Microskin Grafting Technique gives the best results in both focal/segmental & wide spread vitiligo once the patches are stable.  

Surgical Therapies :

IN ORDER TO OVERCOME THE DEFICIENCIES of OTHER current treatments for stable refractory vitiligo given below, I HAVE DEVELOPED A NEW METHOD to treat vitiligo which used mechanical superficial dermabrasion and microskin grafting. Patients with stable segmental or generalised vitiligo on their body sites can be treated using this method. Each operation has been very successful, and excellent repigmentation is observed at all grafting sites without producing any scar on donor and recipient sites. Strictly superficial dermabrasion with a diamond fraise leaves no scar on recipient areas. Microskin grafting can cover a wider area (donor to recipient area ratio up to 1:15) from a smaller donor site compared with the sheet skin grafting technique. PUVA treatment then may be given to promote the spreading of pigmentation particularly in generalised type of vitiligo but not in segmental vitiligo. Thus If topical or systemic steroids or PUVA treatment fail to repigment vitiligo vulgaris, surgical alternatives exist, which include autografting, suction blisters grafting, split thickness skin sheet grafting, mini punch grafting and transplantation of cultured or non cultured melanocytes and the last but not the least the microskin grafting, a most successful and excellent repigmentation procedure even in generalised stable vitiligo.

Vitiligo is a relatively common pigmentary disorder (nearly 1-2% of population) of great socio-medical importance. Depigmentation of the skin, with loss of melanocytes on histology characterizes this disorder. It is defined as a circumscribed, acquired, idiopathic, progressive, hypomelanosis of skin and hair, often familial and characterised by total absence of melanocytes microscopically. This definition excludes post-inflammatory, chemically induced depigmentation, and those which are associated with melanoma, secondary to various dermatoses and after burns. A range of clinical phenotypes lead to varying degrees of morbidity. The cause of vitiligo remains unknown, although an autoimmune pathogenesis seems most likely. Treatment also remains difficult. A number of new therapies show significant potential. Vitiligo or Leukoderma as it is more familiarly known in many parts of the world has gained importance principally because of the serious social stigma especially in the dark skinned people. It can be devastating to their self esteem because the sufferer may face problems related to matrimonial settlements or even in getting employment.

It is very common in the countries like Pakistan, India and Bangladesh. Vitiligo presents as sharply demarcated depigmented macules, that can appear anywhere on the skin. There is a predilection for orifices - eyes, nostrils, mouth, nipples, umbilicus, and genitalia.

The natural history of the disorder is either that it spreads quite quickly (over months) and then is stable, or it relentlessly spreads over the body with time (over years). Sites of trauma (koebnerization), such as the elbows, may develop vitiligo. Twenty-three to twenty-six percent of these are children under the age of twelve. It is the most commonly acquired hypomelanosis. Vitiligo can be extremely disfiguring, leading to significant patient morbidity. A number of different studies have been carried out to measure the quality of life for patients with vitiligo. Low self-esteem, poor body image and poor quality of life has been found in patients with vitiligo, including significant psychiatric morbidity (up to 25% in one study). The typical Vitiligo macules have a well defined light tan border and are chalky or snow white (trichrome Vitiligo), the fourth colour being the dark brown macules of repigmentation which are usually perifollicular (Quadrichrome Vitiligo) . Sometimes there may also be a hyperpigmented border or a red halo (Inflammatory Vitiligo). Segmental Vitiligo presents in dermatomal, multidermatomal, quasidermatomal forms which are arranged unilaterally. Most patients do not develop lesions elsewhere. Vitiligo of distant digits and the lips produces the lip-tip syndrome. Bilateral lesions may be symmetrical or asymmetrical. Palms and soles are commonly involved. Mucosal depigmentation, including gingiva, genitalia, lips and nipples, leukotrichia?depigmented hair is common in Vitiligo patches. Course and Prognosis: Vitiligo is a chronic disease process. The course is highly variable but rapid onset followed by a period of stability or slow progress is most characteristic. Up to 30% may report some spontaneous repigmentation particularly in sun-exposed areas. Rapidly progressive or 'galloping' Vitiligo may lead to extensive depigmentation. Vitiligo zosteriformis / segmental, however, is the most stable form and may show a better prognosis.Segmental Vitiligo is a special subset which usually develops precipitously in a region, which does not usually extend beyond quasidermatomal region, and is very stable once present. A few of the cases may once again start progressing at a rapid pace after a period of dormancy.

Such an occurrence is not uncommon in nonsegmental vitiligo types namely vitiligo vulgaris, acrofacialis and areata. In addition, several other factors may assist in evaluating its prognosis

a) the younger the patient, the shorter the duration, the better is the prognosis,

b) the lesions located on the fleshy regions of the body may show better chance of recovery in contrast to that on bony / friction points and

c) the presence of leukotrichia or lesions on mucous membranes or mucocutaneous junctions may account for a poor prognosis.

Another important aspect in the management of vitiligo is to identify the prognostic factors in each patient as this would be essential to decide on the end point of any modality of therapy. In our experience, a poor prognostic factor includes history of progression, family history of vitiligo, widespread disease, non-segmental vitiligo, acrofacial vitiligo, mucosal involvement and leukotrichia. We would also advise that all patients of vitiligo should be given sunscreens, antioxidants and options regarding cosmetic camouflage. Finally, the management of vitiligo would not be complete without good counseling, motivation and psychological support to the patient.

