Suction device for epidermal grafting in vitiligo: employing a syringe and a manometer to provide an adequate negative pressure

BACKGROUND

Suction devices for epidermal grafting need a suction pump to provide a negative pressure. The authors have developed a suction device in which a syringe and a manometer are employed to provide a negative pressure.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of our suction device in vitiligo patients.

METHODS

The suction device was used to obtain epidermal blisters from the donor site. A CO2 laser was employed to remove the depigmented epidermis. The blister roofs of the donor site were harvested and were placed onto the recipient area. Ten patients with stable vitiligo were treated by epidermal grafting.

RESULTS

Epidermal blisters were produced by suction in all patients. Also, all 10 patients regained repigmentation.

CONCLUSION

Our suction blister device is simple and inexpensive to make, and it may become an alternative to the other suction devices.

Suction blister grafting for stable vitiligo using pulsed erbium:YAG laser ablation for recipient site

BACKGROUND

Suction blister grafting was performed via a modified simple technique using a 20-mL syringe to create the donor graft and pulsed erbium:YAG laser ablation of the recipient site.

METHODS

Two patients with stable vitiligo and one with postinflammatory depigmentation were studied.

RESULTS

The grafts took well in all three patients and pigmentation was retained at 20 weeks. No complications occurred.

CONCLUSIONS

The erbium:YAG laser is an ideal tool for creating graft recipient sites, given its precision in terms of width and depth of ablation. A 20-mL syringe can be used to create a blister of adequate size.

Surgical management of stable vitiligo: A review with personal experience

BACKGROUND

Various modalities are available for surgical management of stable, localized patches of vitiligo, which are resistant to conventional medical treatment. Cutaneous surgeons often struggle to select among various methods of surgical treatment that include camouflage tattooing, melanocyte transplants, excision, and melanocyte culture. The advantages, disadvantages, and limitations of all the available modalities are reviewed.

OBJECTIVE

The purpose of this review is to find out if any guidelines can be drawn regarding the surgical management of stable vitiligo.

METHODS

This article is based on a review of the medical literature and the author's personal experience over the last decade.

RESULTS

It is difficult to draw any fixed guidelines from this review. Treatment must be individualized depending upon the site and the extent of involvement.

CONCLUSION

Although the retrospective nature of this article limits its validity, discussing the various therapeutic options is of value as continuing medical education. Surgical treatment may be individualized to obtain the best possible cosmetic result.

Suction blister epidermal grafting versus punch skin grafting in recalcitrant and stable vitiligo

BACKGROUND

Among various surgical therapies for replenishment of melanocytes in recalcitrant and stable vitiligo, punch skin grafting (PSG) and suction blister epidermal grafting (SBEG) are the simplest ones. Literature is lacking on a comparison of both.

OBJECTIVE

We compared the results of both techniques in small patches of vitiligo.

METHODS

Fifty stable vitiligo (focal, segmental, and generalized) patients were selected for study. One patient was lost to follow-up and excluded. PSG was done in 48 patches of 25 patients and SBEG was done in 38 patches of 24 patients. All patients were kept on psoralen ultraviolet-A (PUVA)/psoralen sunrays (PUVASOL). Results were evaluated after a follow-up of 4-7 months.

RESULTS

Thirty-two (67%) patches of the PSG group and 31 (82%) patches of the SBEG group showed greater than 75% pigmentation. The difference in both groups was not statistically significant. Cobblestone appearance (23%) over the recipient area (RA) and superficial scarring of the donor area (DA) (100%) were seen in PSG. No serious complications were seen in both groups.

CONCLUSION

Both techniques are simple and effective, however, SBEG gives cosmetically better and rapid results.

