Surgical treatment of vitiligo: why, when and how

Melanocyte transplantation to skin prepared by controlled PUVA-induced sunburn-like blistering for vitiligo treatment - A pilot clinical trial

Vitiligo is a common acquired disease of pigment loss. In lesions recalcitrant to non-invasive treatment, transplantation of cultured autologous melanocytes is an emerging choice. Conventionally, the recipient site is often prepared by laser-mediated or mechanical dermabrasion. Such preparation procedures have disadvantages including prolonged transplantation duration, long period for reepithelialization and potential scarring. We propose a method of preparing recipient sites by psoralen and controlled ultraviolet A (PUVA)-induced blistering followed by transplanting suspended melanocytes. We introduced this method in 10 patients with segmental vitiligo on their recipient site 3 to 5 days before transplantation and blistering developed in 2 to 3 days afterwards. On the day of transplantation, the blister roof could be peeled off easily without bleeding and the recipient site preparation could be completed in 20 min. The recipient site became reepithelialized within 1 week. Progressive repigmentation was observed for up to 6 months, with an average of 65.06% repigmentation in the recipient site without scarring at the end of follow-up. Hence, preparation of the recipient site by controlled PUVA-induced sunburn-like blistering can potentially facilitate melanocyte transplantation and prevent scarring.

Monitoring of Vitiligo Patches Over Six Months to Validate Dermoscopic Findings of Lesional Stability

INTRODUCTION

Previously laid down criteria for lesional stability of vitiligo are inconsistent. Longitudinal data on correlation between dermoscopic features of vitiligo and disease activity is limited.

OBJECTIVES

To sequentially determine the dermoscopic features of vitiligo and to assess their association with the dynamic nature of the vitiligo patch.

METHODS

Sixty patients with 200 vitiligo patches fulfilling the inclusion criteria on medical therapy were subjected to sequential clinical and dermoscopic examination for 6 months. Baseline lesional photographs, dermoscopy and tracing of the patch was made and repeated at 6 months. The follow up tracing was superimposed onto the baseline tracing. Based on the increase or decrease in size, their outcomes were grouped as responsive, progressive and quiescent. Paired analysis of dermoscopic features was done between baseline, and their follow up after 6 months.

RESULTS

Well defined border was associated with static nature of the vitiligo patch and ill-defined borders and trichrome pattern depicted its dynamic nature. Statistically significant increase in leukotrichia and satellite lesions amongst progressive patches and a decrease amongst responsive patches was observed. Pigment network changes were statistically significant for both responsive and progressive patches. Satellite lesions and micro-Koebner's phenomena was suggestive of progressive disease, while perifollicular pigmentation and perilesional hyperpigmentation was suggestive of re-pigmenting disease and proved to be an early marker for response to therapy.

CONCLUSIONS

Repeated dermoscopic evaluation of lesions in a serial manner to assess disease activity helps understand their evolving nature and is a valuable tool in planning appropriate further treatment.

Retrospective analysis of ultrathin skin grafting over carbon dioxide ablated lesions supplemented with excimer lamp (308 nm) therapy in stable vitiligo

Background Of all the tissue or cellular grafting techniques used in the treatment of vitiligo, melanocyte transplant/transfer through ultrathin skin grafting (UTSG) provides rapid onset of regimentation. The regimentation process is further accelerated with a combination of psoralen and ultraviolet A radiation, or psoralen and ultraviolet A obtained by sunlight or narrowband ultraviolet light B, or excimer laser/lamp (308 nm). Aims We assessed the efficacy of carbon dioxide laser ablation followed by melanocyte transplant/transfer through ultrathin skin graft sheet/sheets and further treated by excimer lamp therapy in patients with stable vitiligo. Methods One hundred ninety-two patients with stable vitiligo were treated with UTSG following carbon dioxide laser ablation and patients were then put on excimer lamp therapy. Primary efficacy was determined in terms of grades of regimentation and colour match at the end of 1-year. Results A total of 192 stable vitiligo patients with a mean age of 32.71 ± 8.55 years were recruited. Of the total 410 lesions, 394 showed excellent regimentation indicating a success rate of 96.1% at 1-year follow-up, whereas 16 (3.9%) lesions present on fingertips and toe tips showed poor or no regimentation at 3-month and 1-year follow-up. With regards to colour match, 394 (96.1%) lesions had achieved excellent colour match, and 16 lesions (3.9%) had poor or no colour match at 1-year follow-up. Limitations This was a single-center study with a small sample size. Conclusion The effectiveness of carbon dioxide laser ablation followed by melanocyte transfer/transplant through ultra-thin skin graft sheet/sheets when combined with excimer lamp therapy provides favourable cosmetic outcomes with rapid onset of regimentation in stable vitiligo.

