n = 28)
FCO2 laser alone
VASI baseline
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
salicylic acid safely and effectively for refractory vitiligo. inflammatory response. This causes local inflammation
Chen et al.[18] reported a response to FCO2 laser combined and thus the proliferation of melanocytes on the affected
with tacrolimus in the progressive vitiligo cases. Mohamed skin such as the mechanism of post-inflammatory
et al.[19] concluded the use of CO2 laser skin ablation, pigmentation.[18]
followed by 5FU application for acral vitiligo is a safe and
PRP is a plasma fraction that contains 3–5 times higher
tolerable technique. However, El-Zawahry et al.[20] failed
concentration of platelets relative to the whole blood.[21]
to show any noteworthy superior response of combined
PRP contains growth factors such as Platelet Derived
treatment with FCO2 laser with NB-UVB phototherapy
Growth Factor (PDGF), Transforming Growth Factor-
over NB-UVB phototherapy alone. Our study supports
Beta (TGF-β), Epidermal Growth Factor (EGF),
the use of FCO2 laser as an adjuvant therapeutic modality
Vascular Endothelial Growth Factor (VEGF), Insulin
to topical PUVA-sol.
Growth Factor (IGF), Fibroblast Growth Factor (FGF)
Several theories can be attributed to the possible that are stored in alpha granules of the platelets along
mechanism of action of FCO2 laser in vitiligo. First, with numerous plasma proteins such as fibrin, fibronectin,
FCO2 laser causes immediate retraction of the tissues and vitronectin. These growth factors help in the repair
and denaturation of the collagen bundles resulting and regeneration of the tissues.[6] PRP possibly stimulates
in a narrowed vitiligo lesion.[4] Second, when FCO2 the proliferation of keratinocytes and fibroblasts with
laser is extended in the surrounding normal skin, subsequent enhanced interaction with melanocytes,
it causes migration of melanoblasts from the outer resulting in the stabilization of melanocytes.[6] Another
root sheath of the hair follicles present there to advantage of treatment with PRP is the induction of
the vitiliginous area.[4] Finally, FCO2 laser causes escalated proliferation and migration of fibroblasts
local tissue damage, which can lead to an epidermal through the upregulation of cyclin E and cyclin-dependent
Figure 2: (A) and (B): Pre (at the baseline) and post (after 90-day follow-up visit) vitiligo patch on left supraclavicular area and left shoulder in Patient
1 and 2, respectively in Group A
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
kinase 4, which is crucial for migration and proliferation Our study found more improvement of truncal lesions
of cells.[6] PRP also limits the release of cytokines by its as compared to limb lesions of vitiligo. We also noticed
anti-inflammatory action.[7] greater repigmentation on the upper limbs as compared
with the lower limbs. These findings are compatible with
Mahajan et al.[6] found patients not responding adequately
Kadry et al.[7] where the best repigmentation was observed
to traditional therapies can be treated with intralesional
on the lesions on the trunk and the least on the lower
injections of PRP. Ibrahim et al.[5] concluded that a limbs. Abdelghani et al.[8] also observed similar findings,
combination of intradermal PRP along with NB-UVB where truncal lesions showed the best response followed
phototherapy can be contemplated as an effective, by facial, then acral lesions, and lastly the neck lesions.
uncomplicated, safe, and economical treatment modality Hélou et al.[4] reported the least significant improvement
for vitiligo. The study further justified that the use of on the articular surfaces such as knees and elbows and
intradermal PRP could also shorten the duration of UVB axilla. Trunk lesions show better response in comparison
exposure and hence a decrease in the cumulate dose and with the limb and acral areas because the areas over bony
enhanced patient compliance. prominences and acral sites contain less density of hair
Our study differed from previously reported studies in follicles, the reservoir for melanocytes, and also due to the
two ways: First, patients in both the treatment arms thick skin present there.[14]
were allocated the therapy only once, at the baseline The finding of this study is compatible with the finding in a
visit, contrary to multiple sittings, at a time gap of study by Kadry et al.[7] where combination treatment with
15 days–1 month in other studies. Second, patients in both FCO2 laser and PRP achieved the best repigmentation,
the treatment arms in our study were instructed for topical followed by PRP-only group, and least repigmentation was
PUVA-sol on the treated site, 7 days after the treatment observed in FCO2 laser–only group. Results of the study
session. conducted by Abdelghani et al.[8] where the combination
Figure 3: (A) and (B): Pre (at the baseline) and post (after 90-day follow-up visit) vitiligo patch on right buttock and left shin of tibia in Patient 1 and
2, respectively in Group B
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
therapy with FCO2 laser and PRP worked better than erythema, burning sensation, and crusting mostly due to
the FCO2 laser monotherapy, were also accordant with the anti-inflammatory and healing property of PRP.