Repigmentation of vitiligo with autologous blister-induced epidermal grafts

Treatment of vitiligo can sometimes be difficult and disappointing. PUVA treatments give fairly good results. However, acral regions like the hands or feet or areas over bony prominences like the elbow, are resistant to PUVA. Blister-induced epidermal grafts have been used to repigment vitiligo skin. This study was carried out on patients with vitiligo areas unresponsive to either PUVA treatments or who had segmental vitiligo. PUVA treatments were resumed after skin grafting. Twenty-five patients with stable vitiligo were grafted with blister-induced epidermal grafts. Up to 70% of the whole vitiligo areas were grafted in one sitting. A total of 105 grafts were done. In 9 grafts, no repigmentation was seen. The remaining 96 grafts resulted in pigmentation. Twelve had partial and 84 had complete repigmentation. No Koebner phenomenon was noted in both the recipient sites or the donor sites. Blister-induced epidermal graft is an effective alternative to repigment stable vitiligo areas. It is easy to do and results are good. In this study, 96 out of 105 (91%) grafts had repigmentation.

Modified technique of suction blistering for epidermal grafting in vitiligo

BACKGROUND

Suction blister epidermal grafting is a useful modality of treatment of resistant and stable vitiligo; however, it requires expensive and heavy suction apparatus. This study is an attempt to develop a cheap and small apparatus which can be assembled in the physician's own office.

PATIENTS AND METHODS

The method was tried in 22 vitiligo/leukoderma patients. The apparatus consisted of a cylindrical funnel connected with a three-way tap, and suction was given by a 50-mL syringe. The pressure inside the suction cup was retained by changing the position of lock of the three-way tap. The pressure was measured by connecting the three-way tap to a vacuum gauge. The apparatus remained adhered to the donor area because of negative pressure. The blister was formed in about 1.5 h. The roof of the blister was grafted onto the dermabraded recipient site.

RESULTS

The pigmentation was complete in 20 out of 22 patients. There were no complications.

CONCLUSIONS

The technique is inexpensive and easy and obviates the need of cumbersome and heavy equipment.

Correction of vitiligo with contralateral areolar skin graft during mammary reduction plasty

Vitiligo has been reported to be a contraindication against reduction mammaplasty. However, this report shows for the first time that reduction mammaplasty may serve as a means to excise breast vitiligo lesions and to repigment the recipient areola by a contralateral areolar full-thickness skin graft onto the deepidermized recipient areola. The repigmented areolar skin remained stable and cosmetically pleasing for over 4 years by now. There was no vitiligo occurring in the incision lines.

Epidermal grafts for treatment of stable and progressive vitiligo

BACKGROUND

Previous reports have shown the effectiveness of epidermal grafts for patients with stable vitiligo.

OBJECTIVE

Our purpose was to evaluate the effectiveness and complications of epidermal grafts in patients with stable and progressive vitiligo and to compare the results in both groups.

METHODS

Epidermal grafting with suction blisters was performed in 40 patients with vitiligo (26 stable and 14 progressive). The grafted sites and donor sites were examined for repigmentation for longer than 3 months, up to 2.5 years.

RESULTS

Complete repigmentation was observed in 19 patients with stable (73.1%) and 10 with progressive vitiligo (71.4%). Of the 29 patients who experienced complete repigmentation, we noted recurrences in 2 patients with stable disease (10.5%) and 4 with progressive disease (40%).

CONCLUSION

Although patients with progressive vitiligo showed more frequent recurrence than those with stable disease, epidermal grafting may be an effective treatment not only for stable vitiligo but also for progressive vitiligo.

Silicone gel sheet dressings for prevention of post-minigraft cobblestoning in vitiligo

Punch grafting was performed in 15 patients using punches varying in size from 2 to 3 mm in diameter. Silicone gel sheets were used as a post-operative dressing. Removal of the dressings after 7 days revealed no lifting of grafts in 13 patients. A minimally raised surface seen in two patients flattened after 6 to 8 weeks of continuous use of the dressing. At two months of follow-up, no cobblestoning or any other untoward effect was evident. Firm pressure provided by silicone gel sheets probably prevents cobblestoning by counteracting forces which tend to lift the grafts. Additionally, the sheets act as a brace preventing graft dislocation, provide a sterile atmosphere underneath the grafts, facilitate periodic observation due to their transparency, and are easily removed at the time of follow-up.