Clinical and dermoscopic evaluation of follicular unit transplantation vs. Mini-Punch grafting in the repigmentation of resistant and stable vitiligo: A comparative study

BACKGROUND

Various surgical modalities and transplantation techniques had been evolved for the treatment of recalcitrant stable vitiligo. Each of these techniques has its own limitations and side effects. There are insufficient studies evaluating the efficacy of transplantation of hair follicle (HF) units as a surgical modality for vitiligo treatment in comparison with the classic mini-punch grafting.

OBJECTIVES

To compare the efficacy and safety of follicular unit transplantation (FUT) with mini-punch grafting (mPG) in cases of resistant and stable vitiligo.

METHODS

Twenty-five patients with stable vitiligo were included. Treated areas were classified into 2 groups: group I: Areas were treated with the FUT technique and group II: Areas were treated with mPG technique. Treated areas were exposed to narrowband ultraviolet B phototherapy for 6 months. After 3 months, follow-up patients' response was evaluated clinically and by dermoscopy.

RESULTS

Both techniques showed efficacy in repigmentation of stable vitiligo. Group II showed a statistically significant higher percentage of repigmentation and significant earlier repigmentation than group I. Cobblestone-like appearance was the major complication in group II, while no serious side effect was reported in group I. Leukotrichia was present in 8 patients, and 6 of them showed hair repigmentation evidently in group I.

CONCLUSION

Both techniques are effective, safe, and inexpensive methods of surgical repigmentation of stable localized/segmental vitiligo. mPG gives earlier and better percent of repigmentation, with higher incidence of cobblestoning. FUT is a good alternative for mPG, especially in hairy areas with better cosmetic outcome and minimal complications.

Tertiary Health Care-Based Randomized Controlled Study to Compare Autologous, Non-cultured, Non-trypsinized Epidermal Cell Transplant (Jodhpur Technique) with Split-Thickness Skin Grafting (STSG) in Stable Vitiligo

Background

Surgical treatment of vitiligo is reserved for stable recalcitrant vitiligo patches. Split-thickness skin grafting (STSG) is an important established modality for the surgical treatment of vitiligo, whereas autologous, non-cultured, non-trypsinized epidermal cell transplant, also known as Jodhpur technique (JT), is an unconventional innovative surgical modality for the treatment of stable vitiligo.

Aims

To compare the two techniques, JT and STSG, with regards to the extent and pattern of repigmentation achieved, color matching of the repigmented area, patient satisfaction (Dermatology Life Quality Index [DLQI] questionnaire and patient global assessment), and adverse events (if any) in patients with stable vitiligo.

Materials and Methods

It was a randomized comparative study. We randomized 32 patients with 180 stable vitiligo lesions into two groups. Patients in group 1 were treated with JT, and those in group 2 with STSG. They were subjectively evaluated 20 weeks post-surgery for the extent of repigmentation, color match, change in DLQI score, and patient satisfaction. The categorical data were presented as number (percent) and were compared among groups using Chi-square test. Mean and standard deviation were calculated for demographic data, and they were also compared by using student t-test. Probability P value < 0.001 was considered statistically significant.

Results

The extent of repigmentation was excellent (90%-100% repigmentation) in 72.5% of lesions in the JT group and in 40% of lesions in the STSG group (P < 0.001). Seventy-five percent repigmentation (good repigmentation) was observed in 95% of lesions in the JT group and in 83.75% of lesions in the STSG group (P = 0.040). There was a highly significant decline in DLQI score. Post-procedure DLQI (0.79 ± 1.13) and pre-procedure DLQI (15.39 ± 4.76) in the JT group were compared with post-procedure DLQI (3.85 ± 2.89) and pre-procedure DLQI (16.19 ± 4.56) in the STSG group. The mean decline among groups differed significantly (P < 0.001). Adverse events were significantly higher in the STSG group at the recipient site.

Conclusions

JT is found to be significantly better than STSG with regard to the degree of repigmentation.

Effectiveness of dermabrasion plus 5-fluorouracil vs suction blister in treating vitiligo: A comparative study

Vitiligo is a prevalent destructive melanocyte skin disease that negatively affects the patients' life in terms of self-esteem. Suction blister and dermabrasion plus 5-fluorouracil are effective treatments for vitiligo. The present study was conducted to compare the outcomes of these two techniques. The present clinical trial was conducted on 36 patients with persistent refractory vitiligo which defined as the lack of any new or progressed lesion during the previous year as well as no responding to conventional therapies of vitiligo including topical treatments and phototherapy. Individuals with two vitiligo patches, with similar baseline Vitiligo Area Severity Index (VASI) scores were randomly allocated to dermabrasion plus 5-fluorouracil or suction blister treatments. VASI and repigmentation scores were measured and compared at the baseline, four, and 12 weeks after performing the procedures. Both of the approaches accompanied with significant improvement in both entities of VASI and repigmentation scores (P value < .05) at the end of the study, besides the trend of VASI and repigmentation scores between the two groups revealed insignificant difference (P > .05). The short-term follow-up of the patients was the limitation of this study. The present findings suggested that both surgical techniques of dermabrasion plus 5-fluorouracil and suction blister posed acceptable outcomes within 12-week follow-up.

