Vitiligo Awareness Month: The World Belongs to Them Too!

Share

Creating a world of harmony for people with Vitiligo needs a lot of effort & understanding from us. This non-contagious skin condition associates a lot of taboo, stigma and myths which many of us believe without having an understanding of the condition. In Indian society, skin colour is no doubt a big factor for social acceptance and in such a place, people with uneven skin tone often find themselves left out. This often leads to low self-esteem, lack of confidence and even depression in some cases for Vitiligo patients. Life is a gift and how we perceive it, shapes our world. The uneven patches often carry a love-hate relationship with the society and so with the patient’s life.

The world celebrates “VITILIGO AWARENESS MONTH” in June. The awareness this society needs is to understand this condition & accept Vitiligo patients. Almost 1-2% of the world’s total population is affected by this condition. Our skin gets its colour from a naturally occurring pigment – melanin which is produced by melanocytes. Vitiligo or white patches occur when these melanocytes start dying due to unknown reasons. Vitiligo is often called a disease instead of a disorder and that can have a significantly negative social and/or psychological impact on patients, in part because of numerous misconceptions that are present in large parts of the world. People of any skin type can get affected by this condition, but the patches are more noticeable on dark-skinned people. The condition is not life threatening and can be managed with modern treatments and therapies. The first signs of Vitiligo usually appear before 30s. Unfortunately, Vitiligo has no cure but there are a lot of treatment that patients can go for.

Here are some tips given by Dr. Munish Paul to help Vitiligo patients.

  1. Sun exposure: Excessive exposure to the harmful ultraviolet (UV) rays can damage the skin, especially for a Vitiligo patient. Vitiligo skin is more vulnerable to get burned easily. Hence, Vitiligo patients are always recommended to avoid sunlight or use sunscreen while going out. Water-resistant sunscreen with an SPF of 30 or over are recommended which need to be reapplied every 2-3 hours. Protective clothing like sunglasses, covered clothing and hats are also recommended to avoid sun-exposure.
  2. People with Vitiligo always need to be extra careful with their skin. Skin trauma such as scrapes, cuts or burns may develop new patches and helps to widespread the condition. However, you may not stop accidents but do your best to avoid any kind of skin injury.
  3. Tattooing the patches is never a solution. Because tattoos are done by wounding the skin and causes trauma for the skin which may result in development of new patches within a few weeks.
  4. Like any health condition, Vitiligo can be best handled by leading a healthy lifestyle. A healthy lifestyle helps support the immune system. Eat a balanced, nutritional diet and work to reduce stress level. Stress leads to the occurrence of new Vitiligo patches and hence it is best to avoid it. Try meditation, yoga, etc., to minimise stress levels because mental health is an important factor for Vitiligo patients.
  5. Camouflage is the best way to cover the Vitiligo patches and always recommended for children too. Camouflage treatment helps to cover the Vitiligo patches with some concealing cream or makeup giving a unified skin tone. Such concealing creams stay on the skin for longer hours even days. Microskin is one such camouflage cream which stays on the skin for several days and also is water-resistant. This product is safe for children also.

Nowadays, with the advent of technology, Vitiligo has many treatment options like light therapy & surgical treatments. But it is always important to consult a certified dermatologist as soon as the first patch of Vitiligo appears. Early treatment Vitiligo helps to minimise the widespread.

Lastly, it is crucial for people with Vitiligo to not be undermined, discouraged or feel low and it is everyone’s responsibility to make an effort to understand the condition and create a discrimination-free world for them.

Dr. Paul’s Skin At Laser Centre, Vitiligo treatment is performed under the supervision of certified MD Dermatologists after an open discussion about the procedure, results, and possible effects of the treatment. Call today at 9803 029 029 to know more!

Vitiligo Treatment: Light Therapy & Surgery

Share

Vitiligo is a skin condition characterised by white milky uneven patches. These patches can be treated to even tone the skin. The choice of Vitiligo treatment depends on various factors such as patient’s age, percentage of widespread, the progression of the disease and how Vitiligo is affecting one’s life.

Light-based therapies are done to help restore the lost skin colour or to give a unified skin tone. Some people may also experience some side-effects and hence a skin specialist may recommend some self-tanning products before taking you through the treatment process.

Whatever the treatment process your skin specialist recommends, it will take a few weeks or even months to deliver the expected results. Also, be prepared to go for a combination of therapies where the doctor may prescribe more than one therapy to get the desired results through a best suitable treatment for your skin. Moreover, the doctor may prescribe some maintenance therapy to prevent relapse.

