Vitiligo or leukoderma is an autoimmune skin condition that results in partial loss of skin pigmentation cells. Pigmentation cells called ‘melanin’ are responsible for our skin colour and absence of them results in white milky patches over the skin surface. The condition can affect any part of the body and cause white patches. However, commonly the condition starts appearing in the sun-exposed areas of the body such as face, lips, hands, feet, neck etc. Depending on the severity of the condition, doctors for white marks on the skin suggest various treatment. Depigmentation treatment is one of such treatment processes.
Depigmentation therapy can be best described as a medical procedure to remove skin pigmentation cells. It is mostly used for patients with widespread vitiligo but has few patches of original skin colour left. In simple words, people who have incomplete vitiligo on faces or other body parts can go under this treatment. It improves their appearance by giving an even skin tone.
This depigmentation therapy for vitiligo is done by using many methods such as Monobenzyl ether of Hydroquinone (MBEH), Topical Diphencyprone (DPCP), Imiquimod, Phenol, Cryotherapy and Lasers. Among them, Monobenzyl ether of hydroquinone and lasers are most commonly used and tend to deliver the best results. Doctors for white marks on the skin often use combination therapy as well for faster & better results.
This depigmentation therapy is considered for people with more than 50% widespread vitiligo and has patches over the body parts that are exposed or sensitive to cosmetics. It is necessary for the patients to understand some facts about the depigmentation therapy prior to taking it. These factors must be discussed with the patient to let them understand the process & side effects. These factors may include:
Nature of the treatment
Care and protection needed for the long run. For example, people undergone depigmentation therapy need to wear medicated sun protection to maintain the benefits of this therapy and reduce the risks of sun damage, cancer or other skin conditions.
Longer downtime and requires ‘touch–up’ sessions.
May have side effects depending on various individual factors.
Repigmentation can be patchy for a while.
Patients should be given the opportunity to discuss treatment options with their family and friends.
Monobenzyl ether of hydroquinone
Doctors for white marks on the skin commonly uses MBEH or monobenzone as the depigmenting agent to treat vitiligo patches. It is the only medically approved depigmentation therapy agent for treating vitiligo. It is a derivative of hydroquinone which causes irreversible depigmentation by killing the pigmentation cells. Depending on the individual, doctors may suggest different concentrations. The concentration also depends on the area to be treated for.
Side-effects also may cause after MBEH application, but they are mostly mild ones. If MBEH application causes transient irritation or burning sensation to the patient’s skin, then the doctor may stop the treatment for a while. In the case of blistering, scaling or dry skin, the doctor may suggest some topical corticosteroids cream to apply and stop the process for a while. If any of these side-effects happen, the doctor may reduce the strength of MBEH for next sessions. Very few cases of contact allergic dermatitis are found as a side-effect of this treatment which resulted in the permanent stop of this treatment. Few cases of exogenous ochronosis or ashy brown pigmentation have been seen after prolonged use of MBEH treatment. However, all these side-effects occur very rarely and only a few cases have been found around the world.
Application of monobenzyl ether of hydroquinone
Before starting the treatment, best clinics for white patches on the body always carry a tolerance test for MBEH. Under the tolerance test, the patient is given MBEH cream to apply daily for a week or two to apply in a small area such as inner upper arm or elbow. If no side effects experienced in this period, then patients are advised to proceed.
The MBEH creams are usually instructed to apply once daily for two weeks and then increase the daily application frequency. The creams should be applied around the pigmented area to lighten them. Such creams should not be applied on the eyelids or mucosal surfaces. Also, while under this treatment, the patients are advised to avoid sun exposure as that can cause repigmentation in the patches.
Usually, the treatment takes 1-4months to achieve desired results, but there are instances when vitiligo patients have to continue it for a longer period. However, the duration varies from patients to patients depending on various factors and their vitiligo patches.
It is always advised that if desired outcomes are not achieved within 4 months of use than this treatment should be discontinued. Once the cream has delivered the desired results, the patients need to use them intermittently as a maintenance routine. Usually, post-treatment applications are advised to do for twice a week, but it may vary for individual. Also, post-treatment, the patients need to apply SPF50+ broad-spectrum sunscreen daily to avoid repigmentation and sunburn.
Why professional services matters?
Taking depigmentation therapy services from random clinic never deliver the desired results and also could cause serious side effects. In the best clinics for white patches on the body, professional dermatologists do the proper skin test before proceeding with the treatment which minimizes the chances of side-effects and assures the best outcome.
Pixel laser facial or Pixel CO2 system is the proven way to get rid of age spots, wrinkles, acne scars and skin blemishes. It not only helps in rejuvenating the skin but also tightens the skin layers. Pixel laser facial uses the thermal energy pulses that create small micro-perforations in the skin. The perforations are done into target small area while keeping the surrounding area untouched. The laser source used in this treatment is of fractional ablative laser category. Although CO2 lasers are not very different from other fractional laser sources, yet the technology of use and its benefits makes it a lot different than others.
So, what are those benefits?
Delivers Immediate Results
The primary benefit of taking pixel laser facial is an immediate improvement in skin texture which can be visible instantly. In this treatment, the skins collagen production system is utilised which delivers immediate lasts for a longer time. Post the treatment, a bit of redness may appear but in the following days, the result will be clearly evident.
Improves Skin Texture and Tone
Pixel laser facial can improve multiple areas of the skin which makes it more favourable among other treatments. The micro-perforations created with this treatment method helps to signal the skin’s natural repair process to start and thus improves the overall texture of the skin. This treatment also helps to shrink the pore sizes as well. Even the untreated area around the micro-perforations acts as a reservoir and promote natural tissue healing giving the skin an improved even tone.