308nm excimer lamp monotherapy for lip vitiligo-a short case series

Vitiligo is a common depigmenting condition that carries a high psychosocial morbidity, especially when it occurs over exposed areas like lips. Many of the current topical and systemic therapies are less effective in lip vitiligo, and surgical modality remains the mainstay of treatment of lip vitiligo. The 308-nm excimer laser in combination with topical calcineurin inhibitors and calcipotriene is effective in the treatment of lip vitiligo. This case series provide further evidence to support effectiveness of 308-nm excimer lamp even as monotherapy in darker individuals with lip vitiligo.

Effects of autologous micrografts on stable bilateral vitiligo: A focus on hand lesions

Vitiligo is an autoimmune skin disorder characterized by depigmented patches of the skin associated with, among several factors, dysregulation and death of melanocytes. Currently, the treatment of vitiligo is based both on the arrest of the progression of active disease and on the stimulation of the skin repigmentation. The aim of this study was to assess the effects of autologous micrografts and narrowband ultraviolet B (NBUVB) phototherapy for skin repigmentation of patients with bilateral stable vitiligo. Autologous micrografts are derived from mechanical disaggregation of small pieces of the patient's own skin, while phototherapy is a strategy treatment already used. Twenty patients with stable bilateral vitiligo were treated, showing a mean percentage rate of 59.1% at baseline. Combined treatment by autologous micrografts and NBUVB was performed only on the lesions of the hands, and the clinical follow up was performed after 3 and 6 months by photographs taken under Wood's light. After 6 months, we classed 100% of patients as responders. We also reported a mean of repigmentation rate of 36.7% after 3 months and 64.6% after 6 months of treatment. In particular, six of the 20 patients reached a marked repigmentation rate (75-100%), four moderate (51-75%) and 10 mild (26-50%). No adverse effects were observed and no drugs were administrated as co-adjuvant therapy. These results are suggestive of a potential wide use of autologous micrografts associated with NBUVB phototherapy for the treatment of stable vitiligo.

Clinicopathological evaluation of the donor area following autologous suction blister epithelial grafting vs Thiersch grafting in vitiligo patients: A preliminary study

Surgical vitiligo treatment is suggested for recalcitrant small stable lesions. One of the limitations of this approach is the presence of large lesions. The donor site should be designed to be hidden without previous or present lesions; this limits donor sites. Aim of the study was to clinically and histopathologically evaluate donor areas 3 months and 1 year after Thiersch grafting (TG) and suction blister epithelial grafting (SBEG). Forty patients with stable vitiligo were equally divided into two groups before TG and SBEG. In each patient, the donor site was clinically and histopathologically evaluated after 3 months and 1 year. After 3 months in Group I, hyperpigmentation, mixed pigmentation with atrophic scarring, hyperpigmentation with hypertrophic scarring, erythema, and tough skin were detected in 10%, 50%, 10%, 10%, and 20% of cases, respectively. The condition improved with time leaving, leaving tough skin in all cases after 1 year. In Group II, hyperpigmentation was observed in all patients after 3 months and disappeared completely after 1 year. Histologically, biopsies taken 3 months after TG, showed increased basal pigmentation with dermal changes mimicking scar tissue in 92.5% of cases. Collagen homogenization of and fragmented elastic tissue were reported in all cases. Biopsies showed the same features after 1 year. In the SBEG group, biopsies revealed only basal hyperpigmentation that disappeared after 1 year in all patients. We concluded that SBEG is a scarless operation and regrafting from the same area can be performed. This is in contrast to TG, which is considered a scarring operation, and wherein the donor site cannot be reused for grafting.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.

Mesenchymal stem cells promote human melanocytes proliferation and resistance to apoptosis through PTEN pathway in vitiligo

Background

Vitiligo is an acquired chronic and recurrent skin disease that causes a depigmentation disorder, resulting in selective destruction of melanocytes (MC). However, the mechanism that leads to melanocyte dysfunction and death remains unclear.