Light-based therapies

  • Phototherapy: Phototherapy performed with narrowband ultraviolet A (UVA) or ultraviolet B (UVB) has proven to stop or at least slow the disease progression. If used with corticosteroids inhibitors, the therapy works even more effectively. This therapy usually requires two-three sessions per week for two-three months to make a significant difference. Possible side effects of phototherapy include redness, itching or inflammation. However, these side effects usually go away within a few hours of the treatment.
  • Targeted Phototherapy: Also called as concentrated phototherapy, it is performed to delivers ultraviolet radiation on a targeted spot. This phototherapy is targeted on the skin lesion using special delivery mechanisms for treatment.
  • Depigmentation: This therapy is performed to remove the remaining pigment in Vitiligo affected person’s body. It is only recommended for patients with 50% or more widespread Vitiligo. To perform this therapy, the doctor will recommend applying depigmentation agent on the unaffected areas of the skin which will gradually lighten the skin tone to match with the Vitiligo affected areas. The therapy is usually given once or twice a week for a few months. It’s a permanent therapy and cannot be undone afterwards. This therapy does not cause any major side-effects. Minor side effects such as redness, itching, swelling or dryness may occur.

Surgical treatment for Vitiligo

Surgery is recommended when light therapy or other medications do not work to stabilise the condition. This treatment is also recommended for people with stable Vitiligo disease. Surgical techniques used to even out skin tone can be of different types.

  • Skin grafting: This procedure is performed by transferring very small segments of healthy, pigmented skin to the discoloured areas. This procedure is usually recommended for patients with small patches of Vitiligo.
  • Blister grafting: To perform this procedure, the doctor creates blister on the pigmented skin using suction and then transplants the blister tops on the discoloured patches.
  • Cellular suspension transplant: To perform this procedure, the doctor will take some tissue from the pigmented skin and will transfer them to a solution before transplanting them in the affected area. The results usually start showing up within four weeks from the procedure. These procedures may involve small risks of infection, scarring, spotty colour and failure to re-pigment the areas.

At Dr. Paul’s Skin Laser Centre, Vitiligo treatment is performed under the supervision of certified MD Dermatologists after an open discussion about the procedure, results, and possible effects of the treatment. Call today at 9803 029 029 to know more! 

Vitiligo Laser Treatment: Why One Should Go for It

Share

Vitiligo, an autoimmune condition specifically marked by the white patches that appears on the skin. The reason behind this condition is still unknown but vitiligo treatment clinic describes that autoimmune cells suddenly starts killing the healthy pigment cells which results into vitiligo patches. Though vitiligo laser treatment has come as a bliss for many, yet the white patches makes life harder for the patients. It can happen with both children and adults and even can be congenital problem too. skin gets the color from melanin cells and losing them means skin loses color. More pigment cells mean darker skin tone and less pigment cells means lighter skin tone while no pigment in certain areas means uneven skin tone. Losing pigment at certain spots in an uneven manner means vitiligo spots arises. The vitiligo treatment clinic offers best technology such as vitiligo laser treatment which helps to treat the spots.

Around 2% of the world population is estimated to fighting with vitiligo and found in both adults and children. Even, gender is not an aspect to get this condition and one can get the starting sign at any age. Although, it tends to appear between 20-30 years age but not stays limited to that. People over these ages can also get this condition. People with family history of vitiligo are more likely to get these patches. Even it has been seen that people with vitiligo often have some other autoimmune diseases too such as Hashimoto’s thyroiditis or type 1 diabetes. This is why, before giving vitiligo treatment in Delhi specialists check for symptoms related to these conditions.

Types of vitiligo:

Segmental Vitiligo – only 10% of the cases are found to be of this sort of vitiligo where patches appear only in certain areas of the body.

No segmental Vitiligo – most vitiligo patients get this type of vitiligo where patches appear all over the body even in the genital areas.

Vitiligo patches often appears on the sun exposed areas of the body such as face, neck and hands. The patches are always pale white and can be small or big. Vitiligo can be treated to slow the widespread and some treatment helps to get the melanin back into skin. However, there is no complete cure exists for vitiligo, but the discoloured skin can be restored back to normal color. Vitiligo laser treatment is one such treatment offered by vitiligo treatment clinic that helps restores the discoloured skin. In vitiligo laser treatment, UV or PUVA or low bandwidth UVB lasers are used to eliminate the patches.