Improves Heavily Damaged Skin
Most of the non-invasive procedure skin rejuvenating are not very effective against heavily damaged skin. But pixel laser facial is the exception to mention as it is non-invasive yet offers very impressive results. It not only helps to remove skin spots & ageing spots but also eliminate extensive scars from surgeries or accidents. Reviews show that this is the best process to rectify the heavily photodamaged skin. Pixel laser facial not only removes scars & spots but also improves skin tone and texture within a few days.
Stimulates Collagen Production
Lack of collagen production is the primary reason behind many skin issues. Collagen is the most abundant protein in the human body that structures the skin. Hence, stimulating collagen production done in this treatment helps improve the skin immediately. Improving collagen production for a longer time helps the skin to have the best results for a longer time.
No Downtime Required
Being a non-invasive treatment, this requires very small downtime. It not only offers immediate results but also let you go back to your day after the session itself.
No one wants to look aged or have spots/marks on their skin. Yet, many times women can not go for various treatment due to busy schedule. Pixel laser facial requires less downtime and allows women to go back to work immediately which makes it more approachable over other skin resurfacing treatments.
People with vitiligo are often mistreated, looked down or shunned from society. Very few people understand that it’s a skin condition which is not fatal or contagious. People with vitiligo have to struggle mentally and emotionally more than physically. The way society treats people with vitiligo, it only worsens their condition and makes them withdraw from society.
Apart from the physical stress they feel, society’s behaviour towards them leaves a deep scar on their mind and many of them get into depression. Life becomes an everyday struggle for them, and people tend to hide from others. But there are some strong people who shared their story of struggle with everyone to lighten up society and raise the voice against the social stigma. These stories open our eyes that how crucial society can be towards physical outlook and how people with vitiligo feels like. Vitiligo is a never-ending journey, but our affectionate behaviour can make someone’s life easier.
Amit Singh: encouraging life every day
While the society tries best to corner him, he encourages himself and always tries to make people understand that it’s just a different skin tone than others. This brave-hearted man knows how to face society with courage and takes only positive vibes. Am amazing story of inspiration for all of us!
Keya Anand: why I have to paint myself?
She is fighting vitiligo since her 5th grade and ever since society never missed a chance to make her feel low. Even her own parents used to tell her to cover herself and hide the white patches. Medicinal creams were given to paint her patches to look normal. Even after been through such a rough phase, the brave girl dared to share her story with us.
Rahat Khan: I want to Live!
In his turn of sharing his story, he managed to write at times he wants to end his life but in reality, he wants to live a normal life. Instead of writing a long story of sufferings, he only wrote that he is speechless and have no words to share his sufferings.
Shreya Gupta: who cares if you are judgemental.
The brave-hearted girl accepted her white patches with open arms and understand that its only a skin condition that requires a bit more expert care. While she lost all her friends due to these white patches, she made friends with them. Although society never missed to being judgmental, she believes in leaving a happy life. Such an inspiration and answer to social stigma!
Uditi Menon: are we really in the 21st century?
Once she was proud to have the white patches as she used to think that she is different. Well, this feeling lasted only for a while and the society reminded her that a girl with vitiligo is not a desirable one in the matrimonial market. Since her age of eight years, she has been facing such question like who will marry her which not only remind her but also questions if we are actually living in 21st century.
Rayna D’Souza: is an outlook that important?
She was bullied since her school age and had even rough college days. All because of her different skin tone which makes her question if the whole world is so cruel or if it’s only in India.
Can you relate to their stories? Which of them connects to you more? Do these stories help you to a bit more affectionate towards people with Vitiligo?
Vitiligo can be treated and, in some cases, can be cured too. But all they need is some empathy and acceptance from us to fight through the journey.
The world statistics for vitiligo shows that almost 1% of the population is going through this skin condition. Vitiligo is an autoimmune disease where the immune cells attack & destroy the healthy melanin cells. This results in white patches appearing all over the skin, especially the sun-exposed areas. These patches are not contagious yet it affects an individual’s entire physical appearance. The condition indicts psychological stress enhancing social pressure on vitiligo patients that leads to emotional damage and their confidence to face the world, shattered.
To fight the emotional distress and face society with confidence, Vitiligo patients need to raise their confidence. Advancement in vitiligo treatment can help in stopping the widespread and may return the natural skin tone too. In vitiligo, the pigment cells in the skin die and fade away the natural color of the skin. The most complicated part of this condition is, it is dynamic and follows no pattern. Although no cure for such a condition exists, treatments are available to control the growth and bring the individual’s confidence back. A number of Vitiligo treatments are available today that helps patients cover their white patches and get back the natural skin tone.
The treatment can be classified into
Medical treatment: Oral / Applications
Light-based treatment: PUVA, PUVA sol, NB UVB, Excimer Laser and Light
Surgical treatment: Transplantation of skin or Melanocyte cells
Camouflage: Water resistant Make up to cover up the patches (Microskin)
Depigmentation: Removal of residual brown pigment in a case of extensive Vitiligo
Although the cure for this condition is not yet found but these treatments addressed above helps in hiding the patches and giving ‘normal look’. The normal look brings back the confidence in vitiligo patient. The progress of the treatment may take a bit of time but are extremely helpful in masking the white patches.
An individual chooses their own identity. They choose their own color, their own beliefs and their own ideals. Our society discriminates the different deeming them unfit or radical but their choices define who they are. An individual suffering from Vitiligo may choose to accept how they look and wear it on their sleeve and face the world with dignity, but those people whose vanity appeals to them about their physical appearance or are too shy to stand among the crowd and accept who they are, they have a way out with these treatments.