Surgical pearl: fine gauze is a useful carrier for epidermal graft in the treatment of vitiligo by means of the suction blister method

Conventional treatments of vitiligo include topical steroids and PUVA, which necessitate prolonged application and frequent clinic visits; response to such treatments also varies. During the past few years, we have used autologous suction-blister-derived epidermal grafts in more than 150 patients with stable localized vitiligo who did not respond to topical steroids and PUVA. Up to now results are promising. In this method, spreading of the epidermal graft to its maximum size and its accurate transferral onto the recipient area are important steps. However, the graft produced by this method is so thin and soft that it wrinkles and curls frequently, making spreading and transportation to the recipient site cumbersome. In our experience with more than 700 grafts, we found that the use of plain fine gauze makes harvesting and transportation of donor grafts technically simple and effective.

Topical application of a melanotropin analogue to vulgar vitiligo dermo-epidermal minigrafts

Human subjects with active vulgar vitiligo do not respond well to autologous dermo-epidermal minigrafting. Eighteen subjects were treated with the alpha-melanocyte-stimulating hormone (alpha-MSH) synthetic analogue [Nle4, D-Phe7]-alpha-MSH. The hormone (50 microliters, 0.4 mM) was applied topically to 30-cm2 lesions in which 29-48 minigrafts had been made. The hormone did not improve the success of the minigrafting and no differences were observed in local or distant repigmentation in treated subjects as compared to the placebo group. Aliquots of 24-h urine concentrated by lyophilization irreversibly darkened toad skins, demonstrating the presence of the analogue. This is the first report of the transdermal delivery of a topically applied melanotropin in living human subjects.

A systematic review of autologous transplantation methods in vitiligo

OBJECTIVE

A systematic review of the effectiveness, safety, and applicability of autologous transplantation methods in vitiligo.

DATA SOURCES

Computerized searches of bibliographical databases, a complementary manual literature search, and contacts with researchers and pharmaceutical firms.

STUDY SELECTION

Predefined selection criteria were applied to all studies found.

DATA EXTRACTION

Two investigators independently assessed the articles for inclusion. When there was a disagreement, a third investigator was consulted.

DATA SYNTHESIS

Sixty-three studies were found, of which 16 reported on minigrafting, 13 on split-thickness grafting, 15 on grafting of epidermal blisters, 17 on grafting of cultured melanocytes, and 2 on grafting of noncultured epidermal suspension. Of these, 39 patient series were included. The highest mean success rates (87%) were achieved with split-skin grafting (95% confidence interval, 82%-91%), and epidermal blister grafting (87%) (95% confidence interval, 83%-90%). The mean success rate of 5 culturing techniques varied from 13% to 53%. However, in 4 of the 5 culturing methods, fewer than 20 patients were studied. Minigrafting had the highest rates of adverse effects but was the easiest, fastest, and least expensive method.

CONCLUSIONS

Because no controlled trials were included, treatment recommendations should be formulated with caution. Split-thickness and epidermal blister grafting can be recommended as the most effective and safest techniques. No definite conclusions can be drawn about the effectiveness of culturing techniques because only a small number of patients have been studied. The choice of method also depends on certain disease characteristics and the availability of specialized personnel and equipment.

A new model of epidermal culture for the surgical treatment of vitiligo

BACKGROUND

Vitiligo can be successfully treated with grafts of autologous cultured epidermal cells.

OBJECTIVE

To evaluate the efficacy of autologous grafting of epidermal cells, cultured by an original method, in the treatment of localized vitiligo refractory to other therapies.

METHODS

Autologous normally pigmented skin was used to culture keratinocytes and melanocytes on a supporting layer of biomaterial (Laserskin), which was grafted directly onto achromatic skin after de-epithelialization with liquid carbon dioxide. The percentage area of repigmentation was calculated by image analysis.