Vitiligo Laser Treatment

At various vitiligo treatment clinic, they offer best treatment to manage the spots and affected patchy and discoloured skin. Vitiligo laser treatment can be used in two ways. In case of smaller patches, or if the patient has few patches over the body only then the laser rays are thrown on that specific area where the skin need to go under regimentation process. But in most of the cases, the patches are widespread, and, in that case, the patient are made to enter in a light chamber and the whole body gets throw the laser beam. Light chamber vitiligo laser treatment process involves laser imposition on the whole body to give a re-pigmentation treatment.

De-pigmentation, in certain vitiligo treatment clinic in Delhi, offer treatment under supervision of best doctors who are best skilled at treating the vitiligo spots. The treatment involves fading the surrounding skin on the body, or face, to match with the white patches or white spots. Depigmentation therapy is the best treatment option for white spots disease if vitiligo or white spots disease on more than 50 percent of a patient’s body.

In this procedure, the monobenzone drug is applied twice a day to the pigmentation areas of the skin, including face, hands and feet, until they match the areas without pigmentation. Some patients, who are resistant to depigmentation with clinic drug monobenzone will need Q Switch NDYAG Laser, available in approved clinics, skin centers or hospitals, to destroy the cells with pigmentation caused by vitiligo giving patients the best possible results by doctors in Delhi.

Sometimes vitiligo treatment clinic prescribe treatment which is a combination of an ointment with the vitiligo laser treatment. For few cases, such treatment is required which is decided by the surgeons. Patients may need several sessions for the laser therapy and may require to be reaped twice in a week to receive the best results.

Cost of Vitiligo Laser Treatment

Many people give a wonder eyes when they hear about vitiligo laser treatment. People think that it is a costly treatment but nowadays many vitiligo treatment clinics offer an affordable treatment. They design a treatment package for vitiligo laser treatment that are quite affordable for the common man, they understand that people might need to go for several sessions and thus tailoring the prices will help them retain maximum number of patients.

White Patches of Vitiligo: Cause, Symptoms & Treatment

Share

Vitiligo is an autoimmune condition which causes white patches on the skin. In this condition, the melanocyte cells start dying for unknown reasons and melanocytes are the cells responsible for giving colour to our skin. the immune cells of our body start to kill the melanocytes cells and triggers white patches of vitiligo. It is a sheer truth that immune cells play a vital role in our skin health. White spots on skin treatment may help to reduce the widespread but cannot cure the condition completely.

White patches of vitiligo types:

  • Non-segmental vitiligo: The most common type where patients get white patches on both sides of the body.Segmental vitiligo: In this, the patients experience white patches of vitiligo mainly in one area or segment of the body. Such type vitiligo cases are very rare and only 10% of the patient experience it.

The confusing thing with this condition is it is hard to predict how long and to what extent the white patches of vitiligo will be spread. Vitiligo can start at any age but typically it shows first signs by the age of 30s as said by many white patches on skin treatment hospitals. The reasons why immune cells start attacking the melanocytes is still unknown but genetical & environmental triggers are there. It has been seen that people with a family history of vitiligo are more likely to get this condition.

Triggers of Vitiligo:

However, there are a number of factors that put people at an increased risk of developing white patches of vitiligo:

  • Genetics: As per many white patches on skin treatment hospitals, certain genetic profiles trigger the white patches of vitiligo to appear. Researchers have identified around 30 genes that are responsible for vitiligo and the most important ones are NLRP1 and PTPN22. Around 20% of vitiligo patients are the one with the family history of this condition.
  • Environmental triggers: There are environmental triggers that escalate white patches of vitiligo. Environmental triggers induce melanocytes destruction which causes the white spots to appear. Some of the potential triggers include sunlight, chemical exposure, and trauma etc. These triggers even speed up the widespread in patients being diagnosed with white patches of vitiligo.

Autoimmune diseases: People with certain autoimmune diseases such as Hashimoto’s disease or alopecia areata are more prone to experience white patches of vitiligo. Among every 4 vitiligo patients, 1 always has some other autoimmune disease.

Signs and symptoms of Vitiligo

The biggest sign of vitiligo is the appearance of white patches on the skin. The white patches of vitiligo can show up anywhere in the body but usually first appear in the sun-exposed areas such as the face, hands, neck, feet etc. The spots can even appear in armpits, genitals and groin area.