Methods

We performed RNA sequencing, immunohistochemistry, and immunoblotting to characterize the patterns of phosphatase and tensin homolog (PTEN)/phosphatidylinositol 3 kinase (PI3K)/protein kinase B (AKT) pathway activation in vitiligo. We also cocultured primary melanocytes with mesenchymal stem cells (MSCs) in a Transwell system to explore how MSCs inhibit the PTEN/PI3K/AKT pathway in melanocytes.

Results

We identified that vitiligo normal-lesional junction skin presented with high expression of PTEN, which led to the inhibition of AKT phosphorylation (p-AKT) at S^-473. Furthermore, PTEN overexpression led to oxidative stress-induced apoptosis in melanocytes. Coculturing with MSCs enhanced the cell proliferation of human melanocytes and repressed PTEN expression, which inhibited oxidative stress-induced apoptosis.

Conclusion

We report that vitiligo patients present with high PTEN expression, which may play a role in the impairment of melanocytes. Furthermore, our study provides evidence that MSCs target the PTEN/PI3K/AKT pathway to regulate cell proliferation and apoptosis in human melanocytes, indicating that MSCs may serve as a promising therapy for vitiligo.

Cross-Sectional Study of Dermatoscopic Findings in Relation to Activity in Vitiligo: BPLeFoSK Criteria for Stability

Background:

Stability in vitiligo is an important concept in guiding patient management and a vital prerequisite before vitiligo surgery. Disease activity of vitiligo based on patient’s history is imprecise. It is practically impossible to perform biopsy from all lesions of vitiligo to ascertain stability. Dermatoscopy can be used to examine all clinical lesions in a patient of vitiligo. There is a need to validate many reported dermatoscopic findings for universal use.

Aims:

To analyze the significance of dermatoscopic findings in the activity of vitiligo and to devise a cutoff score for stable vitiligo.

Materials and Methods:

Dermatoscopic examination was performed in 85 patients clinically diagnosed with vitiligo. Six dermatoscopic parameters, namely, border, pigment network, perilesional hyperpigmentation, perifollicular pigmentation, satellite lesions, and micro-Koebner phenomenon (acronym: BPLeFoSK) were evaluated against Wood’s lamp findings as standard. Chi-square test was used to test association between categorical variables. Cutoff values for stability for these six parameters were plotted in receiver operating curve.

Results:

A total of 131 vitiligo lesions were analyzed with dermatoscopy. Absence of satellite lesions and absence of micro-Koebner phenomenon were the most sensitive parameters (96.7% and 100%, respectively). Sharp border and absent or reticulate pigment network within the vitiligo patch were the most specific findings (100% and 91.5%, respectively).

Conclusion:

A cutoff score of more than or equal to 1.5 using the “BPLeFoSK criteria” indicates stability in the vitiligo lesion.

Preclinical evaluation of melanocyte transplantation by chitosan-based melanocyte spheroid patch to skin prepared by controlled sunburn blistering

Transplantation of autologous cultured melanocytes as cell suspension has been used for the treatment of vitiligo. The recipient site is often prepared by laser-mediated dermabrasion. Such procedures encounter disadvantages including prolonged transplantation duration, unsecured cell adherence to lesional skin and potential scarring. To improve this, here we propose a method by preparing recipient sites before transplantation by psoralen and ultraviolet A (PUVA)-induced sunburn followed by transplanting cells with a chitosan-based melanocyte spheroid patch. We evaluated the method in nude mice. Application of methoxsalen-soaked filter paper on skin for 30 min followed by ultraviolet A exposure induced controlled sunburn blisters in 2 days. Upon transplantation, the blister roof could be quickly peeled off by a waxing patch. The chitosan membrane on which melanocytes were precultured into multicellular spheroids was transplanted with cells facing the skin. The chitosan patch adhered well to skin and secured the contact of melanocytes with the recipient site. One day later, melanocyte spheroids already detached from the chitosan membrane and adhered to the recipient skin. Our results suggest that the combination of chitosan-based melanocyte spheroid patch with epidermal ablation by PUVA-induced sunburn reaction can be a feasible method to facilitate melanocyte transplantation. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2535-2543, 2018.

Clinicopathologic Analysis of Stable and Unstable Vitiligo: A Study of 66 Cases

Vitiligo is an acquired skin disorder characterized by milky-white macules and absence of functioning melanocytes. The cornerstone of its management is the correct categorization of a case into its 2 broad types-stable and unstable vitiligo. This distinction is at present based mainly on clinical criteria because the histopathological features are not fully established. This study was thus undertaken to examine histopathological features of vitiligo and to come up with a reliable and systematic approach toward this diagnostic challenge. All patients presenting with clinical features of vitiligo at our institution were included in the study. A 3-mm punch biopsy was taken from 3 sites-lesional, perilesional, and normal skin. Histopathological examination was primarily focused on evaluating 5 histopathological variables-spongiosis, epidermal lymphocytes, basal cell vacuolation, dermal lymphocytes, and melanophages. A total number of 66 patients were included in the study. There were 30 patients in stable and 36 in unstable vitiligo groups. It was observed that all 5 histopathological pattens were associated with unstable vitiligo. All the cases were then scored using a scoring system devised by the authors and the scores obtained were correlated with clinical categorization. It was observed that while there is a definite overlap in histological findings in the 2 groups, adoption of a systematic reporting system brings more consistency and objectivity in the diagnosis. The authors have recommended diagnoses that should be reported for the various scores. This in turn will help us to more reliably and confidently manage these patients.