our study. They further concluded both FCO2 laser
and PRP injection produced poor results when received Declaration of patient consent
as monotherapy. We further observed that maximum The authors certify that they have obtained all appropriate
repigmentation was observed at second follow-up visit patient consent forms. In the form the patient(s) has/have
(60 days after treatment session). A hypothesis to this given his/her/their consent for his/her/their images and
finding could be the peak synergistic effect of PUVA-sol, other clinical information to be reported in the journal.
attaining saturation at the second follow-up visit. This The patients understand that their names and initials will
also justifies the role of another sitting of FCO2 laser to not be published and due efforts will be made to conceal
stimulate the peripheral and perifollicular keratinocytes their identity, but anonymity cannot be guaranteed.
and melanocytes.
The secondary objective of our study was to compare the Acknowledgement
safety profiles between patients treated with FCO2 laser We acknowledge Mr. P. K. Brahma for his help for his
combined with PRP and FCO2 laser alone. contribution in statistical evaluation of the study.
In our study, all the patients in both the treatment arms Financial support and sponsorship
experienced mild to moderate pain after therapy session, Nil.
whereas 76.6% of patients in Group A and 100% patients
in Group B complained about burning sensation as seen
Conflicts of interest
by Mahajan et al.,[6] Kadry et al.,[7] and Doghaim et al.[14]
There are no conflicts of interest
However, pain and burning sensation subsided within a
day and erythema as well as crusting within a week after
laser treatment in our study, and they did not affect the References
course of the treatment. No patient dropped out in our 1. Allam M, Riad H. Concise review of recent studies in vitiligo. Qatar
Med J 2013;2013:1-19.
study due to adverse events. 2. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR.
Other adverse effects observed in our study were erythema Fractional photothermolysis: a new concept for cutaneous
remodeling using microscopic patterns of thermal injury. Lasers
and crusting, both were greater in Group B than Group Surg Med 2004;345:426-38.
A. The presence of aforementioned side effects was 3. Kim HJ, Hong ES, Cho SH, Lee JD, Kim HS. Fractional carbon
also reported by Doghaim et al.[14] None of the patients dioxide laser as an “add-on” treatment for vitiligo: a meta-analysis
with systematic review. Acta Derm Venereol 2018;98:180-4.
in either treatment arms witnessed scarring, infection,
4. Hélou J, Maatouk I, Obeid G, Moutran R, Stéphan F, Tomb R.
Koebnerization, and aggravation of vitiligo similar to Fractional laser for vitiligo treated by 10,600 nm ablative fractional
study by Yuan et al.[16] A hypothesis about the combination carbon dioxide laser followed by sun exposure. Lasers Surg Med
of PRP along with FCO2 laser producing fewer side effects 2014;46:443-8.
5. Ibrahim ZA, El-Ashmawy AA, El-Tatawy RA, Sallam FA. The effect
in terms of erythema, burning sensation, and crusting of platelet-rich plasma on the outcome of short-term narrowband-
than FCO2 laser alone, could be due to anti-inflammatory ultraviolet B phototherapy in the treatment of vitiligo: a pilot study.
effects exerted by PRP. J Cosmet Dermatol 2016;15:108-16.
6. Mahajan R, Ninama K, Shah H, Bilimoria F. Effect of intralesional
Limitations: Long-term follow-up could not be conducted platelet rich plasma in chronic localized vitiligo. Int J Res Dermatol
in the patients, to observe the stability of the repigmented 2018;4:550-5.
patches. 7. Kadry M, Tawfik A, Abdallah N, Badawi A, Shokeir H. Platelet-
rich plasma versus combined fractional carbon dioxide laser with
We could not compare the two treatment arms with the platelet-rich plasma in the treatment of vitiligo: a comparative study.