The magic of winter’s cold breeze, snowflakes, and bonfire often fade away by the unpleasant dry skin issues. The onslaught of the long haul of itchy, dry and flaky dry skin just turns the winter experience to a bitter one. A good moisturizer is not always a solution and as dry the winter is, more care you need. Your skin may need a bigger toll to stay alive in this dry weather. Here are some tips and bits of advice which can help you maintain a glowing skin in winters.
Hot Shower? A BIG NO!
The hot shower may feel good at that time, but it actually, damages skin surface and accelerate dry-skin related irritation. Excessive dry skin may lead to eczema or serious skin inflammation such as redness, scaling of the skin or itching. Moreover, you must not rub your skin excessively during the shower as that can worsen the condition.
Mild Soap or Gels Only!
Surveys show that almost 85% of women are not aware of the products that are suitable for their skin. If you are the one with dry skin, always go for a natural product oriented mild soap. It’s very essential for us to realize the need for small products that can make a big difference; a glycerine enriched soap or sandal or honey or natural ingredients made soap.
Avoid Air Heaters
Having some hot air around definitely sounds mesmerizing but is not recommended for the dry skin peeps. Using central heating unit or air heaters can be the big reason for skin damage such as blotchy, chapped and painful skin in winter.
Woollen Fabric Should Not Touch Your Skin!
The woolen fabric may seem a blessing for winter days but in reality, it moves moisture away. Woolens often lead to dry itchy skin and continuous rubbing worsens the condition. Always wear cotton under the woolen clothes to avoid any further skin damage in winter.
Switch to Heavy Creams!
Finally, dry skin needs a lot of; and you must provide a good amount of nourishment to your dry skin. Use heavy creams made with glycerine or aloe vera or honey to add the extra moisture lock, your skin wants in the freezing weather.
Do You Need More Care?
Visit a dermatologist if the above tips do not help your dried skin to rejoice. You may require a prescription ointment or cream or treatment to reduce the discomfort.
Suction blister grafting (SBG) is a procedure wherein epidermis is harvested from the donor site ie the thigh in the form of suction blister and then transferred to the dermabraded vitiliginous area(White Patches ). The graft acquires the characteristics of the recipient site, thus leading to a better color and texture matching and overall excellent cosmetic result.
Suction blister grafting (SBG) is a procedure wherein epidermis is harvested from the donor site ie the thigh in the form of suction blister and then transferred to the dermabraded vitiliginous area(White Patches). The graft acquires the characteristics of the recipient site, thus leading to a better color and texture matching and overall excellent cosmetic result.
Vitiligo patches over hairy areas where the hair are still pigmented response to medical treatments i.e. oral immunosuppressive (systemic steroids / azathioprine /methotrexate), Phototherapy (UVA, NB UVB or PUVA sol) or topical immunomodulators (Steroids, calcineurinin inhibitors5, Vitamin D derivatives)
However the acral areas, vitiligo patches with leukotrichia, i.e. areas having an absence of functional melanocytes will not respond to medical treatments and for such patients with stable disease, grafting is the only option. It is imperative that the disease is stable for a period of minimum one year before any Vitiligo Treatment is attempted.
The various surgical modalities available are Tissue grafting: Mini punch grafting, ultra thin split thickness grafting, blister grafting, hair follicle grafts, smash grafts, Cellular Grafting: Cultured and non cultured autologous cell suspensions and procedures where melanocytes are not being replaced i.e. tattooing,, excision and closure, dermabrasion or chemabrasion
The focus of this chapter is on technique of suction blister grafting in vitiligo
Suction blister grafting (SBG) is a procedure wherein epidermis is harvested from the donor site in the form of suction blister and then transferred to the dermabraded vitiliginous area.
In split skin thickness grafting and punch grafting, no matter how skilled the surgeon is, in most cases there will be a dermal component in the harvested skin, hence the graft retains some donor site characteristics thus resulting in textural and color mismatch.
In suction blister grafting, the negative suction applied on the skin leads to a cleavage between the basal cells and the basal lamina of the basement membrane zone and the blisters thus raised contains only the epidermis. The graft acquires the characteristics of the recipient site, thus leading to a better color and texture matching and overall better cosmetic result.
Graft site The donor site can be the flexor aspect of the arm, forearm, abdomen, and the anterolateral aspect of the thigh or leg. It is ideal to take from the thigh as there can be pigmentary changes which can take time to settle.
Pre graftical medication All patients are given a single dose of antibiotic (cephalexin), ranitidine, analgesic (brufin), and anxiolytic (diazepam) at least one hour before the grafting.
Donor site preparation The site is shaved then surgically prepared with Betadine , spirit After surgically disinfecting the area a field block is given with a combination of 2% xylocaine, bupivacaine, and sterile water for injection (1:1:1 ratio ), Xylocaine gives immediate anesthesia and bupivacaine has a prolonged action which makes the entire procedure relatively painless.
Raising of blisters Blisters are raised using 20 ml or 10 ml syringes. Depending on the amount of area to be covered the number and size of syringes is decided. The piston of the syringe is discarded and then IV tube is used to connect the syringe to the suction machine. At 300mmHg suction clamps are applied on the IV tubing using artery forceps or sponge holders. It takes on an average 1.5 to 2.5 hours for the development of blisters.
Deroofing the blister Once the blisters are formed, the roofs of the blisters are cut with an iris scissors. The roofs are inverted onto a glass slide so that the dermal side faces upwards. The graft is teased out and spread to its maximum size, any blood or dermis is gently removed and it is kept moist with normal saline. Care should be taken the grafts edges are not curled and it is handled carefully because if the graft gets curled up we cannot make out the sides i.e. epidermis and dermis cannot be differentiated since the graft is so thin and transparent The donor site is cleaned and dressed with paraffin dressings, gauze, pad, micropore.