Symptoms of vitiligo also include:

  • Premature greying of hairs
  • Eyelashes or eyebrows turning white
  • The retina of the eye changes colour
  • white patches in the inner mouth

Depending on the area where the white spots of vitiligo appear, specialists diagnose the widespread of the condition. Progress of this condition and widespread area of the marks varies from person to person. People who get white patches of vitiligo on both sides of the bodies are categorized as generalized vitiligo. Most people tend to get the white patches of vitiligo in only one side of the body.

Vitiligo makes skin more sensitive to sunlight. The white patches of vitiligo are the area with no melanin which stores the dangerous UV rays that cause various other skin conditions. People with vitiligo also may experience hearing issues or inflammation in the iris.

Moreover, rather than physical stress, white patches of vitiligo causes more mental stress. The way society looks and behaves with vitiligo patients, it often leads them to depression. If the white patches of vitiligo cannot be covered under the clothes, then it becomes a real struggle for the patients. They struggle with self-confidence & esteem and prefers to stay isolated from the society.

Vitiligo Diagnosis and Treatment

Not all white patches are vitiligo, they can happen due to other conditions as well. So, it is always good to see a dermatologist for proper diagnosis & treatment. To carry a proper diagnosis, the dermatologist may ask a few questions such as:

  • If you have ever been diagnosed with an autoimmune disease
  • If you have a family history of vitiligo
  • If you have experienced any skin condition recently.

All of these factors indicate the presence of vitiligo. Most of the time, the dermatologist identifies vitiligo by white patches on the skin and referring the given answers for the above questions. They also might use UV rays to identify the pigment loss.

Unfortunately, there is no cure available for white spots of vitiligo but there are several white spots on skin treatment exists which helps to lighten the spots. The treatment options include:

  • Cosmetic makeup and self-tanners to cover up the spots
  • Corticosteroid creams and tacrolimus ointments
  • Laser therapy
  • Pigmentation therapy
  • Skin grafting, blister grafting

These white spots on skin treatment may show few side-effects such as scar or dryness or itchiness but also promises good results.

THE MYSTERY OF THE DISAPPEARING WHITE SPOTS

Share

A 27 years old young healthy male reported to the skin OPD with complaints of white patches over his arms and thighs since 8 months. On examination the spots were flat white spots & were numerous and distributed over the arms and legs most of them measuring less than a cm in diameter. the spots were quite subtle almost playing hide and seek looking prominent at sometime and then not so obvious at other times It didn’t fit in clinically with the most common skin issues of similar look ie fungus, allergy, sun sensitivity etc. Routine blood tests Complete blood counts , liver , kidney function tests, thyroid , blood sugars were within normal limits and gave no further insight whatsoever The patient had visited couple of doctors who just like us couldn’t really come to a final diagnosis and he was treated as a case of fungus, allergy white patches with no improvement at all; the case was turning to be most eluding yet teasing,it was like the spots were taunting us having a secret laugh at our ignorance. With nothing more to offer to the patient we admitted to the patient yes even though we are supposed to be specialists we had no clue as to what we were dealing with and we thought let us sleep over this and rake our brains at a later date

Skin Laser Centre
image 1

Thankfully the patient was patient and persistent, and he had more trust in our abilities to help him than what we had frankly and were all about to throw our hands in the air when we noticed that his arms appeared slightly red kinda flushed. So we had a new clue and we started to prod deeper into that and the patient revealed that the redness is very much there on and off but it doesn’t bother him like pain or itch so he choose not to discuss that We then started a cross reference transient redness, flushing we dug into our books and online research ( Dr Google ) threw up a picture akin to our patients condition and we had the diagnosis it was BIER spots, a rare entity but nevertheless reported and published.

So this is how it goes when the patient raises his hands as shown in image 1 they disappear and when the patient puts his arms down the blood gushes down, the flush increase and the white spots reappear magically shining like stars in a dark moonless night (image 2).