 

Other Therapies:

The most frequently used treatment for vitiligo is PUVA (psoralen plus ultraviolet A) and/or topical or systemic steroids. It has been reported that these standard treatments result in limited success rates (about 60% of patients achieve more than 25% repigmentation).These refractory and stable vitiligo can be subjected to various surgical therapies.

All the surgical therapies used in vitiligo are categorised in to either the tissue grafts or the cellular grafts.

The tissue grafts are simple one and used to give good repigmentary results without the need of hi-tech laboratory and infra structure but the disadvantage is that the limited vitiliginous area can be treated at a time. The cellular grafts are the latest one to be used in vitiligo and include both cultured and non cultured melanocytes and promise to cover wide vitiliginous area in one operative session with limited donor site.

The tissue grafts includes split thickness skin grafts, mini punch grafts, hair follicle grafts and suction blister epidermal grafts. These current surgical treatments for stable refractory vitiligo are over-viewed.

Split Thickness Skin Sheet Grafting: This method removes the epidermis and superficial papillary dermis of vitiligo depigmented areas by dermabrasion, and replaces it with very thin dermo-epidermal grafts harvested from normally pigmented donor skin with a derma tome. Although the method is simple, the motor-driven diamond fraise or wire brush used for dermabrasion at recipient sites sometimes leaves a hypertrophic scar if dermabrasion is done deeply and harvesting excessively thick grafts can also result in hypopigmentation or slight scarring at donor sites. Apart from this there is characteristic recipient area deformities like achromic fissuring, stuck on appearance, perigraft hypopigmented halo and rolled up peripheral margin.

Minipunch Grafting: This method consists of harvesting small (1.0-1.2 mm) punches of graft skin from donor sites and transferring these minigrafts to the vitiligo recipient sites, separated 3-4 mm from each other. Repigmentation occurs within several months by coalescence of pigmentation arising from the small grafted islands, but sunlight exposure for 10-15 min daily or ultraviolet A (UVA) irradiation may assist in repigmentation. Usually 4-5 mm of centrifugal pigmentation occurs around each recipient site, corresponding to approximately 20-25 times its original size. This procedure is excellent for segmental vitiligo, but sometimes a cobblestone appearance or scarring may result at the recipient site and donor site, which can be more noticeable with minigrafts larger than 1.2 mm.

Suction Blisters epidermal Grafting This method is performed in two stages. First, recipient sites are dermabraded by diamond fraise or by freezing with liquid nitrogen or blister induced by PUVA, which is performed 2 days prior to grafting. Secondly, blisters are formed at donor sites via a suction apparatus at -200 to -300 mmHg for 2-3 h. After the roof of the blister is removed from the donor sites, the donor epidermis is placed on top of the dermabraded skin at the recipient sites with correct orientation. Repigmentation occurs by proliferation of melanocytes and spreading of pigment from grafts. The advantages of this procedure are a low incidence of scarring and the possibility of reusing the donor site for future treatments, but it takes 2-3 h to make the suction blisters and it is not easy to treat extensive vitiliginous areas in one operative session. There are more chances of hyperpigmentation at both donor and recipient areas particularly in initial months of procedure.

Transplantation of cultured or noncultured melanocytes: A new era has begun in surgical therapy with the development of transplantation techniques with cultured or noncultured melanocytes. This procedure allows the treatment of larger areas in shorter periods. Lerner & colleagues successfully treated a patient of piebaldism by injecting cultured melanocytes into small blisters raised on areas devoid of pigment. Olsson and Juhlin using cultured melanocytes have reported re-pigmentation of vitiligo in 10 and 100 patients, respectively.

Further evolution has led to noncultured epidermal cell transplantation. Olsson andJuhlin have reported excellent results using epidermal cell transplantation on 26 patients in their outpatient clinic. Gauthier and Surleve-Bazeille have described grafting with noncultured melanocytes and keratinocytes. They injected cell suspension into blisters produced with liquid nitrogen. The scalp was chosen as the donor area. However, it is a 2-day procedure and limits treatment to only a very small area in one operative session. Nanny Van Geel and colleagues conducted a pilot study of only four patients with noncultured melanocytes and keratinocytes grafted on superficially laser dermabraded vitiligo lesions. These transplanting techniques have the theoretical advantage of potentially treating large areas using cells harvested from a small piece of donor skin by expanding the culture in vitro. But its major disadvantage lies in the complexities and cost of the culture. Also more knowledge of the biology and safety of in vitro cultured cells is necessary before cultured cells are used in daily practice.

IN ORDER TO OVERCOME THE DEFICIENCIES of OTHER current treatments for stable refractory vitiligo given below, I HAVE DEVELOPED A NEW METHOD to treat vitiligo which used mechanical superficial dermabrasion and microskin grafting. Patients with stable segmental or generalised vitiligo on their body sites can be treated using this method. Each operation has been very successful, and excellent repigmentation is observed at all grafting sites without producing any scar on donor and recipient sites. Strictly superficial dermabrasion with a diamond fraise leaves no scar on recipient areas. Microskin grafting can cover a wider area (donor to recipient area ratio up to 1:15) from a smaller donor site compared with the sheet skin grafting technique. PUVA treatment then may be given to promote the spreading of pigmentation particularly in generalised type of vitiligo but not in segmental vitiligo. Thus If topical or systemic steroids or PUVA treatment fail to repigment vitiligo vulgaris, surgical alternatives exist, which include autografting, suction blisters grafting, split thickness skin sheet grafting, mini punch grafting and transplantation of cultured or non cultured melanocytes and the last but not the least the microskin grafting, a most successful and excellent repigmentation procedure even in generalised stable vitiligo.