Blister dissection All the blisters are taken on glass slides and then are cut into smaller grafts using a 23 no surgical blade. The number and size of these grafts will correspond approximately to the recipient site.
Using smaller grafts helps in placing the grafts more accurately to the recipient area and prevents wastage of the graft.
Preparation of recipient site The vitiligo area is surgically cleaned using spirit and povidone iodine and then anesthetized using plain lignocaine 1%. The area can be dermabraded using motorized dermabrader, Erbium YAG Laser, or a CO2 laser till pinpoint bleeding spots are seen which denotes the papillary dermis level. The dermabrded area is then covered with saline soaked gauzes which helps in maintaining heamostasis and keeps the wounded bed moist.
Transfer of Graft The dissected grafts are transferred to the deepithealized vitilgo site using glass slide after transferring the grafts it’s important to again spread out the grafts esp. the edges, cyanoacrylate glue can be applied along the margins of the grafts to immobilize it. After the graft has been placed it is covered with paraffin dressing, dry guaze, pad, micropore In case of blister grafting of lips stay sutures are given with 3-0 or 4-0 prolene and a tie over dressing is given.
Postoperative Care The patient is asked to lie down for 30 mins after the grafting to ensure good adherence of the graft. Patient is given a short course of antibiotic and analgesic for 5 days and advised to keep the area immobile. The dressing over the recipient and donor site is left on for 7 days. If the lip is operated patient is asked to a liquid diet with a straw, while doing the eyelids it’s a good idea to shut the eye to prevent too much movement which can displace the grafts.
Removal of dressing Dressings are removed at Day 7, it’s important that the dressings are removed carefully so as to avoid dislodging the grafted skin. After removal the guaze and pad it’s advisable to soak the paraffin dressing with normal saline so that the dried blood and scabs are loosened and dressing comes out easily. The grafts usually fall off in most cases or in some cases they are taken up.
Follow-up Repigmentation starts between one to 3 months post op; if the pigmentation is inadequate or there are some achromic islands, phototherapy or topical steroids can be started to hasten up the pigmentation.
Disadvantages It is time consuming and the raising of blisters is painful. Sometimes inadequate blisters or small blisters are formed. For all practical purpose only small areas can be managed with this technique Improper handling may lead graft tears or the epidermal side being grafted, thus failure to pigment. Hyper pigmentation, incomplete pigmentation, perigraft halo are few of the complications.
Efficacy In a systemic review13 blister grafting was compared with mini grafting,split-thickness grafting, and grafting of cultured melanocytes, in this review the highest mean success was found with split-thickness grafting(87%), & grafting of epidermal blisters(87%), and it was better than minigrafting (68%) and grafting of noncultured epidermal suspensions(31%).Minigrafting had the highest rates of adverse effects.
Another study14 comparing punch grafting and blister grafting over the lip showed comparable repigmentation but reported better colour match with punch grafting . In the recipient site, cobblestone appearance was the predominant complication in punch grafting and hyperpigmentation and thickening of grafts were common in suction blister grafting.
Conclusion Blister grafing is a safe, easy, and inexpensive method, with very good success rates. Repigmentation is faster and the color and texture match is better than punch grafting, ultra thin skin grafting and tattooing.
Vitiligo patches (White Patches ) associated with white hair or vitiligo patches on the acral areas i.e. lip tip variety including dorsum of hand, foot, finger tips, toes, knees, elbows tend to respond poorly to medical treatment and the only treatment option is graftical
Vitiligo patches (White Patches) associated with white hair or vitiligo patches on the acral areas i.e. lip tip variety including dorsum of hand, foot, finger tips, toes, knees, elbows tend to respond poorly to medical treatment and the only treatment option is graftical.
For patients with stable disease, grafting is an option when medical therapies fail. In recent years, cellular transplantation such as the non-cultured melanocyte-keratinocyte suspension has gained popularity because of minimal technical complexity, superior aesthetic results and requirement of only a small donor area. We hereby report our experience with this technique.
MATERIALS AND METHODS
The method used at our centre is similar to that described by Mulekar which was a modification of the technique described by Olsson and Juhlin. This report is a retrospective analysis of 58 patients who were operated between December 2003 and August 2006 and were under follow-up for at least 2 years. The duration of the disease varied between 2 and 15 years. At the time of transplantation, all patients were having stable disease for at least 1 year.
Patient selection Patients with patches of vitiligo stable for at least 1 year were recruited for transplantation. The criteria of stability were taken as (a) no new vitiligo patches, (b) no extension of existing vitiligo patches and (c) no loss of pigmentation of previously repigmened patches for at least 1 year. When available, previous photographs were compared to look for any increase in the number or size of the patches. Unstable vitiligo patients, e.g., patients who had noticed increase in their vitiligo patches in the last 1 year, and patients with unrealistic expectations (patients demanding assurance/guarantee that post-procedure, the vitiligo would never recur on the operated patches and/or fresh areas) were excluded.
Donor site The lateral aspect of the gluteal region was selected as the donor area. Care was taken to ensure that the donor area had no vitiligo patches. The size of the split-thickness donor skin was taken as one-tenth of the recipient area while dealing with large confluent patches. In cases having multiple scattered small patches, larger donor skin was taken – approximately one-fifth of the recipient area. Under aseptic precautions, a very superficial sample was harvested using a shaving blade held in straight Kocher’s forceps. The donor area was dressed with a liquid paraffin dressing tulle (Fairlee™) and sterile gauze pad.