Simplified Non-cultured Non-trypsinised Epidermal Cell Graft Technique Followed by Psoralen and Ultraviolet A Light Therapy for Stable Vitiligo

Background and Aims:

Stable vitiligo can be treated by various surgical procedures. Non-cultured melanocyte grafting techniques were developed to overcome the time-consuming process of culture while at the same time providing acceptable results. All the techniques using non-cultured melanocyte transfer involve trypsinisation as an integral step. Jodhpur technique used by the author is autologous, non-cultured, non-trypsinised, epidermal cell grafting.

Settings and Design:

The study was conducted on patients visiting the dermatology outpatient department of a tertiary health centre in Western Rajasthan.

Materials and Methods:

At the donor site, mupirocin ointment was applied and dermabrasion was done with the help of micromotor dermabrader till pinpoint bleeding was seen. The paste-like material obtained by this procedure containing melanocytes and keratinocytes admixed with the ointment base was harvested with spatula and was subsequently spread over the recipient area. Recipient site was prepared in the same manner by dermabrasion. After 10 days, dressing at both sites was removed taking utmost care at the recipient site as there was a theoretical risk of dislodging epidermal cells.

Results:

In a study of 437 vitiligo patches, more than 75% re-pigmentation (excellent improvement) was seen in 41% of the patches. Lesions on thigh (100%), face (75%) and trunk (50%) showed maximal excellent improvement, whereas patches on joints and acral areas did not show much improvement.

Conclusions:

This technique is a simplified, cost effective, less time-consuming alternative to other techniques which involve tryspsinisation of melanocytes and at the same time provides satisfactory uniform pigmentation.

A Practical Approach to the Diagnosis and Treatment of Vitiligo in Children

Vitiligo is a common inflammatory skin disease with a worldwide prevalence of 0.5% to 2.0% of the population. In the pediatric population, the exact prevalence of vitiligo is unknown, although many studies state that most cases of vitiligo are acquired early in life. The disease is disfiguring, with a major psychological impact on children and their parents. Half of vitiligo cases have a childhood onset, needing thus a treatment approach that will minimize treatment side effects while avoiding psychological impacts. Management of vitiligo should take into account several factors, including extension, psychological impact, and possible associations with other autoimmune diseases. This review discusses the epidemiology of vitiligo and outlines the various clinical presentations associated with the disorder and their differential diagnosis. In addition, the pathophysiology and genetic determinants, the psychological impact of vitiligo, and management strategies are reviewed.

Is Lesional Stability in Vitiligo More Important Than Disease Stability for Performing Surgical Interventions? Results from a Multicentric Study

Background:

Ensuring stability of the disease process is essential for undertaking surgical intervention in vitiligo. However, there is no consensus regarding the minimum duration of stability or the relative importance of disease and lesional stability in selecting patients for vitiligo grafting.

Aim:

This multicentric study aims to assess the relative importance of lesional and disease stability on selecting patients for vitiligo grafting.

Materials and Methods:

One hundred seventy patients were recruited into the study and divided into two groups: Group A with lesional stability of >1 year but overall disease stability of only 6-11 months and Group B with overall disease stability of >1 year. Patients underwent either tissue or cellular vitiligo grafting on the selected lesions and the repigmentation achieved was scored from 0 (no repigmentation) to 6 (100% repigmentation). Repigmentation achieved on different sites of the body was compared between the two groups. Adverse effects at both the donor and the recipient sites were also compared.

Results:

Of the 170 patients who were enrolled, 82 patients were placed in Group A and 88 patients in Group B. Average repigmentation achieved (on scale of 0 to 6) was 3.8 and 4.04 in Group A and Group B, respectively. In Group A, ≥90% repigmentation was achieved in 36.6% (30/82) patients, while 37.5% (33/88) achieved similar results in Group B. Additionally, 47.6% (39/82) and 53.4% (47/88) of cases achieved partial repigmentation in Group A and Group B, respectively. Perigraft halo was the commonest adverse effect observed in both groups. Statistical analysis revealed no significant differences between the two groups with respect to the repigmentation achieved or adverse effects observed. Repigmentation achieved was the best on the face and neck area, while acral areas responded the least.

