Know Vitiligo: Symptoms & Treatment

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Vitiligo is a skin condition characterised by white patches on the skin. The patches can occur on any part of the body, even in the scalp and inner mouth. 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. People of any skin type can get affected by this condition, but the patches are more noticeable on dark-skinned people. The first signs of Vitiligo usually appear before the 30s, but it can affect at any age.

Vitiligo is not a life-threatening condition, but it is stressful due to social stigma associated with it. Patients often struggle with low self esteem & confidence due to their uneven skin tone but treatment can help them gain their confidence back. Vitiligo treatment helps restore the skin colour of the affected area and unify the overall skin tone.

Symptoms

Signs & symptoms of Vitiligo include:

  • Loss of skin colour in patches. These patches usually first appear on the sun-exposed areas such as face, hands, shoulders & lips.
  • Loss of skin color in the lining tissues of inner mouth and nose.
  • Premature whitening or greying of the hair, eyelashes, eyebrows, beard and body hairs.

However, the signs of VVitiligo also depend on the type of Vitiligo one has such as:

  • Universal Vitiligo: Wwhen the loss of pigments occurs on nearly everywhere on the body.
  • Generalized Vitiligo: When patches occur in many parts of your body. It is the most common type of Vitiligo.
  • Segmental Vitiligo: When patches occur on only one side or part of the body. This type of Vitiligo usually occurs in children which progress for 1-2 years and then stops.
  • Localized (focal) Vitiligo: When patches occur on one or only a few areas of the body.
  • Acrofacial Vitiligo: When the patches appear only on face and hands, eyes, nose, ears and around body openings.

Predicting the progress of Vitiligo is difficult as sometimes the condition spreads widely or sometimes it stops spreading even without any treatment.

Treatment:

Cosmetic camouflage: This is performed with colouring creams to cover-up the white patches. Usually, a semi-liquid foundation-like application is applied to the skin to hide the depigmented white circles. When correctly applied as per doctor’s instructions, camouflage creams can stay up to 96 hours on the skin. Although the duration may decrease in the case of the face and other exposed areas.

Microskin is a new revolutionary camouflage technique that stays on skin for several days. It’s smudge-proof and waterproof which also allow the skin to breathe. It comes in over 100 shades and gives a natural skin tone,

Phototherapy: Light therapy or phototherapy given with narrowband ultraviolet A (UVA) or ultraviolet B (UVB) has shown to stop the growth of Vitiligo. This treatment is often given with corticosteroids or calcineurin inhibitors for effective results. The treatment is given two to three times a week for several months. Effective changes can be seen within 2-3 months of the therapy.

Excimer (Targeted Phototherapy): It is one of the most effective Vitiligo treatments where ultraviolet radiations are directly focused on the white spots. As the name suggests, this treatment only targets the white spots leaving the rest of the skin unexposed. Usually, this treatment is often recommended for localized Vitiligo patients.

Depigmentation: This treatment is recommended for patients with more than 50% widespread Vitiligo. It is applied to the unaffected skin area to reduce melanin percentage and make a unified skin tone. This is achieved by using strong medicated topical lotion or creams that reduce melanin percentage on the skin. It is a permanent treatment and the entire procedure may take up to 12 to 14 months.

Melanocyte Cell Transfer: under this treatment, the top layer of white spots are removed and replaced with healthy melanocytes(pigment cells) taken from other parts of the body. Within a few months of the transplantation, the melanocytes start working to produce melanin which results in the disappearance of the white spots.

Skin Grafting: under this procedure, a small section of healthy pigmented skin is transferred to replace the depigmented skin areas. This treatment is recommended for Vitiligo patients with limited Vitiligo spots. Due to the complexity involved in this procedure, doctors only recommend it when all other treatment fails to restore the lost skin colour.

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

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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

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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

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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

Suction Blister Grafting

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.

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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.

Technique

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.

Surgical management of acral vitiligo

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

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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.

Anaesthesia

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

  1. Harvesting a Skin graft from the Thigh
  2. Trypsinization and Cell separation
  3. Dermabrasion of the recipient (vitiligo) site
  4. 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

    • Dermabrasion
    • Use cylindrical burs
    • Stabilize well
    • Use a corneal shield to provide base for DA
    • Immobilization
    • 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!!!
      • Dermabrade
      • Deeper DA
      • Immobilization
      • Dress each finger individually and then the whole hand

      How I do it Lips!!!

      • Derambrasion
      • Use bigger wheels
      • Put a guaze inside mouth to make the lips taut
      • Use the co2 laser or erbium YAG Laser
        • Immobilization
        • 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

        • Dermabrasion
        • Pear shaped bur
        • Pinch skin around to make it taught
        • Immobilization
        • Collagen pixel
        • Put in a catheter
        • Admit patient
        • 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.

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