In the image 3 we can see both the arms the right is red and beefy and left pale as it had been just raised for a few seconds a moment ago which had emptied the veins ; the contrast is startling and was staring in our face  Like a kid who has been give a free access to a video game parlor we were grinning and asking the patient to raise one arm and then the other and get them down and so on, even he was mesmerized to see the changes in his body happening with a bit of help from gravity The white patches would crop up the moment his arms were hanging

Skin Laser Centre
image 2 & 3

down in the dependent position and disappear in a jiffy the moment he raised them and even though I’m considered a specialist in treating vitiligo ( White Patches ) I swear I have never seen any white patch getting cured at this speed. Medical literature dispels the mystery behind this phenomenon as abnormal Vascular response to venous hypertension and tissue hypoxia so if u see that’s what was happening But the thrill of making this rare diagnosis was a eureka moment for me and my colleague Dr Nupur, the sweet pleasure of arriving at a diagnosis was just divine . We literally patted each other on the back Good job and after a long slog in the OPD we raised a toast ( with tea In thermacol glasses) and exclaimed Elementary Dr Watson Elementary I know some of u must be wondering why I’m so excited to sit down and write a article about this simple condition but it’s something u really go to experience yourself , and in the end it’s the small pleasures that really count in this beautiful journey of life, for these are the drops that become the ocean, and is it not that the entire ocean is in the drop……

― Dr Paul

Melanocyte Cell Transplantation or MCT as Vitiligo Treatment

This surgical approach is now being considered as “may be a cure”. Unfortunately, science is still not able to find a permanent cure for this condition but there are many cases where Melanocyte Cell Transplantation (MCT) Melanocyte Keratinocyte Transplant Procedure (MKTP) as Vitiligo Treatment has made wonders.

Share

The new approach to treat vitiligo is cellular grafting. This surgical approach is now being considered as “may be a cure”. Unfortunately, science is still not able to find a permanent cure for this condition but there are many cases where Melanocyte Cell Transplantation (MCT) Melanocyte Keratinocyte Transplant Procedure (MKTP) as Vitiligo Treatment has made wonders. The idea of MCT is to remove the top layer of pigmented skin and replace it with healthy pigment cells (melanocytes) taken from another part of the body. Within a few months, the transplanted melanocytes start making pigment and deposit it to the surrounding areas. The success of this treatment wipes away the white spots and, in many cases, it has worked like magic. Patients with successful results don’t need any standard vitiligo treatments after that. However, not everyone is the right candidate for this Treatment of Vitiligo.

A Deep Insight into Melanocyte Cell Transplantation:

Vitiligo or white spots start appearing on the skin when immune cells sneak into the skin to find melanocytes and kill them. Melanocytes are the cells that produce pigment in our skin. So killing melanocytes stops the pigment production process and skin starts to lose its color.

In this Melanocyte Cell Transplantation (MCT) treatment, new melanocytes are transferred to the affected area. But, the immune cells active in that area kill the new melanocytes too which drives failure of this Vitiligo Treatment. This treatment shows higher success rate only if the disease is stable where the immune cells are quiet and no longer destroying the melanocytes. In such condition, the new melanocytes start working and bring the original skin color back. Now, the problem is, it is very difficult to know when the disease is stable. In common practice, the Dermatologist carries out this treatment only if the patient has no lesions from last 1-2 years.

This Vitiligo Treatment appears to be excellent for, segmental vitiligo patients. As in the segmental vitiligo, the disease is limited to one portion of the body, chances of success rates appear to be higher. 80-90% of such cases have seen success and may never require further vitiligo treatment. That’s the reason why this treatment is addressed as “may be a cure” which is normally never used for any other vitiligo treatment.

In Cellular grafting or Melanocyte Cell Transplantation (MCT), the top layer of the affected area’s skin is removed and melanocytes & other skin cells from normal skin is transplanted into that area. Among all other Vitiligo Treatment procedures, cellular grafting has appeared to be the most successful one until now. In medical terms, this process is also called as Melanocyte-Keratinocyte Transplant Procedure or MKTP.

But, I know only a few centers around the world that offer this treatment. This was the biggest reason I have started offering this treatment into my own SKIN LASER CENTRE. Here, we not only offer treatment but also provide post-treatment care to ensure the complete success of this process. This procedure requires special equipment and professional training. At our center, we have experienced excellent success rate for MKTP so far. As per my opinion and experience, it is the best Vitiligo Treatment for right patients, whom we decide after a careful series of examination. This procedure is a bit costly than others and thus I suggest the treatment only to the patients who fulfill the prerequisite health conditions.

Autologous Non-cultured Basal Cell-Enriched Epidermal Cell Suspension Transplantation in Vitiligo

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

Share

INTRODUCTION

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[1] which was a modification of the technique described by Olsson and Juhlin.[2] 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.

Transplantation technique

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.

Post-procedure instructions

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).

RESULTS

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.

DISCUSSION

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.

CONCLUSION

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.

Make an Enquiry

Review
Whatsapp
Call Us