Conclusions:

Lesional stability seems to be as relevant as the overall disease stability in selecting patients for surgical intervention in vitiligo.

Vitiligo

Vitiligo, an acquired pigmentary disorder of unknown origin, is the most frequent cause of depigmentation worldwide, with an estimated prevalence of 1%. The disorder can be psychologically devastating and stigmatising, especially in dark skinned individuals. Vitiligo is clinically characterised by the development of white macules due to the loss of functioning melanocytes in the skin or hair, or both. Two forms of the disease are well recognised: segmental and non-segmental vitiligo (the commonest form). To distinguish between these two forms is of prime importance because therapeutic options and prognosis are quite different. The importance of early treatment and understanding of the profound psychosocial effect of vitiligo will be emphasised throughout this Seminar.

Vitiligo--Part 2--classification, histopathology and treatment

In an unprecedented effort in the field of vitiligo, a global consensus resulted on a suggested new classification protocol for the disease. The main histopathological finding in vitiligo is the total absence of functioning melanocytes in the lesions, while the inflammatory cells most commonly found on the edges of the lesions are CD4+ and CD8+ T lymphocytes. Physical and pharmacological treatment strategies aim to control the autoimmune damage and stimulate melanocyte migration from the unaffected edges of lesions and the outer hair follicle root sheath to the affected skin; moreover, surgical treatments can be combined with topical and physical treatments.

Grafting in vitiligo: how to get better results and how to avoid complications

Grafting procedures in vitiligo have become quite popular over the last one or two decades especially in India. Starting with the simplest punch grafting we have now a multitude of different grafting techniques available in vitiligo. All of these grafting procedures are associated with certain complications. In addition there are certain factors and surgical pearls that can go a long way in improving the cosmetic results achieved with any of these grafting techniques. This paper will try to address these specific factors and complications associated with these grafting techniques and the ways and means to avoid them.

Autologous mini punch grafting: an experience of using motorized power punch in 10 patients

BACKGROUND

Autologous mini punch grafting (MPG) is a safe, effective and easy technique that can be performed on any site with minimal side effects and good cosmetic results. Large areas of stable generalised vitiligo require more grafts and are time consuming. Hence multiple sessions of surgery need to be scheduled. We share our experience of using motorised power punches to increase the speed of surgery in large areas of stable vitiligo in 10 patients.

MATERIALS AND METHODS

Ten patients in the age group of 12-55 years were treated with miniature punch grafting using power punches in single session on various sites. The power punches of 1-1.5 mm diameter were used to score donor and recipient sites, either of same or less than 0.2-0.3 mm size punches. The harvested grafts from donor site were then secured in the recipient beds and dressed.

RESULTS

The average number of grafts harvested per session was 125-185, the duration of surgery ranged from 45 to 90 minutes. Perigraft pigment spread was seen at 3 weeks. Complete repigmentation was observed in 3-4 months in eight patients. Cobble stoning was observed in one patient, and all donor sites healed well with superficial scarring.

CONCLUSION

We conclude that autologous MPG with motorised power punches for stable vitiligo, especially on large areas including difficult sites can be performed with ease in comparatively lesser time in a single session, greatly benefiting the patients.

Stability in Vitiligo: Is there a Perfect Way to Predict it?

Stability is a hard-to-define concept in the setting of vitiligo, but is nonetheless extremely crucial to the planning of treatment regimens and also in prognosticating for the patient. There are several ways to judge stability in vitiligo, which include clinical features and, recently, many biochemical, cytological and ultrastructural correlates of the same. These recent advances help in not only in prognosticating individual patients but also in elucidating some of the mechanisms for the pathogenesis of vitiligo, including melanocytorrhagy and oxidative damage to melanocytes.

Guidelines for the management of vitiligo: the European Dermatology Forum consensus

The aetiopathogenic mechanisms of vitiligo are still poorly understood, and this has held back progress in diagnosis and treatment. Up until now, treatment guidelines have existed at national levels, but no common European viewpoint has emerged. This guideline for the treatment of segmental and nonsegmental vitiligo has been developed by the members of the Vitiligo European Task Force and other colleagues. It summarizes evidence-based and expert-based recommendations (S1 level).

Study of clinical, biochemical and immunological factors determining stability of disease in patients with generalized vitiligo undergoing melanocyte transplantation

BACKGROUND

Stability is considered the most important parameter before performing any melanocyte transplantation procedure in vitiligo; however, current criteria rely on the history given by the patients.

OBJECTIVE

This study was undertaken to determine the clinical, biochemical and immunological factors determining stability of disease in patients with generalized vitiligo to facilitate better patient selection for melanocyte transplantation and to understand immunological mechanisms for disease activity.

