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Keywords:

  • Vitiligo vulgaris;
  • Treatment;
  • Ultrasonic abrasion;
  • Seed-grafting;
  • PUVA

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. COMMENT
  6. References

Vitiligo vulgaris is a common disease throughout the world although its pathogenesis is not yet known. The most frequent treatment used for vitiligo is PUVA (psoralen plus ultraviolet A) and topical steroids but against stable refractory vitiligo, various other surgical techniques have been developed such as autografting, epidermal grafting with suction blisters, epithelial sheet grafting, and transplantation of cultured melanocytes. We have discovered a new method using ultrasonic abrasion, seed-grafting and PUVA therapy. The ultrasonic surgical aspirator abrades only the epidermis of recipient sites. This easily and safely removes only the epidermis, even on spotty lesions or intricate regions which are difficult to remove using a conventional motor-driven grinder or liquid nitrogen. Epidermal seed-grafting can cover more area than sheet-grafting, and subsequent PUVA treatment can enlarge the area of pigmentation with coalescence of adjacent grafts. In this article, we provide a general overview of the current surgical therapies including our method for treating stable refractory vitiligo.


Abbreviations:
PUVA

psoralen plus ultraviolet A

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. COMMENT
  6. References

Vitiligo vulgaris is a common skin disease affecting about 1% of the world's population (1). Although the destruction of melanocytes is the cause of the depigmentation in vitiligo skin, the exact pathogenesis of vitiligo is not yet known. The most frequently used treatment for vitiligo is PUVA (psoralen plus ultraviolet A) and/or topical steroids (2). It has been reported that these standard treatments result in limited success rates (about 60% of patients achieve more than 25% repigmentation). Various other types of treatments have been developed to treat stable refractory vitiligo, including epithelial sheet grafting, minigrafting, epidermal grafting with suction blisters, and transplantation of cultured melanocytes. These current surgical treatments for stable refractory vitiligo are overviewed.

Epithelial 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 dermatome (3). Although the method is simple, the motor-driven grinder used for dermabrasion at recipient sites sometimes leaves a hypertrophic scar and harvesting excessively thick grafts can also result in hypopigmentation or slight scarring at donor sites.

Minigrafting

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 (4[5]–6). Repigmentation occurs within several months by coalescence of pigmentation arising from the small grafted dermo-epidermal 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.

Epidermal Grafting with Suction Blisters

This method is performed in two stages (7, 8). First, recipient sites are denuded 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 200–300 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 denuded skin at the recipient sites and reinforced with a biologic dressing. Repigmentation occurs after several months by proliferation of melanocytes and spreading of pigment from grafts that have coalescenced. 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 remove only vitiligo areas of recipient site even by liquid nitrogen or blister induced by PUVA.

Transplantation of in-vitro Cultured Melanocytes

This newer method of culturing melanocytes in vitro has been successfully used for repigmenting vitiligo and piebaldism (9[10]–11). Cultured melanocytes are injected into skin blisters for small depigmented areas, and cultured melanocyte suspensions are transferred with a collagen dressing to dermabraded larger vitiligo areas. Co-cultured melanocytes and keratinocytes, in which melanocytes can proliferate without growth factors and chemicals, are transplanted onto depigmented areas. 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 these current treatments for stable refractory vitiligo, we have developed a new method to treat vitiligo which used ultrasonic abrasion, seed-grafting, and PUVA therapy. Only the epidermis of vitiligo lesions is abraded using an ultrasonic surgical aspirator. The epidermal abraded recipient sites are re-epithelialized with epithelial seed-grafts, and then are treated using PUVA therapy. Patients with stable segmental vitiligo on their faces can be treated using this method. Each operation has been very successful, and excellent repigmentation is observed at all grafting sites. Epidermal abrasion with an ultrasonic surgical aspirator leaves no scar. Seed-grafting can cover a wider area from a smaller donor site compared with the sheet-grafting technique. PUVA treatment then promotes the spreading of pigmentation from the seed-grafted areas.

Ultrasonic Abrasion, Seed-grafting and PUVA Therapy

Report of cases

Case 1.  A 30-yr-old-man presented with a 20-yr history of segmental vitiligo vulgaris on his face (Fig. 1A). We treated the lesion with topical steroids and PUVA for 2 yr but that was not effective.

image

Figure 1. . (A) Segmental vitiligo on the face of patient 1, (B) following ultrasonic abrasion, (C) 2 months after the operation, (D) 6 months after the operation, (E) segmental vitiligo on the neck of patient 2, (F) 2 years after the operation, (G) segmental vitiligo on the face and neck of patient 3, (H) 5 months after the operation.