Cell separation technique
The cell separation was done under aseptic precautions in a laminar flow bench kept in the operation theatre. The skin sample harvested was transferred to a Petri dish containing 5 ml of the 0.2% w/v trypsin solution, epidermal side facing upwards, and incubated for 45 min at 37°C. After 45 min, the action of trypsin was neutralized with the trypsin inhibitor (Life Technologies, USA).
The epidermis was separated from the dermis and transferred (epidermis) to a test tube containing 2 ml of Dulbecco’s modified Eagle medium: Nutrient Mixture F-12 (DMEM / F-12) medium (Life Technologies) and vortex mixed for 15 s.
The epidermis was further broken into smaller pieces in a Petri dish and washed with the DMEM / F-12 medium and finally transferred to a test tube containing the DMEM / F-12 and centrifuged for 6 min. The supernatant was discarded and the pellet was suspended in a test tube [Figure 1]. The final volume prepared varied from 0.2 to 0.5 ml depending on the size of the area to be treated.
The recipient site was abraded with a dermabrader fitted with a diamond fraise wheel (Delasco™) [Figure [Figure2a2aand andb].b]. While operating close to the eyelid margins, an Erbium:YAG laser was used with a fluence of 1000 mJ, 1-2 passes. The endpoint of ablation was pinpoint bleeding. Haemostasis was achieved and the ablated area was covered with saline-soaked gauze pieces.
(a) Vitiligo patch on shin; (b) uniform dermabrasion; (c) patch covered with collagen dressing; (d) vitiligo patch on the eighth day after the removal of dressing; (e) uniform pigmentation over the treated area at 3 months. The cell suspension was spread evenly on the dermabraded area and covered with collagen dressing (Collomedica Laboratories) to hold the cells applied [Figure 2c]. This was covered with liquid paraffin and gauze pieces. Patients were instructed to lie still in the same position for at least 1 h to ensure cell fixation and then shifted to a room and further instructed to avoid excessive movements of the treated area for at least 6 h. After this, patients operated under local anaesthesia were permitted to return home. Patients operated under general anaesthesia were admitted overnight and discharged the next day morning.
All patients were instructed to take complete rest and avoid all vigorous physical activities. Patients were prescribed oral antibacterial agents for 5 days and non-steroidal anti-inflammatory drugs (NSAIDs) for 3 days. The dressings were removed after 1 week in most cases.
Patients were asked to follow up at weeks 1 and 3, and then at 3-month intervals. Patients were asked to report immediately if they noticed any fresh patches of vitiligo. Patients who had incomplete repigmentation were reoperated after an interval of 6 months only if vitiligo was still stable.
Patients were instructed not to scrub the area and post-procedure no medication was prescribed. Patients were permitted to use make-up on the treated area 10 days after the removal of dressings.
The response to the procedure was graded as excellent if the repigmentation was more than 90%, good if the repigmentation was 70–89%, fair if the repigmentation was 30–69% and poor if the repigmentation was less than 30%.
PUVA or PUVAsol was initiated if there was a delayed onset of pigmentation, if the lesion was appearing hypopigmented or if there were some skipped areas (where pigmentation had not appeared).
Of the 58 patients operated, 9 patients did not turn up for follow-up after the initially operated areas, e.g., the donor and the recipient area, had healed. The remaining 49 patients were observed for 2 years. The recipient area of most cases epithelialized completely in 7 days [Figure 2d] and no further dressings were usually required. Few areas especially near the ankle required a second dressing which was removed after 3 days by the patient.
The onset of pigmentation was seen earliest at 3 weeks post-operatively; however, in few patients the onset was delayed up to 6 weeks and was evident only after the initiation of psoralen photochemotherapy (PUVAsol or PUVA) or narrow-band ultraviolet B (NB-UVB) therapy. The maximum area operated in one individual patient was 230 cm2 and the minimum was 2 cm2. Seven patients required a touch-up procedure to cover up the patches which had incomplete repigmentation following the first procedure. This was done at least 6 months after the patient had stopped showing further improvement in spite of receiving phototherapy. In initial few months following the procedure, the treated areas were hypo- or hyperpigmented in many cases, but after 6–8 months they acquired the same colour as the surrounding skin [Figure 2e].
Thirty-two (65%) patients had excellent (>90%) pigmentation [Figures [Figures33–6], 9 (18%) had good (70–89%) repigmentation and 4 patients (8%) each had fair (30–69%) and poor (<30%) responses. Most cases took around 3–6 months for complete pigmentation.
(a) Vitiligo on foot, pre-treatment; (b) uniform pigmentation over the treated area at 3 months (a) Segmental vitiligo on face and neck, pre-treatment; (b) post-treatment (a) Segmental vitiligo on face, pre-treatment; (b) post-treatment
During the follow-up, eight patients had relapse of the disease after 6 months. Of these, five developed fresh lesions while the operated sites were still retaining pigmentation; three patients had loss of pigment over the operated site as well.
Thirty-nine (79%) patients had excellent colour and texture matching; 6 (12%) developed hyperpigmentation and 4 (8%) showed lesional hypopigmentation as compared to the surrounding normal skin. A hypopigmented border was observed in 12 patients.
The donor site repigmented within 1–6 months. In five patients, the donor area healed with hyperpigmentation.
The exact aetiology of vitiligo still remains unclear with various hypothesis, e.g., autoimmune, neural and autocytotoxic mechanisms being proposed. The treatment can be classified into medical treatment, light-based treatment, graftical treatment, camouflage and depigmentation therapy.
Medical treatmentincludes the use of immune-modulating drugs such as systemic corticosteroids, levamisole, cyclophosphamide, azathioprine, vitamin supplements (especially vitamin B12 and folic acid).