METHODS

Thirty-three patients with generalized vitiligo with < 10% body surface area involved were allocated to three clinical stability groups: Group 1 (stability > 3 months but < 1 year), Group 2 (≥ 1 year but < 2 years) and Group 3 (≥ 2 years). Melanocyte transplantation was done using suction blister epidermal grafting (SBEG) on a single patch. Blood was drawn for catalase estimation from all patients and from 10 healthy control subjects. A 3-mm punch biopsy was taken on the day of transplantation from the margin of the macule in the first five patients in each group for the immunohistochemistry of CD4, CD8, CD45RO, CD45RA and FoxP3. Those with ≥ 75% repigmentation at 6 months were labelled as responders.

RESULTS

The success rate was 0% in Group 1, 37·5% in Group 2 and 77·8% in Group 3. The difference in the success rate between the groups was statistically significant (P = 0·005). The median period of stability was significantly higher in the responders compared with that in the nonresponders (P = 0·001). Catalase levels were not significantly different between patients in the three groups of cases and in controls, or between responders and nonresponders. Lesional CD8 cells were significantly higher in Group 1 compared with Group 3. The percentages of CD8 and CD45RO cells were significantly higher in the nonresponders compared with the responders.

CONCLUSION

Along with clinical stability, the proportion of CD8 and CD45RO cells in skin biopsies might help to determine the stability of the disease and thereby predict the success of transplantation.

The concept of stability of vitiligo: a reappraisal

Stability is taken as the most important parameter before opting for any transplantation technique to treat vitiligo. But, simultaneous donor site repigmentation and depigmentation of grafts at the recipient site has been noted. Similarly donor site depigmentation with complete repigmentation of the recipient area with pigment growing out from each graft has been observed. Successful repigmentation after regrafting in previous punch failure cases has also been reported. Koebner's phenomenon from history (Kp-h) and test grafting were the only available indicators to assess stability. It is quite ironic to note that even after four decades of experience in vitiligo surgery, there seems to be little consensus among workers regarding the optimal required period of stability. Moreover, the exact concept of stability in vitiligo is itself still not transparent and defined beyond doubt Overdependence on KpH or TG may be sometimes misleading in vitiligo. These two reveal the apparent clinical stability only and that may not be the true reflection of stability status of the disease at the molecular level. Antimelanocyte cytotoxic reactivity was observed among CD8+ TCC isolated from perilesional biopsies of patients with vitiligo. An attempt should be made to clearly fathom and define stability, not merely only on clinical ground but along with electron microscopy and histoenzymological analysis of the perilesional and nonlesional skin of vitiligo patients. Probably some growth factors which are responsible for both mitogenic and melanogenic stimulation of melanocytes should also be taken into account. Some serological test(s) could guide us to measure these growth factors.

Treatment of vitiligo with khellin liposomes, ultraviolet light and blister roof transplantation

BACKGROUND

Various surgical and non-surgical methods are available to treat vitiligo. Surgical techniques such as epidermal blister graft transplantation may be effective for the re-pigmentation of stable, but refractory vitiligo areas. Khellin has phototherapeutic properties that are similar to those of the psoralens, but with substantially lower phototoxic effects and DNA mutation effects. Its penetration into the hair follicles is enhanced by encapsulating it into liposomes. Subsequent activation of the khellin with UV light stimulates the melanocytes in the hair follicles.

OBJECTIVE

The first objective was to evaluate the additional value of combining blister roof transplantation (BRT) with khellin in liposomes and ultraviolet light (KLUV) in the treatment of recalcitrant vitiligo patches. The second objective was to assess patients' satisfaction.

MATERIALS AND METHODS

Nineteen patients with vitiligo lesions which did not respond to KLUV treatment for at least a year were treated with BRT followed by KLUV. The transplantation was performed by creating blisters with a suction device, preparing the target site with Erbium laser ablation and the actual transplantation. Locations where randomly assigned. A blinded observer established the results.

RESULTS

Seventy-five percent of the patients were satisfied with the cosmetic result. All of the patients would recommend the treatment to other vitiligo patients. More than 75% re-pigmentation of the vitiligo areas was noted in 47% of the patients according to the blinded evaluation of photographs taken before and after the treatment.

Tissue grafts in vitiligo surgery - past, present, and future

Vitiligo, characterized by depigmented macules is a common disorder with a high psychosocial impact, particularly in darker skins. Surgical methods become important in cases where medical therapy fails to cause repigmentation or in cases of segmental vitiligo where the response to surgery is excellent. The basic principle of surgical treatment is autologous grafting of viable melanocytes from pigmented donor skin to recipient vitiliginous areas. Various grafting methods have been described including tissue grafts and cellular grafts. Stability of the disease is the most important criterion to obtain a successful outcome. Counseling of the patient regarding the outcome is vital before surgery. The technique and followup management of the tissue grafts has been described in detail in this review.