RESULTS

Initial repigmentation of the treated areas was observed 1 month after treatment. Repigmentation continued to increase for 3 months after grafting. Follow-up at 3, 6, 12, and 18 months showed almost complete repigmentation in six out of 11 cases. In four other patients, 40-71% of the grafted achromatic area was repigmented. In one patient, repigmentation was impeded by sepsis.

CONCLUSIONS

The method was found to be effective in the treatment of localized vitiligo refractory to other treatments. The therapeutic procedure was simple, reproducible, and easy to use.

The hair follicle: a specialised UV receptor in the human skin?

Coat colour changes in polar animals are related to seasonal variation in photic inputs. The present work was performed to study the photoresponses of hair follicular melanocytes in human skin. The melanocytes, being photosensitive cells, can function as UV biosensors, since dendrites extend towards the source of UV light. Fifty-one skin biopsies from the margin of vitiligo were subjected to whole skin organ cultures. These were exposed to a pulse of UV light to study hair bulb melanocytes in vitiligo. It is observed that the melanocytes are seen within the anagen matrix. These melanocytes are poorly dendritic in control and dark-incubated cultures. On UV exposure, they become highly dendritic, the dendrites extending towards the hair shaft in 93.5%. They show prominent catechol oxidase and noradrenaline positivity, all features of UV responsiveness. The melanocytes within the hair follicle are not directly exposed to UV light. The melanocyte dendricity and the alignment of dendrites towards the shaft on UV exposure indicate that the columns of the cells in the hair shaft act as an efficient fibre-optic system, transmitting UV light. Morphologically, the keratinocytes in the hair shaft are arranged in compressed linear columns which resemble the coaxial bundles of commercial fibre-optic strands as is observed in plants. Keratinocytes in the inner and outer sheaths do not show this arrangement. Thus the hair follicle functions as a specialised UV receptor in the skin responding to nuances of photic inputs in human skin. This is reflected in coat colour changes in animals exposed to large variations in day-night cycles.

Vitiligo. Therapeutic advances

Vitiligo often induces severe cosmetic disfigurement in patients. Both nonsurgical (medical) and surgical approaches for repigmenting vitiliginous macules are described (Table 1). Currently PUVA therapy appears to be the best method in providing reasonable hope for achieving repigmentation. Guidelines for both topical and systemic PUVA are available. Furthermore, surgical graft of autologous epidermal sheet or cultured melanocytes (often combined with keratinocyte co-culture) can be introduced to repigment the depigmented areas where PUVA is ineffective. PUVA therapy after autologous skin graft can enhance the repigmenting efficiency. Although PUVA with or without surgical procedure represents a useful tool in vitiligo treatment, we should look for other new treatment modalities based upon better understanding of basic biology of melanin pigmentation and pathophysiology of this disease. A recent development of topical pseudocatalase and calcium application combined with UVB phototherapy may be one of the typical examples in this respect. Many patients are significantly affected psychologically by the disease. Physicians should attempt to assess the degree of psychological impairment caused by vitiligo. Supportive care should always be offered if necessary in order to minimize these problems appropriately. In closing, normal skin of vitiligo patients can be totally depigmented by monobenzyl ether of hydroquinone in order to match the skin color in certain generalized vitiligo patients. There is a recent case report of extensive vitiligo with rapid repigmentation of depigmenting vitiliginous skin within a few weeks after discontinuing successful depigmentation therapy by monobenzyl ether of hydroquinone.

Single hair grafting for the treatment of vitiligo

BACKGROUND

Vitiligo is a disease of unknown cause, and many medical and surgical therapeutic methods are used to treat it.

OBJECTIVE

Our purpose was to evaluate the effectiveness of single hair grafting in patients with vitiligo.

METHODS

Single hairs were grafted into vitiliginous areas of 21 patients. The diameter of the spreading pigmentation was evaluated periodically.