Light-based treatment includes psoralen photochemotherapy (PUVAsol and PUVA) and NB-UVB, which are usually delivered to the full body, and targeted phototherapy systems which also include excimer laser and excimer lamp.
Graftical treatments can be classified as procedures involving complete skin transfers (e.g., partial split-thickness grafting, punch grafting and blister grafting) and cell transplantations which are further divided into culture and non-culture techniques.
Camouflage products include creams and lotions which serve as a temporary make-up. Depigmentation therapy involvestheremoval of pigmented skin in a case of universal, extensive vitiligo.
Vitiligo areas devoid of hair, e.g., finger tips, ankles, dorsum of hand, dorsum of foot, lips, etc., and vitiliginous areas with leukotrichia are resistant to most medical and light-based treatments and hence the replenishment of melanocytes needs to be done graftically to achieve good results.
The goal of all graftical treatments is to obtain complete repigmentation of the vitiliginous areas. An ideal graftical treatment should provide good colour and texture matching of the recipient site with that of the surrounding normal skin. It is also desired that there is no permanent scarring induced at the donor site. Punch grafting is associated with a cobblestone appearance of the grafts and donor site especially seen with bigger punches. Split-thickness grafting may lead to milium formation, thickening of the graft margins, hyperpigmentation or stuck-on appearance in some cases. Also larger sized graft donor sites are required that are at risk for scarring or altered pigmentation.
Recent advances in the graftical methods of treating vitiligo involve the transplantation of cultured pigment cells. This technique involves harvesting of pigment cells from a shave biopsy of the normally pigmented skin in the first step, expanding the cells in culture for about 3–4 weeks, and in the second step transplanting them to an area devoid of pigment cells. The procedure of cell culture has certain limitations such as requirement of elaborate laboratory set-up, risk of contamination during culture and very high costs.
The melanocyte transplantation technique has now been modified to a one-time day care procedure in the form of transplantation of non-cultured melanocyte-keratinocyte suspension. Its advantage is that cell culture is not needed and that skin harvesting from the donor area, preparation of cell separation and application of melanocytes can all be undertaken in a single 3-h procedure.
Hyperpigmentation was observed in cases where proportionally a larger donor area was taken (donor:recipient > 1:5) and in two of these patients the donor area also healed with hyperpigmentation suggesting that the patient had a tendency towards developing post-inflammatory hyperpigmentation. This post-inflammatory hyperpigmentation over the donor and recipient area faded spontaneously over 4-6 months.
Hypopigmentation was observed in areas where large confluent recipient patches were operated and the donor:recipient ratio was more than 1:10; hence the ratio of 1:10 seems ideal for non-cultured melanocyte-keratinocyte transplantation. However, we need to quantify this ratio better so that ideal colour matching can be obtained.
The hypertrophic scar, which was also hyperpigmented, was seen in two cases, one over the ankle and the other over the dorsum of finger. Both the cases had delayed healing probably because these sites were prone to excessive movements.
Eight (16%) patients who were previously stable and had achieved pigmentation relapsed in time varying from 6 months to 2 years. Of these, only three lost pigment from the transplanted site; remaining five patients developed fresh lesions; however, the transplanted areas were spared.
The hypopigmented border around the pigmented patch was observed in 8 (16%) cases, this was more in our initial patients when we were dermabrading only the depigmented area of the vitiligo patch; however, later on while carrying out the dermabrasion 2-3 mm into normal skin, this complication was far less.
The repigmentation of white hair (leukotrichia) was observed in only 3 cases out of 14 and was unpredictable.
Melanocyte cell transplantation is very effective in the treatment of stable, non-progressive vitiligo, the main advantage being that large areas can be treated; with a small donor site with just 8–10 cm2 of the donor area, a 100 cm2 area of the vitiligo patch can be treated. Repigmentation occurs in most cases within 2–4 months; repigmentation is uniform and matches well with the surrounding skin [Figures [Figures6a6a–b]. All sites including eyelids, fingers, lips and joints (excluding palms and soles) can be treated.
Vitiligo patches (White Patches ) are the most difficult variety of vitiligo to manage The primary reason behind failure of treatment in these areas is the absence of viable melanocytes in the skin and the absence of hair follicles ,the second reason behind failure to achieve repigmentation in these areas is that there is disease activity
Vitiligo patches (White Patches) are the most difficult variety of vitiligo to manage The primary reason behind failure of treatment in these areas is the absence of viable melanocytes in the skin and the absence of hair follicles ,the second reason behind failure to achieve repigmentation in these areas is that there is disease activity.
The primary reason behind the failure is the absence of viable melanocytes in the skin and the absence of hair follicles as is now evident that the repigmentation in generalized vitiligo following medical therapies is perifollicular (If the hair on the depigmented patches are still pigmented) or it is marginal repigmentation i.e. melanin production from the viable active melanocytes present in the margin of the vitiligo patch.