Treatment of upper- and lower-extremity vitiligo with epidermal grafts after CO2 laser resurfacing with systemic and topical steroids

Vitiligo is an acquired condition that presents as sharply demarcated white macules. It affects 1-2% of people of all races, regardless of gender or age. Although the disease does not have any systemic complications, it is of great concern, particularly in darker-skinned individuals. We treated 14 patients with vitiligo involving the upper and lower extremities. Surgical therapies were used in conjunction with medical therapy to achieve repigmentation after the disease was stabilized.

Vitiligo treatment options: An evolving scenario

Sequential displays of several treatment options for vitiligo have been scanned from the literature, and are presented here. A few of the medical modalities have been resigned to history, whereas others have become customary in clinical practice. There has also been a recent surge of interest in the surgical treatment of this disease. Accordingly, this has been appraised and summarized. Special attention has been given to prevalent medical modalities so that they may be effectively utilized by those currently in practice.

Evolution and evaluation of autologous mini punch grafting in vitiligo

Vitiligo is a result of disrupted epidermal melanization with an undecided etiology and incompletely understood pathogenesis. Various treatment options have resulted in various degrees of success. Various surgical modalities and transplantation techniques have evolved during the last few decades. Of them, miniature punch grafting (PG) has established its place as the easiest, fastest, and least expensive method. Various aspects of this particular procedure have been discussed here. The historical perspective, the instruments, evolution of mini grafting down the ages, and the methodology, advantages, and disadvantages have been discussed. A detailed discussion on the topic along with a review of relevant literature has been provided in this article.

Vitiligo and the melanocyte reservoir

Repigmentation of vitiligo depends on available melanocytes from three possible sources: from the hair follicle unit which is the main provider of pigment cells, from the border of vitiligo lesions, and from unaffected melanocytes within depigmented areas; pigment cells at these locations originate a perifollicular, border spreading and a diffuse repigmentation pattern. In order for repigmentation to take place under stimulation with diverse therapies, melanocytes should be present in appropriate numbers. Melanocyte tissue stem cells located in the niche at the bulge region of the hair follicle are the most important sources for providing immature pigment cells that undergo terminal differentiation and originate repigmentation, but cytokines, UVR and other molecules acting in melanogenesis with adequate regulation mechanisms contribute to successful recovery in vitiligo. The presence of keratinocyte stem cells in the interfollicular epidermis raises the question on the possibility of melanocyte stem cells in a similar location and the development of future strategies for therapeutic purposes.

Autografts and cultured epidermis in the treatment of vitiligo

Skin transplants can be a useful and efficacious method to treat vitiligo. The aim is to repopulate areas lacking melanocytes with functional cells taken from normally pigmented areas. Several procedures have been devised and tested: some consist in the simple transfer of epidermis sampled and implanted as is, whereas others are based on the transplantation of disaggregated and manipulated cells. The therapeutic success of the former methods is partly determined by the ability and experience of the surgeon performing the operation, whereas the results of the latter methods mainly depend on the laboratory facilities and abilities of the personnel who manipulate the cells to be transplanted. The transplantation of cultured cells is the most fascinating and promising procedure but requires the observance of still not completely predictable procedures. The use of biological material of animal origin and the use of factors to stimulate cell proliferation, such as growth factors and promoting agents, are other points that require attention.

Surgical approaches for stable vitiligo

BACKGROUND

Vitiligo therapy is difficult. Depending on its clinical presentation, unilateral or bilateral vitiligo lesions respond well with different repigmentation rates, according to age, affected anatomic area, extension of lesions, time at onset, timing of depigmentation spread, and other associated factors. When stable and refractory to medical treatment, vitiligo lesions may be treated by implanting pigment cells on depigmented areas.

OBJECTIVE

To describe the main events of depigmentation and the fundamentals of surgical techniques for repigmenting vitiligo by implanting noncultured cellular or tissue grafts, in vitro cultured epidermis-bearing pigment cells, or melanocyte suspensions.

METHODS

A description of the available techniques for repigmentation of vitiligo is done, emphasizing the most important details of each procedure to obtain the best repigmentation and minimize side effects.

RESULTS

With most of these techniques, adequate repigmentation is obtained, although there are limitations when applying some methods to clinical practice.

CONCLUSIONS

Restoration of pigmentation may be accomplished with all available surgical procedures in most anatomic locations, but they are of little value for acral areas. Unilateral vitiligo responds well in a high proportion of patients, and bilateral disease may also respond when stable. Appropriate patient selection is important to achieve the best results.