RESULTS

Perifollicular repigmentation around the grafted hair was observed in 15 patients (71%) within 2 to 8 weeks. The diameter of the spreading pigmentation ranged from 2 to 10 mm during a 12-month follow-up period. In cases of generalized vitiligo, perifollicular pigmentation was seen in one of four patients (25%), whereas it was observed in 14 of 17 patients (82%) with localized/segmental vitiligo. Transformation of depigmented hairs into pigmented ones occurred in five patients.

CONCLUSION

Single hair grafting appears to be an effective method for treating localized/segmental vitiligo, especially on hairy parts of the skin, including the eyelids and eyebrows, and for small areas of vitiligo.

Leucoderma treated by transplantation of a basal cell layer enriched suspension

The aim of this study was to test the usefulness of a melanocyte-enriched cell suspension for the treatment of leucoderma. After removal of a superficial (4-30 cm2) skin sample, the cells were mechanically separated in a trypsin-EDTA solution, centrifuged and washed in a melanocyte medium. The melanocyte-enriched epidermal cell suspension devoid of stratum corneum and stratum granulosum was then applied to the dermabraded depigmented skin. The 26 patients treated had piebaldism (three), vitiligo vulgaris (17), segmental vitiligo (three), halo naevi (one), naevus depigmentosus (one) and chemical leucoderma (one). In patients with widespread piebaldism we found that by diluting the cell suspension the recipient area could be increased to up to 10 times the size of the donor area with the same good results as without or with less dilution. In patients with vitiligo areas of between 50 and 90 cm2, the recipient areas were increased three- to fivefold in the donor area. Patients with piebaldism, segmental vitiligo and halo naevi healed completely, as did most patients with vitiligo. In naevus depigmentosus no effect was seen. Our new method for treatment of leucoderma has the advantage that cell culture is not needed and that it is more suitable than epidermal sheet grafts when several small areas are to be treated.

Grafting of in vitro cultured melanocytes onto laser-ablated lesions in vitiligo

A variety of grafting procedures using autologous melanocytes have achieved promising results in the treatment of vitiligo. We here report on the preparation of an adequate graft recipient bed by pulsed Erbium-YAG laser skin ablation. In particular, for irregular lesions on delicate sites, which cannot be approached by utilization of suction blisters or dermabrasion, this technique may offer a distinct advantage.

Repigmentation in vitiligo patients. Melanocyte transfer via ultra-thin grafts

BACKGROUND

Several years ago, a successful surgical technique for treating depigmentation resulting from burn injuries was developed.

OBJECTIVE

The purpose of this study was to investigate results of dermabrasion with melanocyte transplantation using new modifications of the technique in patients with vitiligo.

METHODS

We performed 17 procedures on 12 patients with stable vitiligo. The epithelium of the vitiliginous areas was removed by dermabrasion. The dermabraded area was then reepithelialized with ultra-thin sheet grafts, which more recently were meshed and partially expanded.

RESULTS

Good to excellent repigmentation was observed in 88% of the procedures. Scarring did not develop in the repigmented or donor site regions. The final color match has been good to excellent.

CONCLUSIONS

This technique has proven beneficial in 88% of the procedures on our patients. Both our patients and we feel that this provides a valuable treatment option in patients who have failed medical management.

Epidermal sheet grafts for repigmentation of vitiligo and piebaldism, with a review of surgical techniques

Thin epidermal sheets, obtained by a high-speed air-driven dermatome, were used to repigment white areas in 19 patients with vitiligo and one boy with piebaldism. In the depigmented skin to be treated the epidermis was removed by a rotating diamond fraise under topical and/or local anaesthesia injections. The method was used on most parts of the body, including the eyelids and genitalia. The maximum total area treated on each occasion was 190 cm2. Excellent results could be obtained if the vitiligo had been stable and had not increased anywhere during the last 2 years. Lack of immobilization could explain a poor result in some areas. The donor area on the buttocks healed quickly without depigmentation. In the transplanted area milia were observed in the first 6 months. No scarring was seen. The technique has a niche in the treatment of depigmented skin, especially in larger areas.