The second reason behind failure to achieve repigmentation in these areas is that there is disease activity. Even though most of the patches seem to be stablein a case if generalized vitiligo the acral lesions show a very slow but definite spread in many cases and hence this leads to higher rates of surgical failure in these cases
The third reason for failure is that acral areas are more difficult to operate. The reason of difficulty being two fold i.e. difficult to dermabrade the acral areas and difficulty in immobilizing the grafted area i.e. in retaining the transplanted tissue grafts (Punches, Ultrathin skin grafts ), cellulargrafts (cultured and non cultured autologous cell suspensions). Hence if adequate depths are not achieved while deepitheliazing the recipient area and area is not adequately immobilized the cell/ graft uptakes will be poor and hence result in partial or poor repigmentaion
When we use the term acral vitiligo we broadly include these sites Fingers, toes, Lips, nipples, peri areola, genitalia, peri-anal Dorsum of the hand and feet Lateral and medial malloelus, knees, elbows
These areas are often clubbed as the Lip tip type of vitiligo or the bony vitiligo or acral vitiligo. Besides being notorious to treat all these areas have these characteristics in common There are almost no or few hair follicles on these sites They are difficult to dermabrade e.g. the penis, lips, and vaginal patches It’sdifficult to immobilize and retain the grafts on these sites e.g. the penis, lips, vaginal patches
These patches show some disease activity
Hence they are all labeled as difficult to treat area
The irony in acral vitiligo is that the difficult areas are also the most visible areas and thus they become the most important areas to be treated
Vitiligo after all is a benign cosmetic disease with malignant psychological issues and it’s the acral areas that are the ones which produce most stress and psychological issues in vitiligo patients
Coming to management of acral vitiligo as has been discussed endless medical treatments are not only futile but dangerous if we actually consider the long durations for which some patients of acral vitiligoare subjected to systemic steroids, immunosuppressive, UV radiations when it is quite evident that these areas are unlikely to repigment unless the melanocytes are replaced.
It is important for the treating dermatologist to understand and acknowledge the fact that beyond a certain limit medical treatment will not work and its best to replace the missing cell i.e.the melanocytes with a surgical procedure which he or she is apt at.
The surgical management of acral vitiligo can be classified as
Proceduresin which melanocytes are being replaced i.e. the tissue grafts and the cellular grafts Tissue grafting: Mini punch grafting, ultra thin split thickness grafting, blister grafting10, hair follicle grafts, smash grafts
Cellular Grafting: Cultured11 and non cultured autologous cell suspensions
Procedures in which melanocytes are not being replaced i.e.tattooing, excision and closure, dermabrasion or chemabrasion
How to choose a surgical modality i.e. which type of procedure is best suited for which area Vitiligo is a cosmetic disease and this should never be forgotten when surgical procedure is being planned. The end result should be a match as close to the surrounding skin in terms of texture and color matching, there should be no alteration in the functionality or the shape or size of the recipient area
Also in the process of repigmenting the recipient large areas of donor areas should not be disfigured or scarred permanently
If the surgical end point can’t fulfill the above criteria it defeats the whole purpose of surgery
All the above mentioned procedures can produce varying amount of repigmenation but have their own advantages and disadvantages
Tattooing or micro pigmentation is a process in which artificial pigments are introduced into the mid dermis level of the vitiligo lesion. In most cases the final color matching is very poor and barring few areas like the angles of the mouth, this procedure should be avoided in all patients.
The tattooedparticle imparts a bluish tinge in the vitiligo skin and it is difficult to correct with other surgical procedures.
Excision and closure of the vitiligo patch is also a procedure with limited use since it can be carried out only in cases of small patches and it will always end up with a linear suture scar line
Dermabrasion or chemabrasion is a treatment modality which works primarily in the hairy areas as the process of therapeutic wounding stimulates the inactive melanocytes present in the outer root sheath of the hairs. Since most acral areas are non hair bearing area just dermabrasion not followed by grafting procedures will fail to produce results
Mini punch grafting is the simplest vitiligo surgery but invariably produces cobble stone appearance at the recipient and donor site and the target like appearance of the repigmentation is not well accepted by the patients
Suction blister grafting produces good cosmetic results esp. on the lips however it is a time consuming procedure and only small areas can be taken up at one time because of small sized grafts
Ultra thin split thickness grafting can be used for large areas however it is a highly skilled based procedure not all surgeons can harvest ultrathin grafts and the grafts may give a stuck on appearance, hyper pigmentation and hypertrophy, perigraft halo and milia formation are other issues commonly encountered. Also the biggest disadvantage is that large sheets of donor area skin are required which in many cases may produce scarring at the donor site.
Cultured melanocyte grafting is an excellent procedure where melanocytes can be expanded by 100 times with a very small donor area; this process is limited because of the requirement of an elaborate tissue culture lab which makes the process very expensive
Non cultured epidermal cell suspension can be used to treat large areas with small donor area (5- 10 times expansion) the color and texture matching is excellent
with no stuck on appearance, no cobble stoning, it does require training but elaborate culture labs and equipments are not required
Even though most dermatosurgeons will have their favorite techniques the noncultured autologous epidermal cell suspension scores over most techniques
It’s a cellular graft so no texture, shape functionality alterations will occur at the recipient site, no cobblestone look, no milia formation, no stuck on graft look
Since the cells can be expanded 5-10 times a very small donor area is required so no or minimum scarring at the donor site
Immobilization of the recipient area in the acral is easier as there is no tissue graft to hold
Preoperative counselling and Informed consent13
The entire process starts with detailed history of the patient pertaining not only to vitiligo but general health and associated diseases. The patient needs to be properly counselled about the procedure and the pre and post op care
A detailed consent form elaborating the procedure and possible complications should be signed by the patient. The patient is informed of the nature of the disease. The consent form should specifically state the limitations of the procedure, and the possibility that the NCECS is replacement of functional melanocytes into the vitiligo area which is devoid of melanocytes and the disease can become unstable again in the future and there can be a loss of pigment on other sites as well as operated sites and if the disease shows future progression additional medical line of treatment and or procedures will be needed for proper results. The patient is also counselled that he/she may require additional medical treatments and or phototherapy post op to stimulate pigmentation on the operated patches and that it can take a few months to a year for significant repigmentation and colour match
Preoperative laboratory studies include complete haemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), Thyroid profile, LFT, KFT, serum electrolytes, Chest X ray PA view, ECG in adults. Screening for antibodies for hepatitis B, C and HIV is recommended.