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Case 2.  A 21-yr-old woman presented with a 10-yr history of segmental vitiligo vulgaris on her neck (Fig. 1E). She had been treated with PUVA for 7 yr but that treatment was not effective.

Case 3.  A 20-yr-old man presented with a 10-yr history of segmental vitiligo vulgaris on his face and neck (Fig. 1G). His lesion had been treated with steroid ointment initially and then with PUVA for more than 1 yr at another clinic but that treatment failed to achieve repigmentation.

METHOD

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. COMMENT
  6. References

We used the SUMISONICK (Sumitomo Bakelite Co., Tokyo, Japan) or the SONOPET (M&M Co., Tokyo, Japan) ultrasonic aspirators because these machines abrade only the epidermis of the skin (Fig. 1B). They are used with a short handpiece having a 2.1-mm tip diameter. A local anesthetic is first administered, and then, while holding the handpiece like a pen, the operator presses the tip onto the epidermis of the lesion and moves it around in continuous, circular, brushlike motions.

A very thin piece of epidermal graft skin (5–8/1000 inches) is taken from a normally pigmented donor site, usually the chest or arms, with a hand dermatome (Keisei Co., Tokyo, Japan). The graft skin (about 2 × 4 cm) is then minced using a surgical knife or scissors into fragments <1 mm2. These minced skin pieces are then placed on the epidermal-abraded vitiligo lesions and are covered with Trex gauze with gentamycin, dry sterile gauze and an adhesive bandage for at least 5 d. The donor site is also covered with the same materials. The wound dressings are removed 5–7 d after grafting.

Topical PUVA treatment is started 1 month after the grafting as follows: a solution containing 0.1% methoxypsoralen is applied to the grafted area 30 min before UVA exposure. The initial UVA dose is usually 0.25 J cm–2 and is increased to achieve mild erythema. This PUVA therapy is usually performed twice weekly to promote the spread of pigment cells from the graft (Fig. 1C).

Each operation has been very successful, and excellent repigmentation has been observed at all grafting sites. No recurrences or complications of the treatment have been seen (Fig. 1D, F, H). Following that success, we challenged five additional patients with segmental vitiligo vulgaris, and each operation has also been successful without leaving a scar.

COMMENT

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. COMMENT
  6. References

If topical steroids or PUVA treatment fail to repigment vitiligo vulgaris, surgical alternatives exist, which include autografting, epidermal grafting with suction blisters, epithelial sheet grafting and transplantation of cultured melanocytes. For recipient sites, a motor-driven grinder is usually used for dermabrasion and sometimes that leaves a hypertrophic scar. Even liquid nitrogen, if used excessively, can cause severe inflammation in the recipient site, which results in hypertrophic scarring and postinflammatory hyperpigmentation. The ultrasonic surgical aspirator is currently being used in a wide range of fields such as renal, liver, neurosurgery and plastic surgery (12[13]–14).

We decided to develop this technique as only the epidermis of the skin, i.e. the recipient site of vitiligo vulgaris, is removed. The reason for this success may be that the ultrasonic aspirator easily fragments structures with densely packed cells but not structures with abundant collagen and elastic fibers that have a low aqueous content. Histologic examination of skin that has been dermabraded using the ultrasonic surgical aspirator, the epidermis was cleanly removed but the dermis, including hair follicles and eccrine ducts, was still intact (Fig. 2). Epidermal-abraded areas re-epithelialize within only a few weeks, and excellent re-epithelialization is observed that does not leave a scar. Another advantage is that the ultrasonic surgical aspirator can easily and safely remove only the epidermis, even on spotty lesions and intricate regions which are difficult to remove using a conventional motor-driven grinder or liquid nitrogen.

image

Figure 2. . Histological examination of the skin following ultrasonic abrasion. The epidermis has been cleanly removed but the dermis, including hair follicles and eccrine ducts, are still intact (HE ×100).

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Epidermal seed-grafting can cover more area of the skin than can sheet-grafting and subsequent PUVA treatment can enlarge the area of pigmentation by coalescing of adjacent grafts. One week after seed-grafting, some minced graft skin detaches from the recipient site, but repigmentation is observed after the PUVA treatment. We suspect that melanocytes in the seed-grafting have been transferred to the abraded recipient site by that time.

Our results show that this new method, using seed-grafting of ultrasonic epidermal abrasion areas followed by PUVA treatment, is an easy, safe, inexpensive, and very effective treatment for stable vitiligo. We believe that this offers the best chance of overcoming the deficiencies of current treatments for stable refractory vitiligo.

References

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. COMMENT
  6. References
  • 1
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