Clin Cosmet Investig Dermatol 2018;11:551-9.
third arm containing PRP alone. 8. Abdelghani R, Ahmed NA, Darwish HM. Combined treatment with
fractional carbon dioxide laser, autologous platelet-rich plasma,
Conclusion and narrow band ultraviolet B for vitiligo in different body sites:
a prospective, randomized comparative trial. J Cosmet Dermatol
A combination of FCO2 laser with autologous 2018;17:365-72.
intralesional PRP was found to be more efficacious in 9. Sehgal VN, Srivastava G. Vitiligo: compendium of clinico-
epidemiological features. Indian J Dermatol Venereol Leprol
terms of higher mean VASI score reduction and greater 2007;73:149-56.
repigmentation in comparison with treatment with FCO2 10. Gilchrest BA, Blog FB, Szabo G. Effects of aging and chronic
laser as monotherapy. Younger age patients repigmented sun exposure on melanocytes in human skin. J Invest Dermatol
better compared to the older age-groups. Trunk lesions 1979;73:141-3.
11. Liguori I, Russo G, Curcio F, Bulli G, Aran L, Della-Morte D,
repigmented better than limb lesions, and upper limb et al. Oxidative stress, aging, and diseases. Clin Interv Aging
lesions responded better than lower limb lesions. 2018;13:757-72.
12. Schallreuter KU, Moore J, Wood JM, Beazley WD, Peters EM,
In terms of side effects, the combination therapy fared Marles LK, et al. Epidermal H(2)O(2) accumulation alters
better in the form of lesser adverse events such as tetrahydrobiopterin (6BH4) recycling in vitiligo: identification of a
56 56 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 14 ¦ Issue 1 ¦ January-March 2021
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Raizada, et al.: FCO2 laser vs. FCO2 laser with PRP in vitiligo
general mechanism in regulation of all 6BH4-dependent processes? 17. Cunha PR, Scabine Pessotti N, Bonati Mattos C, Salai AF. New
J Invest Dermatol 2001;116:167-74. approach in the treatment of refractory vitiligo: CO2 laser combined
13. Shin J, Lee JS, Hann SK, Oh SH. Combination treatment by 10,600 nm with betamethasone and salicylic acid solution. Dermatol Ther
ablative fractional carbon dioxide laser and narrowband ultraviolet B 2017;30:1-4.
in refractory nonsegmental vitiligo: a prospective, randomized half- 18. Chen W, Zhou Y, Huang FR, Luo D, Wang DG. Preliminary study
body comparative study. Br J Dermatol 2012;166:658-61. on the treatment of vitiligo with carbon dioxide fractional laser
14. Doghaim NN, Gheida SF, El-Tatawy RA, Mohammed Ali DA. together with tacrolimus. Lasers Surg Med 2018;50:829-36.
Combination of fractional carbon dioxide laser with narrow 19. Mohamed HA, Mohammed GF, Gomaa AH, Eyada MM. Carbon
band ultraviolet B to induce repigmentation in stable vitiligo: a dioxide laser plus topical 5-fluorouracil: a new combination
comparative study. J Cosmet Dermatol 2019;18:142-9. therapeutic modality for acral vitiligo. J Cosmet Laser Ther
15. Li L, Wu Y, Li L, Sun Y, Qiu L, Gao XH, et al. Triple combination 2015;17:216-23.
treatment with fractional CO2 laser plus topical betamethasone 20. El-Zawahry MB, Zaki NS, Wissa MY, Saleh MA. Effect of
solution and narrowband ultraviolet B for refractory vitiligo: a combination of fractional CO2 laser and narrow-band ultraviolet B
prospective, randomized half-body, comparative study. Dermatol versus narrow-band ultraviolet B in the treatment of non-segmental
Ther 2015;28:131-4. vitiligo. Lasers Med Sci 2017;32:1953-8.
16. Yuan J, Chen H, Yan R, Cui S, Li YH, Wu Y, et al. Fractional CO2 21. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA.
lasers contribute to the treatment of stable non-segmental vitiligo. Platelet-rich plasma: from basic science to clinical applications. Am
Eur J Dermatol 2016;26:592-8. J Sports Med 2009;37:2259-72.
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