Small areas can be managed under topical and or local anesthesia in an OT as a day care procedure.
If a case is being done under locallignocaine (2%) with or without adrenaline is generally used. Maximum dosage that can be used is 4.5mg/kg (up to 300 mg) and with epinephrine 7 mg/kg (up to 500mg) Larger areas may need regional blocks or IV sedation
Procedure of preparing the autologous melancyte cell suspension The steps involved in this process are
Harvesting a Skin graft from the Thigh
Trypsinization and Cell separation
Dermabrasion of the recipient (vitiligo) site
Transfer and fixing of melanocyte rich cell suspension
Harvesting of Skin Graft The lateral aspect of the gluteal region is selected as the donor area. Care should be taken to ensure that the Donor area had no vitiligo patches. The size of the split-thickness donor skin takenis one-tenth of The recipient area while dealing with large confluent patches. In cases having multiple scattered small patches, larger donor skin is taken – approximately one-fifth of the recipient area. Under aseptic precautions, a very superficial sample is harvested using a shaving blade held in straight Kocher’s forceps. The donor area is dressed with liquid paraffin dressing tulle (Fairlee™) and sterile gauze pad.
Trypsinization and Cell separation technique The cell separation was done under aseptic precautions in a laminar flow bench kept in the operation theatre. The skin sample harvested is transferred to a Petri dish containing 5 ml of the 0.2% w/v trypsin solution, epidermal side facing upwards, and incubated for 45 min at 37°C. After 45 min, the action of trypsin is neutralized with trypsin inhibitor (Life Technologies, USA).The epidermis is separated from the dermis and transferred (epidermis) to a test tube containing 2 ml of Dulbecco’s modified Eagle medium: Nutrient Mixture F-12 (DMEMF/12) medium (Life Technologies) and vortex mixed for 15 s.
The epidermis is further broken into smaller pieces in a Petri dish and washed with the DMEM F/12 medium and finally transferred to a test tube containing the DMEM F/12 medium and centrifuged for 6 min. The supernatant was discarded and the pellet was suspended in a 1-ml insulin syringe The final volume prepared varied from 0.2 to 0.5 ml depending on the size of the area to be treated.
Derambrasion of the recipient site The recipient site is abraded with a dermabrader fitted with a diamond fraise wheel (Delasco™) While operating close to the eyelid margins, an Erbium: YAG laser is usedwith a fluence of 1000 mJ, 1–2 passes. The endpoint of ablation is pinpoint bleeding. Haemostasis is achieved and the ablated area is covered with saline-soaked gauze pieces.
Transplantation technique The cell suspension is spread evenly on the dermabraded area and covered with collagen dressing (Collomedica Laboratories) to hold the cells applied This is covered with liquid paraffin and gauze pieces. Patients are instructed to lie still in the same position for at least 1 h to ensure cell fixation and then shifted to a room and further instructed to avoid excessive movements of the treated area for at least 6 h.
Post-procedure instructions All patients are instructed to take complete rest and avoid all vigorous physical activities. Patients are Prescribed oral antibacterial agents for 5 days and nonsteroidal anti-inflammatory drugs (NSAIDs) for 3 days. The dressings are removed after 1 week in most cases. Patients are asked to follow up at weeks 1 and 3, and then at 3-month intervals. Patients were instructed not to scrub the area and postprocedureno medication was prescribed. Patients were permitted to use make-up on the treated area 10 daysafter the removal of dressings.
Certain Modifications of the procedure for specific acral areaa Since acral areas are difficult to operate because of the difficulty of dermabrasion and retaining the cells transferred these techniques can be used to improve the results over specific acral sites
How I do it!!! Eyes
Use cylindrical burs
Use a corneal shield to provide base for DA
Small areas only collagen leave it open
Larger area ( full eyelid) collagen>> paraffin>> guaze>> pad>> close eye for 7 daysHow I do it Finger tips!!!
Dress each finger individually and then the whole hand
How I do it Lips!!!
Use bigger wheels
Put a guaze inside mouth to make the lips taut
Use the co2 laser or erbium YAG Laser
Collagen>> Paraffin>> tie up with 4-0 prolene
Specific issues with surgery over penis / scrotum
The length & girth will keep varying
Temperature, anxiety, sleep, all can alter the tumescence of penis
Scrotum skin can considerably contract & expand
How I do it Penis / scrotum
Pear shaped bur
Pinch skin around to make it taught
Put in a catheter
Drugs to reduce erectionDiscussion The advent of vitilgo surgery has definitely changed the treatment outcomes of vitiligo esp. in the acral and segmental variety; and in vitiligo surgery it is the autologous non cultured cell suspension technique which has totally revolutionized the surgical options and has taken the patient and doctor satisfaction to the highest level.However it’s important that before we subject any patient to any vitiligo surgery we have a detailed discussion regarding the advantages, disadvantages, limitations of the treatmentEach patient should be counseled about the risk of failure, riskof incomplete repigmentaion, colour, texture mismatch, and most of all the risk of recurrence. Vitiligo is an autoimmune disease and it can have its phases of stability and activity, surgical procedures should be taken up only in cases which are at least one year stable and in most patients medical treatment may be need to continued even post surgery to keep the autoimmune process in check.Every patient of vitiligo is an individual and the treatment surgical or medical should be customized or tailor made according to the type, extent, stability of the disease, equal consideration need to be given to the medical condition of the person i.e. age, family history, co morbidities e.g. diabetes, hypertension etc. we should keep a watch out for the potential side effects of the medical treatment i.e. medications, lasers, lights.Hence a holistic approach keeping all these Factors in mind will provide a ray of hope to the cases of vitiligo.